Form 1

NBME Form 1 Step 2
Section 1: MedicalBooksVN.com
1. A 70-year-old woman has had increasing abdominal pain over the past 2 days. She
has renal failure and has been receiving peritoneal dialysis for 18 months; her last
treatment was 2 hours ago. She appears toxic. Her temperature is 39 C (102.2 F),
and blood pressure is 140/90 mm Hg. Her abdomen is distended and diffusely
tender to deep palpation with rebound tenderness. Leukocyte count is
18,000/mm3. Which of the following is the most appropriate next step?
A ) X-ray films of the abdomen
B ) Comparison of abdominal fluid amylase with serum amylase activity
C ) Gram's stain of abdominal fluid
D ) Ultrasonography of the abdomen
E ) CT scan of the abdomen and pelvis
2. A 5-year-old girl is brought to the physician because of temperatures to 40 C (104

F), tachypnea, and a nonproductive cough for 12 hours. Four days ago she was
treated with an oral antibiotic for suspected pneumococcal pneumonia. Examination
shows diminished breath sounds over the lower right lung fields and dullness to
percussion at the right costophrenic angle. Which of the following is the most likely
diagnosis?
A ) Bronchopleural fistula
B ) Empyema
C ) Lung abscess
D ) Pleurodynia
E ) Pneumothorax
3. A 40-year-old man is brought to the emergency department 1 hour after a high-

speed motor vehicle collision. On arrival, he is awake and alert but has severe pain
over the sternum. His systolic blood pressure is 80 mm Hg, pulse is 80/min, and
respirations are 10/min. An ECG shows multifocal premature ventricular
contractions but no ST-segment changes. His PO2 is 100 mm Hg. After 1 L of lactated
Ringer's solution is administered, his PO2 decreases to 60 mm Hg while breathing 4
L/min of oxygen by nasal cannula. Pulmonary capillary wedge pressure has
increased from 14 mm Hg to 24 mm Hg (N=1–10). Which of the following is the
most likely explanation for the patient's poor response to fluid resuscitation?
A ) Inadequate administration of fluids
B ) Myocardial contusion
C ) Myocardial infarction
D ) Pulmonary contusion
E ) Traumatic rupture of the aorta
4. A 21-year-old African American college student has had increasing fatigue over
the past 3 weeks. Since an episode of cystitis treated with trimethoprim-
sulfamethoxazole 3 weeks ago, he has been unable to keep up with his physical
education classes. For 6 months, he has been following a vegetarian diet that has
been supervised by student health services. Examination shows no abnormalities.
His hemoglobin level is 10 g/dL, mean corpuscular volume is 85 μm3, and
reticulocyte count is 15%. Which of the following is the most likely cause of anemia
in this patient?
A ) Anemia secondary to infection
B ) Antibiotic therapy
C ) Gastrointestinal blood loss
D ) Sickle cell disease
E ) Vegetarian diet
5. An 87-year-old nursing home resident with dementia, Alzheimer's type, is

admitted to the hospital because of progressive lethargy and decreased appetite for
3 days. She had a flu-like illness followed by a deep cough 1 week ago. Over the past
10 months, she has been hospitalized once for bacterial pneumonia. She is
responsive only to painful stimuli. Her temperature is 38.6 C (101.5 F), blood
pressure is 110/60 mm Hg, pulse is 123/min and regular, and respirations are
28/min. Examination shows dry mucous membranes. There is no adenopathy.
Crackles are heard in the right lung base. An x-ray film of the chest shows an
infiltrate at the right lung base. The remainder of the examination shows no
abnormalities. Which of the following is the most likely predisposing factor for this
patient's pneumonia?
A ) Decreased airway elasticity
B ) Decreased baroreflex
C ) Decreased gag reflex
D ) Decreased thyroid function
E ) Diastolic cardiac dysfunction
F ) Impaired cardiac response to exercise
G ) Impaired T-lymphocyte function
H ) Impaired thirst
I ) Increased lung compliance
J ) Renal salt wasting
6. A 27-year-old woman comes to the physician because of feelings of anxiety about

attending her 10-year high school reunion. She has a 2-year history of profound
anxiety, palpitations, and sweating associated with an uneasiness around people;
she avoids family gatherings and visiting friends because she is afraid of being
embarrassed. She acknowledges that this fear is unreasonable. She does not use
illicit drugs but says that alcohol makes her more comfortable around people. Her
blood pressure is 130/90 mm Hg, and pulse is 88/min. On physical examination, she
appears healthy and well nourished. Occasional wheezing is heard over the left lung
field. The remainder of the examination shows no abnormalities. On mental status
examination, she appears worried. Her leukocyte count is 9000/mm3 with a normal
differential. Which of the following is the most likely diagnosis?
A ) Alcohol abuse
B ) Anxiety disorder due to a general medical condition
C ) Asthma
D ) Generalized anxiety disorder
E ) Panic disorder with agoraphobia
F ) Social phobia
The response options for the next two items are the same. You will be required to
select one answer for each item in the set.
For each patient with urinary incontinence, select the most likely cause.
A ) Detrusor instability
B ) Interstitial cystitis
C ) Overflow incontinence
D ) Stress incontinence
E ) Urethra diverticulum
F ) Urinary fistula
7. A previously healthy 44-year-old woman, gravida 4, para 4, comes to the

physician because of a 9-month history of progressive loss of small amounts of urine
while running; she now has to wear an absorbent pad. Examination shows a second-
degree cystourethrocele.
For each patient with urinary incontinence, select the most likely cause.
A ) Detrusor instability
B ) Interstitial cystitis
C ) Overflow incontinence
D ) Stress incontinence
E ) Urethra diverticulum
F ) Urinary fistula
8. One day after an uncomplicated spontaneous vaginal delivery, a 23-year-old

woman, gravida 1, para 1, has the onset of loss of small amounts of urine. She
received epidural anesthesia during labor and delivery. Examination shows an
episiotomy without evidence of hematoma. She is voiding 50 to 75 mL of urine at a
time. Postvoid residual volume is 300 mL.
9. An 82-year-old woman is brought to the physician by her granddaughter because

of a 6-week history of increasing forgetfulness. She is a retired schoolteacher and
lives independently. Her granddaughter is concerned because on several occasions
she has left the stove on when she went to bed. During conversations with her
granddaughter, she has difficulty remembering past events and seems unconcerned
about her memory lapses. The patient describes trouble sleeping through the night
and has had a decreased appetite resulting in a 4.5-kg (10-lb) weight loss over the
past month. She has a history of similar symptoms 2 and 5 years ago that were
successfully treated with medication. She appears unkempt and has poor personal
hygiene. Her temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, and
pulse is 80/min and regular. Mental status examination shows psychomotor
retardation, a flat affect, impaired ability to recall past events, and trouble repeating
three numbers in sequence. She is unable to recall the names of recent presidents.
Her serum urea nitrogen (BUN) level is 25 mg/dL, and serum creatinine level is 1.7
mg/dL.
For each patient with cognitive impairment, select the most likely diagnosis.
A ) Acute stress disorder
B ) Dementia, Alzheimer's type
C ) Dissociative amnesia
D ) General paresis
E ) Head trauma
F ) Hepatolenticular degeneration (Wilson's disease)
G ) HIV encephalitis
H ) Huntington's disease
I ) Major depressive disorder
J ) Multi-infarct (vascular) dementia
K ) Niacin deficiency
L ) Normal-pressure hydrocephalus
M ) Parkinson's disease
N ) Pick's disease
O ) Schizophrenia, catatonic type

