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Segundo simulador primera parte



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  • 2. Instrucciones1. Preparar hoja de respuesta impresa.2. Activar el simulador aplicando play.3. Escribir nombre y hora de inicio en la hoja derespuesta.4. Circular el reactivo de cada respuesta en hojade respuesta.5. El simulador se activará a las 8:00 hrs y sedesactivará a las 14:00 hrs, la primera parte.6. La segunda parte se activara a las 16:00 hrs y dedesactivará a las 20:00 hrs.
  • 3. Caso clínico No. 58 (ejemplo)Femenino de 51 años, originaria deCampeche, acude control mensual por HAS y DM10 y 5 años respectivamente, sus SV fueron TA155/95 mmHg, FC 51 lpm, FR 21 rpm. Glucosa210 mg/dl, hemoglobina glucosilada 6, urea17, creatinina 1,1 mg/dl, refiere mareoocasional, cefalea global acompañada de sueño yfatiga, frio y mareo ocasional, disnea de leves amoderados esfuerzos, se observa edema demiembros inferiores. Su tratamiento escaptopril, metoprolol y glibenclamida, se realizaECG (ver imagen).
  • 4. Caso clínico No. 58 (ejemplo)
  • 5. Caso clínico No. 58 (ejemplo)PRENGUNTASe realiza ECG, considerando las manifestaciones que sehan presentado, que conducta terapéutica consideramás apropiada realizar de forma mediata?RESPUESTAa.- Incrementar los fármacos hasta meta de <120/80mmHg.b.- Retirar metoprolol continuar con captopril yglibenclamida.c.- Mantener glibenclamida, retirar metoprolol e iniciarlosartan.d.- Agregar hidroclorotiazida al manejo actual
  • 6. Hoja de respuestasd 51 a b c d 101d 52 a b c d 102d 53 a b c d 103d 54 a b c d 104d 55 a b c d 105d 56 a b c d 106d 57 a b c d 107d 58 a b c d 108d 59 a b c d 109d 60 a b c d 110
  • 8. CASE REPORTA recently married 29-year-old nulliparous African-American female presents with uncomplicatedcystitis. She is otherwise healthy. She reports thatshe is currently using barrier birth control methodsbut plans to discontinue this soon, as she wouldlike to become pregnant.
  • 9. QUESTION No. 1Which one of the following supplemental vitamins orminerals would you advise this patient tobegin taking?a) Thiamineb) Iodinec) Folated) Calcium
  • 10. QUESTION No. 2Which one of the following is true regarding testingthe rotator cuff for injury?ANSWERa) The subscapularis is tested with lateral rotationagainst resistanceb) The teres minor is tested with medial rotationagainst resistancec) The infraspinatus is tested with medial rotationagainst resistanced) The supraspinatus is tested with abductionagainst resistance
  • 11. CASE REPORTYou have recently begun caring for a 25-year-old whitefemale who has multiple complaints. You have seenher 3 times for walk-in office visits over the pastmonth. She has shown appreciationfor your work during the encounters, but has beencritical of your care when talking to the officestaff. At times she has been kind and charming, and atother times she has been rude and verballyabusive to your staff. She has a string of multiplerelationships in the past, none of which haslasted very long. During times of intense stress, she hassometimes engaged in self-mutilation.She frequently changes jobs and living arrangements.
  • 12. QUESTION No. 3Which one of the following strategies would be mostappropriate in the care of this patientANSWERa) Strive to develop a close relationship with thepatient.b) Ignore verbal attacks on staff members.c) Provide detailed, technical explanations for. anytherapies provided.d) Schedule frequent office visits for follow-up.
  • 13. In an 11-year-old male with dark brown urine andhand and foot edema.QUESTION No. 4Which one of the following would be most suggestiveof glomerulonephritis?ANSWERa) RBC casts in the urineb) Elevated C3 and C4 complement levelsc) Eosinophils in the urined) Positive serum antinuclear antibody levels
  • 14. A 32-year-old white female at 16 weeks gestationpresents to your office with right lower quadrant pain.QUESTION No. 5Which one of the following imaging studies would bemost appropriate for initial evaluation of this patient?ANSWERa) MRI of the Abdomenb) Intravenous pyelographyc) CT of the abdomend) Ultrasonography of the abdomen
  • 15. QUESTION No. 6Which one of the following is the leading cause ofblindness in individuals over age 65?a) Narrow angle glaucomab) Diabetic retinopathyc) Macular degenerationd) Ophthalmic artery occlusion
  • 16. CASE REPORTA 48-year-old white female complains of anxiety anddifficulty concentrating at home and at work. Shereports that the symptoms have increased over thelast 2 months because of her daughter’s maritaldifficulties. She has had similar symptoms along withintermittent depression since she was a teenager.She admits to a loss of pleasure in work andrecreational activities.
  • 17. QUESTION No. 7Which one of the following is LEAST likely to help hercoexistent depressive symptoms?ANSWERa) Nortriptyline.b) Buspirone.c) Escitalopramd) Venlafaxine
  • 18. CASE REPORTAn 82-year-old white female visits your office. She reports a 2-week history of shoulder stiffness that is severe in themorning, and a 3-day history of pain on the left side of theface while chewing food. She denies dental pain orsensitivity. Her family history is negative for rheumatologicdisorders. Your evaluation reveals a 5-lb weight loss andevidence of mild depression. Her temperature is 38.0° C(100.4° F), she has no dental decay or carotid bruit, and herleft temporal scalp is tender. Her lungs are clear toauscultation, there are no abnormal heart sounds, and herabdomen is nontender. She has no joint swelling orwarmth, but experiences discomfort with shoulder and hiprange of motion. Laboratory analysis reveals a hemoglobinlevel of 11.0 g/dL (N 11.7–16.1), an erythrocytesedimentation rate of 80 mm/hr (N 0–30), a serum glucoselevel of 120 mg/dL, and a BUN level of 24 mg/dL (N 8–23).
  • 19. QUESTION No. 8Which one of the following is the greatest immediaterisk for this patient?ANSWERa) Monocular vision lossb) Hemiparesisc) Sudden deathd) Adhesive capsulitis of the shoulder
  • 20. CASE REPORTA 73-year-old male with COPD presents to theemergency department with increasing dyspnea.Examination reveals no sign of jugular venousdistention. A chest examination reveals decreasedbreath sounds and scattered rhonchi, and the heartsounds are very distant but no gallop or murmuris noted. There is +1 edema of the lower extremities.Chest radiographs reveal cardiomegaly butno pleural effusion. The patient’s B-type natriureticpeptide level is 850 pg/mL (N <100) and hisserum creatinine level is 0.8 mg/dL (N 0.6–1.5).
  • 21. QUESTION No. 9Which one of the following would be the mostappropriate initial management?ANSWERa) Prednisone, 20 mg twice daily for 1 weekb) Furosemide, 40 mg intravenouslyc) Intravenous heparind) Tiotropium
  • 22. CASE REPORTA 28-year-old primigravida is at 20 weeks gestation bydates but her fundal height is consistent with a 26-week gestation. She has had episodes of vomitingduring the pregnancy that were more severe thanthe physiologic vomiting typically seen in pregnancy.A sonogram performed at about 5 weeks gestationfor vaginal bleeding was normal and showed a singlefetus.
  • 23. QUESTION No. 10Which one of the following would be mostappropriate at this point?ANSWERa) Expectant managementb) A repeat sonogramc) MRI of the pelvisd) A serum hCG leve
  • 24. CASE REPORTA 24-year-old male, new to your practice, presents for amental health evaluation. The patient has a past historyof schizophrenia, diagnosed several years ago.QUESTION No. 11Which one of the following, if present, would lead to areconsideration of this diagnosis?ANSWERa) Loose associationsb) Elated moodc) Social dysfunctiond) Auditory hallucinations
  • 25. CASE REPORTA previously healthy 22-year-old female presents forher regular prenatal checkup at 38 weeks gestation.She has a blood pressure of 145/95 mm Hg todayand this is unchanged 1 hour later. Her bloodpressure was normal before pregnancy. She isotherwise feeling well. She has moderate edema atthe ankles and 3+ reflexes at the knees and ankles.A urinalysis for protein is normal.
  • 26. QUESTION No. 12Given this presentation, which one of the followingis the most likely diagnosis?ANSWERa) Hemolysis, elevated liver enzymes, low plateletssyndromeb) Preeclampsiac) Essential hypertensiond) Gestational hypertension
  • 27. CASE REPORTA 72-year-old female with longstanding diabetesmellitus presents to your office. During the reviewof systems, she complains of difficulty voiding andfrequent “dribbling.” A urinalysis is negative forinfection and her post-void residual volume is 250mL.
  • 28. QUESTION No. 13Which one of the following is the most likely cause ofthis patient’s urinary incontinence?ANSWERa) A grade II cystoceleb) Atrophic vaginitisc) Asymptomatic bacteriuriad) Autonomic neuropathy
  • 29. CASE REPORTA 3-year-old male is brought to your office the dayafter he was stung by a honeybee. He hasdeveloped a significant local reaction, with rednessand swelling around the site of the sting on hisforearm, and also has had some swelling of his lipsfor “a couple of hours.” His mother removed thestinger and gave him some oral diphenhydramineThe local reaction has now almost resolved and hehas not had any hives or respiratory distress.
  • 30. QUESTION No. 14Which one of the following is true concerning thissituation?ANSWERa) An antibiotic that covers Streptococcus pyogenesand Streptococcus aureus should be administeredb) If venom immunotherapy is begun, it should bestopped after 2 years of treatmentc) The child is at high risk for a systemic reaction if heis stung again in the futured) Skin tests are not helpful in confirming thepresence of insect sting allergy
  • 31. CASE REPORTA 65-year-old white female develops a burning pain in theleft lateral thorax, followed 2 days later by anerythematous vesicular rash.QUESTION No. 15Of the following, the best treatment is?ANSWERa) topical capsaicinb) oral corticosteroidsc) topical corticosteroidsd) topical acyclovir
  • 32. QUESTION No. 16Which one of the following would be mostappropriate to treat a dental infection requiringantibiotic therapy?ANSWERa) Penicillinb) Dicloxacillinc) Erythromycind) Tetracycline
  • 33. CASE REPORTYou are consulted for medical management of a 45-year-old male, previously unknown to you,who is hospitalized in the psychiatric unit withparanoid schizophrenia. His fasting blood glucoselevel is 180 mg/dL.
  • 34. QUESTION 17Which one of the following medications is the mostlikely cause of the hyperglycemia?ANSWERa) Alprazolamb) Chlorpromazinec) Olanzapined) Haloperidol
  • 35. CASE REPORTA 22-year-old male presents to the emergencydepartment several hours after a rugby match inwhich he was struck in the face. His nose is bleeding.On examination the patient has a depression in hisnose on the side of impact and an outwarddisplacement on the opposite side. Internalinspection reveals a purple area of swelling andfluctuance on the left side of the nasal septum. Theremainder of the examination demonstrates nofindings to suggest other facial or periorbital trauma.
  • 36. QUESTION 18Which one of the following would be most appropriateat this time?ANSWERa) Immediate CT imaging to assess for facial andmandibular fractureb) Incision and drainage of the swollen, fluctuant areac) Immediate plain radiographs of the nose and orbitsd) Immediate closed reduction of the nasal fracture
  • 37. CASE REPORTA 30-year-old gravida 3 para 2 at 28 weeks gestation isa restrained passenger in a high-speed motorvehicle accident. After initial stabilization in the fieldwith supplemental oxygen and intravenousfluids, she is brought into the emergencydepartment on a backboard and wearing a cervicalcollar.
  • 38. CASE REPORTYour hospital administrator asks you to develop acommunity screening program for melanoma.QUESTION 19Which one of the following is true concerning screening forthis disease?ANSWERa) Screening for melanoma is not indicated since screeningtakes too much timeb) No definite clinical evidence has shown that screeningfor melanoma reduces mortalityc) Screening for melanoma is not indicated since thedisease is rared) Because of sunbathing, female patients are the mostimportant population to screen
  • 39. CASE REPORTA 19-year-old white female presents for an initial familyplanning evaluation. Specifically, she is interested inoral contraception. She is not presently sexuallyactive, but has a steady boyfriend. She has nocontraindications to oral contraceptive use. She hasmild acne vulgaris. You discuss possible side effectsand benefits of combined oralcontraceptives, including improvement of her acne.
  • 40. QUESTION 20Which one of the following is also associated with oralcontraceptive use?ANSWERa) Increased incidence of dysmenorrheab) Increased risk of ovarian cancerc) Increased risk for ectopic pregnancyd) Decreased risk of ovarian cysts
  • 41. CASE REPORTA 78-year-old white female notices a scant milkysecretion from her breast.QUESTION 21Which one of the following medications can causethis symptom?ANSWERa) Diazepamb) Risperidonec) Famotidined) Zaleplon
  • 42. CASE REPORTYou have just diagnosed and treated gonorrhealcervicitis in a 24-year-old female who is inher second trimester of pregnancy. Thepatient has a friend who had a stillborn infantand she is concerned that the gonorrhea maypredispose her to stillbirth.
  • 43. QUESTION 22Which one of the following would be most appropriate inthis situation?ANSWERa) Perform monthly vaginal cultures forgonorrhea, starting at 24 weeks gestationb) Perform fetal monitoring and serial vaginalcultures, starting at 32 weeks gestationc) Inform the patient that stillbirth related to gonorrheais very rare, and that special fetaland maternal monitoring is not neededd) Administer prophylactic ciprofloxacin (Cipro) weeklyuntil delivery
  • 44. CASE REPORTA 6-year-old male is brought in for evaluation by hismother, who is concerned that he may haveasthma. She reports that he coughs about 3 daysout of the week and has a nighttime coughapproximately 1 night per week. There is a familyhistory of eczema and allergic rhinitis.
