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Item 1 of 19
Untimed Test
A 43-year-old bus driver presents to his gastroenterologist with complaints of difficulty
swallowing solid foods. The evaluation demonstrates a smooth, tapered stricture of the
esophagus, and biopsies reveal changes consistent with chronic esophagitis and fibrosis.
The stricture is dilated with an endoscopic balloon dilator, and the patient's symptoms
resolve. He reports that although he has had dysphagia for the past 2 months prior to the
endoscopy, he rarely has heartburn and uses an over-the-counter antacid only
Which of the following is the most appropriate future management of this patient?
A. Famotidine
B. Lansoprazole
C. Magnesium hydroxide
D. Metoclopramide
..       E. No medication is necessary
The correct answer is B. AIthough this patient has rarely been aware of symptoms of
gastroesophageal reflux disease (GERD), the development of a peptic stricture clearly
indicates longstanding acid reflux into the distal esophagus. This will be a persistent
process and, if not treated, will lead to recurrent strictures. He therefore requires chronic
treatment with a proton pump inhibitor to suppress acid secretions.
Famotidine and antacids, such as magnesium hydroxide (choices A and C), are adjuncts
to the mainstay of therapy, which is proton pump inhibition.
Even though the patient is not symptomatic, he does require continued acid suppression.
Metoclopramide (choice D) reduces the lower esophageal sphincter pressure and is an
adjunct to acid suppression in the management of patients with reflux. It is not used as
first-Iine therapy, however. It is nowhere near as effective as proton pump inhibitors and
frequently leads to side effects of sedation because of its ability to cross the blood-brain
barrier and inhibit dopamine, producing Parkinson-Iike symptoms.
As stated above, this patient will have recurrent strictures if he does not receive
treatment. Therefore, choice E is incorrect.

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Item 2 of 19
Untimed Test
A 34-year-old international investment banker presents with a 3-month history of
frequent episodes of loose stool preceded by left lower abdominal cramping. For the past
6 weeks,
the stools have become increasingly bloody. On a number of occasions, he has had a
sensation of rectal fullness but has been unable to pass any fecal matter. He travels
and has been to Asia, India, Pakistan, Germany, and Sweden in past year working on
telecommunications infrastructure deals. On physical examination, he has mild
tenderness in the
Ieft lower quadrant. A rectal examination reveals grossly bloody stools. A sigmoidoscopy
reveals inflammation extending in a symmetric and circumferential pattern from the anal
to the distal descending colon. Multiple stool tests are negative for bacterial and parasitic
infections. Which of the following is the most likely cause of the patient's symptoms?
A. Crohn disease
B. Cytomegalovirus
C. Ischemic colitis
D. UIcerative colitis
E. Yersinia enterocolitica
The correct answer is D. This patient has the typical subacute or chronic history of
bloody diarrhea in association with left lower quadrant cramping. He also describes
of tenesmus. AIthough he has traveled extensively, multiple stool tests are negative for
infectious etiology. Pathologically, ulcerative colitis is characterized by inflammation and
superficial ulceration that occur without skip lesions, beginning at the anal verge and
extending varying distances proximally.
Crohn disease (choice A) may produce a colitis but is more typically associated with right
lower quadrant symptoms and ileitis.
Cytomegalovirus (choice B) may cause a picture indistinguishable for ulcerative colitis
but is usually seen only in immunocompromised patients, e.g., those with HIV who have
CD4 cell counts.
Ischemic colitis (choice C) is usually a segmental colitis and does not usually start at the
anal verge. It is more commonly seen in elderly patients or in those with hypercoagulable
Yersinia enterocolitica(choice E) may produce diarrhea, infrequently bloody. However,
Yersinia favors invasion of the terminal ileum and produces the acute onset of right lower
quadrant symptoms.

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Item 3 of 19
Untimed Te
A 74-year-old woman presents complaining of very severe abdominal pain, which began
abruptly 8 hours ago. She describes the pain as "the worst I've ever had." On questioning,
is unable to give a precise location but indicates that her entire mid-abdomen is extremely
painfuI. She has been followed for the past 10 years for symptoms of congestive heart
failure after she had an anterior wall myocardial infarction. She has remained relatively
well controlled with only occasional dyspnea on exertion. Her medications include
furosemide, digoxin, isosorbide dinitrate, and aspirin. She has not had any prior surgery.
On physical examination, she appears extremely uncomfortable. Her temperature is 38.9
(101.9 F), blood pressure is 174/102 mm Hg, and pulse is 118/min and irregularly
irregular. On cardiac examination, there is a regular heart rhythm with a lI/VI
holosystolic murmur
heard best at the apex and radiating to the axilla. She has an irregularly irregular S1 and
S2, and scattered bibasilar rales. An abdominal examination reveals mild distention and
hepatosplenomegaly. The abdomen is diffusely soft but very tender to palpation. A rectal
examination reveals brown, guaiac-positive stooI. She has no audible bowel sounds.
Which of
the following is the most likely diagnosis?
A. Diverticulitis
. .     B. Ischemic colitis
C. Mesenteric ischemia
D. Pancreatitis
E. Small bowel obstruction
The correct answer is C. This patient has symptoms of congestive heart failure and
possible atrial fibrillation, as demonstrated by her irregularly irregular heartbeat. In
addition, she
is on digoxin and is at high risk for the development of an embolic occlusion of the
superior mesenteric artery. These patients will present with severe pain out of proportion
to their
objective physical findings. The diagnosis should be suspected clinically, and immediate
superior mesenteric arteriogram should be performed. If evidence of ischemia is
the patient should proceed to exploratory laparotomy to evaluate for intestinal ischemia
and possible gangrenous boweI.
Diverticulitis (choice A) may present with severe abdominal pain but is generally lower
abdominal and is often localized in the left lower quadrant, the site of sigmoid
Patients will often give a history of chronic crampy, postprandial pain in the left lower
Ischemic colitis (choice B) will usually present as diarrhea, often bloody, in elderly
patients with known atherosclerotic heart disease.
AIthough pancreatitis (choice D) may develop abruptly, particularly with gallstone
pancreatitis, the symptoms are usually localized to the epigastric lesion, with radiation to
the back
and associated nausea and vomiting. Furthermore, chronic pancreatitis does not cause
heme-positive stools, as in this patient.
A small bowel obstruction (choice E) is unlikely in the absence of prior abdominal
surgery, and associated adhesions and will generally present with abdominal distension in
association with high-pitched hyperactive bowel sounds, as well as nausea and vomiting.
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Item 4 of 19
Untimed Te
A 62-year-old woman with a history of alcoholic cirrhosis is brought to the emergency
department by her neighbor because of increasing lethargy. She has continued to abuse
despite a history of multiple esophageal variceal bleeds and prior admissions for hepatic
encephalopathy. Her past medical history is also significant for duodenal ulcer,
and gout. On physical examination she is lethargic and easily falls asleep when not being
stimulated. Her temperature is 37.1 C (98.7 F), blood pressure is 128/82 mm Hg, pulse is
96/min, and respirations are 18/min. She has dry mucous membranes. A neurologic
examination is nonfocaI, but asterixis is present. Which of the following medications is
most likely
to be contributing to this patient's clinical condition?
A. Colchicine
B. Enalapril
C. Furosemide
D. Omeprazole
..      E. Metoprolol
The correct answer is C. Patients with known portal hypertension have multiple risk
factors for hepatic encephalopathy, including dehydration, infection, electrolyte
(hypokalemia and metabolic alkalosis), sedative administration, and gastrointestinal
bleeding. Many of these patients are on diuretics, such as furosemide, to control ascites
related to
their liver disease and hypoalbuminemia. The resulting dehydration from excessive
diuretic use may precipitate an episode or exacerbate underlying hepatic encephalopathy.
The uricosuric agent colchicine (choice A) is used for gout. It can cause gastrointestinal
symptoms, marrow depression, and peripheral neuritis, but would not be expected to
a change in mental status or precipitate hepatic encephalopathy.
The ACE inhibitor enalapril (choice B) is used to control hypertension. It can cause
angioedema, anaphylaxis, hypotension, neutropenia, and fetal morbidity. It very rarely, as
idiosyncratic reaction, will cause a (new) fulminant hepatic necrosis, but would not be
expected to be a specific problem in a patient with underlying cirrhosis. In any event, the
furosemide is a much more common cause of worsening hepatic encephalopathy.
The beta blocker metoprolol (choice D) is used to control either systemic hypertension or
portal hypertension. It can cause depression, but only rarely causes mental confusion and
would not be expected to precipitate hepatic encephalopathy.
The proton pump inhibitor omeprazole (choice E) is used for peptic ulcer disease and is
generally well tolerated. It would not be expected to cause a change in mental status or
precipitate hepatic encephalopathy.
Item 5 of 19
Untimed Te
A 69-year-old retired physician is brought to the emergency department by his wife
because of the onset of severe midabdominal pain. He awoke at approximately 4:00 AM
with severe
pain, which has gradually become "unbearable." He has a history of rheumatic fever,
acute cholecystitis resulting in cholecystectomy, and a gastric ulcer. On physical
examination, he
appears acutely uncomfortable and complains of increasing pain with any movements.
His temperature is 38.7 C (101.6 F), blood pressure is 160/90 mm Hg, and pulse is
He is anicteric and has dry mucous membranes. On abdominal examination, there is
reduction in bowel sounds and diffuse tenderness and involuntary guarding to mild
palpation. A
rectal examination reveals brown, guaiac-negative stooI. Upright chest x-ray and plain
abdominal films reveal free air underneath the left hemidiaphragm. Which of the
following is the
most appropriate next step in management?
A. AbdominaI CT scan
B. High-dose oral omeprazole
C. Histamine-2 receptor antagonist
D. Observation after placement of a nasogastric tube
E. Emergent laparotomy
The correct answer is E. This patient has evidence of a perforated viscus, as demonstrated
by the free air under the left hemidiaphragm. With a history of gastric ulcer, it is
possible that he has perforated a recurrent ulcer. PIans should be made immediately for
emergent exploratory laparotomy to prevent progression of his peritonitis. Peptic ulcers
perforate, producing free air in the abdominal cavity, are usually located in either the
anterior wall of the duodenum or in the stomach. The description of the pain illustrated in
question stem is typicaI. The abdominal findings following perforation may be
misleading, as diffuse abdominal pain, sometimes with prominent right lower quadrant
involvement or
radiation to either or both shoulder, may dominate the clinical picture rather than pain
localized to the epigastrium. Breathing may exacerbate the pain. Prompt diagnosis with
emergent laparotomy will lessen the risks of shock and establishment of a disseminated
chemicaI (or superinfected) peritonitis.
An abdominaI CT scan (choice A) would merely delay the definitive laparotomy.
Oral omeprazole and histamine-2 receptor antagonists (choices B and C) are effective
medical therapies for gastric ulcer; however, they are superfluous in the management of a
perforated ulcer.
Observation after placement of a nasogastric tube (choice D) is inappropriate given the
obvious findings of a perforated viscus. AIthough a nasogastric tube may be placed prior
surgery, there is no role for conservative management for this patient.

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Item 6 of 19
Untimed Test
A 22-year-old man is diagnosed with Crohn disease limited to the terminal ileum. His
symptoms of mild right lower quadrant pain and postprandial diarrhea resolve after the
initiation of
treatment with mesalamine. Two years later, he develops recurrent episodes of abdominal
distention, nausea, and vomiting after large meals. On two occasions, these symptoms are
accompanied by inability to pass flatus or bowel movements. Which of the following has
this patient most likely developed?
A. Fibrosis and a stricture in the terminal ileum
. .       B. A fistula from the ileum to the sigmoid
C. Gastric outlet obstruction
D. An obstructing cecal carcinoma
E. An obstructing ileal carcinoid
The correct answer is A. This patient with Crohn disease has developed symptoms of a
small bowel obstruction, which is a common and important complication of this
This occurs in Crohn disease as a result of chronic transmural inflammation, which both
partially destroys the normal bowel wall and constricts it with thick bands of fibrosis.
important intestinal complications can include fistula formation and chronic abscesses. In
addition, a wide variety of extraintestinal complications can include autoimmune diseases
(arthritis, aphthous ulcers, erythema nodosum, pyoderma gangrenosum, eye involvement,
ankylosing spondylitis primary sclerosing cholangitis) and complications related to
disrupted bowel physiology (renal complications, including kidney stones and urinary
tract obstruction, malabsorption, and amyloidosis secondary to longstanding
A fistula from the ileum to the sigmoid (choice B) can develop in patients with Crohn
disease but will present with symptoms of diarrhea (because of the bypass of a large
portion of
the colon) and not obstruction.
Gastric outlet obstruction (choice C) may produce vomiting, usually of only partially
digested foods, and does not usually result in significant abdominal distension.
Furthermore, there
is no impairment of passage of flatus or bowel movements.
Cecal carcinoma (choice D) can cause obstruction, but it would be extraordinarily rare in
a 22-year-old man. Carcinoma is more likely to complicate ulcerative colitis than Crohn
There is nothing in his history to suggest the development of carcinoid syndrome (choice
E) in this young patient. These tumors, when they do occur, rarely present with a bowel
obstruction, but may present with the carcinoid syndrome, i.e., facial flushing, diarrhea,
wheezing, and tricuspid regurgitation.

Item 7 of 19
Untimed Test
A 21-year old college senior presents with a 2-month history of frequent episodes of
loose stooI, preceded by lower abdominal cramping. Over the past 4 weeks, the stools
become increasingly bloody. On a number of occasions he has the sensation of rectal
fullness but is unable to pass any fecal matter. A sigmoidoscopy is performed and reveals
inflammation in a circumferential pattern from the anal verge to the mid-sigmoid colon,
where a transition to normal mucosa is seen. Which of the following is the most
treatment for this patient?
A. IV hydrocortisone
B. IV infliximab
. .       C. Oral azathioprine
D. Oral prednisone
E. Topical mesalamine
The correct answer is E. The patient described here has ulcerative colitis confined to the
distal colon, also known as ulcerative proctosigmoiditis. Since the disease is limited to
distal colon, topical agents such as mesalamine (or alternatively hydrocortisone) would
be effective in reducing inflammation. Mesalamine is an anti-inflammatory drug used
principally to control ulcerative colitis. Its active ingredient is also known as 5-
aminosalicylic acid, which is available in the forms of rectal suspension, suppositories,
delayed release
oral tablets, and controlled release oral capsules. The mode of action is unknown, but is
thought to involve topicaI (since mesalamine is poorly absorbed), rather than systemic,
modulation of arachidonic acid metabolites, including prostaglandins, Ieukotrienes, and
hydroxyeicosatetraenoic acids. It is usually well tolerated, but it can cause significant
reactions related to sulfite sensitivity.
IV hydrocortisone (choice A) is reserved for patients who do not respond to high doses of
oral prednisone.
IV infliximab (choice B) is used for patients with severe refractory Crohn disease.
Oral azathioprine (choice C) is used in Crohn disease and ulcerative colitis in patients
already refractory or dependent on steroids to control symptoms or maintain remission.
Oral prednisone (choice D) is not warranted in patients who have not been treated
previously with safer medications, such as topical mesalamine or hydrocortisone or oral
mesalamine or sulfasalazine.
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Item 8 of 19
Untimed Test
An AIDS patient undergoes endoscopy for chronic substernal pain that is exacerbated
when he swallows. The studies demonstrate inflammation and superficial ulceration of
the distal
esophagus. Biopsies taken from the area show inflammation and a few cells, particularly
in the endothelium of small blood vessels, with markedly enlarged, smudgy, eosinophilic
nuclei. Which of the following is the most likely cause of the patient's esophagitis?
A. Acid reflux
..     B. Candida
C. Cytomegalovirus
D. Herpes simplex
E. Herpes zoster
The correct answer is C. AIDS and other profoundly immunosuppressed patients are
vulnerable to infectious esophagitis. Endoscopy with biopsy is usually used to identify
causative agents, which are typically Candida, Herpes simplex, or cytomegalovirus.
Careful review of the biopsy material is warranted, since these patients may actually be
by more than one agent. In the case of cytomegalovirus infection, the distinctive
histological finding is the presence of small numbers of cells with markedly enlarged
nuclei, which on
careful observation may show both cytoplasmic and nuclear viral inclusions.
Cytomegalovirus infection can be treated with ganciclovir.
Acid reflux (choice A) could produce inflammation, but would not alter nuclear
Candida (choice B) would have hyphal and yeast forms.
Herpes simplex (choice D) causes multinucleated cells with nuclear viral inclusions.
Herpes zoster (choice E) infection would resemble herpes simplex infection, but it much
less commonly involves the esophagus.
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Item 9 of 19
Untimed Te
A 51-year-old welder presents complaining of severe fatigue and the onset of jaundice.
He has a known history of hepatitis C, which he acquired after IV drug use 20 years
Over the past 6 months, he has developed ascites and has had two admissions to the
hospital for esophageal variceal bleeding. On physical examination, he is icteric with
wasting and multiple stigmata of chronic liver disease. On abdominal examination, his
liver is 7 cm in the midclavicular line, and splenomegaly is present. There is near-tense
and moderately severe lower extremity edema, which extends to the mid-calf. Laboratory
results reveal an albumin of 2.1 g/dL, total bilirubin of 12.1 mg/dL, and a prothrombin
time of
19 seconds. Which of the following is the most appropriate therapy for this patient?
A. Interferon
B. Ribavirin
C. Interferon plus ribavirin
D. Mesocaval shunt
E. Evaluation for liver transplantation
The correct answer is E. This patient has known hepatitis C. Features indicating that he
has advanced signs of cirrhosis and portal hypertension include ascites,
hepatosplenomegaly, jaundice with elevated bilirubin, hypoalbuminemia with leg edema,
increased prothrombin time probably secondary to inadequate synthesis of clotting
factors by
the liver, and esophageal variceal bleeding. In the setting of disease this advanced,
antiviral treatment for hepatitis C is without value and the patient should undergo
evaluation for a
Iiver transplant.
As discussed above, all anti-viral therapy (choices A, B, and C) would be futile given the
advanced stage of his cirrhosis at this point.
A mesocaval shunt (choice D) is a surgical procedure whereby portal flow is diverted
from the superior mesenteric vein into the inferior vena cava to reduce portal pressures. It
often complicated by encephalopathy and does not improve the underlying liver

Item 10 of 19
Untimed Te
A 35-year-old man comes to the physician for a health maintenance examination. He
received blood transfusions for hypovolemic shock following a gunshot wound 10 years
He is currently in good health, and physical examination is unremarkable. A serum
chemistry panel shows:
ALT                               250 U/L
AST                              140 U/L
AIkaline phosphatase             70 U/L
Serologic evaluation for viral hepatitis reveals positive antibodies to hepatitis C virus
(HCV). A percutaneous liver biopsy shows marked portal inflammatory infiltrate
disrupting the
Iimiting plate of hepatic lobules. Which of the following is the incidence rate of this
complication following HCV infection?
A. 5%
B. 10%
C. 20%
. .     D. 40%
E. 80%
The correct answer is E. The acute infection due to hepatitis C virus (HCV) is most
commonly asymptomatic, but 80% of these cases progress to chronic hepatitis. Of the
20% will eventually evolve to cirrhosis. The source of infection remains unknown in a
substantial number of cases, but 50% are related to IV drug abuse and 4% are attributable
blood transfusion. HCV, on the other hand, is now the most common cause of
transfusion-associated hepatitis. The mode of presentation of chronic hepatitis C is often
insidious, and
patients might well be in good health when elevated aminotransferases are discovered.
This laboratory finding prompts additional investigations, usually including a
percutaneous liver
biopsy. This will demonstrate the typical histologic changes of chronic hepatitis, namely
chronic portal inflammation eroding, to varying extents, into the hepatic lobule. The
degree of
Iobular "invasion" by the portal inflammatory infiltrate is the main indicator of the
propensity for evolution to cirrhosis. Male sex, infection after age 40, and alcohol
consumption are risk
factors for evolution of chronic hepatitis C to cirrhosis. Nowadays, HCV is considered
the most common cause of chronic hepatitis and one of the most common causes of
in industrialized countries.
Item 11 of 19
Untimed Te
A 31-year-old woman complains of severe low back pain after playing tennis for 4 hours.
She begins taking ibuprofen every 3 hours but finds little relief. She is prescribed codeine
her pain relief. Her physician also prescribes misoprostoI, since the patient has a history
of a bleeding gastric ulcer 1 year earlier after taking ibuprofen. She has also been taking
sumatriptan for frequent migraine headaches. Which of the following is the most
appropriate advice for this patient?
A. Avoid dietary potassium
B. Increase dietary roughage
C. Use an effective method of contraception
D. Increase her daily folate intake
E. Increase her daily aerobic exercise activity
The correct answer is C. This patient has been appropriately prescribed misoprostol for
the prevention of NSAID-induced ulcers, given the history that she has bled once
with the use of NSAIDs. Since misoprostol is a prostaglandin analogue, it will counter
the effect of NSAIDs on the gastric mucosa. However, as a prostaglandin analogue, it
will cause
smooth muscle contractions, including within the uterus, which can lead to a spontaneous
abortion in a pregnant woman. She should therefore be advised to maintain adequate birth
control measures while using misoprostoI.
None of the other choices (choices A, B, D, or E) have particular relevance to this
patient's health concerns.
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Item 12 of 19
Untimed Test
A 29-year-old man presents to the local health clinic after complaining of severe fatigue
and low-grade fevers over the past 3 weeks. In addition, he has noted "yellow eyeballs"
over the
past several days and has become increasingly nauseated. He admits to occasionally
injecting IV cocaine. He is a sexually active heterosexual who usually, but not always,
barrier contraceptive devices. On physical examination, his temperature is 38.4 C (101.1
F), and he has mildly icteric sclera. The liver edge is smooth and mildly tender and
13 cm in the midclavicular line. The spleen tip is not palpable, and there is no shifting
dullness. Which of the following would most likely be found on serologic testing to
explain his
current symptoms?
A. Hepatitis A IgG antibodies
B. Hepatitis B surface antibodies
C. Hepatitis B surface antigen
D. Hepatitis C antibodies
E. Hepatitis D antibodies
The correct answer is C. This man has multiple risk factors for hepatitis B infection, i.e.,
IV drug use and occasionaI "unsafe" sex. The symptoms are consistent with a mild to
moderate case of hepatitis B infection. This is confirmed by serologic evidence of
hepatitis B surface antigen positivity.
Hepatitis A IgG (choice A) is found in patients who have had a prior hepatitis A infection
and have developed immunity.
Hepatitis B surface antibody (choice B) is found in patients who have had a prior
hepatitis B infection or who have received the hepatitis B vaccine.
Hepatitis C antibodies (choice D) are found in patients who have been exposed to
hepatitis C. This patient is at risk for hepatitis C, given his use of IV drugs and the
possibility of delivering the blood-borne hepatitis C. However, hepatitis C rarely presents
with an acute viral hepatitis syndrome and instead will generally present as an indolent
chronic hepatitis.
Hepatitis D (choice E) is found as a co-existing infection to hepatitis B and is usually
found in patients with a very severe course of hepatitis B, which is not described in this

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Item 13 of 19
Untimed Test
A 19-year-old woman presents with a 2-week history of frequent episodes of loose stools.
The symptoms are accompanied by severe fecal urgency, and she has awoken with
diarrhea several nights weekly. Over the past week, the stools have become increasingly
bloody. A sigmoidoscopy reveals continuous, symmetric inflammation from the anal
verge to
the proximal sigmoid colon. Which of the following infections is most likely causing this
patient's symptoms?
A. Campylobacter - ni
B. Cryptosporidium
C. Giardia lamblia
D. Herpes simplex
E. Yersinia enterocolitica
The correct answer is A. This patient has an acute onset of bloody diarrhea consistent
with colitis, which is confirmed with the sigmoidoscopy. Of the organisms listed,
Campylobacter jejuni is the one most likely to cause these symptoms. This organism can
cause diarrhea in all age groups, although the peak of incidence is in young children. C.
jejuni can be acquired through exposure to contaminated food (especially undercooked
poultry) or water, or through exposure to infected domestic or wild animals. The diarrhea
be either watery or bloody and is often accompanied by a sometimes high fever. White
blood cells are commonly seen in the fecal materiaI. You should also be aware that there
appears to be an association between summer outbreaks of diarrheal disease due to this
organism, and subsequent development of the peripheral nervous system autoimmune
disease Guillain-Barré syndrome.
Cryptosporidium(choice B) causes a small bowel rather than colonic infection, as was
demonstrated by sigmoidoscopy.
Giardia lamblia(choice C) causes nausea, vomiting, eructations, and upper
gastrointestinal symptoms more commonly than diarrhea.
Herpes simplex (choice D) does not cause a bowel infection.
Yersinia enterocolitica(choice E) tends to infect the area of the cecum rather than the
distal colon, causing right lower quadrant findings and diarrhea that can mimic the
of Crohn disease.

