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1.
A 22 year old man has had an acute, painful, red right eye with blurring of vision for one
day. He had a similar episode one year ago and has had episodic back pain and stiffness
relieved by exercise and diclofenac for four years.
What is the SINGLE most likely cause of his red eye?
A Chorioretinitis
B Conjunctivitis
C Episcleritis
D Iritis
E Keratitis
2. A 40 year old divorced man with bipolar affective disorder attends hospital following an
overdose of 30 tricyclic antidepressant tablets. His new partner has left him and he has
stopped taking his medicine and begun drinking heavily. He appears depressed, feels
hopeless and is ambivalent about being alive. He is now fit for discharge from the medical
ward and acknowledges the benefits of previous treatment.
What is the SINGLE most appropriate next management?
A Admission to the psychiatry ward

B Arrange psychiatric outpatient follow-up
C Discharge to the care of the general practitioner
D Referral to local alcohol treatment team
E Referral to clinical psychologist
3. A healthy baby boy is born at term to a woman who was unwell with confirmed acute
hepatitis B during pregnancy. The mother is very concerned that she may have infected the
baby with hepatitis B.
What SINGLE preventative intervention should be given to the baby?
A Full course of hepatitis B vaccine
B Hepatitis B immunoglobulin alone
C Hepatitis B vaccine and hepatitis B immunoglobulin
D Hepatitis B vaccine as single dose
E None until hepatitis B status confirmed
4. A previously well 15 year old girl had an acute onset of fever, sweating, bruising and
petechiae. A blood count showed:
Haemoglobin 63 g/L
White cell count 1.1 x 109/L
Neutrophils 0.1 x 109/L
Platelets 14 x 109/L.
No abnormal white cells were seen on the blood film. She was transfused and given
intravenous antibiotics and her condition improved. Three weeks later her blood count has
returned to a similar picture.
What is the SINGLE most likely underlying diagnosis?
A Acute lymphoblastic leukaemia
B Acute myeloid leukaemia
C Aplastic anaemia
D Chronic myeloid leukaemia
E Pernicious anaemia
5. A 25 year old woman has a blood pressure of 160/90 mmHg at week 10 of her first
pregnancy. She had recurrent urinary infections in childhood. Her urinalysis shows protein
but no blood. Her blood tests show:
Haemoglobin 109 g/L
Serum urea 7.5 mmol/L
Serum creatinine 125 μmol/L.
What is the SINGLE most likely cause of her hypertension?
A Chronic glomerulonephritis
B Chronic pyelonephritis
C Essential hypertension
D Pre-eclampsia
E Renal artery stenosis
6. An 83 year old woman admitted with a chest infection becomes confused with impaired
attention and poor concentration. She is restless and frightened. She is verbally abusive
and has perceptual abnormalities. There is no significant previous psychiatric history.
What is the SINGLE most likely diagnosis?
A Delirium
B Drug induced psychosis
C Lewy body dementia
D Multi-infarct dementia
E Psychotic depression
7. A town has a population of 500,000. In a five year period there are 1250 cases of bladder
cancer diagnosed at the only hospital. During the same period the occupational health
department diagnosed a further 500 cases.
What is the annual incidence per million of bladder cancer in this population?
A 2100
B 1750
C 1400
D 700
E 350
8. A 28 year old woman who has had a previous pulmonary embolism in pregnancy wishes
to discuss contraception. She has menorrhagia but is otherwise well.
What is the SINGLE most suitable contraceptive method for this patient?
A Combined oral contraceptive pill
B Copper intrauterine contraceptive device
C Levonorgestrel intra-uterine system
D Progestogen implant
E Progestogen-only pill
9. An eight year old girl has had left earache for two days. The earache subsided about two
hours ago with the onset of a purulent discharge which relieved the pain. Her temperature
is 39.2o C.
What is the SINGLE most appropriate antibiotic?
A Amoxicillin
B Ciprofloxacin
C Clindamycin
D Erythromycin
E Flucloxacillin
10. A 38 year old man has disturbing thoughts about his house being infected by germs. He
is anxious about safety and checks the locks of his doors repeatedly before going to bed.
For the last eight weeks he has been washing his hands every time he touches the lock, 20-
30 times a day.
What is the SINGLE most appropriate management?
A Antidepressant
B Antipsychotic
C Anxiolytic
D Cognitive behaviour therapy
E Psychodynamic psychotherapy
11. A two year old boy fell off his tricycle, hurting his arm. He got up and started to cry but
before there was any sound he went pale, unconscious and rigid. He recovered after 1-2
minutes but remained pale. After an hour he was back to normal. His mother says she was
afraid he was going to die and that he had a similar episode three months previously after
he fell down some steps.
What SINGLE investigation is indicated?
A Computed tomography scan of the head
B Electroencephalogram
C Full blood count
D None
E Skeletal survey
12. At laparoscopic surgery for gallstones, a trocar is inserted through the midline of the
anterior abdominal wall just below the umbilicus.
Which SINGLE structure(s) would be pierced?
A Conjoint tendon
B External and internal oblique muscles
C External oblique aponeurosis and internal oblique muscle
D Linea alba
E Rectus abdominus muscle
13. A 65 year old man had closure of colostomy performed five days ago. He is not
systemically unwell. There is a tender, localised fluctuant swelling 4 cm in diameter in the
wound.
A Abdominal support
B Antibiotics
C Laparotomy and re-suture wound
D Local exploration of wound
E Observation
14. A 32 year old woman has had a febrile illness and swelling of the small joints of her
hands, feet, wrists and knees for two days. She has a maculopapular rash and a few
palpable, small cervical lymph nodes. She was previously well. There is no history of
relevant travel outside the UK. She has two young children.
A Psoriasis
B Reactive arthritis
C Rheumatoid arthritis
D Sarcoidosis
E Systemic lupus erythematosus
15. A 16 year old girl has had an enlarging mass in the right side of her neck for the last six
weeks. She has had no other symptoms. She has a 2 x 2 cm enlarged lymph node in the
anterior triangle of the neck with several smaller associated lymph nodes palpable.
Oropharyngeal examination shows tonsillar membranes.
A Infectious mononucleosis
B Leukaemia
C Lymphoma
D Sarcoidosis
E Tuberculosis
16. A 19 year old man has been brought by his mother for assessment. She says he has
always been aloof and distant. He has no friends, preferring solitary activities. He likes to
collect model cars and now has 2,000. He appears to be indifferent to either praise or
criticism by his mother.
A Autistic spectrum disorder
B Bipolar affective disorder
C Borderline personality disorder
D Dissocial personality disorder
E Obsessive compulsive disorder
17. A 60 year old man has had increasing pain in both buttocks, thighs and calves on
walking for three months. He has also recently developed impotence. Femoral and distal
pulses are absent in both limbs.
What is the SINGLE most likely site of arterial obstruction?
A Aorto iliac
B External iliac
C Femoropopliteal
D Internal iliac
E Tibial
18. A 72 year old woman has been taking loop diuretics for left ventricular failure. She now
has palpitations and muscle weakness.
What is the SINGLE most likely serum electrolyte pattern to be found?
A Sodium 130 mmol/L, potassium 2.5 mmol/L
B Sodium 130 mmol/L, potassium 5.0 mmol/L
C Sodium 140 mmol/L, potassium 4.5 mmol/L
D Sodium 150 mmol/L, potassium 2.5 mmol/L
E Sodium 150 mmol/L, potassium 3.5 mmol/L
19. A 78 year old man has collapsed. He has had a severe headache for 12 hours and had an
upper respiratory tract infection three days ago. He has a temperature of 39.2o C, a pulse
of 122 beats/minute, a blood pressure of 84/60 mmHg and a respiratory rate of 34
breaths/minute but his chest is clear. He has a Glasgow Coma Scale score of 10 and some
neck stiffness. He has been started on high-flow oxygen.
What is the SINGLE most appropriate immediate management?
A Intravenous antibiotic; computed tomography brain scan
B Intravenous antibiotic; lumbar puncture
C Intravenous fluids; computed tomography brain scan
D Intravenous fluids; intravenous antibiotic
E Intravenous fluids; lumbar puncture
20. A 16 year old boy was brought to hospital in a comatose state having taken methadone
belonging to his sister. He was given naloxone and rapidly became alert. Some hours later,
he gradually becomes semi-conscious again.
What is the SINGLE most likely reason for this patient becoming semi-conscious again in
hospital?
A Methadone hepatotoxicity has caused acute liver failure
B Methadone is eliminated from the body more slowly than naloxone
C Naloxone is a partial agonist at the central nervous system opioid receptor
D The patient has misused another substance that has caused an intracranial bleed
E The patient has misused another substance that is absorbed more slowly than methadone
21. A 27 year old woman who takes the combined oral contraceptive pill has had painless
vaginal spotting and discharge for three days. Her last menstrual period, which lasted four
days, finished 10 days ago. Her last cervical smear two years ago was normal. Abdominal
and vaginal examinations are normal apart from a mild ectropion with contact bleeding.
What is the SINGLE most appropriate initial investigation?
A Cervical smear
B Colposcopy
C Endocervical swab
D Endometrial biopsy
E Pelvic ultrasound scan
22. A 72 year old man being investigated for anaemia is booked for a colonoscopy in 24
hours.
What is the SINGLE most appropriate management the night before the procedure?
A Bisacodyl tablets
B Glycerine suppository
C Lactulose syrup
D Magnesium citrate (orally)
E Senna tablets
23. A 19 year old woman has had progressive bilateral iliac fossa pain and dyspareunia for
three days. She has an offensive vaginal discharge and feels unwell and feverish. Her
temperature is 39o C. An initial antimicrobial regimen is commenced.
What SINGLE set of organisms are the most appropriate for the antimicrobial regimen to
cover?
A Neisseria gonorrhoeae and Candida albicans
B Neisseria gonorrhoeae and Candida albicans and Gardnerella vaginalis
C Neisseria gonorrhoeae and Chlamydia trachomatis
D Neisseria gonorrhoeae and Chlamydia trachomatis and Candida albicans
E Neisseria gonorrhoeae and Chlamydia trachomatis and Gardnerella vaginalis
24. A 48 year old man with renal cancer had radiotherapy for metastatic spinal cord
compression at the 11th thoracic vertebra four weeks ago. He has retained sensation but is
unable to stand. He has pain in a band around his lower trunk controlled by regular oral
morphine. He is distressed by increasingly frequent episodes of painful muscle spasms in
his right leg.
What is the SINGLE most appropriate management of his symptoms?
A Amitriptyline
B Baclofen
C Fentanyl patch
D Gabapentin
E Increase morphine dose
25. An 18 year old woman thinks she is overweight and has a mildly depressed mood. For
the last 18 months she has reduced her food intake and has been exercising for two hours
each day. She has amenorrhoea. Her body mass index is 15.5 kg/m2 and her blood pressure
is 90/60 mmHg.
A Prescribe antidepressants
B Refer for psychodynamic therapy
C Refer to acute medical services
D Refer to dietician
E Refer to eating disorder service
26. A four year old girl has had a temperature of 38.5o C for two days and has not wanted
to eat her food. Yesterday she developed a sore throat and small, painful ulcers inside her
mouth. Today she has small blisters on the palms of her hands and soles of her feet which
are painful but not itchy.
What is the SINGLE most likely underlying cause?
A Coxsackie virus
B Herpes simplex virus
C Staphylococcus aureus
D Streptococcus pneumoniae
E Varicella zoster virus
27. A 32 year old woman has had three episodes of slurred speech and two episodes of
transient weakness of both legs in the past five years. Each episode has resolved within
three months.
A Meningioma
B Migraine
C Multiple sclerosis
D Stroke
E Transient ischaemic attack
28. An eight year old girl is complying with her asthma treatment of low-dose inhaled
corticosteroid prophylaxis and short-acting bronchodilators as required. Her inhaler
technique is good. She now has a frequent night cough and mild exercise-induced wheeze.
What would be the SINGLE most appropriate change in her treatment?
A Add leukotriene antagonist
B Add oral theophylline
C Add regular long-acting bronchodilator
D Increase dose of inhaled corticosteroid
E Short course of oral corticosteroid
29. A 38 year old man with longstanding alcohol dependence has vertigo and a tremor
every morning.
A Anxiety
B Benign positional vertigo
C Cerebellar degeneration
D Optic neuritis
E Temporal lobe epilepsy
30. An 84 year old woman with Alzheimer's dementia has recently become incontinent and
more confused than usual.
A Detrusor overactivity
B Neuropathic bladder
C Nocturnal enuresis
D Urinary tract infection
E Uterine prolapse
31.A 24-year-old female comes for review. She was diagnosed with asthma two years ago
and is currently using a salbutamol inhaler 100mcg prn combined with beclometasone
dipropionate inhaler 200mcg bd. Despite this her asthma is not well controlled. On
examination her chest is clear and she has a good inhaler technique. What is the most
appropriate next step in management?
A Increase beclometasone dipropionate to 400mcg bd
B Switch steroid to fluticasone propionate
C Trial of leukotriene receptor antagonist
D Add salmeterol
E Add tiotropium
32.A 19-year-old female starts Microgynon 30 (combined oral contraceptive pill) on day 8
of her cycle. How long will it take before it can be relied upon as a method of
contraception?
A Immediately
B 2 days
C 5 days
D 7 days
E Until first day of next period
33.A 69-year-old man is started on tamsulosin for benign prostatic hyperplasia. Which one
of the following best describes the side-effects he may experience?
A Urgency + insomnia
B Dizziness + postural hypotension
C Urinary retention + nausea
D Urgency + erectile dysfunction
E Erectile dysfunction + reduced libido
34. A 37-year-old woman presents for review. She is 26 weeks pregnant and has had no
problems with her pregnancy to date. Blood pressure is 144/92 mmHg, a rise from her
booking reading of 110/80 mmHg. Urine dipstick reveals the following:
Protein negative
Leucocytes negative
Blood negative
What is the most appropriate description of her condition?
A Moderate pre-eclampsia
B Mild pre-eclampsia
C Gestational hypertension
D Normal physiological change in blood pressure
E Pre-existing hypertension
35. Whilst examining a patient the following is found on fundoscopy:
What is this finding most suggestive of?
A Central retinal artery occlusion

