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An African-American boy Is In the newborn nursery with a bulge on his abdomen that was
identified Immediately after birth and Is most pronounced during crying. The patient was
born to an 18-year-old woman who did not receive prenatal care or take prenatal
vitamins. Vitals are normal. Examination shows a soft swelling at the umbilical region
that is 1 em in diameter and covered by skin. It is easily reducible through the umbilical
ring. Which of the following Is the most likely diagnosis and best course of action for this
patient?

0 A Gastroschisis, refer for surgical management

c B. Omphalocele, observe for spontaneous resolution
0 C. Omphalocele, refer for operative management
o D. Umbilical granuloma. apply silver nitrate
o E. Umbilical hernia, observe for spontaneous resolution
o F. Umbilical hernia, refer for operative management

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A healthy 35-year-old man comes to the emergency department with severe abdominal
pain for the last 4 hours. The pain started in the periumbilical area but has now shifted to
the right lower quadrant. He also complains of nausea and 2 episodes of vomiting. He
has no history of other medical problems and takes no medications. The patient's
temperature Is 38.9 C (102 F), blood pressure is 125/80 mm Hg, pulse is 100/mln, and
respirations are 20/min. Abdominal examination shows tenderness in the right lower
quadrant that does not worsen with Inspiration. Palpation of the left lower quadrant
produces pain In the right lower quadrant. Urinalysis is normal. Laboratory results are
as follows:

White blood cells 16,000/J.Il

Hematocrit 42%
Platelet count 220,000/J.IL
Leukocytes
Neutrophlls 86%
Eoslnophlls 2%
Lymphocytes 8%
Monocytes 4%

Which of the following Is the most appropriate next step in management of this patient?

0 A. Bowel rest with intravenous antibiotics

0 B. Colonoscopy
0 C. Computed tomography scan of the abdomen
'J D. Laparoscopic appendectomy
C E. Ultrasound of the abdomen

l SUbmit I

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A 55-year-old woman comes to the office with a one-week history of pain in multiple
joints. She has achy pain and stiffness in both wrists and multiple metacarpophalangeal
and proximal interphalangeal joints in both hands. The patient's symptoms are worst in
the morning and partially improve over 10-15.minutes of normal activity. There is no
associated fever, chills, rash, or weight loss. She works in a day care center and does
not use tobacco, alcohol, or illicit drugs. Vital signs are normal. On examination, there is
mild swelling with no redness or tenderness of the involved joints. Laboratory studies
show normal blood counts and serum chemistries. Erythrocyte sedimentation rate is 12
mm/hr. Which of the following is the most likely diagnosis in this patient?

0 A. Acute rheumatic fever

o B. Fibromyalgia
o C. Polymyalgia rheumatica
0 D. Rheumatoid arthritis
0 E. Systemic lupus erythemato.sus
0 F. Viral arthritis

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A 45-year-old man is brought to the emergency department following a serious motor

vehicle collision on a California interstate highway. Despite all attempts to save him, his
condition does not improve. The physician caring for him believes that he is brain dead.
On examination, the patient's temperature is 36.7 C (98 F) and blood pressure is 104/60
mm Hg. He is on mechanical ventilation. Neurologic examination is consistent with brain
death. Laboratory and imaging studies are not suggestive of a reversible cause. Apnea
testing shows no spontaneous breathing. In accordance with local regulations, a second
physician confirms the diagnosis of brain death. The patient's family understands the
prognosis. Unfortunately, the patient does not have an advanced directive or durable
medical power of attorney. Which of the following steps is legally necessary to remove
this patient from the ventilator?

o A. Court-appointed legal guardianship

o B. Ethics consultation
o C. Medical examiner notification
0 D. No additional steps are necessary
0 E. Permission from the patient's next of kin

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A 32-year-old man with type 1 diabetes mellitus comes to the emergency department with
a 2-day history of nausea and abdominal pain. The patient has chronic intermittent
diarrhea and lower back pain for which he takes acetaminophen. He does not use
tobacco or illicit drugs. He lives alone and drinks alcohol occasionally. The patient's
temperature is 37.6 C (99.7 F), blood pressure is 122/86 mm Hg, pulse is 88/min, and
respirations are 25/min. Laboratory results are as follows:

Serum chemistry
132
Sodium
mEq/L
Potassium 5.0 mEq/L
Chloride 90 mEq/L
Bicarbonate 14 mEq/L
Blood urea
19 mg/dL
nitrogen
Creatinine 1.1 mg/dl
450
Glucose
mg/dl

Arterial blood gases

pH 7.31
Pa02 90 mm Hg
PaC02 29 mm Hg

Which of the following best describes this patient's acid-base status?

