148. You are evaluating a 40-year-old male patient in the office who is complaining of chest pain.

His
father had a myocardial infarction at age 42, and the patient is quite concerned. Which
characteristic, if included in the history, decreases the likelihood that his chest pain is cardiac in
origin?

a. The pain is worse with inspiration.

b. The pain radiates to his right arm.

c. The pain radiates to his left arm.

d. The pain is associated with nausea.

e. The pain is associated with sweatiness.

149. You are evaluating a 61-year-old man in the office who is complaining of chest pain. Given his
history and risk factors, you are concerned about myocardial ischemia, and order an ECG. Which of
the following ECG features, if present, would most markedly increase the likelihood of an acute
myocardial infarction?

a. Any ST-segment elevation greater than or equal to 1 mm

b. Any ST-segment depression

c. Any Q wave

d. Any conduction defect

e. New conduction defect

Abdominal Pain

118. You are seeing a 46-year-old man who reports 3 months of discomfort centered around his
upper abdomen. It is associated with heartburn, frequent belching, bloating, and occasional nausea.
What is the most likely result that will be found after workup for these symptoms?

a. Peptic ulcer disease.

b. GERD.

c. Gastric cancer.

d. Gastroparesis.

e. No cause is likely to be identified.

107. You are evaluating a 41-year-old man in your office who reports abdominal pain. He
says the pain began suddenly and is located in the right lower quadrant. He describes the
pain as “gnawing” and it seems to get worse after eating. He has vomited twice since the
pain began. Which historical feature would lead you toward an emergent evaluation?

a. The pain’s location in the right lower quadrant

b. The fact that the pain began suddenly

c. The description of the pain

d. The fact that it is worse after eating

e. The fact that it is associated with emesis

108. A 42-year-old woman presents to your office complaining of the recent onset of
abdominal pain. She describes pain that starts in the midepigastric region, radiating to the
back. It is associated with nausea and vomiting. What is the most likely diagnosis?

a. Acute appendicitis

b. Pancreatitis

c. Gallbladder disease

d. Esophageal spasm

e. Gastroesophageal reflux disease (GERD)

109. An 80-year-old man presents with mild, crampy, bilateral lower quadrant pain,
decreased appetite, and low-grade fever for about 48 hours. Which of the following is the
most likely diagnosis?

a. Small-bowel obstruction

b. Appendicitis

c. Constipation

d. Irritable-bowel syndrome (IBS)

e. Pancreatitis
110. While performing an abdominal examination on a 42-year-old woman in your office,
she suddenly stops inspiratory effort during deep palpation of the right upper quadrant. Of
which of the following problems is this most suggestive?

a. Hepatitis

b. Gallstones

c. Cholecystitis

d. Pancreatitis

e. Right-sided renal calculi

111. A 56-year-old is complaining of gnawing abdominal pain in the center of her upper
abdomen associated with a sensation of hunger. She has a long history of alcohol abuse, and
notes darker stool over the last 3 weeks. Which of the following is the most likely cause of
her illness?

a. Alcoholism

b. Nonsteroidal anti-inflammatory drug (NSAID) abuse

c. Helicobacter pylori infection

d. Gallstones

e. Gastroparesis

112. A 26-year-old man complains of heartburn. He also complains of regurgitation,

belching, and occasional dry cough. His symptoms are worse when he is lying down. He
denies melena, weight loss, or dysphagia. What is the appropriate next step, if you suspect
GERD in this patient?

a. Treat with H 2-receptor antagonists, a proton pump inhibitor, or a

prokinetic agent and evaluate the response.
b. Obtain a barium swallow.

c. Obtain a computed tomographic (CT) scan of the abdomen with oral and intravenous (IV)
contrast.

d. Obtain an ultrasound of the abdomen.

e. Perform an esophagogastroduodenoscopy (EGD).

113. You are seeing a 75-year-old patient with complaints of heartburn, regurgitation, and
belching. You suspect GERD. Which symptom, if present, would necessitate a referral for an
upper endoscopy?

a. Pain radiating to the back

b. Dysphagia

c. Chronic use of NSAIDs for coexisting arthritis

d. Bloating

e. Nausea

258. You are evaluating a 63-year-old man who complains of abdominal pain, distension,
nausea, and vomiting. It began rather suddenly this morning, though he has had mild pain
for several days. His past history is significant for a recent partial sigmoid resection for
diverticulosis and an appendectomy at 23 years of age. On examination, he is afebrile, his
mucous membranes are dry, but he has no orthostatic symptoms. His abdomen is distended
and diffusely tender, and his bowel sounds are hyperactive.Which of the following is the
most likely cause of his nausea and vomiting?

a. Gastroenteritis

b. Ileus

c. Obstruction

d. Diverticulosis

e. Diverticulitis

260. You are seeing a 6-year-old boy with nausea and vomiting. His symptoms began acutely
last evening, starting with malaise, headache, low grade fever, body aches, and diarrhea. On
examination, he has dry mucous membranes, but no orthostatic symptoms. He has diffuse
mild abdominal pain without rebound or involuntary guarding. Which of the following is the
best treatment for his condition?