B Normal fundus
C Papilloedema
D Untreated glaucoma
E Optic atrophy
36. A 55-year-old business man presents with a 15 day history of watery, non-bloody
diarrhoea associated with anorexia and abdominal bloating. His symptoms started 4 days
after returning from a trip to Pakistan. On examination he is apyrexial with dry mucous
membranes but normal skin turgor. What is the most likely causative organism?
A Salmonella
B Giardia lamblia
C Shigella
D Escherichia coli
E Norovirus
37.A 64-year-old man presents with a eight-month history of generalised weakness. On

examination he has fasciculation and weakness in both arms with absent reflexes.
Examination of the lower limbs reveal increased tone and exaggerated reflexes. Sensation
was normal and there were no cerebellar signs. What is the most likely diagnosis?
A Lead poisoning
B Motor neuron disease
C Vitamin B12 deficiency
D Syringomyelia
E Multiple sclerosis
38. At what age would the average child acquire the ability to walk unsupported?
A 6-7 months
B 8-9 months
C 10-11 months
D 13-15 months
E 2 years
39. A new test to screen for pulmonary embolism (PE) is used in 100 patients who present
to the Emergency Department. The test is positive in 30 of the 40 patients who are proven
to have a PE. Of the remaining 60 patients, only 5 have a positive test. What is the
sensitivity of the new test?
A 8.33%
B 30%
C 40%
D 66.66%
E 75%
40. A 54-year-old farm worker presents for review. She has recently been diagnosed with
osteoarthritis of the hand but has no other past medical history of note. Despite regular
paracetamol she is still experiencing considerable pain, especially around the base of both
thumbs. What is the most suitable next management step?
A Add oral diclofenac + lansoprazole

B Switch paracetamol for co-codamol 8/500
C Add topical ibuprofen
D Add oral ibuprofen
E Add oral glucosamine
41. A 29-year-old man is brought to the physician for removal of a cast from his left leg. He
sustained a fracture of the left lower extremity 6 weeks ago and was immobilized in a cast
that extended from just below the knee to the foot. At the time of injury, there was severe
pain but normal strength in the extremity. When the cast is removed today, physical
examination shows a pronounced left footdrop with paresthesia and sensory loss over the
dorsum of the left foot and lateral leg. Injury to which of the following nerves is the most
likely cause of this patient's condition?
(A) Common fibular (peroneal)