Item 14 of 19
Untimed Te
A 31-year-old woman presents at the hospital for a pre-employment physical examination
prior to beginning her year as a medical intern. She is sexually inactive and denies
use. She had infectious mononucleosis while in college and received the recombinant
hepatitis B vaccine before starting medical schooI. Which of the following would
describe her
hepatitis B serologic profile?
A. Hepatitis B surface antigen positive, core antibody positive, and surface antibody
B. Hepatitis B surface antigen negative, core antibody positive, and surface antibody
C. Hepatitis B surface antigen positive, core antibody negative, and surface antibody
D. Hepatitis B surface antigen negative, core antibody negative, and surface antibody
E. Hepatitis B surface antigen negative, core antibody negative, and surface antibody
The correct answer is D. Patients who receive the hepatitis vaccine will develop only
surface antibodies, since the vaccine contains only epitopes of the surface antigen and
NOT of
the intact viral particle, which contains the core antibody. These patients will therefore
have a negative surface antigen, negative core antibody, and positive surface antibody.
Choice A describes a patient who has recent hepatitis B infection and has not yet
developed surface antibody B.
Choice B describes a patient that has had a past hepatitis B infection and has developed
Choice C refers to a patient who has developed acute hepatitis B and has not yet
developed immunity.
Choice E describes a patient who has never been exposed to surface antigen and has no
Item 15 of 19
Untimed Test
A 28-year-old woman has virulent peptic ulcer disease. Extensive medical management,
including eradication of Helicobacter pylori, fails to heal her ulcers. Endoscopy shows
duodenal ulcers in the first and second portions of the duodenum. She also complains of
watery diarrhea. Which of the following is the most appropriate next step in
A. Biopsy of the duodenal ulcers
B. Culture of the watery stools
C. Measurement of serum gastrin
D. Repetition of the H. pylori eradication every 2 months
E. Replenishment of the normal gut flora
The correct answer is C. Virulent and extensive peptic ulcer disease should trigger a work
up for gastrinoma. The presence of watery diarrhea actually adds to our suspicion that a
gastrinoma must be present.
Biopsy (choice A) is not the answer. It would be in gastric ulcers, which often are
malignant. But, duodenal ulcer is virtually never confused with duodenal cancer.
Culture of the stool (choice B) would also miss the point. The diarrhea is secretory, not
Continued medical therapy (choice D) will continue to fail as long as the very high levels
of gastrin are present.
The gut flora does not need to be replenished (choice E). The diarrhea is not due to
overgrowth of pathogens.
Item 16 of 19
Untimed Te
A 39-year-old woman presents with complaints of difficulty swallowing. She has a
history of scleroderma for the past 15 years, during which time she has required a variety
medications to reduce the symptoms of heartburn. Over the past 6 months, she has also
noted difficulty swallowing food, such as steak, and has felt as if food "sticks" in her
chest. She is able to tolerate liquids without difficulty. She denies any weight loss. Which
of the following has most likely occurred?
A. Development of a squamous carcinoma in the upper third of the esophagus
B. Recent return of peristaltic activity in the body of the esophagus
C. Reverse peristalsis in the body of the esophagus
D. Reverse peristalsis of the lower esophagus
E. Scarring at the lower esophagus because of chronic acid reflux
The correct answer is E. This patient has a history of scleroderma, which can cause
esophageal dysfunction secondary to fibrosis. Patients with scleroderma are very
to acid reflux because neither peristalsis nor the lower esophageal sphincter function
normally after much of the muscle tissue has been replaced by fibrosis. The situation is
complicated by the fact that persistent acid reflux will eventually itself induce scarring
with formation of a peptic stricture in the distal esophagus. Care should be taken to
manage even mild reflux symptoms in patients with scleroderma to prevent (or at least to
slow) the development of this troubling complication.
AIthough chronic acid reflux can predispose for Barrett's esophagus, with the risk of
progression to adenocarcinoma of the distal esophagus, squamous carcinoma of the upper
of the esophagus (choice A) would not be an expected complication.
Once peristalsis is lost, there is almost never a return of peristaltic activity (choice B).
Reversed peristalsis (choices C and D) is not usually seen clinically. Disordered
peristalsis can be seen in symptomatic diffuse esophageal spasm.
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Item 18 of 19
Untimed Test
A 32-year-old former heroin addict has a history of being treated for Pneumocystis carinii
pneumonia twice in the past year. Over the past 2 weeks, he has developed bloody
which occurred up to 12 times daily and is associated with urgency and the sensation of
incomplete evacuation. He also complains of left lower quadrant cramping. He denies
history of homosexual activity. Which of the following organisms would most likely be
responsible for his symptoms?
A. Cryptosporidium
B. Cytomegalovirus
C. Entamoeba histolytica
D. Enterotoxigenic Escherichia coli
E. Escherichia coli 0157
The correct answer is B. A heroin addict treated twice for Pneumocystis carinii
pneumonia most probably has clinicaI AIDS. The patient's sensation of incomplete
suggests that his distal colon is involved; the fact that the diarrhea is bloody suggests that
the causative agent is very destructive. Of the choices listed, both cytomegalovirus and
Entamoeba histolytica may produce this symptom pattern, but cytomegalovirus is much
more common than E. histolytica in AIDS patients.
Cryptosporidium(choice A) causes a small bowel diarrheal syndrome with wasting.
E. histolytica(choice C) may occur in patients with HIV but is less common than
cytomegalovirus infection.
Enterotoxigenic                     choice D) would produce a watery diarrhea.
E. coli 01-157 (choice E) is usually acquired by eating contaminated ground beef
products and results in a hemolytic-uremic syndrome.

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Item 19 of 19
Untimed Test
A 32-year-old man has a 15-year history of celiac sprue. He admits to being
noncompliant with the diet prescribed over the past 6 months and he has lost 15 pounds
during that time
in association with frequent diarrhea. Which of the following will be most likely to occur
in this patient?
A. Iron deficiency will produce a microcytic anemia
B. Vitamin A deficiency will produce nystagmus
C. Vitamin B12 deficiency will produce a megaloblastic anemia
D. Vitamin D deficiency will produce hypercalcemia
E. Vitamin K deficiency will produce hypokalemia
The correct answer is A. Celiac sprue will produce signs and symptoms of malabsorption
of the proximal small boweI. Iron (along with folate and calcium) is preferentially
in the proximal small bowel and is not well compensated for in the distal small intestine
when there is proximal small bowel malabsorption. Vitamin A, D, and K deficiencies will
but do not produce the described symptoms.
Vitamin A deficiency (choice B) will produce night visual disturbances rather than
Vitamin B12 deficiency (choice C) rarely occurs in celiac sprue since the malabsorptive
process is generally more severe in the proximal small bowel whereas B12 absorption
occurs in the terminal ileum.
Vitamin D deficiency (choice D) will produce hypocalcemia rather than hypercalcemia.
Vitamin K deficiency (choice E) produces a coagulopathy rather than hypokalemia.

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Item 1 of 1
Time Remaining: 00:00:00
A 59-year-old African American woman, who has been HIV positive for the past 12
years, is brought to the emergency department following an episode of combativeness at
home. Her
family reports that, over the past couple of days prior to admission, she has been talking
"out of her head," stating that her daughter-in-Iaw had been putting poison into the food.
refuses to eat or take medication in the hospitaI, stating that the physicians are also
against her. Her last CD4 count, done 6 months prior to this admission, was 85/mm3.
and neurologic examinations are unremarkable and nonfocaI. The current workup for
HIV-related infection is negative, and laboratory tests are otherwise unremarkable. On
Mini MentaI Status Examination she scores 21/30, missing on delayed recalI, 3-stage
command, writing, and copying, as well as orientation to year. Which of the following is
the most
Iikely diagnosis?
A. Amok
B. Delirium
C. Delusional disorder
D. Dementia
E. Schizophrenia
The correct answer is D. HIV dementia is characterized by affective, cognitive,
behavioraI, and motor symptoms and signs. It presents as a subcortical process and is
most likely to
occur in patients with a CD4 count below 200/mm3. It usually has a slow onset, and,
after a period of stability, there can be a precipitous decline. The diagnosis is made when
causes of delirium are excluded; the disease may present with psychosis within HIV
dementia. The symptoms are controlled with low doses of neuroleptics.
Amok (choice A) is a culture-bound syndrome. It is seen among Malayans and presents
as unprovoked outbursts of wild rage, causing the person to run madly and attack others
commit suicide. There is a period of amnesia afterward.
Delirium (choice B) is the most common cause of mental status changes in patients with
HIV/AIDS. It may be related to the primary effects of HIV infection in the CNS, the
secondary effects of systemic HIV disease, or side effects of medications. It may also be
a result of other usual causes of delirium (e.g., endocrine, metabolic, seizures, trauma,
neoplasms). Typically, the clinical picture includes a waxing and waning level of
consciousness and fluctuations in cognitive functions, as seen in delirium associated with
Delusional disorder (choice C) is defined as a psychotic disorder with persistent
nonbizarre delusions that are firmly held and may be of persecution, somatic nature,
grandeur, or
jealousy, for example.
Schizophrenia (choice E) is a psychosis with the onset of symptoms typically in young
adulthood. Patients with schizophrenia can develop dementia and, if they are HIV
also develop symptoms related to HIV. Typical schizophrenic symptoms include
delusions and hallucinations of at least 1 month's duration and a significant duration of
illness and
impairment of more than 6 months.

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Item 1 of 1
Time Remaining: 00:00
An adult develops insidious onset of a severe infectious disease. The condition is
characterized initially by high fever, headache, pharyngitis, and arthralgias. The patient
then goes on
to develop intestinal complaints of constipation, anorexia, and abdominal pain and
tenderness. During the second week of the illness, he has a rash with discrete pink,
Iesions (rose spots) on the chest and abdomen. The rash resolves about three days later.
By the third week of the disease, the patient appears very ill and has developed a florid
diarrhea that is positive for occult blood. During this same period, the man also develops
secondary pneumococcal pneumonia. At the height of the patient's illness, he was
and had short periods of delirium. The spleen was palpable during this period. BIood
studies demonstrate leukopenia, anemia, Iiver function abnormalities, and a mild
coagulopathy. Which of the following is the most likely diagnosis?
A. Brucellosis
B. Cholera
C. Melioidosis
. .    D. PIague
E. Typhoid fever
The correct answer is E. This is typhoid fever, which, despite widespread immunization
in many parts of the country, still has an incidence of 400 to 500 cases per year in the
United States. The organism is an enteric organism spread most frequently by a fecaI-oral
route (including contamination of food or water supplies). Many of the estimated 2000
carriers of the disease in the United States are elderly women with biliary tract disease.
The disease can be difficult to diagnose, often because it is not suspected. It should be
considered in patients who appear much more ill than a simple listing of their complaints
would suggest. The rose spot rash described in the question stem is a classic diagnostic
clue that will probably show up in test questions about the disease, but you should be
aware that it is only seen in about 10% of cases. CNS symptoms and superinfections such
the pneumococcal pneumonia are relatively common in severe cases. The blood study
results noted in the question stem can be another helpful clue to the possibility of typhoid
fever, and are unusual in other GI conditions. The organism can be cultured from blood
or bone marrow in the first two weeks of illness, and from stool in the third to fifth week
illness. Antibiotic therapy with cephalosporins or quinolones may decrease the severity or
duration of the illness; relapses may occur, which also usually respond to antibiotic
Severely ill patients may benefit from supportive care including nutritional support and
sometimes glucocorticoid therapy.
Brucellosis (choice A) causes a recurrent fever after exposure to contaminated milk
Cholera (choice B) causes a profound secretory diarrhea with rice water stools and has
fewer systemic manifestations (other than those due to dehydration and electrolyte
imbalance) than typhoid fever.
Melioidosis (choice C) causes pneumonia and disseminated infection.
PIague (choice D) causes massive lymph node enlargement and pneumonia after
exposure to infected rodents and their parasites.

Item 1 of 10
Untimed Te
A 67-year-old man presents to the clinic complaining of steady, dull back pain over the
past 3 weeks. He states that he has recently moved after retiring from a career in banking
and is
searching for a new primary care physician. His past medical history is significant for
diverticulosis, prior smoking, and hypertension. He says that he has run out of his blood
medication. He denies trauma to his back and otherwise feels welI. On physical
examination his blood pressure is 170/93 mm Hg with a pulse of 88/min. He has no
tenderness over
the spinal processes or paraspinal areas. His abdomen is obese but there is a suggestion of
a non-tender, pulsatile mass in the epigastric region. The remainder of the physical
examination is normaI. Which of the following diagnoses should be considered at this
A. Abdominal aortic aneurysm (AAA)
B. Acute aortic dissection
C. Cauda equina syndrome
D. Lumbosacral disk herniation
E. Pancreatitis
The correct answer is A. It is imperative to recognize the potential presence of an
abdominal aortic aneurysm (AAA). The combination of the history of hypertension and
the new back pain, and a pulsatile mass on examination is highly suggestive for
abdominal aneurysm. The back pain occurs as the expanding mass compresses structures
in the
retroperitoneum. It is particularly important to make the diagnosis because large
aneurysms (greater than 5 cm in diameter) are associated with a very high risk of rupture
subsequent mortality.
Acute aortic dissection (choice B) is the most common aortic catastrophe requiring
admission to the hospitaI, resulting from an extension of an intimal tear in the wall of the
The hallmark of acute dissection pain is sudden onset, severe chest and abdominal pain
that often radiates from an anterior to posterior direction.
The cauda equina syndrome (choice C) is also important to recognize, as it is a
neurological emergency. However, it is due to compression of the lower lumbar and
sacral nerve
roots, and produces sensory loss in a saddle distribution, decreased reflexes, urinary
incontinence, and flaccid and weak legs, none of which are present in this case.
While lumbosacral disk herniation (choice D) is one of the commonest etiologies of low
back pain, the pain is usually described as sharp or lancinating, with radiation from the
down to the legs. Approximately 90% of disk herniations respond to conservative
medical management.
Pancreatitis (choice E) may also cause dull pain radiating to the back, but the pain is
usually excruciating. The findings in this case that makes pancreatitis less likely are the
tender abdomen and lack of any constitutional symptoms. Patients with pancreatitis
appear acutely ilI.
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Item 2 of 10
Untimed Test
A 14-year-old boy is hit by an automobile while walking across the street and is
immediately taken to the emergency department. On arrivaI, he is conscious and
complains of
shortness of breath and chest pain. Physical examination reveals an ecchymotic area over
his right chest and subcutaneous emphysema. Breath sounds are absent on the right side.
His trachea is deviated to the left, and his right hemithorax is tympanic to percussion.
Which of the following is the most appropriate initial step in management of this patient?
A. 12-Iead ECG
B. CT of the chest
C. PIain radiography of the chest
D. Chest tube thoracostomy
E. Pericardiocentesis
The correct answer is D. The findings on physical examination strongly suggest tension
pneumothorax. This is a life-threatening emergency that needs to be managed
with either chest tube thoracostomy or needle thoracocentesis to relieve the tension on the
affected side of the thorax. Physical examination reveals tachycardia, tachypnea,
decreased or absent breath sounds over the involved hemithorax, increased resonance to
percussion, subcutaneous emphysema, and deviation of the trachea to the opposite side.
Tension pneumothorax develops when air leaking into the chest increases intrathoracic
pressure, completely collapsing the lung on that side. It results in displacement of the
mediastinum and trachea to the opposite side of the chest and impedes venous return.
12-Iead ECG (choice A), CT of the chest (choice B), and plain radiography of the chest
(choice C) may be indicated on a trauma patient after the patient is stabilized. In tension
pneumothorax, no imaging study should precede the emergent relief of tension inside the
Pericardiocentesis (choice E) is indicated when there is cardiac tamponade, caused by
build-up of fluid in the pericardium. Cardiac tamponade significantly affects ventricular
relaxation and markedly decreases cardiac output.

Item 3 of 10
Untimed Test
A 72-year-old African American woman is being readied for discharge from the hospitaI
2 weeks after a stroke affecting her right occipital cortex. A psychiatric consultation is
called to
evaluate the patient for depression, as she has had decreased appetite, some crying spells,
and insomnia. After determining that the patient is not suffering from delirium, which of
following medications would be most appropriate to treat her depressive symptoms?
A. Methylphenidate
B. Nortriptyline
C. Phenelzine
D. Sertraline
E. Thioridazine
The correct answer is D. In a patient with complications from a stroke, a selective
serotonin reuptake inhibitor (SSRI), such as sertraline, has been demonstrated to be the
and most effective medication for the treatment of clinical depression.
Methylphenidate (choice A) is a stimulant medication that would have the potential to
increase heart rate and sympathetic tone, which would not be advantageous in the post-
cerebrovascular injury period.
Nortriptyline (choice B) is a tricyclic antidepressant that has the potential for producing
cardiac arrhythmias and vascular compromise in overdose.
Phenelzine (choice C) is a monoamine oxidase inhibitor, which would be contraindicated
in a patient with a history of recent vascular injury, as the ingestion of tyramine with an
inhibitor could induce a hypertensive crisis.
Thioridazine (choice E) is a low-potency dopamine antagonist antipsychotic medication
that is not indicated for the treatment of depression.
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Item 4 of 10
Untimed Te
A 25-year-old nulliparous woman at 35 weeks' gestation comes to the labor and delivery
ward complaining of contractions, a headache, and flashes of light in front of her eyes.
pregnancy has been uncomplicated except for an episode of first trimester bleeding that
completely resolved. She has no medical problems. Her temperature is 37 C (98.6 F),
pressure is 160/110 mm Hg, pulse is 88/minute, and respirations are 12/minute.
Examination shows that her cervix is 2 centimeters dilated and 75% effaced, and that she
contracting every 2 minutes. The fetal heart tracing is in the 140s and reactive. Urinalysis
shows 3+ proteinuria. Laboratory values are as follows: Ieukocytes 9,400/mm3,
35%, platelets 101,000/mm3. Aspartate aminotransferase (AST) is 200 U/L, and ALT
300 U/L. Which of the following is the most appropriate next step in management?
A. Administer oxytocin
B. Discharge the patient
C. Encourage ambulation
D. Start magnesium sulfate
E. Start terbutaline
The correct answer is D. This patient has severe preeclampsia. Preeclampsia is diagnosed
on the basis of hypertension, edema, and proteinuria. Severe preeclampsia may be
diagnosed when the patient has one of the following: a headache that does not respond to
analgesics, visual changes, seizure, very elevated blood pressures, pulmonary edema,
elevated liver function tests, severe proteinuria, oliguria, an elevated creatinine,
thrombocytopenia, hemolysis, intrauterine growth restriction, or oligohydramnios. The
management of
severe preeclampsia after 32 weeks is with delivery. Prior to 32 weeks, consideration
may be given to expectant management of the patient depending on the clinical
This patient is at 35 weeks' with headache, visual changes, elevated blood pressures,
thrombocytopenia, and elevated liver function tests. She, therefore, needs to be delivered.
appears to already be in labor as she is contracting every two minutes and her cervix is
dilated and effaced. At this point, magnesium sulfate should be started. Magnesium
has consistently been demonstrated to be the most effective medication for seizure
prophylaxis in women with preeclampsia.
To administer oxytocin (choice A) would not be necessary for this patient. She appears to
already be in labor with contractions every two minutes.
To discharge the patient (choice B) would absolutely be incorrect. Severe preeclamptics
need to be delivered or, at the very least, admitted to the hospitaI. There is no role for
discharging a patient home in the management of severe preeclampsia.
To encourage ambulation (choice C) would also be incorrect. Severe preeclamptics
should be kept on bed rest.
To start terbutaline (choice E) would not be appropriate. Terbutaline is used in obstetrics
as a tocolytic agent to treat preterm labor. In this patient, contractions and labor are
desirable and no attempt should be made to stop them, as she requires delivery.