P ) Normal aging
10. A 42-year-old computer science professor is brought to the physician by her

husband, who reports insidious changes in his wife's personality and behavior. He
reports that she believes that aliens have been speaking to her and tampering with
their heating and air-conditioning systems. He says that she was upset when she
turned 40 years old, and her symptoms have developed since that time. She was
adopted, and her family history is unknown. Physical examination shows vermicular
movements of the tongue and bilateral writhing motions of the upper extremities.
Mental status examination shows indifference to her condition and mild to
moderate difficulty with memory and calculations.
11. A 5-month-old boy is brought for a follow-up examination. He was born at 37

weeks' gestation and has had persistent wheezing since shortly after birth despite
treatment with nebulized and oral bronchodilators and oral corticosteroids. His diet
consists of 32 ounces of iron-fortified cow's milk-based formula daily. He appears
well nourished and happy. On examination, there is moderate relief of wheezing
with extension of the neck. Which of the following is the most likely mechanism of
this infant's wheezing?
A ) Allergic reaction to cow's milk
B ) Aspiration of a foreign body
C ) Compression of the airway by a vascular ring
D ) Concurrent upper respiratory tract infection
E ) Persistent immaturity of lungs
12. An 18-month-old boy is brought to the emergency department because he has

not used his left arm since he fell while walking and holding hands with his 8-year-
old sister 2 hours ago. On examination, he holds his left upper extremity at his side
with his forearm pronated. There is no tenderness of the left lower extremity, but
there is restricted movement of the elbow. The remainder of the examination shows
no abnormalities. Which of the following is the most appropriate initial step in
management?
A ) Passive hypersupination of the forearm
B ) Application of figure-of-8 strap
C ) Administration of analgesics and application of ice
D ) Aspiration of the elbow joint

E ) In-place splint immobilization of the elbow
13. A 6-month-old girl is brought to the physician for a routine health maintenance
examination. She was born with a lumbosacral myelomeningocele which was
successfully repaired at 2 days of age. The anterior fontanelle is 6 x 8 cm and
bulging, and the posterior fontanelle is 3 x 4 cm and bulging. She has severe motor
and sensory deficits involving both lower extremities. A head growth chart shows
the following values:
Age
Head circumference (cm)
Birth
34.2
1 month
36.6
2 months
38
4 months
44
6 months
47
Which of the following is the most likely cause of increased intracranial pressure?
A ) Acute cerebral edema
B ) Decreased absorption of cerebrospinal fluid
C ) Dilation of cerebral arteries
D ) Intracranial mass lesion
E ) Obstruction of lateral sinus
F ) Obstruction of superior vena cava
G ) Obstruction of cerebrospinal fluid flow
H ) Overproduction of cerebrospinal fluid
14. An 18-year-old primigravid woman comes for her initial prenatal visit at 16
weeks' gestation. She is not sure about the date of her last menstrual period but says
that the pregnancy probably occurred immediately after she stopped taking oral
contraceptives 5 months ago. Maternal serum α-fetoprotein (MSAFP) level is
increased to 3 multiples of the median. Which of the following is the most
appropriate next step in management?
A ) Repeat measurement of MSAFP level
B ) Triple screening for MSAFP, serum β-hCG, and serum estriol levels
C ) Ultrasonography
D ) Amniocentesis for measurement of α-fetoprotein level
E ) Amniocentesis for chromosomal analysis
15. A 28-year-old man is brought to the emergency department by police because of

severe pain in the right lower quadrant of the abdomen for 36 hours. He has been
incarcerated in the county jail, and his court hearing is scheduled in 12 hours. He
takes no medications. Abdominal examination shows no rebound. Complete blood
count, liver tests, and erythrocyte sedimentation rate are within normal limits. An x-
ray film of the abdomen shows a normal gas pattern. Test of the stool for occult
blood is negative. Which of the following is the most likely diagnosis?
A ) Adjustment disorder
B ) Conversion disorder
C ) Depressive disorder not otherwise specified
D ) Factitious disorder
E ) Hypochondriasis
F ) Malingering
G ) Somatization disorder
16. A 6-year-old girl is brought to the physician because of a 4-week history of

headache, fatigue, and decreased appetite. During this period, she has had nausea
and vomiting. At the age of 4 years, she was diagnosed with poststreptococcal
glomerulonephritis. She is at the 15th percentile for height and the 10th percentile
for weight. Examination shows no abnormalities. Her serum urea nitrogen (BUN)
level is 50 mg/dL. Which of the following is most likely to limit progression of this
patient's renal failure?
A) Increased potassium and sodium bicarbonate intake
B) Decreased sodium and daily calorie intake

C) Low-protein diet
D) Strict fluid restriction
E) Dialysis
17. A previously healthy 62-year-old man comes to the emergency department

because of abdominal pain for 48 hours. His temperature is 38.6 C (101.5 F), blood
pressure is 130/80 mm Hg, pulse is 110/min, and respirations are 15/min.
Abdominal examination shows diffuse left lower quadrant tenderness with no
peritoneal signs. Rectal examination shows no abnormalities; test of the stool for
occult blood is negative. His leukocyte count is 14,700/mm3. Which of the following
is the most appropriate next step in diagnosis?
A) Barium enema
B) CT scan of the abdomen
C) Colonoscopy
D) Cystoscopy
E) Exploratory laparotomy
18. A previously healthy 3-month-old girl is brought to the emergency department

because of a 3-day history of grunting and increasing difficulty breathing. She
appears ill. Her temperature is 36.7 C (98 F), pulse is 160/min, and respirations are
76/min. Examination shows grunting, nasal flaring, and marked intercostal
retractions. Bronchial breath sounds and occasional bilateral crackles are heard on
auscultation. Serum studies show:
Ca2+ 5.6 mg/dL

Phosphorus 11 mg/dL
Alkaline phosphatase 250 U/L
Capillary blood gas analysis on 100% oxygen:
pH 7.36
PCO2 38 mm Hg
PO2 46 mm Hg
An x-ray film of the chest shows bilateral, diffuse interstitial infiltrates and absence
of the thymic shadow. Bronchoalveolar lavage is positive for numerous
Pneumocystis carinii. Which of the following is the most likely mechanism of these
findings?
A ) Adenosine deaminase deficiency
B ) Consumption of complement
C ) Defective opsonization
D ) Destruction of CD4+ T lymphocytes
E ) Developmental arrest of maturation of B lymphocytes
F ) Dysmorphogenesis of the third and fourth pharyngeal pouches
G ) Impaired chemotaxis
H ) Impaired phagocytic oxidative metabolism
19. A 4-year-old boy is brought to the emergency department 20 minutes after being
involved in a motor vehicle collision. He was an unrestrained passenger. On arrival,
his blood pressure is 110/70 mm Hg, pulse is 100/min, and respirations are 32/min
with grunting and retractions. Examination shows multiple bruises over the chest.
Arterial blood gas analysis while breathing 40% oxygen shows:
pH 7.38
PCO2 34 mm Hg
PO2 66 mm Hg
An x-ray film of the chest obtained 4 hours later shows diffuse infiltrates on the
right side. Which of the following is the most likely diagnosis?
A) Acute respiratory distress syndrome
B) Aspiration pneumonia
C) Fat embolism
D) Hemothorax
E) Pulmonary contusion
20. A 72-year-old man comes to the physician because of a 7-month history of leg
weakness and dry eyes and mouth. He also has had a 10.4-kg (23-lb) weight loss
over the past 4 months despite no change in appetite. He has smoked one and a half
packs of cigarettes daily for 50 years. He drinks 4 oz of alcohol daily. He has peptic
ulcer disease and emphysema. Medications include cimetidine, theophylline, and
low-dose prednisone. Examination shows mild ptosis. He has a barrel-shaped chest.
Breath sounds are distant. There is moderate weakness of the proximal muscles of
the lower extremities. Reflexes are absent. He has difficulty rising from a chair.
Sensory examination shows no abnormalities. An x-ray film shows a hyperinflated
chest and a 3 x 4-cm mass in the right hilum. His neurologic findings are most likely
due to a lesion involving which of the following?
A) Muscle membrane
B) Parasympathetic nervous system
C) Peripheral nerve
D) Presynaptic neuromuscular junction
E) Sympathetic nervous system
21. A 42-year-old man comes to the emergency department because of a 2-week