(B) Femoral
(C) Obturator
(D) Sciatic
(E) Tibial
42. A 7-month-old infant is brought to the physician's office because of poor weight gain
despite large food intake. He has had two episodes of pneumonia and has frequent bulky
stools. He coughs frequently. X-rays of the lungs show increased markings and
hyperinflation. Trypsin is absent in a fresh stool sample, and the fat content is increased.
Which of the following is the most likely cause of this infant's disorder?
(A) Autoimmune disorder

(B) Defective ion transport at epithelial surfaces
(C) Disaccharidase deficiency
(D) Inability to synthesize apolipoprotein B
(E) Villous atrophy of the jejunum
43. A 45-year-old man has abnormal circadian variation in body temperature, disruption
of the sleep-wake cycle, and an impaired nocturnal surge of secretion of melatonin. An
MRI of the brain is most likely to show a lesion involving which of the following nuclei?
(A) Accessory optic

(B) Lateral preoptic
(C) Pretectal
(D) Suprachiasmatic
(E) Supraoptic
44. A 4-year-old girl has the sudden onset of abdominal pain and vomiting. She has a mass
in the right lower quadrant and hyperactive bowel sounds. A segment of resected bowel is
shown in the photograph. Which of the following is the most likely diagnosis?
(A) Appendicitis
(B) Intussusception
(C) Meckel diverticulum
(D) Necrotizing enterocolitis
(E) Strangulated hernia
45. A 75-year-old woman has increasing shortness of breath on exertion. Findings on

physical examination are unremarkable. X-rays of the chest show no abnormalities of the
heart or lungs. Pertinent laboratory findings include:
Hematocrit 28%
Hemoglobin 9 g/dL
Mean corpuscular volume 70 μm3
Which of the following is the most likely basis for these findings?
(A) Acquired hemolytic anemia

(B) Chronic blood loss
(C) Folic acid deficiency
(D) β-Thalassemia minor
(E) Pernicious anemia
46. A 64-year-old man comes to the physician because of swelling in his feet for the past
2 years. He says that his skin is dry and itchy and his feet "feel heavy." One of his legs is
shown.Which of the following is the most likely cause of his condition?
(A) Arteriolar constriction and arteriolar hypertension

(B) Arteriolar dilation and venous hypertension
(C) Venous constriction and arteriolar constriction
(D) Venous hypertension and incompetent valves
(E) Venous hypertension and venous constriction
47. An otherwise healthy 3-week-old boy is brought to the physician's office because of
jaundice and dark urine for the past 2 weeks. He has hepatomegaly, and his stools are
loose, claycolored, and acholic. Serum conjugated bilirubin concentration is increased.
Which of the following is the most likely cause of the hyperbilirubinemia?
(A) Defect in cholesterol synthesis

(B) Deficiency of glucuronosyltransferase
(C) Hemolysis
(D) Inflammation of the terminal ileum
(E) Obstruction of the biliary system
48. A 30-year-old woman comes to the emergency department because she thinks she has
had aheart attack. One hour ago, she had the sudden onset of chest pain faintness,
pounding heart,flushed skin, and nausea that lasted 20 minutes. She now feels better. She
has limited her activitybecause she has had two similar episodes over the past 2 weeks.
Medical evaluation is normal.Which of the following is the most appropriate
nonpharmacologic therapy?
(A) Assertiveness training

(B) Cognitive behavioral therapy
(C) Dynamic psychotherapy
(D) Psychoanalysis
(E) Psychodrama
49. A 48-year-old man has hepatic cancer that isunresponsive to standard therapy. He
enrolls in aclinical study of a novel chemotherapeutic agentthat, as a side effect, blocks
kinesin, a componentof the cellular microtubular transport system.One week later, he
develops skeletal muscleweakness. An alteration in which of thefollowing components of
the neuromuscularjunction is the most likely cause of the muscleweakness?
(A) A decrease in the number ofpostsynaptic neurotransmitterreceptors

(B) A decrease in the number of presynaptic neurotransmitter vesicles
(C) A decrease in the presynaptic neuroncalcium permeability
(D) Impaired α-motoneuron action potentialconduction
(E) Impaired skeletal muscle actionpotential conduction
50. A 68-year-old man has had low back pain overthe past 2 months. Laboratory studies
show anormochromic, normocytic anemia andazotemia. Serum and urine
calciumconcentrations are abnormally increased, andurinalysis shows excessive protein
(4+) and proteinaceous casts. Bone marrow examinationis most likely to show uncontrolled
proliferationof which of the following cells?
(A) Basophils
(B) Lymphocytes
(C) Macrophages
(D) Plasma cells
(E) Reticulocytes
51. A 66-year-old man has become increasinglyshort-tempered with his wife. He has
diarrhea,weight loss, and weakness in the proximalmuscles. He has atrial fibrillation and
tachycardia. Which of the following is the mostlikely diagnosis?
(A) Congestive heart failure

(B) Cushing syndrome
(C) Hyperthyroidism
(D) Mitral valve prolapse
(E) Pheochromocytoma
52. A 23-year-old woman has a progressive increasein her serum β-human chorionic
gonadotropin(β-hCG) concentrations during an 8-weekperiod. A hydatidiform mole is
removed, but theβ-hCG concentration continues to increase.Which of the following is the
most likelydiagnosis?
(A) Adrenal adenoma

(B) Choriocarcinoma
(C) Ectopic pregnancy
(D) Pituitary insufficiency
(E) A second noninvasive mole
53. A 74-year-old man with urinary frequency andurgency has benign prostatic
hyperplasia. Herefuses operative intervention but agrees to a trialof finasteride therapy.
During the trial, synthesisof which of the following substances is mostlikely to be inhibited?
(A) Androstenedione
(B) Dihydrotestosterone
(C) Estradiol
(D) Estrone
(E) Testosterone
54. A 63-year-old woman is brought to the physicianbecause of blurred vision in the right
eye for1 day. She also has had a right-sided headachefor the past week and fever with
fatigue for thepast 2 weeks. Physical examination shows avessel along the right temple that
is nodular andtender. Histologic examination of the vesselshows multinucleated histiocytes
infiltrating thewall of a medium-sized artery. Which of thefollowing is the most
appropriate next step inmanagement?
(A) Administration of a β-adrenergicblocking agent

(B) Administration of a corticosteroid
(C) Administration of sulfone
(D) Cranial angiography
(E) Surgical removal of the involved vessel
55. A 55-year-old man is brought to the emergencydepartment because of a 4-hour history

oftemperatures to 39.4°C (103°F). He hascompleted four courses of chemotherapy for lung
cancer. Physical examination shows no otherabnormalities. Combination
intravenousantibiotic therapy is started, but the patient doesnot significantly improve. A
chest x-ray shows anew pulmonary infiltrate. Bronchoalveolarlavage and a lung biopsy
specimen confirm adiagnosis of aspergillosis. A regimen ofamphotericin B is started. This
patient is mostlikely to develop which of the following adverseeffects?
(A) Dermal necrosis

(B) Liver toxicity
(C) Renal impairment
(D) Retinal damage
(E) Vestibular toxicity
56. A previously healthy 3-month-old boy is broughtto the physician because of a runny
nose and adry cough for 2 days. Physical examinationshows tachypnea, a nasal discharge,
andwheezing. An x-ray of the chest showshyperexpansion but no infiltrates. The causal
virus was most likely transmitted by which of thefollowing routes?
(A) Blood transfusion