Item 5 of 10
Untimed Te
A 41-year-old man presents to his physician for a routine physical examination. He is a
new to this office and brings his previous medical record with him. He has no significant
medical history but he does have a strong family history of cancer and heart disease. His
father and his brother both had myocardial infarctions before age of 55, and his sister,
mother, and aunt had breast cancer. He exercises regularly and eats welI, with most of his
diet being low in saturated fat and cholesteroI. He smokes one pack of cigarettes per
His review of systems is unremarkable. He is very anxious and would like only minimal
interventions done because of his good health. Which of the following is an age-
screening test in this patient?
A. Fasting lipid profile
B. Non-fasting total cholesterol level
C. Oral glucose tolerance test
D. Prostate examination
E. Sigmoidoscopy
The correct answer is B. The current recommendations for routine, age-appropriate
screening are based, in some measure, on data from clinical trials. Depending on the
source of
the recommendations, there is considerable variability in these recommendations. One of
the more agreed on recommendations is that, at least every 5 years, a random cholesterol
Ievel should be checked.
A fasting lipid profile (choice A) is usually obtained only after a screening cholesterol is
shown to be greater than 240 mg/dL.
An oral glucose tolerance test (OGTT) (choice C) is given to pregnant women to screen
for gestational diabetes. There is no current recommendation for using OGTT in routine
screening practice in any age group.
The incidence of prostate cancer is age-related and becomes reasonably prevalent after
age 50. Therefore, prostate examinations (choice D) are recommended annually after age
50. Like prostate cancer, colon cancer is also age-related and begins to have significant
incidence after the 5th decade.
Sigmoidoscopy (choice E) is indicated every 3-5 years after age 50 to monitor for lesions
up to the splenic flexure. Colonoscopy is necessary to survey the entire colon.
Item 6 of 10
Untimed Test
A 43-year-old man reports that he has had a 9-pound weight loss over the past 9 months.
The symptoms have been accompanied by difficulty swallowing both solids and liquids
during that time. He has woken on several occasions at approximately 4 AM and
regurgitated partially digested dinner contents. An upper gastrointestinal series is
performed and
reveals a widely dilated esophagus with a smoothly tapering distal esophagus. There
appears to be undigested food present in the esophagus. Which of the following would
most likely
be seen on esophageal manometry?
A. High resting LES pressure
B. High resting upper esophageal sphincter pressure
C. Increased peristalsis in mid esophagus
D. Low resting LES pressure
E. Low resting upper esophageal sphincter pressure
The correct answer is A. This question describes a typical presentation of achalasia.
Achalasia is a neurogenic esophageal disorder thought to be caused by a malfunction of
myenteric plexus of the esophagus. The result is denervation of the distal esophageal
muscle with resulting impaired esophageal peristalsis. The characteristic findings on
esophageal manometry are diminished or absent peristalsis in the body of the esophagus
and a high resting lower esophageal pressure. The latter finding is related to a failure of
usual relaxation of the sphincter as the bolus of food reaches it.
Choices B and E are wrong, because the upper esophageal sphincter is usually unaffected
in this condition.
Choice C is wrong because peristalsis is decreased or absent in the mid-esophagus in
Choice D is wrong because resting lower esophageal pressure is characteristically high in
Item 7 of 10
Untimed T
A 22-year-old college student is brought to the emergency department after being found
unarousable by his roommates in the morning. He had complained of a severe headache
night before. His temperature is 39.5 C (103 F). Physical examination reveals nuchal
rigidity and petechiae over both legs. Chest x-ray films are unremarkable. After
examination, a lumbar puncture is performed. The CSF appears cloudy. Laboratory
studies on a CSF sample show:
Cells....................................8000/mm3mostly neutrophils
Protein.................................6.0 g/L
GIucose................................0.3 g/L
PIasma glucose/CSF glucose < 0.4
On microscopic examination, no bacterial or fungal organisms are detected in the CSF.
Which of the following is the most likely pathogen?
A. Escherichia coli
B. Group B streptococci
C. Hemophilus influenzae
D. Listeria monocytogenes
E. Meningococcus
F. Pneumococcus
The correct answer is E. The clinical presentation, with nuchal rigidity, fever, and
obtundation, is characteristic of acute meningitis. The CSF findings are diagnostic of this
bacterial infection. Acute bacterial meningitis is associated with CSF pleocytosis (mostly
due to neutrophilia), increased protein, and decreased glucose. Furthermore, the patient's
age and finding of petechiae point to meningococcus as the most likely pathogen.
Meningococcus is the most common etiologic agent of cases affecting young
adults. Sometimes, but not always, gram-negative cocci can be detected on gram-stained
samples of the CSF. CSF cultures, however, allow isolation of meningococcus unless the
patient has already received antibiotic treatment (partially treated meningitis). In any
case, antibiotic treatment with penicillin should be immediately started soon after
submitting a
sample of CSF for culture studies. Antibiotic therapy may then be optimized according to
culture and antibiotic sensitivity results.
choice A) and group B streptococci (choice B) are the most common etiologic agents in
infants. In this age group, bacterial meningitis may manifest with
nonspecific symptoms, such as fever, poor feeding, and excessive crying.
Hemophilus influenzae(choice C) has become a relatively rare cause of meningitis since
the introduction of mandatory immunization against this bacillus.
Listeria monocytogenes(choice D) is now a frequent cause of meningitis in infants
younger than 2 months and in immunocompromised adults.
Pneumococcus (choice F) is the most common agent causing purulent meningitis in the
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Item 8 of 10
Untimed Test
A 41-year-old man presents with a 2-week history of fever, anorexia, weight loss, and
fatigue. He is otherwise healthy and has not seen a physician recently, but did recently
have his
teeth cleaned. He is on no medications and has no allergies. He drinks alcohol only
occasionally and denies IV drug use. On physical examination, he appears ilI, with a
temperature of
38.9 C (102 F) and a few petechiae in both eyes. There is a llI/VI systolic ejection
murmur consistent with mitral regurgitation and a pericardial rub. BIood is drawn and
sent to the
Iaboratory for culture. Which of the following is most likely to confirm the diagnosis?
B. Transthoracic echocardiogram (TTE)
C. Stress test
D. Transesophageal echocardiogram (TEE)
E. Cardiac catheterization
The correct answer is D. The patient's history and physical examination are consistent
with subacute bacterial endocarditis. The most effective diagnostic modality would be a
transesophageal echocardiogram (TEE) in order to determine whether this patient has a
valvular vegetation.
An ECG (choice A) will be useful to follow this patient for any evolving cardiac
conduction delay. In the initial evaluation, it will help assess extent of conduction
damage from the
infection but will be of little help in the original diagnosis.
A transthoracic echocardiogram (TTE) (choice B) would be appropriate if a TEE were
not possible. However, a TTE is much less sensitive than a TEE.
A stress test (choice C) would be useful for risk-stratifying a patient with chest pain and
coronary artery disease. If this patient was not febrile and was complaining of stable
pain, a stress test could be conducted to assess the risk of a cardiac event.
Cardiac catheterization (choice E) would show the vegetation but is too invasive. This
option is usually reserved for patients with an acute coronary syndrome arising from
of a coronary artery.
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Item 9 of 10
Untimed Test
A 33-year-old man with a history of IV drug use presents to the emergency department
complaining of fevers, chills, and a productive cough. He has a prior history of cellulitis
tricuspid valve endocarditis. A recent HIV test at his methadone clinic was negative. On
physical examination, his temperature is 39.1 C (102.3 F), blood pressure is 112/62 mm
pulse is 98/min, and respirations are 28/min. Lung examination reveals rhonchi in the
right mid posterior lung field. There is a soft, holosystolic murmur heard at the left lower
border that increases with inspiration. A chest x-ray film shows a lobar consolidation in
the right middle lobe with an air fluid leveI. Which of the following is the most likely
cause of his
A. Escherichia coli
B. Haemophilus influenzae
C. Staphylococcus aureus
D. Staphylococcus epidermis
E. Streptococcus pneumonia
The correct answer is C. This patient is an IV drug abuser with a history that describes
two prior infections probably related to drug use and Staphylococcus infection, i.e.,
and tricuspid valve endocarditis. The lobar consolidation with an air-fluid level is
consistent with Staphylococcus aureus pneumonia with cavitation. None of the other
infections noted
cause a cavitating pneumonia.
Associate                    choice A) with pneumonia secondary to dissemination of a
urinary tract or other E. coli infection.
Associate Haemophilus influenzae(choice B) with community acquired pneumonia,
particularly in children and in the elderly with pre-existing lung disease.
Associate Staphylococcus epidermis(choice D) with conditions causing a skin break.
Remember: the resulting pneumonia will not cause cavitation, since this organism does
have the range of lytic enzymes that Staphylococcus aureus does.
Associate Streptococcus pneumonia(choice E) with the most common form of
community-acquired pneumonia.

Item 10 of 10
Untimed Test
The longtime primary care physician of an 85 year-old woman is asked to help mediate
care between the family and the hospitaI's medical service. The patient sustained an
brain injury during an in-hospital cardiac arrest one week ago in which the patient had a
pulseless period for at least 5 minutes. On physical examination, her vital signs are
normal and
stable with the assistance of continuous mechanical ventilation. Pupillary and corneal
reflexes are present bilaterally. There is episodic decorticate rigidity, but no purposeful
movement present. An electroencephalogram (EEG) suggests severe, diffuse cortical
damage. The patient's husband asks the physician if she is brain dead. Which of the
following is
the most appropriate response?
A. It is too early to predict brain death by the legal definition
B. The diagnosis of brain death can only legally be made by a neurologist
C. The decision on brain death must await the completion of a magnetic resonance image
D. The presence of brain stem function and posturing rules out brain death, but the
examination findings and supportive data suggest extensive brain damage
E. The suggestion of severe cortical damage by the EEG implies brain death
The correct answer is D. As part of the widely accepted University of Pittsburgh criteria
for brain death, the presence of either posturing or brain stem function (e.g.,. pupillary
reflexes or corneal reflexes), as are present in this case, violates the brain criteria for the
formal definition of brain death. That said, the fact that the patient has no purposeful
one week after an anoxic brain injury bodes poorly for a meaningful neurological
recovery. There are published studies that stratify long-term prognosis of such patients
based upon
neurological examinations made in the first 48 hours after injury.
While the passing of time often aids in the prognosticating of likely neurological
recovery, the diagnosis of brain death can be made at any time and is not time-dependent
(choice A).
Neurologists are often asked to help predict neurologic recovery and diagnose brain death
(choice B), but any physician (generally two are required) may do so within current
accepted diagnostic guidelines.
MRI (choice C) may help assess the extent of brain injury but has no role in the formal
diagnosis of brain death.
The EEG, even when suggestive of minimal or no cortical function (choice E), does not
exclude brainstem activity and therefore can not be used in isolation to make the
diagnosis of
brain death.
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Item 1 of 10
Untimed Test
A 62-year-old man presents with symptoms of worsening congestive heart failure. He has
a history of rheumatic heart disease as a child. Over the past 3 years, he has had
progressive symptoms of dyspnea on exertion, paroxysmal nocturnal dyspnea, and
orthopnea. He has been maintained on digoxin, furosemide, and enalapril for symptoms
of his
congestive heart failure. His cardiac examination reveals a loud blowing decrescendo
diastolic murmur. He has bounding peripheral pulses. Which of the following additional
would most likely be found on physical examination?
A. Bradycardia
B. Isolated systolic hypertension
C. Pulsus paradoxus
D. Tachycardia
E. Wide pulse pressure
The correct answer is E. This patient has the characteristic physical findings of an aortic
insufficiency, including the loud blowing decrescendo murmur and the bounding
pulses. These patients typically will have a wide pulse pressure, i.e., elevated systolic
blood pressure related to a large left ventricular volume being ejected (until left
ventricular failure
supervenes). The low diastolic pressure is a result of the rapid run-off from the aorta due
to the regurgitant flow across the aortic valve into the left ventricle, as well as the
flow to the aorta.
Bradycardia (choice A) is not a feature of either aortic insufficiency or left ventricular
Isolated systolic hypertension (choice B) may be found in the elderly and is an
independent risk factor for stroke, but it is not correlated with the presence of aortic
Pulsus paradoxus (choice C) may occur in patients who have severe asthma or other signs
of high right-sided pressures. It is not a feature of aortic insufficiency.
Tachycardia (choice D) may occur in patients with a failed left ventricle, but it is not a
hallmark of aortic insufficiency.
Item 2 of 10
Untimed Test
A 9-year-old boy presents with a 3-month history of multiple episodes of sudden
awakening at night. His mother states that when he wakes up suddenly, he screams, "Go!
Get away!
Go!" and does not respond to the parents. His eyes are wide open, and he sweats heavily
and looks scared. The parents have had to struggle to awaken him. After the episodes, he
has no memory of what happened. Which of the following is the most likely diagnosis?
A. Confusional arousals
B. Night terrors
C. Nightmares
D. Obstructive sleep apnea
E. Panic disorder
The correct answer is B. Night terrors are a form of parasomnias. Parasomnias refer to
unusual behaviors that occur in the context of sleep, specific sleep stages, or in
with arousal from sleep. Night terrors are most common in children aged 4-12 years and
typically occur within the first several hours of sleep. They are characterized by the child
suddenly crying out, sitting up in bed with a terrified look, crying inconsolably, perhaps
thrashing about, and exhibiting evidence of increased autonomic arousal with enlarged
tachycardia, rapid breathing, and sweating. These episodes typically last only a few
minutes, and the child then returns to sleep, with no memory of the events the next
morning. Night
terrors are believed to be disorders of arousal from non-REM sleep (stage 3 and 4), in
which motor behavior occurs, but conscious awareness and memory of the action are not
present. They are more likely to take place during periods of illness, stress, or sleep
deprivation, but they can happen without any obvious associated stress. Those subject to
terrors or somnambulistic events should avoid sleep deprivation, which can increase the
likelihood of their occurrence. Most children with infrequent night terrors grow out of
with maturity and usually require no specific treatment. CIinicians should thoroughly
explain the phenomenon to the parents and reassure them that the child is welI. The
eventual remission of the problem should be emphasized. Parents are encouraged not to
awaken the child, but to allow the episode to run its course. If the child is not awakened,
or she will return to normal sleep at the end of the episode. If the child thrashes about
wildly during the episode, the parents should provide protection from injury at that time.
Confusional arousals (choice A) start gradually (unlike a full sleep terror in older
individuals, which begins precipitously), with moaning progressing to crying, sitting, and
The children are difficult to arouse and do not respond to comforting, but when allowed
to return to sleep, they do not typically remember the event the next morning.
Nightmares (choice C) are frightening dreams that awaken the child from REM sleep.
The child becomes fully awake and is scared. He or she usually can recall details of the
Obstructive sleep apnea (choice D) manifests as apneic episodes during sleep in which
the patient awakens suddenly. Affected patients usually are obese.
Panic disorder (choice E) is characterized by recurrent panic attacks, which initially may
occur spontaneously and, over time, may develop in a number of agoraphobic situations.
The patient may experience a sense of terror or fear associated with a panic attack,
including concerns about dying, going crazy, or losing controI.
Item 3 of 10
Untimed Te
A 61-year-old woman, who has been treated with amitriptyline for depression, is brought
to her psychiatrist by her family. The woman is confused, disoriented, and hallucinating,
her skin appears dry and warm. The family noticed that she took more pills than
prescribed. Which of the following is the most likely cause of this development?
A. Anticholinergic delirium
B. Hypertensive crisis
C. Neuroleptic malignant syndrome
D. Paradoxical reaction
E. Serotonin syndrome
The correct answer is A. Anticholinergic delirium is caused by the use of anticholinergics
or other drugs with anticholinergic properties, Iike tricyclic antidepressants. In elderly
patients, the symptoms can be present even with usual doses. Overdosing results in
clouding of consciousness, as well as constipation, urinary retention, dry mouth, elevated
temperature, dry flushed skin, worsening of glaucoma, and tachycardia.
The primary criterion of a hypertensive crisis (choice B) is an elevated value of both
systolic and diastolic blood pressure. Tricyclic antidepressants usually lower blood
pressure and
cause orthostatic hypotension.
Neuroleptic malignant syndrome (choice C) is a rare complication of neuroleptic therapy
resulting in muscle rigidity and elevated temperature, as well as difficulties swallowing,
tremor, incontinence, diaphoresis, mutism, tachycardia, altered level of consciousness,
Iabile blood pressure, Ieucocytosis, and elevated creatine phosphokinase.
A paradoxical reaction (choice D) is an unusual reaction to benzodiazepines, consisting
of paradoxical agitation and confusion instead of relaxation. It is seen in elderly patients,
well as in patients with organic diseases of the CNS.
Serotonin syndrome (choice E) can result from a combination of MAO inhibitors and
serotonergic agents. Even though altered mental status may be present, tremor,
hyperreflexia, myoclonus, shivering, and diaphoresis make it different from
anticholinergic delirium.
Item 4 of 10
Untimed Te
A 32-year-old woman comes to the hospital for an elective repeat cesarean delivery. Four
years ago she had a primary cesarean delivery for a nonreassuring fetal heart rate tracing.
Two years ago she chose to have an elective repeat cesarean delivery rather than attempt
a vaginal birth after cesarean (VBAC). Her prenatal course was uncomplicated except
she has mitral valve prolapse. An echocardiograph demonstrated the mitral valve
prolapse, but no other structural cardiac disease. Which of the following is the correct
of this patient?
A. Administer intravenous antibiotics 30 minutes prior to the procedure
B. Administer intravenous antibiotics immediately after the procedure
C. Administer intravenous antibiotics for 24 hours after the procedure
D. Administer oral antibiotics 6 hours after the procedure
E. No antibiotics are needed
The correct answer is E. Mitral valve prolapse affects approximately 5% of women of
childbearing age. Consequently, the issue of mitral valve prolapse and the need for
comes up quite often in obstetrics, particularly with delivery (either vaginal delivery or
cesarean delivery). Bacterial endocarditis is a life-threatening infection that can develop
patients with structural cardiac disease who are exposed to bacteremia. The risk for any
given procedure depends upon the nature of the procedure itself and on the nature of the
cardiac lesion. Periodically, the American Heart Association publishes guidelines for the
prevention of bacterial endocarditis. According to the American Heart Association
antibiotic prophylaxis is not necessary for cesarean delivery or normal vaginal delivery.
The possible exception to this is for patients with "high risk" cardiac conditions, which
women with a history of endocarditis or who have prosthetic heart valves, complex
cyanotic congenital heart disease, or surgically corrected systemic pulmonary shunts.
Mitral valve
prolapse, if associated with mitral regurgitation (demonstrated by Doppler or a murmur),
is considered a moderate risk condition and, therefore, antibiotic prophylaxis is not
necessary. This patient, therefore, does not require antibiotics prior to, during, or after her
cesarean delivery.
To administer intravenous antibiotics 30 minutes prior to the procedure (choice A),
immediately after the procedure (choice B), 24 hours after the procedure (choice C), or to
administer oral antibiotics 6 hours after the procedure (choice D) would all be
unnecessary. As explained above, the reason for administering antibiotics to women with
cardiac disease is to prevent bacterial endocarditis. Bacterial endocarditis is a potentially
fatal condition. However, there are different degrees of structural cardiac disease. Mitral
valve prolapse with regurgitation is considered to be a moderate risk condition. The
American Heart Association does not recommend endocarditis prophylaxis for women
moderate risk conditions undergoing vaginal or cesarean delivery.
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Item 5 of 10
Untimed Test
A 29-year-old woman is seen in the emergency department for a broken ankle. She
describes a fall down her stairs at home earlier that day. She denies any alcohol or drug
use at the
time. She has no significant past medical history, but she has been admitted to the
hospital many times for previous fractures and she has been seen in the emergency
on multiple occasions for various lacerations and minor injuries. The patient explains that
all these visits are due to her "active lifestyle" and her frequent home repair projects. The
patient has been married, she claims happily, for 2 years. She is employed as a manager
at a local restaurant; her husband is unemployed and on disability pay for back problems.
The patient is admitted to the hospital and undergoes successful open reduction and
internal fixation for her ankle. She is able to give a more detailed history about her social
She describes feeling very depressed lately and having had an argument with her husband
the morning of her injury. Domestic abuse is suspected. Which of the following is the
appropriate initial step in addressing this concern?
A. Address the concerns with her husband directly
B. Ask her to offer more details about the nature of her relationship with her husband
C. Explain to her that her marriage is obviously not having a positive impact on her life
D. Refer her case to the department of social services as obligated
E. Refer her to a psychiatrist who specializes in domestic abuse
The correct answer is B. The concern for potential abuse must be addressed as any other
new piece of clinical suspicion. The best initial step is to try to gather more information
a non-threatening way that is comfortable for the patient. AIthough the physician will
ultimately want to ask her directly if she is being abused, it is often better to let that
disclosure "fall
out" from a discussion about the particulars of the relationship.
AIthough physicians often feel the desire to "take things into their own hands" and
address alleged abusers directly (choice A), this approach can be extremely dangerous for
abused party. Abusers obviously dread being discovered and are likely to seek retribution
against their victim if they are confronted by a doctor.
Explaining that her marriage is not having a positive impact on her life (choice C) is
presumptuous without first exploring all of the particulars of the relationship.
Physicians in most states are obligated to report (choice D) potential abuse only in cases
involving children younger than 18 and adults older than 65. There is no obligatory
for domestic abuse not falling within these parameters.
AIthough the patient may respond very well to treatment from a psychiatrist who
specializes in domestic abuse (choice E), this referraI, Iike any other, should be made
after an
earnest attempt to gather the clinical and social details from the patient by the referring

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Item 6 of 10
Untimed Test
A 37-year-old woman presents with complaints of severe heartburn with or without
meals. She has a history of hypertension, which has been treated with captopriI. She also
has a
history of Raynaud disease, multiple facial telangiectasias, and very taut skin on the
dorsum of both hands. She has failed to obtain relief for her heartburn with large doses of
antacids, ranitidine, or omeprazole. Esophageal manometry is ordered. Which of the
following would be the most likely results of this test?
A. Decreased esophageal peristalsis and decreased LES pressure
B. Decreased esophageal peristalsis and increased LES pressure
C. Increased esophageal peristalsis and decreased LES pressure
D. Increased esophageal peristalsis and increased LES pressure
E. Normal esophageal peristalsis and normaI LES pressure
The correct answer is A. This patient has the classic presentation of gastroesophageal
reflux disease (GERD) in association with scleroderma. These patients have the
of collagen in the body of the esophagus, as well as the lower esophageal sphincter
(LES). This results in the typical pattern of decreased esophageal peristalsis and the
ability of the LES to maintain its high pressures between swallowing. These patients are
therefore at risk for severe GERD and subsequent complications of peptic stricture and
Barrett's esophagus. AIthough there is no corrective therapy to improve esophageal
motility or increase LES pressure, aggressive treatment is generally aimed at reducing
production with the use of high doses of proton pump inhibitors. Nevertheless, many of
these patients develop the long-term consequences of GERD.
Choice B suggests achalasia, in which impaired esophageal peristalsis is often
accompanied by a lack of lower esophageal sphincter relaxation.
Choice C doesn't describe any of the more common esophageal motor disorders.
Choice D suggests symptomatic diffuse esophageal spasm, particularly if the peristaltic
waves were poorly organized.
Choice E would be seen in patients without esophageal motor disease.

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Item 7 of 10
Untimed T
A 31-year-old homeless woman is brought to the emergency department after being
found face down on the street. The woman has a long history of admissions to the
hospital for
alcohoI-related issues, including seizures, withdrawaI, and hallucinations. Today, she was
seen to fall in the street, have what were described as "convulsions" and then vomit. She
remained face down in the street until the paramedics arrived. On physical examination,
she has dry mucous membranes, a jugular venous pressure of less than 5 cm, and diffuse
ecchymoses on her face, body, and breasts. Which of the following vitamins should be
administered prior to volume resuscitation with IV fluids containing glucose?
A. Vitamin B1 (Thiamin)
B. Vitamin B3(Niacin)
C. Vitamin B12 (Cobalamin)
D. Vitamin C
E. Vitamin K
The correct answer is A. Administering glucose to a patient who is deficient in thiamin
may precipitate Wernicke-Korsakoff syndrome, which is a combination of confusion,
ophthalmoplegia, anterograde and retrograde amnesia, and confabulation. It is therefore
imperative to administer IV thiamin prior to glucose-containing IV fluids.
Niacin (choice B) is an essential component of the coenzymes involved in oxidation-
reduction reactions. Profound deficiency in niacin causes the classic triad of pellagra:
diarrhea, and dementia.
Vitamin B12 deficiency (choice C) may lead to megaloblastic anemia, neurologic
complications, and dementia.
Vitamin C deficiency (choice D) may lead to difficulty with wound healing and scurvy.
Vitamin K (choice E) is essential for the production of selected clotting factors. AIthough
alcoholics may be deficient in all the vitamins mentioned in the answer choices, only
in thiamin are associated with harmful effects if glucose is administered without

