MCQ Basic Science New

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"Which of the following can induce menstrual bleeding in a 21-year-old anovulatory, amenorrheic woman with PCOS? A. administration of progestins B. administration of estrogens C. withdrawal of progestin therapy D. withdrawal of estrogen therapy E. danazol"

"Apatient with a known family history of multiple endocrine neoplasia (MEN) I, now presents with intractable ulcer disease. Which of the following statements about his condition is most accurate? A. diarrhea is a frequent complaint. B. Tumors are rarely multiple. C. Tumors are rarely malignant. D. An elevated fasting gastrin level is diagnostic for the Zollinger-Ellison syndrome. E. CT is useful in localizing the tumor in greater than 75% of patients."

"You are called to see a 12-hour-old male infant who was born to a 19-year-old G1 woman with no prenatal care. She presented to the emergency room completely dilated and crowning. The baby was born minutes later. On examination, the baby is febrile and tachypneic. A CXR confirms the presence of pneumonia. What is the most likely infectious agent? A. group B Streptococcus (GBS) B. HSV C. E. coli D. respiratory syncytial virus (RSV) E. Streptococcus pneumoniae"

"You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. If you were to perform an abdominal x-ray, what is the most likely finding that would be seen? A. ""double-bubble"" sign B. scimitar sign C. normal gas patterns D. free fluid in the abdomen E. pneumatosis intestinalis"

"A 45-year-old male receives a cadaveric liver transplant for alcoholic cirrhosis. Postoperatively, the patient is taken to the surgical intensive care unit (SicU). There is concern for primary nonfunction of the allograft. Which of the following is a sign of this? A. coagulopathy with an INR of 2 B. normalizing albumin level C. hyperglycemia requiring an insulin drip D. initial rise of transaminases E. high urine output"

"A 46-year-old female presents to your office with rectal bleeding, itching, and irritation. On examination, a 3-cm ulcerating lesion is seen in the anal canal. Biopsy of the lesion reveals squamous cell carcinoma (SCC). Which of the following is the most appropriate treatment? A. chemotherapy and pelvic radiation protocol B. low anterior resection C. abdominal perineal resection D. wide local excision of the lesion E. wide local excision of the lesion and bilateral inguinal lymph node dissection"

"A 48-year-old male truck driver presents for evaluation of bright red rectal bleeding with bowel movements. He also has the feeling that something protrudes through his anus while he strains to move his bowels but that it withdraws into the bowel when he relaxes. He has no abdominal pain, weight loss, or other symptoms. A colonoscopy reveals no polyps or tumors but does note internal hemorrhoids. Which of the following is the best initial treatment for him? A. high fiber diet, frequent sitz baths, and topical steroid ointment B. rubber band ligation C. sclerotherapy injection D. infrared coagulation E. surgical hemorrhoidectomy"

"A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Which of the following irreversible complications is also associated with gentamicin use? A. vestibular dysfunction B. cardiomyopathy C. optic nerve dysfunction D. myelodysplastic disease E. cerebellar degeneration"

"A 48-year-old woman with metastatic breast cancer presents to the Emergency Center complaining of a 4 day history of nausea, anorexia, and generalized weakness. Her husband reports that she has been more somnolent, sLEEPing 1214 hours per day, and at times she seems confused. CT scan of the brain revealsno abnormalities. Initial laboratory evaluation reveals a normal CBC, but her BUN is elevated at 32 mg/dL with a slight elevation of serum creatinine above her baseline. Her serum calcium is elevated at 15 mg/dL. What is the most appropriate initial therapy for the patient's hypercalcemia? A. volume resuscitation with normal saline B. administration of furosemide every 6 hours C. subcutaneous calcitonin D. intravenous zoledronate E. treatment of the patient's underlying malignancy with chemotherapy"

"A 50-year-old man comes to the emergency room (ER) with a history of vomiting of 3 days' duration. His past history reveals that for approximately 20 years he has been experiencing epigastric pain that lasts for 23 weeks during spring and autumn. He remembers getting relief from pain by taking milk and antacids. Physical examination showed fullness in the epigastric area with visible peristalsis, absence of tenderness, and normal active bowel sounds. What is the most likely diagnosis? A. gastric outlet obstruction B. small bowel obstruction C. volvulus of the colon D. incarcerated umbilical hernia E. cholecystitis"

"A 54-year-old male presents to the ED with acute onset of severe abdominal pain. His history is significant for gnawing epigastric pain that radiates to the back for several months. Physical examination demonstrates mild hypertension and tachycardia as well as a rigid ""board like"" abdomen with generalized rebound tenderness and hypoactive bowel sounds. rectal examination reveals dark hemoccult positive stools without gross blood. Which of the following would be the next appropriate step in management? A. order upright chest and abdomen x-rays B. obtain a CT scan of the abdomen and pelvis C. plan for upper GI endoscopy D. take patient to the OR for immediate exploratory laparotomy E. schedule the patient to be seen in surgery clinic in 1 week"

"A 54-year-old male with uncontrolled type II diabetes and well-controlled hypertension presents with complaints of erectile dysfunction. The patient requests Viagra (sildenafil), as his friends have used it with success. However, he is concerned as he was told by someone that Viagra can be fatal if used with some blood pressure medications. You would advise the patient that the use of which of the following is contraindicated in patients taking sildenafil? A. isosorbide mononitrate B. metoprolol C. verapamil D. captopril E. clonidine"

"A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. You order a CXR. Which of the following are you most likely to find? A. normal B. diffuse pulmonary congestion C. increased bronchial wall markings D. cardiomegaly E. flattening of the diaphragms"

"A20-year-old male has had a recent wide local excision of a 1. 5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? A. the Breslow depth of the tumor B. the Clark level of the tumor C. the location of the tumor D. the age of the patient E. the number of prior severe blistering sunburns"

"A20-year-old male has had a recent wide local excision of a 1. 5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? Which of the following interventions is most appropriate in addition to wide local excision of the patient's melanoma? A. sentinel lymph node biopsy B. no further intervention is warranted C. adjuvant therapy with interferon alpha-2 for 1 year D. single-agent chemotherapy E. complete lymph node dissection"

"A40-year-old woman presents with headaches and visual disturbances for the past 6 months. She suddenly developed amenorrhea 2 years ago. One year ago, she noticed milky discharge from her left breast. The most likely diagnosis is which of the following? A. prolactinoma B. premature ovarian failure C. Kallman syndrome D. Sheehan syndrome E. polycystic ovarian syndrome (PCOS)"

"A45-year-old man undergoes a distal esophagectomy for Barrett's esophagus. During his hospital course, a left chest tube is placed for an effusion. Milky white fluid is found to come out through the tube. Which of the following statements is most accurate about this condition? A. Diagnosis can be confirmed by checking the lymphocyte count and triglyceride level in the fluid. B. This condition requires immediate surgical intervention to repair. C. The chest tube should be removed due to the possibility of an iatrogenic source of infection. D. Usually found on the right if due to a traumatic source. E. The use of TPN is contraindicated until the condition resolves."

"A54-year-old man without significant past medical history presents to his primary care physician complaining of epigastric discomfort and early satiety. He subsequently undergoes an endoscopic procedure revealing an ulcerated mucosal lesion. The biopsy of this lesion is interpreted as a well differentiated lymphoma. Which of the following statements regarding his treatment and prognosis is most accurate? A. His prognosis is poorer than if he were diagnosed with a gastric adenocarcinoma. B. This lymphoma is not associated with Helicobacter pylori infection. C. Antibiotic therapy may induce regression of the lesion in the majority of cases. D. Treatment will not offer curative potential, so he should be referred for hospice care. E. Gastric resection is recommended for well-differentiated, bbut not higher grade, lymphomas."

"A 10-year-old male has a history of seizures which are controlled with dilantin. The child also has asthma and often uses an albuterol inhaler. Which of the following asthma medications can lower the seizure threshold in children? A. theophylline B. salmeterol C. beclomethasone D. montelukast E. nedocromil"

"A 16-year-old sexually active woman is being seen in the emergency department. She is complaining of vaginal discharge. She has a temperature of 99. 5°F, but is otherwise well. On pelvic examination, you see a mucopurulent cervical discharge with scant blood. Samples of the discharge are sent to the laboratory for culture. There are no cervical ulcers noted. She does not have any medical allergies. For this patient, what is the most appropriate regimen for initial therapy? A. azithromycin (Zithromax) 1 g orally once and ceftriaxone (Rocephin) 125 mg intramuscular (IM) once B. amoxicillin/clavulanic acid (Augmentin) 500 mg orally twice a day for 7 days and ceftriaxone 125 mg IM once C. metronidazole (Flagyl) 500 mg orally twice a day for 7 days and amoxicillin/clavulanic acid 500 mg orally twice a day for 7 days D. ceftriaxone 125 mg IM once E. azithromycin 1 g orally once and metronidazole 500 mg orally for 7 days"

"A 22-year-old female (G3P0020) presents to your office for an initial obstetric visit in her third pregnancy. She reports a sure LMP date approximately 6 weeks ago, with a history of regular cycles. Her two previous pregnancies ended in spontaneous abortions. She denies any significant medical or surgical history. She denies use of alcohol, tobacco, or illicit drugs, though she does report a history of IV drug use as a teenager. She is a full-time student. She reports that twins run in her family, but she does not have any family history of diabetes, hypertension, or congenital anomalies. On review of her prenatal labs that have already been drawn, you find that her human immunodeficiency virus (HIV) antibody test (enzyme-linked immunosorbent assay [ELISA]) is positive. Her test results are otherwise normal Which of the following is recommended to reduce the risk of perinatal transmission of HIV from mother to infant? A. A scheduled cesarean delivery can reduce the risk of transmission if the maternal viral load is greater than 1000 copies/mL. B. All pregnant women with HIV should receive highly active antiretroviral therapy regardless of severity of HIV infection. C. No treatment is required; the risk of perinatal transmission of HIV is quite low. D. All patients with HIV should be required to have a cesarean delivery. E. Treatment of opportunistic infections such as Pneumocystis carinii pneumonia in the mother is most important in reducing the perinatal transmission of HIV."

"A 32-year-old woman presents with complaints of irritability, heat intolerance, hyperdefecation, and frequent palpitations. She has lost 20 lb over the past six months. She has always been in good health and does not take any prescription or OTC medications. She denies any prior history of thyroid disease or exposure to head/neck irradiation, but she states that one of her relatives was diagnosed with a thyroid disorder at roughly the same age. Vital signs are as follows: BP 138/78, HR 112, RR 22, temp. 98. 8°F. On examination, her thyroid is diffusely enlarged and smooth. Auscultation of the thyroid reveals a bruit. Her hair is fine in texture, and she has warm velvety skin. She has hyperactive deep tendon reflexes. There is a fine tremor in her outstretched hands. Which of the following interventions is most appropriate at this time? A. propylthiouracil B. thyroidectomy C. radioactive iodine therapy D. propranolol E. potassium iodide"

"A 34-year-old male undergoes an uneventful excision of a parathyroid adenoma. The following postoperative day, he complains of numbness around his lips. Which of the following is the most appropriate intervention? A. oral calcium gluconate B. intravenous rehydration with normal saline C. intravenous magnesium sulfate infusion D. blood transfusion E. reassurance and close observation"

"A 35-year-old woman presents to your office complaining of fatigue and global achiness. She states that she has ""not been myself"" since she developed a bad whiplash after a motor vehicle accident. Her health has otherwise been good. About 3 years ago, she saw a cardiologist for chest pain. A full evaluation ensued including heart catheterization that showed no coronary disease, although her cholesterol levels were elevated and a statin was prescribed. She sLEEPs poorly and notes that she has gained a considerable amount of weight. She has seen a gastroenterologist who has told her that her abdominal pain and alternating constipation and diarrhea are because of irritable bowel syndrome. Physical examination shows that her height is 5 ft 2 in. and her weight is 240 lb. blood pressure is 126/78. Pulse is 86 and regular. Heart and lung examinations are completely normal. Her pharynx is normal and she has no lymphadenopathy. Abdominal examination shows diffuse mild tenderness, but no masses, rebound, guarding, or organomegaly. rectal and pelvic examinations are normal. Muscular strength is 4/5 distally and proximally, but there is a considerable give way secondary to pain. She is tender bilaterally at the occiput across the trapezius, iliac crest at the greater trochanteric, anserine bursae bilaterally, and at the second intercostal space bilaterally. In this patient, which of the following conditions may also be exacerbating her symptoms? A. sLEEP apnea B. hyperthyroidism C. RA D. celiac sprue E. medication side effect"

"A 35-year-old woman schedules an appointment in an outpatient clinic for evaluation and treatment of a ""mouth problem. "" She says that she has white spots in her mouth that have been present for a few weeks. In response to your questioning, she states that she has been experiencing fatigue and a 20-lb weight loss over the past several months, although she attributes these symptoms to a dramatic increase in work hours at her job over the same period of time. She denies having any other chronic medical issues and does not use any prescription or OTC medications. As you examine her, you note the presence of white plaques on her buccal mucosa, palate, and tongue. Scraping of the plaques with a tongue depressor elicits pain as well as a small amount of bleeding. Nontender generalized cervical and submandibular lymphadenopathy is present. Which of the following immunizations is safe to administer to this patient? A. inactivated influenza vaccine B. live attenuated influenza vaccine (FluMist) C. varicella vaccine D. oral polio vaccine (OPV) E. measles mumps rubella (MMR) vaccine"

"A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy. A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. One month later, a repeat measurement of the patient's CD4 count is 225/L. Which of the following interventions would be the most appropriate at this time? A. Continue the current regimen without change. B. Modify the patient's antiretroviral therapy to prevent development of resistance. C. Discontinue any prophylactic medications that the patient is taking. D. Begin azithromycin for M. avium complex prophylaxis. E. recheck CD4 count due to suspected laboratory error."

"A 4-year-old is brought to your office by his mother for evaluation. She is concerned because the child has been spiking fevers and pulling on his left ear. Your examination reveals a bulging and erythematous tympanic membrane (TM). You determine that the child should receive antibiotics. The initial antibiotic of choice should be? A. amoxicillin B. azithromycin (Zithromax) C. erythromycin D. trimethoprim/sulfamethoxazole (septra) E. tetracycline"

"A 45-year-old male has received intravenous contrast dye prior to CT scan of the abdomen. Twenty minutes later the patient reports severe pruritus. He denies respiratory distress, syncope, or palpitations. His blood pressure is 98/54, pulse is 90, and respiratory rate is 22. On physical examination, he has widespread urticaria. His lungs are clear to auscultation. The next appropriate step would be which of the following? A. administration of 0. 5 mL of 1:1000 epinephrine subcutaneously B. administration of 0. 5 mL of 1:100,000 epinephrine subcutaneously C. administration of 25 mg of diphenhydramine subcutaneously D. administration of intravenous glucocorticoids E. careful observation but no medications"

"A 58-year-old male presents to your office for a well-male examination. It has been several years since he last visited a doctor, but he states that he has been in ""excellent health. "" He denies any history of drinking, smoking, or using illegal drugs. He maintains a diet low in sodium and fat. An avid sports enthusiast, he also spends at least 2 hours per day engaged in some type of outdoor physical activity. On physical examination, you discover a translucent waxy papule with raised borders on the posterior aspect of his left shoulder. Which of the following is true of this patient's skin condition? A. It is the most common malignancy in the United States. B. Total body skin examination reduces the morbidity and mortality associated with this condition. C. Metastasis is common. D. The cure rate is approximately 50%. E. If appropriately treated, the rate of recurrence (development of a second lesion) is equal to that found in the general population."

"A 59-year-old White male with a 40 pack-year history of smoking presents to your clinic complaining of three prior episodes of a ""shade passing over his left eye"" over the last 2 months. He reports that last week he experienced some weakness in his right arm, which resolved after 5 minutes. Appropriate management and counseling for this patient includes which of the following? A. Initial management of this patient should include bilateral cerebral vessel duplex ultrasonography. B. Explanation to him that he has had a stroke and will be referred to a neurologist for management. C. The most common cause of strokes in these patients is related to decreased blood flow. D. Presence of a carotid bruit confirms the diagnosis and may lead to operative intervention without the need for imaging studies. E. The presence of a 50% stenosis in the right carotid artery should lead to bilateral surgical repair."

"A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chest pains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. An abnormal result of which of the following laboratory tests would be most likely to explain the cause of this condition? A. TSH B. troponin T C. BUN and creatinine D. serum glucose E. arterial blood gas"

"A 64-year-old male has been suffering from lower back pain for over 10 years. You have been following him for this period. You have prescribed stretching exercises and, occasionally, an antiinflammatorymedication to alleviate his pain. Although he has had no neurologic deficits in the past, today he has shown up in your office unexpectedly, complaining of bilateral lower back pain with numbness and tingling over the dorsal aspect of both feet. His symptoms have become progressively worse over the past 2 weeks and he is now unable to stand for more than 5 minutes without developing extreme pain and numbness. His symptoms are much improved by sitting down or kneeling over a chair. Climbing stairs seems to be tolerated well, but walking greatly exacerbates the pain. He denies bladder or bowel incontinence or retention, point tenderness or anesthesia in the lower back along the spinal cord or in the saddle area. Which of the following imaging studies would be most helpful to confirm the diagnosis? A. an MRI of the lumbosacral spine B. an x-ray of the lumbosacral spine C. an indium-tagged WBC scan D. a bone scan of the sacrum E. nerve conduction study of the legs bilaterally"

"A 64-year-old male with a history of hypertension and tobacco abuse presents for follow-up after a routine physical during which he was found to have 45 red blood cells (RBCs) per high-power field (HPF) on a screening urinalysis. The urinalysis was negative for leukocytes, nitrites, epithelial cells, and ketones. The patient denies any complaints and the review of systems is essentially negative. In detecting microscopic hematuria, which of the following is true? A. The office urine dipstick is 91100% sensitive and 6599% specific for detection of RBCs, Hgb and myoglobin. B. Urinalysis must reveal a minimum of 5 RBCs per HPF in order to continue the workup. C. The presence of epithelial cells makes the urinalysis invalid. D. The presence of ""large blood"" on a urine dipstick effectively distinguishes RBCs from myoglobinuria. E. Any urinalysis with RBCs should be recollected via a catheterized specimen prior to initiating a workup for hematuria."

"A 70-year-old male is seen in the office for chest pain. He reports that he is getting substernal chest pain, without radiation, when he mows his lawn. The pain resolves with 1015 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 160/70, pulse 85, and respiratory rate 16. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Which of the following would be the most appropriate test to order next? A. echocardiogram B. exercise stress test C. cardiac catheterization D. 24-hour Holter monitor E. electrophysiologic studies"

"A 72-year-old diabetic is transferred to your hospital for fever and altered mental status in the late summer. Symptoms started in this patient 1 week prior to admission. On physical examination, the patient was disoriented. There were no focal neurologic findings. There was a fine rash on the patient's trunk. On oral examination, there were tongue fasciculations. A lumbar puncture was performed which showed a glucose of 71 and a protein of 94; microscopy of the cerebrospinal fluid (CSF) revealed 9 RBC and 14 WBC (21 P, 68 L, 11 H). The creatinine phosphokinase was 506. An electroencephalogram and MRI of the brain were normal. What further diagnostic test is the most appropriate? A. Perform a West Nile virus IgM on the CSF. B. Perform a serum cryptococcal antigen. C. Perform C. immitis complement fixation tests. D. Perform a sinus series. E. Perform a purified protein derivative (PPD) skin test."

"A64-year-old man with a long history of smoking but no significant past medical history presents to his physician's office complaining of a 12 week history of worsening dyspnea, facial swelling, and discoloration. He has also had swelling and discomfort of his right arm. Physical examination reveals edema with plethora of the face and right arm, with prominent collateral veins over the chest wall. Following the establishment of a diagnosis, what is the most appropriate initial therapy? A. elevation of the head and monitoring for airway obstruction B. urgent radiation therapy C. administration of glucocorticoids D. empiric chemotherapy for suspected lung cancer E. surgical evaluation for resection of the obstructing mass"

"A 72-year-old man with a diagnosis of prostate cancer was recently seen in the clinic for restaging and reevaluation. His bone scan showed development of widespread osseous metastases and his PSA was rising. He was started on leuprolide acetate, a gonadotropin releasing-hormone (GnRH) agonist. He now returns to the clinic complaining of new severe mid-thoracic back pain, which is worse with recumbency and worse with Valsalva maneuver. He also reports that he has a brief but intense electric shock sensation in his lower extremities when he bends over to tie his shoes. On physical exam, he had localized tenderness over the mid-thoracic spine, but his motor strength, sensation, and deep tendon reflexes are all intact. What is the most appropriate next step? A. Obtain an MRI of the thoracic spine. B. refer for neurosurgical evaluation. C. Initiate radiation therapy to the affected thoracic spine. D. Start the patient on scheduled narcotics for relief of the back pain and follow up in 1 week. E. Stop the leuprolide and schedule the patient to return to clinic in 1 week for re-evaluation."