0 A. Normal acid-base status

0 B. Primary metabolic acidosis with respiratory compensation
0 C. Primary metabolic acidosis without compensation
0 D. Primary metabolic alkalosis with renal compensation
0 E. Respiratory acidosis with compensation

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A 24-year-old primigravid woman at 10 weeks gestation is brought to the emergency

department for vaginal bleeding. She has colicky pain in the suprapubic region radiating
to her back. Her temperature is 37 C (98.7 F), blood pressure is 11 0/76 mm Hg, pulse is
94/min, and respirations are 18/min. Physical examination shows a dilated cervix with
visible products of conception. Suction curettage is performed and all products of
conception are evacuated. Maternal serum laboratory results are as follows:

Hematocrit 32%
Leukocyte count 8,000/j.il
AB
Blood type
negative
Anti-Rh antibody
Negative
titer

Which of the following is the most appropriate next step in management of this patient?

0 A. Administer anti-D immune globulin to the woman

0 B. No further workup or therapy for the woman or fetus
0 C. Order maternal antiphospholipid antibodies
0 D. Order maternal blood and endometrial cultures
0 E. Order maternal karyotyping
0 F. Order maternal thyroid function testing

Su bmit
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A 50-year-old man Is admitted to the hospital with worsening jaundice, anorexia, general
malaise, and right upper quadrant abdominal pain over the past 3 days. The patient's
other medical problems Include major depression with an attempted suicide 30 years
ago. His temperature is 38.3 C (101 F). blood pressure is 130/86 mm Hg, pulse Is
86/min. and respirations are 16/min. Cardiopulmonary examination is unremarkable.
Scleral icterus and tender hepatomegaly are present Laboratory results are as follows:

Complete blood count

Hemoglobin 12 gfdl
Mean corpuscular
102pm'
volume
Platelets 120,000/mm•
LeuKocytes 13,000/mm'

Serum chemistry
Urea nitrogen 20 mg/dl
Creatinine 1.2 mg/dL

Liver function studies

Albumin 3.4 g/dl
Total bilirubin 5.3 mg/dl
Direct bilirubin 3.7 mg/dl
AlKaline
105 U/L
phosphatase
Aspartate
212 U/L
aminotransferase
Alanine
99 U/L
aminotransferase
Amylase 91 U/L
v

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Serum chemistry
Urea nitrogen 20 mg/dl
Creatinine 1.2 mg/dl

Liver function studies

Albumin 3.4 g/dl
Total bilirubin 5.3 mg/dl
Direct bilirubin 3.7 mg/dl
Alkaline
105 U/L
phosphatase
Aspartate
212 U/L
aminotransferase
Alanine
99 U/L
aminotransferase
Amylase 91 U/L

Coagulation studies
INR 1.2 (0.8-1.1 )

Which of the following would be the most helpful in establishing a diagnosis in this
patient?

0 A. Family history
8 B. Medication history
0 C. Right upper quadrant ultrasound
0 D. Serum acetaminophen level
0 E. Substance abuse history
0 F. Travel history to a developing country

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A 5-year-old boy is brought to the office by his parents for evaluation of "clumsiness."
The patient's fine and gross motor development have been normal at prior visits, but he
now frequently runs into doorways or corners of furniture while walking around the
house. He has also begun drinking large amounts of water and urinating "all the time."
Temperature is 37 C (98.6 F), blood pressure is 95/65 mm Hg, and pulse is 130/min.
Physical examination shows dry mucous membranes and loss of bitemporal visual fields.
Laboratory results are as follows:

Serum studies
Sodium 145 mEq/L
Potassium 3.9 mEq/L
Bicarbonate 20 mEq/L
Blood urea nitrogen 18 mg/dL
Creatinine 0.9 mgtdL
Blood glucose 88 mg/dL

Urinalysis
Specific gravity 1.001
Glucose negative

CT scan of the brain (exhibit) reveals an abnormality (red arrow). Which of the following
is the most likely diagnosis?

0 A. Craniopharyngioma
0 B. Empty sella syndrome
0 C. Medulloblastoma
0 D. Pituitary adenoma
0 E. Rathke cleft cyst
0 F. Retinoblastoma

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A 45-year-old woman comes to the office due to progressive weakness for the past
several months. The patient has had difficulty lifting her foster children and getting in
and out of her car. She also reports difficulty swallowing and has had several episodes
of choking while drinking water. She has no medical problems, but there is a history of
breast cancer in her mother. The patient does not use tobacco, alcohol, or illicit drugs.
Vital signs are within normal limits, and she has normal sensation and deep tendon
reflexes. Strength is 4/5 in the deltoid and quadriceps muscle groups, and there is no
limitation in range of motion. Physical examination is otherwise unremarkable.
Erythrocyte sedimentation rate is 50 mm/hr, and serum creatine kinase is elevated. TSH
is normal. Which of the following is the best initial treatment for this patient?