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Item 8 of 10
Untimed Test
A 9-year-old boy is being evaluated for a syncopal episode. He was playing basketball
when the syncope occurred. The episode lasted about 1-2 minutes, and then the patient
up on his own. His mother also noticed that he has been having hearing problems. His
physical examination is unremarkable. An ECG shows a prolonged Q-T intervaI, with a
QTc of
0.49 sec. Which of the following is the most appropriate management if he has long Q-T
A. AIpha-adrenergic blocker
B. Angiotensin converting enzyme inhibitor
C. Beta-adrenergic blocker
..       D. Calcium channel blocker
E. Diuretic
The correct answer is C. The boy in this clinical vignette has long Q-T syndrome
(LQTS). About 50% of cases are familiaI: Romano-Ward syndrome has autosomaI-
transmission; JervelI-Lange-Nielsen syndrome has autosomaI-recessive transmission.
LQTS occurs in all races and ethnic groups. The principal symptoms are syncope and
sudden death from torsades de pointes (TDP). Most often, TDP is self-terminating and
causes a syncopal episode from which the patient quickly recovers. Cardiac arrest occurs
the TDP is more persistent, and sudden death results if the rhythm does not return to
normal spontaneously and the patient is not resuscitated.
Syncope, caused by TDP, is the primary symptom in inherited LQTS. Patients may have
one to hundreds of episodes. The symptoms commonly occur within the first few years of
Iife in patients with JervelI-Lange-Nielsen syndrome, and the mortality rate with this
form is higher than in patients with Romano-Ward. In Romano-Ward syndrome, the
median ages
at symptom onset and sudden death are in the pre- to mid-teenage years. Of interest, at
least one third of gene carriers never develop symptoms, Iead completely normal
and have normal life spans. Approximately one third has just one to a few syncopal spells
as children, then none thereafter. Syncope and sudden death occur most often during
exercise or intense emotion, with an important minority occurring during sleep. Events
are uncommon while patients are awake and at rest and without apparent provocation.
predominant feature on an ECG is QT prolongation. The QTc averages 0. 49 seconds.
The gold-standard therapy for LQTS remains beta-blocker administration, which is
effective in 80% to 90% of patients, with a significant reduction in the rate of sudden
Asymptomatic children and young persons should be treated prophylactically with beta-
blockers on diagnosis. The implantable cardiac defibrillator (ICD) is being used with
frequency, especially in apparently high-risk patients, such as those experiencing TDP
while on beta-blockers and those who have had cardiac arrest.
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Item 9 of 10
Untimed Te
A patient is seen by a specialist because of chronic, intractable, sinusitis. The decision is
made to treat the patient surgically, with evacuation of sinus contents and dilation of the
ostia. The material removed is sent routinely for pathologic examination. An unexpected
finding is the presence of fungi with broad, nonseptate, irregularly shaped hyphae.
review of the patient's chart reveals a long history of poorly controlled diabetes mellitus.
Which of the following is the most likely causative organism?
A. Aspergillus
..      B. Blastomyces
C. Candida
D. Rhizopus
E. Sporothrix
The correct answer is D. The patient has rhinocerebral mucormycosis, which can be
caused by fungal species including Rhizopus, Rhizomucor, Absidia, and Basidiobolus.
Predisposing conditions include immunosuppression, uncontrolled diabetes mellitus, and
patients using the iron-chelating drug desferrioxamine. While these infections
appear more or less incidentally, as in this case, they are very important to diagnose
because they have a tendency to become fulminant. The lesions tend to be very locally
destructive and can erode into the eye, palate, and central nervous system, often from an
initial site in the sinuses. Fulminant infections are frequently fataI. Pulmonary infections
also occur. The organism can be difficult to culture. The appropriate antibiotic is IV
amphotericin B, but surgical debridement should also be strongly considered, since
penetration of
antibiotic into necrotic tissues may be poor.
Aspergillus(choice A) can also cause sinusitis, but has narrow hyphae.
Blastomyces(choice B) usually involves the lung and occurs as a yeast form in the body.
Candida(choice C) can infect sinuses, but has narrow hyphae and yeast forms.
Sporothrix(choice E) usually infects the skin and subcutaneous tissues and occurs as a

Item 10 of 10
Untimed Te
A 50-year-old man consults a physician because he has been having transient periods of
rapid heart beat accompanied by sweating, flushing, and a sense of impending doom.
Physical examination is unrevealing, with no evidence of arrhythmia at the time of the
exam. However, the man's wife is a nurse, so the physician asks that she take vital signs
next time one of the episodes occurs. She does, and demonstrates a blood pressure of
195/140 mm Hg with heart rate 160/min during the episode. She promptly takes her
to the emergency room, but the spell is over by the time that he is seen. Urinary
measurement of which of the following would most likely be diagnostic in this case?
A. Dehydroepiandrosterone (DHEA)
B. Human chorionic gonadotropin (hCG)
C. 17-ketosteroids
D. Vanillylmandelic acid VMA
E. Zinc protoporphyrin
The correct answer is D. This patient's history suggests pheochromocytoma. This rare
(but often considered diagnostically) tumor is most often found in the adrenal medulla,
although it can also be found in other tissues derived from neural crest cells. The tumor
cells secrete catecholamine hormones or their precursors, which can cause either
paroxysmaI (as in this case) or persistent hypertension. Urinary metabolites of
epinephrine and norepinephrine are vanillylmandelic acid (VMA) and homovanillic acid,
so screening 24
hour urine collections for these substances can be helpful in establishing or excluding
these diagnoses even in cases in which a physician does not observe one of the
and thus blood cannot be drawn for serum catecholamine levels at that time.
DHEA (choice A) is the adrenal androgen dehydroepiandrosterone (made by the adrenal
cortex rather than the adrenal medulla), and is measured in serum in cases where adrenal
virilism is suspected.
hCG (choice B) is human chorionic gonadotropin, and both serum and urine levels can
increase in pregnancy or trophoblastic disease.
17-ketosteroids (choice C) are measured in urine during evaluation of congenital adrenal
hyperplasia (a disorder of the adrenal cortex rather than medulla).
Zinc protoporphyrin (choice E) is measured in blood when evaluating possible porphyria.
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Item 1 of 10
Untimed Test
An 18-year-old girl comes to the physician for a "check-up" before going off to college.
She has no complaints. She states that she is very excited to finally be on her own. She
exercises "regularly", gets good grades in schooI, and is sexually active. Her weight is
normal for her height. Physical examination shows many dental caries, periodontal
pharyngeal abrasions, nail changes, and multiple, Iinear lacerations on her forearms in
various stages of healing. Laboratory studies show hypokalemia and metabolic alkalosis.
of the following would most likely establish a diagnosis?
A. "Do you ever feel guilty about drinking alcohoI?"
B. "Do you typically restrict your diet to under 800 calories a day?"
C. "Have you ever taken laxatives as a way to lose weight?"
D. "Have you ever consumed large quantities of food and then regurgitated it to prevent
weight gain?"
. .       E. "PIease describe your exercise routine."
The correct answer is D. This patient most likely has bulimia nervosa. It is a condition
characterized by recurrent episodes of binge eating followed by a compensatory behavior
prevent weight gain (vomiting, exercise, Iaxative abuse). Other features include stealing
(food), alcohol and drug abuse, self-mutilation, and depression. The individuals are
usually at
or slightly over the normal weight for their height, sexual activity is normal or increased,
and they continue to menstruate. CIinical findings that are caused by recurrent vomiting
include dental caries, periodontal disease, pharyngeal lacerations and nail changes.
Metabolic alkalosis and hypokalemia are also present. Complications include aspiration
rupture of the esophagus or stomach.
"Do you ever feel guilty about drinking alcohoI?" (choice A) is a question that would be
asked to an alcoholic. While alcohol abuse has been associated with bulimia nervosa, it
not seem that this patient is an alcoholic.
"Do you typically restrict your diet to under 800 calories a day?" (choice B) would be an
indication of anorexia nervosa, which is characterized by the refusal to maintain a
healthy body weight and the disturbance of body image. These individuals have an
intense fear of gaining weight and therefore restrict food intake to dangerously low
levels. Women
become amenorrheic, have decreased sexual desire, ritualized exercise routines, and
changes in their skin and hair. Complications include ventricular tachyarrhythmias.
"Have you ever taken laxatives as a way to lose weight?" (choice C) and "PIease describe
your exercise routine." (choice E) are questions that should be asked to both anorexics
and bulimics. Laxative abuse and exercise rituals are common in both diseases, but
laxative abuse is probably more common in bulimia, while ritualized exercise is more
common in
anorexia. This patient has the clinical findings associated with vomiting and therefore the
question about bingeing and purging would more likely establish a diagnosis.

Item 2 of 10
Untimed Test
A 9-month-old infant is seen in the pediatrician's office because of failure to gain weight.
Her length and weight are both below the 5th percentile at her age. The patient's chart
indicates that at the age of age of 6 months, her length and weight were at the 50th
percentile. A careful history reveals that the mother returned to work when the infant was
6 months
old, and the grandmother assumed the care of the infant most of the time since then. She
is receiving 6-8 oz of iron-fortified, cow protein-based formula every 4 hours. Which of
following is the best initial step in the management of this infant?
A. Ask how the formula is mixed
B. Obtain a detailed family history for lactose intolerance
. .     C. Obtain a stool specimen
D. Obtain a sweat chloride test
E. Obtain a urinalysis
The correct answer is A. This 9-month-old infant presents with failure to thrive, which is
determined by the decline in her length and weight to below the 5th percentile. Failure to
thrive can be either organic or inorganic (i.e., sociaI). AIthough it is important to identify
the causes of organic failure to thrive, most cases are inorganic. In this clinical vignette,
the reduction of weight happens after the mother returned to work, an inorganic cause is
likely. One of the most common causes of failure to thrive is improper preparation of the
formula, resulting either from an incorrect water-to-formula ratio or from poor mixing
techniques. In addition to obtaining a detailed history of how the formula is mixed, it
might be very
useful to have the caretaker actually demonstrate how he or she prepares the formula. In
this case, the most likely reason that the infant has failure to thrive is that the
has improperly mixed the formula.
Lactose intolerance (choice B) is an uncommon cause of failure to thrive. It usually
presents with abdominal pain, bloating, and diarrhea.
Obtaining a stool specimen (choice C), sweat chloride test (choice D), or urinalysis
(choice E) might be helpful if no identifiable inorganic causes of failure to thrive are
Urinalysis is helpful in screening for renal disease. A sweat chloride test is used to detect
cystic fibrosis. Stool specimens can be useful in a great variety of gastrointestinal
such as gastroenteritis, parasitic infection, and fat malabsorption.
Item 3 of 10
Untimed Te
A mother brings her 8-year-old son to a psychiatrist for new-onset enuresis. A prior
workup to determine a medical cause was negative. In conversation, it seems that the
started following parental arguments and separation. The boy wets himself at least twice
a week and feels upset about it, refusing to go for a sleep-over at his friend's house.
Which of
the following is the most commonly used treatment for this condition?
A. Behavioral therapy
B. Interpersonal therapy
C. Pharmacotherapy
D. Psychodrama
..     E. Psychotherapy
The correct answer is A. Behavioral therapy is the most frequently used treatment in
children with enuresis. Dry nights are recorded on a calendar and rewarded with a star as
gift. The buzzer and pad apparatus are used less for conditioning nowadays.
Interpersonal therapy (choice B) is short-term therapy developed for nonpsychotic,
milder forms of depression. It addresses current relationships and roles, and is used with
It is not indicated for enuresis treatment.
Pharmacotherapy (choice C) is rarely used, given the success of behavioral approaches.
Tolerance to imipramine, which has been used, can develop within 6 weeks.
Desmopressin has shown some success.
Psychodrama (choice D) is a method of group therapy in which conflicts and
interpersonal relationships are explored by means of special dramatic methods. It is not
indicated in
children with enuresis.
Psychotherapy (choice E) is not recommended unless there is evidence of other
psychopathology. The exploration of conflicts in enuresis has shown little success.
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Item 4 of 10
Untimed Test
A 43-year-old primigravid woman at 10 weeks' gestation comes to the physician for a
prenatal visit. She is feeling well except for some occasional nausea. She has had no
from the vagina, abdominal pain, dysuria, frequency, or urgency. She has asthma for
which she occasionally uses an inhaler. Examination is normal for a woman at 10 weeks
gestation. Urine dipstick is positive for nitrites and leukocyte esterase and a urine culture
shows 50,000 colony forming units per milliliter of Escherichia coli. Which of the
following is
the most appropriate next step in management?
A. Wait to see if symptoms develop
B. Resend another urine culture
C. Obtain a renal ultrasound
D. Treat with oral antibiotics
E. Admit for intravenous antibiotics
The correct answer is D. Asymptomatic bacteriuria is present in 2 to 9% of pregnant
women. An association between asymptomatic bacteriuria and preterm delivery/Iow birth
weight has been demonstrated. Therefore, all pregnant women should be screened for
asymptomatic bacteriuria early in the pregnancy, and women who demonstrate
(defined as a clean-catch, midstream urine specimen with 25,000 to 100,000 colony
forming units per milliliter of a single organism) should be treated. E. Coli is the
organism that is
isolated in roughly 80% of cases while other gram-negative organisms (e.g., Klebsiella,
Enterobacter, and Proteus species) and gram-positive cocci (e.g. enterococci and group B
streptococci) are responsible for the remainder. Antibiotic sensitivities are often available
at the time of diagnosis of the asymptomatic bacteriuria, which will allow for correct
of medications. A 3-day course of antibiotics may be given. Possible choices include
trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin. Ampicillin and
amoxicillin can
also be used, but up to 1/3 of E. Coli isolates will be resistant to these drugs. Therefore,
these drugs should be chosen only if the organism is sensitive. 10 days after completing
medication, the patient should have a follow-up urine culture as a test-of-cure.
Waiting to see if symptoms develop (choice A) is not appropriate. Bacteriuria, even
without symptoms, has been shown to be associated with preterm labor and low birth
Asymptomatic bacteriuria should, therefore, be treated.
Resending another urine culture (choice B) would not be the most appropriate next step.
This patient already has demonstrable bacteriuria and treatment should be instituted.
Admitting for intravenous antibiotics (choice E) or obtaining a renal ultrasound (choice
C) would not be necessary. This patient has asymptomatic bacteriuria and not
therefore, a 3-day course of oral antibiotics followed by a repeat culture 10 days later is
all that is necessary.

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Item 5 of 10
Untimed Te
A 45-year-old Swedish man presents for follow-up after discharge from the hospital for
an esophageal variceal bleed. He had undergone esophageal sclerotherapy to control the
bleeding. On discharge, he was prescribed atenoloI. He has no history of alcohol use or
medication use. He has no risk factors for hepatitis. He knows of two cousins who "died
Iiver disease." His sister died of melanoma, so he takes precautions to avoid sun
exposure. On physical examination, his skin has a dark, bronzed appearance. He is
anicteric. His
Iiver and spleen are normal in size. There is no ascites or peripheral edema. Which of the
following are the most appropriate laboratory tests to order?
A. AIpha1 antitrypsin genotype
B. AIpha1 antitrypsin phenotype
. .      C. Serum copper
D. Serum ferritin
E. Serum nickel
The correct answer is D. This patient has bronzed skin and a family history of liver
disease, and does not use alcohol or drugs his combination should suggest
hemochromatosis. A serum ferritin would be the appropriate screening test to evaluate for
iron overload. Technically, hemochromatosis is diagnosed when the total body iron load
estimated to be greater than 5 g; hemosiderosis is the term used for milder iron overload
conditions. Hemochromatosis can be either primary (genetic) or secondary to a wide
of conditions, including blood disorders (hemolytic anemias, thalassemias), parenteral
iron overload (many transfusions), and increased iron ingestion. If the term "secondary"
deleted, the genetic form of hemochromatosis is usually assumed. Despite massive
amounts of research (which have even identified mutations in an HLA-A Iike molecule),
underlying pathogenesis is still unclear. The problem does appear to be primarily an
overabsorption of iron through the gut, which cannot be corrected because the body's
mechanisms for excreting iron are limited (e.g., blood loss or its equivalent of
menstruation). Patients usually do not become symptomatic until middle age, when
significant tissue
injury has occurred. The skin discoloration in non sun-exposed areas is a very helpful
clinical clue. Important complications include hepatic cirrhosis (which may itself be
by hepatocellular carcinoma), diabetes mellitus secondary to pancreatic damage,
cardiomegaly or arrhythmias, pituitary failure, and arthritis. Phlebotomy is the preferred
method of
iron removal in patients with established genetic hemochromatosis. The chelating drug
deferoxamine has sometimes been used to increase urinary iron secretion in
relatives with the underlying genetic problem.
AIpha1 antitrypsin deficiency (choices A and B) also presents with familial liver disease,
often associated with emphysema in nonsmokers. However, it does not demonstrate the
typical skin pigmentation seen in hemochromatosis.
EIevated serum copper levels (choice C) are associated with Wilson disease, which, Iike
hemochromatosis, has a strong family history but generally presents at a younger age and
without the skin hyperpigmentation.
Nickel (choice E), Iike copper, is used in coins, but does not cause liver disease.

Item 6 of 10
Untimed Te
A 43-year-old white woman presents to the emergency department with 1 day of
increasingly severe pain localized to the right upper quadrant and radiating to the right
lower scapula.
She has also been experiencing nausea and vomiting. The woman has had similar, but
milder, episodes of pain in the past, which had resolved spontaneously in a few days.
examination demonstrates involuntary guarding of abdominal muscles on the right. The
gallbladder is palpable. Which of the following is the most appropriate next step in
A. CT scan
B. Endoscopic retrograde cholangiography
C. Esophagogastroduodenoscopy
D. MRI scan
E. UItrasound
The correct answer is E. The presentation is typical for acute cholecystitis, which occurs
most frequently in the setting of cholelithiasis (gallstones). Other common features
an initially low-grade fever with neutrophilia and painful splinting during deep breathing.
Serum amylase is typically elevated in gallstone pancreatitis. Seriously ill patients with
fever, rigors, or significant rebound tenderness may require urgent surgical intervention;
in less seriously ill patients, it is feasible to establish the diagnosis and defer surgical
intervention until after the acute episode has resolved. In most hospitals, ultrasound is
ordered first, since this relatively inexpensive, fast, and noninvasive study can usually
the presence of gallstones. In atypical cases, when acute cholecystitis without stones is
present, cholescintigraphy using radioactive technetium 99m may be used to sequentially
visualize the liver, extrahepatic bile ducts, gallbladder, and duodenum.
CT (choice A) and MRI (choice D) scans are expensive and are usually not required for
typical acute cholecystitis.
Endoscopic retrograde cholangiography (choice B) can be helpful in defining a small
stone in the extrahepatic bile duct system, but it is not usually used as an initial test.
Esophagogastroduodenoscopy (choice C) would not be helpful in classic gallstone
disease, but might demonstrate a duodenal cancer compressing the ampulla of Vater if a
with what appeared clinically to be gallstone disease had a negative ultrasound.
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Item 7 of 10
Untimed T
A 35-year-old man comes to the physician because of daily severe, periorbitaI, right-
sided headaches over the past 6 weeks. The pain often awakens him from sleep and is so
excruciating that he wants to bang his head against the walI. He reports nasaI "stuffiness"
and nausea. He has had similar episodes on 2 previous occasions. Physical examination
shows right-sided ptosis, Iacrimation, and reddening of the right eye. Laboratory studies
Hemoglobin....................................16 g/dL
Leukocyte count.............................6000/mm3
Erythrocyte sedimentation rate.........5 mm/hr
Which of the following is the most likely diagnosis?
A. CIassic migraine
B. CIuster headache
C. Common migraine
D. Subarachnoid hemorrhage
E. Temporal arteritis
F. Tension headache
The correct answer is B. This patient has cluster headaches, which are daily, unilateraI,
severe headaches that occur over a period of 1-2 months. They are associated with nasal
stuffiness, ptosis, and lacrimation. Middle-aged males are most commonly affected.
Treatment during the acute attack is oxygen. Prophylaxis includes prednisone, Iithium,
ergotamine, and verapamiI.
CIassic migraine (choice A) is a severe, throbbing headache that is associated with
nausea, vomiting, and photophobia. It is preceded by an aura (focal neurological
Treatment is with sumatriptan and ergotamine.
Common migraine (choice C) is similar to classic migraine except that it is not preceded
by an aura.
A subarachnoid hemorrhage (choice D) is often caused by a ruptured saccular aneurysm,
and is described as the "worst headache of my life". It may be associated with a loss of
consciousness and vomiting. A CT scan followed by a lumbar puncture confirms the
diagnosis. Prompt microsurgical clipping of the aneurysm is the treatment.
Temporal arteritis (choice E) produces a unilateraI, throbbing headache with temporal
artery tenderness. Associated findings include anemia and an increased erythrocyte
sedimentation rate. Diagnosis is made by temporal artery biopsy. Treatment is with
corticosteroids, which should be given immediately to prevent blindness.
Tension headache (choice F) is a bilateral occipital headache that is described as "band-
Iike" or "vise-Iike". Therapy consists of analgesics.

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Item 8 of 10
Untimed Te
A 54-year-old man presents to his physician complaining of intermittent palpitations. The
patient reports that, a few times over the past few months, he has had episodes of
in his chest" that are associated with shortness of breath and occasional chest pain. He is
forced to sit down if he is standing because of weakness and vertigo. The patient has a
history of hypertension and mitral valve prolapse. He takes nifedipine and thiazide daily.
While sitting in the office, the patient begins to complain of increasing shortness of
breath and
palpitations. His blood pressure is 100/50 mm Hg, and his pulse is 110-130/min and
irregularly irregular. Which of the following is the most appropriate management at this
A. CalI 911 for assistance
B. Give the patient an oral dose of a beta blocker
C. Give the patient an oral dose of digoxin
D. Give the patient on oral dose of calcium channel blocker
E. Make arrangements to have the patient brought to the local emergency department for
electrical cardioversion
The correct answer is A. This patient now has atrial fibrillation (AF) with rapid
ventricular response (RVR) and is consequently hypotensive. This is a medical
emergency. Even the
physician caring for this patient is ill equipped to deal with a potentially life-threatening
episode of AF with RVR. Activating the system is always appropriate and ensures that
persons with additional equipment and medications appropriate to an emergency situation
will be on hand as soon as possible.
Giving the patient an oral dose of a beta blocker (choice B), digoxin (choice C) or a
calcium channel blocker (choice D) is not appropriate for an emergent setting. These
medications will take too long to be effective.
Making arrangements to have the patient brought to the local emergency department for
electrical cardioversion (choice E) is appropriate ONLY AFTER 911 has been called in
case that the patient needs IMMEDIATE assistance in the office. Without calling 911, the
patient may have a seriously adverse event en route to the hospitaI.

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Item 9 of 10
Untimed Te
A 5-week-old infant is brought to the clinic for a 4-week history of noisy breathing that
has not improved. She has otherwise been healthy except for a current upper respiratory
for the past 4 days, which according to the parents, has worsened the noisy breathing. On
examination, she has inspiratory stridor. The noisy breathing improves when the infant is
asleep. Which of the following is the most likely diagnosis?
A. Bronchoalveolar carcinoma
. .     B. Foreign object obstruction
C. Laryngomalacia
D. Bacterial pneumonia
E. Tuberculosis
The correct answer is C. The patient has stridor on examination. This is an inspiratory
obstruction that is sensitive to airflow changes. In children, the most common cause of
stridor is laryngomalacia.
Bronchoalveolar carcinoma (choice A) may cause stridor in an adult with an extensive
smoking history but should not be seen in someone this young.
Foreign object obstruction (choice B) should be acute in onset and cause severe distress.
Pneumonia would be notable for a fever and productive sputum. Stridor would not be
present (choice D).
Tuberculosis (choice E) would be associated with systemic symptoms of fever, weight
loss, sweats, and hemoptysis.

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Item 10 of 10
Untimed Te
A 69-year-old woman presents to her physician's office complaining of 1 week of crampy
lower abdominal pain and bloody diarrhea. She had previously been followed for
symptoms of
stable exertional angina and hypertension. She had an uncomplicated myocardial
infarction 3 years earlier. Her symptoms began 1 week ago with mild postprandial
cramping followed by diarrhea, which became bloody after 2 days. She has not traveled
recently and is a retired librarian. Her temperature is 38.6 C (101.4 F), blood pressure is
120/84 mm Hg, and pulse is 96/min. She has moderate tenderness to palpation of the left
lower quadrant. A rectal examination reveals bloody stool and no masses. Which of the
following is the most likely diagnosis?
. .     A. Arteriovenous malformation
B. Diverticulitis
C. Diverticulosis
D. Ischemic colitis
E. UIcerative colitis
The correct answer is D. This elderly woman with a history of atherosclerotic vascular
disease as demonstrated by a history of a myocardial infarction and exertional angina has
developed colitic symptoms, as demonstrated by the left lower quadrant pain and bloody
diarrhea. This is typically due to ischemia of small branches of the inferior mesenteric
The diagnosis is suspected clinically and generally confirmed with a flexible
sigmoidoscopy, since many cases involve the rectosigmoid region.
Arteriovenous malformation (choice A) produces painless bleeding in the elderly, most
commonly located in the cecum and often, but not always, associated with aortic stenosis.
Diverticulitis (choice B) does present with postprandial crampy left lower quadrant
abdominal pain and fever, but does not produce bloody diarrhea. Often, these patients
symptoms of constipation.
Diverticulosis (choice C) also presents with postprandial crampy left lower quadrant pain
or may be asymptomatic, but does not produce a blood diarrheal illness.
UIcerative colitis (choice E) typically presents in a subacute or chronic fashion in a
younger patient population. AIthough it can occur in this patient's age group, it rarely
presents as
an acute illness.