a. Nothing by mouth until his symptoms improve

b. Oral rehydration with clear liquids, advancing the diet as tolerated

c. IV rehydration, advancing to oral as tolerated

d. Antiemetics, given intravenously or intramuscularly

e. Trimethoprim/sulfamethoxazole therapy

263. A new mother brings her infant to see you to discuss his vomiting. He is 4 weeks old and
is exclusively breast-fed. He vomits with every meal. On examination, his abdomen is
distended with normal bowel sounds, and he appears dehydrated. He has lost 4 oz since his
visit with you 2 weeks ago. Which of the following is the most likely diagnosis?

a. Allergy to breast milk

b. GERD

c. Pyloric stenosis

d. Intussusception

e. Small-bowel obstruction

264. You are evaluating a 31-year-old man with the acute onset of nausea and vomiting. It is
associated with significant epigastric pain that radiates to the back and occurs after eating
any type of food. It is somewhat better if he does not eat at all. Which of the following tests
is most likely to be abnormal in this case?

a. CBC

b. Amylase and lipase level assessment

c. Hemoccult testing of the stool

d. Abdominal x-rays

e. Upper endoscopy

265. A 42-year-old woman is seeing you to evaluate nausea and vomiting. It happens about
60 minutes after eating a big meal and is associated with pain in the epigastric area. Which
of the following tests is most likely to be abnormal in this case?

a. Amylase and lipase level assessment

b. Hemoccult testing of the stool

c. Abdominal x-rays

d. Ultrasound
e. Upper endoscopy

cardiac disease
272. You are evaluating a 33-year-old woman complaining of palpitations. Which of the
following characteristics, if present, increase the likelihood that the symptoms are cardiac in
etiology?

a. The fact that the patient is female

b. The fact that the patient has a sister with similar symptoms

c. Her description of the symptoms as an “irregular heartbeat”

d. The fact that her father has a history of heart disease

e. The fact that the episodes last less than 1 minute

273. You are seeing a hypertensive 56-year-old woman who is complaining of a “fluttering in
her chest.” She describes a rapid heart rate and to her it seems irregular. She is otherwise
well, and denies shortness of breath, light-headedness pedal edema, or other acute
symptoms. On examination, her pulse rate is rapid and irregular. Which of the following is
her most likely diagnosis?

a. Atrial fibrillation

b. Paroxysmal supraventricular tachycardia (PSVT)

c. Stable ventricular tachycardia

d. Stimulant abuse

e. Hyperthyroidism
275. You are seeing a 19-year-old African-American student who reports that he can “feel his
heartbeat.” It happens with exercise and is associated with some light-headedness and
shortness of breath. On examination, his heart has a regular rate and rhythm, but you hear a
holosystolic murmur along his left sternal border. It increases with Valsalva maneuver.
Which of the following is the most likely cause of his symptoms?

a. Mitral valve prolapse

b. Hypertrophic obstructive cardiomyopathy

c. Dilated cardiomyopathy

d. Atrial fibrillation

e. CHF

276. A 32-year-old woman reports that she sometimes “skips heartbeats.” Her medical and
social histories include moderate daily caffeine use, but are otherwise unremarkable. Her
physical examination and 12-lead ECG are normal, as are her CBC, electrolytes, and TSH.
Which of the following is the next appropriate step in her workup?

a. Reassure her and continue observation.

b. Perform ambulatory ECG monitoring (a 24-Holter monitor, or a continuous

loop event recorder).

c. Electrophysiology consultation.

d. Stress testing.

e. Echocardiography.
Sore throat
284. You are evaluating an 18-year-old male with a sore throat. It has been present for 3
days and is associated with fever, aches, and fatigue. On examination, he has an exudative
pharyngitis, soft palate petechiae, and posterior cervical adenopathy. Which of the following
is the most likely diagnosis?

a. Group A streptococcal infection

b. Group A streptococcal colonization

c. Corynebacterium diphtheriae infection

d. Gonorrhea infection of the throat

e. Infectious mononucleosis

285. A 7-year-old boy comes to see you for a sore throat. He reports fevers, chills, myalgias,
and pain on swallowing. On examination, you note anterior adenopathy, erythematous
tonsils, and edema of his uvula. He has no drug allergies. Which of the following would be
the best treatment for his condition?

a. Symptomatic care

b. Antiviral therapy

c. Doxycycline (Vibramycin)

d. Amoxicillin (Amoxil)

e. Erythromycin (Emycin)

286. An 11-year-old patient has a history of recurrent pharyngitis with repeatedly positive
streptococcal rapid antigen detection tests. You test him when he is asymptomatic and find
that the test continues to be positive. Assuming that the patient has no allergies, what
would be the best treatment for him?

a. No antibiotics are required.

b. Penicillin (PenVK).

c. Amoxicillin (Amoxil), using high dosages.

d. Azithromycin (Zithromax).

e. Clindamycin (Cleocin).
287. You are treating a 16-year-old patient with a sore throat. She has had 3 days of
symptoms and does not have nasal congestion or cough. She also reports laryngitis. On
examination, she has an erythematous pharynx without exudate. Which of the following is
the most appropriate therapy based on the symptoms described?

a. Supportive care

b. Penicillin (PenVK)

c. Amoxicillin (Amoxil)

d. Erythromycin (Emycin)

e. Clindamycin (Cleocin)

288. You are caring for a 19-year-old who came in for evaluation of his sore throat. He has
been ill for 24 hours. In addition to the sore throat, he has a fever, but no cough. On physical
examination, his temperature is 101°F, tender anterior cervical adenopathy, and tonsillar
exudate. Which of the following is the next best step in his care?

a. Reassurance and observation for a few more days.

b. Perform a rapid streptococcal screening test.

c. Perform a throat culture.

d. Treat with penicillin.

e. Treat with steroids.