history of increasingly severe headaches and a 2-day history of nausea, vomiting,
neck stiffness, and unsteadiness. He has type 2 diabetes mellitus treated with
glyburide. His temperature is 38.1 C (100.5 F). Funduscopic examination shows
bilateral papilledema. Neurologic examination shows mild meningismus and
diffusely brisk deep tendon reflexes. He walks with a moderately broad-based gait.
He is able to recall two out of three objects after 5 minutes and makes several errors
on serial sevens. A CT scan of the head shows no abnormalities. Cerebrospinal fluid
analysis shows a glucose level of 18 mg/dL, a protein level of 108 mg/dL, and a
leukocyte count of 59/mm3 (1% segmented neutrophils and 99% lymphocytes); a
cryptococcal antigen assay is positive. Which of the following is the most
appropriate pharmacotherapy for this patient?
A) Acyclovir
B) Amphotericin B
C) Itraconazole
D) Penicillin
E) Vancomycin
22. A 3-year-old girl is brought to the physician after her mother noted blood on her
underpants. Examination shows genital condylomata acuminata in the perineal,
peri-introital, labial, and anal areas. Some of the pedunculated condylomata appear
to have caused the bleeding. She has no visible intravaginal condylomata or vaginal
or anal tears. Her mother has a palmar wart on her hand but no history of
condylomata acuminata. Her mother has a boyfriend who does not live with them
and who has never been left alone with the girl. They live with the mother's 27-year-
old brother who only baby-sits the children when they are asleep. Which of the
following is the most appropriate next step in management?
A) Psychiatric assessment of the mother
B) DNA typing of the mother's palmar wart for papillomavirus
C) Treatment of the mother's palmar wart
D) Vaginal, anal, and throat cultures for Chlamydia trachomatis and Neisseria
gonorrhoeae in the child
E) Laser therapy of the condylomata acuminata in the child
23. A 55-year-old man has had crushing substernal chest pain on exertion over the
past 6 weeks. He had a myocardial infarction 2 months ago. He takes nitroglycerin
as needed and one aspirin daily. He has smoked two packs of cigarettes daily for 30
years. Examination shows normal heart sounds and no carotid or femoral bruits.
Treatment with a β-adrenergic blocking agent is most likely to improve his
symptoms due to which of the following mechanisms?
A) Decreasing diastolic relaxation
B) Decreasing myocardial contractility
C) Dilating the coronary arteries
D) Peripheral vasodilation
E) Preventing fibrin and platelet plugs
24. A previously healthy 52-year-old woman comes to the physician because she has
had a large pimple on her right hand for 2 weeks that has failed to heal. She resides
in southeastern USA where she owns a nursery and garden shop. Examination
shows a painless red papule on the hand with several nontender subcutaneous
nodular lesions above it. Which of the following is the most likely diagnosis?
A)Blastomycosis
B)Candidiasis
C)Coccidioidomycosis
D)Histoplasmosis
E)Sporotrichosis
25. A 28-year-old woman at 28 weeks' gestation reports excessive fatigability and

dyspnea. Her blood pressure is 118/74 mm Hg, pulse is 110/min and regular, and
lungs are clear to auscultation. The cardiac apex is not palpable. S1 is loud, and there
is a sharp sound after S2. A low-frequency diastolic murmur is heard at the apex
that increases in intensity before S1. Which of the following is the most likely
diagnosis?
A) Aortic regurgitation
B) Ebstein's anomaly
C) Mitral regurgitation
D) Mitral stenosis
E) Tricuspid regurgitation
26. A 27-year-old woman comes to the physician because of a 2-year history of

intermittent diarrhea and severe cramping abdominal pain. The stools are watery,
occasionally foul-smelling, and nonbloody. She is currently pain-free and has not
had diarrhea for 2 days. She also has intermittent constipation. She has not had
fever or weight loss. She returned from a trip to Mexico 3 months ago. She had an
appendectomy at the age of 12 years and a cesarean delivery 4 years ago.
Examination shows no abnormalities. Which of the following is the most likely
diagnosis?
A) Bacterial gastroenteritis
B) Crohn's disease
C) Intermittent small-bowel obstruction
D) Irritable bowel syndrome
E) Laxative abuse
27. An asymptomatic 21-year-old woman is found to have an adnexal mass on pelvic

examination. She uses oral contraceptives. A photograph of the mass is shown.
Which of the following is the most likely diagnosis?
A) Benign cystic teratoma
B) Corpus luteum cyst
C) Dysgerminoma
D) Endometrioma
E) Mucinous cystoadenoma
28. A 16-year-old girl is brought to the physician because of episodes of palpitations

over the past 6 months. The episodes occur when she runs or plays basketball. She
is otherwise asymptomatic. Her blood pressure is 124/46 mm Hg, pulse is 78/min,
and respirations are 18/min. She weighs 55 kg (121 lb) and is 180 cm (71 in) tall.
Her arm span is 188 cm (74 in), and the upper segment to lower segment ratio is
0.85. Her fingers appear long and are hyperextensible. A grade 4/6, early diastolic
murmur is heard along the upper and middle left sternal border with radiation to
the apex. Peripheral pulses are bounding. Which of the following is the most likely
cause of these findings?
A) Aortic incompetence
B) Aortic stenosis
C) Mitral incompetence
D) Mitral stenosis
E) Pulmonary incompetence
F) Pulmonary stenosis
G) Tricuspid incompetence
H) Tricuspid stenosis
29. A previously healthy 87-year-old woman comes to the physician because of a 4-