  • 45. QUESTION 23Which one of the following would be the preferredinitial treatment for this patient?ANSWERa) A mast-cell stabilizer such as cromolyn sodiumb) A leukotriene receptor antagonist such asmontelukastc) A long-acting beta-agonist such as salmeterold) A low-dose inhaled corticosteroid such asbudesonide
  • 46. QUESTION 24Which one of the following is the most correct recommendationregarding seat belt use for a woman at 38 weeks gestation?ANSWERa) The seat belt should be positioned over the dome of the uterusand the shoulder harness should be positioned between thebreastsb) The seat belt should be positioned under the abdomen over boththe anterior superioriliac spines and the pubic symphysis; the beltshould be applied with some slackc) The seat belt should be positioned under the abdomen over boththe anterior superior iliac spines and the pubic symphysis; theshoulder harness should be positioned between the breasts; thebelt should be applied as snugly as comfort will allowd) Seat belts should not be used in the later stages of pregnancy
  • 47. CASE REPORTA 34-year-old female presents to the emergencydepartment with a severe migraine headacheunresponsive to tramadol and sumatriptan at home.She takes fluoxetine for depression. Soon after beinggiven an injection of meperidine, she developsagitation, diaphoresis, tremor, diarrhea, fever, andincoordination.
  • 48. QUESTION 25The most likely cause of this patient’s symptoms is?ANSWERa) serotonin syndromeb) panic attackc) thyrotoxic stormd) viral encephalitis
  • 49. QUESTION 26The development of azotemia suggests the presenceof underlying renal artery stenosis in a patienttaking which one of the following?ANSWERa) Amlodipineb) Lisinoprilc) Hydrochlorothiazided) Metoprolol
  • 50. QUESTION 27Which one of the following is a risk factor forendometrial cancer?ANSWERa) Multiparityb) Use of oral contraceptivesc) Late menarched) Polycystic ovary syndrome
  • 51. QUESTION 28Promoting good sleep hygiene is basic in the treatment ofinsomnia. Which one of the following measures will aidin promoting healthy sleep habits?ANSWERa) Taking an enjoyable book or magazine to bed to readb) Eating the heaviest meal of the day close to bedtimec) Drinking a glass of wine as a sedative before retiringd) Maintaining a regular sleep/wake schedule
  • 52. QUESTION 29Until you are able to rule out a spinal injury, in whatposition should the patient be kept?ANSWERa) Supine, with the uterus manually deflectedlaterallyb) Pronec) Trendelenburg’s patternd) Left lateral decubitus
  • 53. QUESTIONA 47-year-old male presents with a history offatigue, arthralgias, nonspecific abdominalpain, and erectile dysfunction. The initiallaboratory workup reveals a normal CBC andbasic metabolic profile, but slightly elevatedtransaminases.
  • 54. QUESTION 30Which one of the following is the most appropriateinitial test to evaluate for hereditaryhemochromatosis?ANSWERa) Serum transferrin saturationb) Serum ceruloplasmin testingc) Serum alpha-fetoprotein testingd) Serum ferritin testing
  • 55. CASE REPORTA 56-year-old female presents for a healthmaintenance examination. She has a history of atotal hysterectomy for benign disease 4 years ago.You are able to document that the hysterectomypathology was benign and that she has had normalPapanicolaou (Pap) tests for 10 years. The patientasks about regular Pap smears.
  • 56. QUESTION 31Which one of the following would be the mostappropriate recommendation?ANSWERa) Routine Pap smears should be continued until age70b) A Pap smear should be done every 3 yearsc) A Pap smear should be done yearly for 3 years andonly if indicated thereafterd) A Pap smear is not indicated
  • 57. QUESTIONA 31-year-old African-American female presents withthe chief complaint of bilateral galactorrhea of 3months’ duration. She also has not menstruated for1 year despite changing birth control pills severaltimes. A review of systems is otherwisenoncontributory. Except for a milky discharge withstimulation of the breasts, her examination is withinnormal limits. Serum prolactin on two occasions is>200 :g/L (N 0–20).
  • 58. QUESTION 32Which one of the following would be mostappropriate at this point?ANSWERa) Stop her oral contraceptive and repeat the serumprolactin level in 1 monthb) Start the patient on risperidonec) Order bilateral mammographyd) Order a brain MRI with enhancement andemphasis on the pituitary fossa
  • 59. CASE REPORTAn 84-year-old African-American female is brought toyour office by her daughter, who is concerned that themother has memory problems and is neglecting to payher monthly bills. The mother also is forgettingappointments and asks the same questions repeatedly.This problem has been steadily worsening over the last1–2 years. The patient has very little insight into herproblems, scores 24 out of a possible 30 points on theMini-Mental State Examination, and has difficulty withshort-term recall and visuospatial tasks. Her physicalexamination and a thorough laboratory workup arenormal. A CT scan of the brain mreveals diffuseatrophy.
  • 60. QUESTION 33Which one of the following is the most likely etiologyfor this patient’s memory problem?ANSWERa) Alzheimer’s diseaseb) Dementia resulting from depressionc) Normal agingd) Lewy body dementia
  • 61. CASE REPORTA 23-year-old female is at 8 weeks gestation with herfirst pregnancy. She is planning to travel to ThirdWorld countries soon for job-related reasons.QUESTION 34Which one of the following is contraindicated in thispatient?ANSWERa) Hepatitis B vaccineb) Rabies vaccinec) Varicella vaccined) Meningococcal vaccine
  • 62. QUESTION 35In the evaluation of foot ulcerations, a neuropathicetiology is suggested by which one of the following?ANSWERa) Abnormal monofilament testingb) Absence of toe hairc) Erectile dysfunctiond) Distal foot pain when supine
  • 63. QUESTION 36A 72-year-old white male has new-onset hypertensionwith a current blood pressure of 190/110mm Hg.Which one of the following agents can be used aspart of a test for diagnosing renovascularhypertension, but would also increase the risk forazotemia if used for treatment?ANSWERa) Furosemideb) Metoprololc) Captoprild) Amlodipine
  • 64. QUESTION 37Which one of the following treatments for childhoodnocturnal enuresis has both the highest curerates and the lowest relapse rates?ANSWERa) Positive reinforcementb) Imipraminec) Responsibility trainingd) Bed-wetting alarms
  • 65. CASE REPORTYou see a 30-year-old male who has just fallen on anoutstretched hand. He complains of wrist pain andedema. Examination reveals tenderness over theanatomic snuffbox and over the scaphoid tubercle atthe proximal wrist crease with the hand in extension.Radiographs of the wrist are negative.
  • 66. QUESTION 38Which one of the following would be the mostappropriate action at this point?ANSWERa) Order high-spatial-resolution ultrasonography ofthe wristb) Order a bone scan for the next dayc) Immobilize in a thumb spica splint for 1–2 weeksand then order repeat radiographsd) Immobilize in a cast for 6–8 weeks
  • 67. CASE REPORTA 15-month-old male is brought to the emergencydepartment following a generalized tonic-clonicseizure at home. The parents report that theseizure lasted 5 minutes, with confusion for thenext 15 minutes. This is the child’s first seizure.There is no family history of seizures. His medicalhistory is normal except for a 1-day history of aURI. While initially lethargic in the emergencydepartment, the child is now awake andplayful, with a temperature of 39.5° C (103.2° F)and a normal examination. Appropriatediagnostic tests are performed, including a bloodglucose level, which is 96 mg/dL.
  • 68. QUESTION 39Which one of the following would be most appropriateto administer at this point?ANSWERa) Ceftriaxone intravenouslyb) Phenobarbital orallyc) Carbamazepine orallyd) Acetaminophen orally
  • 69. CASE REPORTA 77-year-old white male complains of urinaryincontinence of more than one year’s duration. Theincontinence occurs with sudden urgency. Noassociation with coughing or positional change hasbeen noted. There is no history of fever or dysuria.One year ago he underwent transurethral resectionof the prostate (TURP) for benign prostatichypertrophy and says his urinary stream hasimproved. Rectal examination reveals a smoothlyenlarged prostate without nodularity, and normalsphincter tone. No residual urine is found with post-void catheterization.
  • 70. QUESTION 40Which one of the following is the most likely cause ofthis patient’s incontinence?ANSWERa) Overflowb) Urinary tract infectionc) Fecal impactiond) Detrusor instability
  • 71. QUESTION 41A health-care worker has a negative tuberculin skin test(Mantoux method). A second test 10 dayslater is positive. This result indicatesANSWERa) a false-positive skin testb) long-standing, latent infectionc) probable immunodeficiencyd) previous vaccination with BCG
  • 72. QUESTION 42The most common manifestation of uterine ruptureduring labor isANSWERa) vaginal hemorrhageb) regression of the fetusc) sudden, tearing uterine paind) fetal distress
  • 73. QUESTION 43Which one of the following tests is most useful for theinitial workup of suspected Alzheimer’s disease?ANSWERa) Carotid Doppler ultrasonographyb) An erythrocytesedimentation ratec) A cardiac stress testd) A TSH level
  • 74. CASE REPORTA 78-year-old white female presents with a 3-day history oflower thoracic back pain. She denies any antecedent fall ortrauma, and first noted the pain upon arising. Herdescription of the pain indicates that it issevere, bilateral, and without radiation to the arms or legs.Her past medical history is positive for hypertension andcontrolled diabetes mellitus. Her medications includehydrochlorothiazide, enalapril, metformin, and a generalmultivitamin. She is a previous smoker but does not drinkalcohol. She underwent menopause at age 50 and tookestrogen for “a few months” for hot flashes. Physicalexamination reveals her to be in moderate pain with asomewhat stooped posture and mild tenderness over T12–L1. She has negative straight-leg raising and normal lowerextremity sensation, strength, and reflexes.
  • 75. QUESTION 44Which one of the following is true regarding this patient’slikely condition?ANSWERa) Subcutaneous or intranasal calcitonin may be veryhelpful for pain reliefb) Investigation for an underlying malignancy isindicatedc) Prolonged (approximately 2 weeks) bed rest willincrease the chance of completerecoveryd) An MRI or nuclear medicine bone scan should beperformed
  • 76. QUESTION 45Which one of the following agents used for tocolysishas the unique adverse effect of respiratorydepression?ANSWERa) Ritodrineb) Magnesium sulfatec) Terbutalined) Indomethacin
  • 77. QUESTION 46A 5-year-old male is scheduled for elective herniarepair at 11:00 a.m. Which one of the followingwould be the most appropriate recommendation?ANSWERa) No solid food for 8 hours prior to surgery and clearliquids until 2 hours prior to surgeryb) No solid food after midnight and nothing by mouth8 hours prior to surgeryc) Nothing by mouth 8 hours prior to surgeryd) Nothing by mouth 2 hours prior to surgery
  • 78. QUESTION 47The only nonsexual behavior that is consistentlyand strongly correlated with cervical dysplasiaand cervical cancer isANSWERa) caffeine consumptionb) cigarette smokingc) cocaine used) a high-fat diet
  • 79. QUESTION 48Which one of the following is the first-line antibiotictreatment for uncomplicated acute otitis media?ANSWERa) Ceftriaxoneb) Trimethoprim/sulfamethoxazolec) Amoxicillind) Cefuroxime
  • 80. CASE REPORTA 4-year-old male has a fever of 1 week’s duration. Ithas been at or slightly above 38° C (101°F) and hasresponded poorly to antipyretics. The patientcomplains of photophobia, burning in his eyes, and asore throat. His mother also notes that his eyes lookred, his lips are red and cracked, and he has a“strawberry tongue.” The child’s palms and soles areerythematous and the periungual regions showdesquamation of the skin. He has minimally painfulnodes located in the anterior cervical region, about2×2 cm in size. A Streptococcus screen is negative.
  • 81. QUESTION 49The most appropriate management at this timewould be?ANSWERa) intravenous nafcillinb) intramuscular benzathine penicillin G 600,000 Uc) intravenous immune globulin and aspirind) prednisone, 2–3 mg/kg daily
  • 82. QUESTION 50Patients with symptomatic congestive heart failureassociated with a reduced systolic ejectionfraction or left ventricular remodeling should beinitially treated with which one of the followingagents?ANSWERa) Verapamilb) An ACE inhibitorc) Hydralazined) Warfarin
  • 83. CASE REPORTA 6-year-old white male visits your office with chiefcomplaints of a recent onset of fever, bilateral kneeand ankle pain, colicky abdominal pain, and rash. Onexamination, his temperature is 38.3° C (101.0°F), and there is a prominent palpable reddish-brownrash on the buttocks and thighs. There is pain onmotion of his knees and ankles, and mild diffuseabdominal tenderness. The stool is positive for occultblood. Laboratory Findings: Hemoglobin 11.0 g/dLHematocrit 33% WBCs 14,500/mm; 85% segs, 3 15%lymphs, Platelets 345,000/mm 3 Prothrombin time12 sec
  • 84. QUESTION 51Which one of the following is the most likely diagnosis?ANSWERa) Henoch-Schönlein purpurab) Rocky Mountain spotted feverc) Acute iron ingestiond) Systemic onset juvenile rheumatoid arthritis
  • 85. QUESTION 52Which one of the following drug classes is preferred fortreating hypertension in patients who also havediabetes mellitus?ANSWERa) alpha-Blocking agentsb) ACE inhibitorsc) Centrally-acting sympatholyticsd) Calcium channel blockers
  • 86. CASE REPORTA 76-year-old white male with a history of recurrentdepression has recently become more depressed anddeveloped psychotic features. His symptoms havenot responded to antidepressants and antipsychoticagents, prescribed by his psychiatrist. Thepsychiatrist has recommended electroconvulsivetherapy (ECT) for the patient. The patient’s familyvisits you to ask for your opinion andrecommendations regarding ECT in this individual.
  • 87. QUESTION 53In your consultation with this family, which one of thefollowing would be accurate advice regarding ECT?ANSWERa) It has a low response rateb) It is efficacious and safec) There is evidence that it predisposes to thedevelopment of dementiad) It causes irreversible short-term memory loss
  • 88. QUESTION 54Metformin, which is normally used in the managementof diabetes mellitus, has also been shown to have abeneficial effect inANSWERa) hyperthyroidismb) polycystic ovary syndromec) right ventricular hypertrophyd) osteoporosis
  • 89. CASE REPORTA 45-year-old white male presents with a 3-day historyof new-onset acute upper abdominal pain radiatingto the back. His pulse rate is 110 beats/min andother vital signs are normal. Bowel sounds arehypoactive and epigastric tenderness withoutguarding is present.