"A 72-year-old woman undergoes a sigmoid colectomy for diverticulitis. Postoperatively, she develops a wound infection for which she is transferred to the ICU for 2 days because of hypotension. Which of the following would have had the most effect on reducing her risk of developing complications? A. preoperative treatment of her concomitant urinary tract infection B. nurses changing gloves in between their patient assessments so they don't have to wash their hands as often C. using a preoperative antibiotic specific for E. coli, the most common intestinal flora D. giving preoperative antibiotics immediatel after the skin incision E. treatment of the infected wound with an antibiotic only"

"A mobile mass is found on rectal examination in a 77-year-old male with complaints of blood in his stool. On workup, he is found to have a stage I (Dukes' A), well differentiated adenocarcinoma. The most appropriate intervention is which of the following? A. transanal excision B. abdominal perineal resection C. low anterior resection D. placement of endorectal wallstent E. neoadjuvant chemotherapy followed by transanal resection"

"A mother brings her 15-year-old son in for a preparticipation sports physical examination. She feels that her son has not yet undergone pubertal changes and that makes her concerned. Which of the following physical examination findings is usually the first sign of the onset of puberty in males? A. increased testicular volume B. increased skeletal muscle mass C. deepening of the voice D. increased facial hair E. physiologic gynecomastia"

"A newborn male is brought to you in the neonatal intensive care unit (NicU). On physical examination, you notice that the infant has deficient abdominal musculature and undescended testes. Your suspicion is high for a certain condition. Upon further imaging, what associated finding would be expected? A. posterior urethral valves on a voiding cystourethrogram (VCUG) B. hydrocephalus on head ultrasound C. cardiomegaly on chest x-ray (CXR) D. bilateral adrenal enlargement on abdominal ultrasound E. tracheoesophageal fistula on an upper gastrointestinal (UGI) series"

"A patient presents with a new neck mass. On examination, she has a palpable thyroid nodule and a palpable cervical lymph node on the same side. Needle biopsy of the thyroid nodule shows amyloid in the stroma. The treatment for this patient is which of the following? A. total thyroidectomy and modified neck dissection B. resection of the involved thyroid lobe, isthmusectomy, and removal of the palpable lymph node C. total thyroidectomy and radiation therapy D. resection of the involved lobe and part of the contralateral lobe, isthmusectomy, and removal of the palpable lymph node E. radioactive iodine administration"

"A1-month-old female presents after an episode of bilious emesis. She became irritable 12 hours ago, began vomiting 6 hours ago, and is now lethargic. She had one small stool that was somewhat bloody 2 hours ago. Which of the following statements is true? A. An upper GI contrast study should be obtained immediately. B. The most likely explanation is pyloric stenosis. C. The patient should be admitted for IV fluid resuscitation and observation. If she does not improve over the next 24 hours, a surgical consultation should be obtained. D. An air contrast enema is the most appropriate next step. E. A nasogastric tube should be inserted and IV antibiotics started to treat probable necrotizing enterocolitis."

"A15-year-old female presents to the emergency room (ER) with acute onset right lower quadrant pain and nausea. She recently became sexually active and is ""in the middle"" of her menstrual cycle. Physical examination is notable for generalized guarding, rebound, and 8/10 pain in both lower quadrants. A pelvic examination shows no vaginal discharge, a normal appearing cervix, and general pelvic tenderness, but the examination is limited by the patient's guarding. Her complete blood count is notable for a borderline elevated white blood cell (WBC) count, and a urinary -hCG is negative. Pelvic ultrasound shows a 2-cm simple appearing cyst on the right ovary and a mild amount of fluid in the cul-de-sac. Acomputed tomographic (CT) scan cannot definitively visualize the appendix, confirms the presence of a 2-cm cystic structure in the right ovary, and otherwise notes normal anatomy. Which of the following is the most appropriate next step? A. diagnostic laparoscopy B. pelvic MRI C. intravenous antibiotics D. admission for serial physical examinations and pain control E. discharge home on oral antibiotics"

"A19-year-old college student is found to have an elevated serum calcium on routine physical examination. She has a family history of hypercalcemia that has not resulted in any known symptoms. Further workup reveals a slightly elevated serum parathyroid hormone with depressed levels of serum phosphate. A 24 hour urine calcium excretion is obtained and is low. Which of the following is the correct diagnosis? A. familial hypocalciuric hypercalcemia (FHH) B. primary hyperparathyroidism C. secondary hyperparathyroidism D. tertiary hyperparathyroidism E. metastatic bone cancer"

"A24-year-old female presents to your office for excision of a nevus. After obtaining consent and prepping the site, you anesthetize the area with 1% lidocaine. However, as you start the procedure, you note that the patient is not sufficiently anesthetized. Your partner suggests the use of lidocaine with epinephrine. The addition of epinephrine with local anesthetics is useful because of which of the following properties? A. It prolongs and increases the depth of local anesthesia. B. It neutralizes the irritant action of the local anesthetic agent. C. It increases the rate of systemic absorption and therefore hastens the onset of action of the anesthetic agent. D. It increases the pH of the anesthetic so that less anesthetic is required to produce nerve block. E. It blocks neurotransmitter release (thus decreasing pain perception) via stimulation of presynaptic alpha-adrenergic receptors."

"A27-year-old female whose father had a colon resection for adenocarcinoma undergoes her first colonoscopy. Over 100 small polyps are seen distributed mainly in her sigmoid and rectum. Multiple polyps are removed and histologic review reveals tubular adenomas with no evidence of atypia or dysplasia. The most appropriate next step in her management is which of the following? A. total proctocolectomy with ileoanal J pouch reconstruction B. surveillance colonoscopy in 5 years C. surveillance colonoscopy every 2 years until all polyps are removed D. flexible sigmoidoscopy with representative biopsy every 6 months for 2 years, then yearly for 3 years, then every 35 years E. abdominal perineal resection with sigmoid resection and end colostomy"

"A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a ""pink eye"" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. The patient's symptoms do not respond to your initial therapeutic management. You suspect that his condition is refractory to treatment. Which of the following should you consider at this time? A. He may have human immunodeficiency virus (HIV) infection and should be tested. B. His condition will require high doses of prednisone (60 mg daily) for adequate control. C. His joints are obviously not infected and should be directly injected with corticosteroids. D. He must have a disseminated bacterial infection that will require IV antibiotics. E. He is resistant to indomethacin, so the dose should be doubled to 400 mg daily."

"A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix. Infection with which of the following agents is most likely to have resulted in her cancer? A. human papillomavirus type 16 B. hepatitis C virus C. hepatitis B virus D. Chlamydia trachomatis E. human papillomavirus type 11"

"A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix. Subsequent work-up confirms the presence of micro-invasive cervical carcinoma [Stage Ia]. What would be the most appropriate treatment? A. simple hysterectomy B. radical hysterectomy with pelvic lymph node dissection C. cervical radiation therapy D. cervical radiation followed by chemotherapy E. hysterectomy followed by chemotherapy"

"A35-year-old woman with two prior term pregnancies presents for her first prenatal visit at 12 weeks' gestation. She recalls having had hypertension near the end of her first pregnancy. She believes her blood pressure has been normal since, but admits that she rarely seeks preventive health care visits, and that her last examination by a physician was more than 2 years ago. Today, you find her blood pressure to be 160/100. Her blood pressure comes under good control after initiating medication and remains well controlled until the 36th week, when her blood pressure is noted to have risen again to 170/110. She is also noted to have 3+ proteinuria on urine dipstick testing. For which of the following complications is she at risk? A. eclampsia B. fetal macrosomia C. abnormal progress of labor D. postpartum hemorrhage E. breech presentation"

"A37-year-old woman (gravida 3, para 3) presents with a 4-month history of postcoital spotting On pelvic examination, you visualize a 2-cm friable lesion on the anterior lip of the cervix. The next most appropriate step is which of the following? A. colposcopy B. pap smear C. office biopsy of the cervical lesion D. cervical cone biopsy E. metronidazole vaginal cream followed by re-examination"

"A38-year-old woman presents to the ER with heavy vaginal bleeding. A pelvic examination using a speculum to visualize the cervix reveals a large, friable, fungating cervical mass. On bimanual examination, the mass extends to the right pelvic sidewall. A biopsy from a recent gynecologic visit reveals invasive squamous cell carcinoma of the cervix. An abdominal/pelvic CT scan shows enlarged pelvic lymph nodes and right hydronephrosis. Her hematocrit (HCT) in the ER is 24%, but she is hemodynamically stable with a BP of 124/70 and a pulse of 73. The cervical mass is actively bleeding. Which of the following is the most appropriate immediate management of the vaginal bleeding in the ER? A. vaginal packing soaked with Monsel solution B. vitamin K C. transfusion of fresh frozen plasma (FFP) D. uterine massage E. supportive care with transfusion of packed red blood cells"

"A39-year-old obese female presents with irregular menstrual periods, mild acne and hirsutism, and acanthosis nigricans on the nuchal fold, axilla, and intertriginous areas (inner upper thighs). You suspect PCOS. Which of the following laboratory tests would be most important to perform to rule out a likely confounding diagnosis? A. 2-hour oral glucose tolerance test B. testosterone C. prolactin D. dehydroepiandrosterone sulfate (DHEAS) E. LH and FSH"

"Apatient you see routinely in the clinic has elevated liver function tests. ALT is 89, AST is 75, and the total bilirubin and alkaline phosphatase are normal. The patient has no past history of hepatitis, taking medications, or excessive drinking. You order hepatitis serologies. The results are as follows: Positive: HBsAg and anti-HBc. Negative: anti-HBs, anti-HBc IgM, anti-HAV, and anti-HCV Which statement best describes this clinical situation? A. If the patient was found to be HBe antigen positive, he would be considered highly infectious to spread hepatitis B. B. This patient is in the ""window period"" because the antibody to hepatitis BsAg is negative. C. This patient is not at risk for delta hepatitis because the patient has antibody to hepatitis B core. D. The low level of transaminase elevations indicates that this patient is not a candidate for hepatitis B antiviral treatment. E. If this patient has antibody to hepatitis Be, he is a candidate for antiviral therapy."

"Avascular necrosis is most likely to occur in fracture dislocations involving which of the following? A. the femoral head B. the shaft of the femur C. the shaft of the humerus D. the scapula E. the clavicle"

"Biopsy of a 4-cm sessile polyp of the cecum during a routine screening colonoscopy reveals it to be a villous adenoma with atypia. Attempt at piecemeal snare polypectomy through the colonoscope is unsuccessful. Which of the following is the most appropriate management? A. right hemicolectomy B. colonoscopy with electrocoagulation of the tumor C. colonoscopy with repeat biopsy in 6 months D. open surgery with colotomy and excision of polyp E. external beam radiation"

"Bupivacaine is a local anesthetic agent that is much more potent and the duration of action of which is considerably longer than procaine. Possible reasons for this difference include which of the following? A. higher partition coefficient for bupivacaine than for procaine B. covalent binding to the receptor site C. lower protein binding of bupivacaine than procaine D. decreased rate of metabolism of procaine compared to bupivacaine E. bupivacaine constricts blood vessels"

"Gastrin secretion is enhanced by which of the following? A. antral distention B. antral acidification C. presence of fat in the antrum D. sympathetic nerve stimulation E. duodenal acidification"

"On a Monday morning you see a 12-year-old otherwise healthy boy in the emergency department. The parents brought the boy in because they noticed that he started to have an abnormal gait in the past few days. He seems to be shuffling his feet. The boy complains that his legs feel heavy and are tingling. He relates that his arms feel fine. His past history is significant for attention deficit/hyperactivity disorder (ADHD) for which he is taking methylphenidate. He denies trauma or taking any other medicines or drugs. On examination, he is afebrile with normal vital signs. His entire physical examination is normal with the exception of the examination of is lower extremities. He has 3/5 strength throughout both of his lower extremities with a normal muscle mass. His all joints have a full range of motion, without any pain or swelling. His reflexes are absent and he describes some paresthesias of his feet and ankles. Which of the following is the most appropriate initial management plan? A. hospitalization and close observation for progression of his weakness B. high-dose corticosteroids C. gastric lavage and activated charcoal D. outpatient family counseling E. plasmaphoresis"

"Parents bring you a 9-month-old boy they recently have adopted from western Russia. They have sparse medical records of the child's past. They do know that the boy was the result of a sexual assault on the mother and was given up at birth. The child has been in a ""baby home"" for 5 months. The records which accompanied the boy indicate that there had been some testing done. These tests include HIV, hepatitis B and C serologies, and a rapid plasma reagin (RPR), all of which are negative at 8 months of age. There is what appears to be a Russian immunization record as well. It seems to indicate that the child has had three diphtheria, tetanus, pertussis (DTP), three oral polio, and three hepatitis B vaccinations. There is also an indication that BCG (Bacille Calmette-Guérin) was given. The parents are concerned about fetal alcohol syndrome (FAS). Which physical feature is most consistent with FAS? A. smooth philtrum B. single palmar crease C. hypertelorism D. synophrys (confluent eye brows) E. low set ears"

"Which of the following is characteristic of Hirschsprung's disease? A. Constipation is the most frequent presenting feature. B. severity of the symptoms corresponds with the extent of bowel involvement. C. Acetylcholinesterase activity is decreased in the aganglionic segment. D. The proximal colon is most commonly affected. E. It presents most commonly in young adults."

"Which of the following structures can be found outside of the spermatic cord during a hernia repair? A. direct hernia sac B. indirect hernia sac C. vas deferens D. testicular artery E. ovary"

"While working in the emergency department in the winter, you examine a 3-week-old female infant. The baby is accompanied by her mother and father. They report that the baby has been congested for the past 24 hours. The parents have been taking the infant's temperature rectally and report that it has been normal. The infant was a born at 35 weeks' gestation and was delivered by caesarian due to preeclampsia. On examination, you see a well-appearing infant with a respiratory rate (RR) of 46 and a heart rate (HR) of 112. The TMs are normal and the lung fields are clear to auscultation. The mother relates that she has had a ""cold"" for the past few days. The father reports that he smokes, but only outside. As part of your evaluation you perform a nasopharyngeal swab for RSV antigen, which comes back positive. The best course of action for this infant is which of the following? A. full sepsis workup with empiric intravenous antibiotic B. IM RSV-IVIG administration C. admit to the hospital for IV ribavirin for 5 days D. admit to the hospital for observation E. begin prophylactic oral amoxicillin"

"You are asked to perform a high school physical examination for a 16-year-old female patient. She is on the track team. By history, she is healthy except for the fact that she has been amenorrheic for 4 months. She denies current or past sexual activity. On examination, she is 5 ft 9 in. tall and weighs 115 lbs. Her heart rate is 50 bpm. She has dry skin with lanugo. She has several sores in her mouth and obvious dental caries. She has several scratches on the backs of her hands. She is tanner stage III on breast examination. Her pelvic examination is remarkable for findings of urogenital atrophy. Her urine -hCG is negative. At this point in time, appropriate management of this patient would include which of the following? A. laboratory assessment of electrolytes and an electrocardiogram B. intensive care unit (icU) admission C. antipsychotic medication D. reassurance E. IM Depo-Provera injection"

"You are called to the ER to assist with a series of trauma patients who arrived following a multiple vehicle accident. You are assigned to a 22-year-old male who was an unrestrained driver involved in a head-on collision. After you confirm the presence of an adequate airway and equal breath sounds bilaterally, you address his hypotension and tachycardia by giving 2 L of lactated Ringer's solution. His pulse remains elevated at 130 and his blood pressure is 92/55. His pelvic x-ray returns and demonstrates a widening of the pubic symphysis. In addition to continued fluid resuscitation, what is your next step in management? A. reduce the pelvic volume with a sheet or pneumatic compression garment B. exploratory laparotomy to isolate and control the hemorrhage C. CT scan to evaluate for other source of hemorrhage D. angiography to embolize pelvic vasculature E. obtain additional pelvic x-rays for preoperative planning"

"You perform an upper endoscopy on a patient and find changes suggestive of Barrett's esophagus. How do you explain this to the patient and his family? A. Is a condition where the normal esophageal lining is replaced by columnar epithelium. B. Is a condition where the normal esophageal lining is replaced by dysplastic squamous cells. C. Two biopsies with histologic changes are needed to confirm the diagnosis. D. The main risk associated with Barrett's esophagus is bleeding. E. It is related to peptic ulcer disease."

"You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers. Which laboratory result would be most consistent with the diagnosis? A. an elevated platelet count B. a positive rapid strep test C. a low platelet count D. elevated viral IgM titers E. a low ESR"

"several days following an uneventful laparoscopic cholecystectomy, the pathology report reveals gallbladder cancer that is invasive into the submucosa of the specimen. The most appropriate management is which of the following? A. observation and close follow-up B. chemotherapy with a 5-fluorouracil (5-FU)-based regimen C. laparotomy with 23 cm wedge resection of the gallbladder liver bed D. laparotomy with 23 cm wedge resection of the gallbladder liver bed and regional lymphadenectomy including the portal and hepatic nodal basins E. radiation to the gallbladder liver bed"

"A 10-year-old boy presents to your clinic with right knee pain for 2 weeks. He is physically active at school and plays soccer and basketball. He describes pain in his knees when he runs or jumps. He denies any recent trauma. His physical examination is normal except for mild edema and tenderness over the right tibial tubercle. What is the most likely diagnosis? A. slipped capital femoral epiphysis B. Osgood-Schlatter disease C. patellar tendonitis D. iliotibial band friction syndrome E. septic joint"

"A 17-year-old male presents for evaluation of shortness of breath. He has episodes where he will audibly wheeze and have chest tightness. His symptoms worsen if he tries to exercise, especially when it is cold. He has used an OTC inhaler with good relief of his symptoms, but he finds that his symptoms are worsening. He now has episodes of wheezing on a daily basis and will have nighttime wheezing and coughing, on average, five or six times a month. You suspect a diagnosis of asthma. Which of the following would confirm your suspicion of the diagnosis of asthma? A. presence of expiratory wheezing on examination B. increase in FEV1 of 15% after giving inhaled albuterol C. a decreased serum IgE level D. presence of eosinophils on a sputum sample E. a peak expiratory flow measurement 30% below the predicted normal value for the patient"

"A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy. Which of the following is typically seen as a feature of tumor lysis syndrome? A. hypokalemia B. hypocalcemia C. hypophosphatemia D. acute necrosis of renal tubules E. urine alkalinization"

"A 23-year-old pregnant woman with type 1 diabetes was admitted to the Obstetrics service for DKA. The DKA was appropriately treated and has resolved. You were consulted for medical management of the diabetes, as her sugars have been labile throughout the hospital stay. Your history and review of records reveals that the patient has a long-standing history of noncompliance with diet and medication regimens. She currently uses any insulin she can get and does not eat regular meals. She has fluctuating blood sugars with episodes of hypoglycemia. You counsel the patient extensively, order nutrition and diabetic teaching consults, and discuss keeping home glucose logs. Assuming the patient will follow your advice, which regimen would you recommend to minimize fluctuating glucose readings? A. NPH insulin twice daily B. insulin glargine once daily and insulin lispro before meals C. Humulin 70/30 twice daily D. NPH twice daily and regular insulin three times daily with meals E. insulin glargine twice daily"

"A 24-year-old G1 presents to you for initiation of obstetric care. She informs you that she is on a medication that was prescribed for acne. The drug is listed as category X in your pharmacy book. The pregnancy risk factor category X for a drug indicates which of the following? A. Controlled human studies demonstrate no risk to a fetus. B. This drug should never be used by a pregnant female under any circumstances. C. Evidence of human teratogenic risk exists but in some cases the known risks may be outweighed in some serious situations, such as life-threatening disease. D. Animal reproduction studies have not demonstrated fetal risk but there are no controlled human studies to assess the risk. E. Animal reproduction studies have demonstrated risk to a fetus and no controlled human studies are available."