Item 1 of 10
Untimed Test
A patient with a history of chronic bacterial sinusitis presents to the emergency
department with a very severe headache. While waiting to be seen, he develops a
generalized grand
mal seizure. Physical examination, after the seizure is over, demonstrates high fever,
exophthalmos, papilledema, and nerve palsies of the VI and lll cranial nerves on one side.
of the following is the most appropriate next step?
A. Admit to the medical floor for monitoring of progression of symptoms
B. Emergency CT scan
C. Emergency exploratory surgery
D. Emergency ultrasound
E. Keep in emergency department for monitoring of progression of symptoms
The correct answer is B. This is the way that cavernous sinus thrombosis presents. This
condition is due to a septic thrombosis that can complicate chronic bacterial sinusitis.
Meningitis is another significant possibility. Lumbar puncture is dangerous in a patient
with increased intracranial pressure, as indicated by the papilledema. Emergency CT scan
the cavernous sinus, air sinuses, orbit, and brain is warranted. Additionally, cultures of
blood and any nasal discharge are warranted; Gram's stain of the nasal discharge may
give a
preliminary indication of the causative organism. High dose intravenous antibiotics are
started, and then altered, if necessary, when culture results are reported. Cavernous sinus
thrombosis has a 30% mortality rate, even when prompt, appropriate medical care is
Simply monitoring (choices A and E) a patient like this would be very dangerous.
UItrasound (choice D) would probably not adequately visualize the complex structures of
the sinuses, orbits, and brain.
Surgery (choice C) is not indicated in this setting.

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Item 2 of 10
Untimed Te
A 24-month-old child is seen in the pediatrician's office for a regular health supervision
visit. He has no history of developmental delay. He was born by an uncomplicated
vaginal delivery at term, and he has not had any significant illness or injury prior to this
visit. Which of the following motor milestones is most consistent with his age?
. .     A. Building a tower of two cubes
B. Copying a circle
C. Scribbling
D. Throwing a ball overhead
E. Walking backward
The correct answer is D. Throwing a ball overhead is most consistent with the motor
development of a 24-month-old child. As the cerebral cortex develops, the child's hands
arms are more able to perform more skillful and delicate motor functions.
Building a tower (choice A) is a good way to assess a child's motor function. A child
should be able to build a tower of two cubes by 14 months of age. By 24 months, he or
should be able to build a tower of at least 6 cubes.
A 24-month-old child will not usually be able to copy a circle (choice B). This ability
emerges around 36 months of age.
Imitative scribbling (choice C) appears around 16 months; spontaneous scribbling
appears around 18 months.
A child should be able to walk backward (choice E) by 18 months. CIimbing stairs or
going down stairs with support are more consistently seen at 24 months.
Two other milestones that are consistent with 24 months of age are jumping up and
kicking a ball forward.

Item 3 of 10
Untimed Te
A medicine consult is requested on a 32-year-old woman with paranoid schizophrenia
who is a patient in a closed psychiatric unit. Several days after the patient's admission,
developed polyuria, vomiting, stupor, diarrhea, and restlessness. She is currently taking
risperidone, 10 mg given at bedtime, but no other medications. Which of the following is
most likely diagnosis?
A. Anticholinergic crisis
B. Acute dystonic reaction
C. Serotonin syndrome
D. Tardive dyskinesia
E. Water intoxication
The correct answer is E. This patient is showing the symptoms of psychogenic
polydipsia, which is the excessive intake of water as a result of a psychiatric disorder.
symptoms of excessive water intake include polyuria, vomiting, and diarrhea. As the
patient is on a closed psychiatric unit, the chances of reactions to excessive medications
rare, given the careful monitoring of medication intake on most psychiatric units.
Surreptitious water consumption would be easy to overlook in a patient without a
previous history.
Anticholinergic crisis (choice A) is not a possibility in a patient not receiving
anticholinergic medications, such as diphenhydramine or Cogentin.
Acute dystonic reaction (choice B) is an adverse reaction of some antipsychotics, such as
haloperidol or trifluoperazine, and is rare in a patient taking risperidone.
Serotonin syndrome (choice C) is a reaction of autonomic instability that is accompanied
by fluctuations in blood pressure and flushing. It is associated with the mixing of
monoamine oxidase inhibitors and serotonin specific reuptake inhibitors.
Tardive dyskinesia (choice D) is a syndrome of abnormal involuntary movements
associated with chronic use of typical neuroleptics, such as haloperidoI.
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Item 4 of 10
Untimed Test
A 34-year-old woman, gravida 3, para 2 at term comes to the labor and delivery ward
with a gush of blood, abdominal pain, and irregular, painful contractions. Her prenatal
course was
significant for her being Rh negative and antibody negative. Her temperature is 37 C
(98.6 F), pulse is 110/minute, blood pressure is 110/70 mm Hg, and respirations are
Abdominal examination shows a tender abdomen and cervical examination shows the
cervix to be closed and long with a significant amount of blood in the vagina. The fetal
heart rate
is in the 170s with moderate to severe variable decelerations with contractions. The
diagnosis of placental abruption is made and an emergent cesarean delivery is performed.
determine the correct amount of RhoGAM (anti-D immune globulin) that should be
given, which of the following is the most appropriate laboratory test to send?
A. Apt test
B. Complete blood count
C. KIeihauer-Betke
D. Partial thromboplastin time
E. Serum potassium
The correct answer is C. Women that are Rh negative are at risk for developing Rh
isoimmunization. Rh isoimmunization occurs when an Rh-negative mother becomes
to the Rh antigen on the red blood cells of an Rh-positive fetus. This exposure may lead
the mother's immune system to become sensitized to the Rh antigen such that in a future
pregnancy with an Rh-positive fetus, the mother's immune system may "attack" the Rh
antigen on the fetal red blood cells. This immune response may lead to the development
fetal anemia, hydrops, and death. To prevent Rh isoimmunization from occurring, Rh-
negative women who are not Rh alloimmunized should receive RhoGAM (anti-D
globulin) at 28 weeks of gestation, within 72 hours after the birth of an Rh-positive
infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis.
should also be strongly considered in cases of threatened abortion, antenatal bleeding,
external cephalic version, or abdominal trauma. The amount that is usually given after the
delivery of an Rh-positive fetus is 300 g. This amount is sufficient to cover a fetal to
maternal hemorrhage of 30 mL (or 15 mL of fetal cells). However, some women will
have a fetal
especially in cases such as manual removal of the placenta or placental abruption (as this
patient had). To determine the
amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a
KIeihauer-Betke test which is an acid-dilution procedure that allows fetal red blood cells
to be
identified and counted. Knowing the amount of fetal to maternal hemorrhage that took
place allows the correct amount of RhoGAM to be given.
An apt test (choice A) is used to differentiate fetal from maternal blood. It can be used in
the diagnosis of vasa previa or with neonatal melena.
A complete blood count (choice B) will demonstrate the amount of maternal hemorrhage,
but not the amount of fetal to maternal hemorrhage.
Partial thromboplastin time (choice D), and serum potassium (choice E) do not allow for
the determination of the amount of fetal to maternal hemorrhage.

Item 5 of 10
Untimed Test
A 57-year-old man comes to the physician because of "erectile problems". He says that
he has not been able to have an erection in months. He has seen so many television
commercials lately that he expects a cure in the form of a "Iittle blue pilI". He is married,
has 3 children, works as a trader on the stock exchange, and is an avid cyclist. He takes
medications, does not drink alcohoI, and has had no serious medical conditions. Physical
examination is normaI. Which of the following questions is most likely to help determine
cause of this patient's condition?
A. "How often do you ride your bicycle?"
B. "Are you sexually attracted to your wife?"
C. "Are you feeling unusually anxious lately?"
D. "Do you have nocturnal or early morning erections?"
E. "Do you love your wife?"
The correct answer is D. The main issue in evaluating impotence is distinguishing
between psychological causes and organic causes. The presence of nocturnal or early
erections basically eliminates the organic causes and leads to a diagnosis of psychological
impotence. The most common psychological causes include anxiety and depression.
Nocturnal penile tumescence, which occurs during REM sleep, can be assessed in a sleep
lab. If nocturnal erections are not present, the impotence is most likely due to an organic
cause. The most likely causes are testicular failure, hyperprolactinemia, medications,
alcohoI, opioids, nicotine, trauma, priapism, diabetes, vascular disease, and neurologic
diseases, such as diseases of the spinal cord and loss of sensory input. Physical
examination should include a detailed genital examination, evaluation for signs of
feminization, and
neurologic and vascular exams.
"How often do you ride your bicycle?" (choice A) may be relevant because of neurologic
and vascular compromise caused by the seat, however it will not distinguish between
organic and psychologic causes.
"Are you sexually attracted to your wife?" (choice B) is a relevant question if the patient
is having nocturnal erections and is not depressed or anxious.
"Are you feeling unusually anxious lately?" (choice C) is a good question to follow the
question about nocturnal erections (if he is having them).
"Do you love your wife?" (choice E) is a question that may be asked if he is having
nocturnal erections and is anxious and depressed. It may be a little blunt and can probably
asked in a subtler manner.

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Item 6 of 10
Untimed Test
A patient with a history of hypertension calls his physician's office for advice. He has had
longstanding heartburn and recently consulted with a gastroenterologist. He underwent an
endoscopy and was told that "Barrett's mucosa" was found by biopsy. The patient has
read in the newspaper that people with this condition will probably develop esophageal
Which of the following is the most appropriate response to this concern?
A. "Your concerns are ungrounded"
B. "It is foolish to worry because this type of cancer is unlikely to develop and would
occur many years later"
C. "You should chew food very carefully to prevent the possibility of a mechanical
D. "Only a small minority of patients with Barrett's esophagus will develop cancer, and
you should undergo endoscopic surveillance"
. .        E. "You should consult with an oncologist regarding esophageal cancer
prevention strategies"
The correct answer is D. Barrett's esophagus may occur in a small number of patients
who have gastroesophageal reflux disease (GERD). This condition is a metaplasia of the
normal squamous mucosa of the esophagus to a columnar (glandular) type of epithelium,
and is usually seen as a response to repeated acid exposure to the distal esophagus.
Tobacco and alcohol use are also thought to contribute to the process. The significance of
Barrett's esophagus is that it may lead to the development of low-grade dysplasia, high-
grade dysplasia, or esophageal adenocarcinoma. However, this is a very infrequent
occurrence when considering the large number of patients with GERD and even those
Barrett's esophagus. Barrett's esophagus usually does not resolve with either medical or
surgical therapy. Endoscopic surveillance (with multiple small biopsies, since dysplasia
cannot be reliably evaluated by endoscopic appearance alone) every 1-2 years has been
often recommended, but some studies suggest that it may not be cost-effective.
It is not factually true to inform the patient that his concerns are "ungrounded" (choice
A), because there is in fact a small risk of adenocarcinoma.
It is never appropriate to belittle a patient's concerns and inform him that his worries are
"foolish" (choice B).
Barrett's esophagus is a histologic change and, unless accompanied by a stricture, does
not produce symptoms of mechanical dysphagia (choice C).
It is inappropriate to refer the patient to a cancer specialist (choice E) for the prevention
of a very unlikely development of cancer; furthermore, preventive strategies should
instructions to avoid factors that exacerbate GERD and should be delivered to the patient
by the primary care physician.

Item 7 of 10
Untimed Test
A 50-year-old man is brought to his new primary care physician by his family, who
report that he has developed personality changes, impaired memory, and difficulty with
speech. His
medical history is notable for mental retardation. His medical chart indicates that, at birth,
he was diagnosed with trisomy 21 by genetic karyotyping. Physical examination reveals
epicanthal folds, a transverse palmar crease, and Brushfield spots on the iris. He is slow
to respond to questions and can recall only one out of three objects after 5 minutes.
Which of
the following is the most likely cause of these new neurologic symptoms?
A. AIzheimer dementia
B. Hydrocephalus
C. Hypothyroidism
D. Multiple strokes
E. Prion infection
The correct answer is A. The patient has the clinical and genetic features of Down
syndrome. Such patients are at a high risk of developing senile dementia of the
AIzheimer type
(SDAT) in the 4th and 5th decades of life. Neuropathology often reveals senile plaques
and neurofibrillary tangles.
Hydrocephalus (choice B) can cause neurologic deterioration. It may occur in Down
syndrome patients, but no association has been described. Diseases such as normal
hydrocephalus may cause ataxia, incontinence, and dementia.
Hypothyroidism (choice C) may cause mental status changes, such as lethargy and
obtundation, but are not particularly associated with Down syndrome. The ailment may
reversible with thyroid hormone replacement.
Multi-infarct dementia due to multiple strokes (choice D) can be a cause of dementia in
patients prone to embolic strokes, such as those with vasculopathies. However, patients
usually older.
Prion diseases (choice E), such as Creutzfeldt-Jakob disease, cause dementia. Some types
have been found to be transmitted via infected cattle.
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Item 8 of 10
Untimed Test
A 70-year-old man is found unresponsive at home. The emergency medical technicians
note his blood pressure to be 70 mm Hg by palpation. His pulse is 120/min. He is brought
the emergency department, where his temperature is 39.5 C (103 F), and respirations are
30/min. He has rales halfway up his chest. Heart sounds are inaudible. His urine output is
mL/hr. A chest x-ray film reveals Kerley B Iines, and an ECG shows sinus tachycardia.
He is given antibiotics and is taken to the intensive care unit, where a right-sided
shows an elevated wedge pressure and diminished cardiac output. His right atrial pressure
is not elevated. Which of the following is the most likely cause of this man's
A. Gastrointestinal bleeding
B. Gram-negative sepsis
C. Left ventricular dysfunction
D. Pericardial tamponade
E. Pulmonary embolus
The correct answer is C. This patient is hypotensive and has oliguria. He has shock,
fever, and pulmonary edema. His elevated wedge pressure is an indication of left
failure. This may be the result of a myocardial infarction. This patient has cardiogenic
shock, severe cardiomyopathy, or myocarditis.
Gastrointestinal bleeding (choice A) would present with hypotension, tachycardia, and
shock. Hypovolemia from a gastrointestinal bleed would cause a decrease in the wedge
pressure as welI.
Similarly, septic shock (choice B) would lead to hypotension and decreased wedge
pressure. The cardiac output would be increased, and the systemic vascular resistance
be decreased. In the setting of fever, however, this diagnosis must be considered.
Treatment would include supportive therapy with vasopressors and fluids, as well as
Pericardial tamponade (choice D) could produce elevated wedge pressures, but the
obstruction to the right ventricular inflow should be associated with equally abnormal
right atrial
mean, right ventricular end diastolic, and pulmonary artery end-diastolic pressures.
A pulmonary embolus (choice E) would lead to decreased wedge pressure. The patient
would be tachycardic, tachypneic, and hypotensive. Pulmonary edema would not be seen,
however. Treatment would include administering a lytic agent and heparin.

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Item 9 of 10
Untimed Test
A 76-year-old man presents to the clinic for his semiannual examination. The patient is
well known to the clinic and has been having semiannual examinations for the past 3
years to
follow up his chronic obstructive pulmonary disease (COPD). The patient is a long-time
smoker, with a 300+ pack year history. He is status post a right upper wedge resection 2
ago for adenocarcinoma, and at that time had severe obstructive disease. A recent chest
CT showed apical bullae and severe emphysematous changes. The patient has moderate
dyspnea on exertion and often has shortness of breath with minimal activity. On this visit,
the patient relates that he is even more short of breath at rest and is almost unable to
perform any physical activity as a result. Which of the following would most strongly
suggest the need to initiate home oxygen therapy?
A. Exercise-induced oxygen desaturations to less than 92%
B. Resting arteriaI PaO2 showing an alveolar arterial gradient of more than 12 mm Hg
C. Resting arteriaI PaO2of less than 55 mm Hg
D. Resting PaO2 of greater than 40 mm Hg
E. Room air oxygen saturation of less than 92%
The correct answer is C. The requirements for utilization of home oxygen therapy have
been determined on the basis of placebo-controlled, randomized trials. In patients on a
stable medical regimen, an arterial oxygen pressure of less than 55 mm Hg has been
determined as the cutoff below which maximal benefit is obtained.
Exercise-induced oxygen desaturations to less than 92% (choice A) are common in
patients with chronic obstructive pulmonary disease (COPD).
A resting arteriaI PaO2 showing an alveolar arterial gradient of more than 12 mm Hg
(choice B) is abnormaI, but is not specific for COPD, and is not generally an indication
supplemental oxygen therapy.
Most COPD patients late in the disease have a resting PaO2 of greater than 40 mm Hg
(choice D). This is one of parameters that benefits from supplemental oxygen, but it is
used in the decision tree to initiate therapy.
Room air oxygen saturation of less than 92% (choice E) certainly indicates some element
of V/Q mismatching, but not enough to merit continued supplemental oxygen.

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Item 10 of 10
Untimed Te
A 45-year-old male suddenly loses consciousness and falls to the ground. He has been
previously healthy and has been on no medications. There is no obvious evidence of
An electrocardiogram reveals wide complex tachycardia at a rate of 300 beats per minute.
Which of the following is the most appropriate intervention?
A. Obtain vital signs
B. Administer a bolus of intravenous lidocaine
C. Administer a thrombolytic agent
D. Perform asynchronous cardioversion
. .     E. Perform synchronous cardioversion
The correct answer is D. The patient is in ventricular tachycardia and is hemodynamically
unstable as apparent from the loss of consciousness. He should be emergently
cardioverted asynchronously with 200 joules of energy initially.
He is hemodynamically unstable, as apparent from his loss of consciousness. Precious
time will be lost by obtaining vital signs (choice A) if cardioversion can be done now.
A Iidocaine bolus should be given once a pulse and sinus rhythm is obtained to keep him
out of ventricular tachycardia. This is especially beneficial if the event is ischemic in
(choice B).
He may be having an infarct, and this may be the cause of his ventricular tachycardia.
Emergently, the physician needs to restore sinus rhythm and then the man will be treated
myocardial infarction, if indicated (choice C).
If the patient were stable, synchronous cardioversion could be attempted (choice E).

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Item 1 of 10
Untimed Test
A 22-year-old graduate student returns from hiking in the Rocky Mountains in Colorado.
Beginning on the last day of his trip and continuing over the past week, he has developed
abdominal cramping with gaseous distention, frequent eructations, and loose, non-bloody
stools. On physical examination, he is afebrile and on abdominal examination he has mild
tenderness in the mid epigastric area. His stool is guaiac negative. Which of the following
is the most likely infection causing his symptoms?
A. Entamoeba histolytica
B. Enteroinvasive Escherichia coli
C. Enterotoxigenic E. coli
D. Giardia lamblia
E. Shigella dysenteriae
The correct answer is D.Giardia lamblia is often acquired during hiking if fresh stream
water is ingested before it is purified. Giardia will primarily infect the primary small
boweI, i.e.,
the duodenum and proximal jejunum, producing upper gastrointestinal symptoms with
frequent eructation, bloating, distention, flatus, and loose stools.
Entamoeba histolytica(choice A) is often acquired during travel and can produce an
ileocolitis and/or a hepatic abscess. These patients tend to appear systemically ilI.
Enteroinvasive                     choice B) can be acquired during travel or as a food
poisoning and will produce an invasive-type diarrhea, i.e., bloody stools with mucopus,
and leukocytosis.
Enterotoxigenic          choice C) is most frequently acquired as a traveler's diarrhea and
produces a watery diarrheal syndrome, which is usually self-Iimiting.
Shigella dysenteriae(choice E) produces the typical dysenteric picture with a toxic
appearing patient with fever, Ieukocytosis, abdominal tenderness, and bloody stools with

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Item 2 of 10
Untimed Test
A 14-year-old girl presents to clinic for an annual check up. Her parents are concerned
that the child is not meeting normal milestones of adolescent growth. The patient reports
recent illnesses. She is up-to-date on her vaccines, and is not having any trouble in
schooI. She denies drug use and is active in sports. On examination, her vital signs are
stable. Her
Iungs are clear and heart is regular in rate and rhythm. Breast and areolar enlargement is
noted with no contour separation of the areola. Pubic hair is noted to be dark. The patient
also reports that she started menstruating 8 months ago. Which of the following is the
most likely Tanner stage of development in this patient?
A. Stage l
B. Stage ll
C. Stage lll
. .     D. Stage IV
E. Stage V
The correct answer is C. Physical changes occur rapidly during adolescence.
Neuroendocrine changes along the hypothalamic-pituitary axis alter gonadotropin
function and
concentrations of steroid hormones. Reproductive growth in adolescents is generally
classified by the Tanner stages, which provide a range of ages at which normal changes
Stage l (choice A) occurs in children aged 0-15. This is the stage of preadolescent breast
development with no pubic hair.
Stage ll (choice B) is notable for breast budding or thelarche and occurs in children aged
8-15. A small amount of pubic hair near the labia is noted and a growth spurt often
stage lI.
Stage IV (choice D) is seen in ages 10-17. Further breast and nipple enlargement with
some contour separation of the areola is noted. There is more pubic hair than in Stage llI,
adult quality, but not distribution.
Stage V (choice E) is seen in ages 12-18 and is characterized by complete breast
enlargement with no contour separation of the areola. Pubic hair is of adult quality and

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Item 3 of 10
Untimed Te
A patient is talking to his psychotherapist about his problems. During the session, the
patient inquires about the meaning of their talk and asks why the therapist hasn't said
The therapist responds, "Perhaps it was difficult to get feedback from your troubled
parents, so you got used to turning to others for reassurance that you are worthwhile ust
like you
are doing now with me." Which of the following types of intervention did the therapist
A. Advice
B. CIarification
C. Confrontation
D. Facilitation
E. Interpretation
The correct answer is E. Interpretation is a technique used when a therapist states
something about the patient's behavior or thoughts of which the patient may not be aware.
It is
used after good rapport with the patient has been established, in order to be timely and
Advice (choice A) is, in many instances, desirable to help the patient. It must be
perceived as empathic rather than intrusive. Thus, it should be given after the patient has
freely about the problematic issue.
CIarification (choice B) is a technique in which the therapist attempts to get details from
a patient about the things already said.
Confrontation (choice C) is a technique used when the therapist points out a thought or
behavior that the patient is not paying attention to, or missing, or denying in some way. It
meant to help the patient face the problem in a direct but respectful way.
Facilitation (choice D) is a technique used by the therapist to help the patient continue the
interview by providing verbal and nonverbal cues to encourage the patient's talking.