month history of vulvar itching. Examination shows excoriated areas from
scratching and a white, thin vulva. The labia minora are absent, and there are small
fissures at the introitus. The remainder of the examination shows no abnormalities.
A) Escherichia coli infection
B) Lichen sclerosus
C) Squamous cell carcinoma
D) Trichomoniasis
E) Vulvar melanoma
F) Vulvar vestibulitis
30. One month after undergoing an uneventful renal transplant for chronic renal
failure secondary to glomerulonephritis, a 38-year-old woman is hospitalized
because of increased serum urea nitrogen (BUN) and creatinine levels. Prior to
transplantation, she had been receiving hemodialysis for 3 years. Current
medications include cyclosporine and prednisone. Examination shows no
abnormalities. Over the past 48 hours, urine output has remained stable. Both renal
biopsy and a radionuclide scan confirm the diagnosis of acute rejection. Which of
the following is the most effective treatment?
A) Immediate discontinuation of cyclosporine
B) Increased dosage of corticosteroids
C) Diuresis and alkalinization of the urine
D) Renal dialysis for 1–2 weeks
E) Transplant nephrectomy
31. An 18-year-old man comes to the physician 1 week after he had a blood pressure
of 140/110 mm Hg during a routine precollege examination. His temperature is 37.1
C (98.7 F), blood pressure is 140/100 mm Hg, pulse is 92/min, and respirations are
12/min. The upper extremities appear to be more muscular than the lower
extremities. Radial pulses are normal; femoral, posterior tibial, and dorsalis pedis
pulses are decreased. A grade 2/6 systolic murmur is heard over the precordium,
anterior chest, and back. An ECG shows left ventricular hypertrophy. Which of the
A ) Limiting physical activity
B ) Repeat blood pressure measurement in 1 month
C ) Initiate a low-sodium diet and exercise program
D ) Pharmacologic management
E ) Operative treatment
32. A 77-year-old woman comes to the physician because of a 2-day history of

cramping abdominal pain and distention accompanied by nausea and vomiting. She
is otherwise healthy and has no history of abdominal operations. Her temperature is
37.4 C (99.4 F), blood pressure is 110/86 mm Hg, pulse is 112/min, and respirations
are 24/min. Cardiopulmonary examination shows no abnormalities. Examination of
the abdomen shows distention and mild diffuse tenderness; bowel sounds are high-
pitched. An x-ray film of the abdomen shows air-fluid levels throughout the small
bowel and air in the liver; there is no gas in the colon or free air. Which of the
following is the most likely diagnosis?
A) Adhesive small-bowel obstruction
B) Cecal cancer
C) Gallstone ileus
D) Intussusception
E) Mesenteric infarction
F) Ruptured appendicitis
G) Small bowel lymphoma
33. Four hours after undergoing a cesarean delivery at term followed by tubal
ligation, a 37-year-old woman, gravida 2, para 2, has dizziness and confusion. The
operation was uncomplicated, and blood loss is estimated to be 800 mL. Patient-
controlled epidural analgesia has been moderately effective for pain. Her blood
pressure now is 80/40 mm Hg, decreased from 120/72 mm Hg intraoperatively,
and pulse is 152/min, increased from 96/min intraoperatively. Breath sounds are
decreased bilaterally. No murmurs are heard. Abdominal examination shows
distention and tenderness. Bowel sounds are absent. The incision is intact with no
drainage. She is disoriented to person, place, and time. Her hematocrit is 23%;
preoperative hematocrit was 35%. Which of the following is the most likely cause of
the hemodynamic changes?
A) Epidural-related hypotension
B) Insufficient intraoperative fluid replacement
C) Postoperative intra-abdominal hemorrhage
D) Supine hypotensive syndrome
E) Underestimated intraoperative blood loss

34. A 42-year-old woman comes to the physician for evaluation of persistently
increased blood pressures. At her last two office visits during the past 3 months, her
blood pressure has ranged between 150–170/105–115 mm Hg. During this period,
she has had occasional headaches. In addition, she has had an increased urine
output over the past 6 weeks that she attributes to a diet high in sodium. She is
otherwise healthy and takes no medications. Her blood pressure today is 168/115
mm Hg, pulse is 68/min, and respirations are 14/min. Funduscopic examination
shows mild arteriovenous nicking. The point of maximal impulse is not displaced.
There is no edema, abdominal bruits, or masses. Serum studies show:
Na+ 144 mEq/L

Cl– 90 mEq/L
K+ 2.9 mEq/L
HCO3– 32 mEq/L
Urea nitrogen (BUN) 20 mg/dL
Creatinine 1.2 mg/dL
Which of the following is the most likely underlying cause of this patient's
hypertension?
A) Autonomous production of aldosterone
B) Catecholamine-producing tumor
C) Decreased arterial distensibility caused by atherosclerosis
D) Excess production of atrial natriuretic peptide
E) Juxtaglomerular cell hypertrophy and sclerosis
35. A previously healthy 4-year-old girl is brought to the physician because of fever
and refusal to walk for 1 day. She appears mildly ill. Her temperature is 38.6 C
(101.5 F), pulse is 120/min, and respirations are 22/min. The right knee is
erythematous and swollen. She holds her right knee in flexion and resists any
attempted movement of her right leg. She cries when the right knee is moved. Which
of the following is the most appropriate next step in management?
A) Acetaminophen with codeine therapy
B) Arthrocentesis
C) Bone marrow aspiration
D) Bone scan
E) Immobilization and traction
F) Lyme titer
G) MRI of the spine
H) Physical therapy
I) Reassurance
J) Serum rheumatoid factor assay
K) Systemic antibiotic therapy
36. An 18-year-old man comes for an examination prior to participation in school

sports. He states that he has had a dull ache in the scrotum since being hit in that
area during a basketball game 2 months ago. Examination shows a 2-cm, hard,
nontender mass in the right testicle. The mass does not transilluminate or change in
size when the patient is placed in the supine position. Which of the following is the
most likely cause?
A) Cystic dilations of the efferent ductules
B) Dilated pampiniform venous plexus
C) Fluid accumulation within the tunica vaginalis testis
D) Germinal cell tumor
E) Vascular trauma
37. A 14-year-old boy is brought to the physician by his parents because of a 2-year
history of increasing academic problems. His parents say that he has always been
hyperactive and distractible, but now his academic performance has deteriorated to
the point that he is failing ninth grade. His teachers say that his hyperactivity is
disrupting the classroom. He weighs 54 kg (120 lb) and is 152 cm (60 in) tall. Sexual
development is Tanner stage 5; examination shows macro-orchidism, which was not
shown on previous examinations. He has a high forehead and long, protruding ears.
He exhibits poor eye contact during the examination. Psychoeducational testing
shows an IQ of 70. Which of the following is the most likely diagnosis?
A) Attention-deficit/hyperactivity disorder
B) Autistic disorder
C) Down syndrome
D) Fetal alcohol syndrome
E) Fragile X syndrome
F) Lesch-Nyhan syndrome
G) Pervasive developmental disorder, not otherwise specified
H) Prader-Willi syndrome
I) Rett's disorder
J) Seminiferous tubule dysgenesis (Klinefelter's syndrome)
38. A 32-year-old woman comes to the physician because of vaginal discharge for 2
weeks. She has been sexually active with one female partner for 5 years. She has not
been treated with antibiotics over the past 2 years. Her last Pap smear was 6 years
ago when she was sexually active with a male partner. She has not used illicit drugs
or alcohol. Examination shows a grayish vaginal discharge with a pH greater than
4.5. A wet mount preparation of the vaginal discharge is most likely to show which
of the following?
A) Budding yeast
B) Clue cells
C) Ferning
D) Leukocytes in sheets
E) Trichomonas vaginalis
39. A 57-year-old woman with breast cancer comes to the physician because of
increasing neck pain over the past 3 days. She has fallen frequently because of
muscle weakness. Vital signs are within normal limits. Examination shows
hyperreflexia of all extremities. There is tenderness over the cervical spine. Serum
calcium level is 11 mg/dL. X-ray films show metastases to the cervical spine. Which
A) Application of a soft cervical collar
B) Physical therapy
C) Mithramycin therapy
D) Tamoxifen therapy
E) Spinal cord decompression and cervical stabilization
40. A 57-year-old man comes to the physician because of intermittent urinary

incontinence over the past 6 months. He has loss of small amounts of urine when he
coughs or sneezes. He has not had pain or blood with urination. He has a 15-year
history of type 2 diabetes mellitus with peripheral neuropathy, retinopathy, and
gastroparesis. Current medications include metoclopramide and glyburide. He
appears well. Rectal examination shows a normal-sized prostate. Neurologic
examination shows decreased sensation in a stocking-glove distribution. Achilles
tendon reflexes are absent bilaterally. Test of the stool for occult blood is negative.
Urinalysis shows 2+ protein with no leukocytes or erythrocytes. His postvoid
residual volume is 500 mL. Which of the following is the most likely mechanism of
this patient's incontinence?
A) Central nervous system disorder
B) Functional incontinence
C) Intrinsic sphincter deficiency
D) Overflow incontinence from acontractile bladder
E) Overflow incontinence from bladder outlet obstruction