"A 24-year-old White (G1P1001) female presents to your office 6 weeks after a normal spontaneous vaginal delivery at term. She reports that she has been unable to breast-feed her baby despite helpfrom her pediatrician and a lactation consultant. On further questioning, you elicit that she has also experienced nausea, weakness, and weight loss. In addition, she reports dizziness when getting out of bed in the morning. On your examination, she has a waxy texture to her skin and periorbital edema. You also note decreased axillary and pubic hair, which she reports is a change for her. This condition is most commonly associated with which of the following? A. obesity and increased facial hair B. postpartum hemorrhage C. acute thrombosis D. no specific association is known, this condition is idiopathic E. serotonin imbalance"

"A 25-year-old nulligravid woman presents as a new patient to your gynecology practice. She has recently moved to the area. She is a healthy woman with no medical problems and is currently using oral contraceptives without problems. She informs you that she and her husband are planning to start a family within the next year. On review, you find her family history is unremarkable, but she informs you that her husband's sister has cystic fibrosis. Given that the husband's sister has cystic fibrosis, what is the likelihood that he is a carrier? A. 100% chance of being a carrier B. 67% (2 in 3) chance of being a carrier C. 50% (1 in 2) chance of being a carrier D. 25% (1 in 4) chance of being a carrier E. his chance of being a carrier is no greater than the general population"

"A 28-year-old White G1 woman presents to your office for an initial obstetric visit. Her LMP is certain and allows you to estimate a 9-week gestational age today. She denies bleeding, cramping, or other symptoms of concern. She is excited about being pregnant. She has already started taking her prenatal vitamins with folic acid. She reports no significant past medical history. In fact, she states that she has not been to a doctor in many years because she has not had any problems. She has had no surgeries. She does not smoke. She drank alcohol socially prior to pregnancy but has not consumed any alcohol since she became pregnant. She has family history of hypertension, but no other significant history is elicited. On physical examination, her blood pressure is 110/60. She is healthy appearing, and there are no significant findings on examination. Your pelvic examination confirms uterine size consistent with stated dates. As part of a routine laboratory evaluation, you decide to check a thyroid-stimulating hormone (TSH). The TSH is 0. 4 IU/mL (normal range 0. 55. 5) and a free T4 of 1. 8 ng/dL (normal range 0. 72. 0). What is the most appropriate management of this condition? A. thyroid ablation with radioactive iodine B. prescription for propylthiouracil (PTU) C. prescription for propranolol D. subtotal thyroidectomy E. no intervention is necessary as the problem will go away after the pregnancy"

"You see a 3-week-old infant in your office for an acute visit. She was born via spontaneous vaginal delivery following a term, uncomplicated prenatal course. The parents are concerned because they have seen some streaks of blood in her diaper over the past few days. The infant's stools have been soft and not difficult to pass. The parents relate that she is eating 2 oz every 2 hours of a cow's milk based formula. What is the carbohydrate source in most infant formula? A. casein B. lactose C. human milk fortifier D. coconut oil E. soy oil"

"A 34-year-old male presents with a penile lesion. Your history, physical examination, and serology confirm a diagnosis of syphilis. The patient reports that his mother told him he was ""allergic"" to penicillin. He does not recall any personal history of anaphylaxis or rash to antibiotics however he has never been ""sick. "" How would you manage this patient? A. Admit to the ICU for penicillin desensitization as you don't want to risk anaphylaxis especially with the uncertain history. B. Do skin testing for penicillin allergy. C. Avoid penicillin or cephalosporins in future. D. Treat with erythromycin. E. Treat with penicillin as he is not likely to have a true allergy."

"A 42-year-old man presents to your clinic with a 1-week history of pain and inflammation involving his right first metatarsophalangeal (MTP) joint. He describes the pain as sudden in onset and worse at night. He denies experiencing any fever or traumatic injury to the joint and states that he has never had this type of pain before. He denies any chronic medical conditions, any prior surgery, and any current medication use. Besides an erythematous and exquisitely tender right first MTP joint, the remainder of his physical examination is unremarkable. Which of the following is true of the patient's condition? A. It commonly presents in premenopausal women. B. It commonly presents as a monoarticular arthritis. C. Episodes of pain and inflammation become more frequent but resolve more quickly as the disease progresses. D. The presence of tophi is a common early finding. E. A blood test is the diagnostic gold standard."

"A 45-year-old male with type II diabetes, hypertension, and hyperlipidemia presents to your clinic as a new patient. He has been out of his cholesterol medications and came to your office requesting a refill. The patient brought his most recent lipid profile (done after he was off his cholesterol medication for 3 months) which revealed: Cholesterol (total): 242 mg/dL HDL cholesterol: 38 mg/dL Triglycerides (TGs): 660 mg/dL LDL cholesterol = unable to calculate due to high TGs He also had recent liver function tests that were normal. Based on Adult Treatment Panel (ATP) III guidelines, which of the following medications should be the initial pharmacologic treatment for this patient? A. atorvostatin B. gemfibrozil C. cholestyramine D. omega-3 fatty acids E. nicotinic acid"

"A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Before doing so, you explain to the patient that antibiotics such as gentamicin are often associated with which of the following? A. hepatotoxicity B. nephrotoxicity C. interstitial pulmonary fibrosis D. pulmonary edema E. splenomegaly"

"A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Which of the following would lead to the classification of this patient's infection as ""complicated?"" A. a history of recurrent UTIs B. a diagnosis of type II DM C. the patient's gender D. a history of undergoing a laparoscopic appendectomy 1 month ago E. a postvoid residual volume of 25 cc"

"A 48-year-old woman with metastatic breast cancer presents to the Emergency Center complaining of a 4 day history of nausea, anorexia, and generalized weakness. Her husband reports that she has been more somnolent, sLEEPing 1214 hours per day, and at times she seems confused. CT scan of the brain reveals no abnormalities. Initial laboratory evaluation reveals a normal CBC, but her BUN is elevated at 32 mg/dL with a slight elevation of serum creatinine above her baseline. Her serum calcium is elevated at 15 mg/dL. What is the most likely cause of her hypercalcemia? A. widespread osteolytic metastases B. ectopic production of a parathyroid hormone-related protein C. excessive administration of oral calcium and Vitamin D supplementation to prevent osteoporosis D. undiagnosed primary hyperparathyroidism E. side effect of medications such as thiazide diuretics"

"A 5-year-old girl presents for evaluation of breast development, history of multiple bone fractures, and vaginal bleeding. Physical examination is notable for ""café au lait"" spots on her skin, tanner stage 2 breasts, and she appears tall for her age. What is the most likely cause of precocious puberty in this child? A. acromegaly B. McCune-Albright syndrome C. ovarian cyst D. ingestion of her mother's oral contraceptives E. hyperparathyroidism"

"A 50-year-old female presents to your office for evaluation of solid food dysphagia without weight loss. Symptoms have been present for 6 months and are progressive. The patient has had two episodes of near impaction, but copious water ingestion and repeated swallows allowed the food bolus to pass. She has never had to present to the ER for disimpaction. She drinks five to six beers per day, loves spicy foods, and smokes a pack of cigarettes daily with a total lifetime history of 30 pack-years. She has had intermittent heartburn symptoms for years and has not sought treatment. She takes hydrochlorothiazide for hypertension. review of symptoms reveals chronic cough. Physical examination is unremarkable. Upper endoscopy reveals a distal esophageal stricture with inflammatory changes. Esophageal biopsies reveal benign mucosa with chronic inflammation. Gastric biopsies are unremarkable. Helicobacter pylori testing is negative. The patient is at increased risk for which of the following illnesses? A. esophageal squamous cell cancer B. esophageal adenocarcinoma C. gastric cancer D. gastric lymphoma E. duodenal adenocarcinoma"

"A 50-year-old man presents to your office with fatigue and weakness. He first noticed it a few weeks ago while trying to hang pictures with his wife. His legs have begun to ache as he walks up stairs. He has lost about 20 lbs in the last 3 months. Most recently, he has found that he is more constipated and has trouble rising from the commode. Your physical examination reveals modest proximal weakness, no articular swelling, rash, or any other pertinent findings. blood work from a recent insurance examination revealed: Sodium 142 meq/L; potassium 3. 8 meq/L; chloride 107 meq/L; bicarbonate 29 meq/L; BUN 30 mg/dL; Cr 1. 6 mg/dL; WBC 6. 8; Hgb 13. 6 g/dL; HCT 40%; MCV 88. 0 m3; platelets 240,000/mm3; AST 200 U/L; ALT 250 U/L; alkaline phosphatase 70 U/L; bilirubin 0. 3 mg/dL; ESR 40 mm/h. Along with a creatine phosphokinase (CPK), which of the following tests should be ordered first? A. muscle biopsy B. gamma glutamyl transferase (GGT) C. MRI of the lumbar spine D. ultrasound of the liver and gallbladder E. kidney ultrasound with renal artery Doppler"

"A 55-year-old male is brought to the ED, by ambulance, because of crushing chest pain radiating to his left shoulder and arm that started 1 hour ago. He has a history of hypertension, high cholesterol, and has smoked a pack of cigarettes a day for 30 years. He has never had symptoms like this before. Fortunately, the patient survives this episode. As part of his long-term treatment, which of the following would be an appropriate therapeutic intervention to initiate due to its proven effect on survival rate? A. flecainide B. captopril C. quinidine D. digoxin E. nitroglycerin"

"A 56-year-old thin, White woman, who has recently undergone a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for a stage IB, grade 1, endometrioid tumor of the uterus, presents to your office complaining of hot flashes and vaginal dryness. She wants advice about the use of estrogen replacement in women treated for endometrial cancer. Which of the following is the best treatment for this woman? A. psychotherapy B. estrogen replacement therapy C. increased soy intake D. combination hormone replacement therapy E. referral to an endometrial cancer support group"

"A 58-year-old male presents to your office for a well-male examination. It has been several years since he last visited a doctor, but he states that he has been in ""excellent health. "" He denies any history of drinking, smoking, or using illegal drugs. He maintains a diet low in sodium and fat. An avid sports enthusiast, he also spends at least 2 hours per day engaged in some type of outdoor physical activity. On physical examination, you discover a translucent waxy papule with raised borders on the posterior aspect of his left shoulder. The treatment modality associated with the lowest recurrence rate is which of these? A. radiation therapy B. Mohs micrographic surgery C. surgical excision D. electrodesiccation with curettage E. cryotherapy"

"A 61-year-old female is diagnosed with osteoporosis by a screening dual-energy x-ray absorptiometry (DEXA) scan. Which of these is a risk factor for postmenopausal osteoporosis? A. black race B. lack of exercise C. obesity D. multiparity E. late menopause"

"A 62-year-old man undergoes transplantation of a kidney from a cadaveric donor. The surgery is uncomplicated and his recovery proceeds well for the first week postoperatively. In the second postoperative week, he develops hypertension, peripheral edema, and decreased urinary output. He states that he has been taking his medications as ordered What is the most appropriate management at this time? A. remove the donated kidney B. pulse steroid dose and increase immunosuppresion C. oral furosemide with follow-up in 1 week D. hospitalization for IV furosemide, angiotensin-converting enzyme (ACE) inhibitor, and close monitoring E. explain that the kidney transplant failed and that he needs to restart dialysis"

"A 62-year-old man undergoes transplantation of a kidney from a cadaveric donor. The surgery is uncomplicated and his recovery proceeds well for the first week postoperatively. In the second postoperative week, he develops hypertension, peripheral edema, and decreased urinary output. He states that he has been taking his medications as ordered. What is the most likely cause of this condition? A. hyperacute organ rejection B. acute organ rejection C. chronic organ rejection D. congestive heart failure E. failure of physician to restart him on his preoperative furosemide"

"A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. On further evaluation, the patient is found to be diabetic. He has an elevated HgbA1C and fasting hyperglycemia. The patient is sent for diabetic teaching sessions and begun on insulin therapy, but is unable to achieve euglycemia. He experiences frequent bouts of symptomatic hypoglycemia requiring ER visits. What is the most likely cause for these episodes? A. insulin overdose B. impaired glucagon production C. inadequate oral intake D. vitamin K deficiency E. vitamin B12 deficiency"

"A 72-year-old man comes to your clinic for the first time, accompanied by his wife. His wife states that she is concerned because he has been growing increasingly forgetful over the past year. Within the past month, he has forgotten to turn off the stove and has got lost while walking to the post office one block away from their home. His past medical history is significant for well-controlled diabetes and chronic lower back pain. He has no history of falls or traumatic injury to the head. Examination of the patient is significant for a score of 18 on a Mini Mental Status Examination (MMse). During the administration of the MMse, the patient blurts out that his wife brought him to the doctor because she is having an extramarital relationship. Use of which of the following medications would be the most likely to lead to worsening of symptoms in this patient? A. risperidone B. amitriptyline C. olanzapine D. quetiapine E. trazodone"

"A 74-year-old male with gout, osteoporosis, and type II diabetes presents for routine followup. As you review his medication list you note that he is on insulin, vitamin D, glypizide, quinidine, and allopurinol. You now diagnose him with hypertension that requires pharmacologic management. Which of the following medications would be contraindicated in this patient? A. enalapril B. hydrochlorothiazide C. diltiazem D. losartan E. atenolol"

"A mildly mentally retarded 9-year-old girl is brought to your office for acne. On examination, she does not actually have acne but has small flesh colored papules along her nasolabial fold. Her past history is significant for having had a first (afebrile) seizure last year. The mother reminds you that she has a faint birthmark on her hip that is pale and becomes more prominent in the summer, when the child's skin tans. Examination of this area reveals a 5-cm oval patch that is hypopigmented. Which condition would she most likely have? In evaluating her first seizure, a head CT was performed. Which finding would be most consistent with her diagnosis? A. frontal cortical atrophy with dysplastic vessels B. periventricular ""tubers"" C. diffuse white matter calcifications D. hydrocephalus from aqueductal stenosis E. poor gray-white differentiation"

"A mother brings her 21/2-year-old daughter to your office for evaluation of frequent urination. The mother relates that the daughter seems to be urinating more frequently, up to 810 times in a day, over the past week. The girl complains of pain when she urinates, but the urine does not have any different odor to it. The mother says that the girl otherwise seems fine and still loves to take her bubble bath at night. The girl does not have a fever, weight loss, diarrhea, or vomiting What is the most likely diagnosis? A. pyelonephritis B. chemical urethritis C. retained vaginal foreign body D. type 1 diabetes mellitus E. diabetes insipidus"

"A previously healthy 34-year-old man, a lifelong nonsmoker, sought medical care at an Urgent Care Center for an upper respiratory infection. A chest x-ray was obtained, which revealed a peripherally located right lower lobe lung nodule. A follow-up CT of the chest showed the 1. 8 cm nodule with multiple nonspecific calcifications, and no associated hilar or mediastinal adenopathy. What is the most appropriate next step? A. refer the patient to a thoracic surgeon to evaluate for wedge resection for suspected malignancy. B. repeat the CT chest in 3 months to assess for stability of the nodule. C. refer the patient for a percutaneous needle biopsy of the lesion to rule out malignancy. D. refer the patient to a pulmonologist to evaluate for possible bronchoscopy with transbronchial biopsy. E. Treat with empiric antibiotics for possible pneumonia and repeat the chest x-ray in6 weeks to see if the nodular opacity has resolved."

"A term infant male is born after an uncomplicated vaginal delivery. The mother's prenatal labs were negative with the exception of being GBS positive at 36 weeks' gestation. The mother received two doses of ampicillin prior to delivery and did not have a fever. The infant had APGAR scores of 9 at 1 minute and 9 at 5 minutes. The infant was brought to the newborn nursery and appears well The father tells you that he has hemophilia. His wife neither has hemophilia nor is a carrier. What does this mean for the baby? A. The baby has a 50% chance of having hemophilia. B. The baby neither has hemophilia nor is a carrier of the hemophilia gene. C. The baby is a carrier of the hemophilia gene but does not have the disease. D. The baby has a 25% chance of being a carrier for hemophilia. E. The baby has a 50% chance of being a carrier for hemophilia."

"A woman complains of amenorrhea for several months following a dilation and curettage. Which of the following is the most likely reason? A. occult perforation of uterus during the procedure B. intrauterine scarring C. infection of the endometrium (endometritis) D. iron-deficiency anemia from blood loss during the procedure E. premature menopause"

"A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. What is the single best treatment for preventing symptoms in this patient? A. long-acting beta-2 agonists B. an inhaled steroid C. an inhaled anticholinergic D. leukotriene modifiers E. long-acting oral bronchodilators"

"A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. Six hours after treating this patient, he calls your office with complaints of new-onset headache, myalgia, and malaise. He also states that he felt feverish immediately prior to calling and measured his temperature, which was 99. 8°F. Which of the following is most appropriate at this time? A. Advise transport to the nearest ED for immediate evaluation. B. Advise use of acetaminophen and provide reassurance. C. Advise immediate use of Benadryl and then have the patient go to the nearest ED. D. Start treatment with levaquin. E. Start treatment with oral corticosteroids."

"A24-year-old male medical student is admitted to the hospital for the evaluation of a 3-month history of bloody stools. The patient has approximately six blood stained or blood streaked stools per day, associated with relatively little, if any, pain. He has not had any weight loss, and he has been able to attend classes without interruption. He denies any fecal incontinence. He has no prior medical history. review of systems is remarkable only for occasional fevers and the fact that the patient quit smoking approximately 8 months ago. A colonoscopy is performed and reveals a granular, friable colonic mucosal surface with loss of normal vascular pattern from the anal verge to the hepatic flexure of the colon. Biopsies reveal prominent neutrophils in the epithelium and cryptitis with focal crypt abscesses, and no dysplasia. The patient is diagnosed with ulcerative colitis. Which of the following is the best initial treatment for this patient? A. colectomy B. oral prednisone C. oral metronidazole D. cortisone enemas E. intravenous cyclosporine"

"An 18-year-old female presents for evaluation of facial acne. On examination, she has multiple comedones, papules, and pustules on her forehead, nose, cheeks, and chin. She also has several distinct nodules, each greater than 5 mm in diameter. After 6 months of appropriate treatment, the severity of your patient's acne remains essentially unchanged. You rule out several potential causes for the patient's recalcitrant acne and decide that more aggressive therapy is warranted. As you discuss this option with your patient, which of the following side effects of the proposed treatment necessitates extensive counseling prior to initiation of therapy? A. pseudotumor cerebri B. teratogenicity C. hepatotoxicity D. nephrotoxicity E. cardiotoxicity"

"A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a ""pink eye"" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. What would be the appropriate management for this patient's arthritis? A. Screen him for the suspected disease with HLA-B27 testing. B. Treat with daily indomethacin (150200 mg daily). C. Start him on empiric antibiotics. D. Start treatment with prednisone 10 mg daily. E. Assume that the patient is not being honest and perform the appropriate urogenital testing to confirm gonorrhea."

"A28-year-old woman presents for evaluation of primary infertility. She has had fewer than four periods per year since menarche at age 14, facial hirsutism, acne, and weight gain. On examination, she has a BP 150/100. Her body mass index (BMI) is 40. Acanthosis nigricans is noted along the posterior surface of her neck. How would you counsel this patient? A. The primary treatment for this problem is with medications. B. Weight loss is key to her management. C. Her hypertension would be best treated with a thiazide diuretic. D. regardless of her lipid panel result, she should be on a statin. E. Her infertility is due to lack of estrogen production."

"A42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diarrhea is large volume, occasionally greasy, and nonbloody. In addition, the patient has mild abdominal pain for much of the day. He has been smoking a pack of cigarettes a day for 20 years and drinks approximately five beers per day. His physical examination reveals a thin male with temporal wasting and generalized muscle loss. He has glossitis and angular cheilosis. He has excoriations on his elbows and knees and scattered papulovesicular lesions in these regions as well What is the most serious long-term complication this patient could face? A. pancreatic cancer B. small bowel cancer C. gastric cancer D. colon cancer E. rectal cancer"

"A57-year-old male presents for annual examination. On history, you note a history of colon cancer that was successfully surgically resected 2 years ago. He had a negative postoperative colonoscopy 6 months later and another negative colonoscopy last year. Which of the following would be the most appropriate colon cancer screening regimen for this patient? A. colonoscopy or virtual colonoscopy in 1 year B. colonoscopy in 3 years C. colonoscopy or double contrast barium enema in 5 years D. colonoscopy annually E. digital examination and fecal occult blood test (FOBT) annually with colonoscopy in 10 years"

"A61-year-old man comes to your office for a checkup. He currently feels well and has no focal complaints. He has a past medical history significant for wellcontrolled hypertension, and his gallbladder was removed 3 years ago in the setting of acute cholecystitis. He does not smoke and drinks one to two alcoholic beverages per day. Family history is remarkable for colon cancer in his mother at age 45 and a brother at age 49. He has a sister who developed endometrial cancer at age 53. He has never undergone colon cancer screening and is interested in pursuing this. The patient's family history is strongly suggestive of which of the following? A. familial adenomatous polyposis (FAP) syndrome B. hereditary nonpolyposis colorectal cancer (HNPCC) syndrome C. Peutz-Jeghers syndrome D. Cronkhite-Canada syndrome E. Turcot syndrome"

"A64-year-old man with hypertension presents for routine follow-up of his blood pressure. His home blood pressure log reveals readings in the 150/70 range. His home monitor had previously been verified by clinic BP readings. He denies any complaints. His current medications include HCTZ 25 mg daily, metoprolol 100 mg twice daily, enalapril 20 mg twice daily, and amlodipine 10 mg daily. He states he is adherent to his medication, drug, and exercise regimen as you recommended. At this time, how would you advise the patient? A. You need to take another blood pressure medication. B. I need to order some tests to look for secondary causes of high blood pressure. C. In spite of your efforts, you need to exercise more and lose more weight. D. Your blood pressure is acceptable where it is. Continue your current regimen. E. I need to refer you to a cardiologist."