  • 90. QUESTION 55Which one of the following is most accurate regardinglaboratory testing for possible pancreatitis in this situation?ANSWERa) Serum amylase and lipase levels may be falsely low in renalfailureb) Elevated serum triglyceride levels can cause falsely elevatedserum amylase levelsc) There is a direct correlation between serum amylase levelsand the severity of thepancreatitisd) A serum amylase level that is three times normal is highlyspecific for pancreatitis
  • 91. QUESTION 56You are evaluating a 28-year-old primigravida for anabnormal Papanicolaou (Pap) test. Which one of thefollowing procedures would be contraindicated?ANSWERa) Endocervical curettageb) Human papillomavirus (HPV) testingc) Colposcopyd) Cervical staining
  • 92. QUESTION 57Which one of the following should be withheld beforethe administration of intravenous contrast?ANSWERa) Insulinb) Metforminc) Rosiglitazoned) Glyburide
  • 93. CASE REPORTYou are considering how useful a new treatment mightbe in preventing stroke. A well designed study isreported with 200 patients in the treated group and200 patients in the untreated group. The study findsa 5-year risk of stroke of 3% in the treated groupversus 5% in the untreated group.
  • 94. QUESTION 58Assuming this study is valid and applicable to yourpatient population, how many patients would youhave to treat for 5 years to prevent one stroke(number needed to treat, or NNT)?ANSWERa) 200b) 25c) 400d) 50
  • 95. CASE REPORTOver the past year, a 27-year-old female has hadmarked feelings of anxiety, tension, and irritabilityduring the week preceding most menstrualcycles, accompanied by extreme fatigue andinsomnia. She has regularly missed several days ofwork each month because of fatigue. She has noprevious history of any health or mentalproblems, and within a few days of the onset of herperiod she is back to normal.
  • 96. QUESTION 59Which one of the following is true concerning thiscondition?ANSWERa) Alprazolam is an effective first-line agent fortreatment of this conditionb) This condition is a variation of a depressive disorderc) Neither biologic nor psychological factors play a partin this conditiond) This problem can be effectively treated withserotonergic antidepressants
  • 97. CASE REPORTAn 81-year-old retired electrical engineer whose wife is adiabetic was experimenting with his wife’s glucose meterand found that his glucose level was 198 mg/dL. He usedher strips and lancets, and started his own log. After aweek, he brings the log to you. His premeal glucose levelsrange from about 150 mg/dL to 250 mg/dL. A review ofhis medications shows none that would be likely toincrease his glucose level. A physical examination doesnot suggest glucose intolerance secondary to a processother than diabetes. His hemoglobin A1c is 9.0%.Additional laboratory studies should be performedbefore prescribing
  • 98. QUESTION 60which one of the following for this patient?ANWSERa) Metforminb) Glimepiridec) Miglitold) Insulin NPH
  • 99. QUESTION 61A 23-year-old gravida 3 para 1 at 28 weeks gestation whoseblood type is O-negative is antibody positive (D antibody)on a routine 28-week screen. Which one of the followingbest describes the clinical significance of this finding?ANSWERa) The fetus HAS hemolytic disease and requiresappropriate monitoring and treatmentb) The current fetus is NOT at risk for hemolyticdisease, but subsequent pregnancies maybe at riskc) The fetus is AT RISK for hemolytic disease only if thebiological father is Rh-negatived) The fetus is AT RISK for hemolytic disease only if thebiological father is Rh-positive
  • 100. CASE REPORTA 5-year-old African-American male presents withbehavior problems noted in the first 3 months ofkindergarten. The mother explains that the childdoes not pay attention and often naps in class. Heaverages 10 hours of sleep nightly and is heardsnoring frequently. The mother has a history ofattention-deficit disorder and takes atomoxetine(Strattera). The boy’s examination is within normallimits except for his being in the 25th percentile forweight and having 3+ tonsillar enlargement.
  • 101. QUESTION 62The most reasonable plan at this point would includewhich one of the following?ANSWERa) Polysomnographyb) An electroencephalogramc) Methylphenidated) Atomoxetine
  • 102. CASE REPORTA 16-year-old male is brought to your office by hismother for “stomachaches.” On review ofsystems, he also complains of headaches, occasionalbedwetting, and trouble sleeping. His examination iswithin normal limits. His mother says that he is oftenin the nurse’s office at school, and doesn’t seem tohave any friends. After some questions from you, headmits to being called names and teased at school.
  • 103. QUESTION 63Which one of the following would be mostappropriate?ANSWERa) Explain that these symptoms are a stress reactionand will lessen with timeb) Explain that he must try to conform to be morepopularc) Order a TSH leveld) Explore whether his school counselor has a processto address this problem
  • 104. QUESTION 64You are evaluating a 68-year-old male with obstructiveurinary symptoms. Which one of the followingmedications may lead to falsely depressed levels ofprostate-specific antigen (PSA)?ANSWERa) Tamsulosinb) Doxazosinc) Lycopened) Finasteride
  • 105. QUESTION 65The most appropriate initial treatment for scabies inan 8-year-old male is?ANSWERa) trimethoprim/sulfamethoxazole orally for 10 daysb) 0.5% malathion lotionc) 5% permethrin creamd) 5% precipitated sulfur in petroleum
  • 106. CASE REPORTA 3-year-old female presents with urinaryfrequency, dysuria, and fever to 39.0° C (102.2° F).She denies nausea, vomiting, fever, and flank pain.There is no prior history of urinary infection and nofamily history of urinary tract abnormalities. Urethralcatheterization reveals bacteriuria and a urineculture reveals >100,000 colony-forming units ofEscherichia coli. She is started on appropriateantibiotic therapy.
  • 107. QUESTION 66Evaluation to rule out anatomic abnormalities shouldinclude?ANSWERa) renal ultrasonography and voidingcystourethrography (VCUG) only if she has recurrentinfectionsb) renal ultrasonography only if she has recurrentinfectionsc) renal ultrasonography for this primary episode ofinfectiond) renal ultrasonography and VCUG for this primaryepisode of infection
  • 108. CASE REPORTA slender 22-year-old female is concerned about arecent weight loss of 10 lb, frequent mild abdominalpain, and significant diarrhea of 2 months’ duration.Her physical examination is unremarkable, andlaboratory studies reveal only a moderatemicrocytic, hypochromic anemia. Based on thispresentation.
  • 109. QUESTION 67which one of the following is the most likely diagnosis?ANSWERa) Villous adenomab) Ulcerative colitisc) Infectious colitisd) Celiac disease
  • 110. QUESTION 68A 73-year-old white male has severe COPD manifestedby repeated hospital admissions, 30-step dyspnea onexertion, asthenia, and a resting pO of 58 mm Hg. Ofthe following, which intervention will most likelypositively affect his survival?ANSWERa) Inhaled corticosteroidsb) Beta -Agonistsc) Oxygen supplementationd) Pulsed antibiotic therapy
  • 111. QUESTION 69In patients with bipolar depression, monotherapy withwhich one of the following may trigger amanic episode?ANSWERa) Lithiumb) Carbamazepinec) Lamotrigined) Fluoxetine
  • 112. CASE REPORTA 30-year-old female presents with concerns aboutvaginal bleeding. She states that her menstrualperiods have occurred at regular intervals of 28–30days for the past 15 years, but recently bleeding hasalso occurred for a day or two in the middle of hercycle. This bleeding has been heavy enough torequire the use of multiple pads.
  • 113. QUESTION 70Which one of the following terms best describes herbleeding pattern?ANSWERa) Polymenorrheab) Metrorrhagiac) Menometrorrhagiad) Acute emergent abnormal uterine bleeding
  • 114. QUESTION 71A 25-year-old female presents with abdominal painlocalized to the right lower quadrant. Which one ofthe following would be most helpful in diagnosingacute appendicitis?ANSWERa) Abdominal/pelvic ultrasonographyb) A CBCc) Plain abdominal filmsd) Abdominal/pelvic C
  • 115. QUESTION 72A 17-year-old white female presents with new-onsetleft-sided lower abdominal pain. Color flow Dopplerultrasonography, in addition to pelvicultrasonography, would be most useful forevaluating?ANSWERa) pelvic inflammatory diseaseb) pelvic abscessc) adnexal torsiond) ruptured ovarian cyst
  • 116. QUESTION 73A 30-year-old female presents with a vaginal discharge. Onexamination the discharge is homogeneous with a pH of5.5, a positive whiff test, and many clue cells. Which oneof the following findings in this patient is most sensitivefor the diagnosis of bacterial vaginosis?ANSWERa) The character of the dischargeb) The presence of clue cellsc) The pH of the discharged) The whiff test
  • 117. CASE REPORTA 25-year-old female at 36 weeks gestation presents fora routine prenatal visit. Her blood pressure is 118/78mm Hg and her urine has no signs of protein orglucose. Her fundal height shows appropriate fetalsize and she says that she feels well. On palpation ofher legs, you note 2+ pitting edema bilaterally.
  • 118. QUESTION 74Which one of the following is true regarding thispatient’s condition?ANSWERa) Her leg swelling requires no further evaluationb) She most likely has deep venous thrombosisc) She most likely has preeclampsiad) You should order a 24-hr urine for protein
  • 119. QUESTION 75Which one of the following is most likely to inducewithdrawal symptoms if discontinued abruptly?ANSWERa) Divalproexb) Venlafaxinec) Fluoxetined) Olanzapine
  • 120. CASE REPORTA 78-year-old male comes to your office with a 3-dayhistory of pain in the right side of his chest. The painis described as burning and intense. Two days ago henoted a rash at that site. Examination reveals groupsof vesicles on an erythematous base in a T-5dermatome distribution on the right.
  • 121. QUESTION 76Which one of the following would be the mostappropriate treatment to minimize the chance ofpost-herpetic neuralgia?ANSWERa) Carbamazepineb) Capsaicinc) Prednisoned) Famciclovir
  • 122. QUESTION 77Which one of the following is the most common causeof bacterial diarrhea?ANSWERa) Shigella dysenteriaeb) Escherichia coli O157:H7c) Campylobacter jejunid) Salmonella enterica
  • 123. CASE REPORTA 28-year-old gravida 2 para 1 at 32 weeks gestationpresents with severe itching. She denies fever orvomiting. Her physical examination is remarkablefor jaundice, but is otherwise benign. Laboratorystudies reveal a normal CBC, normalplatelets, normal glucose and serum creatininelevels, normal transaminase levels, and a bilirubinlevel of 4.0 mg/dL.
  • 124. QUESTION 78Which one of the following is the most likely diagnosis?ANSWERa) Serum hCG levels should double every 2–3 days ifthe pregnancy is viableb) Painless bleeding excludes the diagnosis of ectopicpregnancyc) Laparoscopy should be performed to excludeectopic pregnancyd) A serum progesterone level >25 ng/mL indicatesthat ectopic pregnancy is likely
  • 125. CASE REPORTA 35-year-old white female presents with a 6-monthhistory of irregular menstrual bleeding. Before thisproblem began, her periods occurred every 30 daysand lasted 5 days. Now they occur every 20 days andlast for 10 days, and are heavier than they werepreviously. A physical examination reveals no obviousanatomic source of bleeding, and a Papanicolaou(Pap) test is normal. A pregnancy test is negative anda blood workup for organic causes of irregularmenses is also negative. She takes no medications.
  • 126. QUESTION 79Which one of the following would be most appropriateat this point?ANSWERa) Reassurance that the problem will resolve on itsownb) Changing to a progesterone-only contraceptivec) Increasing the dosage of the oral contraceptived) Pelvic ultrasonography
  • 127. QUESTION 80Which one of the following is true regarding the risk ofphysical spouse abuse?ANSWERa) It increases with alcohol and substance abuseb) It decreases when a woman exits an abusiverelationshipc) It is higher among patients from racial minoritiesd) It increases as socioeconomic status rises
  • 128. QUESTION 81Which one of the following causes rhinitismedicamentosa with prolonged use in the treatmentof rhinitis?ANSWERa) Intranasal decongestantsb) Intranasal antihistaminesc) Intranasal mast cell stabilizersd) Leukotriene antagonists
  • 129. CASE REPORTAn 83-year-old female presents to your office as a newpatient. She recently moved to the area to be closerto her family. A history reveals that she has been inexcellent health, has no complaints, and is on nomedications except occasional acetaminophen forknee pain. She has never been in the hospital andhas not had any operations. She says that she feelswell. The examination is normal, with expected age-related changes, except that her blood pressure onthree different readings averages 175/70 mm Hg.These readings are confirmed on a subsequentfollow-up visit. In addition to lifestyle changes.
  • 130. QUESTION 82which one of the following would be most appropriatefor the initial management of this patient’shypertension?ANSWERa) A thiazide diureticb) An angiotensin receptor blockerc) An ACE inhibitord) A beta-blocker
  • 131. QUESTION 83Surgery for obesity would be most appropriate for which one ofthe following?ANSWERa) A 37-year-old African-American female who has failedmultiple diets, has no coexisting medical problems, and has aBMI of 38b) A 43-year-old African-American male with type 2 diabetesmellitus who has failed multiple diets and has a BMI of 38c) A 31-year-old white male who has lost 50 lb on his diet andimproved his sleep apnea, hypertension, and diabetesmellitus, but still has a BMI of 42d) A 45-year-old white female with a history of depression andalcohol abuse who has failed multiple diets and has a BMI of40
  • 132. CASE REPORTA 22-year-old gravida 2 para 1 presents to your officewith a 1-day history of vaginal bleeding andabdominal pain. Her last menstrual period was 10weeks ago, and she had a positive home pregnancytest 6 weeks ago. She denies any passage of clots. Onpelvic examination, you note blood in the vaginalvault. The internal cervical os is open.