(B) Ingestion of contaminated formula
(C) Inoculation onto mucous membranes
(D) Insect bite
(E) Transplacental transfer
57. A 40-year-old woman comes to the physicianbecause of pain in the region of her left
jaw, leftsidedearache, and headache for 3 days. Thepatient has not had any trauma to her
face or jawbut says she often grinds her teeth. She isconcerned because she is a singer, and
it ispainful when she opens her mouth wide to sing.There is also a clicking sound when she
opensher mouth. Physical examination shows the leftside of the jaw deviating slightly to the
left onelevation. The area around the left mandibularcondyle is painful on palpation.
Mandibulardepression is difficult to perform because ofpain. This movement also elicits an
audibleclicking sound. There is tightness indicative of amuscle spasm along the left
mandibular ramus.Palpation shows no other area of tightness.Spasms of which of the
following muscles aremost likely associated with this condition?
(A) Buccinator
(B) Masseter
(C) Mylohyoid
(D) Posterior belly of the digastric
(E) Superior pharyngeal constrictor
58. A 30-year-old man comes to the clinic becauseof a painful ulcer on his penis for the past
week.He has had multiple sexual partners, includingcommercial sex workers. Physical
examinationshows lymphadenopathy in the inguinal regionand a 1-cm tender ulcer with no
indurationlocated on the frenulum. A culture of the ulcergrows colonies on supplemented
chocolate agar.A Gram stain of the colonies shows gramnegativecoccobacilli. Which of the
following isthe most likely causal organism?
(A) Haemophilus ducreyi

(B) Herpes simplex virus
(C) Neisseria gonorrhoeae
(D) Treponema pallidum
(E) Trichomonas vaginalis
59. A 74-year-old man has had confusion for 2weeks. He has smoked two packs of
cigarettesdaily for 50 years. An x-ray of the chest shows a5-cm mass in the lung.
Laboratory studies ofserum show:
Na+ 110 mEq/L
Cl− 72 mEq/L
K+ 4.5 mEq/L
HCO3− 30 mEq/L
Glucose 200 mg/dL
Creatinine 1.4 mg/dL
Which of the following is the most likely causeof these findings?
(A) Adenocarcinoma of the lung

(B) Craniopharyngioma
(C) Medullary carcinoma of the thyroidgland
(D) Renal cell carcinoma
(E) Small cell carcinoma of the lung
60. A 52-year-old man comes to the emergencydepartment because he has had vomiting,
nausea,and abdominal pain for the past 12 hours. Hesays he attempted suicide 3 days ago
by "takingeverything in the medicine cabinet." He wasstuporous for approximately 12
hours after theoverdose but felt better the following day. At thistime, he has jaundice and
pain in the right upperquadrant. Which of the following drugs is mostlikely to have caused
the pain, vomiting, andjaundice?
(A) Acetaminophen
(B) Aspirin
(C) Cimetidine
(D) Diphenhydramine
(E) Triazolam
61. A previously healthy 48-year-old man comes tothe physician because of fever and cough
for 2days. He attended a convention 10 days ago, andtwo of his friends who stayed in the
same hotelhave similar symptoms. His temperature is38.3°C (101°F), pulse is 76/min,
respirations are20/min, and blood pressure is 130/70 mm Hg.Crackles are heard over the
right lung base. Achest x-ray shows a patchy infiltrate in the rightlower lobe. A Gram stain
of sputum showssegmented neutrophils and small gram-negative rods that Which of
thefollowing is the most likely causal organism?
(A) Campylobacter jejuni

(B) Eikenella corrodens
(C) Legionella pneumophila
(D) Proteus mirabilis
(E) Pseudomonas aeruginosa
62. A 12-year-old girl is admitted to the hospital because of marked shortness of breath, an
erythematous rash, and painful, swollen hip and knee joints. She is agitated. A chest x-ray
showsan enlarged heart and changes consistent with pulmonary edema. Intractable
congestive heartfailure develops, and she dies on the second hospital day. This child most
likely had a recent history of which of the following?
(A) Cyanosis with chest pain

(B) Jaundice
(C) Meningitis
(D) Pharyngitis
(E) Skin infection
63. A 29-year-old woman comes to the physician fora consultation 1 month after her 7-
year-olddaughter was killed in a motor vehicle collision.The patient is upset and restless
and wrings herhands frequently. She cannot sleep at night, haslost her appetite, and cries
easily and frequently.She is preoccupied with thoughts of her daughterand sometimes
thinks she momentarily sees herdaughter sitting in the living room. She says shewishes that
she had been hit by the car, too. Shedenies any thoughts of killing herself. Which ofthe
following is the best explanation for thesefindings?
(A) Dysthymic disorder

(B) Major depressive disorder
(C) Normal grief reaction
(D) Obsessive-compulsive disorder
(E) Schizoaffective disorder
64. A 2-year-old girl is brought to the emergencydepartment because of pain in her right
forearmafter a fall 1 hour ago. She has a history offractures of the left femur and right
tibia. Physical examination shows blue sclerae. Thereis tenderness to palpation over the
distal right radius. A mutation in which of the followinggenes is the most likely cause of the
recurrent fractures in this patient?
(A) Calcitonin
(B) Collagen, type I
(C) 1α-Hydroxylase
(D) Parathyroid hormone
(E) Vitamin D receptor
65. A 12-year-old girl with sickle cell disease haspain in her right arm. An x-ray of the right
upperextremity shows bony lesions consistent withosteomyelitis. Which of the following is
the mostlikely causal organism?
(A) Clostridium septicum

(B) Enterococcus faecalis
(C) Listeria monocytogenes
(D) Proteus mirabilis
(E) Pseudomonas aeruginosa
(F) Salmonella enteritidis
(G) Serratia marcescens
66. A previously healthy 30-year-old African American woman has had fatigue, arthralgia,
and a nodular rash over the trunk and upper extremities for 3 weeks. There are twelve 0.3-
to 0.8-cm, pale, indurated nodular plaques over the chest, back, and upper extremities.The
liver is palpable 2 cm below the right costal margin with a percussion span of 14 cm, and
the spleen tip is palpable 3 cm below the left costal margin. There is no pain or limitation of
motion of the joints. The rest of the examination shows normal findings. An x-ray of the
chest shows bilateral hilar lymphadenopathy. A biopsy specimen of the skin lesions is most
likely to show which of the following?
(A) Dermal infiltration with monocytes and Reed-Sternberg cells

(B) Fat-laden histiocytes
(C) Noncaseating granulomas
(D) Paravascular homogeneous eosinophilic infiltrate
(E) Vasculitis with giant cells
67. A 32-year-old man who is a jackhammer operator comes to the physician because of
pain and swelling of his right arm for 3 days.The symptoms are moderately exacerbated by
exertion. Examination of the right upper extremity shows erythema and moderate edema.
Capillary refill time is less than 3 seconds. Which of the following is the most likely
diagnosis?
(A) Axillary-subclavian venous thrombosis

(B) Deep venous valvular insufficiency
(C) Superficial thrombophlebitis of the basilic vein
(D) Superior vena cava syndrome
(E) Thoracic outlet syndrome
68. A 52-year-old woman has had dyspnea and hemoptysis for 1 month. She has a history
of rheumatic fever as a child and has had a cardiac murmur since early adulthood. Her
temperature is 36.7°C (98°F), pulse is 130/min and irregularly irregular, respirations are
20/min, and blood pressure is 98/60 mm Hg. Jugular venous pressure is not
increased.Bilateral crackles are heard at the lung bases. There is an opening snap followed
by a lowpitched diastolic murmur at the third left intercostal space. An x-ray of the chest
shows left atrial enlargement, a straight left cardiac border, and pulmonary venous
engorgement.
Which of the following is the most likely explanation for these findings?
(A) Aortic valve insufficiency

(B) Aortic valve stenosis
(C) Mitral valve insufficiency
(D) Mitral valve stenosis
(E) Tricuspid valve insufficiency
69. A 47-year-old man comes to the physician 12 hours after the sudden onset of a
severeoccipital headache and stiff neck. He has not had any other symptoms and has no
history of severe headache. He has hypertension and gastroesophageal reflux disease.
Current medications include hydrochlorothiazide and ranitidine. He is oriented to person,
place, and time. His temperature is 36.7°C (98.1°F), pulse is 100/min, and blood pressure is
160/90 mm Hg. Range of motion of the neck is decreased due to pain. Neurologic
examination shows no focal findings. Which of the following is the most likely diagnosis?
(A) Cluster headache