0 A. Amitriptyline
0 B. Beta interferon
0 C. Cyclobenzaprine
0 D. Prednisone
0 E. Pyridostigmine
0 F. Radiation therapy
0 G. Riluzole

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A 27-year-old woman comes to the office due to a 2-month history of dark hair growth on
h.er ch.eeks, chin, and upper lip. Her last menstrual period was 12 weeks ago, but she
did not seek medical care because a home pregnancy test was negative. The patient is
gravida 0 para 0; her menstrual cycles began at age 11 and have previously been
regular. She has no associated weight changes, visual disturbances, skin striae,
headaches, or proximal muscle weakness. She takes no medications, including
over-the-counter medications. Family history is unremarkabl.e. Physical examination
shows a BMI of 24 kg/m•. Her skin is oily with acne on the forehead and cheeks. Dark
terminal hairs are noted on the upper lip, cheeks, chin, chest, and lower abdomen.
Examination of the genitals shows clitoromegaly. Abdominal examination is normal.
Pelvic ultrasound reveals a normal uterus and ovaries. CT scan of the abdomen reveals
a left adrenal mass. Which of the following patterns of plasma hormone levels is likely to
be present in this patient?

Dehydroepiandrosterone Luteinizing
Testosterone
sulfate hormone

O A. High High Low

0 B. Low Low Low

0 c. Normal High Low

0 D. Normal or high High High

0 E. Normal Normal Normal

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A 36-year-old woman who is a known patient comes to the office for a routine annual
examination. Toward the end of the visit, she glumly mentions that she intends to file for
divorce from her husband. For the past few years, he has been irritable, less interested
in his work, and obsessed with making huge sums of money in Las Vegas. This behavior
has increased even more since his mother's death 2 months ago. The patient says,
"Sometimes my husband stays up all night to gamble online and then misses work the
next day. He was recently fired from his job as an insurance agent after he was caught
forging signatures to finance some gambling trips to Las Vegas." The patient confronted
him about his behavior, but he became more angry and irritable and insisted that his trips
are the only thing that makes him feel really good. Now he admits that he finds it hard to
control himself and is in debt to several creditors. Although he has lost a considerable
amount of money, he is convinced that he could win it all back if he could just borrow
enough from friends. Which of the following is her husband's most likely diagnosis?

0 A. Adjustment disorder
0 B. Antisocial personality disorder
0 C. Bereavement
0 D. Bipolar disorder
0 E. Gambling disorder
0 F. Major depressive disorder
0 G. Obsessive-compulsive disorder

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A new test is devised to detect HIV. It has a sensitivity of 90% and specificity of 85%
compared to the gold standard. The test is used in 2 populations: a population in Africa
with a 20% prevalence of HIV, and a population in Asia with a 1% prevalence of HIV.
Which of the following is the most accurate statement concerning the new test?

o A The negative predictive value of the test is lower in the Asian population
o B. The positive predictive value of the test is higher in the African population
o C. The sensitivity of the test is higher in the African population
o D. The specificity of the test is higher in the Asian population
o E. The test is not valid in the African population

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A 32-year-old man comes to the office due to exc.essive sleepiness for the past several
months. He says, "I am very worried that I will lose my job. I feel like napping all the time
and once fell asleep while talking with a customer. The other day, I nearly had an
accident when I fell asleep while driving." The patient is also concerned that he
occasionally hears voices while falling asleep and finds himself "temporarily frozen" and
unable to move on awakening. He has a history of hypertension controlled with
hydrochlorothiazide. His family history is noncontributory. The patient does not smoke
cigarettes or drink alcohol but does smoke marijuana a few times a month. Physical
examination is remarkable for obesity and no other abnormalities. Which of the following
is the most appropriate treatment for this patient?

o A. Clonazepam
0 B. Continuous positive airway pressure
o C. Melatonin
o D. Modafinil
o E. Pramipexole
o F. Quetiapine

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The following vignette applies to the next 2 Items.

Item 1 of2

A 26-year-old woman comes to the clinic for a routine examination. The patient has been
doing well and has no concerns. She is a gymnast and her main activity is the balance
beam; last year, she sustained a vulvar contusion during a competition, but otherwise
she has been healthy. The patient is sexually active and uses an intrauterine device for
contraception. She occasionally drinks alcohol but does not smoke cigarettes or use
illicit drugs. Examination shows a mobile, soft, well-circumscribed mass the size of an
egg at the 4 o'clock position on the left vulva. Which of the following is the most likely
diagnosis for this patient?

o A. Bartholin duct cyst

0 B. Condylomata acuminate
0 C. Gartner duct cyst
0 D. Hematoma
o E. Molluscum contaglosum
0 F. Primary syphilis
0 G. Squamous cell carcinoma

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A 44-year-old psychology professor with a chronic history of rheumatoid arthritis presents

for a follow-up examination. She is currently taking prednisone and infliximab, a regimen
that has successfully stabilized her condition. Physical examination reveals no significant
changes. Toward the end of the visit, she mentions that she would like to try acupuncture
as an adjunct treatment in addition to the medications she is currently taking. What is the
most appropriate response to her request?

A. "I'm sorry, but I am not very familiar with acupuncture and am reluctant to
0 combine the two therapies."

0 B. "I hope you are aware that acupuncture has its limitations."
o C. "If you want to try acupuncture, I cannot continue serving as your physician."
o D. "Why do you want to try acupuncture?"
o E. "How can an educated woman like you suggest something like this?"