"A72-year-old African American male presents for a routine health examination. He states that he would like to have a ""screening for cancer. "" In the United States, based on his sex, race, and age, what is the most likely malignancy for this patient? A. lung cancer B. prostate cancer C. colon cancer D. testicular cancer E. multiple myeloma"

"Afather and son come to your office because of persistent diarrhea. They relate the presence of watery diarrhea for over 2 weeks. They noted that the diarrhea began after returning from a Boy Scout camping trip in the Rocky Mountains. The diarrhea has waxed and waned for 2 weeks. It is nonbloody and foul smelling. They have had increased flatulence and mild abdominal cramping. What is the most likely etiology of their diarrhea? A. enterotoxigenic Escherichia coli B. Giardia lamblia C. Rickettsia rickettsii (Rocky Mountain spotted fever [RMSF]) D. rotavirus E. Norwalk virus"

"Afather and son come to your office because of persistent diarrhea. They relate the presence of watery diarrhea for over 2 weeks. They noted that the diarrhea began after returning from a Boy Scout camping trip in the Rocky Mountains. The diarrhea has waxed and waned for 2 weeks. It is nonbloody and foul smelling. They have had increased flatulence and mild abdominal cramping. What would be the most appropriate treatment? A. oral ciprofloxacin B. oral metronidazole C. bismuth subsalicylate (Pepto-Bismol) D. an antidiarrheal agent only; no antimicrobials necessary E. oral rehydration only"

"An 8-month-old boy is brought to the clinic by his mother because he has been lethargic, fussy, and not feeding well over the past several days. The mother has been working two jobs so the baby has been cared for by her boyfriend for the past month. She is very worried because he has not been smiling and vocalizing as much as he normally does and he has not been able to lift his head. Which of the following findings on physical examination is suggestive of child abuse? A. superficial abrasions on the shins of a 5 year old B. retinal hemorrhages visualized on funduscopy in a 4 month old C. a laceration on the forehead of a 6 year old D. a partial dislocation of the elbow in a 3 year old E. a linear skull fracture in a 9-year-old boy"

"Apatient you see routinely in the clinic has elevated liver function tests. ALT is 89, AST is 75, and the total bilirubin and alkaline phosphatase are normal. The patient has no past history of hepatitis, taking medications, or excessive drinking. You order hepatitis serologies. The results are as follows: Positive: HBsAg and anti-HBc. Negative: anti-HBs, anti-HBc IgM, anti-HAV, and anti-HCV What is the most appropriate next step for this patient? A. verify the diagnosis with a qualitative hepatitis B viral load. B. Vaccinate the patient with hepatitis A vaccine. C. Vaccinate the patient with hepatitis B vaccine. D. Investigate other causes of hepatitis, such as cytomegalovirus (CMV) and Epstein-Barr virus. E. recommend the patient's spouse receive hepatitis A vaccine."

"On a Monday morning you see a 12-year-old otherwise healthy boy in the emergency department. The parents brought the boy in because they noticed that he started to have an abnormal gait in the past few days. He seems to be shuffling his feet. The boy complains that his legs feel heavy and are tingling. He relates that his arms feel fine. His past history is significant for attention deficit/hyperactivity disorder (ADHD) for which he is taking methylphenidate. He denies trauma or taking any other medicines or drugs. On examination, he is afebrile with normal vital signs. His entire physical examination is normal with the exception of the examination of is lower extremities. He has 3/5 strength throughout both of his lower extremities with a normal muscle mass. His all joints have a full range of motion, without any pain or swelling. His reflexes are absent and he describes some paresthesias of his feet and ankles. What is the most likely diagnosis? A. methylphenidate toxicity B. acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome) C. acute poliomyelitis D. malingering (school avoidance) E. polymyositis"

"Parents bring their 12-year-old son to your clinic for evaluation. The child states that he gets teased a lot in school because of his short stature. His weight and height are below the 10th percentile for his age. His parents are of average height. Following your physical examination, you determine that he has tanner stage 1 development and his bone age is that of a 9-year-old male. His examination is otherwise normal. What is the most likely diagnosis? A. familial short stature B. constitutional growth delay C. deficiency in GH D. chronic renal failure E. vitamin D deficiency"

"Vitamin D supplementation can be helpful in treating which disease? A. hyperparathyroidism B. hypoparathyroidism C. alcoholic neuritis D. pernicious anemia E. scurvy"

"What is the most sensitive indicator of pneumonia in a child? A. tachycardia B. tachypnea C. hypotonia D. vomiting E. coughing"

"You are asked to perform a high school physical examination for a 16-year-old female patient. She is on the track team. By history, she is healthy except for the fact that she has been amenorrheic for 4 months. She denies current or past sexual activity. On examination, she is 5 ft 9 in. tall and weighs 115 lbs. Her heart rate is 50 bpm. She has dry skin with lanugo. She has several sores in her mouth and obvious dental caries. She has several scratches on the backs of her hands. She is tanner stage III on breast examination. Her pelvic examination is remarkable for findings of urogenital atrophy. Her urine -hCG is negative. Which of the following would be the most likely diagnosis for this patient? A. domestic abuse B. eating disorder C. hyperthyroidism D. herpes simplex virus serotype I E. congenital adrenal hyperplasia"

"You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. After confirming that the child does indeed have Down syndrome, the parents ask you what problems their baby may have in the future. With which of the following is the infant most likely to have problems? A. renal failure B. hypothyroidism C. osteoporosis D. hemophilia E. lens dislocation"

"You are called to the trauma bay to evaluate a 42-year-old male who suffered a blow to his knee at the construction site where he works. He is awake, alert, and his vital signs have been stable in transport. After completing your primary survey, you continue with your secondary survey and determine that his only injury is to his right leg. It is clear that he has suffered a posterior knee dislocation. As part of your examination, you determine that you cannot feel a pulse in his right foot. realizing that there is compromised blood supply to the patient's right foot, you immediately do which of the following? A. Transport the patient to radiology for an arteriogram. B. relocate the knee into anatomical position and re-examine the pulse. C. Take the patient directly to the OR to explore his popliteal artery. D. Obtain an orthopedics consultation and order films to identify any fractures. E. Determine the ankle brachial indices for his right and left foot."

"You are working in a community clinic on a Native American reservation. A mother brings in her 8year-old son for an ophthalmic evaluation. On examination, you find bilateral corneal ulceration and decreased visual acuity. What is the most common infectious cause of blindness in the world? A. HSV B. C. trachomatis C. GAS D. S. pneumoniae E. E. coli"

"You see a 2-month-old infant in the emergency department for vomiting. The mother says that the baby has been spitting up more over the past few days and has become more irritable. She denies any fever, diarrhea, or change in formula. The mother tells you that there is a family history of ""heartburn"" and that her other children have all spit up. The infant has some emesis in the emergency department that seems to be formula mixed with some bile. The infant is intermittently irritable and sLEEPy. What is the most concerning diagnosis that this could be? A. biliary atresia B. malrotation C. pyloric stenosis D. imperforate anus E. diaphragmatic hernia"

"A 43-year-old patient presents with his fourth episode of culture-proven shingles in a T7 distribution. What is the most likely associated underlying condition? A. leukemia B. lymphoma C. acquired immunodeficiency syndrome (AIDS) D. chro"

"A 14-year-old nulligravid female is brought to the ER by her parents with a 12-hour history of severe, intermittent left lower quadrant pain. She has had nausea and vomiting for the past 2 hours. On history, the patient experienced menarche at age 12 and denies past or current contact with a sexual partner. Her last normal menstrual period was 3 weeks ago. On examination, she is afebrile, pulse 100, BP 110/70, respiratory rate (RR) 20. She is visibly uncomfortable. She has no costovertebral tenderness, has diminished bowel sounds, her abdomen is nondistended, and exhibits rebound and guarding in both lower quadrants. She is unable to tolerate a pelvic examination due to pain. Laboratory values are as follows: WBC 13, HCT 39, -hCG (-), UA (-). Apelvic ultrasound shows a normal nonpregnant uterus, normal right adnexa, and an 8-cm left adnexal mass with a 3-cm solid component The most likely etiology of this patient's pain is which of the following? A. ectopic pregnancy B. acute appendicitis C. ovarian torsion D. pancreatitis E. somatization disorder"

"A 17-year-old female presents with primary amenorrhea. On physical examination, she has normal secondary sexual characteristics, scant pubic and axillary hair, and a blind ending vaginal pouch. Apelvic MRI indicates inguinal gonads and no uterus. Her karyotype is 46,XY. Which of the following is the most likely etiology of primary amenorrhea in this patient? A. Müllerian agenesis (Mayer-RokitanskyKüster-Hauser syndrome) B. Klinefelter syndrome C. androgen insensitivity D. Turner mosaic E. Kallmann syndrome"

"A 19-year-old (G2P1001) female at 354/7 weeks EGA presents for a routine prenatal visit. Her pregnancy has been uncomplicated. She reports good fetal movement and denies vaginal bleeding, loss of fluid, or contractions. She is excited about the arrival of her baby and is planning to breast-feed. Her past medical history is significant for chlamydia that was treated approximately 1 year ago. She is otherwise healthy. Her blood pressure today is 110/60. Fundal height is appropriate. UA is negative. The patient would like to discuss options for postpartum birth control. Which of the following would be an appropriate and effective option for postpartum birth control for this patient? A. combined OCP B. intrauterine device (IUD) C. progesterone-only pill D. no birth control is necessary as the patient will be breast-feeding E. rhythm method"

"A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy. Which of the following is an appropriate medication to use as a preventative measure prior to and during her treatment for leukemia? A. indomethacin B. colchicine C. allopurinol D. probenecid E. sulfinpyrazone"

"A 22-year-old White female (gravida 2, para 1, abortus 1) comes to your office with a 3-week history of lower abdominal pain and increased vaginal discharge. She has a prior history of an ectopic pregnancy at age 16. Her last menstrual period (LMP) was 7 days ago, and she has had unprotected vaginal intercourse with a new sexual partner several times over the past few weeks. Her temperature is 38. 0°C; her vital signs are stable. She has bilateral lower quadrant tenderness but no peritoneal signs. On speculum examination, she has foul smelling green discharge emanating from her cervix. She has cervical motion tenderness on bimanual examination and is tender in both adnexae. Her wet mount shows copious white cells. Her urine hCG is (-). Which of the following would be the most appropriate treatment regimen for this patient? A. metronidazole PO for 5 days B. gentamicin IV × one dose C. ceftriaxone intramuscular (IM) plus doxycycline PO for 14 days D. Diflucan PO × one dose E. ampicillin PO qid × 14 days 44. Most cases of PID are associated with which of the following?"

"A 22-year-old female (G3P0020) presents to your office for an initial obstetric visit in her third pregnancy. She reports a sure LMP date approximately 6 weeks ago, with a history of regular cycles. Her two previous pregnancies ended in spontaneous abortions. She denies any significant medical or surgical history. She denies use of alcohol, tobacco, or illicit drugs, though she does report a history of IV drug use as a teenager. She is a full-time student. She reports that twins run in her family, but she does not have any family history of diabetes, hypertension, or congenital anomalies. On review of her prenatal labs that have already been drawn, you find that her human immunodeficiency virus (HIV) antibody test (enzyme-linked immunosorbent assay [ELISA]) is positive. Her test results are otherwise normal. Which of the following indicates how you counsel the patient? A. This result is a false positive due to pregnancy, and she does not need any further testing. B. She is infected with HIV and will need to begin treatment right away. C. She will require an additional, confirmatory test to determine whether or not she has HIV. D. She may have HIV, but she should wait until after she delivers her baby to have further testing. E. Because it has been years since she participated in high-risk behaviors, she is unlikely to have HIV."

"A 24-year-old White (G1P1001) female presents to your office 6 weeks after a normal spontaneous vaginal delivery at term. She reports that she has been unable to breast-feed her baby despite helpfrom her pediatrician and a lactation consultant. On further questioning, you elicit that she has also experienced nausea, weakness, and weight loss. In addition, she reports dizziness when getting out of bed in the morning. On your examination, she has a waxy texture to her skin and periorbital edema. You also note decreased axillary and pubic hair, which she reports is a change for her. She most likely has which of the following diagnoses? A. postpartum depression B. normal postpartum changes C. Sheehan syndrome D. PCOS E. medication reaction"

"A 24-year-old male presents with sore throat, subjective fever, abdominal pain, and bad breath. He says that a neighbor's child is currently being treated for strep throat. On examination, his temperature is 101. 1° F and his other vital signs are normal. He appears well. His throat is erythematous and his tonsils are enlarged, but there are no pharyngeal or tonsillar exudates. He has no cervical adenopathy. He has an occasional cough but his lungs are clear. His abdominal examination is normal. The presence of which of the following findings is a clinical predictor for the diagnosis of streptococcal pharyngitis? A. erythematous tonsils B. cough C. tonsillar exudates D. posterior cervical lymphadenopathy E. halitosis"

"A 24-year-old male presents with sore throat, subjective fever, abdominal pain, and bad breath. He says that a neighbor's child is currently being treated for strep throat. On examination, his temperature is 101. 1° F and his other vital signs are normal. He appears well. His throat is erythematous and his tonsils are enlarged, but there are no pharyngeal or tonsillar exudates. He has no cervical adenopathy. He has an occasional cough but his lungs are clear. His abdominal examination is normal. The presence of which of the following findings is a clinical predictor for the diagnosis of streptococcal pharyngitis? Which of the following is the recommended first-line agent for the treatment of group A streptococcal pharyngitis? A. levofloxacin B. amoxicillin C. penicillin D. amoxicillin-clavulinic acid E. clindamycin"

"A 25-year-old nulligravid female, whose LMP was 4 weeks ago, is seen by her OB/GYN for a left breast mass. The patient discovered it 2 weeks ago while in the shower. Her maternal aunt died of breast cancer at age 60, and the patient is very worried about this new finding. On examination, a mobile, nonerythematous, 3-cm nonsolid feeling mass is palpated in the left upper outer quadrant of her left breast. There is no nipple discharge, and the axillary lymph nodes are nonpalpable. Her right breast examination is normal. The patient wants you to schedule a mammogram that same day. Your response is which of the following? A. A surgical biopsy should be performed instead. B. A needle core biopsy can be done at the same time of her mammogram. C. Ultrasound would be a better imaging modality for her situation. D. In-office cyst aspiration is reassuring i the fluid is bloody. E. Antibiotics can treat her mastitis."

"A 25-year-old woman presents to your office complaining of cold hands. She describes them turning white as she reaches for orange juice in the frozen food section of the supermarket. It seems to be getting worse lately. She has no other symptoms but does note that she and her husband are contemplating pregnancy. Her examination today is unremarkable. In this patient, which of the following studies would be most likely to describe an increased risk of future systemic disease? A. echocardiogram B. nerve conduction study C. ANA D. joint aspiration E. arterial Doppler of the upper limbs with cold stimulation"

"A 25-year-old woman with acute myelocytic leukemia is undergoing induction chemotherapy and presents to the Emergency Center complaining of a 1-day history of fever to 102º F with no other symptoms. Other than having a fever, her vital signs and physical examination are normal. Laboratory evaluation reveals pancytopenia, with a WBC count of 0. 3 k/L, hemoglobin concentration of 9. 2 mg/dL, and platelet count of 23,000/L. What is the most appropriate initial management? A. Obtain blood cultures, urine culture, a chest x-ray, and discharge patient to home with follow-up in 12 days to review culture results. B. Obtain blood cultures, urine culture, a chest x-ray, and admit the patient to the hospital for observation with plan to institute antibiotics if any culture becomes positive. C. Obtain blood culture, urine culture, a chest x-ray, and admit the patient to the hospital for empiric broadspectrum antibiotics with Gram-negative coverage. D. Obtain blood culture, urine culture, a chest x-ray, and admit the patient to the hospital for empiric antibiotics with Gram-positive coverage. E. Forego cultures and admit the patient to the hospital for empiric antibiotics with both Gram-positive and Gram-negative coverage."

"A 26-year-old HIV-positive man is admitted to the hospital for treatment of a varicella-zoster infection. On the fourth day of treatment, he develops an acute renal insufficiency. What is the most likely treatmentrelated mechanism accounting for the patient's acute renal insufficiency? A. the formation of toxic metabolites B. decreased glomerular filtration rate C. the precipitation of acyclovir in renal tubules D. direct tubular cytotoxic injury E. hypersensitivity interstitial nephritis"

"A 44-year-old female has a history of endometriosis resulting in chronic pelvic pain. She presents to you 6 months after her total abdominal hysterectomy and bilateral salpingooophorectomy. She reports continued pelvic pain. Which of the following would be your most appropriate recommendation for medical management? A. GnRH B. oral estrogens C. oral progestins D. tamoxifen E. GnRH antagonist"

"A 29-year-old woman complains of fatigue and decreased exercise tolerance. She takes no medications and denies changes in the color of the stool. Physical examination is significant for pale skin and conjunctivae. Stool was negative for blood. Laboratory evaluation revealed Hgb of 7. 8 g/dL, reticulocytopenia, microcytosis, and hypochromia. In vitamin B12 or folate deficiency, which of the following statements is correct? A. High serum levels of homocysteine and decreased levels of methylmalonic acid are reliable indicators of cobalamin deficiency. B. The recommended amount of dietary folate is 800 g/day. C. The peripheral smear in patients with cobalamin deficiency is identical to that found in folate deficiency. D. The most common cause of cobalamin deficiency is hypersecretion of gastric acid (i. e. , Zollinger-Ellison syndrome). E. Because body folate stores are high, individuals with low consumption of folate will take several years to become anemic."

"A 32-year-old man comes to the office for his annual checkup. He is asymptomatic and his physical exam is normal. He reports that his father died of colon cancer at age 46 and his older brother was recently diagnosed with colon cancer at age 37. His paternal aunt was previously diagnosed and treated for endometrial cancer. He is concerned about his family history of malignancy and wants to discuss cancer screening. What would be the most appropriate recommendation at this time? A. flexible sigmoidoscopy B. fecal occult blood testing, with referral for endoscopy if positive C. screening colonoscopy D. screening colonoscopy starting at age 50 E. prophylactic colectomy"

"A 32-year-old woman complains of episodic confusion in the morning for the past 6 months. During one of these episodes, she was brought to the ER and her serum glucose was found to be 40 mg/dL. She was given intravenous dextrose and her symptoms resolved within 15 minutes. She has gained approximately 25 lbs during the past year. Which of the following would be the most appropriate next step? A. measure serum insulin and proinsulin 2 hours after a mixed meal B. MRI of the pancreas C. measure insulin, C-peptide, and sulfonylurea level on the initial blood sample in ER D. octreotide scan E. advise a high protein diet with frequent feedings"

"A 32-year-old woman presents with complaints of irritability, heat intolerance, hyperdefecation, and frequent palpitations. She has lost 20 lb over the past six months. She has always been in good health and does not take any prescription or OTC medications. She denies any prior history of thyroid disease or exposure to head/neck irradiation, but she states that one of her relatives was diagnosed with a thyroid disorder at roughly the same age. Vital signs are as follows: BP 138/78, HR 112, RR 22, temp. 98. 8°F. On examination, her thyroid is diffusely enlarged and smooth. Auscultation of the thyroid reveals a bruit. Her hair is fine in texture, and she has warm velvety skin. She has hyperactive deep tendon reflexes. There is a fine tremor in her outstretched hands. Which of the following is a common finding in this condition? A. macroglossia B. hyperkeratosis C. infiltrative ophthalmopathy D. cerebellar ataxia E. pericardial effusion"

"A 32-year-old woman presents with complaints of irritability, heat intolerance, hyperdefecation, and frequent palpitations. She has lost 20 lb over the past six months. She has always been in good health and does not take any prescription or OTC medications. She denies any prior history of thyroid disease or exposure to head/neck irradiation, but she states that one of her relatives was diagnosed with a thyroid disorder at roughly the same age. Vital signs are as follows: BP 138/78, HR 112, RR 22, temp. 98. 8°F. On examination, her thyroid is diffusely enlarged and smooth. Auscultation of the thyroid reveals a bruit. Her hair is fine in texture, and she has warm velvety skin. She has hyperactive deep tendon reflexes. There is a fine tremor in her outstretched hands. Which of the following sets of laboratory results would be consistent with this patient's presentation? TSH free T3 free T4 A. low lowhigh B. low normal normal C. low high high D. highlow low E. high high high"

"A 34-year-old male undergoes an uneventful excision of a parathyroid adenoma. The following postoperative day, he complains of numbness around his lips. Which of the following is the most likely cause of this symptom? A. hypocalcemia secondary to hypomagnesemia B. hypocalcemia due to acute renal failure C. hypocalcemia due to hungry bone syndrome D. hypocalcemia due to inadvertent injury to the recurrent laryngeal nerve E. postoperative hematoma of the neck"

"A 35-year-old 80-kg male was transported to the regional burn center at your hospital after suffering secondand third-degree burns from the eruption of a brush fire fueled with gasoline. He was intubated by EMS to secure his airway for transport. On arrival, he is found to have burns across his face, anterior neck, chest, and anterior abdomen, as well as bilateral circumferential upper extremity burns. What do you estimate the total body surface area (TBSA) of his burns to be? A. 30% B. 35% C. 40% D. 50% E. 60%"

"A 35-year-old woman schedules an appointment in an outpatient clinic for evaluation and treatment of a ""mouth problem. "" She says that she has white spots in her mouth that have been present for a few weeks. In response to your questioning, she states that she has been experiencing fatigue and a 20-lb weight loss over the past several months, although she attributes these symptoms to a dramatic increase in work hours at her job over the same period of time. She denies having any other chronic medical issues and does not use any prescription or OTC medications. As you examine her, you note the presence of white plaques on her buccal mucosa, palate, and tongue. Scraping of the plaques with a tongue depressor elicits pain as well as a small amount of bleeding. Nontender generalized cervical and submandibular lymphadenopathy is present. Which of the following questions would potentially yield the most useful information in this patient's diagnosis and treatment? A. ""Do you have a family history of cancer?"" B. ""Have you traveled outside of the country within the past 12 months?"" C. ""Have you engaged in unprotected sexual intercourse?"" D. ""Do you have any sick contacts?"" E. ""How much do you smoke?"""