(B) Meningitis
(C) Migraine
(D) Subarachnoid hemorrhage
(E) Tension-type headache
70. A previously healthy 20-year-old college student comes to the emergency department
because she has been unable to urinate for 8 hours. She has a 2-day history of fever,
fatigue, severe burning with urination, and pain in the genital area. She is sexually active
and uses a diaphragm for contraception. She takes no medications. She appears
uncomfortable. Her temperature is 38.7°C (101.7°F), pulse is 110/min, and blood pressure
is 110/70 mm Hg. Abdominal examination shows a large, cystic, midline pelvic mass. The
groin nodes are enlarged and tender. Pelvic examination shows erythematous external
genitalia with extensive ulceration. The lesions extend into the vagina.Internal examination
is not possible due to patient discomfort. Which of the following is the most appropriate
initial step in management?
(A) Measurement of serum urea nitrogen concentration

(B) Vaginal cultures
(C) Intravenous pyelography
(D) Renal ultrasonography
(E) Placement of a Foley catheter
71. A 47-year-old man is brought to theemergency department 2 hours after thesudden onset of
shortness of breath, severechest pain, and sweating. He has no history ofsimilar symptoms. He has
hypertension treatedwith hydrochlorothiazide. He has smoked onepack of cigarettes daily for 30
years. His pulseis 110/min, respirations are 24/min, and bloodpressure is 110/50 mm Hg. A grade
3/6,diastolic blowing murmur is heard over theleft sternal border and radiates to the rightsternal
border. Femoral pulses are decreasedbilaterally. An ECG shows left ventricularhypertrophy.
Which of the following is themost likely diagnosis?
(A) Acute myocardial infarction

(B) Aortic dissection
(C) Esophageal rupture
(D) Mitral valve prolapse
(E) Pulmonary embolism
72. A 10-year-old boy with chronic sinusitis is brought to the emergency department
following a 3-minute generalized tonic-clonic seizure. He has a 3-day history of increasingly
severe headaches and a 2-day history of vomiting and temperatures to 38.7°C (101.7°F).
His
temperature is 39.5°C (103.1°F), pulse is 80/min, respirations are 16/min, and blood
pressure is 135/90 mm Hg. He is slightly lethargic but answers questions appropriately.
Examination shows papilledema. No other abnormalities are noted. Which of the following
is the most appropriate initial step in management?
(A) Measurement of serum ammonia concentration

(B) X-rays of the sinuses
(C) EEG
(D) CT scan of the head
(E) Lumbar puncture
73. A 19-year-old college student comes to the physician because of vaginal irritation and
pain with urination for 5 days. Two weeks ago, she had streptococcal pharyngitis treated
with amoxicillin. She has been sexually active with two partners over the past year; she
usescondoms for contraception. Her last menstrual period was 1 week ago. Her
temperature is37.2°C (99°F), and blood pressure is 90/60 mm Hg. Pelvic examination shows
erythema of the vulva and vagina and a thick white vaginal discharge. The pH of the
discharge is 4. Which of the following is the most likely cause of these findings?
(A) Bacterial vaginosis

(B) Candidiasis
(C) Chlamydia trachomatis infection
(D) Escherichia coli infection
(E) Neisseria gonorrhoeae infection
(F) Trichomoniasis
74. An 18-year-old man is brought to theemergency department by friends after hepassed

out and became unarousable. He has nohistory of medical problems. There is alcoholon his
breath and no evidence of trauma. Hispulse is 70/min, respirations are 6/min, andblood
pressure is 110/60 mm Hg. The lungsare clear to auscultation. There is a normal S1and S2.
A grade 2/6, systolic ejection murmuris heard. The liver edge and spleen tip are
notpalpable. Test of the stool for occult blood isnegative. Neurologic examination is
difficultto assess. Reflexes are 1+ bilaterally. Allextremities respond to painful stimuli.
Hisblood alcohol concentration is 200 mg/dL;toxicology screening is also positive
forbenzodiazepines in the blood and cocainemetabolites in the urine. The patient does
notrespond to infusion with naloxone, glucose, orvitamin B1 (thiamine). Abuse of which of
thefollowing substances is the most likely causeof these findings?
(A) Alcohol only

(B) Alcohol and benzodiazepines
(C) Alcohol and cocaine
(D) Alcohol and PCP (phencyclidine)
(E) Alcohol and salicylates
75. A 4-year-old boy with a displaced supracondylar fracture of the humerus without
neurovascular complication is placed in skeletal traction. Six hours later, he has severe
pain in the forearm and increased pain on passive extension of the wrist and fingers. Which
of the following is the most appropriate next step in management?
(A) Increased weight on the traction apparatus

(B) Administration of analgesic medication
(C) Exploration of the fracture and fasciotomy of the flexor
compartment of the forearm
(D) Closed reduction with the patient under anesthesia
(E) Open reduction and internal fixation of the fracture
76. During abdominal closure after a right hemicolectomy for colon cancer, a medical
student accidentally receives a solid needlestick. The patient's status for hepatitis
B,hepatitis C, and HIV is unknown. The student has received hepatitis B vaccine and
tetanus toxoid within the past 10 years. Examination of the student's hand shows a single
bleeding puncture wound of the right index finger. Which of the following is the most
appropriate pharmacotherapy?
(A) Administration of tetanus immune globulin

(B) Intravenous immune globulin therapy
(C) Pegylated interferon alfa and ribavirin therapy
(D) Reverse transcriptase inhibitor therapy
(E) No pharmacotherapy is indicated at this time
77. A previously healthy 17-year-old girl is brought to the physician for evaluation because
of loss of appetite, sleeplessness, and extreme irritability for 3 weeks. After missing many
practices, she quit the softball team that she previously enjoyed. She often feels tired and
has difficulty sitting still and concentrating on schoolwork. Her menses occur at regular
intervals. She is 168 cm (5 ft 6 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m2. Her
pulse is 74/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Which of the
following is the most likely diagnosis?
(A) Adjustment disorder with mixed disturbance of emotions and conduct

(B) Anorexia nervosa
(C) Attention-deficit/hyperactivity disorder
(D) Dysthymic disorder
(E) Major depressive disorder
78. A previously healthy 17-year-old boy comes to the physician because of moderate upper
abdominal pain for 24 hours. He appears jaundiced. His temperature is 37.9°C (100.2°F),
pulse is 90/min, respirations are 14/min, and blood pressure is 110/60 mm Hg. Abdominal
examination shows right upper quadrant tenderness. The spleen tip is palpated 3 cm below
the left costal margin. Laboratory studies show:
Hematocrit 32%
Leukocyte count 9800/mm3
Mean corpuscular volume 7 8 μm3
Serum bilirubin, total 4.1 mg/dL
Direct 3.6 mg/dL
A blood smear shows spherocytes. Ultrasonography of the abdomen shows gallstones and splenomegaly.
Which of the following is the most likely underlying mechanism of these laboratory findings?
(A) Activation of factor XII

(B) Cytoskeletal protein deficiency
(C) Defective iron absorption
(D) Presence of an IgM antibody
(E) Pyruvate kinase deficiency
79. A 3-year-old child is brought to the emergency department by his teenage sister because
he refuses to walk. The sister reports that she has been babysitting for 3 days while her
parents are away on a trip and that the boy has been fussy for the past 2 days. Physical
examination is normal except for painful swelling of the left lower leg. In addition to
radiography of the leg, you should obtain which of the following?
(A) Abdominal ultrasonography

(B) CT scan of the abdomen
(C) CT scan of the head
(D) Skeletal survey
(E) Serum lead concentration
80. An 81-year-old white woman is in the hospital following a hip replacement operation 2
days ago because of an intertrochanteric fracture of the left femur following a fall. Her
condition had been stable since the operation, but today the nurses note that the patient is
confused and short of breath. Vital signs are temperature 37.0°C (98.6°F), pulse 110/min,
respirations 32/min, and blood pressure 150/104 mm Hg. Pulse oximetry on 2 L/min of
oxygen by nasal cannula shows an oxygen saturation of 79%. Scattered crackles are heard
in both lung fields. ECG shows sinus tachycardia with right bundle branch block. Chest x-
ray shows bilateral basilar infiltrates. X-ray of the left hip shows intact repair. Leukocyte
count is 15,600/mm3 and hematocrit is 29%. You note that she has an advance directive at
the front of her medical chart that requests "Do Not Resuscitate" orders. She has been
receiving oral oxycodone with acetaminophen for pain, docusate sodium for constipation,
lisinopril for mild hypertension, and aspirin for thrombosis. She has no other medical
problems. Which of the following is the most appropriate step at this time?
(A) Order diagnostic tests and begin therapy