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A 73-year-old man comes to the office due to 3 days of fever, facial pain over his right
cheek, and bloody nasal discharge. Last night he was able to see without difficulty, but
this morning, he developed double vision. He has had no recent trauma to the face or
dental procedures. The patient has a 30-year history of type 2 diabetes mellitus
complicated by nephropathy and retinopathy. His medical history also includes
hypertension and hyperlipidemia. He is widowed and lives alone. He does not use
tobacco or alcohol. Temperature is 39 C (102.2 F), blood pressure is 130/76 mm Hg,
and pulse is 102/min. The patient appears ill. Chemosis and mild proptosis of the right
eye are present. There is tenderness over the right maxillary sinus. Nasal examination
shows right nasal congestion and necrosis of the right nasal turbinate. Necrosis of the
hard palate is present. Cardiopulmonary examination is normal. The patient has no skin
rash. CT scan reveals opacification and bony erosion of the right maxillary sinus.
Hemoglobin A1c is 11%. Which of the following is the most likely causative organism?

0 A. Actinomyces
0 B. Clostridium septicum
0 C. Oral anaerobic bacteria
0 D. Pseudomonas aeruginosa
0 E. Rhizopus species
0 F. Staphylococcus aureus
0 G. Streptococcus pneumoniae

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A 33-year-old woman comes to the office due to blistering on the backs of her hands.
She has had occasional blisters in the past, but numerous lesions appeared last week
after she spent some time outdoors gardening. The lesions are not painful but are
associated with mild itching. The patient says her skin is also fragile and trivial trauma
has caused superficial erosions that heal with scarring. She occasionally drinks alcohol
but does not use tobacco. The patient used injection drugs in the past but stopped after
being diagnosed with hepatitis C infection 8 years ago. She has not yet received
treatment for hepatitis, and her only medication is a daily oral contraceptive. Vital signs
are within normal limits. Physical examination shows several vesicles and erosions on
the dorsum of both hands. Some of the lesions are healing with crusts and scars. Which
of the following is the most likely underlying cause of this patient's skin lesions?

0 A. Allergen-induced delayed-type hypersensitivity

0 B. Bacterial invasion and superficial skin infection
0 C. Porphyrin accumulation due to impaired metabolism
0 D. Reactivation of latent virus in sensory ganglia
0 E. Subepidermal anti-transglutaminase lgA autoantibody
0 F. Vasculitis due to cryoglobulin immune complexes

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A 5-month-old full-term boy is brought to the physician for fever. He was doing well until
this morning, when he felt warm to his mother. He has had a "runny nose" and
intermittent coughing but otherwise has been breastfeeding well. His 3-year-old brother
had an upper respiratory tract infection last week. The infant takes vitamin D, and his
vaccinations are up to date. His temperature is 38. 9 C (1 02 F), blood pressure is 90/60
mm Hg, pulse is 120/min, and respirations are 32/min. Pulse oximetry shows an oxygen
saturation of 96%. Examination shows crusted rhinorrhea at the nares. The patient's
chest radiograph is shown below.

Which of the following is marked on this patient's chest radiograph?

0 A Hilar lymphadenopathy
0 B. Right atrium
0 C. Right middle-lobe infiltrate
0 D. Right upper-lobe atelectasis
0 E. Right upper-lobe infiltrate
0 F. Thymus
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A 5-day-old girt Is brought to the emergency department for evaluation of vaginal

discharge. Her mother has noticed white vaginal discharge mixed with a small amount of
blood since yesterday. The girt does not appear to be in pain and has been voiding and
stooling adequately. She Is exclusively breastfed every 2-3 hours. The mother mentions
that she was treated "with a shot and a pill" for a sexually transmitted disease early In her
pregnancy and subsequently tested negative. The girt was born via forceps-assisted
vaginal delivery due to protracted labor at 38 weeks gestation. Temperature Is 36.7 C
(98 F). Physical examination reveals a thin, white, odorless vaginal discharge with blood
streaking. The external genitalia are otherwise unremarkable, and the abdomen Is soft
and nontender without palpable masses. What is the most likely cause of this patient's
vaginal discharge?

:) A. Candldal vaginitis
0 B. Chlamydia trachomatis Infection
o C. Maternal hormone withdrawal
0 D. Rhabdomyosarcoma
o E. Traumatic Injury
0 F. Vaginal foreign body

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A 38-year-old woman comes to the emergency department with a 2-week history of

worsening headaches and low-grade fever. She has no weakness or sensory loss. The
patient has lost a significant amount of weight over the last 6 months. Her temperature is
38.1 C (1 00.5 F), blood pressure is 11 5/70 mm Hg, pulse is 100/min, and respirations are
14/min. BMI is 18.7 kg/m2 • The patient has neck stiffness and cervical
lymphadenopathy. Oropharyngeal examination shows thrush. The neurologic
examination is nonfocal, and fundoscopy is within normal limits. CT scan of the head
without contrast is normal. Lumbar puncture is performed and results of cerebrospinal
fluid analysis are as follows:

Opening pressure 250 mm HP

Glucose 35 mg/dL
Protein 120 mg/dL
Leukocytes 45/!JL
Red blood cells 0/!JL

Cerebrospinal fluid fungal stain shows encapsulated yeast. Which of the following is the.
most appropriate next step in management of this patient?