  • 133. QUESTION 84Which one of the following best describes the patient’scurrent condition?ANSWERa) Completed abortionb) Threatened abortionc) Incomplete abortiond) Inevitable abortion
  • 134. CASE REPORTA 34-year-old white female visits your office with a chiefcomplaint of pelvic pain that intensifies with her menstrualperiod. She has a history of pain during intercourse, whichstarted in her mid-twenties and has gradually becomeworse. She reports recently missing some work during hermenstrual period due to the pain. She has had twouneventful deliveries and the pain was absent during andafter each pregnancy, but gradually returned. She and herhusband do not wish to have any more children and herhusband has had a vasectomy. The patient denies vaginaldischarge or fever and a review of systems is negative. Acomplete physical examination is normal except formoderate nonspecific tenderness on pelvic examination. Inaddition, her uterus is moderately retroverted and hasdecreased mobility.
  • 135. QUESTION 85Which one of the following would be the mostappropriate initial step in the management of thispatient?ANSWERa) A complete hysterectomy and bilateraloophorectomyb) Conjugated estrogensc) Depot medroxyprogesterone acetated) contraceptives
  • 136. CASE REPORTA 62-year-old male presents for surgical clearance priorto transurethral resection of the prostate. His pasthistory is significant for a pulmonary embolus after acholecystectomy 15 years ago. His examination isunremarkable except that he is 23 kg (50 lb)overweight.
  • 137. QUESTION 86The most appropriate recommendation to the urologistwould be to?ANSWERa) place the patient on 650 mg of aspirin daily prior tosurgeryb) start warfarin after surgery with a goal INR of 1.5c) start the patient on subcutaneous enoxaparin, 40mg 1–2 hr prior to surgery and once a day aftersurgeryd) cancel the surgery indefinitely
  • 138. CASE REPORTA 28-year-old white female sees you for preconceptioncounseling. For the past 3 years she has beensuccessfully treated with fluoxetine (Prozac) fordepression, and she asks if she can continue taking itwhen she becomes pregnant. It is labeled by the FDAas category C for use in pregnancy.
  • 139. QUESTION 87Which one of the following would you advise?ANSWERa) Animal studies do not indicate any risk to the fetus;there are no studies in womenb) Animal studies demonstrate some risk to the fetus;there are no studies in womenc) Controlled studies in women fail to demonstrate risk tothe fetus; it is safe to continue itd) There is evidence of harm to the human fetus, and sheshould discontinue it
  • 140. QUESTION 88Which one of the following is most predictive ofincreased perioperative cardiovascular eventsassociated with noncardiac surgery in the elderly?ANSWERa) An age of 80 yearsb) Renal insufficiency (creatinine 2.0 mg/dL)c) Left bundle-branch blockd) A history of previous stroke
  • 141. QUESTION 89Which one of the following statements regardingvaricoceles is true?ANSWERa) The incidence of varicoceles in adult males is <5%b) Varicoceles usually begin between 5 and 8 years ofagec) A unilateral varicocele on the right side should bereferred for further evaluationd) Most varicoceles are bilateral
  • 142. QUESTION 90A 2-year-old white female is brought to your office byher parents, who are concerned about the child’s“flat feet.” On evaluation, the child’s feet are flat withweight-bearing, but with toe standing and withsitting the arch appears. You would?ANSWERa) reassure the parentsb) recommend surgeryc) recommend foot-stretching exercisesd) recommend orthotics
  • 143. QUESTION 91When a woman less than 50 years of age developsvulvar cancer, which one of the following associatedconditions is most frequently present?ANSWERa) Lichen sclerosusb) Syphilisc) Human papillomavirusd) Lymphogranuloma venereum
  • 144. QUESTION 92A 35-year-old white male with known long QTsyndrome has a brief episode of syncope requiringcardiopulmonary resuscitation. Which one of thefollowing is most likely responsible for this episode?ANSWERa) Asystoleb) Atrial flutter with third degree blockc) Sinus tachycardiad) Torsades de pointes
  • 145. QUESTION 93Which one of the following is associated with a reducedrisk of postmenopausal osteoporosis?ANSWERa) Diuretic useb) Cigarette smokingc) Low BMId) Corticosteroid use
  • 146. QUESTION 94A 59-year-old female with type 2 diabetes develops a2×1-cm ulcer on the plantar aspect of her right foot.The ulcer is very deep and there is surroundingcellulitis. A plain film is normal. Which one of thefollowing would be the imaging study of choice torule out osteomyelitis in this patient?ANSWERa) A leukocyte scanb) A CT scanc) Angiographyd) An MRI scan
  • 147. CASE REPORT• An 83-year-old female is admitted to the hospitalwith an exacerbation of her COPD. On the secondhospital day she is clinically improved but is quitedisoriented, experiencing visualhallucinations, agitation, and problems with recentmemory and attention span. She is noted bynthenursing staff to periodically fall asleep duringconversation. Her previous medical history is notablefor emphysema and hypertension, but there is nohistory of psychiatric problems. Her blood pressure is140/82 mm Hg, pulse 88 beats/min, and oxygensaturation 98% on 2 L of nasal Oxygen.
  • 148. QUESTION 95Which one of the following does this patient mostlikely have?ANSWERa) Schizophreniab) Maniac) Acute depressiond) Delirium
  • 149. QUESTION 96A 31-year-old white female presents with her thirdstress fracture of a lower extremity in the past4years. Her history and examination are otherwiseunremarkable except for a controlled seizuredisorder. The most likely cause of her bone problemis?ANSWERa) hypothyroidismb) Addison’s diseasec) anticonvulsive medicationd) osteogenesis imperfecta
  • 150. QUESTION 97A 25-year-old female has unprotected intercourse andchooses to use Plan B (two 0.75 mg tablets oflevonorgestrel, taken 12 hours apart) as a form ofemergency contraception. Plan B has been shown toANSWERa) prevent implantation, ovulation, and fertilizationb) protect against sexually transmitted diseasesc) be teratogenic to an already established pregnancyd) be effective only if used within 24 hours ofunprotected intercourse
  • 151. QUESTION 98The antimalarial agent mefloquine would becontraindicated in which one of the followingpatients?ANSWERa) A 50-year-old female with chronic renal failure anda creatinine clearance of 50 mg/minb) A 25-year-old female at 32 weeks gestationc) A 55-year-old male with COPD who uses inhaledalbuterol and ipratropium bromided) A 45-year-old male with epilepsy controlled withphenytoin.
  • 152. CASE REPORTRecent studies and meta-analyses have shown thatsupplementation with a particular vitamin may domore harm than good. This has resulted in a reversalin the recommendation for its use in patients withknown coronary artery disease, and arecommendation for caution in its use in general forelderly patients.
  • 153. QUESTION 99This is true of which one of the following?ANSWERa) Vitamin Ab) Vitamin Cc) Vitamin B 12d) Vitamin E
  • 154. CASE REPORTIn early February, you receive a call from your officenurse. Her 5-month-old daughter has been ill forseveral days. What started as a mild upperrespiratory infection has progressed and she now hasprofuse rhinorrhea, a temperature of 100.2° F (37.9°C), and audible wheezing. In spite of an almostnonstop cough, she does not appear acutely ill.
  • 155. QUESTION 100The organism responsible for this child’s illness ismost likely to be?ANSWERa) Bordetella pertussisb) respiratory syncytial virusc) group B Streptococcusd) parainfluenza virus 3
  • 156. QUESTION 101Of the following, which is the most frequent cause ofseizures in the elderly?ANSWERa) Strokeb) Head traumac) Dementiad) Alcohol withdrawal
  • 157. CASE REPORTA 4-week-old full-term male is brought to your office byhis parents. They report that their child startedvomiting just after his 1-week visit. The parents areconcerned because they think the vomiting isworsening, occurring after every feeding, and“shooting across the room.” You note that the baby isafebrile, but has not gained any weight since birth.
  • 158. QUESTION 102A 32-year-old gravida 3 para 2 is in labor at term followingan uncomplicated prenatal course. As you deliver thefetal head it retracts against the perineum. Downwardtraction fails to free the anterior shoulder. The mostappropriate course of action would be to?ANSWERa) have an assistant apply fundal pressureb) place the mother’s thighs on her abdomenc) apply increasingly strong downward traction to the fetalheadd) deliberately fracture the clavicle of the fetus
  • 159. CASE REPORTA 14-year-old male is brought to your office by hismother to establish care. The patient has beendiagnosed with asthma, but has not been on anymedications for the past year. When questioned, hereports that his asthmatic symptoms occur daily andmore than one night per week. On examination, he isfound to have a peak expiratory flow of 75%.
  • 160. QUESTION 103Based on these findings, the most accurateclassification of this patient’s asthma is?ANSWERa) mild persistentb) moderate persistentc) severe persistentd) mild intermittent
  • 161. QUESTION 104Which one of the following Papanicolaou (Pap) testresults is most likely to indicate a cancerous lesion?ANSWERa) High-grade squamous intraepithelial lesion (HSIL)b) Atypical glandular cells not otherwise specified(AGC-NOS)c) Low-grade squamous intraepithelial lesion (LSIL)d) Atypical squamous cells cannot exclude high-gradeintraepithelial lesion (ASC-H)
  • 162. CASE REPORTA 72-year-old female has stable but moderatelysevere COPD requiring 2 L of continuous oxygen.She plans to attend the college graduation of herfirst grandchild, and wants to fly to avoid a 12-hourcar ride. Her PaO on room air is 55 mm Hg.
  • 163. QUESTION 105• According to the Federal Air Regulations, she MUST?ANSWERa) find a form of transportation other than air travelb) bring a medical certificate from you certifying thatshe is cleared to fly without oxygenc) arrange through the airline for oxygen to beavailable on board and in the airportsd) undergo preflight testing, including pulmonaryfunction testing and high-altitude simulationtesting, before she can be cleared to fly
  • 164. QUESTION 106Which one of the following criteria is most likely to signifythat an individual has bulimia nervosa rather thananorexia nervosa?ANSWERa) The absence of at least three consecutive menstrualcycles in a postmenarchal nonpregnant femaleb) Recurrent episodes of binge eatingc) Intense fear of weight gain or becoming fat, eventhough underweightd) Denial of the seriousness of the current low bodyweight
  • 165. QUESTION 107Painful ingrown toenails that display granulation tissueand lateral nail fold hypertrophy are besttreated by?ANSWERa) removal of the entire nailb) cotton-wick elevation of the affected nail cornerc) antibiotic therapyd) excision of the lateral nail plate combined withlateral matricectomy
  • 166. CASE REPORTA 36-year-old female makes an appointment becauseher husband of 12 years was just diagnosed withhepatitis C when he tried to become a blood donorfor the first time. He recalls multiple bloodtransfusions following a motorcycle crash in 1988.His wife denies past liver disease, bloodtransfusions, and intravenous drug use. She has hadno other sexual partners. The couple has threechildren.
  • 167. QUESTION 108Which one of the following is the best advice abouttesting the wife and their three children?ANSWERa) No testing is required if her husband has normalliver enzyme levelsb) No testing is required because tests have lowsensitivityc) All family members should be tested because ofpossible household fecal-oral spreadd) She should be offered testing because sexualtransmission is possible
  • 168. QUESTION 109You are evaluating a 5-month-old withfever, tachypnea, and mild respiratory distress in theemergency department. You hear mild basilar rales.The child does not appear toxic. Which one of thefollowing tests would be the most appropriate as aninitial study?ANSWERa) A C-reactive protein levelb) A chest radiographc) A CBCd) Oxygen saturation by pulse oximetry
  • 169. QUESTION 110The elderly patient may process medications differentlythan a younger adult. Which one of the following isLEAST affected by aging?ANSWERa) Absorptionb) Distributionc) Complianced) Metabolism
  • 170. QUESTION 111A 72-year-old Asian female is found to have asymptomaticgallstones on abdominal ultrasonography performed toevaluate an abdominal aortic aneurysm. Which one ofthe following would be the most appropriatemanagement for the gallstones?ANSWERa) Lithotripsyb) Laparoscopic cholecystectomyc) Open cholecystectomyd) Observation
  • 171. • A 34-year-old female presents to you forpreconception counseling regarding themanagement of her chronic hypertension. Herblood pressure has been well controlled onbenazepril, 20 mg/day, without any side effects.The patient’s blood pressure was 145/95 mm Hgprior to beginning benazepril. She has beenpregnant once before, and her physician switchedher to methyldopa during that pregnancy, but shesuffered from drowsiness and a dry mouth duringmuch of that time. The pregnancy and deliverywere otherwise uncomplicated. She has nohistory of diabetes mellitus, renal insufficiency, orasthma. She is a nonsmoker.
  • 172. QUESTION 112• Which one of the following would you do when shebecomes pregnant?ANSWERa) Switch to atenolol until after deliveryb) Switch to long-acting nifedipine until after deliveryc) Continue the benazepril through the pregnancy anddeliveryd) Discontinue the benazepril and monitor closelythroughout the pregnancy for signs ofpreeclampsia or fetal growth restriction
  • 173. QUESTION 113Which one of the following is the preferred treatmentfor patients with obsessive-compulsive disorder?ANSWERa) Valproic acidb) Alprazolamc) Fluoxetined) Lithium carbonate
  • 174. QUESTION 114When repairing a perineal laceration after a vaginaldelivery, which one of the following suture materialsdecreases both wound dehiscence and postpartumperineal pain?ANSWERa) Polyglactin 910 (Vicryl)b) Silkc) Plain catgutd) Polypropylene
  • 175. QUESTION 115A 40-year-old female is scheduled for acholecystectomy and you wish to estimate her riskfor postoperative bleeding. Which one of thefollowing provides the most sensitive method foridentifying her risk?ANSWERa) Prothrombin time (PT)b) Activated partial thromboplastin time (aPTT)c) Bleeding historyd) Bleeding time
  • 176. QUESTION 116A mother is nearing the end of maternity leave. Sheasks for your advice regarding breastfeeding herinfant after she returns to work. Which one of thefollowing would be accurate advice?ANSWERa) Breast milk should be stored in glass bottlesb) Separation of breast milk indicates spoilagec) Breast milk should be thawed in boiling waterd) Refreezing breast milk destroys some proteins
  • 177. QUESTION 117Compared to anesthesia using only parenteralopioids, the use of epidural anesthesia in labor anddelivery increases the rate of which one of thefollowing?ANSWERa) Low Apgar scores (<7)b) Maternal low backache 3 months post deliveryc) Prolonged second stage of labord) Cesarean section
  • 178. CASE REPORTA 70-year-old white female presents with a pruritic rashof her sacrum that has occurred intermittently overthe last 6 years. She reports that the area is alwaysvery tender just before the blister-like lesions erupt.She is otherwise in good health, and takes nomedications. Her past medical history isunremarkable. You provide appropriate treatmentfor the condition.