Respiratory tract
337. You are caring for an 18-month-old infant, whose mother brings him in for “wheezing.”
She reports that he has had a runny nose and a slight cough for 2 days, along with a low-
grade fever. On examination, he does not appear to be in respiratory distress, but his lung
examination does reveal bilateral wheezing. Which of the following is the most likely
diagnosis?

a. Acute viral respiratory tract infection

b. Pneumonia

c. Bronchiolitis
d. Aspiration

e. Asthma

338. A 61-year-old man comes to see you for shortness of breath. He has a history of
hypertension, type 2 diabetes, and hyperlipidemia. He quit smoking 4 years ago after a more
than 30-pack-year history. On physical examination, he is not in respiratory distress, but he
has diffuse wheezing in the bilateral lower lobes of his lungs. His cardiac examination
demonstrates an S 4 and he demonstrates JVD. Which of the following treatments would
likely relieve his symptoms?

a. Antibiotic therapy

b. Epinephrine

c. Steroid therapy

d. Diuretics

e. Anticoagulation

339. You are seeing a 24-year-old woman who presents to your office complaining of
“wheezing.” She reports acute shortness of breath that occurred while she was shopping,
and her wheezing is associated with pleuritic pain. She is otherwise healthy, only taking oral
contraceptives. On examination, she is tachypneic, but not in acute distress. Auscultation of
her lungs is normal. After the appropriate diagnostic workup, what is the best treatment
option for this patient?

a. Reassurance and observation

b. Antibiotic therapy

c. Anticoagulation

d. Bronchodilators

e. Steroids
340. You are seeing a 23-year-old man for shortness of breath. He has no history of asthma
or wheezing and is otherwise healthy. His lung examination does reveal significant wheezing
bilaterally. Which of the following tests is necessary?

a. Observation and treatment

b. Chest x-ray

c. Peak flow testing

d. Pulmonary function tests

e. CBC

341. You are evaluating a 9-month-old child with recurrent wheezing. His mother also
reports that he vomits after formula as well. Which of the following is the best test to
determine the cause of his wheezing?

a. Pulmonary function testing

b. Chest x-ray

c. Upper GI barium swallow

d. Upper endoscopy

e. Twenty-four hour pH probe

342. You are evaluating a 35-year-old patient with known asthma. He comes to your office
complaining of increased shortness of breath despite compliance with his usual asthma
regimen. He reports cough, but denies fever or sputum production. His pulmonary
examination reveals wheezing bilaterally without crackles or rhonchi. Which of the following
is most useful in this setting?

a. Chest x-ray

b. Peak flow testing

c. Pulmonary function testing

d. CBC

e. Nasopharyngeal washing
372. You are seeing a patient in the office for the first time. She has had recent episodic
shortness of breath and is concerned that she has developed asthma. Which of the following
features, if present, is the strongest predisposing factor in the development of asthma?

a. Family history of asthma

b. History of atopy

c. A history of childhood pneumonia

d. Exposure to cigarette smoke

e. Exposure to environmental pollution

373. You are seeing a 19-year-old college student complaining of recurrent and persistent
cough. She has been treated for “bronchitis” several times, and you are concerned that her
true diagnosis is asthma. Which of the following is most important in the diagnosis of
asthma?

a. History

b. Allergy testing

c. Chest x-ray

d. Pulmonary function tests with and without bronchodilator therapy

e. Provocative testing with methacholine

374. You are caring for a 30-year-old woman who has had asthma since childhood. Currently,
she reports symptoms three or four times a week, but never more than once a day.
Sometimes her symptoms cause her to skip her usual exercise regimen. She wakes in the
night approximately three or four times a month to use her inhaler and return to bed. Which
of the following classifications best characterizes her asthma?

a. Mild intermittent

b. Moderate intermittent

c. Mild persistent

d. Moderate persistent

e. Severe persistent
375. You are caring for an 18-year-old man with asthma. He smokes, and reports needing to
use his short-acting bronchodilator daily. He gets flares of asthma at least twice a week, and
while some days are relatively symptom free, some exacerbations may last several days. He
wakes up at least once a week with symptoms. Which of the following classifications best
characterizes his asthma?

a. Mild intermittent

b. Moderate intermittent

c. Mild persistent

d. Moderate persistent

e. Severe persistent

376. You are discussing asthma control with a 22-year-old patient. She monitors her therapy
closely and reports that her current peak flows are at about 80% of her best levels. Which of
the following is the best approach to take at this point?

a. Commend the patient on her diligent monitoring and excellent control.

b. Reassure the patient that this is well within the normal range.

c. Review the patient’s medications and technique and review environmental control.

d. Have the patient take additional medication, or add a medication to her regimen.

e. Consider hospitalization.

377. You are caring for a young woman who has had mild intermittent asthma for years. She
uses a short-acting bronchodilator as needed, but in the past has only needed therapy once
or twice a month. Over the past 2 months, she has noted that she is using her inhaler more.
In fact, she uses it at least three times a week and on occasion has had to wake up in the
middle of the night to use her inhaler. Which of the following is the most appropriate
treatment option at this point?

a. Change her short-acting β-agonist from albuterol (Proventil, Ventolin) to pirbuterol

(Maxair).

b. Add a long-acting β-agonist.

c. Add an inhaled corticosteroid.

d. Add a leukotriene receptor antagonist.

e. Add cromolyn (Intal).