Item 4 of 10
Untimed Test
A 18-year-old woman comes to the physician for an annual examination. She has no
complaints. She has been sexually active for the past 2 years. She uses the oral
contraceptive pill
for contraception. She has depression for which she takes fluoxetine. She takes no other
medications and has no allergies to medications. Her family history is negative for cancer
and cardiac disease. Examination is unremarkable. Which of the following screening tests
should this patient most likely have?
A. Colonoscopy
B. Mammogram
C. Pap smear
D. Pelvic ultrasound
E. Sigmoidoscopy
The correct answer is C. The Pap smear has been shown to be a highly effective
screening test for cervical cancer. The Pap test was introduced in the U.S. roughly 50
years ago,
and since that time the mortality rate from cervical cancer has decreased by 70%. The
main drawbacks to Pap testing are that many women do not get a regular (or any) Pap
and that the test has a high false-negative rate. That is, a given Pap smear may be read as
negative when, in fact, the woman has abnormal cytology. The reason for this false
negative rate is that there may be errors in sampling, preparation, screening, and
interpretation, such that abnormal cells are missed. Yet, if a woman has a yearly Pap test,
it is
assumed that these abnormal cells will eventually be discovered. Because the natural
history of most cervical cancers is believed to be a gradual progression over many years,
annual screening (even with a high false-negative rate) will lead to lesions eventually
being discovered and appropriate treatment being given. Women should have an annuaI
Pap test
when they begin having sexual intercourse or at the age of 18, whichever comes first.
Colonoscopy (choice A) is used to screen for colon cancer in some at-risk patients. This
patient is not high-risk and therefore, at age 18, does not need to have a colonoscopy.
The mammogram (choice B) is used to screen for breast cancer. Women should begin
having regular mammograms at age 40.
Pelvic ultrasound (choice D) is not used as a screening test. Certain studies have been
done to evaluate whether pelvic ultrasound is a good screening test for ovarian cancer.
the basis of these studies, however, pelvic ultrasound is not recommended for this
Sigmoidoscopy (choice E) is also used to screen for colon cancer. As explained above,
this patient is not high-risk and therefore does not need a sigmoidoscopy.
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Item 5 of 10
Untimed Te
A 38-year-old woman presents complaining of a burning discomfort in the substernal
region. The symptoms are worse following any meal and after reclining for sleep at night.
has a history of Raynaud phenomenon and mild hypertension. On physical examination,
her blood pressure is 162/94 mm Hg, pulse is 78/min, and respirations are 16/min. She is
afebrile. There are multiple facial telangiectasias on both cheeks, and she has taut skin on
both hands. The remainder of her musculoskeletal examination is unremarkable. Which
the following is most likely responsible for her chest discomfort?
A. Coronary vasospasm
B. Costochondritis
C. Esophageal hypomotility
D. Hypertension of the lower esophageal sphincter
E. Pulmonary fibrosis
The correct answer is C. This patient has typical features of progressive systemic
sclerosis (systemic scleroderma), as demonstrated by her Raynaud phenomenon, facial
telangiectasias, taut skin, and hypertension. (If she later develops calcinosis, she will have
exhibited the characteristic features of the CREST variant of progressive systemic
sclerosis.) The symptoms she describes are typical of gastroesophageal reflux disease,
which is seen in these patients as a result of esophageal hypomotility, as well as fibrosis
the lower esophageal sphincter (LES), which causes reduced lower esophageal sphincter
pressures. The underlying disease process in progressive systemic sclerosis is a small
vessel obliteration that leads to secondary diffuse fibrosis. When this affects the
esophagus, the esophageal musculature no longer contracts effectively. No specific
therapy is
available for the esophageal dysfunction of progressive systemic sclerosis, and patients
are treated with anti-esophageal reflux regimens (e.g., antacids, H2 blockers, frequent
feedings, and elevated head of bed) and periodic (mechanicaI) dilation of any esophageal
strictures that develop. Remember also that the long history of reflux esophagitis will
predispose for development of Barrett's esophagus with the risk of progression to
esophageal cancer.
Scleroderma patients are at risk for coronary artery disease (choice A), but her symptoms
(particularly the tie to ingestion of food) are not typical of coronary ischemia.
Costochondritis (choice B) is generally diagnosed with tenderness over palpation of the
costochondral joints and is not associated with scleroderma.
As stated above, these patients develop reduced pressures in the LES and not
hypertension of the LES (choice D).
Pulmonary fibrosis (choice E) can be seen in these patients, but her symptoms
(particularly the tie to ingestion of food) are of gastroesophageal reflux and not of
pulmonary disease.

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Item 6 of 10
Untimed Test
A 54-year-old man presents for a periodic health examination. His family history is
significant for his mother who died of a cerebrovascular accident at age 72, his father
who died of a
myocardial infarction at age 68, and a brother who developed sigmoid cancer at age 60.
The patient is on no medications except for aspirin, 81 mg daily. His physical
examination is
unremarkable. The patient asks for a recommendation regarding current cancer screening.
Which of the following is the most appropriate screening test for this patient?
..     A. Annual digital rectal examination and fecal occult blood testing
B. FIexible sigmoidoscopy
C. FIexible sigmoidoscopy and barium enema
D. Colonoscopy
E. Genetic testing for the p53 gene
The correct answer is D. Any patient with a first-degree relative who has developed an
adenoma or colorectal cancer should undergo colonoscopy for screening at age 50, or 10
years before the relative developed the adenoma or carcinoma, whichever comes first.
This patient has a brother who has a colon cancer at age 60; therefore, a full colonoscopy
warranted. AIthough there are various opinions regarding appropriate screening in the
"average risk individuaI," there is a consensus that full colonoscopy is required in
patients who
have an increased risk, e.g., first-degree relative with a positive history.
Annual digital rectal examination and fecal occult blood testing (choice A) are no longer
considered a reliable method of screening for colon cancer, since a shift in the
of colon cancer has lead to more than half being identified in the first half of the colon.
Digital rectal examination also often fails to identify premalignant colonic polyps.
FIexible sigmoidoscopy (choice B) is a good initial screening technique for patients older
than 50 with no specific known risk factors. If polyps are identified, they can be biopsied,
their type established, and subsequent complete colonoscopy performed if adenomas
were identified microscopically.
FIexible sigmoidoscopy and barium enema (choice C) offers an alternative way of
screening the entire colon in patients in whom a complete colonoscopy cannot be
Genetic testing for the p53 gene (choice E) is not currently used for colon cancer

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Item 7 of 10
Untimed Te
A 9-year-old boy is brought to the pediatric clinic by his mother, who noticed that the left
side of his mouth has started to droop over the past several days. In addition, he is unable
close his left eye completely and complains of it burning. Review of systems reveals a
cold approximately two weeks ago and recent decreased taste sensation. Physical
reveals a well nourished male with normal vital signs. There is left eye ptosis and mild
erythema of the left conjunctiva. His smile is asymmetrical on the left. Laboratory
including a complete blood count and chemistry profile, are normaI. Which of the
following infections is most closely associated with this patient's condition?
A. Epstein-Barr Virus
B. Group A Streptococcus
C. Human lmmunodeficiency Virus
D. Influenza
E. Measles
The correct answer is A. This patient has Bell palsy, a postinfectious allergic or immune
demyelinating facial neuritis. Epstein-Barr virus is the preceding infection in
20% of cases. 85% of patients have their symptoms resolve on their own over a period of
several weeks. 10% retain mild facial weakness and 5% have permanent severe facial
weakness. Therapeutic intervention should include daily and nocturnal eye lubricants to
protect the cornea from drying.
Group A Streptococcus(choice B), HIV (choice C), and influenza (choice D) are not
associated with Bell palsy. However, herpes simplex virus, Lyme disease caused by
burgdorferi and mumps have been associated with Bell palsy.
Measles (choice E) is associated with subacute sclerosing panencephalitis, a chronic
encephalitis of the central nervous system manifested by progressively bizarre behavior
decline in cognitive function.

Item 8 of 10
Untimed T
A 14-year-old boy presents with decreased exercise tolerance. He is noted to have a grade
llI/VI systolic ejection murmur best heard at the left upper sternal border and a grade
mid-diastolic murmur at the lower left sternal border. The first heart sound is normaI. The
second heart sound is widely split and fixed. A right ventricular impulse is palpated. On a
chest roentgenogram, the pulmonary artery segment is enlarged, and pulmonary vascular
markings are increased. An ECG shows right axis deviation. Which of the following
congenital heart diseases does this boy most likely have?
A. Aortic stenosis
B. Atrial septal defect
C. Coarctation of the aorta
D. Patent ductus arteriosus
E. Ventricular septal defect
The correct answer is B. One of the most common types of structural congenital heart
disease to present in adolescence is atrial septal defect (ASD), and the most common
presentation is a heart murmur. However, some patients present with arrhythmias,
decreased exercise tolerance, or a paradoxic embolus.
The physical examination can show classic findings of an ASD; in some cases, however,
the findings may be extremely subtle. The murmur associated with the ASD is not caused
by blood flow traversing the actual defect but rather by the increased volume of blood
flow across the pulmonary valve and, to a lesser extent, across the tricuspid valve. Thus,
murmurs of an ASD are a systolic ejection murmur at the upper left sternal border and a
mid-diastolic murmur at the lower left sternal border. The second heart sound is widely
and fixed with regard to respiration. On palpation, a right ventricular impulse is present.
The chest radiogram shows evidence of an enlarged pulmonary artery segment in the
posteroanterior projection. The superior vena cava shadow may not be visible because of
rotation of the heart secondary to right ventricular volume overload. Pulmonary
vascularity is increased, and the heart may be somewhat enlarged. The lateral projection
shows the
right ventricular enlargement with filling of the retrosternal airspace. The ECG has a
normal to rightward axis and a right ventricular volume overload pattern in the precordial
An echocardiogram with color Doppler examination can demonstrate the ASD. However,
because the atrial septum is a posterior structure, it may not be visualized adequately with
transthoracic echocardiogram; therefore, a transesophageal echocardiogram is frequently
necessary for diagnosis. CIosure of the defect is recommended for patients with ASD to
decrease the risk of pulmonary vascular obstructive disease, stroke, and arrhythmias.
Aortic stenosis (choice A) is often associated with bicuspid aortic valve and presents with
dyspnea on exertion, chest pain, and syncope. A harsh systolic ejection murmur is
heard at the right upper sternal border.
Coarctation of the aorta (choice C) results in obstruction between the proximal and the
distal aorta. On examination, the femoral pulses are weak and delayed relative to the
pulses. Turner syndrome must be considered in a girl with coarctation of the aorta.
Patent ductus arteriosus (PDA) (choice D) usually presents with a "machinery murmur"
that is continuous beginning after S1, peaking at S2, and trailing off during diastole.
Indomethacin is often effective in closing the PDA in premature infants.
Ventricular septal defect (choice E) is the most common congenital defect of the heart
and usually presents with a wide spectrum of symptoms including growth failure,
heart failure, and chronic lower respiratory infections. Patients with small defects might
be asymptomatic but would have a holosystolic murmur.
Item 9 of 10
Untimed Test
A 55-year-old man complains of shortness of breath and wheezing. He has now
developed worsening dyspnea on exertion. He reports a past history of smoking more
than three
packs of cigarette a day for the past 40 years. He has never been intubated but has been
admitted in the past for treatment with bronchodilators. On physical examination, he has
air movement in his lungs. A chest x-ray film shows flattening of the diaphragm and a
barrel chest. He undergoes pulmonary function testing. Which of the following patterns
will be
seen on his pulmonary function tests?
A. Decreased residual volume/total lung capacity (RV/TLC)
B. Decreased RV
C. Normal forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)
D. Reduced FEV1/FVC
E. Reduced VC and TLC
The correct answer is D. The forced expiratory volume in 1 second/forced vital capacity
(FEV1/FVC) is a ratio that is effort dependent. It increases with increasing expiratory
FEV1 is the volume of air forcefully expired during the first second after a deep breath.
FVC is the maximal volume of air expelled with deep expiration. Residual volume (RV)
is the
volume of air remaining in the lungs after a maximal expiratory effort. Vital capacity
(VC) is the maximal volume of air that may be expelled from the lungs following a
inspiration. A reduced FEV1/FVC is indicative of obstructive airway disease. The
reduced ratio implies decreased airway emptying because of air trapping. This patient
probably has
chronic obstructive pulmonary disease (COPD) from smoking.
COPD would cause an increase in RV/TLC, not a decrease (choice A) as a result of air
trapping since the terminal airways close before all the air is expelled.
RV (choice B) will be increased because of air trapping.
The obstructive pattern should cause a decrease in FEV1/FVC (choice C). The flow loop
would show characteristic scooping because of this phenomenon.
A reduction in VC and TLC (choice E), which is caused by lung stiffness and reduced
lung compliance, is seen in restrictive lung disease. It is the most useful indicator of this
type of
Iung disease.
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Item 10 of 10
Untimed Te
A 71-year-old man presents to the hospital with an episode of bright red blood per
rectum. The patient reports that, a few hours ago, he passed a grossly bloody bowel
movement. The
passage was associated with some cramping, Iower abdominal pain. The patient's past
medical history is significant for coronary artery disease and a myocardial infarction 3
ago. He is poorly compliant with his beta blocker and diuretic therapy, and his blood
pressures have run around 140/85 mm Hg. While the patient is on the floor, he has
episode of large-volume, bright red blood per rectum. His blood pressure is 100/60 mm
Hg while supine, and his pulse is 120/min. His hematocrit is 28%. He then begins to
of substernal chest tightness radiating to his left shoulder. An ECG shows new T wave
inversions in the anterior leads. Which of the following is the most appropriate
intervention at
this juncture?
A. Administration of aspirin by mouth
..       B. Administration of a beta blocking agent
C. Administration of nitroglycerin sublingually
D. Administration of nitroglycerin topically
E. BIood transfusion
The correct answer is E. According to the available data, the patient is presenting with
myocardial ischemia in the presence of anemia. The appropriate treatment, therefore, is a
blood transfusion.
Administration of aspirin (choice A) would not be appropriate in this man who is passing
bright red blood per rectum.
This patient's tachycardia is an appropriate response to the anemia and hypovolemia (an
effort to maintain oxygen delivery). The administration of a beta blocking agent (choice
therefore, would be inappropriate.
The patient's blood pressure (compare it with his previous pressures) while supine
strongly suggests hypovolemia. The administration of nitroglycerin, either sublingually
(choice C)
or topically (choice D), therefore, becomes inappropriate. The nitroglycerin will further
reduce preload, which in turn, could further compromise the patient's cardiac output and
worsen his myocardial ischemia.

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Item 1 of 10
Untimed Te
A 40-year-old man is brought to the emergency room by his friends. Apparently, he has
ingested some unknown medication in a suicide attempt. The patient is disoriented to
time. His
temperature is 39.3 C (103 F), blood pressure is 120/85 mm Hg, pulse is 100/min and
irregular, and respirations are 22/min. The skin is flushed and dry. Dilated pupils and
twitching are also noted on physical examination. ECG reveals prolonged QRS
complexes. Hepatic transaminases are normaI, and blood gas analysis shows a normal
pH. These
findings are most likely due to intoxication by which of the following substances?
A. Acetaminophen
B. AIcohol
C. Benzodiazepines
D. CIonidine
E. Monoamine oxidase (MAO) inhibitors
F. Tricyclic antidepressants
The correct answer is F. This patient's clinical picture is consistent with intoxication with
tricyclic antidepressants such as amitriptyline and imipramine. Toxic effects are mediated
by peripheral anticholinergic activity and "quinidine-Iike" action. The anticholinergic
effects include mydriasis, tachycardia, impaired sweating with flushed skin, dry mouth,
constipation, and muscle twitching. Quinidine-Iike effects (due to block of sodium
channels in the heart) result in cardiac arrhythmias, especially ventricular
tachyarrhythmias. In this
setting, prolongation of the QRS complex is particularly important in the diagnosis. QRS
width is, in fact, an even more faithful parameter of drug toxicity than serum drug levels.
severe intoxication, patients will develop seizures, severe hypotension, and coma.
Acetaminophen (choice A) results in liver toxicity. Liver enzymes would be elevated.
AIcohol intoxication (choice B) manifests with respiratory depression, hypothermia, and
The manifestations of benzodiazepine intoxication (choice C) are similar to alcohol
inasmuch as central nervous system depression is common to both drugs. Thus, acute
benzodiazepine intoxication produces stupor, coma, and respiratory depression.
The sympatholytic properties of clonidine (choice D) explain the clinical symptoms of
intoxication. CIonidine overdose causes bradycardia, hypotension, miosis, and respiratory
Monoamine oxidase (MAO) inhibitors (choice E) represent a second-Iine treatment for
major depression. Overdose induces ataxia, excitement, hypertension, and tachycardia.
reactions can be precipitated by concomitant ingestion of tyramin containing foods
(aged cheese and red wine, for example).

Item 2 of 10
Untimed Test
A 14-year-old boy is evaluated for short stature. He has no significant past medical
history and is considered otherwise healthy by his parents. He eats a normal diet and has
meals. His height and weight have been consistently at the 5th percentile since early
childhood. His physical examination is normaI, with genitalia at Tanner stage 3. Which
of the
following is the most likely laboratory finding for this boy?
A. Bone age that is equivalent to chronologic age
B. Decreased complement C3 Ievel
C. Decreased serum albumin concentration
D. Decreased thyroid stimulating hormone
E. Increased serum creatinine concentration
The correct answer is A. This boy most likely has familial short stature (FSS). Children
with FSS usually have a normal birth weight and length. At the age of 2-3 years,
their growth begins to decelerate and drops to around the 5th percentile. The onset and
progression of puberty in children with FSS are normaI. Bone age is typically consistent
the chronologic age.
A decreased complement C3 Ievel (choice B) may suggest chronic inflammatory
disorders. But, the lack of any signs or symptoms makes any chronic inflammatory
A decreased serum albumin concentration (choice C) can be secondary to a variety of
conditions, such as nephrotic syndrome and malnutrition. But, the lack of supportive
and physical examination data makes these conditions unlikely.
Decreased thyroid stimulating hormone (choice D) suggests hyperthyroidism as the
etiology of the boy's short stature, but it is highly unlikely in this case.
An increased serum creatinine level (choice E) indicates renal failure, but this is
inconsistent with the child's history and physical examination.
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Item 3 of 10
Untimed Test
A 40-year-old man is brought in for evaluation by the Coast Guard after the small plane
he was piloting crashed into the ocean. The man's wife and two friends were also on the
The man has survived the crash with cuts and a broken arm, but he claims he has no
memory of the crash or how he escaped the plane. He is also unable to explain how he
got his
Iife jacket on. His physical examination now is significant only for minor lacerations and
a fractured right humerus, and he has no alteration in consciousness. A CT scan is
normaI. He
is very upset that the fate of his wife is unknown, and he has nightmares for the next
several nights while trying to sleep. Which of the following is the most likely diagnosis?
A. Dissociative amnesia
B. Dissociative fugue
C. Dissociative identity disorder
D. Factitious disorder
E. Transient global hypoxia
The correct answer is A. In this instance, an extremely stressful event has been followed
by localized loss of memory or amnesia of circumstances surrounding the event, making
the diagnosis of dissociative amnesia the most likely diagnosis. Dissociative amnesia is
often accompanied by nightmares and anxiety concerning the event, both of which this
patient also has.
Dissociative fugue (choice B) is a disturbance of identity that requires a sudden,
unexpected travel away from home or one's place of work, with inability to recall one's
Dissociative identity disorder (choice C) is also a disturbance of identity. It requires the
presence of two or more distinct identities or personality states, which recurrently take
of the person's behavior. This is popularly known as multiple personality disorder.
Factitious disorder (choice D) is a diagnosis requiring intentional production of
symptoms and gratification from assuming the sick role.
Transient global hypoxia (choice E) is not a likely diagnosis given this patient's lack of
altered consciousness following this event.

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Item 4 of 10
Untimed Test
A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestation comes to the labor and
delivery ward after a gush of fluid with regular, painful contractions every two minutes.
She is
found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated,
a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to
the labor and delivery ward. Two hours later she states that she feels hot and sweaty.
Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8
centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the
most appropriate management of this patient?
. .     A. Administer antibiotics to the mother after vaginal delivery
B. Administer antibiotics to the mother now and allow vaginal delivery
C. Perform cesarean delivery
D. Perform cesarean delivery and then administer antibiotics to the mother
E. Perform intra-amniotic injection of antibiotics
The correct answer is B. Chorioamnionitis is an infection that can develop at any time
before and during delivery. The most common findings in patients with chorioamnionitis
are a
fever and uterine tenderness. An elevated fetal heart rate is also often seen. This patient
has a temperature elevation and uterine tenderness, which make the diagnosis of
chorioamnionitis. It is essential that antibiotics be started immediately because prompt
initiation of antibiotics, once the diagnosis of chorioamnionitis is made, results in better
maternal and neonatal outcomes than if therapy is delayed. It is also essential that broad-
spectrum antibiotic therapy be chosen because a mixture of organisms is usually involved
including aerobes and anaerobes. The most frequently used regimen is ampicillin or
penicillin with gentamicin. In terms of the mode of delivery, vaginal delivery is
acceptable in
patients with chorioamnionitis. While it is desirable to have an expeditious delivery,
chorioamnionitis is not an indication for cesarean delivery.
To wait to administer antibiotics to the mother after vaginal delivery (choice A) would
not be correct, as the delay would deprive both the mother and the fetus of the beneficial
of the antibiotics.
To perform cesarean delivery (choice C) or to perform cesarean delivery and then
administer antibiotics to the mother (choice D) would not be indicated. As explained
above, when
a woman has chorioamnionitis, it is desirable to expedite delivery, but cesarean delivery
should be performed only for obstetric indications.
To perform intra-amniotic injection of antibiotics (choice E) would not be indicated.
Intra-amniotic injection of antibiotics during labor is not a therapy used to treat
during labor.

Item 5 of 10
Untimed Test
A 20-year-old pregnant woman is experiencing rapidly progressive hearing loss. Several
relatives in her family developed deafness prior to age 25. Otoscopic examination shows
normal tympanic membranes bilaterally. Hearing testing shows a conductive hearing loss,
with one ear being effected more severely than the other. Which of the following
is most likely?
A. Acoustic neuroma
B. Chronic otitis media
C. Otosclerosis
D. Meniere disease
E. Presbycusis
The correct answer is C. This is otosclerosis, which is an often hereditary (autosomal
dominant) disease in which new, immature bone with abundant vascular channels cause
ankylosis of the stapedial foot plate. This causes progressive conductive (and in severe
cases sensory) hearing loss which may become clinically significant in the late teens to
twenties. (While otosclerotic lesions occur in up to 10%of Caucasian adults, significant
hearing loss occurs in only about 10% of patients with bony lesions. ) Pregnancy may
the condition to progress more rapidly. Many patients can be managed with hearing aids;
severe cases may respond to removal of the stapes with implantation of a prosthesis.
Acoustic neuroma (choice A) would usually be unilateraI, and would cause tinnitus,
hearing loss, and sometimes dizziness and unsteadiness.
Chronic otitis media (choice B) would produce an obviously scarred or inflamed
tympanic membrane.
Meniere disease (choice D) causes recurrent severe vertigo that may be accompanied by
sensory hearing loss, tinnitus, and a feeling of fullness in the ear.
Presbycusis (choice E) is the common sensorineural hearing loss seen with aging.
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Item 6 of 10
Untimed Te
A 43-year-old man reports that he had a 9-Ib. weight loss over the past 9 months. The
symptoms are accompanied by difficulty swallowing both solids and liquids during that
time. He
has woken on several occasions at approximately 4 AM and regurgitated partially
digested dinner contents. An upper gastrointestinal series is performed and reveals a
widely dilated
esophagus with a smoothly tapering distal esophagus. There appears to be partially
digested food present in the esophagus. Which of the following is the most likely cause of
patient's symptoms?
A. Achalasia
B. Diffuse esophageal spasm
C. Esophageal squamous cancer
D. Peptic stricture
E. Scleroderma
The correct answer is A. This patient has the symptoms of a motility-type dysphagia in
that he has difficulty with both solids and liquids, from the onset of his symptoms. The
nocturnal aspiration of food occurs because the esophagus remains filled for hours or
even days after completing a meaI. The x-ray film reveals the typical dilated esophagus
achalasia, which is termed a bird's-beak esophagus, with distal esophageal tapering.
Diffuse esophageal spasm (choice B) will typically produce "non-cardiac chest pain" in
association with a motility-type dysphagia.
Esophageal squamous cancer (choice C) would produce a mechanical type dysphagia and
is unlikely in a 42-year-old man without any specific risk factors, i.e. smoking, drinking,
Iye ingestion, or PIummer-Vinson syndrome.
Peptic stricture (choice D) is wrong because it would produce a mechanicaI, not a
motility, type dysphagia.
Scleroderma (choice E) will also produce a motility-type dysphagia, but it is very
uncommon for men to develop this disease. Furthermore aspiration in scleroderma occurs
only after
a peptic stricture has developed. Prior to this, the lower esophageal sphincter is wide
open, and foods do not accumulate in the esophagus.