  • 179. QUESTION 118You should advise the patient to avoid which one ofthe following during future outbreaks?ANSWERa) Sexual contactb) Prolonged sittingc) Sun exposured) Excessive intake of green, leafy vegetables
  • 180. • A 32-year-old female presents with bilateralpretibial tender, mildly red nodules 2–4 cm indiameter. A nodule that appeared earlierresolved, leaving a “bruised” area. She had asimilar problem once when she was pregnant butit resolved spontaneously. Her medicationsinclude lovastatin (Mevacor) for hyperlipidemiaand a low-dose oral contraceptive prescribed 5months earlier. Her past history and a review ofsystems are otherwise unremarkable.
  • 181. QUESTION 119The most appropriate next step would be toANSWERa) order a serum creatine phosphokinase levelb) discontinue her oral contraceptivec) obtain a cervical culture for gonorrhead) discontinue lovastatin
  • 182. QUESTION 120A 23-year-old female was recently diagnosed withbipolar disorder after experiencing her first episodeof acute severe mania. Which one of the followingwould be appropriate initial maintenance therapy forher?ANSWERa) No medication unless she has a second severeepisodeb) Valproatec) Gabapentind) Lorazepam
  • 183. CASE REPORTA 23-year-old sexually active female presents to youroffice with a 2-week history of vaginal discharge andmild coital discomfort. On physical examination, younote the presence of a mucopurulent vaginaldischarge and cervical friability. She is afebrile andthere are no other positive physical findings. Notrichomonads or yeast is seen on vaginalpreparations. Material for Chlamydia trachomatis–specific DNA testing is submitted and results will beavailable in 2 days.
  • 184. QUESTION 121Which one of the following is true regarding appropriatemanagement?ANSWERa) No treatment is indicated until laboratory results areknownb) metronidazole given now will clear her dischargec) A 7-day course of doxycycline is superior to a 1-g doseof azithromycind) The patient should be instructed to refrain from sexualintercourse until 7 days afterinitiating therapy
  • 185. QUESTION 122Compared to children with ADHD, adults with ADHD?ANSWERa) tend to be less impulsiveb) tend to be more hyperactivec) are less likely to complain of inattention difficultiesd) are less likely to have corroboration of symptoms byfamily members
  • 186. QUESTION 123A 33-year-old female requests combined oralcontraceptive pills (OCPs) for birth control. Whichone of the following would be a contraindication toprescribing OCPs for this patient?ANSWERa) A family history of ovarian cancerb) A history of controlled hypertensionc) A history of hepatitis C infection with no liverdiseased) A history of thromboembolic disease
  • 187. QUESTION 124Routine blood tests frequently reveal elevated calciumlevels. When this elevation is associated withelevated parathyroid hormone levels, which one ofthe following is an indication for parathyroid surgery?ANSWERa) Concurrent hyperthyroidismb) Increased bone densityc) Age >50d) Kidney stones
  • 188. QUESTION 125A 21-year-old female had a pelvic examination and anormal Papanicolaou (Pap) test 3 months ago. She is nowbeing treated for chlamydial cervicitis withazithromycin, 1 g in a single dose. When should she nexthave a test for Chlamydia?ANSWERa) Never, unless she is symptomatic or has a suspectedexposure to Chlamydia at somepoint in the futureb) 3–4 monthsc) 1–2 weeksd) 9 months (at her next routine pelvic examination)
  • 189. QUESTION 126A 10-year-old male develops a fever 3 months afterreturning to the U.S. following a year in the tropics. Hewas treated with the proper immunizations and givenappropriate prophylactic medications before he wentabroad with his parents. Which one of the followingtropical illnesses should be considered in the differentialdiagnosis?ANSWERa) Typhoid feverb) Dengue feverc) Plagued) Malaria
  • 190. CASE REPORTA mother brings her 12-month-old son to yourclinic, concerned that he is repeatedly banging his headagainst the floor, wall, or crib. She reports that thisbehavior began about 2 months ago. It now occursseveral times per week, and at times is incited whenthe child is frustrated with a toy or when he does notget what he wants from his parents. The mother notesthat she is sometimes awakened at night by the soundof her son rhythmically banging his head against therail of hiscrib. Physical examination reveals a normalchild with some soft-tissue swelling of theforehead, but no broken skin, ecchymosis, or signs ofbony damage. Developmental milestones and growthhave been normal, and the child is not on anymedications.
  • 191. QUESTION 127Children with this presentation are most likely to havewhich one of the following?ANSWERa) A skin laceration or skull fractureb) An eventual diagnosis of Lesch-Nyhan syndromec) Extinction of this habit by age 3d) Future cognitive delay when compared withchildren without this habit
  • 192. CASE REPORTA 4-year-old white female is brought to your office byher mother, who reports that the child recentlydeveloped a foul-smelling vaginal discharge. After anappropriate history and general examination, youdetermine that a genital examination is necessary.
  • 193. QUESTION 128Which one of the following positions is most likely toallow for visualization of the child’s vagina and cervixwithout instrumentation?ANSWERa) The knee-chest position on an examination tableb) Trendelenburg’s position on an examination tablec) The left lateral decubitus position on anexamination tabled) Supine in the mother’s lap
  • 194. QUESTION 129Which one of the following has been shown to transmitSalmonella infections to humans?ANSWERa) Iguanasb) Guinea pigsc) Civet catsd) Rabbits
  • 195. QUESTION 130The likelihood of postpartum depression is increased bywhich one of the following?ANSWERa) A prior history of depressionb) Bottle feedingc) Low educational leveld) Cesarean delivery
  • 196. QUESTIONA 31-year-old female presents with her first outbreak ofgenital herpes. She has been married for 4 years andsays she has not had sexual relations with anyoneother than her husband since they started dating.
  • 197. QUESTION 131When counseling this patient, which one of the followingwould be appropriate advice?ANSWERa) Suppressive therapy can decrease transmission tosexual partnersb) Daily application of topical acyclovir is effective forsuppressant therapyc) If type-specific serologies are negative, genital herpescan be ruled outd) Because the average incubation period for herpes is 3months, her husband has most likely had anothersexual partner in the past few months
  • 198. CASE REPORTA 32-year-old female is concerned about ovariancancer. She has no symptoms at this time.However, she has a close friend who was recentlydiagnosed with ovarian cancer at an advancedstage. This friend told the patient that a “simpleblood test” for CA-125 could detect ovariancancer at a curable stage.
  • 199. QUESTION 132As part of your discussion, you inform the patient thatwhich one of the following is true?ANSWERa) A high serum CA-125 level is not associated withovarian cancerb) Most consensus opinions recommend performingthis test for average-risk womenc) This test should not be ordered due to its high false-negative rated) Detecting ovarian cancer at an earlier stage usingserum CA-125 has not been shown to reducemortality
  • 200. QUESTION 133Ehrlichiosis may result from exposure to?ANSWERa) freshwater snailsb) fleasc) ticksd) rats
  • 201. QUESTION 134The best method of influenza prophylaxis in high-riskpatients is administration of?ANSWERa) oral amantadine daily during the influenza seasonb) influenza vaccine intramuscularly prior to theinfluenza seasonc) oral rimantadine daily during the influenza seasond) oral oseltamivir daily during the influenza season
  • 202. QUESTION 135A 75-year-old male is brought in by his family due toconcerns about memory loss. Which one of thefollowing is best for determining whether or not hehas dementia?ANSWERa) A Mini-Mental State Examination (MMSE)b) Non–contrast-enhanced CT of the headc) An electroencephalogramd) MRI of the head
  • 203. QUESTION 136Of the following, which one has the greatest potentialto spread via human-to-human transmission?ANSWERa) Pneumonic plagueb) Botulismc) Typhoidal tularemiad) Coxiella burnetii (Q fever)
  • 204. QUESTION 137The mother of a 3-year-old male is concerned that hedoesn’t like being held, doesn’t interact much withother children, and rarely smiles. Of thefollowing, which feature would be most helpful indistinguishing Asperger’s syndrome from autism inthis patient?ANSWERa) Repetitive fine motor mannerismsb) Delayed gross motor developmentc) Normal language developmentd) Preoccupation with parts of objects
  • 205. CASE REPORTA 76-year-old male is brought to your office by his son. Thepatient complains of dizziness that has slowly beenworsening over the past year. His description is vague, buthe says that he notices the dizziness when he tries to walk.The review of systems is normal, except for increasingproblems with his “prostate” in the last 6 months, withdribbling and accidents at times. The patient admits to“going more often,” and sometimes “without warning.” Theson states that his father seems more forgetful, slower ofspeech, and not as “full of life” as he used to be. Aneurologic examination reveals the patient to be oriented ×3, with a somewhat flat affect and a wide-based, slow, shuffling gait. The examination is otherwisenormal. His Mini-Mental State Examination (MMSE) score is22 out of 30. No tremor is noted. A CBC, creatininelevel, TSH level, vitamin B 12 level, and VDRL are all normal.
  • 206. QUESTION 138Which one of the following should you do next?ANSWERa) Order a brainstem auditory evoked potentialb) Prescribe sertraline (Zoloft)c) Order physical therapyd) Order a brain MRI
  • 207. QUESTION 139The most appropriate initial pharmacologic treatmentof panic disorder is?ANSWERa) valproic acid (Depakene)b) lithiumc) an SSRId) a tricyclic antidepressant
  • 208. CASE REPORTA 24-year-old worker at a local day-care center has nothad a menstrual period in over 2 months. A homepregnancy test is positive and is confirmed in youroffice. She is concerned because she was recentlyexposed to a child who was diagnosed with rubella.A serum rubella IgG antibody test is negative.
  • 209. QUESTION 140Which one of the following would be the best courseof action?ANSWERa) Order level III ultrasonography to screen forcongenital anomaliesb) Repeat the serologic testing in 2–3 weeksc) Administer rubella immune globulind) Tell the patient she is immune to rubella and is notat risk
  • 210. CASE REPORTA 23-year-old male with Down syndrome is brought toyour office by his parents. The patient has had a low-grade fever (approximately 100° F) for 7 days. Thefever is not associated with rhinorrhea, sorethroat, cough, dysuria, or shortness of breath. Theparents note that their son has complained of achesin various places, and has not been eating well forseveral weeks. The physical examination isremarkable for swollen lymph glands in multipleplaces, pale conjunctivae, and an 8-lb weight losssince his last visit 1 month ago.
  • 211. QUESTION 141Which one of the following is most consistent withthis patient’s symptoms?ANSWERa) Urinary tract infectionb) Atypical pneumoniac) Acute myeloid leukemiad) Hodgkin’s lymphoma
  • 212. QUESTION 142Which one of the following is true regarding Osgood-Schlatter disease?ANSWERa) Complete symptom resolution usually occurs in 18–24monthsb) Effusions are often present on examination and kneerange of motion is limitedc) Most cases are triggered by a single traumatic eventd) Pain is localized to the inferior patellar pole at the originof the patellar tendon
  • 213. QUESTION 143Which one of the following is an indicator of low riskfor streptococcal infection in a patient with acutepharyngitis?ANSWERa) Soft palate petechiaeb) Coughc) Anterior cervical lymphadenopathyd) Fever
  • 214. QUESTION 144Your community recently experienced an outbreak ofinfectious diarrheal illness due to the protozoanCyrptosporidium, a chlorine resistent organism. Areporter from the local newspaper asks you if there areother chlorine-resitant fecal organisms that couldcontaminate public drinking water. You would tell thereporter that such organisms include. 15/20 missedANSWERa) Escherichia Colib) Giardia Lambliac) Rotavirusd) Campylobacter jejuni
  • 215. CASE REPORTA 32-year-old white female comes to your officecomplaining of dysuria. She denies fever , backpain, and urinary frequency. She appears to be wellotherwise, and has a normal abdominal examination. Aclean-catch urinalysis shows 15-20 WBCs/hpf and adipstick test for leukocyte esterase is positive. You senda urine sample for culture and start the patient onnitrofurantoin (Macrodantin), as she is allergic to sulfa.Three days later, the patient returns with persistentdysuria despite taking the medication as prescribed.Her urine culture has returned with no growth. A pelvicexamination is normal, and the rest of the physicalexamination is unchanged. A wet prep is normal andtests for sexually transmitted diseases are pending.
  • 216. QUESTION 145Which one of the following antibiotics is mostappropriate for this patient now?ANSWERa) Metronidazoleb) Doxycyclinec) Cephalexind) Ciprofloxacin
  • 217. QUESTION 146In which one of the following would misoprostol beappropriate?ANSWERa) A primigravida at term whose cervix is dilated to 7 cmand whose frequency of contractions has slowedb) A primigravida with a long, thick cervix at term who hasa previous history of myomectomyc) A diabetic primigravida with a long, thick cervix at 38weeks gestation for whom induction is indicatedd) A gravida 2 para 1 with a long, thick cervix at term whois interested in vaginal birth after a cesarean section
  • 218. QUESTION 147Which one of the following therapeutic interventionsis useful in the treatment of croup, but is not anaccepted treatment for bronchiolitis?ANSWERa) Oral dexamethasoneb) Extracorporeal membrane oxygenationc) Nebulized racemic epinephrined) Oxygen via the blow-by method
  • 219. CASE REPORTYour office nurse reports an accidental needlestick witha used venipuncture needle. She had drawn bloodfrom a 35-year-old white male, who is a new patientundergoing evaluation for hypertension andhyperlipidemia. He has no evidence of other healthproblems and no risk factors for HIV. Both the nurseand the patient are found to be HIV negative.