378. You are caring for a man with asthma. He is currently taking an inhaled corticosteroid
twice daily and using his short-acting β-agonist as needed. Over the past 3 months, he has
required escalating doses of his inhaled corticosteroid, and now he is at the maximum
dosage, still using his “rescue” inhaler more than he would like. Which of the following is the
best medication to add to his regimen?

a. A burst and rapid taper of oral steroids

b. A long-acting β-agonist

c. Cromolyn (Intal)

d. Ipratropium (Atrovent)

e. Theophylline

379. You are caring for a 19-year-old man who has been treated for mild intermittent
asthma since childhood. He has been controlled using a shortacting bronchodilator as
needed. Over the past month, he has been using his inhaler more than four times a week,
and has had to wake up in the middle of the night to use his inhaler on three occasions. In
the past, he was intolerant of the side effects associated with an inhaled corticosteroid.
Which of the following is the most appropriate treatment option?

a. Long-acting β-agonist

b. Leukotriene receptor antagonist

c. Cromolyn (Intal)

d. Theophylline

e. Oral corticosteroids
380. You are caring for a 22-year-old with moderate persistent asthma who has been well-
controlled for several months. He developed an upper respiratory infection and his control
worsened. He has not had a fever, but is coughing up sputum. In addition to stepping up his
therapy, which of the following is true?

a. You should begin a course of amoxicillin.

b. You should begin a course of amoxicillin/clavulanate.

c. You should begin a course of azithromycin.

d. You should begin a course of ciprofloxacin.

e. No antibiotics are necessary.

COPD
386. You are assessing a 59-year-old patient with an 80-pack-year history of smoking
cigarettes. He stopped smoking 1 year ago. He reports a cough productive of white frothy
sputum for the past 4 months. Reviewing his chart, you discover that he had a similar
presentation last winter, with a cough that lasted more than 3 months. Given this
information, which of the following tests is necessary for him?

a. Complete blood count

b. Arterial blood gas measurements

c. Office spirometry

d. Computerized tomographic scans of the chest

e. An electrocardiogram

387. You have diagnosed a 66-year-old female patient of yours with chronic obstructive
pulmonary disease (COPD). Which of the following therapies has been shown to improve the
natural history of COPD?

a. Smoking cessation

b. Bronchodilators

c. Inhaled steroids

d. Antibiotics

e. Supplemental oxygen
388. You are caring for a 68-year-old smoker who complains of increasing shortness of
breath with exertion and at rest. You observe that he is somewhat “barrel-chested,” he
breathes with pursed lips, and leans forward resting on his elbows when sitting in your
office. On examination, he has decreased breath sounds and distant heart sounds. You are
concerned about COPD and order office spirometry. Which of the following measurements is
most sensitive to diagnose COPD?

a. Total lung capacity (TLC)

b. Forced vital capacity (FVC)

c. Forced expiratory volume in 1 second (FEV 1)

d. Forced expiratory flow rate over the interval from 25% to 75% of the total FVC

(FEF25%-75%)

e. FEV1:FVC ratio

389. A 62-year-old smoker comes to your office for treatment. After a thorough history and
physical examination, you believe he has chronic obstructive pulmonary disease. He quit
smoking 8 months ago, but has not had any other treatment. Which of the following is the
best first-line therapy for his condition?

a. A short-acting β-agonist (albuterol)

b. An inhaled anticholinergic (ipratropium)

c. An inhaled corticosteroid

d. Oral theophylline

e. Oxygen
390. You are treating a patient with COPD for an acute exacerbation. Assuming he has no
allergies to medications, which of the following is true regarding antibiotic treatment in this
case?

a. He should be prescribed amoxicillin.

b. He should be prescribed trimethoprim-sulfamethoxazole.

c. He should be prescribed doxycycline.

d. He should be prescribed azithromycin.

e. No antibiotics are necessary.

33. You are performing a physical examination on a student traveling to Mexico with her
college Spanish class. She is concerned about traveler’s diarrhea, and asks about antibiotic
prophylaxis. Which of the following best represents the current guideline from the Centers
for Disease Control and Prevention (CDC) for prevention of traveler’s diarrhea?

a. The CDC does not have an antibiotic guideline regarding antibiotic prophylaxis for
traveler’s diarrhea.

b. The traveler should take trimethoprim-sulfamethoxazole.

c. The traveler should take doxycycline.

d. The traveler should take ciprofloxacin.

e. The traveler should take metronidazole.