0 A. Amphotericin plus flucytosine

0 B. Griseofulvin
0 C. HIV testing and antiretroviral therapy
0 D. ltraconazole
0 E. Sulfadiazine-pyrimethamine

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An 85-year-old man presents with a rash over his forehead, tip of nose and left eye. He
also complains of pain and decreased vision. He has had fever, malaise, and a burning
sensation around his left eye for the past 5 days. His blood pressure is 140/90 mm Hg,
pulse is 92/min, respirations are 14/min, and temperature is 38. 1o C (101o F). Physical
examination reveals a vesicular rash on the periorbital region and lid margins. The left
eye is red, with chemosis of the conjunctiva. Dendriform ulcers are seen on the cornea.
What is the most likely diagnosis?

o A Herpes simplex keratitis

o B. Dacryocystitis
o C. Bacterial keratitis
o D. Trigeminal neuralgia
0 E. Herpes zoster ophthalmicus

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A 28-year-old African American female complains of recurrent nasal discharge and

increasing nasal congestion. She has a constant sensation of dripping in the back of her
throat, and states that food has tasted bland to her recently. She is known to have sickle
cell trait. She came to the emergency department for severe wheezing after taking
naproxen for menstrual cramping one year ago.. She has no history of head trauma. She
does not smoke cigarettes, but she admits to smoking marijuana occasionally. Which of
the following is the most likely diagnosis?

0 A Angiofibroma
o B. Inverted papilloma
o C. Nasal polyp
0 D. Perforated nasal septum
0 E. Pyogenic granuloma

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A 58-year-old woman presents to the emergency department with severe headache and
agitation. She describes her pain as right-sided and retro-orbital, and also reports
blurred vision, constipation, and vomiting. Her medical history is significant for
Parkinson's disease, hypothyroidism, hypertension and chronic hepatitis C. Work-up
reveals that her current condition is medication-induced. Which of the following agents is
most likely responsible?

o A Levodopa
o B. Selegiline
o C. Bromocriptine
o D. Trihexyphenidyl
o E. Propranolol
o F. Levothyroxine

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A 25-year-old man presents to the emergency room with shortness of breath and cough
productive of blood-tinged sputum for the past few days. He denies associated fever,
arthralgias or weight loss. He has never had these symptoms before, and is extremely
concerned. He has no history of recent travel or sick contacts. He smokes half a pack of
cigarettes daily, and has had two sexual partners in the past six months. On physical
examination, his temperature is 37.2° C (98.9° F), blood pressure is 120/70 mm Hg, pulse
is 102/min, and respirations are 22/min. Lung auscultation reveals patchy bilateral
rales. Chest x-ray demonstrates bilateral pulmonary infiltrates. His serum creatinine is
2.6 mg/dL and urinalysis shows dysmorphic red cells. Which of the following is the most
likely cause of his current condition?

o A Basement membrane antibodies

o B. Pneumocystis pneumonia
0 C. Infection with acid fast bacilli
0 D. Pulmonary thromboembolism
0 E. Cardiac valve infection

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A 7-year-old girl is brought to the emergency department due to a cat bite on her right
arm. She was bitten while picking up a neighbor's cat by its tail. Afterward, her mother
immediately cleaned the wound with hydrogen peroxide. The patient's vaccinations are
up to date, and her most recent tetanus vaccine was 3 years ago. Her temperature is
36.9 C (98.4 F), blood pressure is 108/70 mm Hg, pulse is 107/min, and respirations are
21/min. Physical examination shows a deep puncture wound on the anterolateral aspect
of her right forearm. There is no visible debris in the wound and no active bleeding.
Neurovascular function is intact. Her wound is copiously irrigated with saline and
cleaned with povidone-iodine. Which of the following is the best next step in
management?

oA Administer tetanus booster

0 B. Closure with sutures
o C. Observation and close follow-up
o D. Prescribe amoxicillin/clavulanate
o E. Prescribe azithromycin
o F. Prescribe clindamycin

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0. ld : 2242 Prev1ous Ne>tt Lab Values Notes Calculator Reverse Color Text Zoom

A 27-year-old man comes to the physician because of a 1-day history of fever and joint
pains. He is being treated with cephalexin for a skin infection. His urine has turned
darker. His temperature is 38.SO C (101 .3• F), blood pressure is 125/70 mm Hg, pulse is
90/min, and respirations are 15/min. Examination shows a skin rash; examination
otherwise shows no abnormalities. Urinalysis shows: 8 RBCs/HPF, 12 WBCs/HPF with
white cell casts, eosinophiluria, and a mild degree of proteinuria. Laboratory studies
show a BUN of 40 mg/dl and serum creatinine of 2.2 mg/dl. Which of the following is the
most appropriate next step in management?