"A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy. A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. He has a PPD placed and follows up in 48 hours. At the site of the injection you find 6 mm of induration. A CXR is normal. He has never been treated for tuberculosis or a positive PPD before. Which management option is most appropriate? A. Collect sputum samples for 3 days to send for AFB (acid fast bacilli) staining. B. Empirically start four-drug therapy for active tuberculosis. C. Empirically start isoniazid daily for 9 months. D. Have the patient return in 1 week for a second PPD to assess for the presence of a ""booster"" phenomenon; treat with isoniazid if 10 mm induration. E. No intervention at this time but repeat the test in 6 months."

"A 5-year-old male is admitted to the hospital following a 3-week history of spiking fevers and fatigue. Your examination reveals pale mucous membranes and skin. You also find splenomegaly. You are concerned about a possible malignancy. What is the most common malignancy of childhood? A. medulloblastoma B. Wilms' tumor C. leukemia D. neuroblastoma E. rhabdomyosarcoma"

"A 50-year-old female presents to your office for evaluation of solid food dysphagia without weight loss. Symptoms have been present for 6 months and are progressive. The patient has had two episodes of near impaction, but copious water ingestion and repeated swallows allowed the food bolus to pass. She has never had to present to the ER for disimpaction. She drinks five to six beers per day, loves spicy foods, and smokes a pack of cigarettes daily with a total lifetime history of 30 pack-years. She has had intermittent heartburn symptoms for years and has not sought treatment. She takes hydrochlorothiazide for hypertension. review of symptoms reveals chronic cough. Physical examination is unremarkable. Upper endoscopy reveals a distal esophageal stricture with inflammatory changes. Esophageal biopsies reveal benign mucosa with chronic inflammation. Gastric biopsies are unremarkable. Helicobacter pylori testing is negative. What is the most likely etiology of the patient's stricture? A. alcohol ingestion B. tobacco use C. gastroesophageal reflux D. hydrochlorothiazide E. spicy food ingestion"

"A 52-year-old female has been referred to you for consultation following a core biopsy of an area of calcifications seen on a screening mammogram. She has no family history of breast or ovarian cancer. She has not been taking hormone replacement therapy and has no reproductive risk factors. On physical examination, there is no palpable mass. The core biopsy results demonstrate atypical ductal hyperplasia. What should be the next step in her treatment? A. close observation with semiannual mammograms and clinical examinations B. treatment with tamoxifen for 5 years C. needle localized excisional biopsy D. unilateral mastectomy E. bilateral mastectomy"

"A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees. There does not appear to be an arrhythmia present. A transesophageal echocardiogram (teE) is performed which reveals a left ventricular ejection fraction (LveF) of 30%. Which of the following accurately describes this patient and his condition? A. A transthoracic echocardiogram (Tte) would give a more accurate estimation of the patient's true LveF. B. He has diastolic heart failure. C. Digoxin would be an appropriate choice in attempting to control symptoms. D. He has class I heart failure according to the New York Heart Association (NYHA) classification. E. Hypertension is the most common cause."

"A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes (""although I know they are bad for me"") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After a thorough discussion with your patient, you determine that pharmacologic intervention would be beneficial given the severity of her osteoporosis. Which of the following is most appropriate for your patient? A. estrogen replacement therapy B. combined HRT with estrogen and progestin C. alendronate D. calcitonin intranasal spray E. raloxifene"

"A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes (""although I know they are bad for me"") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After performing the appropriate imaging study, you determine that your patient has osteoporosis. Of the following choices, which is risk factor most likely contributing to her osteoporosis? A. active lifestyle B. late menopause C. cigarette smoking D. frequency of alcohol intake E. her intake of calcium and vitamin D"

"A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chest pains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. Which of the following is most likely to be found on an ECG? A. saw-tooth P waves B. wide QRS complexes C. absent P waves D. Q waves in leads II, III, and aVF E. peaked T waves"

"A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chestpains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. Which of the following studies would be most appropriate to order at this time? A. radionuclide ventriculography B. exercise stress test C. echocardiogram D. cardiac catheterization E. electrophysiologic studies"

"A 64-year-old male has been suffering from lower back pain for over 10 years. You have been following him for this period. You have prescribed stretching exercises and, occasionally, an antiinflammatory medication to alleviate his pain. Although he has had no neurologic deficits in the past, today he has shown up in your office unexpectedly, complaining of bilateral lower back pain with numbness and tingling over the dorsal aspect of both feet. His symptoms have become progressively worse over the past 2 weeks and he is now unable to stand for more than 5 minutes without developing extreme pain and numbness. His symptoms are much improved by sitting down or kneeling over a chair. Climbing stairs seems to be tolerated well, but walking greatly exacerbates the pain. He denies bladder or bowel incontinence or retention, point tenderness or anesthesia in the lower back along the spinal cord or in the saddle area. What is the likely diagnosis? A. spondyloathropathy of the sacroiliac joint B. age-related early degenerative joint disease (DJD) of the hips C. spinal stenosis of the lumbosacral area D. muscle spasm of the lower back E. cauda equina syndrom"

"A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. What would be the best initial test to do in this patient? A. spot fecal fat collection B. 72-hour fecal fat collection C. CT scan of the abdomen D. ERCP E. upper endoscopy"

"A 72-year-old diabetic is transferred to your hospital for fever and altered mental status in the late summer. Symptoms started in this patient 1 week prior to admission. On physical examination, the patient was disoriented. There were no focal neurologic findings. There was a fine rash on the patient's trunk. On oral examination, there were tongue fasciculations. A lumbar puncture was performed which showed a glucose of 71 and a protein of 94; microscopy of the cerebrospinal fluid (CSF) revealed 9 RBC and 14 WBC (21 P, 68 L, 11 H). The creatinine phosphokinase was 506. An electroencephalogram and MRI of the brain were normal. What is the best interpretation of these findings? A. The patient may have cryptococcal meningitis. B. The patient may have disseminated candidiasis. C. The patient may have West Nile virus. D. The patient may have Coccidioides immitis infection. E. The patient may have rhinocerebral mucormycosis."

"A 72-year-old previously healthy woman was diagnosed with Stage II breast cancer and was initiated on FAC chemotherapy (5-fluorouracil, doxorubicin, cyclophosphamide) 3 months ago. She now presents to the emergency room complaining of exertional dyspnea, orthopnea, and lower extremity edema. Her vital signs are normal, her EKG is normal, and her chest x-ray shows cardiomegaly and pulmonary vascular congestion. What is the most likely cause of the patient's new symptoms? A. malignant pericardial effusion with cardiac tamponade B. acute pericarditis due to viral infection C. anthracycline-induced cardiomyopathy D. valvular aortic stenosis E. acute myocardial infarction"

"A 74-year-old male with a history of hypertension, type II diabetes, myopia, and cataract surgery 2 weeks ago presents with the sudden onset of severe flashes of light and multiple new floaters in his right eye. He denies photophobia, ocular trauma, or diplopia. He also states that he feels as if there is a curtain lowering over his right eye. Your examination and a stat ophthalmology consultation confirm your clinical diagnosis. Of the choices listed below, what would be the most appropriate next step to provide definite treatment for this patient? A. lens removal and surgical replacement B. corneal transplant C. removal of vitreous humor (posterior vitrectomy) D. intraocular antibiotics E. stat angiogram and thrombolytics if needed"

"A concerned mother brings in her 18-monthold infant girl. The baby's developmental milestones have been normal. The mother states that there is a ""funny glint"" in her baby's eyes. She also states that sometimes the infant's eyes look crossed. Which of these supports the diagnosis of a serious lifethreatening disease? A. Baby reaches for small objects. B. Baby fusses when each eye is covered. C. Bright red reflex in one eye, a white reflex in the other. D. Baby rubs both eyes. E. Baby holds objects close to inspect them."

"A mildly mentally retarded 9-year-old girl is brought to your office for acne. On examination, she does not actually have acne but has small flesh colored papules along her nasolabial fold. Her past history is significant for having had a first (afebrile) seizure last year. The mother reminds you that she has a faint birthmark on her hip that is pale and becomes more prominent in the summer, when the child's skin tans. Examination of this area reveals a 5-cm oval patch that is hypopigmented. Which condition would she most likely have? A. Sturge-Weber syndrome B. neurofibromatosis, type 1 (von recklinghausen disease) C. tuberous sclerosis D. CHARGE association E. Beckwith-Wiedemann syndrome"

"A mother brings her 4-year-old son to your office, relating that he fell earlier that morning while at the playground. She says that the boy tripped over another child and landed on his outstretched hands. On examination, the boy has some mild swelling around his left wrist, and he says that it hurts when you palpate it. What is the most appropriate next step? A. Call the department of Children's Protective services to investigate the accident. B. Attempt a nursemaid's elbow reduction. C. Perform anterior-posterior (AP) and lateral x-rays of the left wrist and elbow. D. Wrap the wrist in an Ace wrap, and put the arm in a sling. E. Order a magnetic resonance imaging (MRI) of the wrist looking for a growth plate injury."

"Which of the following agents is considered the first-line therapy for prevention of eclamptic seizures? A. diazepam B. phenytoin C. magnesium sulfate D. phenobarbital E. carbamazepine"

"A patient with dyspepsia has a positive serologic test for Helicobacter pylori and is concerned that he could have an ulcer. Which of the following statements about H. pylori and ulcer disease would be most accurate? A. Gastric ulcers are usually caused by hypersecretion of acid, not bacteria. B. A positive IgG serology confirms an active infection with H. pylori. C. H. pylori is associated with both gastric and duodenal ulcers. D. Most patients with H. pylori have ulcers. E. The use of antibiotics alone is successful in eradicating H. pylori."

"A term infant male is born after an uncomplicated vaginal delivery. The mother's prenatal labs were negative with the exception of being GBS positive at 36 weeks' gestation. The mother received two doses of ampicillin prior to delivery and did not have a fever. The infant had APGAR scores of 9 at 1 minute and 9 at 5 minutes. The infant was brought to the newborn nursery and appears well. The most appropriate management of the infant would be which of the following? A. Draw a CBC and blood culture, but do not start empiric antibiotics. B. Give the baby a prophylactic dose of ampicillin. C. Routine care. D. Cultures of blood, urine, and spinal fluid and wait for culture results before starting antibiotics. E. Cultures of blood, urine, and spinal fluid and begin empiric antibiotics before getting culture results."

"A well-appearing 6-year-old presents to your office with a chief complaint of bruising. The parents report that the child had a cold 2 weeks ago but completely recovered. The child is sitting on the examining table, in no distress, discussing her favorite cartoons. On examination, you find mucosal bleeding and bruises on the child's arms and chest. You order a complete blood count (CBC) that has the following results: WBC 12,000, hemoglobin 11 g/dL, and a platelet count of 45,000. After discussing various options with a regional pediatric hematologist and the patient's parents, your most appropriate initial management would be which of the following? A. a platelet transfusion at the regional children's hospital B. an IM dose of methylprednisolone as an outpatient C. reassurance to the parents with close outpatient follow-up D. intravenous immunoglobulin (IVIG) at the regional children's hospital E. bone marrow biopsy at the regional children's hospital"

"A20-year-old male has had a recent wide local excision of a 1. 5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? Which of the following is true regarding melanoma? A. Chest radiographs are not recommended as a part of a patient's follow-up surveillance. B. Timely treatment of metastatic melanoma has been shown to have an effect on mean survival. C. Elevated serum LDH suggests metastatic melanoma. D. Patients without clinical lymphadenopathy are not at risk for metastatic involvement. E. High mitotic rate and a lower Clark level are poor prognostic signs."

"A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. The drug of choice for treating this patient works by which of the following mechanisms? A. interfering with protein synthesis at the ribosome B. attaching to sterols in cell membranes C. inhibiting bacterial cell wall synthesis D. inhibiting the transport of amino acids into bacteria E. inhibiting dihydrofolate reductase"

"A22-year-old nulliparous woman who desires future fertility is found to have a pap smear consistent with high-grade squamous intraepithelial lesion (HGSIL). Initial management should be which of the following? A. routine pap smear in 1 year B. random cervical biopsies C. colposcopy D. endometrial biopsy E. human papilloma virus (HPV) testing"

"A23 year old female presents to the emergency department (ed) with ""abdominal cramping"" nausea, and vaginal bleeding. Ahuman chorionic gonadotropin (hCG) level returns 5150 mIU/mL. A vaginal probe ultrasound is performed and notes no evidence of an intrauterine pregnancy, normal appearing ovaries, a mild amount of fluid in the cul-de-sac, and no evidence of ectopic gestation. The ED physician can exclude which diagnosis from the differential? A. spontaneous abortion B. ectopic pregnancy C. singleton intrauterine pregnancy D. ruptured ovarian cyst (corpus luteum) E. molar pregnancy"

"A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a ""pink eye"" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. Which of the following is the most likely diagnosis? A. pseudogout B. gout C. reactive arthritis D. resistant gonococcal arthritis E. ankylosing spondylitis"

"A28-year-old woman presents for evaluation of primary infertility. She has had fewer than four periods per year since menarche at age 14, facial hirsutism, acne, and weight gain. On examination, she has a BP 150/100. Her body mass index (BMI) is 40. Acanthosis nigricans is noted along the posterior surface of her neck. Which of the following laboratory studies is most likely to be abnormal in this patient? A. TSH B. prolactin C. glucose tolerance test D. growth hormone E. cosyntropin (Cortrosyn) stimulation test"

"A28-year-old woman presents for evaluation of primary infertility. She has had fewer than four periods per year since menarche at age 14, facial hirsutism, acne, and weight gain. On examination, she has a BP 150/100. Her body mass index (BMI) is 40. Acanthosis nigricans is noted along the posterior surface of her neck. Which of the following would be her most likely fasting lipid profile? A. high TGs, high HDL B. low TGs, low HDL C. high TGs, low HDL D. high LDL cholesterol E. normal lipid profile"

"A35-year-old woman with two prior term pregnancies presents for her first prenatal visit at 12 weeks' gestation. She recalls having had hypertension near the end of her first pregnancy. She believes her blood pressure has been normal since, but admits that she rarely seeks preventive health care visits, and that her last examination by a physician was more than 2 years ago. Today, you find her blood pressure to be 160/100. Which of the following antihypertensive agents would be contraindicated for management of her hypertension during pregnancy? A. labetalol B. alpha-methyldopa C. enalapril D. nifedipine E. hydralazine"

"A38-year-old woman presents to the ER with heavy vaginal bleeding. A pelvic examination using a speculum to visualize the cervix reveals a large, friable, fungating cervical mass. On bimanual examination, the mass extends to the right pelvic sidewall. A biopsy from a recent gynecologic visit reveals invasive squamous cell carcinoma of the cervix. An abdominal/pelvic CT scan shows enlarged pelvic lymph nodes and right hydronephrosis. Her hematocrit (HCT) in the ER is 24%, but she is hemodynamically stable with a BP of 124/70 and a pulse of 73. The cervical mass is actively bleeding. Your initial treatment of the vaginal bleeding in the ER only partially controls the bleeding, and she is requiring frequent retreatment. The best definitive treatment to control the bleeding at this time is which of the following? A. emergency bilateral hypogastric artery ligation B. uterine artery embolization C. emergency high-dose radiation therapy D. emergency radical hysterectomy E. loop excision electrocautery procedure (LEEP)"

"A41-year-old woman, recently diagnosed with a 2-cm, stage IB1 cervical cancer, undergoes a radical hysterectomy, bilateral salpingooophorectomy, and retroperitoneal pelvic lymph node dissection. Her surgery and postoperative course are uncomplicated. Four weeks postoperatively, she presents to the ER complaining of left leg swelling and left lower quadrant abdominal pain. On physical examination, she is afebrile, has a normal WBC count, and you palpate a 5 4 cm mass in the left lower quadrant. You order a pelvic ultrasound that shows a 5 5 cm simple cyst in the left lower quadrant. Which of the following is the most likely diagnosis? A. deep venous thrombosis (DVT) B. pelvic abscess B. lymphocyst C. ovarian cyst D. diverticular abscess"

"A42-year-old male with extensive Crohn's disease undergoes a near complete resection of the ileum. Adeficiency of which of the following vitamin is likely to result? A. niacin B. thiamine C. vitamin B12 D. vitamin C E. vitamin B6"

"A42-year-old man without prior significant medical history comes to your office for evaluation of chronic diarrhea of 12 months duration, although the patient states he has had loose stools for many years. During this time he has lost 25 lbs. The diarrhea is large volume, occasionally greasy, and nonbloody. In addition, the patient has mild abdominal pain for much of the day. He has been smoking a pack of cigarettes a day for 20 years and drinks approximately five beers per day. His physical examination reveals a thin male with temporal wasting and generalized muscle loss. He has glossitis and angular cheilosis. He has excoriations on his elbows and knees and scattered papulovesicular lesions in these regions as well Which of the following is the best test to confirm the suspected diagnosis? A. abdominal CT scan with contrast B. small bowel x-ray C. esophagogastroduodenoscopy with small bowel biopsy D. colonoscopy with colonic biopsy E. 72-hour fecal fat quantification"

"A43-year-old Black female (gravida 3, para 3) with a previous tubal ligation, presents to your office complaining of increasing menorrhagia, dysmenorrhea, and fatigue over the past 6 months. On examination, her vital signs are normal, and on abdominal examination you palpate a firm, mobile mass just below the umbilicus. On pelvic examination, there is a moderate amount of old blood coming from the cervical os. A urine pregnancy test is negative, her last pap smear was normal and her spun HCT today is 28%. Which diagnostic test would be most costeffective in confirming a diagnosis? A. pelvic MRI B. abdominal plain films C. pelvic ultrasound D. hysterosalpingogram E. office laparoscopy"

"A54-year-old Asian female with no significant medical history presents with frontal headache, eye pain, nausea, and vomiting. Her abdominal examination shows mild diffuse tenderness but no rebound or guarding. Her mucous membranes are dry. Her vision is blurry in both eyes, her eyes are injected but her extraocular muscles are intact. Her pupils are mid-dilated and fixed Which of the following is the most likely diagnosis? A. diabetic ketoacidosis (DKA) B. appendicitis C. angle closure glaucoma D. perforated colon due to inflammatory bowel disease (IBD) E. cerebellar malignancy"

"A70-year-old White woman has been faithful about taking 1200 mg of calcium, 400 IU of vitamin D supplements, and performing weight-bearing exercise on a daily basis. Her hip T score from her current DEXA scan has changed from -2. 0 SDs to -2. 55 SDs compared with last year's test. Which of the following is associated with a reduced risk of osteoporotic fractures? A. family history of hip fractures B. estrogen deficiency C. body mass index of greater than 23 D. tobacco use E. vision problems"

"An 8-year-old male presents to your office complaining of a 1-week history of painful knee and elbow joints. On examination, you find a painful, hot, and swollen knee. He also has multiple erythematous macules with pale centers on his trunk and extremities. The laboratory work you order reveals elevated antistreptococcal antibodies. What is the most likely diagnosis? A. JRA B. septic arthritis C. acute rheumatic fever (ARF) D. child abuse E. Sle"

"Apatient undergoes a gastrectomy following a gunshot injury. How would you counsel him about postgastrectomy syndromes? A. Most patients tolerate gastrectomy without a change in their digestive habits. B. Dumping syndromes can be treated with high carbohydrate liquid diets. C. Cholestyramine is a treatment for postvagotomy diarrhea. D. Most patients with these syndromes require surgical intervention. E. Proton pump inhibitors are effective against alkaline reflux syndrome."