201. A 19-year-old male patient presented to your office with a 3-day history of fatigue, sore
throat, and low-grade fevers. On examination, his temperature was 100.3°F, and you noted
an exudative pharyngitis with cervical adenopathy. You sent a throat culture and started him
on amoxicillin prophylactically. Two days later, he presents for follow-up with continued
symptoms and a diffuse, symmetrical erythematous maculopapular rash. Which of the
following is the most likely cause of his symptoms?

a. Scarlet fever

b. Allergic reaction to amoxicillin

c. Viral exanthem

d. Mononucleosis
e. Measles

459. You are treating a 61-year-old man for hypertension. He is not responding well to
combination therapy with a thiazide diuretic and a β-blocker. On physical examination, you
note an abdominal bruit. Which of the following tests is most likely to help you evaluate him
further?

a. Chest x-ray

b. Angiotensin-converting enzyme inhibitor renal scan

c. Urinary metanephrines and vanillymandelic acid levels

d. Aortic CT scan

e. Echocardiogram

hypertension
455. You have diagnosed a 42-year-old patient with hypertension. He is 5 ft 9 in tall, weighs
230 lb, and admits to poor eating habits, drinking 4 alcoholic beverages daily, and no regular
exercise. Which of the following lifestyle modifications, if instituted, will result in the largest
systolic blood pressure reduction?

a. Moderate alcohol consumption to no more than 2 drinks daily.

b. Engage in physical activity for 30 minutes per day, most days of the week.

c. Reduce dietary sodium intake to no more than 100 mEq/L per day.

d. Adopt a DASH eating plan (a diet rich in fruits, vegetables, and low-fat dairy

products with a reduced saturated and total fat content).

e. Lose 10 lb.
456. You have seen a 36-year-old man with elevated blood pressure. On one occasion, his
blood pressure was 163/90 mm Hg, and on a second occasion, his blood pressure was
158/102 mm Hg. You have encouraged lifestyle modifications including weight loss using
exercise and dietary changes. Despite some modest weight loss, at his current visit, his blood
pressure is 166/92 mm Hg. Which of the following is the best treatment strategy at this
point?

a. Use a thiazide diuretic.

b. Use an ACE inhibitor.

c. Use an angiotensin receptor blocker.

d. Use a β-blocker.

e. Use a two-drug combination of medications.

457. You are examining a 24-year-old patient for the first time and find her blood pressure to
be 155/92 mm Hg. On examination, you find that she has a very weak femoral pulses. Which
of the following is true regarding this patient?

a. Her blood pressure is not high enough to consider correction of her anatomical defect.

b. She is too young to consider intervention regardless of her blood pressure.

c. Correction of her deficit should eliminate the need for blood pressure medication.

d. She is likely to have a bicuspid aortic valve.

e. Her chest radiograph is likely to be normal.

458. You have just diagnosed a 35-year-old man with hypertension. He is otherwise healthy
and has no complaints. Which of the following is indicated in the initial evaluation?

a. TSH level assessment

b. Resting electrocardiogram

c. Stress test
d. Echocardiogram

e. Renal ultrasound

459. You are treating a 61-year-old man for hypertension. He is not responding well to
combination therapy with a thiazide diuretic and a β-blocker. On physical examination, you
note an abdominal bruit. Which of the following tests is most likely to help you evaluate him
further?

a. Chest x-ray

b. Angiotensin-converting enzyme inhibitor renal scan

c. Urinary metanephrines and vanillymandelic acid levels

d. Aortic CT scan

e. Echocardiogram

460. Despite lifestyle changes, a 37-year-old patient of yours still has blood pressures above
goal. She has no other medical concerns and no abnormalities on physical examination or
initial laboratory evaluation. Which of the following medications is best as an initial first-line
monotherapy, according to the Joint National Committee 7 (JNC 7)?

a. A thiazide diuretic

b. An ACE inhibitor

c. An angiotensin receptor blocker

d. A calcium channel blocker

e. A β-blocker

Liver disease
400. You are evaluating a 48-year-old man with liver disease. His laboratory evaluation is as
follows:

AST: 268 U/L (H)

ALT: 114 U/L (H)

Alk Phos: 140 U/L (H)

Bilirubin: 2.3 mg/dL (H)

GGT: 220 U/L (H)

Which of the following is the most likely cause of his liver disease?

a. Autoimmune hepatitis

b. Hepatitis B

c. Hepatitis C

d. Hematochromatosis

e. Alcoholic hepatitis

401. You are evaluating a 45-year-old man with liver disease. His laboratory evaluation
reveals the following:

AST: 52 U/L (H)

ALT: 56 U/L (H)

Alkaline phosphatase: 132 U/L (H)

GGT: 188 U/L (H)

Albumin: 2.9 g/dL (L)

Bilirubin: 3.5 mg/dL (H)

Prothrombin time: 14.9 seconds (H)

Which of his laboratory results suggests that his liver disease is chronic?

a. AST

b. ALT

c. GGT

d. Alkaline phosphatase

e. Albumin
402. You care for a patient who contracted hepatitis C after a blood transfusion many years
ago. Her liver disease has progressed, and she now has end-stage disease. Which of the
following will be the most likely cause of death in this patient?

a. Liver failure

b. Hepatocellular carcinoma

c. Bleeding varices

d. Encephalopathy

e. Renal failure

403. You are taking care of a 47-year-old woman with cirrhosis. She asks you about
transplantation as a definitive treatment option. Which of the following is an absolute
contraindication to transplantation?

a. Active alcoholism

b. Portal vein thrombosis

c. Hepatitis B surface antigen positivity

d. HIV positivity

e. Extensive previous abdominal surgery

240. You are evaluating a 5-year-old girl whose mother brought her in to evaluate jaundice.
Laboratory evaluation reveals a conjugated hyperbilirubinemia. Which of the following is the
most likely cause of her problem?

a. G6PD deficiency

b. Gilbert disease

c. Crigler-Najjar syndrome

d. Wilson disease

e. Viral hepatitis
241. You are caring for a 65-year-old man with new-onset jaundice. Laboratory evaluation
reveals conjugated hyperbilirubinemia. Statistically speaking, which of the following is the
most likely cause of his condition?