o A Discontinue cephalexin
o B. Start ampicillin and gentamicin
o C. Start oral ciprofloxacin
o D. Start intravenous steroids
o E. Start oral steroids

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0. ld : 3228 Prev1ous Ne>tt Lab Values Notes Calculator Reverse Color Text Zoom

A 17-year-old white female comes to the office for the evaluation of fatigue which has
been present for the past 4 months. Her past medical history is insignificant. She denies
the use of any drugs. Her pulse is 74/min, blood pressure is 110/70 mm Hg, and
temperature is 36.7° C (98.0° F). Physical examination shows scars on the dorsum of
her hands and dental erosions. Laboratory studies show:

Plasma sodium 139 mEq/L

Serum potassium 2.3 mEq/L
Bicarbonate 40 mEq/L

Urine chloride concentration is 15 mEq/L (Normal = 80-250 mEq/L). Based on these

findings, what is the most likely diagnosis?

0 A Chronic diarrhea
0 B. Diuretic abuse
0 C. Surreptitious vomiting
0 D. Primary hyperaldosteronism
0 E. Bartter's syndrome

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A 2-year-old child Is brought to the office due to vomiting. He is recovering from an upper
respiratory Infection, which was treated by his mother with over-the-counter aspirin. On
examination he Is Irritable, lethargic, agitated and uncooperative. His height, weight and
head circumference are at the 50th percentile. The pupils are equal and have a sluggish
reaction to light. The sclera Is non-icteric. The neck is supple and without adenopathy.
The abdomen Is flat, with normal bowel sounds. The lab findings are as follows:
Serum bilirubin Normal
Serum AST and
Increased
ALT
Serum ammonia Increased
Prothrombin time Prolonged

ACT scan of the brain shows cerebral edema. CSF analysis is normal. except for
increased pressure. What Is the most likely diagnosis?

0 A. Aseptic meningitis
0 B. Reye syndrome
0 c. Carnltlne deficiency
0 D. Sepsis
0 E. Viral encephalitis

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A 48-year-old woman comes to the physician because of a small swelling on her neck.
She has worked outdoors her entire life. This swelling has been present for the past 6
months and is slowly enlarging. On examination, there is a small nodular lesion with
central ulceration that is firm, nontender, pearly, and indurated.

Which of the following is the most likely diagnosis?

0 A Basal cell carcinoma

0 B. Keratoacanthoma
0 C. Malignant melanoma
0 D. Rosacea
0 E. Sebaceous hyperplasia
0 F. Seborrheic keratosis

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0. ld : 21 6 4 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 65-year-old female is admitted to the hospital with increasing shortness of breath,

weight gain and lower extremity edema. She has a history of hypertension, nonischemic
cardiomyopathy with an ejection fraction of 30%, and hyperlipidemia. Her home
medications include oral aspirin, digoxin, furosemide, metoprolol, lisinopril and
atorvastatin. She is started on intravenous furosemide. On day three of hospitalization
telemetry reveals six beats of wide complex ventricular tachycardia. Physical
examination now shows decreased leg edema and clear lungs. Which of the following is
the most appropriate next step in the management of this patient's tachycardia?

o A Add spironolactone
o B. Add metolazone
0 C. Measure serum electrolytes
0 D. Discontinue atorvastatin
0 E. Discontinue metoprolol

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An 80-year-old woman with multiple medical problems is admitted to the hospital for
evaluation of syncope. Her heart rate is found to be 3.6/min. She was admitted to
another hospital rec·ently, then discharged to an acute rehabilitation facility, and then sent
to a nursing home. Review of her history shows that the patient is taking high-dose
diltiazem, metoprolol, and atenolol. Which of the following medication reconciliation
interventions is most likely to result in a decrease in adverse drug events and health care
utilization?

o A. Educational booklets distributed to patients

0 B. Educational booklets distributed to physicians
o C. Information technology-related interventions
0 D. Nurse and nurse assistant-directed interventions
0 E. Pharmacist-directed interventions

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0. ld: 11961 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 3-day-old girl is being evaluated for fussiness, poor feeding, and decreased urine
output that began this morning. She was born to a 31-year-old woman by an
uncomplicated home vaginal delivery. During the first 2 days of life, the infant had
latched and fed well and made an adequate number of wet diapers. However, she is
now afebrile but tachypneic, tachycardic, and mildly hypertensive. Oxygen saturation in
the right hand is 96% and oxygen saturation in the right foot is 85% on room air.
Capillary refill is equal in both lower extremities and duration is about 4 seconds. A
systolic murmur is heard at the left paravertebral interscapular area. A flat bluish-grey
discoloration with well-demarcated, irregular borders is seen overlying the sacrum.
Laboratory results are as follows:

Serum
Sodium 137 mEq/L
Potassium 4. 1 mEq/L
Chloride 100 mEq/L
Bicarbonate 16 mEq/L
18 mg/dL (normal: 9-1 6
Lactic acid
mg/dL)

Arterial blood gases

pH 7.23
Pa02 47 mm Hg
PaC02 37 mm Hg

Which of the following is the most likely underlying pathophysiology of this patient's
findings?