"C1 deficiency has three subcomponents, of which the most common is deficiency of C1q. Most of those patients will have clinical and serologic findings typical of which of these? A. polymyositis B. RA C. Sle D. recurrent Streptococcus pneumoniae infections E. recurrent H. influenzae type B infections."

"Following tubal ligation what percentage of pregnancies are ectopic? A. 1% B. 5% C. 30% D. 50% E. 75%"

"Which anatomic location is the most common site of extra-adrenal pheochromocytomas? A. duodenum B. inferior pole of the kidney C. paraaortic area D. parasplenic area E. peripancreatic area"

"Which of the following risk factors has the strongest association with the development of malignant melanoma? A. dark skin and hair color with tendency to tan easily and not to burn easily B. personal history of sunburn, especially early in life C. pigmented lesion with asymmetric irregular borders, color variegation, and diameter 8 mm D. family history of non-melanoma skin cancer E. development of actinic keratosis"

"You are asked to see a 74-year-old man who has been admitted for evaluation of abdominal pain. During his workup, he was found to have hemoccult positive stool and a CT scan that was concerning for a mass in his sigmoid colon. Which should be the next step in his treatment? A. cardiology consultation for preoperative clearance B. contrast enema to evaluate the lesion C. colonoscopy to biopsy the mass and rule out synchronous lesions D. sigmoidectomy to resect the mass and obtain mesenteric lymph nodes for staging E. positron emission tomography (PET) scan to determine if the lesion is cancerous"

"You are consulted by a 55-year-old asymptomatic postmenopausal woman who has been on tamoxifen for 2 years following a diagnosis of breast cancer. She has no other risk factors for endometrial cancer but she was searching the Internet and found information about the risks of tamoxifen therapy. She inquires about endometrial cancer screening. You tell her that for asymptomatic woman on tamoxifen, the screening recommendations for endometrial cancer are which of the following? A. yearly pelvic ultrasounds B. yearly endometrial biopsies C. yearly gynecologic examinations D. yearly pelvic CT scans E. yearly hysteroscopy"

"You see a 3-week-old infant in your office for an acute visit. She was born via spontaneous vaginal delivery following a term, uncomplicated prenatal course. The parents are concerned because they have seen some streaks of blood in her diaper over the past few days. The infant's stools have been soft and not difficult to pass. The parents relate that she is eating 2 oz every 2 hours of a cow's milk based formula. What is the most likely cause of the blood in her stool? A. Meckel diverticulum B. group B streptococcal colitis C. cow's milk protein intolerance D. pseudomembranous colitis E. lactose intolerance"

"You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers. What is the most likely diagnosis? A. group A beta-hemolytic streptococcal pharyngitis B. hand-foot-mouth disease (Coxsackie viral infection) C. Kawasaki disease D. ITP E. erythema infectiosum (parvovirus B-19 infection)"

"A 10-month-old infant has a dysplastic right external ear, some preauricular tags, and a small notch (coloboma) in the iris and lower lid. Which condition does he likely have? A. Vater association B. neurofibromatosis, type 1 (von recklinghausen disease) C. retinoic embryopathy D. CHARGE association E. DiGeorge syndrome"

"A 14-year-old nulligravid female is brought to the ER by her parents with a 12-hour history of severe, intermittent left lower quadrant pain. She has had nausea and vomiting for the past 2 hours. On history, the patient experienced menarche at age 12 and denies past or current contact with a sexual partner. Her last normal menstrual period was 3 weeks ago. On examination, she is afebrile, pulse 100, BP 110/70, respiratory rate (RR) 20. She is visibly uncomfortable. She has no costovertebral tenderness, has diminished bowel sounds, her abdomen is nondistended, and exhibits rebound and guarding in both lower quadrants. She is unable to tolerate a pelvic examination due to pain. Laboratory values are as follows: WBC 13, HCT 39, -hCG (-), UA (-). Apelvic ultrasound shows a normal nonpregnant uterus, normal right adnexa, and an 8-cm left adnexal mass with a 3-cm solid component. Which of the following would be the next appropriate step in managing this patient? A. abdominal and pelvic CT scan B. social work referral for possible sexual abuse C. obtain liver enzymes, amylase, and lipase D. consultation for immediate surgical intervention E. discharge to home with pain medications"

"A 17-year-old male presents for evaluation of shortness of breath. He has episodes where he will audibly wheeze and have chest tightness. His symptoms worsen if he tries to exercise, especially when it is cold. He has used an OTC inhaler with good relief of his symptoms, but he finds that his symptoms are worsening. He now has episodes of wheezing on a daily basis and will have nighttime wheezing and coughing, on average, five or six times a month. You suspect a diagnosis of asthma. Which of the following is the most appropriate pharmacologic regimen for this patient? A. a systemic antihistamine as needed B. a short-acting inhaled bronchodilator as needed C. a scheduled inhaled steroid and a shortacting inhaled bronchodilator as needed D. a scheduled long-acting beta agonist, a scheduled inhaled steroid, and a shortacting inhaled bronchodilator as needed E. a systemic corticosteroid, a scheduled inhaled steroid, and a scheduled longacting beta agonist"

"A 17-year-old male presents for evaluation of shortness of breath. He has episodes where he will audibly wheeze and have chest tightness. His symptoms worsen if he tries to exercise, especially when it is cold. He has used an OTC inhaler with good relief of his symptoms, but he finds that his symptoms are worsening. He now has episodes of wheezing on a daily basis and will have nighttime wheezing and coughing, on average, five or six times a month. You suspect a diagnosis of asthma. Your diagnostic workup confirms the diagnosis of asthma. What clinical classification of asthma does this patient have? A. exercise-induced asthma B. mild asthma C. mild persistent asthma D. moderate persistent asthma E. severe persistent asthma"

"A 19-year-old woman who is 2 months postpartum complains of palpitations, heat intolerance, tremulousness, weight loss, and fatigue. Her thyroid is prominent and firm but nontender. serum TSH level was undetectable. A nuclear medicine radioactive iodine uptake is performed and shows no uptake of iodine in the neck. Which of the following is the most appropriate next step? A. administer radioactive iodine B. initiate glucocorticoid therapy C. initiate levothyroxine therapy D. initiate propranolol therapy E. initiate methimazole therapy"

"A 25-year-old woman presents to your office complaining of cold hands. She describes them turning white as she reaches for orange juice in the frozen food section of the supermarket. It seems to be getting worse lately. She has no other symptoms but does note that she and her husband are contemplating pregnancy. Her examination today is unremarkable. Which of the following antibodies can cross the placenta and cause the syndrome of neonatal lupus? A. anti-double-stranded DNA antibodies B. antiscleroderma antibodies C. anticardiolipin antibodies D. Sjögren syndrome antibodies (SSA/SSB) E. anticentromere antibody"

"A 29-year-old woman complains of fatigue and decreased exercise tolerance. She takes no medications and denies changes in the color of the stool. Physical examination is significant for pale skin and conjunctivae. Stool was negative for blood. Laboratory evaluation revealed Hgb of 7. 8 g/dL, reticulocytopenia, microcytosis, and hypochromia. Which of the following is the most appropriate next step in the management of the anemia in this woman? A. Start iron therapy as soon as possible. B. Transfuse RBCs and start iron therapy. C. Start B12 and folate replacement. D. Identify the cause of the anemia with a thorough history and physical examination. E. Start iron therapy and B12 replacement."

"A 31-year-old female health care worker presents to your clinic after a needlestick injury from a patient who subsequently left against medical advice prior to laboratory analysis for HIV or hepatitis. You advise your colleague that: A. If the patient had HIV, her risk of seroconversion is 20%. B. If the patient had Hepatitis B, her risk of seroconversion is 2%. C. If the patient had Hepatitis C, her risk of seroconversion is 5%. D. If the patient had HIV, her risk of seroconversion is 0. 3%. E. If the patient had Hepatitis C, her risk of seroconversion is 50%."

"A 31-year-old female presents to her physician complaining of rapid onset of hirsutism, deepening of the voice, irregular menses, clitoral enlargement, and acne. Which of the following is the most likely cause of this clinical presentation? A. polycystic ovary syndrome (PCOS) B. Cushing syndrome C. type II diabetes mellitus D. androgen secreting tumor E. congenital adrenal hyperplasia"

"A 32-year-old man who is HIV-positive was found to have Burkitt's lymphoma with diffuse bulky abdominal disease. He now reports to the hospital and is scheduled to begin chemotherapy. Admission laboratory studies show elevations of his uric acid at 15 mg/dL, serum phosphorus at 8. 5 mg/dL, creatinine at 2. 9 mg/dL, and potassium at 6. 1 mEq/L. What therapy is most likely to reverse the patient's metabolic abnormalities? A. administration of intravenous saline with mannitol to try to keep urine output >2. 5 L/day B. allopurinol 300 mg/day C. administration of intravenous sodium bicarbonate to keep urinary pH >7. 0 D. hemodialysis E. administration of the recombinant uricase enzyme rasburicase to lower uric acid levels"

"A 35-year-old 80-kg male was transported to the regional burn center at your hospital after suffering secondand third-degree burns from the eruption of a brush fire fueled with gasoline. He was intubated by EMS to secure his airway for transport. On arrival, he is found to have burns across his face, anterior neck, chest, and anterior abdomen, as well as bilateral circumferential upper extremity burns. Over the first 8 hours of his resuscitation, you estimate that he will require which of the following? A. 500 mL/h of isotonic fluid B. 600 mL/h of isotonic fluid C. 600 mL/h of hypertonic fluid D. 800 mL/h of isotonic fluid E. 800 mL/h of hypotonic fluid"

"A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy. A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. Which of the following management options is most appropriate at this time? A. Continue with current regiment without change. B. Add azithromycin for Mycobacterium avium complex prophylaxis. C. Add TMP-SMZ (Bactrim DS) for Pneumocystis carinii prophylaxis. D. test the patient for IgG antibody to Toxoplasma gondii if such a test has not yet been done. E. Start ganciclovir for CMV prophylaxis."

"A 4-year-old boy is brought to the emergency room by his mother after the child spontaneously admitted to swallowing part of a toy. The child is unable to describe what he ate further, although he appears to be in no distress. His vital signs are normal and his respiratory and abdominal examinations are unremarkable. The child is hungry and is demanding to eat something. ACXR reveals what appears to be a watch battery (""button battery"") in the patient's esophagus. What is the best course of action in this situation? A. admit the child to the hospital and allow him to eat B. admit the child to the hospital but keep him in a fasting state C. induce vomiting D. emergency endoscopy E. discharge the patient with instructions to look in his stools for the battery to confirm passage"

"A 4-year-old boy returns for his second visit to the emergency room. Three days ago he was brought in with a 4-day history of fever up to 102°F. At that time, his physical examination was significant for injection of the oropharynx and an enlarged left anterior cervical lymph node. His left TM was nonbulging and nonerythematous. He was sent home on amoxicillin with a diagnosis of streptococcal pharyngitis. He returns today with a persistent fever, edema of both hands, bilateral conjunctivitis, and a polymorphous truncal rash. What is the most likely diagnosis? A. rickettsial infection B. drug hypersensitivity reaction C. measles D. Kawasaki disease E. Scarlet fever"

"A 42 year old male admitted for pulmonary embolus was placed on heparin, dosed by a weight based protocol. However, later in the day, you receive a call from the floor nurse stating that the patient had spontaneous epistaxis and a very high aPTT. Use of which of the following would be best at this time? A. cimetidine B. heparinase C. clofibrate D. protamine sulfate E. vitamin K"

"A 45-year-old male comes to your office for his first annual checkup in the last 10 years. On first impression, he appears overweight but is otherwise healthy and has no specific complaints. He has a brother with diabetes and a sister with high blood pressure. Both of his parents are deceased and his father died of a stroke at age 73. He is a long-standing heavy smoker and only drinks alcohol on special occasions. On physical examination, his blood pressure is 166/90 in the left arm and 164/88 in the right arm. The rest of the examination is unremarkable. He is concerned about his health and does not want to end up on medication, like his siblings In the initial evaluation of a patient such as this, which of the following should be routinely recommended? A. a urine microalbumin/creatinine ratio B. an echocardiogram C. thyroid function tests D. renal function tests (serum creatinine and blood urea nitrogen [BUN]) E. an exercise stress test"

"A 45-year-old male has received intravenous contrast dye prior to CT scan of the abdomen. Twenty minutes later the patient reports severe pruritus. He denies respiratory distress, syncope, or palpitations. His blood pressure is 98/54, pulse is 90, and respiratory rate is 22. On physical examination, he has widespread urticaria. His lungs are clear to auscultation. The next appropriate step would be which of the following This intervention works well in cases such as this due to activity directed toward which of these receptors? A. dopaminergic receptors B. muscarinic receptors C. nicotinic receptors D. adrenergic receptors E. N-methyl D-aspartate (NMDA) receptors"

"A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a ""walking pneumonia"" that she had a year ago. Her breathing has worsened progressively since that time. She has a ""smoker's cough"" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure Which of the following is most likely to be found on a CXR? A. cardiomegaly B. residual infiltrate from inadequately treated pneumonia C. a pulmonary mass with hilar adenopathy D. hyperinflation of the lungs E. Kerley B lines"

"A 50-year-old man presents to your office with fatigue and weakness. He first noticed it a few weeks ago while trying to hang pictures with his wife. His legs have begun to ache as he walks up stairs. He has lost about 20 lbs in the last 3 months. Most recently, he has found that he is more constipated and has trouble rising from the commode. Your physical examination reveals modest proximal weakness, no articular swelling, rash, or any other pertinent findings. blood work from a recent insurance examination revealed: Sodium 142 meq/L; potassium 3. 8 meq/L; chloride 107 meq/L; bicarbonate 29 meq/L; BUN 30 mg/dL; Cr 1. 6 mg/dL; WBC 6. 8; Hgb 13. 6 g/dL; HCT 40%; MCV 88. 0 m3; platelets 240,000/mm3; AST 200 U/L; ALT 250 U/L; alkaline phosphatase 70 U/L; bilirubin 0. 3 mg/dL; ESR 40 mm/h His CPK is 2400 and an EMG shows fibrillation potentials, positive sLEEP waves, and myotonic discharges. In addition to addressing his myositis, diagnostic testing should be performed to evaluate for the possibility of which of these? A. Hodgkin lymphoma B. testicular cancer C. multiple myeloma D. lung cancer E. prostate cancer"

"A 55-year-old male is brought to the ED, by ambulance, because of crushing chest pain radiating to his left shoulder and arm that started 1 hour ago. He has a history of hypertension, high cholesterol, and has smoked a pack of cigarettes a day for 30 years. He has never had symptoms like this before. Which of the following would be most likely to be seen on an ECG? A. Q waves B. P-R interval depression diffusely C. S-T segment elevation in anterior and inferior leads D. S-T segment elevation in anterior leads with reciprocal S-T segment depression in inferior leads E. normal ECG"

"A 55-year-old woman presents to your office with painful hands, causing difficulty opening jars and turning the key in the ignition of her car. She is fatigued and she notices joint stiffness, but limbers up by lunch. She has trouble getting her rings off because of enlarging knuckles. About a year ago, she tried some OTC ibuprofen, which seemed to help, but led to the development of a bleeding ulcer severe enough to require transfusion and ICU care. Otherwise, her health is good, and her review of systems is negative. Your physical examination reveals tenderness and swelling at the index proximal interphalangeal and metacarpophalangeal joints bilaterally. There are small effusions on both knees. She has tenderness to lateral compression of the forefoot area bilaterally. Which of the following tests is most likely to result in a diagnosis? A. joint aspiration B. ESR C. serum uric acid D. rheumatoid factor E. ACE level"

"A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms. The patient undergoes a cardiac catheterization and is found to have 70% narrowing of the left anterior descending and proximal left circumflex arteries. Which of the following would be the most appropriate management of this condition? A. percutaneous transluminal coronary angioplasty (PTCA) B. medical management with a beta-blocker, statin, and aspirin C. medical management with an ACE inhibitor, statin, and aspirin D. referral for coronary artery bypass grafting (CABG) E. placement of a cardiac defibrillator"

"A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes (""although I know they are bad for me"") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. Which of the following tests is best to detect and monitor osteoporosis? A. plain film radiography B. dual photon absorptiometry C. single photon absorptiometry D. dual-energy x-ray absorptiometry (DEXA) E. quantitative CT scan"

"A 63-year-old Black female presents to your office complaining of leaking urine. She gets up at night five times to urinate and occasionally loses urine en route to the toilet. During the daytime, she urinates every 45 minutes ""to help prevent the leakage. "" She denies loss of urine with coughing or sneezing. She has not had dysuria or any other pelvic floor complaints. She has a family history of diabetes. She drinks several caffeinated beverages throughout the day. On examination, her postvoid residual urine is normal, and a urine dipstick shows 3+ glucose but is otherwise negative. Her abdominal and pelvic examinations are normal. Which of the following do you recommend? A. surgery for her incontinence B. antibiotics for a UTI C. diuretic therapy D. timed voids, decrease in caffeine intake, and screening for diabetes E. referral to a urologist for cystoscopy"

"A 63-year-old woman with a grade 2 endometrioid adenocarcinoma of the uterus diagnosed by endometrial biopsy is taken to the operating room for surgical treatment with a total abdominal hysterectomy, bilateral salpingooophorectomy, and pelvic and paraaortic lymphadenectomy. No complications are noted intraoperatively. On postoperative day 1, the patient complains of numbness in her medial thigh. Your neurologic examination suggests absence of cutaneous sensation to the medial thigh and an inability to adduct her hip. Which of the following is the most likely etiology for this clinical presentation? A. femoral nerve injury B. genitofemoral nerve injury C. pudendal nerve injury D. obturator nerve injury E. peroneal nerve injury"

"A 64 year old woman presents with bilateral symmetric arthralgias and morning stiffness for several years. She says that she has been worked up for RA in the past. On review of her records as well as the examination you note subcutaneous nodules, positive rheumatoid factor, and radiographs of the hands that revealed joint erosions. Which of her findings has the highest positive likelihood ratio (LR) for the diagnosis of RA? A. morning stiffness B. rheumatoid nodules on examination C. symmetric arthralgias D. joint erosions of the hand on xray E. positive rheumatoid factor."