a. Hemolytic anemia

b. Viral hepatitis

c. Extrahepatic obstruction

d. Metastatic disease

e. Heart failure

heart failure
404. You have diagnosed a 66-year-old woman with heart failure. She has a history of
hypertension, but has never had heart failure before. Which of the following tests is
routinely indicated in the initial evaluation of a person with a new diagnosis of heart failure?

a. Echocardiogram

b. Holter monitor

c. Left heart catheterization

d. Treadmill stress test

e. Pharmacologic stress test

405. You are seeing a patient who was discharged from the hospital. She initially presented
to the emergency room with dyspnea and was found to be in CHF. They admitted her for
diuresis and initiation of appropriate first-line therapy. Since being released, she reports that
she is comfortable at rest, but that ordinary activity results in mild dyspnea. According to the
New York Heart Association (NYHA) functional classification, which class of heart failure best
describes this patient?

a. Class I
b. Class II

c. Class III

d. Class IV

e. Class V

406. A 62-year-old woman comes to your office complaining of dyspnea. She has a history of
COPD, hypertension, and diabetes. She also smokes and drinks heavily. Her evaluation
reveals that she is in heart failure. Which of the following interventions will lead to
functional improvement in this patient?

a. Optimizing the treatment of her COPD

b. Optimizing the treatment of her hypertension

c. Optimizing her glycemic control

d. Discontinuing cigarette smoking

e. Discontinuing alcohol use

407. You have diagnosed a 49-year-old man with CHF because of left ventricular systolic
dysfunction. In addition to acute diuresis, which of the following is the best first-line agent to
use for treatment, in the absence of contraindications?

a. ACE inhibitors

b. β-Blockers

c. Calcium channel blockers

d. Nitrates

e. Hydralazine

409. You are considering adding an angiotension II receptor blocker (ARB) to the regimen of
one of your patients with congestive heart failure. Which of the following statements is true
regarding the use of ARBs in CHF?

a. ARBs and ACE inhibitors have the same effects on the neurohormonal mechanisms
involved in heart failure.

b. Adding an ARB to an ACE inhibitor reduces mortality in patients with CHF.

c. Adding an ARB to an ACE inhibitor can reduce hospitalizations in patients with CHF.

d. Using an ARB instead of an ACE inhibitor increases mortality in CHF.

e. Using an ARB instead of an ACE inhibitor increases hospitalizations in patients with CHF.

Diabetes
418. You are performing a screening physical examination on a 47-year-old man. He is
generally healthy, and his review of systems is negative. His mother has type 2 diabetes, and
he is overweight. Which of the following is generally accepted as the test of choice to screen
for type 2 diabetes?

a. A random glucose test

b. A fasting glucose

c. A urinalysis to screen for glycosuria

d. A 1-hour glucose tolerance test

e. A 3-hour glucose tolerance test

419. You are evaluating a 36-year-old obese woman who complains of fatigue. She denies
polydipsia, polyuria, polyphagia, or weight loss. Which of the following laboratory reports
confirms the diagnosis of diabetes?

a. A random glucose reading of 221 mg/dL

b. A random glucose reading of 221 mg/dL, and another, on a later date, of 208 mg/dL

c. A fasting glucose measurement of 128 mg/dL

d. A glucose reading, taken 2 hours after a 75-g glucose load, of 163 mg/dL

e. A fasting glucose of 114 mg/dL, and a reading of 184 mg/dL 2 hours after a 75-g glucose
load

420. An 18-year-old morbidly obese patient in your office is found to have a fasting glucose
of 314 mg/dL. Which of the following test results would indicate that he is a type 1 diabetic?

a. Low levels of C-peptide

b. Markedly elevated levels of C-peptide

c. Elevated levels of microalbumin in the urine

d. A markedly elevated hemoglobin A 1C

e. Nerve conduction studies showing mild peripheral neuropathy

421. You are managing a 36-year-old woman with a new diagnosis of type 2 diabetes. Her
hemoglobin A 1C was 7.2% at diagnosis. Her subsequent sugars were well-controlled using
metformin, 1000 mg twice daily. At her visit 3 months later, her blood pressure is 100/72
mm Hg, her hemoglobin A1C is 6.0%, but her microalbumin screen is positive. Which of the
following is the most appropriate response?

a. Continue weight loss and recheck in 3 months.

b. Limit dietary protein intake.

c. Intensify diabetic therapy to more tightly control glucose.

d. Initiate therapy with an ACE inhibitor.

e. Refer to nephrology.

422. A 44-year-old man is seeing you for a routine diabetic check. He was diagnosed with
type 2 diabetes 2 years ago. He is worried because his grandmother went blind as a
complication from her diabetes. Which of the following statements about diabetic
retinopathy is true?

a. The risk of retinopathy increases with increased hemoglobin A 1C levels.

b. It generally takes 10 to 20 years to see signs of retinopathy in a diabetic patient.

c. A daily aspirin decreases the risk of retinopathy development.

d. The first sign of retinopathy is usually the growth of new vessels on the retina.

e. Retinopathy is an uncommon cause of visual loss in this day and age.