0 A. Adrenal cortical hyperplasia

0 B. Adrenal medullary tumor
0 C. Cystic dilations in renal collecting ducts
0 D. Increase in ductal prostaglandin concentration
0 E. Proliferation of the metanephric blastema
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uncomplicated home vaginal delivery. During the first 2 days of life, the infant had
latched and fed well and made an adequate number of wet diapers. However, she is
now afebrile but tachypneic, tachycardic, and mildly hypertensive. Oxygen saturation in
the right hand is 96% and oxygen saturation in the right foot is 85% on room air.
Capillary refill is equal in both lower extremities and duration is about 4 seconds. A
systolic murmur is heard at the left paravertebral interscapular area. A flat bluish-grey
discoloration with well-demarcated, irregular borders is seen overlying the sacrum.
Laboratory results are as follows:

Serum
Sodium 137 mEq/L
Potassium 4.1 mEq/L
Chloride 100 mEq/L
Bicarbonate 16 mEq/L
18 mg/dL (normal: 9-16
Lactic acid
mg/dL)

Arterial blood gases

pH 7.23
Pa02 47 mm Hg
PaC02 37 mm Hg

Which of the following is the most likely underlying pathophysiology of this patient's
findings?

0 A Adrenal cortical hyperplasia

0 B. Adrenal medullary tumor
0 C. Cystic dilations in renal collecting ducts
0 D. Increase in ductal prostaglandin concentration
0 E. Proliferation of the metanephric blastema
0 F. Thickening of the tunica media in the aortic arch

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0. ld : 4899 Previous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 32-year-old man comes to the physician complaining of erectile dysfunction and

decreased libido for the past month. He has no problems with urination. He has never
experienced these symptoms before and finds them very upsetting. The patient has a
history of schizophrenia and was discharged from a psychiatric hospital 3 months ago on
risperidone. He has no current hallucinations or delusions, and his thoughts are well
organized. Review of systems is negative except for a recent 3-kg (6.6-lb) weight gain.
Physical examination shows bilateral breast enlargement. Which of the following is the
most likely mechanism responsible for this patient's decreased libido?

0 A Decreased dopamine activity in the mesolimbic pathway

o B. Decreased dopamine activity in the nigrostriatal pathway
o C. Decreased dopamine activity in the tuberoinfundibular pathway
0 D. Increased dopamine activity in the mesolimbic pathW?Y
0 E. Increased dopamine activity in the nigrostriatal pathway
o F. Increased dopamine activity in the tuberoinfundibular pathway

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A 45-year-old woman, gravida 1 para 1, comes to the office due to bleeding between
periods and heavy menses for the past 6 months. Her menstrual cycles were Irregular,
occurring every 26-37 days, and In the past few weeks the bleeding has become nearly
continuous. Her medical problems Include hypertension, type 2 diabetes mellitus. and
hyperlipidemia. The patient had a tubal ligation 5 years ago after a vaginal delivery. She
has no family history of cancer. Blood pressure is 144/86 mm Hg. BMI is 40 kg/m'.
Bimanual examination Is limited by the patient's body habitus but shows no
abnormalities. Endometrial biopsy shows complex endometrial hyperplasia. Which of the
following is the most likely mechanism of this patient's biopsy result?

C A Continuous exposure to endogenous progesterone

0 B. Distortion of the endometrial cavity by myocyte proliferation
0 C. Ectopic Implantation of endometrial glands
0 D. Germ line mutation of mismatch repair protein
0 E. Invasion of endometrial tissue into the myometrium
0 F. Peripheral aromatlzatlon of androgens to estrone

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A 23-year-old woman, gravida 1 para 1, comes to the office due to right lower quadrant
pain for 2 months. The pain Is unrelieved by acetaminophen and worsens with physical
activity. Menses are regular and occur every 28 days for 5 days. The patient has a
history of gonorrhea cervicitis during adolescence. Two years ago, she was treated with
methotrexate for an ectopic pregnancy. Her paternal grandmother died of ovarian cancer
at age 67. Pelvic ultrasonography shows a 4-cm ovarian mass. During laparoscoplc
cystectomy, the cyst Is inadvertently ruptured and dense yellow fluid Is noted, along with
hair and a solid, calcified, Irregularly shaped object. Which of the following Is the most
likely diagnosis?

c A. Corpus luteum cyst

0 B. Endometrioma
~"' C. Epithelial ovarian carcinoma
0 D. Hydrosalpinx
0 E. Mature cystic teratoma
o F. Mucinous cystadenocarcinoma
0 G. Tubo-ovarlan abscess