"A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. On further questioning, the patient reports that he recently had a motor vehicle accident at night because he felt he could not see clearly. The most likely cause of this symptom is which of the following? A. vitamin B12 deficiency B. vitamin C deficiency C. vitamin D deficiency D. vitamin A deficiency E. vitamin K deficiency"

"A22-year-old nulliparous woman who desires future fertility is found to have a pap smear consistent with high-grade squamous intraepithelial lesion (HGSIL). The test you performed above was inadequate. What would be your next step in management? A. transvaginal ultrasound (TVUS) B. endometrial dilation and curettage C. ECC D. cold knife cervical conization E. repeat pap smear in 3 months"

"A 70-year-old male is seen in the office for chest pain. He reports that he is getting substernal chest pain, without radiation, when he mows his lawn. The pain resolves with 1015 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 160/70, pulse 85, and respiratory rate 16. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Which of the following would be most likely to be seen on an ECG? A. S-T segment elevations in the precordial leads B. Q waves in the precordial leads C. low-voltage QRS complexes D. left ventricular hypertrophy pattern E. normal ECG"

"A 74-year-old male with a history of hypertension, type II diabetes, myopia, and cataract surgery 2 weeks ago presents with the sudden onset of severe flashes of light and multiple new floaters in his right eye. He denies photophobia, ocular trauma, or diplopia. He also states that he feels as if there is a curtain lowering over his right eye. What is the most likely cause of his symptoms? A. central retinal artery occlusion B. acute lens displacement C. iritis D. retinal detachment E. staphylococcal endophthalmitis"

"A CT scan in a patient with a temperature of 102. 1°F and a history of an abdominal aortic graft reveals fluid around the graft. Which of the following is the most appropriate treatment? A. IV antibiotics and repeat CT scan in 2448 hours B. CT-guided catheter drainage of fluid collection C. exploration with graft excision, irrigation, and replacement with fresh graft D. exploration with graft excision and construction of axillobifemoral graft E. open exploration with debridement and drainage of fluid collection"

"A well-appearing 6-year-old presents to your office with a chief complaint of bruising. The parents report that the child had a cold 2 weeks ago but completely recovered. The child is sitting on the examining table, in no distress, discussing her favorite cartoons. On examination, you find mucosal bleeding and bruises on the child's arms and chest. You order a complete blood count (CBC) that has the following results: WBC 12,000, hemoglobin 11 g/dL, and a platelet count of 45,000. Following your initial evaluation and treatment, you see the child for follow-up in 1 week. She continues to appear well but still has obvious purpura and her platelet count is now 17,000. All other cell lines are normal. Of the options listed below, what is your most appropriate management at this time? A. admission to the regional children's hospital for a platelet transfusion B. admission to the children's hospital for a splenectomy C. reassurance to the parents and close outpatient follow-up D. admission to the children's hospital for IVIG and steroids E. whole-blood transfusion with several hours of observation to ensure that there is no transfusion reaction"

"A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. The pulmonary function test that is most likely to be diagnostic in this patient is which of these? A. increased total lung capacity B. increased functional residual capacity C. increased residual volume D. decreased forced expiratory volume in 1 second (FEV1) E. decreased forced inspiratory volume"

"A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. Which of the following properties of albuterol makes it a more appropriate choice than epinephrine for relief of acute episodes of bronchoconstriction? A. rapid onset of action B. longer duration of action C. specificity for beta-1 receptors D. specificity for beta-2 receptors E. direct activation of both alphaand beta-receptors"

"A20-year-old male has had a recent wide local excision of a 1. 5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? One year after his initial diagnosis and treatment, the patient develops a palpable right inguinal lymph node. Inguinal lymphnode dissection reveals one node positive for metastatic melanoma; the remaining nodes are negative. Acomplete restaging workup shows no evidence of any additional metastatic disease. What is the correct stage for this patient? A. stage I B. stage IIa C. stage IIb D. stage III E. stage IV"

"A21-year-old Asian female, with past medical history of exertional asthma, comes to your office complaining of mild low back pain. It started after her working out in the gym 3 days ago. The pain is 24 out of 10 in intensity, has no radiation, increases with bending or lying down for a long time, and improves with warm showers. You examine the patient, diagnose her with paravertebral muscle spasm, and give her prescriptions for cyclobenzaprine and naproxen to use as needed for pain and stiffness. You receive a call from your patient 2 hours later. She is having generalized itching, dizziness, and swelling of the tongue and lips. She is having difficulty breathing. She tells you that she took the first dose of the medication you prescribed about 30 minutes ago. The most beneficial immediate intervention for this patient would be which of the following? A. oxygen B. albuterol nebulizer treatment C. IV fluids D. epinephrine E. diphenhydramine"

"A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. Which of the following is true about this patient's condition? A. The causative agent is a virus. B. Light microscopy of fluid from the lesions will reveal gram-negative rods in chains. C. The presence of multiple distinct lesions is uncommon. D. There is a latent phase in which patients are asymptomatic. E. Although associated with persistent symptoms if left untreated, it does not carry a significant risk for mortality."

"A23-year-old male is brought by ambulance to the ER after being found in a house fire. He was in a closed room with a large amount of smoke and has sustained burns to his face, torso, arms, and legs. His pulse is 120, BP 110/55, and SpO2 92% on 2 L of oxygen by nasal cannula. Which of the following statements is true? A. The burns should be covered in cool, moist dressings. B. An inhalation injury is unlikely since he is able to oxygenate on minimal supplementation. C. Fluids should be limited to prevent pulmonary edema after his smoke inhalation. D. This patient meets criteria for transfer to a dedicated burn center. E. Depth of the burn does not affect the management."

"A26-year-old female with recurrent pregnancy loss undergoes a laparoscopy and hysteroscopy. She is found to have a Müllerian anomaly with a heart-shaped uterus that has two uterine horns but one common cervix. What is the name of the uterine anomaly? A. didelphic B. septate C. unicornuate D. bicornuate E. Müllerian agenesis (Mayer-RokitanskyKüster-Hauser syndrome)"

"A34-year-old woman was found to have a 2-cm right thyroid nodule at the time of a well woman examination. The remainder of the thyroid was palpably normal and there were no lymph nodes palpable. There was no history of thyroid disease or radiation therapy to her head or neck. She was clinically euthyroid. thyroid-stimulating hormone (TSH) was normal. Which of the following tests would be the most useful in establishing a specific diagnosis? A. ultrasound of the thyroid B. nuclear scan of the thyroid C. thyroid antibody studies D. fine needle aspiration of the nodule E. CT of the neck"

"A37-year-old White executive secretary comes to you after she found a lump in her right breast while she was showering. She describes a lesion beneath her right nipple. You question her about her personal and family history. She began menarche at age 12, and she is still having regular menstrual periods. She has had two children; the first was born when she was 25 years old. She has no family history of breast, ovarian, or colon cancer on either her maternal or paternal side. You perform a physical examination including a careful examination of her breasts. You note that her breasts contain many small cysts bilaterally. However, you also palpate a localized, firm, nontender mass below the right areola. You also describe a peau d'orange appearance of the areola. Amammogram is performed; however, the mammogram demonstrates no abnormality involving either breast. What next should be done? A. tell your patient to feel reassured and return if the mass enlarges. B. tell her to stop drinking caffeine, not to eat chocolate, and to reduce the stress in her life. C. return for another physical examination and mammogram in 6 months. D. Order an ultrasound of the right breast and lymph node basin. E. Order a CT scan of the breast, chest, and axilla."

"A45-year-old male presents to the hospital for acute abdominal pain and is found to have acute pancreatitis. He has no past medical history but recently has noticed urinary frequency and muscle weakness. He takes no medications. He denies alcohol use. His liver function tests during the episode are normal and magnetic resonance cholangiopancreatography study (MRCP) demonstrates an absence of stones in the biliary tree as well as a normal pancreatic duct. His serum calcium is found to be markedly elevated during this episode. The patient recovers clinically, and repeat serum calcium is also found to be elevated 1 month after hospital discharge. What is the most likely cause of his hypercalcemia? A. metastatic bone disease B. sarcoidosis C. vitamin D overdose D. hyperparathyroidism E. laboratory error"

"A67-year-old female with past medical history of rheumatoid arthritis on chronic steroid treatment and past surgical history (PSH) of complete hysterectomy secondary to fibroids presents for routine visit. Patient states that she has had multiple arthralgias worsening over the last 2 years. She had a DEXA scan done that showed a T score of -1.5. She has been taking calcium + vitamin D, and even started an exercise program at her local gym. She was started on bisphosphonates, which she has tolerated well. Prior to discharging the patient, how soon would you counsel her to repeat the DEXA scan? A. never: although she has risk for osteoporosis, she has already made all the lifestyle changes and is on pharmacotherapy B. repeat in 5 years, since she only has osteopenia B. 6 months C. repeat in 1 year D. repeat in 2 years"

"A74-year-old male with a history of hypertension, CAD, and a 50 pack-year history of smoking presents with complaints of pain and cramping sensation of the thigh and buttock areas for the past 2 months. On detailed history, patient reports that the pain is usually during ambulation and relieves with sitting down. The pain does not change with respect to sitting or supine position. He denies any recent trauma, weakness of the legs, or paresthesias. He takes his prescription medications regularly and denies using alcohol, drugs, or any herbs/ supplements. Which of the following should be performed as an initial test to help confirm your clinical impression? Which of the following measures should be implemented for the management of this patient's condition? A. referral to vascular surgeon B. glucosamine and chondroitin sulfate C. subcutaneous injections of low molecular weight heparin D. smoking cessation and walking program E. pentoxyfylline"

"In January, you see an 18-month-old boy in the middle of the night in the pediatric emergency department. The father relates that 1 hour ago his son started coughing. The father describes the cough as barking (""seal"" like). The child has mild stridor at rest, but otherwise is not in respiratory distress. His RR is 45 breaths per minute. He has a temperature of 103. 4°F . What is the most common etiology of this illness in children? A. HIB B. RSV C. influenza, type B D. parainfluenza, types 1 and 2 E. S. pneumoniae"

"In order to prevent unintended pregnancy following an episode of unprotected intercourse, by when is it recommended that ""emergency"" oral contraception should be initiated? A. 12 hours B. 24 hours C. 48 hours D. 72 hours E. 1 week"

"Parents bring you a 9-month-old boy they recently have adopted from western Russia. They have sparse medical records of the child's past. They do know that the boy was the result of a sexual assault on the mother and was given up at birth. The child has been in a ""baby home"" for 5 months. The records which accompanied the boy indicate that there had been some testing done. These tests include HIV, hepatitis B and C serologies, and a rapid plasma reagin (RPR), all of which are negative at 8 months of age. There is what appears to be a Russian immunization record as well. It seems to indicate that the child has had three diphtheria, tetanus, pertussis (DTP), three oral polio, and three hepatitis B vaccinations. There is also an indication that BCG (Bacille Calmette-Guérin) was given. You place a purified protein derivative (PPD) and the parents come back in 48 hours to have it read. The response is 15 mm of induration. The boy does not have any respiratory symptoms at this time. What is the most appropriate response to this information? A. Collect three morning sputum and send for acid-fast stain and TB culture. B. Give a repeat BCG vaccine. C. Do nothing as the PPD is considered negative given the prior BCG vaccination. D. Perform a CXR and begin isoniazid (INH) for 9 months if the x-ray is negative. E. Perform a CXR and begin ""triples"" (INH, rifampin, pyrazinamide) even if the x-ray is negative."

"Which of the following are currently recommended for all children for every well-child visit? A. serum lead levels B. hematocrit C. PPD D. full physical examination E. urinalysis"

"While visiting a neighbor, a 14-year-old girl is bitten on the left hand by the neighbor's pet cat. The cat is an indoor pet and has had all of the required routine vaccinations. You see the girl in the office approximately 1 hour after the injury. On the dorsum of the left hand you see two shallow puncture wounds that are not actively bleeding. She has full range of motion of her hand, normal capillary refill, and sensation. You see in the chart that the patient had a diphtheria/tetanus (dT) booster vaccine last year. What is the most appropriate management at this time? A. recommend local care at home with hydrogen peroxide and topical antibiotics. B. Give a booster dT and start oral cephalexin. C. Give an intramuscular (IM) dose of penicillin and emergently refer to a hand surgeon for debridement. D. Irrigate the wounds and prescribe oral amoxicillin/clavulanic acid (Augmentin). E. Start oral ciprofloxacin and refer to the health department for rabies prophylaxis."

"You are a second-year surgery resident and have just left work after a 30-hour shift. On your way home you witness a recent collision where there is an obviously injured pedestrian. several bystanders are providing care for the injured victim. You elect to keep driving. Awitness at the scene recognizes you as a physician and reports you to the authorities for neglecting to stop to provide care. As a consequence of your actions, which of the following will most likely happen? A. You will lose your medical license. B. You will be found guilty of negligence in a court of law. C. You will have your medical license suspended. D. You will have no legal action taken against you. E. You will be subject to a malpractice suit."

"You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. The infant begins to have progressively large amounts of bilious emesis. The infant feeds well and has only a small amount of abdominal distention. What is the most likely diagnosis? A. pyloric stenosis B. Hirschsprung disease C. biliary atresia D. duodenal atresia E. milk protein allergy"

"You are working in the emergency department and are called to perform a lumbar puncture on a 3monthold infant who presented with fever and lethargy. The spinal fluid that you obtain is turbid. The laboratory reports that there are 200 WBCs and 5 RBCs per high-power field (HPF). Ninety-five percent of the WBCs in the spinal fluid are neutrophils. Which of the following is the most probable cause of this illness? A. GBS B. HSV C. GAS D. S. pneumoniae E. E. coli"

"You see a 31/2-year-old child in the emergency department who has had fever for the past week. The parents relate that their son has some swollen glands, fever, and now seems to be getting a rash on his arms. On examination, you find an uncomfortable appearing young boy whose vital signs are normal with the exception of a temperature of 104°F. You note t hat he has a red posterior oropharynx with dry, cracked lips. His TMs are normal. He has mild conjunctival injection bilaterally without any discharge. His chest is clear, and his heart sounds are normal. He does not have any hepatosplenomegaly. His has a lacy, confluent macular rash on his chest and upper arms, with mild peeling of the tips of his fingers. What is the most appropriate treatment at thispoint? A. no medicine is needed, only supportive care B. an IM dose of long-acting penicillin (LA Bicillin) C. oral acyclovir D. IVIG E. topical lidocaine gel 1%"

"A 12-month-old male child is brought to your office for a well-child examination and immunizations. You have been following the child since delivery and are aware that he has acquired immune deficiency syndrome (AIDS) and a markedly reduced T-cell count. Which of the following vaccinations should he not receive? A. diphtheria, tetanus, and acellular pertussis (DTaP) B. diphtheria tetanus (dT) C. hepatitis B D. injectable polio vaccine (IPV) E. varicella"

"A 19-year-old female presents to the ED complaining of swelling in her left lower extremity. She reports that she had arthroscopy of the right knee about a week ago for a torn meniscus. The swelling started last night and is uncomfortable. Which of the following statements most accurately describes the situation? A. This condition is less likely to occur in women than men. B. The patient should be put on strict bed rest with leg elevation until her swelling resolves. C. Her surgically treated knee should be aspirated immediately to rule out a septic joint. D. Prophylaxis to prevent this complication includes subcutaneous heparin or daily coumadin. E. Directed lytic therapy is indicated for this patient if her lower extremity becomes bluish and has evidence of vascular compromise."

"A 28-year-old White G1 woman presents to your office for an initial obstetric visit. Her LMP is certain and allows you to estimate a 9-week gestational age today. She denies bleeding, cramping, or other symptoms of concern. She is excited about being pregnant. She has already started taking her prenatal vitamins with folic acid. She reports no significant past medical history. In fact, she states that she has not been to a doctor in many years because she has not had any problems. She has had no surgeries. She does not smoke. She drank alcohol socially prior to pregnancy but has not consumed any alcohol since she became pregnant. She has family history of hypertension, but no other significant history is elicited. On physical examination, her blood pressure is 110/60. She is healthy appearing, and there are no significant findings on examination. Your pelvic examination confirms uterine size consistent with stated dates. As part of a routine laboratory evaluation, you decide to check a thyroid-stimulating hormone (TSH). The TSH is 0. 4 IU/ mL (normal range 0. 55. 5) and a free T4 of 1. 8 ng/dL (normal range 0. 72. 0). What is the most likely cause of this patient's hyperthyroidism? A. toxic adenoma B. multinodular goiter C. hyperemesis gravidarum D. lymphocytic thyroiditis E. Grave's disease"

"A 28-year-old woman presents to your clinic complaining of feeling ""on edge. "" Upon further questioning, you discover that she has also noticed problems with irritability, insomnia, fatigue, and restlessness. She also has a history of worrying about things that seem to not bother those around her. She states these symptoms have been present for years but have recently become worse. When you try to gather more information, she interrupts to say that she cannot stay much longer because she is afraid that she will lose her new job as a machinist. Which of the following medications would be most appropriate in this patient? A. diazepam B. amitriptyline C. doxepin D. oxazepam E. buspirone"

"A 52-year-old man presents to the ED with a complaint of rectal bleeding and hematuria. He has a medical history significant for atrial fibrillation diagnosed 10 years ago and states that he takes metoprolol as well as warfarin for this condition. Upon examination, you find that his blood pressure is 122/78, his pulse is 84, his respiratory rate is 18, and his O2 saturation is 98% on room air. He has an irregularly irregular heart rhythm, gingival bleeding, and some bruises on his extremities. He has a positive fecal occult blood test, and laboratory studies return showing an international normalized ratio (INR) of 16. 5. You order that the patient's warfarin be held. Which of the following is the most appropriate additional intervention at this time? A. repeat INR measurement as an outpatient in 5 days B. admit the patient to the hospital and conduct serial INR measurements C. administer vitamin K1 D. administer fresh frozen plasma E. administer vitamin K1 and fresh frozen plasma"

"A 30-year-old (G2P0101) female presents to the clinic for a new obstetric visit. She has an unknown LMP. She reports that she discovered she was pregnant when she took a urine pregnancy test at home a month ago. She vaguely recalls having a period about 2 months ago, but is not sure exactly when that occurred. She reports that she is generally healthy. She had a previous delivery at 36 weeks EGA, though she reports her doctor was not really sure about her due date in that pregnancy. She reports that she had a normal spontaneous vaginal delivery in her previous pregnancy, and the child is healthy. Her postpartum course was complicated by depression, which has since resolved and not recurred. She denies history of sexually transmitted diseases or abnormal pap smears. She has no surgical history. She does not smoke, drink alcohol, or use illicit drugs. She does not have any family history of hypertension, diabetes, twins, or congenital anomalies. She does report that her mother has a history of depression. Which of the following tests will provide the most useful information to determine this patient's EDD? A. pelvic examination B. serum FSH and LH C. serum quantitative -hCG level D. measurement of fundal height E. pelvic ultrasound"

"A 31-year-old (gravida 1, para 1) female had a forceps-assisted vaginal delivery 3 months ago. Her infant weighed 4250 g. During the delivery she sustained a fourth degree perineal injury that was repaired. She now complains of fecal incontinence and foul vaginal discharge when her stools are loose, which happens several days a week. The most likely etiology for her fecal incontinence and foul vaginal discharge would be which of the following? A. Crohn's disease B. a perianal abscess C. a vaginal hematoma D. a retained vaginal foreign body E. a rectovaginal fistula"

"A 4-year-old child is brought to your office because of a sudden onset of irritability, weakness, and pallor. The mother tells you that both of her children have been experiencing episodes of vomiting and diarrhea. Your physical examination reveals a blood pressure of 115/80, dry mucus membranes, petechiae, and diffuse abdominal pain. The following laboratory work is obtained: Urinalysis: microscopic hematuria and proteinuria blood urea nitrogen (BUN)/creatinine (Cr): 20/1. 0 mg/dL Hemoglobin: 7 g/dL Peripheral blood smear: fragmented RBCs Prothrombin time (PT), partial thromboplastin time (PTT): normal Coombs' test: negative What is the most likely diagnosis? A. ITP B. HSP C. Evans syndrome D. meningococcemia E. HUS"

"A 4-year-old is brought to your office by his mother for evaluation. She is concerned because the child has been spiking fevers and pulling on his left ear. Your examination reveals a bulging and erythematous tympanic membrane (TM). Which of the following is most likely to be the cause of his illness? A. Haemophilus influenzae, type B (HIB) B. Moraxella catarrhalis C. Mycoplasma pneumoniae D. GAS E. S. pneumoniae"

"A 45-year-old male comes to your office for his first annual checkup in the last 10 years. On first impression, he appears overweight but is otherwise healthy and has no specific complaints. He has a brother with diabetes and a sister with high blood pressure. Both of his parents are deceased and his father died of a stroke at age 73. He is a long-standing heavy smoker and only drinks alcohol on special occasions. On physical examination, his blood pressure is 166/90 in the left arm and 164/88 in the right arm. The rest of the examination is unremarkable. He is concerned about his health and does not want to end up on medication, like his siblings. regarding your initial recommendations, which of the following would be most appropriate? A. You should take no action and ask him to return to the clinic in 1 year for a repeat blood pressure check. B. You should immediately start him on an oral antihypertensive medication and ask him to return to the clinic in 1 week. C. You should advise him to stop smoking, start a strict diet and exercise routine with the goal of losing weight, and return to the clinic in 6 months. D. You should consider starting a workup for potential causes of secondary hypertension. E. You should screen him for diabetes and evaluate him for other cardiovascular risk factors before proceeding any further."

"A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a ""walking pneumonia"" that she had a year ago. Her breathing has worsened progressively since that time. She has a ""smoker's cough"" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure You recommend smoking cessation to your patient. She asks why, at this point, she should quit. Which of the following statements is true? A. Her pulmonary function will improve 50% or more if she quits. B. Quitting will not affect her pulmonary status but may reduce her risk of having a heart attack. C. At this point, quitting will not improve her survival. D. She is going to require supplemental oxygen and smoking will represent a significant fire hazard. E. If she is able to stay off of cigarettes, the rate of worsening of her lung function will slow."