423. You are seeing an African-American man with newly diagnosed diabetes. His blood
pressure at the last visit was 118/76 mm Hg, and at this visit it is 112/72 mm Hg. Which of
the following statements is true regarding the use of an ACE inhibitors in this patient?
a. An ACE inhibitor should be added to his regimen because he is diabetic, regardless of his
blood pressure.

b. An ACE inhibitor should be added to his regimen based on his blood pressure readings.

c. An ACE inhibitor should not be added to his regimen unless his blood pressure goes above
120 systolic.

d. An ACE inhibitor should not be added to his regimen unless he has microalbuminuria.

e. An ACE inhibitor should not be given to this patient if his creatinine is elevated.

425. A 39-year-old diabetic man asks you questions about his diet. Which of the following is
true?

a. A high-fiber diet improves glycemic control

b. A low-carbohydrate diet improves glycemic control

c. A high-protein diet improves glycemic control

d. Sucrose should not be included in the diabetic diet

e. A formalized dietary program is more likely to produce long-term sustained effects

426. A 44-year-old African American with type 2 diabetes transfers care to you. Reviewing
her records, you find she is on the maximum dose of sulfonylurea, but her hemoglobin A 1C
is 9.2% (H). Review of her baseline laboratory tests reveals normal liver enzymes and a
creatinine of 2.3 mg/dL. Which of the following management options would be most
beneficial?

a. Change to another sulfonylurea.

b. Add a biguanide.

c. Add a meglitinide.

d. Add a thiazolidinedione.

e. Add an α-glucosidase inhibitor.

435. You are caring for a patient with newly diagnosed diabetes. He is currently on no
medications, and you have just obtained a screening lipid profile. You find that the patient’s
LDL cholesterol is 180 mg/dL. Given this patient’s history, what is the patient’s LDL treatment
goal?

a. Less than or equal to 70 mg/dL.

b. Less than or equal to 100 mg/dL.

c. Less than or equal to 130 mg/dL.

d. Less than or equal to 160 mg/dL.

e. There is no recognized treatment goal.

hypertension
455. You have diagnosed a 42-year-old patient with hypertension. He is 5 ft 9 in tall, weighs
230 lb, and admits to poor eating habits, drinking 4 alcoholic beverages daily, and no regular
exercise. Which of the following lifestyle modifications, if instituted, will result in the largest
systolic blood pressure reduction?

a. Moderate alcohol consumption to no more than 2 drinks daily.

b. Engage in physical activity for 30 minutes per day, most days of the week.

c. Reduce dietary sodium intake to no more than 100 mEq/L per day.

d. Adopt a DASH eating plan (a diet rich in fruits, vegetables, and low-fat dairy products with
a reduced saturated and total fat content).

e. Lose 10 lb.

456. You have seen a 36-year-old man with elevated blood pressure. On one occasion, his
blood pressure was 163/90 mm Hg, and on a second occasion, his blood pressure was
158/102 mm Hg. You have encouraged lifestyle modifications including weight loss using
exercise and dietary changes. Despite some modest weight loss, at his current visit, his blood
pressure is 166/92 mm Hg. Which of the following is the best treatment strategy at this
point?

a. Use a thiazide diuretic.

b. Use an ACE inhibitor.

c. Use an angiotensin receptor blocker.

d. Use a β-blocker.

e. Use a two-drug combination of medications.

457. You are examining a 24-year-old patient for the first time and find her blood pressure to
be 155/92 mm Hg. On examination, you find that she has a very weak femoral pulses. Which
of the following is true regarding this patient?

a. Her blood pressure is not high enough to consider correction of her anatomical defect.

b. She is too young to consider intervention regardless of her blood pressure.

c. Correction of her deficit should eliminate the need for blood pressure medication.

d. She is likely to have a bicuspid aortic valve.

e. Her chest radiograph is likely to be normal.

458. You have just diagnosed a 35-year-old man with hypertension. He is otherwise healthy
and has no complaints. Which of the following is indicated in the initial evaluation?

a. TSH level assessment

b. Resting electrocardiogram

c. Stress test

d. Echocardiogram

e. Renal ultrasound

459. You are treating a 61-year-old man for hypertension. He is not responding well to
combination therapy with a thiazide diuretic and a β-blocker. On physical examination, you
note an abdominal bruit. Which of the following tests is most likely to help you evaluate him
further?

a. Chest x-ray

b. Angiotensin-converting enzyme inhibitor renal scan

c. Urinary metanephrines and vanillymandelic acid levels

d. Aortic CT scan

e. Echocardiogram
460. Despite lifestyle changes, a 37-year-old patient of yours still has blood pressures above
goal. She has no other medical concerns and no abnormalities on physical examination or
initial laboratory evaluation. Which of the following medications is best as an initial first-line
monotherapy, according to the Joint National Committee 7 (JNC 7)?

a. A thiazide diuretic

b. An ACE inhibitor

c. An angiotensin receptor blocker

d. A calcium channel blocker

e. A β-blocker

462. A 55-year-old man comes to your office after not being seen by a physician in more
than 10 years. He is found to be hypertensive, and his creatinine is found to be 2.3 mg/dL
(H). Which medication is most likely to control his blood pressure and decrease the
likelihood of progression of his renal disease?

a. A thiazide diuretic

b. An ACE inhibitor

c. A calcium channel blocker

d. A β-blocker

e. An aldosterone antagonist

463. You have diagnosed a 35-year-old African-American man with hypertension. Lifestyle
modifications helped reduce his blood pressure, but he was still above goal. You chose to
start hydrochlorothiazide, 25 mg daily. This helped his blood pressure, but it is still 142/94
mm Hg. Which of the following is the best approach to take in this situation?

a. Increase his hydrochlorothiazide to 50 mg/d.

b. Change to a loop diuretic.

c. Change to an ACE inhibitor.

d. Change to a β-blocker.

e. Add an ACE inhibitor.