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A 6-day-old boy is brought to the office for a routine visit after discharge from the
hospital. He is exclusively breastfed and is gaining weight appropriately. He was born at
40 weeks gestation to a primigravida who had an uncomplicated vaginal delivery.
Physical examination at rest shows bilateral medial deviation of the forefoot. Ankle
movements appear normal, and passive and active movement of the. foot results in lateral
deviation of the forefoot. The remainder of the physical examination is normal. Which of
the following is the best next step in management of this patient?

o A. Foot radiographs
0 B. Karyotype analysis
o C. Reassurance
o D. Serial manipulation and casting
0 E. Ultrasound of hips

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0. ld : 3658 Previous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 9-year-old boy is brought to the emergency department after having a seizure in

school. His teacher says he suddenly fell to the ground with sustained flexion of the
arms and extension of the legs, followed by clonic movements of the whole body for 5
minutes. The boy has also been tired and irritable lately, and his school performance
has declined this semester. His parents arrive shortly and say that he has had frequent
headaches over the last month, especially in the morning. The patient has no medical
problems and takes no medications. Physical examination shows decreased muscle
strength on the left side of the body, with brisk deep-tendon reflexes in the left arm and
leg. Visual field examination is normal. MRI of the brain reveals a space-occupying
lesion in the right parietal lobe. Which tumor is most likely responsible for this patient's
symptoms?

o A Craniopharyngioma
o B. Ependymoma
o C. Glioblastoma
o D. Medulloblastoma
0 E. Neuroblastoma
o F. Pilocytic astrocytoma

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0. ld: 2530 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 25-year-old primigravid woman at 36 weeks gestation is brought to the emergency

department with constant, excruciating abdominal pain and sudden vaginal bleeding for
the past 3 hours. The patient is Rh negative and received Rh (D) immune globulin at 28
weeks gestation. Group B streptococcal cultures were collected at her prenatal care visit
last week, during which her cervix was examined and noted to be closed. The patient
also has a history of nephrolithiasis diagnosed during the pregnancy and managed
expectantly. Blood pressure is 160/100 mm Hg and pulse is 11 8/min. Physical
examination shows a firm, distended, and tender uterus. Speculum examination shows
approximately 75 ml of red blood in the vagina. After evacuation of the blood, a
moderate amount of blood is observed coming from an open cervical os. Fetal heart
tracing shows a baseline of 108/min and no variability. Which of the following is the most
likely cause of this patient's bleeding?

0 A. Attachment of the placenta onto the myometrium

o B. Full-thickness disruption of the uterine wall
o C. Injury to fetal placental vessels
0 D. Placental implantation over the cervix
o E. Premature placental separation

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A 45-year-old woman comes to the emergency department with left leg pain and swelling
that has worsened over the last 2 days. The patient has no fevers, chills, dyspnea, or
chest pain and has had no trauma to the left leg. Her medical history includes
rheumatoid arthritis and gastroesophageal reflux disease, for which she takes low-dose
methotrexate, folic acid, and omeprazole. The patient has smoked a pack of cigarettes
daily for 10 years and does not consume alcohol. Temperature is 37 C (98.6 F), blood
pressure is 140/80 mm Hg, pulse is 70/min, and respirations are 14/min. BMI is 30
kg/m2 • The left leg is swollen (>4 em) compared to the right and is warm and tender on
palpation. Pitting edema is present. Her legs are shown in the image below.

palpation. Pitting edema is present. Her legs are shown in the image below.

Which of the following is the most appropriate next step in management of this patient?

0 A Aspirin
0 B. Blood cultures followed
 Which of the following is the most appropriate next step in management of this patient?

0 A. Aspirin
0 B. Blood cultures followed by antibiotics
0 C. Chest CT angiogram
0 D. Compression ultrasonograpl'!y
0 E. D-dimer test
0 F. Empiric anticoagulation

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A 31-year-old woman comes to the outpatient clinic due to excessive anxiety associated
with her work. She has been in her current position as a nurse manager for 5 years and
enjoyed her job until the past year. Her symptoms had begun after she filed a complaint
against a colleague for not following departmental policy protocol. Since the incident, the
patient has felt that all of her coworkers have been treating her differently and seem to be
very critica.l of her. Although she is included in all work-related social events and
meetings and is being considered for a promotion, she feels that she is disliked by
everyone and has concluded, "They must think I'm doing a terrible job." This is causing
her a great deal of stress and makes her feel very anxious during her entire shift. The
patient does not want to go to work and has used a week of sick time to avoid the
situation. The patient says, "I have always been overly sensitive; my family tells me that
all the time. But now I am worried that I will be fired for repeated absences." During the
interview, the patient appears anxious and tends to automatically jump to negative
interpretations of events. She and the physician decide on a course of
nonpharmacologic treatment. Which of the following is the most appropriate treatment for
this patient?

0 A. Biofeedback
0 B. Cognitive behavioral therapy
o C. Dialectical behavior therapy
0 D. Interpersonal psychotherapy
0 E. Motivational interviewing
0 F. Psychodynamic psychotherapy
0 G. Supportive psychotherapy

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