Item 7 of 10
Untimed Test
A 65-year-old man comes to medical attention because of multiple neurologic deficits,
including loss of sensation in his right hand, weakness of the left lower leg, and a visual
deficit. He has smoked two packs of cigarettes daily for 40 years. His medical history is
remarkable for asthma and emphysema. Examination of the fundus is unremarkable. His
temperature is 37 C (98.6 F), blood pressure is 137/86 mm Hg, pulse is 86/min, and
respirations are 24/min. MRI of the head reveals five different intracerebral lesions,
ranging from 1
to 3 cm in main diameter and located at the gray-white matter junction in both cerebral
hemispheres. The lesions are sharply demarcated, and contrast enhancement after
administration is present in all of them. Which of the following is the most likely
A. Abscesses
B. Arteriovenous malformations
C. Embolic infarcts
D. Metastases
E. Multifocal glioblastoma multiforme
The correct answer is D. Awareness of the typicaI MRI/CT appearance of brain
metastases is important because often patients present with cerebral metastases without
history of cancer disease. Thus, a radiologic diagnosis of brain metastatic disease may
prompt a search for the underlying primary tumor, which is often a lung carcinoma in
and lung or breast carcinoma in woman. Melanomas also have a peculiar propensity to
metastasize to the brain. The typical radiologic features of brain metastases are
in this case: multiplicity of lesions, welI-circumscribed borders, and location at the gray-
white matter junction.
Multiple abscesses (choice A) may develop in patients with sepsis and, particularly, in
association with conditions leading to septic emboli (e.g., infective endocarditis).
Arteriovenous malformations (AVMs) (choice B) are abnormal conglomerates of
disorganized blood vessels composed of arteries, veins, and intermediate vessels with
discontinuous elastic lamina. Intracerebral hemorrhage is their most frequent mode of
clinical presentation.
Embolic infarcts (choice C) would be associated with wedge-shaped cortical lesions.
Frequently, embolic infarcts are hemorrhagic.
Multifocal glioblastoma multiforme (GBM) (choice E), the most frequent malignant
primary brain neoplasm, manifests as an ilI-defined mass in the white matter. Contrast
enhancement is usually present. MultifocaI GBM is a rare event. Even so, the lesions are
poorly circumscribed and centered in the white matter.
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Item 8 of 10
Untimed Test
A 22-year-old woman goes to the emergency department because she feels very weak
and is having muscle cramping and fasciculations. BIood chemistry studies demonstrate a
plasma potassium of 1.5 mEq/L. On questioning, she admits to chronic use of laxatives
and diuretics to control her weight. Which of the following ECG changes would be most
characteristic of changes related to her K+ IeveI?
A. Increased U wave amplitude
B. Prolongation of the P wave
C. Shortening of the QT interval
D. TalI, symmetric, peaked T waves
E. Widening of the QRS complex
The correct answer is A. Both chronic laxative use and chronic diuretic use can produce
hypokalemia. Severe hypokalemia, with plasma potassium <3 mEq/L, can markedly
skeletaI, smooth, and cardiac muscles. Skeletal muscle effects can include weakness,
cramping, fasciculations, paralysis (with risk of respiratory failure), tetany, and
rhabdomyolysis. Smooth muscle effects include hypotension and paralytic ileus. Cardiac
muscle effects include premature ventricular and atrial contractions, tachyarrhythmias,
AV block. AdditionaI ECG changes can include ST segment depression, increased U
wave amplitude, and T wave amplitude less than U wave.
The changes illustrated in choices B, C, D, and E are characteristic of hyperkalemia.
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Item 9 of 10
Untimed Te
A 39-year-old automobile mechanic presents because of the new onset of wheezing. He is
otherwise healthy and runs approximately 3 miles per day. He denies any nocturnal
wheezing or cough. He has a history of chronic heartburn, for which he takes ranitidine
nightly. He also has a history of hypertension, which has been difficult to controI, and
over the
past several months he has been taking a combination of propranoloI, enalapriI, and
hydrochlorothiazide. His only other medication is occasional pseudoephedrine for
symptoms of
allergic rhinitis. On physical examination, he appears comfortable. His blood pressure is
134/88 mm Hg, pulse is 68/min, and respirations are 18/min. On lung examination, soft
expiratory wheezes are heard throughout both lung fields. Which of the following
medications is most likely contributing to his wheezing?
A. Enalapril
B. Hydrochlorothiazide
C. Propranolol
D. Pseudoephedrine
E. Ranitidine
The correct answer is C. PropranoloI, Iike other nonspecific beta blockers, may cause
bronchospasm by blocking the beta receptors in the bronchial tree. Beta stimulation in the
Iungs produces bronchodilation, and its blockade leads to bronchoconstriction. In fact,
propranolol is contraindicated in patients with known asthma or chronic obstructive
disease (COPD).
Enalapril (choice A) may cause pulmonary symptoms, in that it may cause a
nonproductive cough, but is not usually associated with wheezing.
Hydrochlorothiazide (choice B) and ranitidine (choice E) have no effect on airway
responsiveness, although the patient's underlying gastroesophageal reflux disease may
lead to
acid induced bronchoconstriction.
Pseudoephedrine (choice D) does not cause bronchoconstriction.
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Item 10 of 10
Untimed Test
A 24-year-old white woman presents complaining of 6 months of crampy abdominal
pain. The pain has been localized to the right lower quadrant and is made worse by
eating. She
has also noted an increase in the number of her bowel movements to approximately four
per day, and the stools have become semi-formed. She denies any fevers, chills, or night
sweats during this period. She has lost 15 pounds from her baseline weight of 128 pounds
over the past 6 months. She has also noted aching in her knees and ankles during this
intervaI. On physical examination, she is slightly pale and has two oral aphthous ulcers
on the inner lower lip. The abdomen is soft but tender in the right lower quadrant. No
are palpable, and there is no hepatosplenomegaly. A rectal examination reveals brown
stooI, which is guaiac positive. Which of the following diagnostic tests would be most
appropriate for this patient?
A. AbdominaI CT scan
B. Barium enema
..       C. Sigmoidoscopy
D. Abdominal sonogram scan
E. Upper gastrointestinal and small bowel barium x-ray films
The correct answer is E. This patient has the classic presentation of Crohn disease. This
generally presents in young adults with subacute or chronic symptoms, typically of right
Iower quadrant pain, diarrhea, and weight loss. She also has extraintestinal manifestations
of aphthous ulcers and arthralgias. The description of this patient's pain suggests that it is
Iocated in the terminal ileum. This area is best seen with an upper gastrointestinal and
small bowel barium study.
An abdominaI CT scan (choice A) is sometimes useful in patients with Crohn disease
with a suspected abscess or fistula. However, this is not suggested by the history or
in this case.
An abdominal sonogram (choice B) would not provide sufficient infromation for the
diagnosis of Crohn disease. Barium studies are much better for visualization of the
features of inflammatory bowel disease.
A barium enema (choice C) is not as effective a test as a small bowel series at visualizing
the terminal ileum. The barium enema would demonstrate evidence of colonic Crohn
disease but the history and physical here suggest ileal disease is more likely.
A sigmoidoscopy (choice D) would not be of value in assessing the terminal ileum.

Item 1 of 10
Untimed T
A 53 year old-man is brought to the emergency department by a friend. The friend reports
that the patient has "Iiver disease" and has been drinking heavily lately and has not taken
medications. He has gotten progressively more confused over the past few days. On
examination, the man is afebrile, his blood pressure is 120/70 mm Hg and his heart rate is
100/min. He has no obvious signs of trauma but has some old, welI-healed lacerations on
his forehead. He has deep scleral icterus and his skin is jaundiced. His lungs are clear.
cardiac examination is normaI, but he has a distended abdomen with shifting dullness. He
is alert to person only and his neurological examination is remarkable for the inability to
perform finger-to-nose touching and heeI-to-shin maneuvers. Asterixis is present.
Laboratory studies show:
Sodium.....................................125 mEq/L
Potassium.................................3.1 mEq/L
Bicarbonate..............................18 mEq/L
Urea nitrogen............................25 mg/dL
Creatinine.................................1.2 mg/dL
Aspartate aminotransferase.......230 U/L
AIanine aminotransferase..........310 U/L
Prothrombin time......................14.8 seconds
AIkaline phosphatase................75 U/mL
Leukocyte count.......................6,400/mm3
BIood alcohol leveI....................2100 mg%Which of the following is the most likely
. .     A. Acute hyponatremia
B. Ascending cholangitis
C. Hepatic encephalopathy
D. Metabolic acidosis
E. Subdural hematoma
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The correct answer is C. The patient most likely has developed hepatic encephalopathy,
one of the many complications that affect cirrhotic patients. One of the most useful and
essential components of the evaluation of such a patient is the history. When the history
is given of a confused cirrhotic "not taking his medications", an understanding that
encephalopathy is a possible diagnosis should immediately come to mind.
Acute hyponatremia (choice A) is not supported by the serum sodium level of 125. Acute
signs of hyponatremia are seen when the serum sodium falls more than 12 mEq/L in less
than 24 hours. The signs of such an illness involve nausea, vomiting, confusion and
neurological findings related to brain edema.
Ascending cholangitis (choice B) is not supported by the physical examination or by the
classic Charcot's triad (fever, right upper quadrant pain, and jaundice).
Metabolic acidosis (choice D) is not supported by the data. The patient does have a low
bicarbonate leveI, but his pH is not known. He is likely acidemic, but this is not the most
cause of his confusion.
Subdural hematoma (choice E) is not supported by the physical examination. The most
common cause of SH is traumatic tearing of the bridging veins of the dura.
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Item 2 of 10
Untimed Test
A 7-year-old boy arrives at the emergency room in acute distress. Over the past 3 to 4
days he has become progressively ill with generalized fatigue and mild, mid-abdominal
pain that
have become steadily worse. On physical examination he has a maculopapular rash on his
thighs and feet with some spread of the rash to his buttocks. The rash does not blanch
and the some lesions near the ankles look petechial or bruised. His temperature is 39.0
C(102.2 F) and he is drawing his knees to his chest for relief of his stomach pains. He is
nauseated and vomited once before coming to the hospitaI. He has semi-soft dark stooI,
which is guaiac-positive. The boy has not voided since early morning and cannot provide
urine sample. The doctor determines that he is 10% dehydrated and asks the nurse to start
intravenous fluids. Which of the following is the most likely diagnosis?
A. Pancreatitis
B. Rocky Mountain spotted fever
C. Nephrotic syndrome
D. Henoch-Schönlein Purpura
E. Appendicitis
The correct answer is D. Henoch- Schönlein Purpura (HSP) is the most likely diagnosis.
This boy has abdominal pain with guaiac-positive stools, but also has a prominent rash,
mostly on his lower extremities. Other characteristic findings of HSP include hematuria
and joint pains. The illness may follow an upper respiratory infection or strep throat. The
starts out as an urticarial rash and progresses to become petechial and purpuric. There
may be a history of migratory joint pain and arthritis. Affected joints include ankles,
wrists, and elbows.
If the abdominal pain were described as epigastric with radiation to the back, pancreatitis
(choice A) might have been the likely diagnosis.In children, pancreatitis is frequently
associated with viral illnesses (e.g., mumps), drugs (e.g., sulfonamides), or underlying
systemic disease (e.g., Iupus). AIthough pancreatitis has been reported in association with
HSP, it is not the most likely diagnosis.
Rocky Mountain spotted fever (choice B) is one of the most common tick-borne diseases.
The typical rash of RMSF appears within a week of the tick bite. It begins on the palms,
soles, and extremities and spreads centrally. Severe headache and photophobia are
common complaints.
This child did not have the typical findings of nephrotic syndrome (choice C) including:
proteinuria, edema, and oliguria. Nephrotic syndrome frequently follows an infectious
In the classic case of appendicitis (choice E) periumbilical pain progresses with
localization to the right lower quadrant.Anorexia, nausea, vomiting and changes in bowel
may all occur. Fever is typically low-grade and rash is not present.
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Item 3 of 10
Untimed Te
A 32 year-old male with a history of panic disorder who works as a salesman presents to
his psychiatrist after several weeks of treatment with paroxetine. While he has noted
significant improvement in his symptoms, he still notes residual anxiety when put into
social situations in which he has to speak in public or become the center of attention.
Given that
he had some improvement on his current medication regimen, which of the following
would be the most appropriate next step in management?
A. Cognitive-behavior therapy
B. EIectroconvulsive therapy
C. Medication change
D. Psychoanalysis
E. Seeing the patient more often for supportive psychotherapy
The correct answer is A. In many cases of panic disorder, effective treatment involves the
use of cognitive behavior therapy, which incorporates exposing the patient to disturbing
stimuli in an attempt to develop coping mechanisms in response to the stimuli.
EIectroconvulsive therapy (choice B) is not indicated for use in panic disorder.
Medication change (choice C) is not indicated when the current regimen leads to
significant symptom relief, as the amount of time necessary to achieve adequate response
on a
new medication does not justify a medication switch.
Psychoanalysis (choice D) is a long term, time consuming process that is not indicated to
treat the acute residual anxiety of this patient's panic disorder.
Seeing the patient more often for supportive psychotherapy (choice E) would not be as
effective a treatment as cognitive behavioral therapy, according to research on panic
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Item 4 of 10
Untimed Test
A 16-year-old female comes to the physician because of an increased vaginal discharge.
She developed this symptom 2 days ago. She also complains of dysuria. She is sexually
active with one partner and uses condoms intermittently. Examination reveals some
erythema of the cervix but is otherwise unremarkable. A urine culture is sent which
comes back
negative. Sexually transmitted disease testing is performed and the patient is found to
have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be
for which of the following?
A. Bacterial vaginosis
B. Chlamydia
C. Herpes
D. Syphilis
E. Trichomoniasis
The correct answer is B. This patient has a gonorrhea infection. Gonorrhea is one of the
most prevalent sexually transmitted diseases (STDs) in the United States. It is more
common in patients of lower socioeconomic status, patients with multiple sexual
partners, and in urban settings. The causative organism is N. gonorrhoeae, a gram-
negative aerobic
diplococcus. Up to 80% of women that are infected with the organism will have no
symptoms at all or only vague symptoms. Symptoms that are frequently noted are vaginal
discharge, postcoital spotting, and urinary symptoms if the urethra is involved.
Examination may reveal a cervicitis, although this is not always present. A patient found
to have
gonorrhea should be treated with intramuscular ceftriaxone or oral cefixime, ofloxacin, or
ciprofloxacin. These medications will effectively eradicate the gonococcus. However,
because Chlamydia trachomatis can be isolated in up to 50% of women with gonorrhea
and because women treated for gonorrhea only may soon go on to develop Chlamydia or
pelvic inflammatory disease (PID), any woman receiving treatment for gonorrhea should
also be treated for Chlamydia. Treatment of Chlamydia is with azithromycin or
doxycycline. It
is also essential that this patient's partner be treated as welI.
When treating a patient for gonorrhea, there is no need to treat the patient with
metronidazole to treat bacterial vaginosis (choice A) as welI, unless there is evidence of a
vaginosis .
Herpes (choice C) often presents as painful vesicles and ulcers. Patients with gonorrhea
do not need to be treated for herpes as welI, unless there is evidence for herpes infection.
Patients with gonorrhea are at increased risk of having other sexually transmitted
diseases, including syphilis (choice D). It would be prudent to check this patient for
syphilis with a
blood test. However, in the absence of a positive syphilis test, patients with gonorrhea do
not need to be treated for syphilis.
Trichomoniasis (choice E) is treated with metronidazole. Again, as with bacterial
vaginosis, herpes, and syphilis, unless there is evidence of Trichomonas infection, the
patient does
not needed to be treated for trichomoniasis.
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Item 5 of 10
Untimed Test
An 8-year-old boy presents with a 2-day history of rash. The rash started on the head and
spread downward to his trunk and extremities. He also complains of a fever, cough, and a
runny nose for the past 5 days. On physical examination, his temperature is 38.2 C (100.7
F), blood pressure is 88/56 mm Hg, pulse is 76/min, and respirations are 16/min. There is
smalI, irregular red spot with a central gray color on his buccal mucosa. The rash on his
body is erythematous and maculopapular in quality. Which of the following is the most
A. Erythema infectiosum
B. Hand-foot-mouth disease
C. Measles
D. Roseola infantum
E. Rubella
The correct answer is C. Measles (rubeola) is a very contagious, exanthematous
respiratory disease with a pathognomonic enanthem. A Iive attenuated measles vaccine
available in 1963 in the U. S. and elsewhere, and measles is now an unusual disease in
countries where this vaccine is widely used. However, measles continues to occur
sporadically in mini-epidemics.
The measles virus is transmitted by respiratory secretions, predominantly through
exposure to aerosols but also through direct contact with larger droplets. Patients are
for 1-2 days before the onset of symptoms untiI, 4 days after the appearance of the rash.
Measles begins with a few-day respiratory prodrome of malaise, cough, coryza,
conjunctivitis, nasal discharge, and increasing fever. Just before the onset of the rash,
Koplik's spots appear as 1- to 2-mm blue-white spots on a bright red background. The
characteristic erythematous, non-pruritic, maculopapular rash of measles begins at the
hairline and behind the ears, spreads down the trunk and limbs to include the palms and
soles, and often becomes confluent. At this time, the patient is at the most severe point of
the illness. By the 4th day, the rash begins to fade in the order in which it appeared.
Brownish discoloration of the skin and desquamation may occur later. Fever usually
resolves by the 4th or 5th day after the onset of rash; prolonged fever suggests a
complication of
measles. Lymphadenopathy, diarrhea, vomiting, and splenomegaly are common features.
Therapy for measles is largely supportive and symptom based.
Erythema infectiosum (choice A), or Fifth's disease, is a mild illness caused by
parvovirus B-19. It usually begins as a marked erythema of the cheeks, giving a "slapped
Hand-foot-mouth disease (choice B) presents with a prodrome of fever and anorexia,
followed by ulcers on the tongue and oral mucosa and a vesicular rash on the hands and
Roseola infantum (choice D) presents with an abrupt onset of a high fever, with
temperatures up to 39.5-41.1 C (103-106 F). A maculopapular rash appears on the trunk
on the 3rd
or 4th day when the fever breaks.
Rubella (choice E) causes a mild syndrome, which is characterized by an erythematous,
maculopapular, discrete rash, generalized lymphadenopathy, and fever. It can cause
congenital rubella syndrome in the infant if the pregnant mother is infected with the

Item 6 of 10
Untimed Test
A 51-year-old man presents to the emergency department with abdominal pain. He was
well untiI 2 days ago, when he began to experience severe right upper quadrant pain,
to the epigastric region. He reports temperatures to 38.3 C (101 F) and some nausea and
vomiting. His temperature is now 39.1 C (102.3 F), blood pressure is 130/70 mm Hg, and
pulse is 90/min. Physical examination reveals tenderness in his right upper quadrant, with
abrupt cessation of inspiration on deep palpation of his right upper quadrant. Which of
following is the most appropriate management for this patient?
..     A. IV fluids and observation
B. IV antibiotics and observation
C. Admission to a surgical service for next day surgery
D. Urgent surgical evaluation for immediate surgery
E. Urgent percutaneous drainage
The correct answer is C. This patient has symptomatic cholecystitis. This complication is
most commonly associated with long-standing gallstones and less frequently with severe
illness (so-called acalculous cholecystitis). The therapy for such patients is usually
prompt surgical removal of the inflamed gallbladder. If left in place, there is an increased
risk of
infection, abscess formation, or sepsis. AII such patients should receive IV fluids,
resuscitation, and, if very ill appearing, coverage with broad-spectrum antibiotics.
IV fluids and observation (choice A) and IV antibiotics and observation (choice B) are
inappropriate since the patient requires surgery. Failure to recognize this fact will result
serious morbidity. Once the patient is appropriately referred, then fluids and possibly
antibiotics are crucial components of therapy.
Urgent surgical evaluation for immediate surgery (choice D) is not appropriate since the
patient appears stable, although febrile and uncomfortable.
Urgent percutaneous drainage (choice E) is an interventional radiology procedure that
allows for drainage of the gallbladder. These procedures are usually reserved for very ill
patients who could not tolerate surgery and general anesthesia.
Item 7 of 10
Untimed Test
A 70-year-old man presents to the emergency department with a 3-day history of right
temporal headache, fever, and profound malaise. He appears acutely ilI. His temperature
is 39.5
C (103.1 F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are
24/min. Tenderness over the right temporal region is appreciated on palpation. The right
artery is tender and slightly nodular. Neurologic examination is normaI, including
funduscopic examination. However, visual acuity is reduced. Laboratory studies show:
Hematocrit                          39.0%
Hemoglobin                          10.9 g/dL
Leukocytes                          8800/ L (neutrophils 68%)
Erythrocyte sedimentation rate 80 mm/hr
Which of the following is the most appropriate next step in management?
A. Measurement of intraocular pressure
B. Visual field assessment
C. Low-dose (10 mg/day) prednisone treatment
D. High-dose (60 mg/day) prednisone treatment
E. Temporal artery biopsy
The correct answer is D. The patient needs urgent treatment with high-dose prednisone
for giant cell arteritis (i.e., temporal arteritis). This systemic disease overlaps with
polymyalgia rheumatica in approximately 40% of cases. It affects elderly persons who
present with fever, malaise, temporal headache, and scalp tenderness. Giant cell arteritis
is a
frequent cause of fever of unknown origin in the elderly. The leukocyte count may be
entirely normaI, while the erythrocyte sedimentation rate (ESR) is markedly elevated.
condition may involve arteries other than the superficial temporal artery, including the
aortic branches. The most important reason to start prednisone therapy is to prevent
secondary to extension of the process to the ophthalmic artery. Prednisone should be
administered in high doses (usually 60 mg/day).
Measurement of intraocular pressure (choice A) is appropriate to confirm a diagnosis of
acute (narrow-angle) glaucoma. This gives rise to a characteristic acute symptomatology
painfuI, red eyes, blurred vision, and halos around lights.
Visual field assessment (choice B) is not indicated in this case.
High-dose prednisone may be slowly tapered to low-dose (10 mg/day) prednisone
treatment (choice C) over a period of 2 months, once the acute phase has resolved. Low-
prednisone is used for polymyalgia rheumatica.
Temporal artery biopsy (choice E) is performed routinely in any patient with clinical
signs and symptoms of giant cell arteritis. It is positive in up to 80% of cases. It shows
characteristic giant celI-rich granulomatous reaction in the media, with destruction of the
elastic lamina. The biopsy should be performed after starting corticosteroid treatment.
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Item 8 of 10
Untimed T .
A 61-year-old woman presents for her first physical examination in more than 10 years.
She reports that she has been in excellent health, does not smoke or drink, and exercises
running 3 miles daily. She is a retired accountant and has three healthy grown children.
She has been taking estrogen replacement therapy since menopause, and has been taking
mg daily after reading about its cardioprotective effects in the newspaper. On physical
examination, she appears welI. Her blood pressure is 122/76 mm Hg, pulse is 70/min, and
respirations are 14/min. She is afebrile. A head and neck examination is normaI. There is
no jugulovenous distention. Her lungs are clear. On cardiac examination, she has a
S1 and S2, and a I/IV crescendo blowing diastolic murmur is heard at the aortic area. An
abdominal examination is normaI. A rectal examination noted no masses, and her stool is
brown and guaiac negative. Which of the following is the most likely explanation of the
cardiac findings on physical examination?
A. Prior Bacteroides infection
B. Prior Escherichia coli infection
C. Prior gonococcal infection
D. Prior Haemophilus ducreyi infection
E. Prior streptococcal infection
The correct answer is E. This patient has findings of asymptomatic aortic insufficiency on
physical examination. This lesion may result from a number of causes, several of which
are infectious in etiology. Aortic insufficiency may result as a sequela of rheumatic heart
disease, which occurs as an immunologic response to a streptococcal infection. Acute
rheumatic fever is typically characterized by cardiac involvement that may cause
pericarditis, myocarditis, or endocarditis. Often, the initial cardiac manifestations are
and become apparent only years later with the development of cardiac valvular disease.
Bacteroides (choice A) is a gram-negative anaerobe of intestinal origin, which, Iikewise,
does not cause cardiac disease.
choice B), an enteric gram-negative organism, very rarely causes any form of cardiac
Treponema pallidum, the etiology of syphilis, may cause aortic insufficiency in its
tertiary stages. However, sexually transmitted diseases with this, Neisseria gonorrhoeae
C), and Haemophilus ducrey choice D) have no cardiac manifestations.
Item 9 of 10
Untimed Test
A 17-year-old boy presents with chronic low back pain for the past 8 months. He was the
most promising member of the high school swim team but was forced to quit because of
back pain. The pain begins frequently at night, radiates down the thighs, and is
accompanied by pronounced stiffness of the lumbar spine. He denies any gastrointestinal
or genital
infections. His temperature is 37.0 C (98.6 F). Examination reveals moderate limitation
of back motion and tenderness of the lower spine. A diastolic murmur along the left
border is heard on chest examination. Laboratory investigation shows an elevated
erythrocyte sedimentation rate (ESR) and negative rheumatoid factor. X-ray films of the
column and pelvic region show flattening of the lumbar curve and subchondral bone
erosion involving the sacroiliac joints. Which of the following is the most likely
A. Ankylosing spondylitis
B. Degenerative join disease
C. Reiter syndrome
D. Seronegative rheumatoid arthritis
E. Still disease
The correct answer is A. The patient's young age, occurrence of pain at night, negativity
of rheumatoid factor, and especially, bilateral involvement of sacroiliac joints are
with ankylosing spondylitis. This is one of the seronegative spondyloarthropathies,
characterized by onset before 40 years of age, absence of circulating autoantibodies,
association with HLA-B27 histocompatibility antigen, and common involvement of the
spinal column. Ankylosing spondylitis should be suspected in any young person
complaining of
chronic lower back pain and confirmed by radiographs or CT scans of sacroiliac joints.
The disease usually progresses to involve the whole vertebral column, producing
and respiratory failure secondary to restrictive lung disease. Uveitis and aortic
insufficiency are additional manifestations.
Degenerative joint disease (choice B) would be exceptional at such a young age, unless
predisposing conditions were present. Degenerative joint disease is not associated with
systemic signs and symptoms. Radiographs of affected joints show narrowed
interarticular spaces, osteophytes, and increased density of subchondral bone. Sacroiliac
joints are not
Reiter syndrome (choice C) is one of the seronegative spondyloarthropathies. It develops
as a sequela of gastrointestinal infections due to Salmonella, Shigella, or Campylobacter,
or after sexually transmitted infection caused by Chlamydia or Ureaplasma. Arthritis of
large joints (knee and ankle), conjunctivitis, and skin vesicular eruption are the hallmarks
of this
Seronegative rheumatoid arthritis (choice D) refers to those cases in which a typical
picture of rheumatoid arthritis is associated with negative rheumatoid factor. Rheumatoid
arthritis involves small joints, especially those of the hands.
Still disease (choice E) is a rare systemic form of arthritis with onset before age 17. It
manifests with spiking fever and systemic symptoms that usually antedate arthritis.
manifestations include a morbilliform rash, hepatosplenomegaly, serositis, anemia, and
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Item 10 of 10
Untimed Test
A 69-year-old patient is admitted to the neurology service following a stroke. During the
next few days, the staff observes that the patient has developed the clinical picture of
Which area of the brain has most likely been affected by the stroke?
A. Left hemispheric lesions including Broca's area
. .     B. Left prefrontal cortex
C. Midbrain lesion
D. Right frontal lobe
E. Thalamus
The correct answer is D. Post-stroke mania is a rare phenomenon usually seen in
infarctions of right frontal lobe and sometimes other parts of the right hemisphere.
Left hemispheric lesions including Broca's area (choice A), are sometimes associated
with the development of catastrophic reactions that include restlessness,
irritability, and sudden outbursts of emotion.
Stroke in the left prefrontal cortex (choice B) is associated with the development of
depression in more than 20% of stroke victims within the first 6 months.
Midbrain lesions (choice C) are associated with dreamlike hallucinations called
peduncular hallucinosis.
Thalamic strokes (choice E) are associated with pain syndromes and an altered level of