464. You are seeing a 49-year-old man with a known history of hypercholesterolemia and
hypertension who has had recent complaints of chest pain. He reports a chest pressure,
described as “heaviness” in the substernal area. It is not associated with activity, but will
occur intermittently throughout the day. Which of the following is the best way to describe
what the patient is feeling?

a. Classic angina

b. Atypical angina

c. Anginal equivalent

d. Nonanginal pain

e. Atypical nonanginal pain

465. You are seeing a 36-year-old man complaining of shortness of breath. He reports
symptoms associated with activity and relieved by rest. He is otherwise healthy, takes no
medications, and denies chest pain or pressure. Which of the following is the best way to
describe what the patient is feeling?

a. Classic angina

b. Atypical angina

c. Anginal equivalent

d. Nonanginal pain

e. Atypical nonanginal pain

466. You are seeing a 44-year-old woman with a known history of asthma who has had
recent complaints of chest pain. She reports a stabbing pain that seems to be worse with
inspiration. It is not associated with activity, but will occur intermittently throughout the
day. Which of the following is the best way to describe what the patient is feeling?

a. Classic angina

b. Atypical angina

c. Anginal equivalent

d. Nonanginal pain

e. Atypical nonanginal pain

Thyroiditis
495. A 45-year-old woman presents to your office for evaluation. She reports that over the
last few weeks, she has noted an enlarging mass in the front of her neck. She feels well, has
had no changes in her health, and denies symptoms of hyper- or hypothyroidism. She also
denies recent viral illness. On examination, you note a diffusely enlarged thyroid that is
tender to touch. Which of the following is her most likely diagnosis?

a. Hashimoto thyroiditis

b. Subacute lymphocytic thyroiditis

c. Subacute granulomatous thyroiditis

d. Suppurative thyroiditis

e. Invasive fibrous thyroiditis

496. You are performing a review of systems on a 40-year-old female patient, and find that
several symptoms are pointing toward thyroid disease. Of the following symptoms and signs,
which is most commonly seen and reported in people with hyperthyroidism?

a. Weight loss

b. Tremor

c. Fatigue

d. Anorexia

e. Increased sweating

497. You are caring for a 35-year-old man who is complaining of fatigue and an inability to
gain weight. Laboratory evaluation reveals a TSH of 6.0 mIU/L (H) but a normal free T 4.
Which of the following is the best next step?

a. Test for antithyroid peroxidase.

b. Test for thyroid autoantibodies.

c. Treat with levothyroxine.

d. Treat with levothyroxine and T 3.

e. Monitor at yearly intervals.

498. A 26-year-old woman presents with weight gain, lethargy, dry skin, sweatiness, cold
intolerance, and thinning hair. You suspect hypothyroidism and order the appropriate
laboratory tests. Her TSH is high, and her free T 3 and free T 4 are both low. Which of the
following is the most likely diagnosis?

a. Primary hypothyroidism

b. Secondary hypothyroidism

c. Iodine deficiency

d. Thyroid hormone resistance

e. Subclinical hypothyroidism

499. You are screening a 35-year-old woman who presents with tachycardia, nervousness,
tremor, palpitations, heat intolerance, and weight loss. You suspect Graves disease. What
single test is best for differentiating Graves disease from other causes of hyperthyroidism?

a. TSH

b. TSH with free T 4 and free T 3

c. Thyroid receptor antibodies

d. Radionucleotide imaging of the thyroid

e. Thyroid ultrasound

500. When examining a 35-year-old, you notice a firm 3-cm thyroid nodule. His thyroid
studies are normal, and he is clinically euthyroid. Radionucleotide imaging demonstrates
uptake in the thyroid nodule. Which of the following is the most likely diagnosis?

a. Colloid cyst

b. Thyroid adenoma

c. Thyroid carcinoma

d. Metastatic disease

e. Neurofibroma
436. You are doing a screening physical examination for a 40-year-old female patient. She
does not have diabetes or known coronary artery disease. Based on National Cholesterol
Education Program risk calculation, you determine that her risk for coronary disease is less
than 10% in the next 10 years. Given this information, what is the patient’s LDL treatment
goal?

a. Less than or equal to 70 mg/dL.

b. Less than or equal to 100 mg/dL.

c. Less than or equal to 130 mg/dL.

d. Less than or equal to 160 mg/dL.

e. There is no recognized treatment goal.

NMS BOOK
1.Which of the following is the best choice of therapeutic agents among those presented for
the treatment of pseudomembranous colitis?

(A) Clindamycin

(B) Third-generation cephalosporin

(C) Amoxicillin-clavulanate

(D) Metronidazole

(E) Doxycycline

2.To assist in the decision whether to hospitalize a patient with community acquired
pneumonia (CAP), each of the following may be a factor in favor of hospitalization except for
which one?

(A) The patient is confused

(B) Serum creatinine 2.0 mg/dL

(C) Respiratory rate 30

(D) Blood pressure 90 mm Hg

(E) Age 64 years