F) Pelvic floor muscle weakness
G) Retroperitoneal fibrosis
H) Retroperitoneal lymphadenopathy
I) Urinary tract infection
41. A 27-year-old primigravid woman at 38 weeks' gestation is admitted in labor.

Her pregnancy has been uncomplicated, and a routine prenatal visit 2 days ago
showed no abnormalities. On admission, fetal heart tones cannot be heard.
Ultrasonography shows little amniotic fluid, fetal edema, and no evidence of a fetal
heartbeat. After 1 hour, she delivers a 3175-g (7-lb) stillborn infant; examination of
the infant shows no obvious abnormalities except for mild edema. The placenta and
membranes appear normal. Which of the following is the most appropriate
immediate course of action?
A) Notify the hospital liability department
B) Obtain consent for fetal organ donation from the parents
C) Recommend autopsy of the infant
D) Tell the mother not to worry since she can get pregnant again
E) Tell the parents that there is a 1 in 4 chance of recurrence in future pregnancies
42. A previously healthy 16-year-old high school wrestler comes to the physician
because of a rash on his forearms and the back of his legs for 1 week. He is allergic
to pollen and dust. Examination shows patches of erythema with mild lichenification
over the antecubital and popliteal fossae. There are clusters of painful umbilicated
vesicles at sites of active skin inflammation. Which of the following is the most likely
diagnosis?
A) Eczema herpeticum
B) Herpes zoster
C) Keratosis pilaris
D) Lichen planus
E) Pityriasis rosea
43. A 5-week-old boy is brought to the physician because of vomiting for 3 days.
Switching from a cow's milk-based formula to a soy-based formula and one bottle of
an electrolyte solution has not decreased his vomiting. His mother says that there is
no yellow color to the vomitus, but it is forceful and occurs immediately after he has
had 1 to 2 ounces of liquid. He appears to vomit more liquid than he drank. He has
one mustard-colored seedy stool daily. Examination shows no abnormalities. Which
of the following is the most likely explanation for his vomiting?
A) Duodenal atresia
B) Gastroesophageal reflux
C) Hypertrophic pyloric stenosis
D) Lactose intolerance
E) Protein malabsorption
F) Rotavirus infection
44. A 28-year-old woman is hospitalized after taking a massive overdose of

acetaminophen tablets in a suicide attempt. She has type 1 diabetes mellitus and
major depressive disorder refractory to tricyclic antidepressant therapy. Despite
appropriate therapy, she develops rapidly progressive hepatic failure and becomes
progressively encephalopathic. On the 6th day of hospitalization, she is comatose. A
CT scan of the brain shows mild diffuse swelling. An appropriately crossmatched,
size-appropriate donor liver is available. Which of the following is the most
appropriate course of action regarding transplantation?
A) Do not proceed with the transplantation because diabetes mellitus is a

contraindication
B) Do not proceed with the transplantation because hepatic function is likely to

return over the next week
C) Do not proceed with the transplantation because major depressive disorder

places the patient at risk for another suicide attempt
D) Do not proceed with the transplantation because the onset of encephalopathy

and CT findings suggest bacterial meningitis
E) Proceed with the transplantation
45. A 3-year-old boy who is HIV positive is brought for a routine examination. His
diet is appropriate for age. His medications include three antiretroviral drugs and
trimethoprim-sulfamethoxazole for Pneumocystis carinii prophylaxis. Laboratory
studies show:
Hemoglobin 8.6 g/dL

Mean corpuscular hemoglobin 38 pg/cell
Mean corpuscular hemoglobin concentration 30% Hb/cell
Mean corpuscular volume 101 μm3
Leukocyte count 5600/mm3
Segmented neutrophils 60% (many hypersegmented)
Bands 3%
Lymphocytes 37%
Red cell distribution width 21% (N=10–16)
Which of the following is most likely to have prevented this patient's anemia?
A) Folic acid supplementation
B) Iron supplementation
C) Thyroid supplementation
D) Vitamin B12 (cyanocobalamin) supplementation
E) Monthly intravenous immune globulin therapy
46. A 20-year-old man is brought to the emergency department on a summer day 20

minutes after developing headache, nausea, and unsteady gait while running the last
2 miles of a marathon. On arrival, he is confused and disoriented. His temperature is
40 C (104 F), blood pressure is 100/60 mm Hg, and pulse is 155/min. His skin is
warm and dry. Neurologic examination shows no focal findings. Which of the
following is the most likely mechanism of this patient's condition?
A) Depletion of total body potassium
B) Depletion of total body sodium
C) High-output cardiac failure
D) Inadequate dissipation of body heat
E) Release of creatine kinase from muscle cells
__________________________________________________________________________________
Form 1--Section 2:--
1. A 77-year-old woman is brought to the physician by her son for a routine health
maintenance examination. She says that she feels well. Her son reports that 1 month
ago, she got lost while driving home from the local supermarket. Two weeks ago,
she forgot to turn off the stove after cooking dinner. She has been wearing bilateral
hearing aids since audiometry 2 years ago showed bilateral high-frequency hearing
loss. Her visual acuity corrected with glasses is 20/25 in both eyes. Neurologic
examination shows mild fine tremors of the hands when the arms are outstretched;
the tremor is not present at rest. Muscle strength is 5/5 in all extremities. Deep
tendon reflexes are decreased at the ankles and 2+ elsewhere. Her gait is normal.
Sensation to vibration is mildly decreased over the toes. On mental status
examination, she is awake, alert, and conversant. Her language function is normal.
She is oriented to person, place, and time and recalls one out of three objects after
10 minutes. Which of the following findings in this patient warrants further
evaluation?
A) Decreased deep tendon reflexes at the ankles
B) Decreased sensation to vibration over the toes
C) High-frequency hearing loss
D) Memory loss
E) Tremor of the outstretched hands
2. A 10-year-old girl is brought to the emergency department because of diffuse,

aching abdominal pain, nausea, and recurrent vomiting over the past 5 hours. She
has an 8-year history of type 1 diabetes mellitus treated with 20 U of NPH and 6 U of
regular insulin in the morning and 14 U of NPH and 5 U of regular insulin in the
evening. She appears lethargic but is easily arousable. There is an obvious odor of
ketones on her breath. Her blood pressure is 100/70 mm Hg, pulse is 95/min, and
respirations are 20/min and deep. Serum studies show:
Na+ 142 mEq/L