(B) Order diagnostic tests but give no therapy
(C) Order no diagnostic tests and give no therapy
(D) Provide analgesia and comfort measures only
(E) Speak with family members before proceeding with any action
81. A 22-year-old woman is brought to the emergency department by her parents because
of muscular weakness, muscle twitches, and palpitations. She is extremely thin and
somewhat cachectic. Her parents report that she has a history of self-induced vomiting and
overuse of laxatives and thiazide diuretics. Routine blood studies are obtained. Which of
the following findings is most likely to explain these signs and symptoms?
(A) Decreased hematocrit and hemoglobin concentration

(B) Decreased serum glucose concentration
(C) Decreased serum potassium concentration
(D) Increased serum calcium concentration
(E) Increased serum sodium concentration
82. You are asked to evaluate a 78-year-old German American woman who is admitted to
the hospital for replacement of her left knee joint due to degenerative joint disease. She is a
retired seamstress. She has type 2 diabetes mellitus, a long history of hypertension, and
chronic renal failure presumed secondary to diabetes mellitus and hypertension.
Reversible causes of renal failure have been excluded. She underwent a tonsillectomy at age
9 years and a laparoscopic cholecystectomy at age 68 years. Serum creatinine
concentration on admission was 6.0 mg/dL. Her current therapy includes a low-sodium,
low-protein American Diabetes Association (ADA) diet, enalapril, and acetaminophen. She
and her husband live on a farm 90 miles from the nearest dialysis facility. In considering
longterm treatment options for this patient, which of the following is the most appropriate
factor to consider?
(A) Her eligibility to receive Medicare

(B) Her history of an abdominal operation
(C) Her history of arthritis
(D) Her suitability for home dialysis
(E) Her willingness to move to the city
83. A 42-year-old white man is brought to the emergency department by his same sex
partner because of confusion, diplopia, and mild weakness of his right arm. The patient is
somewhat agitated and shows confusion for recent events. Temperature is 38.3°C (101.0°F).
There is decreased pupillary response on the left with paresis of lateral gaze on the right.
Peripheral leukocyte count is increased. Which of the following is the most appropriate
next step in evaluation of this patient's neurologic signs and symptoms?
(A) Bilateral carotid arteriography

(B) CT scan of the head
(C) EEG
(D) Lumbar puncture for examination of cerebrospinal fluid
(E) Serum HIV antibody test
84. A 28-year-old woman who is known to be HIV-positive comes to the emergency

department because of a 1-week history of increasing headaches, right-sided weakness, and
disorientation. A generalized, tonic-clonic seizure occurs shortly after admission. Following
the seizure, vital signs are normal. There is no nuchal rigidity. Funduscopic examination
shows papilledema. There is also right hemiparesis and aphasia. Which of the following is
the most likely diagnosis?
(A) Meningioma
(B) Meningococcal meningitis
(C) Neurosyphilis
(D) Toxoplasmosis
(E) Tuberculous meningitis
85. A 35-year-old white man with spina bifida is admitted to the hospital for a urologic
procedure. He has been functionally independent in activities of daily living and is
employed doing inventory control in a local sporting goods store. He has maintained
continence through periodic self-catheterization. The patient is paraplegic, has recurrent
calcium oxalate kidney stones, and recent onset of incontinence secondary to detrusor and
bladder neck dysfunction. Vital signs are normal. Physical examination shows a well-
developed, well-nourished man in no acute distress. Aside from paraplegia, lower extremity
muscle atrophy, and lower abdominal surgical scars, the physical examination discloses no
abnormalities. He had an episode of anaphylaxis secondary to latex allergy during a
previous operation for functional expansion of his bladder through a bowel anastomosis.
Which of the following is most important to consider in the care of this patient?
(A) Administration of injectable medications with disposable syringes

(B) Preparation of food by outside contractors
(C) Type of cleaning agents used to sterilize bed linens
(D) Use of rubber urethral catheters
(E) Use of topical moisturizing agents for skin care
86. A 68-year-old man is in the hospital because he requires mechanical ventilation for an
exacerbation of chronic obstructive pulmonary disease. On the second day after admission
he developed a pneumothorax on the right side that required tube thoracostomy. An air
leak is noted for the next 24 hours, which now has stopped. However, the patient has
become restless and combative. Breath sounds are diminished in the right side of the chest
and the patient now has tachycardia. Blood pressure is 130/80 mm Hg. After ordering a
STAT portable x-ray of the chest, which of the following is the most appropriate step?
(A) Add 4 cm of positive end-expiratory pressure

(B) Administer β-blocking medications
(C) Administer alprazolam
(D) Remove the patient from the ventilator and ventilate him with a bag-valve
mask
(E) Reposition the chest tube
87. A 16-year-old high school student, whose prenatal course you have managed, gave birth
to a 3256-g (7-lb 3-oz) baby girl during the night with the assistance of your associate. On
morning rounds you note that the delivery records report that she had mildly elevated
blood pressure during labor and sustained an estimated third-stage blood loss of 500 mL.
Today blood pressure is 132/84 mm Hg, she is afebrile, and deep tendon reflexes are
normal. The uterine fundus is firm and at the level of the umbilicus, and her perineum is
slightly edematous. Hematocrit is 33%. She is cuddling her infant and normal bonding
seems to be occurring. Which of the following is the most important next step in
management?
(A) Begin oral ferrous sulfate

(B) Begin oral methyldopa
(C) Institute fundal massage
(D) Order daily sitz baths
(E) Provide education for well-baby care
88. Three weeks ago a 45-year-old man was admitted to the hospital because of frostbite of
both feet. He was treated by rapid rewarming and protective care of the feet. All the toes
on the right foot have turned black. He has become slightly febrile and progressively more
confused over the past few days. Examination discloses cellulitis in the midfoot. Which of
the following is the most appropriate treatment?
(A) Amputation
(B) Application of topical collagenase
(C) Debridement of necrotic skin over the toes
(D) Hyperbaric oxygen
(E) Whirlpool therapy
89. A 50-year-old man comes to the emergency department because of a 2-hour history of
vomiting "coffee-ground" material. He has lost 4.5 kg (10 lb) in the past 6 months. Dark
blood is obtained on passing a nasogastric tube. Which of the following is the most
important factor in determining this patient's long-term prognosis?
(A) Amount and rate of blood loss

(B) Cause of the bleeding
(C) History of previous gastrointestinal bleeding
(D) Initial hematocrit measurement
(E) Initial response to a bolus of saline
90. A previously healthy 15-year-old boy is brought to the emergency department in

August 1 hour after the onset of headache, dizziness, nausea, and one episode of vomiting.
His symptoms began during the first hour of full-contact football practice in full uniform.
He reported feeling weak and faint but did not lose consciousness. He vomited once after
drinking water. On arrival, he is diaphoretic. He is not oriented to person, place, or time.
His temperature is 39.5°C(103.1°F), pulse is 120/min, respirations are40/min, and blood
pressure is 90/65 mm Hg.Examination, including neurologic examination, shows no other
abnormalities.Which of the following is the most appropriate next step in management?
(A) Obtain a CT scan of the head

(B) Administer sodium chloride tablets
(C) Administer intravenous fluids
(D) Immerse the patient in an ice water bath
(E) Obtain a lumbar puncture
91. A 54-year-old woman with a 10-year history of progressive systemic sclerosis

(scleroderma) undergoes an emergency laparotomy for a perforated appendix
withperitonitis. During the immediate postoperative period, she has a blood pressure of
180/110mm Hg. Over the next 3 days, herserum creatinine concentration increases, andher
urinary output decreases to 250 mL/day.On postoperative day 4, she has mild shortnessof
breath. Her peripheral oxygen saturation onroom air is 89%. Serum studies show
apotassium concentration of 6.2 mEq/L, a ureanitrogen concentration of 34 mg/dL, and
acreatinine concentration of 3.9 mg/dL. Whichof the following is the most appropriate
nextstep in management?
(A) Intravenous administration of ACE inhibitors