  • 220. QUESTION 148Which one of the following would be the most appropriateadvice?ANSWERa) No further testing for HIV is necessaryb) She should begin treatment with prophylacticantiretroviral therapy within the next 48 hoursc) She should refrain from unprotected sexual contactwith her husband until another negative test 6 weeksafter the exposured) She should have repeat HIV testing at 6, 12, 24, and 52weeks after the exposure
  • 221. QUESTION 149Which one of the following is consistent with currentrecommendations?ANSWERa) Cervical cytologic screening should be done yearly prior tothe age of 30, with either a conventional Pap smear orliquid-based cytologyb) Cervical cancer screening should begin no later than 18years of age in all womenc) Cervical cancer screening with Papanicolaou (Pap) smearsshould begin within 1 year after the onset of vaginalintercoursed) Screening with vaginal cytology is not indicated in womenwho have had a total hysterectomy for benign gynecologicdisease
  • 222. QUESTION 150The predominant symptom associated with dysthymicdisorder is?ANSWERa) loosening of associationsb) delusionsc) incoherenced) depression
  • 223. QUESTION 151Which one of the following is a common early sideeffect of fluoxetine?ANSWERa) Skin rashb) Orthostatic hypotensionc) Constipationd) Loss of appetite
  • 224. CASE REPORTYou see a 17 year old white female who has recentlybecome sexually active. She requests oralcontraceptives and you perform a briefevaluation, including blood pressure measurment. APregnancy test is negative. She is resistant to furtherevaluation unless it is necessary.
  • 225. QUESTION 152In addition to appropriate counseling, which one of thefollowing should be done before prescribing oralcontraceptives? 17/20 missed.ANSWERa) No further evaluation at this visit unless indicatedby history.b) A pelvic examination and Papanicolaou testc) Screening for sexully transmitted diseases.d) A breast exam.
  • 226. CASE REPORTYou diagnose depression in a 27 year old whit maleand prescribe buproprion. He returns for a followup visit 4 weeks later. He now reports lessdespondency, but says he has developed severeinsomnia. He also report that his mind "races" allthe time, and that he has recieved two speedingtickets in the past 2 weeks
  • 227. QUESTION 153Which one of the following would be appropriatenow?ANSWERa) Add Valproateb) Add imipramine at bedtimec) Substitute sertraline for the bupropriond) Add Alprazolam
  • 228. CASE REPORTA 73-year-old white female presents to the office with herdaughter. She complains of a several-year history ofintermittent involuntary loss of urine which is graduallyworsening. She frequently loses small amounts of urinewhen she rises from a low chair, and greater amounts if shecoughs, sneezes, or laughs. She has taken to wearingabsorbent undergarments and admits to significantembarrassment and limitation of activities as a result of herproblem. Her daughter states that the patient has graduallywithdrawn from her usual social contacts. Physicalexamination reveals a well-appearing elderly female. Herpelvic examination shows mucosal atrophy and a mildcystocele. With a full bladder, she loses a few ml of urineinto a gauze pad when standing and coughing. Her post-void residual is normal. Her physical examination isotherwise normal for her age, and her urinalysis is normal.
  • 229. QUESTION 154If nonpharmacologic interventions are notcompletely successful in the management of thispatients problem, which one of the followingmedications is most likely to help? 19/20 missed.ANSWERa) Bethanecholb) Hycosaminec) Flavoxated) Pseudoephedrine
  • 230. QUESTION 155Which one of the following is the medical treatmentof choice for acute delirium in the intensive careunit?ANSWERa) Intravenous droperidol every 6-8 hoursb) Intravenous haloperidol in increasing dosesevery 30 minutes as neededc) Intramuscular diphenhydramined) Intramuscular chlorpromazine
  • 231. QUESTION 156Screening for Chlamydia trachomatis infection should beperformed on which one of the following asymptomaticpatients who present for routine evaluation?ANSWERa) A 20-year-old female who uses birth control pills forcontraception and has a new sexual partnerb) A 22-year-old male with multiple sexual partners whouses condoms, but not consistentlyc) A 16-year-old female who states that she is not sexuallyactived) A 28-year-old female who is married, has no history ofsexually transmitted disease, and uses the rhythm methodto avoid pregnancy
  • 232. QUESTION 157The most common hospital errors associated withpreventable adverse drug effects are in the stageof 16/20 missed?ANSWERa) transcriptionb) dispensingc) administrationd) ordering
  • 233. CASE REPORTA 73-year-old white female complains of difficultyreading for the past several months. Examinationreveals 20/100 near vision bilaterally, and normalvisual fields by confrontation. An ophthalmoscopicexamination reveals only small yellow lesionsclustered in the retina.
  • 234. QUESTION 158The most likely diagnosis is?ANSWERa) glaucomab) retinal detachmentc) cataractd) macular degeneration
  • 235. QUESTION 159The most effective way to diagnose chronic alcoholismis to?ANSWERa) ask the patient directly if he/she is an alcoholicb) confront the patient when he/she is intoxicatedc) obtain a careful history of alcohol intake from thepatientd) inquire about problems resulting from drinking
  • 236. QUESTION 160Compared with younger adults, healthy older adults?ANSWERa) spend fewer hours in stages of deep sleepb) fall asleep more quickly at bedtimec) spend less time awake in bedd) awaken less frequently during the night
  • 237. QUESTION 161Which one of the following is more likely to occurwith glipizide than with metformin?ANSWERa) Lactic acidosisb) Gastrointestinal distressc) Hypoglycemiad) Weightloss
  • 238. QUESTION 162While examining a male infant during a routine well childvisit, you palpate only one testicle within the scrotum.Which one of the following is true concerning thisproblem?ANSWERa) The risk of malignancy in the undescended testis isseveral times higher than in the general populationb) Surgery should be postponed until 3 years of age toallow for spontaneous descentc) Orchiopexy with antecedent hormonal therapy (LH-RH, hCG) is the currently recommended treatmentd) In spite of orchiopexy, more than 50% of patients with ahistory of an undescended testis are infertile as adults
  • 239. CASE REPORTA 21-year-old white female presents to the emergencydepartment with a history consistent with a lateralankle sprain that occurred 2 hours ago while she wasplaying softball. She complains of pain over the distalanterior talofibular ligament, but is able to bearweight. There is mild swelling, mild black and bluediscoloration, and moderate tenderness to palpationover the insertion of the anterior talofibularligament, but the malleoli are nontender topalpation.
  • 240. QUESTION 163Which one of the following statements is true regardingthe management of this case? 13/20 missed.ANSWERa) Anteroposterior, lateral, and 30° internal oblique(mortise view) radiographs should be done to rule outfractureb) For best results, functional rehabilitation should beginwithin the first 24 hours after injuryc) Stress radiographs will be needed to rule out a majorpartial or complete ligamentous teard) Early range-of-motion exercises should be initiated tomaintain flexibility
  • 241. QUESTION 164In evaluating an adult with anemia, which one of thefollowing findings most reliably indicates adiagnosis of iron deficiency anemia?ANSWERa) Microcytosisb) Low serum ferritinc) Low total iron-binding capacityd) Hypochromia
  • 242. QUESTION 165During a routine well child examination of a 9-month-old female, you discover labial adhesions with a 5-mm opening anteriorly. Which one of the followingstatements is true concerning this condition?ANSWERa) It is rarely associated with urinary tract infectionsb) The labia majora are most likely affectedc) It is rarely found in neonatesd) Oral estrogens are an accepted alternate treatment
  • 243. CASE REPORTA 37-year-old gravida 6 para 5 is given oxytocin toinduce delivery at 41 weeks gestation. Her prenatalcourse is significant for chronic hypertension. Shedelivers a 4020-g (8 lb 14 oz) baby. Soon afterdelivery of the placenta, she begins to have excessivevaginal bleeding.
  • 244. QUESTION 166Which one of the following would you do initially?ANSWERa) Chromosome analysisb) A TSH levelc) Phenylketonuria screeningd) A serum creatine kinase level
  • 245. QUESTION 167Of the following antidepressants, which one is LEASTlikely to cause drug interactions?ANSWERa) Citalopramb) Paroxetinec) Fluoxetined) Mirtazapine
  • 246. QUESTION 168When advising women about the need for breast cancerscreening, which one of the following statements isaccurate regarding risk factors and the need for screening?ANSWERa) Hereditary breast cancer is more common inpostmenopausal womenb) Having several second degree relatives with breast cancercarries the same risk as having one first degree relativewith breast cancerc) Most women with breast cancer have no identifiable riskfactorsd) When hereditary breast cancer strikes several generationsof a family, women descended from a male familymember are not at increased risk
  • 247. QUESTION 169Of the following, the INITIAL treatment of choice inthe management of severe hypertension duringpregnancy is?ANSWERa) labetalol intravenouslyb) reserpine intramuscularlyc) nifedipine sublinguallyd) enalapril intravenously
  • 248. QUESTION 170A 35-year-old female complains that her nose is toolarge, even after having cosmetic surgery on her nosethree times. She has a minimal social life because ofher concern about the appearance of her nose. Aphysical examination, including her appearance, isnormal. What is the most likely diagnosis?ANSWERa) Body dysmorphic disorderb) Social phobiac) Obsessive-compulsive disorderd) Delusional disorder
  • 249. QUESTION 171A 39-year-old white male comes to your office withsevere pain, fluctuance, erythema, and, tendernesslocalized over the pad of the distal long finger. Themost likely diagnosis is?ANSWERa) digital cellulitisb) a felon (whitlow)c) a paronychiad) an eponychial abscess
  • 250. CASE REPORTYou see a 24-year-old obstetric patient late in herthird trimester for mild dysuria and urinaryurgency. Microscopic examination of the urinarysediment is notable for bacteria and you make apresumptive diagnosis of cystitis.
  • 251. QUESTION 172Which one of the following antibiotics would beCONTRAINDICATED?ANSWERa) Trimethoprim/sulfamethoxazoleb) Cephalexinc) Nitrofurantoind) Amoxicillin-clavulanate
  • 252. QUESTION 173The antiphospholipid syndrome in women iscommonly associated withANSWERa) recurrent abortionb) secondary amenorrheac) metrorrhagiad) dysmenorrhea
  • 253. QUESTION 174Which one of the following statements is true regardingthe association between oral contraceptive use and therisk of breast cancer?ANSWERa) The longer the duration of oral contraceptive use, thegreater the risk of breast cancerb) The risk of breast cancer is directly correlated with ahigher estrogen content in the oral contraceptivec) The risk of breast cancer in women who use oralcontraceptives is linked to a family history of breastcancerd) There is no significant difference in the risk of breastcancer between women who have used oralcontraception and those who have not
  • 254. CASE REPORTA 67-year-old white male sees you for a newpatient visit. He is asymptomatic and has notseen a doctor in 10 years. He does not smoke ordrink and takes no medication. He says he has ahistory of "mild high blood pressure" but hasnever been treated for this. His blood pressuretoday is 180/90 mm Hg. He has a decreasedarteriovenous ratio on funduscopicexamination, his point of maximal intensity isdisplaced laterally, and he has decreased pedalpulses.
  • 255. QUESTION 175The most appropriate management at this point wouldbe to?ANSWERa) perform two blood pressure measurements 1 weekapart to establish the diagnosis of hypertensionb) prescribe a diureticc) order a laboratory workup to rule out causes ofsecondary hypertensiond) order ambulatory blood pressure monitoring
  • 256. QUESTION 176You see a 90-year-old male with a 5-year history ofprogressive hearing loss. The most common type ofhearing loss at this age affects?ANSWERa) all frequencies roughly the sameb) predominantly high frequenciesc) predominantly low frequenciesd) predominantly mid-frequencies
  • 257. QUESTION 177A 24-year-old white female presents to the office with a6-month history of abdominal pain. A physicalexamination, including pelvic and rectalexaminations, is normal. Which one of the followingwould indicate a need for further evaluation?ANSWERa) Changes in stool consistency from loose and wateryto constipationb) Worsening of symptoms at nightc) Passage of mucus with bowel movementsd) Abdominal bloating
  • 258. QUESTION 178Which of the following is the most reliable clinicalsymptom of uterine rupture? 14/20 missed.ANSWERa) Vaginal bleedingb) Fetal distressc) Sudden tearing uterine paind) Loss of uterine tone
  • 259. QUESTION 179Which one of the following is a risk factor for pretermbirth?ANSWERa) High prepregnancy weightb) Prior preterm deliveryc) Smokingd) First-trimester bleeding
  • 260. QUESTION 180The hospital nursery reports that a 24-hour-old malehas developed "acne" confined to his nose andcheeks. Your examination confirms the presence ofacneiform lesions,including papules. Which one ofthe following would be most appropriate?ANSWERa) Clindamycin topicallyb) Boric acid rinsesc) No treatmentd) An emollient lotion
  • 261. QUESTION 181A 38-year-old alcoholic male has successfullycompleted outpatient alcohol detoxification and hasplans to participate in Alcoholics Anonymous. Whichone of the following pharmacologic agents can aid inrelapse prevention?ANSWERa) Naloxoneb) Bupropionc) Naltrexoned) Mirtazapine
  • 262. CASE REPORTAn 85-year-old white male is brought to youfor the first time by his son. The father hasrecently seen a neurologist who performeda workup for dementia and diagnosedmoderate Alzheimers disease.
  • 263. QUESTION 182Which one of the following is true regarding the useof a cholinesterase inhibitor in this patient?ANSWERa) Agitation is often intensified by these agentsb) If the patient has a vascular dementia rather thanAlzheimers dementia the drug will not be usefulc) Nursing-home placement may be delayed a yearor longerd) Memory is likely to improve significantly
  • 264. QUESTION 183In a 27-year-old white female with irregularmenstrual cycles and infertility , which one of thefollowing would be more indicative of Cushing , ssyndrome rather than the more commonpolycystic ovarian syndrome?ANSWERa) Acneb) Hirsutismc) Acanthosis nigricansd) Easy bruising
  • 265. QUESTION 184You diagnose attention-deficit/hyperactivity disorder in a 10-year-old male, and the parents ask about drugtreatment. Which one of the following would you tell theparents with regard to potential side effects of drugtreatment?ANSWERa) The effect on eventual adult height is minimal in patientstreated with methylphenidate or dextroamphetamineb) Methylphenidate has significantly fewer side effects thandextroamphetanrinec) Although anorexia may occur, it will not lead to substantialweight lossd) Methylphenidate may precipitate seizures
  • 266. CASE REPORTA 60-year-old female has been on conjugated equineestrogens/medroxyprogesterone (Prempro) since shewent through menopause at age 52. She still has heruterus and ovaries. She is having no side effects thatshe is aware of and is experiencing no vaginalbleeding. She is worried about the health effects ofher hormone replacement therapy and asks youradvice about risks versus benefits.