K+ 5.3 mEq/L
HCO3– 6 mEq/L
Glucose 710 mg/dL
Which of the following laboratory findings is most likely to be increased?
A ) Arterial pH
B ) Serum C-peptide level
C ) Serum magnesium level
D ) Serum osmolality
E ) Serum phosphorus level
3. A healthy 24-year-old woman comes for a routine health maintenance

examination. Menses occur at regular 28-day intervals and last 5 to 6 days. Her last
menstrual period was 3 weeks ago. She takes no medications. Bimanual examination
shows a 5-cm, mildly tender left adnexa. A pregnancy test is negative. Which of the
A) Repeat examination in 2 weeks
B) Measurement of serum CA 125 level
C) Measurement of serum α-fetoprotein level
D) CT scan of the pelvis
E) Diagnostic laparoscopy
4. A 24-year-old primigravid woman at 18 weeks' gestation comes for a routine

prenatal visit. She has had increased bowel movements over the past 9 weeks; the
stools are sometimes covered with mucus and blood. Use of over-the-counter
antidiarrheal drugs has not relieved her symptoms. Pregnancy has been otherwise
uncomplicated. She has never traveled outside the USA. Examination shows
erythematous, tender nodules over the anterior surface of both lower extremities;
some of the nodules have a violaceous hue. The uterus is consistent in size with an
18-week gestation. Rectal examination shows no hemorrhoids or fissures. Fetal
heart tones are audible by Doppler. Which of the following is the most likely
diagnosis?
A) Amebiasis
B) Diverticulitis
C) Hyperperistaltic diarrhea
D) Inflammatory bowel disease
E) Viral gastroenteritis
5. A 32-year-old woman at 38 weeks' gestation comes for a routine prenatal visit.

During routine screening at 28 weeks' gestation, she tested positive for hepatitis B
surface antigen. Her pregnancy has been otherwise uncomplicated. Examination
shows a uterus consistent in size with a 38-week gestation. Which of the following
measures is most likely to decrease the risk for hepatitis B infection in her
newborn?
A) Recommendation of bottle-feeding rather than breast-feeding
B) Maternal administration of hepatitis B immune globulin (HBIG) now
C) Neonatal administration of HBIG after delivery and hepatitis B vaccine at 3

months of age
D) Neonatal administration of HBIG and hepatitis B vaccine immediately after

delivery
E) Cesarean delivery
6. A 37-year-old woman comes to the physician because of progressive shortness of

breath over the past 5 years; she now has fatigue and shortness of breath with mild
exertion. She has a history of mitral stenosis secondary to rheumatic fever at the age
of 15 years. She was asymptomatic until 5 years ago when she developed severe
shortness of breath during pregnancy. She was treated with diuretics, low-sodium
diet, and bed rest, and she was able to deliver the baby at term. Her only medication
is hydrochlorothiazide. Her temperature is 37 C (98.6 F), blood pressure is 110/80
mm Hg, pulse is 100/min and regular, and respirations are 26/min. Cardiac
examination shows an obvious opening snap in S2. A grade 3/6, late diastolic
murmur is heard at the apex. A right ventricular lift is palpated along the left sternal
border. Which of the following is most likely increased in this patient?
A) Blood flow to the lower lung fields
B) Diastolic filling time
C) Left-to-right shunt of blood
D) Left ventricular end-diastolic pressure
E) Pulmonary artery pressure
7. A 5-year-old girl with ventricular septal defect is scheduled for tonsillectomy in 2

weeks. She has no known drug allergies. Her temperature is 37 C (98.6 F).
Examination shows no abnormalities. Which of the following is the most
appropriate prophylaxis prior to tonsillectomy?
A) Amoxicillin
B) Ciprofloxacin
C) Rifampin
D) Tetracycline
E) Trimethoprim-sulfamethoxazole
F) No prophylaxis indicated
8. An 8-year-old girl with type 1 diabetes mellitus is brought to the emergency

department 10 minutes after being involved in a motor vehicle collision. She was in
the back seat of a small automobile that was rear-ended. Initially, she was alert
during transport and reported bilateral thigh pain, but then she stopped talking,
closed her eyes, and became unresponsive to voice; on arrival, she responds to
noxious stimuli with brief grimaces and no withdrawal. Her blood pressure is
40/palpable mm Hg, pulse is 148/min, and respirations are 28/min. Air entry is
symmetric. The pupils are equal and react to light. No cardiac murmur is heard. The
abdomen is soft. There is swelling of the upper portions of both thighs. Her
hematocrit is 37%. Which of the following is the most appropriate next step in
management?
A) Measurement of arterial blood gases

B) X-ray film of the chest
C) CT scan of the head
D) Administration of 50% dextrose in water
E) Infusion of 0.9% saline
9. A previously healthy 16-year-old boy is brought to the emergency department 20

minutes after an episode of left arm shaking that lasted approximately 3 minutes.
Over the past 2 days, he has had fever and emotional lability. On arrival, his
temperature is 38.9 C (102 F). He is somnolent and disoriented to person, place, and
time. He responds poorly to pain. Neurologic examination shows no other
abnormalities. Laboratory studies show:
Hematocrit 34%
Segmented neutrophils 50%
Lymphocytes 50%
Platelet count 280,000/mm3
Analysis of cerebrospinal fluid shows:

Lymphocytes 80%
Erythrocyte count 300/mm3
Glucose 60 mg/dL
Protein 400 mg/dL
Which of the following is the most likely cause of this patient's neurologic findings?
A) Bacterial infection
B) Congenital malformation
C) Fungal infection
D) Hemorrhage
E) Immune-mediated demyelination
F) Parasitic infection
G) Viral infection
10. A 72-year-old man with hypertension has had increasingly severe back pain
over the past 2 months. He had a myocardial infarction 4 years ago. He has marked
tenderness over T11, T12, L1, and L2. An x-ray film of the lumbosacral spine shows
osteoblastic lesions in these vertebrae. Which of the following is the most likely
diagnosis?
A) Abdominal aneurysm
B) Fibrosarcoma
C) Metastatic prostate carcinoma
D) Multiple myeloma
E) Osteosarcoma
11. A 64-year-old woman has moderately severe postoperative pain 1 day after a
total abdominal hysterectomy and bilateral salpingo-oophorectomy. Which of the
following is the most appropriate analgesic pharmacotherapy?
A) Oral aspirin-codeine compound
B) Oral diazepam
C) Oral ibuprofen
D) Intermittent intravenous naloxone
E) Patient-controlled intravenous morphine
F) Transcutaneous administration of fentanyl