(B) Intravenous administration of morphine
(C) Fluid bolus with 2 L of lactated Ringer solution
(D) Hemodialysis
92. A 37-year-old man with type 1 diabetes mellitus is admitted to the hospital because of
inadequate control of his glucose concentrations for the past 2 months. Despite his poor
control, he demands that he be discharged. He reports that he has had a 3-month history of
fatigue, irritability, and feelings of hopelessness. He says that he has been noncompliant
with his diabetic regimen, adding, "Sometimes I forget." He has been avoiding his family
and friends because he is not in the mood to see them but admits that he is lonely. He did
not get out of bed for 2 days, which prompted his wife to call an ambulance and have him
admitted to the hospital. Prior to admission to the hospital, his only medication was insulin,
although he often missed doses. He does not drink alcohol. He is 168 cm (5 ft6 in) tall and
weighs 100 kg (220 lb); BMI is36 kg/m2. His temperature is 37°C (98.6°F), pulse is 68/min,
respirations are 18/min, and blood pressure is 150/85 mm Hg. Physical examination shows
no abnormalities. Onmental status examination, he is tired and has a restricted affect.
There is no evidence of suicidal ideation. Cognition is intact. His fasting serum glucose
concentration is 120 mg/dL. Which of the following is the most appropriate next step in
management?
(A) Adhere to the patient's wishes and discuss home-care options

(B) Adhere to the patient's wishes on the condition that he agree to home nursing
care
(C) Schedule neuropsychological testing
(D) Seek a court order to appoint a legal guardian
(E) Involuntarily hold the patient in the hospital
93. A 95-year-old woman in a nursing home has hadadvanced vascular dementia, severe
dysphagia,and a 9-kg (20-lb) weight loss over the past 2months. Her four children are
divided regardingthe decision to provide artificial feeding througha gastrostomy tube.
There is no living will. Theoldest son approaches the physician after afamily meeting and
says, "You should simplydecide what is best for her and tell the othersthat's what we
should do." Assuming thephysician proceeds in this manner, which of thefollowing best
describes the physician's action?
(A) Paternalism
(B) Preserving fairness in use of resources
(C) Protecting patient autonomy
(D) Rationing care
(E) Truth-telling
94. A 25-year-old man comes to the physicianbecause of progressive weakness and

anincreasingly protuberant abdomen during thepast 3 years. Physical examination
showssplenomegaly. His hematocrit is 28%, andplatelet count is 20,000/mm3. A biopsy
specimen of bone marrow shows accumulation of lipidladenmacrophages.
Glucocerebroside hasaccumulated in the patient's reticuloendothelialcells (macrophage
system). Inheritance of mutantalleles most likely caused impairment of whichof the
following enzyme activities in thispatient?
(A) Ceramidase
(B) α-Galactosidase
(C) β-Glucosidase
(D) Hexosaminidase
(E) α-L-Iduronidase
(F) Sphingomyelinase
95. A 21-year-old man has weight loss and severeintermittent bloody diarrhea. A barium
enemaand colonoscopy show multiple ulcers andinflammatory changes extending from the
rectumto the mid-transverse colon. Biopsy specimenstaken from multiple sites show acute
and chronicinflammation restricted to the mucosa. Which ofthe following is the most likely
diagnosis?
(A) AIDS-associated gastroenteritis

(B) Amebiasis
(C) Crohn disease
(D) Clostridium difficile-associated colitis
(E) Escherichia coli-associated colitis
(F) Ischemic colitis
(G) Salmonella gastroenteritis
(H) Ulcerative colitis
96. A 6-week-old male infant is brought to theemergency department because of a swollen

abdomen. He is refusing to eat and has not had abowel movement for 3 days. His mother
saysthat he had constipation since birth and was keptin the hospital an extra day after
birth because ofdelayed passage of stool. Physical examinationshows abdominal distention.
An x-ray of theabdomen shows distended loops of proximalbowel with an abrupt
narrowing to a smallcaliber of the distal 15-cm segment of colon.Which of the following
pathologic findings ismost likely in a biopsy specimen of the distalrectum in this patient?
(A) Absent myenteric ganglion cells

(B) Abundant inspissated mucus
(C) Hypertrophy of the muscle wall
(D) Nodular lymphoid hyperplasia
(E) Transmural coagulative necrosis
97. A 25-year-old man is started on clozapine forschizophrenia, paranoid type. He had been
unsuccessfully treated for the past 2 months withhaloperidol. The patient should be
monitored forwhich of the following adverse effects?
(A) Decreased erythrocyte count

(B) Decreased leukocyte count
(C) Decreased platelet count
(D) Increased eosinophil count
(E) Increased hemolysis
98. A 32-year-old man is brought to the emergencydepartment because of multiple

nonlethal stabwounds. He is incarcerated and serving a lifesentence for murder and armed
robbery. Afterhis condition is stabilized, he insists that it is his"right" to remain in the
hospital until he is fully"cured." He threatens to harm the attendingphysician if she
endorses his return to prison.Which of the following is the most likelydiagnosis?
(A) Adjustment disorder with mixedfeatures

(B) Antisocial personality disorder
(C) Bipolar disorder, manic
(D) Borderline personality disorder
(E) Narcissistic personality disorder
(F) Paranoid personality disorder
(G) Post-traumatic stress disorder
(H) Schizophrenia, paranoid type
99. After infection with measles virus, a 6-year-oldboy produces antibodies to all eight viral
proteins. The next year he is again exposed tomeasles virus. Antibodies to which of the
following viral proteins are most likely to beprotective?
(A) Hemagglutinin
(B) Matrix
(C) Nonstructural
(D) Nucleocapsid
(E) Polymerase
100. A 52-year-old man with recently diagnosed type2 diabetes mellitus comes to the
physician for afollow-up examination. Physical examinationshows no abnormalities.
Laboratory studies showan increased hemoglobin A1c despite patientcompliance with diet
and exerciserecommendations. Treatment with a sulfonylureais started. Which of the
following is most likelyto occur in this patient?
(A) Decreased entry of glucose into themuscle cells

(B) Decreased production of glucose fromthe liver
(C) Decreased secretion of insulin from thepancreas
(D) Decreased speed of carbohydrateabsorption from the intestines
(E) Increased entry of glucose into themuscle cells
(F) Increased production of glucose fromthe liver
(G) Increased secretion of insulin from the pancreas
(H) Increased speed of carbohydrateabsorption from the intestines
101. A 20-year-old man comes to the physician's office for a scheduled health maintenance
examination. His father died of a myocardial infarction at age 55 years. Physical
examination shows a tendon xanthoma on the elbow. His serum total cholesterol
concentration is 360 mg/dL. A mutation is most likely to be found in which of the following
genes?
(A) apoA2
(B) apoC2
(C) apoE-ε4
(D) LDL receptor
(E) VLDL receptor
102. Fill in the anatomical term for the given definition
The _____________________ are the turbinal bones of the nose that make the nasal passage
winding.
____________________ are finger-like projections that cover the interior surface of the small
intestine wall.
___________________ conveys non-oxygenated blood from the right ventricle to the lungs and
carries back oxygenated blood from the lungs to the left atrium.
The _______________ is a smaller airway that branches from a bronchus or from larger
bronchioles.
The ______________ are stretched membranous flaps in the larynx
107. What is the medical equivalent of the given common English term
body _____________ corpus
working tissue of the organ _____________parenchyma
upper jaw _____________ maxilla
limbs __________________extremities
111. Supply the missing word which match their definitions, choosing from the given ones
Major renal Cardia Chromosome Minor renal Synarthroses

calyx calyx
Pancreas Gene Isthmus faucium Sigmoid colon Diarthroses
_______________ is part of the colon in the pelvis that opens into the rectum.

calyx calyx
The ___________________ is a long, thin gland that lies crosswise just behind the
stomach.

calyx calyx
_________________ is a region of DNA that contains the information required to control

the structure of individual peptide chains.

calyx calyx
________________ is one of the several cup-shaped divisions of the major renal calices.

calyx calyx
_______________________is the narrow opening which connects the oral cavity with
the pharynx.

calyx calyx
_______________________ are types of joints that allow very little or no movement


calyx calyx
_________________ are synovial joints that allow various kinds of movement.
118. Supply the missing words which match their definitions, choosing from the given ones

calyx calyx
______________ is a ring of muscles that connects the esophagus with the stomach.

calyx calyx
______________ is a thread-like structure in the nucleus of a cell, in which genes are

located.