Item 1 of 10
Untimed Test
A 60-year-old man presents to the emergency room with severe abdominal pain. Physical
examination demonstrates tender, smooth hepatomegaly and mild jaundice. Serum
chemistries demonstrate an aspartate aminotransferase (AST) and alanine
aminotransferase (ALT) of over ten times the upper limit of normaI. The hematocrit is
63%. The patient has
no known history of smoking or lung disease. Complete blood count shows an increased
number in all cell lines, with the most marked elevation in the erythrocyte line. The
morphology of the cells in the peripheral smear is normaI. Which of the following is the
most likely cause of this patient's liver function abnormalities?
A. AIcoholic cirrhosis
B. Budd-Chiari syndrome
C. Cholelithiasis
D. Chronic hepatitis B
E. Fulminant hepatitis A
The correct answer is B. This patient has probable polycythemia vera (a below normal
erythropoietin level would be a helpful confirmatory study) which is presenting with
Chiari syndrome. Budd-Chiari syndrome is a rare disorder with high mortality rate
usually caused by the thrombosis of major hepatic veins. It can present either acutely, as
in this
case, or more slowly with chronic vague abdominal pain and portal hypertension.
Underlying predisposing causes include myeloproliferative disorders (notably
polycythemia vera, as
in this case); other hematologic disorders (sickle cell disease, paroxysmal nocturnal
hemoglobinuria); defective inhibition of coagulation (antiphospholipid antibodies, Iow
III, Iow protein C, Iow protein S, and low factor V Leiden); possibly estrogens (oral
contraceptives, pregnancy); and local liver disease (malignancies, trauma, or suppurative
AIcoholic cirrhosis (choice A) can cause jaundice, but AST and ALT elevations are
usually not very high. Further, nothing in this man's history suggests significant alcohol
Cholelithiasis (choice C) can cause obstructive jaundice when a small stone occludes a
bile duct, but AST and ALT elevations are usually not very high.
No risk factors are noted for either chronic hepatits B (choice D) or fulminant hepatitis A
(choice E). Chronic viral hepatitis does not usually have very high elevations of AST or
but fulminant hepatitis, which Budd-Chiari syndrome mimics, can.
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Item 2 of 10
Untimed Test
A 3-week-old boy presents to the physician's office with a 1-week history of forcefuI,
projectile vomiting. He has been vomiting after almost every feeding. The vomitus
contains mostly
undigested formula and is non-bilious. On examination, his oral mucosa is dry, his
anterior fontanel appears to be depressed, and his capillary refill is 3-4 seconds. An
examination reveals an olive-sized mass in the epigastrium. Which of the following
electrolyte findings will most likely be seen?
A. Hypochloremic metabolic acidosis
B. Hypochloremic metabolic alkalosis
C. Normal electrolytes
D. Respiratory acidosis with metabolic compensation
E. Respiratory alkalosis
The correct answer is B. This baby most likely has pyloric stenosis. Pyloric stenosis
occurs in approximately 1:500 births. Male infants are more commonly affected than
infants are, and the incidence is far greater in fulI-term infants than in preterm infants.
CIinical manifestations include projectile non-bilious vomiting shortly after feeding and
an olive-
sized mass palpable in the epigastrium. Symptoms typically present in the 2nd or 3rd
week of life. As the vomiting continues, hydrogen ions and chloride ions begin to
decrease in the
body, causing hypochloremic metabolic alkalosis. In addition, the infant might also be
hypokalemic from repeated vomiting. PIain radiographs may demonstrate the absence of
distal to the obstructed pylorus. In barium contrast studies, a small amount of barium may
pass through the hypertrophied pylorus, causing the "string sign." UItrasound studies are
also useful in demonstrating the hypertrophied pylorus. The dehydration and electrolyte
abnormalities should be corrected. Definite treatment is pyloromyotomy.
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Item 3 of 10
Untimed Test
A grandmother brings her 13-year-old grandson, who is in her custody, to a psychiatrist.
He has been talking back to his teachers and not complying with school rules. When
asked to
stop, he gets angry and blames others, usually his classmates. In addition, his grades are
deteriorating. The grandmother has been struggling with him in the past year and thinks
needs "structure and controI." The boy says she doesn't let him do anything, and he
resents having to live with her. Psychological testing shows no indications of a learning
Which of the following is the most likely diagnosis?
A. Adjustment disorder with disturbance of conduct
B. Attention deficit/hyperactivity disorder
. .      C. Conduct disorder
D. Cornelia de Lange syndrome
E. Oppositional defiant disorder
The correct answer is E. Oppositional defiant disorder belongs to the group of disruptive
behaviors characterized by a pattern of negativistic hostile behavior lasting at least 6
months and including four or more of the following: arguing with others, blaming others
for own mistakes, being angry and resentfuI, being vindictive, refusing to comply with
requests, and being easily annoyed by others. The disorder is not due to a mood or
psychotic disorder. It causes significant impairment in functioning.
Adjustment disorder with disturbance in conduct (choice A) represents a maladaptive
response to a stressor within 3 months of an exposure and does not meet the criteria for
oppositional disorder.
Attention deficit/hyperactivity disorder (choice B) includes either inattention, presenting
with six or more associated symptoms for 6 months, or six of the hyperactivity-
symptoms that are inconsistent with developmental leveI.
Conduct disorder (choice C) is a repetitive pattern of behavior in which the basic rights of
others or social rules are violated. The criteria include aggression to animals, destruction
property, violation of rules, deceitfulness, and theft. Three of the criteria need to be
present at least for 12 months, and at least one needs to be present in the past 6 months, to
this diagnosis.
Cornelia de Lange syndrome (choice D) is characterized by mental retardation, short
stature, continuous eyebrows, thin downturning lip, microcephaly, small and malformed
and hirsutism.

Item 4 of 10
Untimed Te
A 31-year-old woman comes to the physician for follow-up after an abnormaI Pap test
and cervical biopsy. The patient's Pap test showed a high-grade squamous intraepithelial
(HGSIL). This was followed by colposcopy and biopsy of the cervix. The biopsy
specimen also demonstrated HGSIL. The patient was counseled to undergo a loop
excision procedure (LEEP). Which of the following represents the potential long-term
complications from this procedure?
A. Abscess and chronic pelvic inflammatory disease
B. Cervical incompetence and cervical stenosis
C. Constipation and fecal incontinence
D. Hernia and intraperitoneal adhesions
E. Urinary incontinence and urinary retention
The correct answer is B. The loop electrosurgical excision procedure (LEEP) is relatively
simple and can be performed in the outpatient setting with local anesthesia. The
procedure involves using a wire loop to excise lesions of the transformation zone. A
benefit of LEEP, along with its ease of performance, is that it provides tissue that can be
examined histologically. The most appropriate candidates for LEEP are women with
high-grade squamous intraepithelial lesions (HGSIL). The immediate risks of LEEP are
and infection. The possible long-term risks include cervical incompetence and cervical
stenosis. These may seem like exact opposites, but LEEP can lead to both of them
to a certain extent, it injures the cervix. If the body's response to this injury is with "too
much" scarring, then cervical stenosis can result. If too much of the cervix is injured, the
may be too weakened to carry a pregnancy to term, and cervical incompetence may
Abscess and chronic pelvic inflammatory disease (choice A) are not known to be long-
term complications of the procedure.
Constipation and fecal incontinence (choice C) should not be caused by LEEP. LEEP
involves the distal portion of the cervix and should not involve the intestines or rectum at
Hernia and intraperitoneal adhesions (choice D) should not result from LEEP. The
procedure does not involve entry into the peritoneal cavity; therefore, there should be no
risk of
hernia or intraperitoneal adhesions.
Urinary incontinence and urinary retention (choice E) are not known to be long-term
complications from LEEP, as the procedure does not involve the bladder.
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Item 5 of 10
Untimed Test
A 52-year-old, obese African American woman is admitted to the hospital for an elective
gastric bypass operation for weight reduction. On post-op day 1, the patient acutely
tachypnea, tachycardia, and an oxygen requirement of 4 L. She complains of left-sided
pleuritic chest pain. Which of the following is the most appropriate diagnostic study?
. .     A. Chest x-ray
B. CT scan
C. ECG with rhythm strip
E. Ventilation-perfusion scan
The correct answer is E. The most likely diagnosis in this case is pulmonary embolus
(PE). The risk factors for this patient are obesity and surgery. PIeuritic chest pain can
in patients with a PE. Tachycardia, tachypnea, and increased oxygen requirements are
highly suggestive of the diagnosis. The most appropriate test to confirm the clinical
is a ventilation-perfusion scan.
A chest x-ray (choice A) can suggest a PE by showing a wedge-shaped area if there is an
infarct; however, this is not the most sensitive or specific test to confirm the diagnosis.
Chest x-ray films are most often normaI.
A CT scan (choice B), Iike a chest x-ray, may reveal an area of infarct, but is not the most
appropriate test in this scenario.
An ECG with rhythm strip (choice C) might show tachycardia, possible right axis
deviation due to pulmonary hypertension, and right ventricular strain with ST-T wave
changes. But,
the most common finding is a normaI ECG.
MRI (choice D) is used to show soft tissue abnormalities and is most often used in
neurologic and orthopedic diagnoses. It would not be the test of choice for PE.
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Item 6 of 10
Untimed Test
A 48-year-old woman presents complaining of fatigue and malaise. She has been
previously healthy, except for a motor vehicle accident that required an emergency
splenectomy 22
years earlier. During that operation, she required the transfusion of multiple units of red
cells. In her current evaluation, hepatitis serologies are checked and reveal the following:
hepatitis A IgG antibody positive, hepatitis B surface antibody positive, and hepatitis C
antibody positive. A Iiver biopsy is consistent with chronic hepatitis with moderate
fibrosis. Which
of the following is the most appropriate treatment?
A. AIpha interferon
B. AIpha interferon and ribavirin
C. Azathioprine
D. Prednisone
E. Ribavirin
The correct answer is B. This patient's chronic hepatitis is probably related to her history
of viral infections by hepatitis viruses. Hepatitis A does not cause chronic disease, and
thus be excluded from consideration as a cause of her chronic hepatitis. Both hepatitis B
and hepatitis C are major causes of chronic hepatitis. AIthough the patient has antibodies
hepatitis B surface antigen, the question stem does not indicate that she still has the
antigen. This makes it less likely that hepatitis B is the cause of her current problems. On
other hand, positivity for hepatitis C antibody, particularly when coupled with biopsy
evidence of chronic hepatitis, is considered diagnostic for current hepatitis C infection.
currently lack direct markers for viral antigens.) The combination of alpha-interferon and
ribavirin antiviral medications is the current state-of-the-art treatment for hepatitis C.
Formerly, alpha-interferon (choice A) was used as monotherapy but had only a moderate
short-term success rate and a very high relapse rate. The addition of ribavirin
increased the short-term and long-term remission rates.
Prednisone (choice D) and azathioprine (choice C) are immunosuppressant drugs that are
contraindicated in patients with active hepatitis C infection.
Ribavirin as monotherapy (choice E) was found to be unsuccessful in multiple placebo
control trials.
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Item 7 of 10
Untimed Te
A 74-year-old woman with a long history of type 2 diabetes mellitus undergoes surgery
for small bowel obstruction. After surgery, she develops acute renal failure. However, she
refuses to undergo dialysis on the advice of her physician, who then calls for an
immediate psychiatric consultation. The patient tells the psychiatrist that she has lived a
long life and
does not want to be kept alive by or attached to a machine, even if it means she will die.
A mental status examination shows that she is not psychotic, that she is fully oriented and
alert, and that she has no fluctuations of cognition or level of consciousness. The patient's
family is insistent that she be dialyzed immediately. Which of the following is the most
appropriate statement the psychiatric consultant could make?
A. The patient is aware of the consequences of her decision and does not show signs of a
major psychiatric illness.
. .       B. The patient is competent to decide on treatment, and her refusal to undergo
dialysis must be respected.
C. The patient is competent to decide on treatment, but her refusal can be overruled
because of a medical emergency.
D. The patient is operating in a suicidal manner and should be committed for treatment
against her wilI.
E. The patient is temporarily incompetent, so start her on dialysis.
The correct answer is A. This patient raises one of the most difficult legal and ethical
problems in psychiatry. It is important to understand that competency, or lack of
(choices B, C, and E), can be determined only by a legal authority, such as a court of law.
The role of psychiatrists is solely advisory in determining competency. In this situation,
only if the patient is suicidal by virtue of a major psychiatric illness, or if the patient were
subject to an immediate medical emergency, could treatment be involuntarily
The psychiatrist's role is to assess a person's mental status for evidence of cognitive
impairment, as well as to ascertain that the patient has a thorough understanding of the
consequences of treatment decisions that are made. This patient does not meet criteria for
treatment against her will (choice D), which requires both a mental disorder and the
threat of impending immediate harm to self or others.

Item 8 of 10
Untimed Test
A 30-year-old medical resident presents to her physician complaining of excessive
fatigue. She is concerned because several weeks vacation has failed to alleviate her
fatigue. She
finds that she is somewhat tired throughout the day and goes to sleep almost immediately
after eating dinner. She did not have this problem during her first 2 years of residency
and is
concerned about why, in her last year, she should be so exhausted. Her review of systems
is otherwise unremarkable. She has regular menses and she denies pregnancy. She has
had no fevers or sweats, and she has not traveled recently. Her physical examination
reveals normal vital signs and is without any significant findings. A review of her
laboratory data
reveals a hematocrit of 31%, with a mean corpuscular volume of 69 fL. Which of the
following is the most likely cause of her anemia?
A. Folate deficiency
B. Hemolysis
C. Iron deficiency
D. Renal disease
E. Vitamin B12 deficiency
The correct answer is C. Iron deficiency usually results in a microcytic, hypochromic
anemia. In women of child-bearing age, iron deficiency usually results from monthly
In older women, colon cancer is the most common etiology. This is a classic presentation
for iron deficiency anemia in women of this age and activity leveI.
Folate deficiency (choice A) results in a macrocytic anemia and has been associated with
neural tube defects. Folate is contained in green, Ieafy vegetables, but starting in the mid
1990s, many grain products were supplemented with folate.
Hemolysis (choice B) can cause a normochromic, normocytic anemia. Disease states that
are associated with hemolysis are often obvious, and the peripheral manifestations of
hemolysis (jaundice, scleral icterus, tea-colored urine) are also often present. There is no
evidence in this patient's history that she has hemolysis.
Renal disease (choice D) is a fairly common cause of anemia, especially if the patient is
dialysis dependent. The kidney, in addition to its role in plasma filtration and in blood
pressure controI, also controls the hematocrit via secretion of erythropoietin, which acts
to stimulate bone marrow production of red blood cells. When erythropoietin production
declines, a normochromic, normocytic anemia often ensues.
Vitamin B12 deficiency (choice E) is often associated with a megaloblastic or macrocytic
anemia. B12 deficiency is exceedingly rare, since most people have at least a 3-year
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Item 9 of 10
Untimed Test
An 18-year-old college student comes to the student health clinic because of a 2-week
history of fever, chills, and a sore throat. His temperature is 38.3 C (101 F), blood
pressure is
110/70, pulse is 70/min, and respirations are 18/min. Physical examination shows marked
pharyngeal hyperemia, tonsillar exudates, cervical lymphadenopathy, and splenomegaly.
Ampicillin therapy is begun and the patient is sent back to his dormitory. Two days later
he returns because of a maculopapular rash. Which of the following is most likely to
the diagnosis?
A. Chest x-ray
B. Heterophile antibody test
C. Lateral x-ray film of the neck
D. Rapid Streptococcus test
E. Varicella virus antibody immunofluorescence
The correct answer is B. This patient most likely has infectious mononucleosis, which is
caused by the Epstein-Barr virus. The clinical features include sore throat, headache,
fever, malaise, Iymphadenopathy, pharyngitis and tonsillitis, hepatosplenomegaly,
periorbital edema, rash, and a palatal enanthem. The diagnosis is made by heterophile
testing, EBV antibody titers, and lymphocytosis with atypical lymphocytes. Treatment
includes rest, fluids, and analgesics. Ampicillin therapy leads to a maculopapular rash.
antibiotic should not be given because this is a viral infection.
A chest x-ray film (choice A) is useful for a respiratory or cardiac process. Infectious
mononucleosis cannot be diagnosed by any radiographic study.
A Iateral x-ray of the neck (choice C) is useful in acute epiglottitis. It would show
epiglottic swelling. The symptoms of epiglottitis include extreme sore throat, drooling,
and difficulty
A rapid streptococcus test (choice D) is used to diagnose streptococcal pharyngitis.
Streptococcal pharyngitis is characterized by fever, sore throat, tonsillar exudates, and
Iymphadenopathy. A scarlatiniform rash may follow the pharyngitis. The rash is a diffuse
erythema that later desquamates. It is caused by an erythrotoxin.
Antibodies to the varicella virus (choice E) can be detected by immunofluorescence. The
symptoms of varicella include a vesicular rash in various stages of evolution, fever, and
malaise. The treatment is bathing, soaks, and antipruritic topical medication. Treatment
with aspirin has been associated with Reye syndrome and should therefore be avoided.

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Item 10 of 10
Untimed Te
A 67-year-old retired librarian presents to her physician because of 48 hours of persistent
fevers, shaking chills, and a productive cough. She is a former smoker who quit 25 years
ago. She is in otherwise good health, except for a history of a transient ischemic attack 2
yeas ago. On physical examination, there are coarse rhonchi at the left posterior lung base
with increased fremitus and hyperresonance to percussion. A chest x-ray film reveals a
lobar consolidation in the left lower posterior lung segment. Which of the following
would be
most likely to appear on a sputum Gram's stain?
A. Gram-negative cocci in chains
B. Gram-negative rods
C. Gram-positive cocci in chains
D. Gram-positive cocci in clusters
E. Gram-positive rods
The correct answer is C. The most likely organism in an otherwise healthy patient
residing at home ("community-acquired pneumonia") is Streptococcus pneumoniae,
known as the "pneumococcus." This organism appears as a gram-positive, Iancet-shaped
diploccus in short chains on a Gram's stain of sputum. It is usually present in very large
numbers in clinical cases of pneumococcal pneumonia. S. pneumoniae accounts for about
two thirds of community acquired pneumonias and occurs most frequently in the very
young and the elderly. More than 80 distinct serotypes exist, which is why the
pneumococcal vaccine (directed against 23 different polysaccharide antigens), although
very usefuI,
does not protect perfectly against pneumonia caused by S. pneumoniae.
Gram-negative cocci in chains (choice A) is consistent with gonococcus, which rarely
causes a bacterial pneumonia_and almost always in people who have gonorrhea of the
genital organ systems.
The patient has no underlying diseases to suggest that there might be a predisposition to a
gram-negative pneumonia (choice B), such as due to Pseudomonas or Escherichia coli.
E. coli pneumonia is seen in patients with underlying E. coli infection elsewhere, notably
in the urinary tract. Pseudomonas pneumonia is common in patients with underlying
fibrosis, neutropenia, AIDS, bronchiectasis, or other organ system disease serious enough
to require therapy in an intensive care unit.
Gram-positive cocci in clusters (choice D) suggest Staphylococcus aureus. AIthough S.
aureus can occur (2% of the time) in community-acquired pneumonias and may affect the
elderly, it is more commonly seen as a nosocomial infection, particularly in patients who
have tracheostomy, endotracheal intubation, immunosuppression, or recent surgery.
particularly vulnerable patients include those with underlying cystic fibrosis,
granulomatous lung disease, IV drug abuse with staphylococcal endocarditis, or bacterial
following viral pneumonia.
Finally, there is no history to suggest an anaerobic infection with Clostridium or Listeria
monocytogenes, which are gram-positive rods (choice E). Clostridium infection can
complicate wounds; Listeria infection can be acquired in utero or through ingestion of
contaminated milk products.

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