12. A 37-year-old woman comes to the physician because of a 1-day history of
throbbing facial pain. She describes the pain as 7 out of 10 in intensity. Over the past
9 days, she has had nasal congestion, purulent nasal discharge, sore throat, and a
nonproductive cough. She does not smoke. Her husband and children have had no
recent illness. Her temperature is 38.5 C (101.3 F). Examination shows congested
nasal mucosa and purulent discharge on the left. There is tenderness to palpation
over the left cheek and no transillumination over the left maxillary sinus. The
tympanic membranes are normal, and there is no erythema of the throat.
Examination shows no cervical adenopathy. The lungs are clear to auscultation.
Which of the following is the most likely causal organism?
A) Haemophilus influenzae type b
B) Moraxella catarrhalis
C) Staphylococcus aureus
D) Streptococcus pneumoniae
E) Streptococcus pyogenes (group A)
13. A 42-year-old woman comes to the physician for an annual pelvic examination
and Pap smear. Over the past year, she has had increasing fatigue and difficulty
sleeping. She has two children who both attend college. She is currently looking for
part-time work outside the home. Her husband has been busy in a new start-up
business. Examination shows no abnormalities. Laboratory studies show:
Hemoglobin 15 g/dL
Leukocyte count 6000/mm3 with a normal differential
Serum
Na+ 145 mEq/L
Cl– 102 mEq/L
K+ 4.5 mEq/L
HCO3– 25 mEq/L
Aspartate aminotransferase (AST, GOT) 22 U/L
Alanine aminotransferase (ALT, GPT) 19 U/L
γ-Glutamyltransferase (GGT) 83 U/L(N=5–50 U/L)
Which of the following is the most likely explanation for this patient's laboratory
abnormalities?
A) Acetaminophen
B) Alcohol
C) Diphenhydramine
D) Estrogen effect
E) Ibuprofen
14. Five weeks after vaginal delivery of a healthy full-term newborn, a 22-year-old
woman, gravida 1, para 1, is brought to the physician by her mother because of
depressed mood for 2 weeks. Her mother is concerned that her daughter is not able
to take care of her infant. Physical examination shows no abnormalities. She is quiet
and tearful and does not engage in conversation easily. She states that she lives
alone with her infant and has had thoughts of suicide and infanticide. Which of the
A) Reassurance
B) Long-term outpatient counseling
C) Antipsychotic therapy
D) Selective serotonin reuptake inhibitor therapy
E) Admission to the hospital for treatment
15. A 72-year-old man comes for a routine follow-up examination. He has chronic
obstructive pulmonary disease treated with β-adrenergic agonists and ipratropium
by metered-dose inhaler and mild arterial insufficiency of the lower extremities
treated with aspirin. His blood pressure is 160/60 mm Hg, pulse is 70/min, and
respirations are 12/min. Funduscopic examination shows arteriovenous nicking.
Pedal pulses are decreased bilaterally. Which of the following antihypertensive
drugs is most likely to cause adverse effects in this patient?
A) α2-Adrenergic agonist
B) α-Adrenergic blocking agent
C) β-Adrenergic blocking agent
D) Angiotensin-converting enzyme (ACE) inhibitor
E) Calcium-channel blocking agent
F) Loop diuretic
G) Thiazide diuretic
H) Vasodilator
For each patient with loss of consciousness, select the most likely diagnosis.
A) Aortic stenosis
B) Carotid sinus hypersensitivity
C) Conversion reaction
D) Hypertrophic obstructive cardiomyopathy
E) Hypoglycemia
F) Mitral valve prolapse
G) Orthostatic hypotension
H) Pulmonary embolus
I) Seizure
J) Vasovagal syncope
K) Vertebrobasilar insufficiency
16. A 15-year-old boy is brought to the emergency department 30 minutes after a 2-

minute episode of loss of consciousness after completing a 400-meter race. On
awakening, he says that he feels fine except for shortness of breath. He weighs 82 kg
(180 lb) and is 191 cm (75 in) tall. His blood pressure is 110/70 mm Hg, pulse is
70/min and regular, and respirations are 15/min. The lungs are clear to
auscultation. A grade 2/6 systolic murmur is heard at the left sternal border with
minimal radiation to the neck; the murmur becomes louder when he stands.
17. A 62-year-old woman is brought to the emergency department 1 hour after a 1-

minute episode of loss of consciousness; her symptoms began when she stood up
after she passed a dark, watery stool. She has had diarrhea and dark stools for 2
days. She has been receiving warfarin therapy for deep venous thrombosis for 2
weeks. On arrival, her blood pressure is 82/60 mm Hg, and pulse is 150/min and
regular. She is unable to stand. The lungs are clear to auscultation. A grade 2/6
systolic murmur is heard at the second right intercostal space with no radiation.
Examination shows a soft, nontender abdomen. There is 1+ edema of the right lower
extremity with no tenderness. Test of the stool for occult blood is positive.
18. A 50-year-old woman has had progressive dyspnea over the past 2 weeks and
constant, sharp chest pain for 4 days. The pain is localized to the center of the chest
and is worse while supine. She underwent a right, modified radical mastectomy and
adjuvant chemotherapy for breast cancer 3 years ago. She has a history of
hypothyroidism treated with thyroid replacement therapy. She has smoked one
pack of cigarettes daily for 30 years and drinks two ounces of alcohol daily. She is
dyspneic and diaphoretic. Her temperature is 37.2 C (99 F), blood pressure is 90/70
mm Hg with a pulsus paradoxus of 20 mm Hg, pulse is 110/min, and respirations
are 28/min. Examination shows jugular venous distention to the angle of the
mandible. The liver span is 14 cm with 4 cm of shifting abdominal dullness. Arterial
blood gas analysis on room air shows a pH of 7.50, PCO2 of 30 mm Hg, and PO2 of
70 mm Hg. An x-ray film of the chest shows an enlarged cardiac silhouette with a
globular configuration. An ECG shows sinus tachycardia with nonspecific ST-
segment changes diffusely. Which of the following is the most appropriate next step
in management?
A ) Echocardiography
B ) CT scan of the abdomen
C ) Ventilation-perfusion lung scans
D ) Bronchoscopy
E ) Paracentesis
19. A 3-year-old boy is brought to the physician because of a 7-day history of fever
and a painful swollen lymph node in his groin. This is his sixth episode of lymph
node swelling; the previous episodes resolved after drainage and prolonged
antibiotic therapy. He also had pneumonia at the age of 12 months that required
chest tube placement for drainage. A maternal uncle died during childhood of
recurrent infections. The patient is at the 5th percentile for height and weight. His
temperature is 38.5 C (101.3 F). Examination shows a warm, tender, erythematous
lymph node in the right inguinal area. There are several healed incisions over the
inguinal area and neck from old drainage sites. Laboratory studies show:
Hematocrit 35%
Leukocyte count 17,000/mm3
Bands 10%
Lymphocytes 25%
A Gram's stain of the lymph node aspirate shows numerous segmented neutrophils
filled with bacteria; cultures grow Staphylococcus aureus. Which of the following is
the most likely mechanism for these findings?
A) Adenosine deaminase deficiency
B) Consumption of complement
C) Defective opsonization
D) Destruction of CD4+ T lymphocytes
E) Developmental arrest of maturation of B lymphocytes
F) Dysmorphogenesis of the third and fourth pharyngeal pouches
G) Impaired chemotaxis
H) Impaired phagocytic oxidative metabolism
20. A 67-year-old woman has been intubated for 1 week after undergoing a left
lobectomy for lung cancer. She has chronic obstructive pulmonary disease. Her
preoperative functional vital capacity was 40% of predicted. She is awake and alert.
Her blood pressure is 130/75 mm Hg, and pulse is 72/min. The ventilator settings
are a synchronized intermittent mandatory ventilation of 8/min, FIO2 of 40%, and
positive-end expiratory pressure of 5 cm H2O. Arterial blood gas analysis shows:
pH 7.42
PCO2 47 mm Hg
PO2 90 mm Hg
O2 saturation 96%
Which of the following is the most appropriate next step in management?
A) Antibiotic therapy
B) Bronchodilator therapy
C) Chest physiotherapy
D) Decrease inotropes
E) Diuretic therapy
F) Fiberoptic bronchoscopy
G) Heparin therapy
H) Incentive spirometry
I) Increase FIO2
J) Increase inotropes
K) Increase respiratory rate
L) Placement of thoracostomy tube
M) Tracheostomy
N) Wean from the ventilator
21. A 67-year-old woman is brought to the emergency department because of