"A 5-year-old male is admitted to the hospital following a 3-week history of spiking fevers and fatigue. Your examination reveals pale mucous membranes and skin. You also find splenomegaly. The best course of care for this young man would be which of the following? A. initiate high-dose aspirin therapy (100 mg/kg/day) B. initiate ""renal sparing"" course of oral prednisone C. a repeat bone marrow evaluation with AFB (acid fast bacilli) staining and mycobacterial cultures D. obtain serum for Lyme enzyme immunoassay (EIA) testing and begin an empiric course of doxycycline E. obtain EBV serologies (IgM and IgG) and treat symptomatically with comfort measures"

"A 50-year-old female presents to your office for evaluation of solid food dysphagia without weight loss. Symptoms have been present for 6 months and are progressive. The patient has had two episodes of near impaction, but copious water ingestion and repeated swallows allowed the food bolus to pass. She has never had to present to the ER for disimpaction. She drinks five to six beers per day, loves spicy foods, and smokes a pack of cigarettes daily with a total lifetime history of 30 pack-years. She has had intermittent heartburn symptoms for years and has not sought treatment. She takes hydrochlorothiazide for hypertension. review of symptoms reveals chronic cough. Physical examination is unremarkable. Upper endoscopy reveals a distal esophageal stricture with inflammatory changes. Esophageal biopsies reveal benign mucosa with chronic inflammation. Gastric biopsies are unremarkable. Helicobacter pylori testing is negative. What is the next best step in therapy for this patient? A. esophageal dilation B. histamine receptor antagonist therapy C. PPI therapy D. esophageal dilation with histamine receptor antagonist therapy E. esophageal dilation with PPI inhibitor therapy"

"A 54-year-old male presents to the ED with acute onset of severe abdominal pain. His history is significant for gnawing epigastric pain that radiates to the back for several months. Physical examination demonstrates mild hypertension and tachycardia as well as a rigid ""board like"" abdomen with generalized rebound tenderness and hypoactive bowel sounds. rectal examination reveals dark hemoccult positive stools without gross blood. While you are in the process of working up the patient he becomes hypotensive and tachycardic. Bright red blood per rectum is now noted. The most likely explanation for his condition is which of the following? A. ruptured esophageal varices B. diverticulosis C. ruptured abdominal aortic aneurysm (AAA) D. ruptured splenic artery aneurysm E. erosion of the gastroduodenal artery"

"A 54-year-old man presents with a 3-cm right thyroid nodule that was found incidentally by the patient while shaving. He denies any pain or discomfort. He denies any history of thyroid disease, any family history of thyroid disease, and any history of head/neck irradiation. He notes a 10-lb weight loss over the past 6 months. His examination is only remarkable for the firm right thyroid nodule. The remainder of the thyroid is not palpable. There is no adenopathy. Heart rate is 90/minute and regular. The skin is warm and moist, and a fine tremor is present when he holds his hands out. TSH level is <. 02 U/mL. Which of the following is the most appropriate next step? A. thyroid ultrasound B. antithyroid peroxidase antibodies C. thyroid-stimulating immunoglobulins D. fine needle aspiration of the nodule E. thyroid nuclear scan"

"A 55-year-old male is brought to the ED, by ambulance, because of crushing chest pain radiating to his left shoulder and arm that started 1 hour ago. He has a history of hypertension, high cholesterol, and has smoked a pack of cigarettes a day for 30 years. He has never had symptoms like this before. The patient's rhythm converts to asystole. What is the most appropriate first action to take? A. IV epinephrine B. IV atropine C. discontinuation of resuscitation D. direct current (DC) cardioversion E. check a second monitor lead"

"A 55-year-old woman presents to your office with painful hands, causing difficulty opening jars and turning the key in the ignition of her car. She is fatigued and she notices joint stiffness, but limbers up by lunch. She has trouble getting her rings off because of enlarging knuckles. About a year ago, she tried some OTC ibuprofen, which seemed to help, but led to the development of a bleeding ulcer severe enough to require transfusion and ICU care. Otherwise, her health is good, and her review of systems is negative. Your physical examination reveals tenderness and swelling at the index proximal interphalangeal and metacarpophalangeal joints bilaterally. There are small effusions on both knees. She has tenderness to lateral compression of the forefoot area bilaterally. The test ordered above is negative and an anticyclic citrullinated peptide (anti-CCP) antibody is strongly positive (600). Which of the following is the probable source of her symptoms? A. cryoglobulinemia B. osteoarthritis C. polymyalgia rheumatica D. Sle E. RA"

"A 58-year-old male presents to your office for a well-male examination. It has been several years since he last visited a doctor, but he states that he has been in ""excellent health. "" He denies any history of drinking, smoking, or using illegal drugs. He maintains a diet low in sodium and fat. An avid sports enthusiast, he also spends at least 2 hours per day engaged in some type of outdoor physical activity. On physical examination, you discover a translucent waxy papule with raised borders on the posterior aspect of his left shoulder. Which of the following is the most important risk factor for development of this skin condition? A. immunosuppression B. presence of a chronic inflammatory skin condition C. chronic arsenic exposure D. exposure to long-wavelength ultraviolet radiation E. exposure to short-wavelength ultraviolet radiation"

"A 64-year-old male with a history of hypertension and tobacco abuse presents for follow-up after a routine physical during which he was found to have 45 red blood cells (RBCs) per high-power field (HPF) on a screening urinalysis. The urinalysis was negative for leukocytes, nitrites, epithelial cells, and ketones. The patient denies any complaints and the review of systems is essentially negative. What would be your initial approach in the workup of this patient with asymptomatic microscopic hematuria? A. check PSA and urine culture B. CT scan with and without contrast of the abdomen and pelvis C. intravenous pyelography (IVP) D. observation and reassurance as patient is asymptomatic E. repeat urinalysis"

"A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. The patient's abdominal pain worsens and his weight loss progresses despite therapy, and you suspect that he may have a malignancy. If a malignancy was present, which tumor marker would be most likely to be elevated in this patient? A. carcinoembryonic antigen (CEA) B. prostate-specific antigen (PSA) C. cancer antigen (CA)-125 D. -Fetoprotein (AFP) E. CA-19-9"

"A 70-year-old male is seen in the office for chest pain. He reports that he is getting substernal chest pain, without radiation, when he mows his lawn. The pain resolves with 1015 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 160/70, pulse 85, and respiratory rate 16. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Subsequent workup confirms the diagnosis of critical aortic stenosis. Which of the following treatments would be most appropriate at this time? A. a beta-blocker B. an ACE inhibitor C. a long-acting nitrate with as-needed sublingual nitroglycerin D. balloon valvuloplasty E. aortic valve replacement"

"A 72-year-old man comes to your clinic for the first time, accompanied by his wife. His wife states that she is concerned because he has been growing increasingly forgetful over the past year. Within the past month, he has forgotten to turn off the stove and has got lost while walking to the post office one block away from their home. His past medical history is significant for well-controlled diabetes and chronic lower back pain. He has no history of falls or traumatic injury to the head. Examination of the patient is significant for a score of 18 on a Mini Mental Status Examination (MMse). During the administration of the MMse, the patient blurts out that his wife brought him to the doctor because she is having an extramarital relationship. Which of the following accurately describes this patient's condition? A. There is no genetic basis for development of this disease. B. It is usually abrupt in onset. C. There is no correlation between age and prevalence of this disease. D. Environmental exposure is a proven risk factor for development of this disease. E. It is one of the most common terminal illnesses in developed nations."

"A 76-year-old alcoholic male with hypertension, type II diabetes, and a history of congestive heart presented with cough, fever, malaise, and chills. His initial vitals were: HR 110, T: 102°F, RR: 25, B P 90/60, O2 saturation 93% on 4L/NC. The patient decompensated in the ER and was intubated. Intubation was achieved after three attempts secondary to patient vomiting during the initial attempts. Patient was admitted to the ICU with a diagnosis of sepsis and respiratory failure secondary to suspected pneumonia. After obtaining blood and sputum cultures, the initial empiric antibiotic coverage should be which of the following? A. gatifloxacin alone B. vancomycin and metronidazole C. ceftriaxone and azithromycin D. ceftriaxone, gatifloxacin, and azithromycin E. ampicillin/sulbactam and gatifloxacin"

"A mother brings her baby girl for a 9-month wellchild visit. You have been following her since birth. Her growth chart is shown in Figure. Her vital signs and examination are otherwise normal. The growth pattern is most consistent with which of the following? A. congenital growth hormone (GH) deficiency B. constitutional short stature C. constitutional growth delay D. familial short stature E. nutritional failure to thrive (FTT)"

"A mother relates seeing worms in her 3-yearold's stool. She describes them as 1-cm long white threads that seemed to be moving. What is the most likely infectious etiology for this finding? A. Ascaris lumbricoides B. Diphyllobothrium latum C. Taenia solium D. Toxocara canis E. Enterobius vermicularis"

"A newborn male is brought to you in the neonatal intensive care unit (NicU). On physical examination, you notice that the infant has deficient abdominal musculature and undescended testes. Your suspicion is high for a certain condition. You presumptively diagnose the child with which of the following? A. Vater association B. Cushing's triad C. Potter's syndrome D. Jones criteria E. Eagle-Barrett syndrome"

"A21-year-old Asian female, with past medical history of exertional asthma, comes to your office complaining of mild low back pain. It started after her working out in the gym 3 days ago. The pain is 24 out of 10 in intensity, has no radiation, increases with bending or lying down for a long time, and improves with warm showers. You examine the patient, diagnose her with paravertebral muscle spasm, and give her prescriptions for cyclobenzaprine and naproxen to use as needed for pain and stiffness. You receive a call from your patient 2 hours later. She is having generalized itching, dizziness, and swelling of the tongue and lips. She is having difficulty breathing. She tells you that she took the first dose of the medication you prescribed about 30 minutes ago. What should you do at this time? A. Advise patient to use her albuterol inhaler as she is having an asthma attack. B. Advise her to take another dose of naproxen and stop cyclobenzaprine for now. C. Assure her that this is a common side effect to cyclobenzaprine; she will get used to it as she takes the next dose. D. Ask her to return to your clinic for evaluation. E. Ask her to call 911 immediately."

"A22-year-old nulliparous woman who desires future fertility is found to have a pap smear consistent with high-grade squamous intraepithelial lesion (HGSIL). The final pathology report indicates a single focus of squamous carcinoma invasive into the cervical stroma to a depth of 2. 0 mm. An ECC is negative. There is no lymphvascular space invasion, and the cone margins are negative. The most appropriate therapy for this patient is which of the following? A. radiation therapy B. simple hysterectomy with pelvic lymphadenectomy C. radical hysterectomy with pelvic lymphadenectomy D. radical trachelectomy E. observation with close follow-up"

"A24-year-old male medical student is admitted to the hospital for the evaluation of a 3-month history of bloody stools. The patient has approximately six blood stained or blood streaked stools per day, associated with relatively little, if any, pain. He has not had any weight loss, and he has been able to attend classes without interruption. He denies any fecal incontinence. He has no prior medical history. review of systems is remarkable only for occasional fevers and the fact that the patient quit smoking approximately 8 months ago. A colonoscopy is performed and reveals a granular, friable colonic mucosal surface with loss of normal vascular pattern from the anal verge to the hepatic flexure of the colon. Biopsies reveal prominent neutrophils in the epithelium and cryptitis with focal crypt abscesses, and no dysplasia. The patient is diagnosed with ulcerative colitis. In addition to an increased lifetime risk of colon cancer, the patient is also at increased risk for which of the following tumors? A. hepatocellular carcinoma B. hepatoblastoma C. desmoid tumors D. small bowel lymphoma E. cholangiocarcinoma"

"A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix. What should be the next step in her work-up? A. human papillomavirus testing virus typing B. CT scan of the pelvis C. ultrasound of the uterus and ovaries D. cone biopsy of the cervix E. colposcopy and directed cervical biopsy"

"A39-year-old woman with a long-standing history of normal pap smears undergoes a total abdominal hysterectomy for a large uterine fibroid and menorrhagia. Six months after her hysterectomy she had a negative vaginal pap smear from the vaginal apex. She presents to your clinic today for a routine physical examination. Based on the American College of Obstetricians and Gynecologists recommendations, when should this patient have pap smears? A. yearly B. every 3 years C. every 5 years D. never again E. only if she develops risk factors"

"A43-year-old morbidly obese woman presents to your office with a 3-week history of increasing vulvar burning. She has had no new sexual partners or practices. She has not noticed any change in her vaginal discharge. She has attempted to medicate herself with over-thecounter antifungals, herbal creams, and old antibiotics, none of which have provided relief. On examination, her entire labia majora and minora are markedly erythematous and tender to the touch. Her vaginal mucosa appears to have normal rugae. Her vaginal pH is normal and whiff test is negative. The wet mount shows a few WBCs and normal squamous cells. What is the most likely diagnosis? A. chemical dermatitis B. bacterial vaginosis C. PID disease D. atrophic vaginitis E. lichens sclerosis et atrophicus"

"A62-year-old female with a history of a recent pulmonary embolus presents to your office for followup on anticoagulation treatment. She takes warfarin on a daily basis. She reports that for the last week she has noticed mild rectal bleeding and multiple bruises over the extremities with minimal trauma. She is comfortable appearing with normal vital signs and is not orthostatic. You ordered a stat CBC and PT/INR which revealed a mildly decreased Hgb at 11 g/dL and an elevated INR of 7. Which of the following would be the most appropriate intervention? A. subcutaneous injections of heparin B. oral allopurinol C. intravenous protamine sulfate D. oral vitamin E E. oral vitamin K"

"A64-year-old female with no significant medical history presents with vague complaints of progressive generalized muscle weakness and fatigue. She denies any history of trauma or drug use and does not take any prescription, OTC or herbal medications. This is a new complaint and she has not had any prior workup. There is no evidence of trauma and a recent TSH was normal. On examination, you find mild muscle tenderness and atrophy. She has difficulty standing from a chair unless she pushes up with her arms at the same time. Her neurologic examination is normal. Which of the following tests would be most helpful in confirming your clinical diagnosis? A. complete blood count (CBC) B. antinuclear antibody (ANA) C. ESR D. MRI of spine E. aldolase"

"A70-year-old White woman has been faithful about taking 1200 mg of calcium, 400 IU of vitamin D supplements, and performing weight-bearing exercise on a daily basis. Her hip T score from her current DEXA scan has changed from -2. 0 SDs to -2. 55 SDs compared with last year's test. At this time, which of the following do you recommend? A. an oral bisphosphonate B. weekly GnRH injections C. discontinuation of her vitamin D D. glucocorticoid therapy E. IM testosterone"

"An 82-year-old woman schedules an appointment to see you for neck and back pain. At age 50, she had an L4-L5 diskectomy and laminectomy. She also has long-standing hypothyroidism for which she takes levothyroxine 0. 1 mg daily. Over the past few months, she has become more fatigued and describes pain in both of her arms, her low back, and the front of her thighs. She notes that the tops of her shoulders are also achy. She decided to call for an appointment because of worsening headache. She tells you that she has an appointment later this afternoon with her ophthalmologist, because she noticed some flickering of the vision in her left eye. Upon further questioning, she does acknowledge that she has cut her telephone conversation short with her daughter because her jaw begins to ache if she talks too long. Physical examination shows that she has normal vital signs. She has diffuse scalp tenderness. The oral mucosa is normal without aphthous ulcers and the salivary pool is normal. Her pupils are equal, round, and reactive to light and accommodation, and extraocular muscles are intact. The funduscopic examination appears normal for her age. Neck motion is slightly reduced to lateral flexion and rotation. Her trapezii are tender to palpation, but there is no significant loss of range of motion in her shoulders. Her supraspinatus and infraspinatus tendons appear intact. Her quadriceps are mildly tender, but her gastrocnemius muscles are normal. Her strength is normal for age. Her reflexes are normal and symmetrical. The most likely diagnosis is which of the following? A. polymyalgia rheumatica B. osteoarthritis of the cervical spine C. osteoarthritis of the lumbar spine D. bilateral rotator cuff tears E. temporal arteritis"

"An amenorrheic 17-year-old female is diagnosed with Kallmann syndrome. blood testing of this patient would indicate which of the following results? A. FSH, LH, normal estradiol B. high FSH, high LH, low estradiol C. normal FSH, normal LH, normal estradiol D. low FSH, low LH, normal estradiol E. low FSH, low LH, low estradiol"

"In January, you see an 18-month-old boy in the middle of the night in the pediatric emergency department. The father relates that 1 hour ago his son started coughing. The father describes the cough as barking (""seal"" like). The child has mild stridor at rest, but otherwise is not in respiratory distress. His RR is 45 breaths per minute. He has a temperature of 103. 4°F. What is the most common x-ray finding in this illness? A. swollen adenoids B. the ""thumb"" sign C. a lobar pulmonary infiltrate D. a deviated tracheal air column E. the ""steeple"" sign"

"In your internal medicine clinic you are caring for a 42-year-old woman with hereditary nonpolyposis colon cancer (HNPCC), Lynch syndrome II, which is a hereditary, autosomal dominant, cancer syndrome that results from a mutation in a mismatch deoxyribonucleic acid (DNA) repair gene. These patients have a lifetime risk of colon cancer nearly 6080%, but are also at risk for several other malignancies. For which gynecologic malignancy is this woman most at risk? A. ovarian cancer B. breast cancer C. cervical cancer D. vulvar cancer E. endometrial cancer"

"The predicted length of the follicular phase of a patient with a consistent 34-day menstrual cycle is which of the following? A. 14 days B. depends on the length of the luteal phase C. 16 days D. 18 days E. 20 days"

"Use of which medication can result in enamel staining of primary teeth? A. erythromycin B. ciprofloxacin (Cipro) C. cephalexin D. trimethoprim/sulfamethoxazole (septra) E. tetracycline"

"Which of the following conditions usually causes hypoglycemia at birth? A. Sturge-Weber syndrome B. neurofibromatosis, type 1 (von recklinghausen disease) C. tuberous sclerosis D. CHARGE association E. Beckwith-Wiedemann syndrome"

"Which of the following is the most appropriate treatment for a 32-year-old male with a toxic nodular goiter and compressive airway symptoms? A. radioactive iodine therapy B. propranolol C. propylthiouracil D. Lugol's solution E. total lobectomy"

"You are asked to see a 64-year-old man with left lower quadrant abdominal pain that was admitted to the medicine service after a CT scan demonstrated diverticulitis of the sigmoid colon. There was no evidence for gross perforation and no abscess was identified. He had been admitted 6 months ago for the same problem and had an uneventful recovery. Which treatment do you recommend? A. antibiotics only B. antibiotics and sigmoidectomy prior to discharge C. emergent sigmoidectomy D. antibiotics and sigmoidectomy 12 weeks after discharge E. antibiotics, interval colonoscopy, and subsequent sigmoidectomy"

"You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. What is the most common central nervous system (CNS) complication of Down syndrome? A. seizures B. hydrocephalus C. microcalcifications D. berry aneurysms E. mental retardation"

"You are called to the trauma bay to evaluate a 42-year-old male who suffered a blow to his knee at the construction site where he works. He is awake, alert, and his vital signs have been stable in transport. After completing your primary survey, you continue with your secondary survey and determine that his only injury is to his right leg. It is clear that he has suffered a posterior knee dislocation. As part of your examination, you determine that you cannot feel a pulse in his right foot. Later that night after the patient had been treated and stabilized, you are called to the patient's room to evaluate severe pain in his right lower leg. Upon examining the patient, you determine that he has a bounding pulse in his right foot. However, the patient does state that he has a tingling sensation in his foot and he is in excruciating pain when you flex his foot. Which of the following should be the next step in his treatment? A. Increase the dose of intravenous narcotics to help control the pain. B. Prescribe an anti-inflammatory drug to enhance the effects of the narcotics. C. Order a series of right foot x-rays looking for an occult fracture. D. Obtain an emergent arteriogram looking for missed vascular injury. E. Emergently take the patient to the OR."

"You are working in the emergency department and are called to perform a lumbar puncture on a 3-monthold infant who presented with fever and lethargy. The spinal fluid that you obtain is turbid. The laboratory reports that there are 200 WBCs and 5 RBCs per high-power field (HPF). Ninety-five percent of the WBCs in the spinal fluid are neutrophils If the laboratory result showed that 98% of the WBCs in the spinal fluid were lymphocytes, what would be the most likely etiology of the infection? A. Mycobacterium tuberculosis B. HSV C. C. trachomatis D. RSV E. nonpolio enteroviruses"

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