  • 267. QUESTION 185Which one of the following would be accurate adviceregarding these risks and benefits?ANSWERa) The incidence of myocardial infarction is decreasedb) The incidence of pulmonary embolus is decreasedc) The incidence of colorectal cancer is increasedd) The incidence of breast cancer is increased
  • 268. QUESTION 186Which on of the following is the most effective initialtreatment of head lice in an 8 year old child?ANSWERa) Head Shavingb) Malathionc) Wet combing every 4 days, to continue for 2 weksafter any louse is foundd) Lindane
  • 269. QUESTION 187Which one of the following is associated with anincreased risk of developing Alzheimers disease?ANSWERa) A low-fiber dietb) A positive homozygous genotype forapolipoprotein E4c) Elevated serum aluminumd) Decreased serum B-carotene
  • 270. QUESTION 188Which one of the following is true regarding testiculartorsion?ANSWERa) It is most common in boys under the age of 10b) Testicular scanning is necessary prior to surgicalexploration in order to document loss of blood flowto the testisc) Testicular torsion is often preceded by acommunicating hydroceled) Surgical exploration and detorsion must be donewithin 6 hours of the onset in order to preservetesticular function
  • 271. QUESTION 189Which one of the following can contribute to serumcalcium elevation?ANSWERa) Hydrochlorothiazideb) Enalaprilc) Verapamild) Allopurinol
  • 272. QUESTION 190Which one of the following intravenous antibioticregimens is most appropriate for the treatment ofpostpartum endometritis?ANSWERa) Ciprofloxacin plus doxycycline.b) Gentamicin plus methicillinc) Ciprofloxacin plus nafcillind) Gentamicin plus clindamycin
  • 273. QUESTION 191Female victims of domestic assault?ANSWERa) seldom spontaneously offer accounts of partnerabuseb) usually seek medical care for their injuriesc) are less likely to be abused during pregnancyd) usually resent unsolicited questions about abuse
  • 274. CASE REPORTTo establish a reference range for a particular bloodtest in pregnant teenagers, your laboratory hasplotted measurements for a large cohort of healthysubjects. The laboratory finds that thesemeasurements fit a Gaussian distribution, and setsits reference range to include measurements withintwo standard deviations above and below themean.
  • 275. QUESTION 192What is the approximate probability that ahealthy person will have a test result that fallsoutside the laboratory reference range?ANSWERa) 10%b) 0.01%c) 0.1%d) 5%
  • 276. QUESTION 193If an abnormally high maternal serum alphafetoprotein level is found at 16-18 weeksgestation, the next step is?ANSWERa) repeating the measurement of the maternal serumalpha fetoprotein at 24 weeks gestation.b) amniocentesis for amniotic fluid alphafetoprotein, acetylcholinesterace, and karyotyping.c) recommending termination of the pregnancy.d) high resolution ultrasonography
  • 277. CASE REPORTAfter one of many inappropriate late-night phone calls fromthe same patient, you review in your mind recentproblems of his that you have dealt with.You have treated him four times over the past 2 years forsexually transmitted diseases and he has been to youroffice three times in the past year for job-related injuries.More than once you have felt anger at the patient formanipulating you, and he caused a scene in your waitingroom 2 months ago over a IO-minute delay for hisappointment. He often has episodes of unexplainedblues or anxiety. Six months ago you saw in thenewspaper that he was arrested for shoplifting.
  • 278. QUESTION 194You have started to wonder if the patient has anunrecognized underlying psychopathology. If hedoes indeed have a psychiatric disorder, which oneof the following diagnoses is most likely?ANSWERa) Borderline personality disorderb) Bipolar disorderc) Masochistic personality disorderd) Anxiety neurosis
  • 279. QUESTION 195Which one of the following is true regarding the useof alendronate for the treatment of osteoporosis inmen?ANSWERa) It is contraindicated in patients taking NSAIDsb) It is ineffective in patients with Pagets diseasec) Its effectiveness is similar to that seen in womend) It causes a decrease in height
  • 280. CASE REPORTYou see a 29-year-old white gravida 2 para 1 at 18 weeksgestation. She had routine prenatal laboratory tests 2weeks ago, and her platelet count was 100,000/mm3 (N150,000-300,000). She is on no medications exceptprenatal vitamins, her past medical history isnegative, and she denies drug use. On the review ofsystems, she denies easy bruising or bleeding. Herprevious pregnancy was normal. You order tests forantinuclear antibody, antiphospholipidantibody, anticardiolipin antibody, lupusanticoagulant, and HIV. All results are normal. Aperipheral smear is normal except for a low plateletcount.
  • 281. QUESTION 196Appropriate management of this condition wouldinclude which one of the following?ANSWERa) Obtaining a fetal platelet count at 20 weeksgestationb) No intervention except periodic monitoring ofmaternal platelet countsc) Cesarean deliveryd) Platelet transfusion if the maternal platelet countdrops below 75,000/mm3
  • 282. QUESTION 197Which one of the following is indicated in thediagnostic workup for attention-deficit/hyper-activity disorder (ADHD)?ANSWERa) An EEGb) A blood lead levelc) Continuous performance testingd) Home- and school-specific ADHD rating scales
  • 283. QUESTION 198A 31-year-old married white female complains ofvaginal discharge, odor, and itching. Speculumexamination reveals a homogeneous yellowdischarge, vulvar and vaginal erythema, and a"strawberry" cervix. The most likely diagnosis is?ANSWERa) herpes simplex type 2b) bacterial vaginosisc) trichomonal vaginitisd) candidal vaginitis
  • 284. QUESTION 199A 24 year old white female contracts a primary herpesvirusinfection during her 25th week of gestaton. Which oneof the following statements is true?ANSWERa) She has a high liklihood of miscarriage.b) She should be scheduled for a cesarean section atterm.c) She should be treated with antiviral therapy for 7-14days.d) She should be advised against breast feeding her child.
  • 285. QUESTION 200A small child with failure to thrive is found to have abone age that is markedly delayed relative toheight age and chronologic age. The most likelyetiology is?ANSWERa) hypothyroidismb) cystic fibrosisc) gonadal dysgenesisd) Down syndrome
  • 286. CASE REPORTA 30-year-old female sees you because her hair hasbeen falling out over the past 2 months. She tellsyou that she straightened, waved, and lightenedher hair about 3 months ago. Examination showsmost of the hair loss to be in the midline of thescalp, with an area of dark hairs about 3 cm inlength in the center region. There is no evidence ofbalding or scarring. A potassium hydroxide (KOH)scraping is negative
  • 287. QUESTION 201Which one of the following is the most appropriatemanagement?ANSWERa) Intralesional corticosteroidsb) Topical minoxidilc) Psoralen plus ultraviolet lightd) Advising the patient to avoid hair treatmentproducts
  • 288. QUESTION 20246. A patient with bipolar disorder is being treatedwith lithium. Of the following, which one is themost likely side effect of this therapy?ANSWERa) Hypoaldosteronismb) Diabetes insipidusc) Hypothyroidismd) Hypoparathyroidism
  • 289. CASE REPORTAn otherwise healthy 72-year-old white malepresents with pain on the right side of hishead, increasing in severity over the past 2 days.Today he broke out in a rash consisting of groupedvesicles on an erythematous base in thedistribution of the first division of the fifth cranialnerve . The right eyelid is involved, but the patientcomplains of no pain in the eye itself, or of anyvisual disturbance. There are no lesions on any partof the nose.
  • 290. QUESTION 203Appropriate management at this time would includethe administration of which one of the following?ANSWERa) Oral famciclovirb) Intravenous acyclovirc) Topical capsaicind) Varicella-zoster immune globulin
  • 291. QUESTION 204As a member of the local emergency responsemanagement team you are asked about thetreatment of nerve gas (e.g., sarin) poisoning.Which one of the following is most effective inreversing the symptoms of nerve gas toxicity?ANSWERa) Parenteral verapamilb) Atropinec) Ciprofloxacind) Albuterol via inhalation
  • 292. QUESTION 205A 34-year-old white female at 32 weeks gestationdevelops a venous thromboembolism. Following 5 daysof intravenous heparin in the hospital, which one of thefollowing regimens would be most appropriate?ANSWERa) Aspirin twice a day until deliveryb) Subcutaneous heparin every 12 hours until deliveryc) Outpatient intravenous heparin every 6 hours untildeliveryd) Warfarin throughout the remainder of her pregnancy
  • 293. QUESTION 206A 30-year-old white primigravida asks you about the benefitsand drawbacks of corticosteroid therapy for premature laborat 30 weeks gestation. Which one of the following statementsis most accurate?ANSWERa) Therapy is associated with a higher rate of persistent patentductus arteriosusb) Weekly corticosteroid injections until 34 weeks gestation isthe standard regimen to prevent respiratory distresssyndromec) Therapy will decrease the risk of neonatal necrotizingenterocolitisd) Therapy is associated with a higher rate of neonatalintraventricular hemorrhage
  • 294. CASE REPORTAn 85-year-old white male with terminal pancreaticcancer is expected to survive for another 2 weeks.His pain has been satisfactorily controlled withsustained-release morphine. He has now developeda disturbed self-image, hopelessness, andanhedonia, and has told family members that he hasthought about suicide. Psychomotor retardation isalso noted. His family is supportive. His daughterfeels he is depressed, while his son feels this is moreof a grieving process.
  • 295. QUESTION 207Which one of the following would be mostappropriate for managing this problem?ANSWERa) Reassuranceb) Methylphenidatec) Trazodoned) Alprazolam
  • 296. QUESTION 208A nurse who completed a hepatitis B vaccine series ayear ago is accidentally stuck by a needle that hasjust been used on a dialysis patient. The patient isknown to be HBsAg-positive. Your first responseshould be?ANSWERa) administer hepatitis B immune globulin (HBIG) onlyb) provide reassurance onlyc) repeat the hepatitis B vaccine seriesd) test the nurse for hepatitis B antibody
  • 297. QUESTION 209A 30-year-old white primigravida asks you about the benefitsand drawbacks of corticosteroid therapy for premature laborat 30 weeks gestation. Which one of the following statementsis most accurate?ANSWERa) Therapy is associated with a higher rate of persistent patentductus arteriosusb) Weekly corticosteroid injections until 34 weeks gestation isthe standard regimen to prevent respiratory distresssyndromec) Therapy will decrease the risk of neonatal necrotizingenterocolitisd) Therapy is associated with a higher rate of neonatalintraventricular hemorrhage
  • 298. CASE REPORTA nurse who completed a hepatitis B vaccine series ayear ago is accidentally stuck by a needle that hasjust been used on a dialysis patient. The patient isknown to be HBsAg-positive.
  • 299. QUESTION 210Your first response should be?ANSWERa) administer hepatitis B immune globulin (HBIG)onlyb) provide reassurance onlyc) repeat the hepatitis B vaccine seriesd) test the nurse for hepatitis B antibody
  • 300. CASE REPORTA 62-year-old white male comes to your office withpain and swelling of the left great toe at themetatarsophalangeal joint. Examination shows it iserythematous, warm, swollen, and tender to touch.The patient has a history of diabetes mellituscontrolled by diet, and hypertension. , Hismedications include hydrocWorothiazide, 25 fig/day.A CBC and blood chemistry profIle arenormal, except for a uric acid level of 9.2 fig/dL (N3.6-8.5).
  • 301. QUESTION 211Which one of the following is true in this situation?ANSWERa) The elevated uric acid level establishes thediagnosis of goutb) lntra-articular steroid injection should be avoidedc) Stopping the hydrochlorothiazide may control thehyperuricemiad) Allopurinol therapy should be started
  • 302. QUESTION 212• Which one of the following is true regarding urinary tractinfections in febrile infants and young children (age 2-24months)?ANSWERa) A perineal bag should be used to collect urine forculturesb) Prophylactic antibiotics should be continued for 1 yearin all children after the first febrile UTIc) A 3-day course of oral antibiotic therapy is appropriated) Ultrasonography should be performed after the firstfebrile UTI
  • 303. QUESTION 213Which one of the following intravenous agents given tothe mother during labor is the drug of choice forprophylaxis of neonatal group B streptococcaldisease?ANSWERa) Erythromycinb) Metronidazolec) Clindamycind) Penicillin G
  • 304. CASE REPORTA 75-year-old Hispanic male presents with dyspnea onexertion which has worsened over the last severalmonths. He denies chest pain and syncope, and wasfairly active until the shortness I of breath slowedhim down recently. You hear a grade 3/6 systolicejection murmur at the right ! upper sternal borderwhich radiates into the neck. Echocardiographyreveals aortic stenosis, with a mean transvalvulargradient of 55 mm Hg and a calculated valve area of0.6 cm2. Left ventricular function is normal.
  • 305. QUESTION 214Which one of the following is appropriate managementfor this patient?ANSWERa) Aortic balloon valvotomyb) Aortic valve replacementc) Watchful waiting until the gradient is severe enoughfor treatmentd) Medical management with B-blockers and nitrates
  • 306. CASE REPORTWhile performing a vasectomy on a 33-year-oldmale, you are unable to definitely identify the left vasdeferens. You take some time to try and find thevas, but the patient is becoming very uncomfortable.You can easily isolate the right vas. The patient hasfathered three children and has no difficulty witherectile function. The examination of his externalgenitalia was normal.
  • 307. QUESTION 215What should you do next?ANSWERa) Abandon the attempt at vasectomy andrecommend a tubal ligation for his wifeb) Make a large scrotal incision and continue to tryto find the left vas deferensc) Recommend that you try to find the left vasdeferens under general anesthesiad) Ligate the right vas deferens and check a semenspecimen in 6 weeks.