calyx calyx
_______________ is one of the two or three cup-shaped subdivisions of the renal pelvis.
121. Fill in the sentence with the missing adjective denoting anatomical location (e.g.
superior, inferior, anterior, posterior, medial, lateral, internal, external, proximal, distal,
central, peripheral, visceral, parietal).
The arms are _____________________ to the body.
The forearm is _____________________ to the cubital joint.
The humerus is _____________________ to the ulna and radius.
The phalanges are _____________________ to the wrist.
The neurocranium is _____________________ to the viscerocranium.
The tibia and fibula are _____________________ to the femur.
The hip bones are _____________________ to the sacral bone.
The sternum is _____________________ to the clavicle.
The scapula is _____________________ to the vertebral column.
The periosteum is _____________________ to the compact bone.
131. Choose the shape that describes the part of the body
snail-like tube-shaped wedge-shaped pear-shaped pouch-shaped
The liver is a _________________organ.
snail-like tube-shaped wedge-shaped pear-shaped pouch-shaped
The uterus is a _______________organ.
The cochlea is a _____________________structure.
The cecum is a _____________________organ.
The rectum is a ___________________organ
136. Match the term with respective explanation
Fistula is _____
a) recurrent at intervals.
b) degenerative disease of the spine

c) erosion of tissues because of spreading abscess within the anus
d) a disorder in which the marrow produces far more blood cells than usual
e) a malignant tumor of the lymph glands.
Spondylosis is _____
Lymphoma is ____
Intermittant means _____

Polycythemia is __
141 - 150. Complete the table with the corresponding nouns or adjectives.
NOUNS ADJECTIVES NOUNS ADJECTIVES
141. glossal 146. sacral
142. responsible 147. coccyx
143. trochlea 148. pharynx
144. spine 149. abdominal
145. Facial 150. epithelium
151-160. Fill in the gaps with respective disorders
Ileus Aneurysms Cystitis Myocarditis Anxiety

Acromegaly Multiple Influenza Acute kidney Phobia
myeloma failure
151. _______________________is a overproduction of the growth hormone in adults.
152. ____________________is inflammation of the bladder.
153. _________________is an illness in which the kidney suddenly stop functioning.
154. ______________is a serious disorder in which the intestines become paralyzed.
155. __________________is a disorder in which the plasma cell undergoes a

malignant change and begins to multiply excessively.
156. _____________________are permanent swellings of arteries due to weaknesses

in their walls.
157. ________________inflammation of the heart muscle.
158. ___________________is an infectious respiratory disorder in which there are

general body pains and a very high temperature.
159. ________________________is an irrational fear of a specific object or situation
160. ________________________is a persistent reaction to a previous stress which

prevents the affected person from leading a normal life.
161 - 165. Fill in the anatomical terms for the given definitions
161. The ____ _________________ protects the visceral organs.
162. The ___________ _________ produces synovial fluid.
163. ___________________ conveys non-oxygenated blood from the right ventricle to

the lungs and carries back oxygenated blood from the lungs to the left atrium.
164. The _______________ is a double layer of a thin membranous covering that

surrounds each lung lobe.
165. The ______________ are stretched membranous flaps in the larynx.

166-175. Match the medical equivalents with the given common English term
166. cavity _____________ uterus
167. access _____________ emesis
168. womb _____________ cholecyst
169. cup _____________ hematuria
170. bowels ______________ ventricle
171. vomiting ______________ cyst
172. gallbladder ______________ hypertrophy
173. blood in urine ______________ calix
174. bladder ______________ intestine
175. enlargement ______________ accession
176-185. Supply the missing words which match their definitions, choosing from the given
ones:
Sinuses Dyspepsia Follicle Salpingectomy Peritonitis

Pharynx Eclampsia Alveolus Gastritis Pericarditis
176. An _______________ is a balloon-like cavity at the tip of a bronchiole.
177. ___________________ is inflammation of the peritoneum.
178. _________________ is the ovum together with its surrounding cells, at any stage
of development.
179. ________________ is inflammation of the mucous membrane of the stomach.

180. _______________________is a surgical removal of an oviduct, also called
tubectomy.
181. _______________________ is an acute disorder peculiar to pregnant and

puerperal women associated with hypertension, edema and/or proteinuria.
182. The _________________ are air-filled cavities in the cranial bones.
183. ______________ is inflammation of the membrane that surrounds the heart.
184. ______________ is a collection of symptoms which usually occur during or after

eating or drinking.
185. The_______________ is a musculomembranous tube with a complex function

situated behind the nasal cavity, mouth and larynx.
186-195. Fill in the gaps with respective disorders
Bronchus Poliomyelitis Aneurysms Spondylosis Urinary

bladder
Genes Multiple Promoters Kidneys Ribosomes
myeloma
186. _______________ is a tube that branches from the trachea.
187. ________________ are found in the 5’ flanking region of genes.
188. _________________ are situated on specific loci on chromosomes.
189. __________ is an infectious disease which causes paralysis.
190. __________________ is a disorder in which the plasma cell undergoes a

malignant change and begins to multiply excessively.
191. __________________ are located on each side of the spin.

192. ________________ are found floating in the cytoplasm.
193. _________ is located anteriorly to the reproductive organs.
194. ___________are permanent swellings of arteries due to weaknesses in their walls.
195. __________________ is a degenerative disease of the spine.
196-200. Match the terms with respective explanation
196. Glomeruli are __ a) the pressure exerted by a prolapsed disk on

the roots of the sciatic nerve.
197. Ovary is ___ b) a pain somewhere in the vertebral column.
198. Sciatica means __ c) closely packed blood vessels in the kidney
199. Backache is __ d) the sexual gland in which the ovi are produced
200. The base uracil is found __ e) in RNA

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1.

A Admission to the psychiatry ward

What is the most appropriate description of her condition?

35. Whilst examining a patient the following is found on fundoscopy:

What is this finding most suggestive of?

A Central retinal artery occlusion

37.A 64-year-old man presents with a eight-month history of generalised weakness. On

A Add oral diclofenac + lansoprazole

(A) Common fibular (peroneal)

(A) Autoimmune disorder

(A) Accessory optic

45. A 75-year-old woman has increasing shortness of breath on exertion. Findings on

(A) Acquired hemolytic anemia

(A) Arteriolar constriction and arteriolar hypertension

(A) Defect in cholesterol synthesis

(A) Assertiveness training

(A) A decrease in the number ofpostsynaptic neurotransmitterreceptors

(A) Congestive heart failure

(A) Adrenal adenoma

(A) Administration of a β-adrenergicblocking agent

55. A 55-year-old man is brought to the emergencydepartment because of a 4-hour history

(A) Dermal necrosis

(A) Blood transfusion

(A) Haemophilus ducreyi

Which of the following is the most likely causeof these findings?

(A) Adenocarcinoma of the lung

(A) Campylobacter jejuni

(A) Cyanosis with chest pain

(A) Dysthymic disorder

(A) Clostridium septicum

(A) Dermal infiltration with monocytes and Reed-Sternberg cells

(A) Axillary-subclavian venous thrombosis

(A) Aortic valve insufficiency

(A) Cluster headache

(A) Measurement of serum urea nitrogen concentration

(A) Acute myocardial infarction

(A) Measurement of serum ammonia concentration

(A) Bacterial vaginosis

74. An 18-year-old man is brought to theemergency department by friends after hepassed

(A) Alcohol only

(A) Increased weight on the traction apparatus

(A) Administration of tetanus immune globulin

(A) Adjustment disorder with mixed disturbance of emotions and conduct

(A) Activation of factor XII

(A) Abdominal ultrasonography

(A) Order diagnostic tests and begin therapy

(A) Decreased hematocrit and hemoglobin concentration

(A) Her eligibility to receive Medicare

(A) Bilateral carotid arteriography

84. A 28-year-old woman who is known to be HIV-positive comes to the emergency

(A) Administration of injectable medications with disposable syringes

(A) Add 4 cm of positive end-expiratory pressure

(A) Begin oral ferrous sulfate

(A) Amount and rate of blood loss

90. A previously healthy 15-year-old boy is brought to the emergency department in

(A) Obtain a CT scan of the head

91. A 54-year-old woman with a 10-year history of progressive systemic sclerosis

(A) Intravenous administration of ACE inhibitors

(A) Adhere to the patient's wishes and discuss home-care options