  • 308. QUESTION 216Which one of the following is contraindicated in apatient taking an SSRI?ANSWERa) Monoamine oxidase inhibitorsb) Benzodiazepinesc) a-Receptor blocking agentsd) Electroconvulsive therapy
  • 309. QUESTION 217A 27 year old white female sees you for the first time for aroutine evaluation. A Papanicolaou test revealsatyrpical glandular cells of undetermined significance(AGUS). Of the following, which one is most commonlyfound in this situation?ANSWERa) Endometrial Hyperplasiab) Endometrial Cancerc) An Endocervical Polypd) Cervical Intraepithelial neoplasia
  • 310. QUESTION 218You perform a health maintenance examination on a 2-year-old white male. He is asymptomatic and is meetingall developmental milestones. The only significantfinding is a grade 3/6 diastolic murmur heard at theright upper sternal border . Which one of the followingwould be most appropriate at this time?ANSWERa) Referral to a pediatric cardiologistb) Maintenance doses of digoxinc) No further evaluationd) Reevaluation in 6 months
  • 311. QUESTION 219The tumor marker most closely associated withovarian cancer is?ANSWERa) carcinoembryonic antigenb) alpha-fetoproteinc) CA 19-9d) CA-125
  • 312. QUESTION 220A newborn term male infant at 2 hours of age isnoted by the nurse to be mildly jaundiced. Whichone of the following causes of jaundice can beruled out because of the infant s age?ANSWERa) Concealed hemorrhageb) Erythroblastosis fetalisc) Congenital toxoplasmosisd) Physiologic jaundice.
  • 313. QUESTION 221Which one of the following is indicated for treatmentof chlamydial urethritis during pregnancy?ANSWERa) Doxycyclineb) Ofloxacinc) Ciprofloxacind) Erythromycin base
  • 314. CASE REPORTA 28-year-old female complains of generalizedheadache, dizziness and generally not feeling well for 3 days.This started at the same time as her menses and coincidedwith a major examination in a college class she is taking. Herreview of symptoms is otherwise negative. Her past medicalhistory includes a recent acute onset of low back pain relatedto lifting, and a recent depressive episode which respondedwell to medication. Her current medications include an oralcontraceptive which she has taken for 2 years, a corticosteroidnasal spray, and ibuprofen for the past 2 weeks. She was onparoxetine, 30 mg/day, for 7 months, but this was stopped 5days ago because of sexual dysfunction. Because of hersymptoms she has not taken any medications for the past 2days. Since then the headache has eased substantially, but thefeeling of lightheadedness has remained
  • 315. QUESTION 222Which one of the following is the most likely cause ofher symptoms?ANSWERa) Paroxetine withdrawalb) Stressc) Serotonin syndromed) Viral infection
  • 316. CASE REPORTA 29-year-old gravida 0 para 0 presents to your officewith a chief complaint of irregular , infrequentmenses. Over the past few years, she has notedincreasing dark hair growth on her chin and above herupper lip. On examination, she is normotensive andmoderately overweight. Examination of the skinreveals acne and abdominal striae. The remainder ofthe examination is normal. Laboratory Findings TSH2.1JLU/mL(NO.3-5.0) FSH 8 U/L (N 1-10) LH 38 U/L(N1-20) Free testosterone 50ng/dL(N 0.3-1.9) Prolactin.28 ng/mL (N 0-23) 17 hydroxyprogesterone 4 ng/dL (N0-8) DHEA -S ( dehydroepiandrosterone sulfate) 2.0mg/dL (N 0-3.0)
  • 317. QUESTION 223In addition, a dexamethasone suppression test andpelvic ultrasonography are normal. Which one ofthe following is the most likely diagnosis for thispatient?ANSWERa) Cushings syndromeb) Virilizing adrenal tumorc) Adult-onset congenital adrenal hyperplasiad) Polycystic ovarian syndrome
  • 318. QUESTION 224Which one of the following patients should be screenedfor hepatitis C virus (HCV) infection?ANSWERa) A 35-year-old nurse finishing her first year of work ina dialysis unitb) A 30-year-old day-care worker after a 1-year-old childin her room was diagnosed with hepatitis Cc) A 45-year-old who received a blood transfusion in1996 subsequent to a serious motor vehicle accidentd) A 9-month-old born to a mother positive for HCV
  • 319. QUESTION 225Which one of the following best describes the reason forthe marked decline in the incidence of epiglottitis inthe pediatric population?ANSWERa) More effective use of appropriate broad-spectrumcephalosporin antibioticsb) Increased use of the new polyvalent pneumococcalvaccinesc) Immunization with Haemophilus influenzae type bvaccined) Genetic drift in strains of parainfluenza virus
  • 320. QUESTION 226The best way to remove a tick is to?ANSWERa) manually extract it with blunt forcepsb) crush the tick and remove itc) carefully apply a lit matchd) apply petroleum jelly to the tick
  • 321. QUESTION 227A 22 year old male has acute low back pain withoutparesthesias or other neurologic signs. There is nolower extremity weakness. Which treatment hasbeen shown to be of the most benefit initially?ANSWERa) Bed rest plus local injection of steroidsb) Complete bed rest for 2 weeks.c) Low back strengthening programd) Resumption of physical activity as tolerated
  • 322. QUESTION 228Which one of the following is a cause ofthyrotoxicosis characterized by a decreasedradioactive iodine uptake?ANSWERa) Subacute thyroiditisb) Solitary toxic thyroid nodulec) Graves diseased) Toxic multinodular goiter
  • 323. CASE REPORTA healthy 8-month-old white male has suddenlydeveloped recurrent bouts of what appears to besevere abdominal pain. He cries inconsolably anddraws up his legs, but does not seem ill betweenepisodes. He has vomited and on examination has asmall amount of bloody mucoid stool in his diaperand a palpable mass in his undistended right upperabdomen.
  • 324. QUESTION 229The most likely diagnosis is?ANSWERa) pyloric stenosisb) intussusceptionc) gastroschisisd) Meckels diverticulum
  • 325. CASE REPORTA 25-year-old healthy female presents with a 1-weekhistory of a thin, mildly odorous vaginal dischargeaccompanied by mild vaginal itching. Physicalexamination is normal except for athin, homogeneous discharge, with no significantcervical or vaginal inflammation. A wet-mountpreparation of the discharge reveals numerousepithelial cells coated with small non-motileorganisms. A KOH preparation is negative but has a"fishy" odor .
  • 326. QUESTION 230Which one of the following is correct regarding thispatients condition?ANSWERa) Failure to treat the male partner may result in urethritisor prostatitisb) Symptomatic relief of the infection frequently requiresseveral courses of treatment in patients taking oralcontraceptivesc) The infection should be reported to local healthauthorities for contact trackingd) This infection can be treated with oral or vaginalclindamycin
  • 327. CASE REPORTA 38-year-old male who is a new patient reports mildintermittent jaundice without other associatedsymptoms for the past several years. His liverfunction tests are normal except for a total bilirubinof 1.3 fig/dL (N 0.3-1.0) and an indirect orunconjugated bilirubin of 1.0 fig/dL (N 0.2-0.8). HisCBC is normal. His past medical and surgical historyis unremarkable .
  • 328. QUESTION 231Findings are similar on repeat laboratory testing. Themost likely cause of these findings is?ANSWERa) hepatitis Cb) Wilsons diseasec) sickle cell anemiad) Gilberts syndrome
  • 329. CASE REPORTA 24-year-old white female in her first trimester ofpregnancy presents with low-grade fever, myalgias, headache, and a rash consistent witherythema migrans. Ten days ago she was hiking inan area where deer ticks are present. Sheremembers being bitten by a tick which shediscovered and removed 2 days after her hike.
  • 330. QUESTION 232Which one of the following is the most appropriatetreatment option?ANSWERa) Azithromycinb) Amoxicillinc) Doxycyclined) Erythromycin
  • 331. CASE REPORTA 43-year-old white male cut his foot when he steppedon a walnut shell while walking barefoot in his backyard. On examination the laceration is deep, withragged edges. Your records indicate that the patienthas completed a full primary immunization serieswith tetanus toxoid. His last tetanus toxoid injectionwas 7 years ago.
  • 332. QUESTION 233This patient should be given?ANSWERa) tetanus immune globulin (TIG) and tetanustoxoidb) combined tetanus and diphtheria toxoid (Td)c) no immunizations at this timed) TIG and Td
  • 333. QUESTION 234Pallidotomy is a surgical therapy for?ANSWERa) temporal lobe epilepsyb) Parkinsons diseasec) vascular dementiad) Alzheimers disease
  • 334. QUESTION 235In addition to routine immunizations, which one of thefollowing is specifically indicated for adolescentmales who have sex with other males?ANSWERa) Varicella virus vaccineb) Hepatitis A vaccinec) MMRd) Pneumococcal polysaccharide vaccine
  • 335. QUESTION 236Which one of the following procedures carries thehighest risk for, postoperative deep venousthrombosis?ANSWERa) Coronary artery bypass graftb) Abdominal hysterectomyc) Lumbar laminectomyd) Total knee replacement
  • 336. QUESTION 237Which one of the following procedures carries thehighest risk for, postoperative deep venousthrombosis?ANSWERa) Coronary artery bypass graftb) Abdominal hysterectomyc) Lumbar laminectomyd) Total knee replacement
  • 337. QUESTION 238A 17-year-o1d white female is brought in by her parentsbecause of concern about her recent weight loss. Her pastmedical history is unremarkable. Physical examination isnotable for a body mass index of 23, bilateral parotid glandenlargement, dental erosions on the lingual surfaces of herteeth, submandibular lymphadenopathy, and elongatedabrasions on the dorsal surface of her right hand. The mostlikely diagnosis is?ANSWERa) Sjogren s syndromeb) bulimia nervosac) sarcoidosisd) HIV infection
  • 338. QUESTION 239A 74-year-old African-American female has moderatelysevere pain due to osteoarthritis. However, she is alsoon medication for a seizure disorder.When choosing medications to manage her chronicpain, which one of the following should be used withcaution because of her history of seizures?ANSWERa) Rofecoxibb) Salsalatec) Hydrocodoned) Tramadol
  • 339. QUESTION 240Which one of the following is characteristic of drug-seeking behavior in patients who abuseprescription drugs?ANSWERa) They refuse non-narcotic alternativesb) They request that other modalities be tried firstbefore narcotics are usedc) They rarely report drug allergiesd) They minimize their symptoms
  • 340. QUESTION 241A 70-year-old white male has a slowlyenlarging, asymptomatic abdominal aortic aneurysm.You should usually recommend surgical interventionwhen the diameter of the aneurysm approaches?ANSWERa) 4.5 cmb) 3.5 cmc) 5.5 cmd) 6.5 cm
  • 341. QUESTION 242A 60-year-old male indicates that he occasionally bringsup what appears to be undigested food long after hismeal. He also admits that he sometimes chokes onfood, and that his wife says he has bad breath.The most likely diagnosis is?ANSWERa) Zenkers diverticulumb) esophageal refluxc) achalasiad) cancer of the esophagus
  • 342. QUESTION 243A recent study of cholesterol-reducing medication showsthat healthy patients taking the investigational drugover 5 years had a 5% incidence of myocardialinfarction, whereas 7% of control subjects not takingthe drug suffered from a myocardial infarction. Howmany patients must be treated with the new drug for 5years in order to prevent one myocardial infarction?ANSWERa) 14b) 20c) 35d) 50
  • 343. CASE REPORTYour 57 -year-old white male patient has been inthe ICU for the past 10 days recovering from anexploratory laparotomy performed for aperforated duodenal ulcer. Postoperatively hedeveloped acute renal failure and sepsis. Whenthe patient became hypothermic 3 days ago, theresident.on duty ordered a thyroid function paneland obtained the following results: T4RIA 4J1g/dL(N 5-12) T3RIA 60ng/dL(N 70-190) TSH 2.0J1U/mL(N 0.5-5.0).
  • 344. QUESTION 244The patient has no previous history of thyroid disease.His gland is normal in size. His condition today iscritical but stable. The most appropriatemanagement at this time is ?ANSWERa) begin parenteral thyroxine and hydrocortisoneimmediatelyb) order a TRH stimulation testc) continue present managementd) begin parenteral thyroxine immediately
  • 345. QUESTION 245A 10-year-old male is brought to your office aftersustaining a fall on an outstretched hand. Radiographsshow a nondisplaced fracture of the middle third ofthe clavicle. Appropriate management would includewhich one of the following?ANSWERa) Orthopedic consultation for surgical interventionb) Weekly radiographs to assess callus formationc) Intermittent heat to the area to help control paind) A figure-of-8 splint or sling support
  • 346. QUESTION 246Which one of the following is the most common causeof infectious enteritis in children in temperateclimates?.ANSWERa) Campylobacter jejunib) Cytomegalovirusc) Human rotavirusd) Parvo-like virus
  • 347. QUESTION 247A 10-year-old white male is brought to your office with achief complaint of "head congestion" associated withmoderate malaise and a low-grade fever for 7 days. Hehas had a thick, discolored nasal discharge for the last 2days. Which one of the following is correct regarding hismanagement?ANSWERa) Amoxicillin should be prescribedb) Erythromycin should be prescribedc) Sinus radiographs should be ordered, and the decisionto use antibiotics should be based on the findingsd) No antibiotics should be used at this time
  • 348. QUESTION 248A 30-year-old white gravida 2 para 2 presents to youroffice complaining of mild to moderate tenderness inthe left groin. She and her husband use condoms andcontraceptive foam for birth control. An examinationfails to elicit any significant abdominal pain, but onpelvic examination a tender, 4.5-cm, freely movableleft adnexal mass is felt. A qualitative serum hCG isnegative. The most likely diagnosis is?ANSWERa) corpus luteum cystb) dysgerminomac) ovarian fibromad) dermoid cyst
  • 349. QUESTION 249You are asked to perform a preoperative evaluation ona 75-year-old male scheduled for a cholecystectomy.Which one of the following would be most predictiveof postoperative delirium?ANSWERa) Dementiab) Anxietyc) Depressiond) Psychosis
  • 350. QUESTION 250A 19-year-old white male with a history offever, fatigue, weight loss, and mild diarrhea of 2months duration is found to have a palpable mass inthe right lower quadrant of the abdomen. The mostlikely diagnosis is?ANSWERa) lymphomab) Crohns diseasec) amebic colitisd) diverticulitis