severe chest pain 4 hours after undergoing outpatient endoscopy and dilatation of
an esophageal stricture caused by reflux. At discharge, she reported no chest pain.
Three hours later, she vomited a small amount of blood and had severe pain. She is
pale. Her temperature is 38 C (100.4 F), blood pressure is 140/85 mm Hg, pulse is
125/min, and respirations are 22/min. Examination shows crepitus in the neck and
moderate epigastric tenderness. The lungs are clear to auscultation, and breath
sounds are equal bilaterally. Rectal examination shows no masses; test of the stool
for occult blood is positive. Which of the following is the most likely cause of these
symptoms?
A) Bleeding from erosive esophagitis
B) Esophageal perforation
C) Mallory-Weiss syndrome
D) Myocardial infarction
E) Perforated gastric ulcer
22. An 87-year-old woman is brought to the physician by her son because of

progressive memory loss over the past 2 years. Her son says that she repeats herself
frequently and has been forgetting to take her routine medications. She takes
hydrochlorothiazide for mild systolic hypertension and levothyroxine for
hypothyroidism. She had vulvar cancer 10 years ago treated with wide excision. Her
blood pressure is 138/78 mm Hg. Physical examination is within normal limits for
her age. Mini-Mental State Examination score is 23/30. Laboratory studies,
including serum vitamin B12 (cyanocobalamin), thyroxine (T4), and thyroid-
stimulating hormone levels, are within normal limits. A CT scan of the head shows
mild volume loss. Which of the following is the most appropriate pharmacotherapy?
A) β-Adrenergic agonist
B) Cholinesterase inhibitor
C) Dopamine agonist
D) Prednisone
E) Selective serotonin reuptake inhibitor
23.
A newborn is in severe respiratory distress immediately following delivery. She was
born at 35 weeks' gestation to a 35-year-old woman, gravida 2, para 1, aborta 1,
who did not receive prenatal care. The newborn's pulse is 60/min, and respirations
are irregular and labored. Examination shows pallor with perioral cyanosis,
anasarca, hepatosplenomegaly, and scattered petechiae. Cord blood hemoglobin is 4
g/dL, and reticulocyte count is 18%. A direct antiglobulin (Coombs') test is positive.
Which of the following sets of blood groups is most likely in the mother and her
newborn?
Mother Newborn
A) A, Rh-positive O, Rh-positive
B) A, Rh-positive O, Rh-negative
C) A, Rh-negative O, Rh-negative
D) O, Rh-positive O, Rh-negative
E) O, Rh-negative O, Rh-positive
24. After an uncomplicated laparoscopic cholecystectomy, a 62-year-old man has

not had any urine output since the Foley catheter was removed 12 hours ago.
During the hour before the operation, the 40 minutes of operating room time, and
the 2 hours in the recovery room, his fluid input was 2.5 L and urine output was 1 L.
Since that time, he has been receiving intravenous 5% dextrose in water with 0.45%
saline and morphine. He is awake and alert and has a moderate amount of
abdominal pain. Preoperative serum studies showed:
Na+ 137 mEq/L
K+ 4.2 mEq/L
One hour after receiving an intravenous bolus of 0.9% saline, the patient does not
produce any urine. Which of the following is the most appropriate next step in
management?
A) Increase in the dose of morphine

B) Intravenous administration of an additional bolus of 0.9% saline
C) Intravenous administration of doxazosin
D) Intravenous administration of furosemide
E) Reinsertion of a Foley catheter
25. A healthy 55-year-old man comes for an initial health maintenance examination.
His last visit to a physician was over 10 years ago. He does not smoke and drinks
only on social occasions. Examination shows no abnormalities. Which of the
following immunizations should be administered?
A) Hepatitis A vaccine
B) Influenza virus vaccine
C) Measles-mumps-rubella vaccine
D) Pneumococcal vaccine
E) Diphtheria-tetanus toxoid
26. A 19-year-old man comes to the physician because of frequent nosebleeds over
the past 3 weeks. He has bipolar disorder currently well controlled with lithium
carbonate, bupropion, and valproic acid. Physical examination shows no
abnormalities except for dried blood in the nares. Mental status examination shows
an anxious mood and slight motor restlessness. Serum studies show a lithium
carbonate level of 1.3 mEq/L (therapeutic range=0.6–1.2), and valproic acid level of
77 μg/mL (therapeutic range=40–100). Which of the following is the most
A) Measurement of serum aspartate aminotransferase (AST, GOT) activity
B) Measurement of serum bupropion level
C) Platelet count
D) Discontinuation of lithium carbonate therapy
E) Discontinuation of valproic acid therapy

27. An asymptomatic 32-year-old man comes for a routine health maintenance
examination. He has a 10-year history of frequent sinus and pulmonary infections.
He had an anaphylactic reaction to a blood transfusion following a motor vehicle
collision 3 years ago. His temperature is 37 C (98.6 F). Examination shows mild
erythema in the posterior pharynx. The lungs are clear to auscultation. A complete
blood count and serum protein electrophoresis are within normal limits. Which of
the following is the most likely cause of the frequent infections?
A) Colonization with Streptococcus pneumoniae
B) Common variable immunodeficiency
C) HIV infection
D) Selective IgA deficiency
E) X-linked agammaglobulinemia
28.
A 37-year-old man is brought to the emergency department 6 hours after the onset
of constant, increasingly severe abdominal pain and nausea. His symptoms awoke
him from sleep, and he has vomited once since that time. He has no history of
similar symptoms, and he does not take any medications or use alcohol or illicit
drugs. Family history is noncontributory. He is in acute distress and lying in the fetal
position. Any movement exacerbates the pain. His temperature is 37.8 C (100 F),
blood pressure is 108/68 mm Hg, pulse is 112/min, and respirations are 24/min.
The lungs are clear to percussion and auscultation. Examination shows a rigid
abdomen; bowel sounds are absent. Laboratory studies show:
Hemoglobin 14 g/dL
Serum
Total bilirubin 1.2 mg/dL
An x-ray film of the chest shows a small amount of free air under the left diaphragm.
Administration of antibiotics and fluids is begun. Which of the following is the most
A) Barium swallow
B) CT scan of the abdomen
C) Intravenous administration of an H2-receptor blocking agent
D) Upper endoscopy
E) Laparotomy
29. A 52-year-old woman with alcoholism comes to the physician after a serum
cholesterol level of 290 mg/dL was found on a routine screening. She drinks a pint
of vodka daily. She takes captopril for hypertension and glyburide for type 2
diabetes mellitus. She also has intermittent episodes of gout. Fasting serum studies
show:
Total cholesterol 252 mg/dL

HDL-cholesterol 80 mg/dL
Triglycerides 300 mg/dL
Glucose 118 mg/dL
Thyroid-stimulating hormone 4.5 μU/mL
A) Alcohol cessation
B) Better control of diabetes
C) Switch from captopril to calcium-channel blocking agent therapy
D) Gemfibrozil therapy
E) Thyroid replacement therapy
30. A 23-year-old woman has pain, cramping, and swelling of the right calf 3 days
after an uncomplicated labor and delivery. The right foot is swollen, and there is
marked tenderness with dorsiflexion and palpation of the right calf. Examination
shows no other abnormalities. A complete blood count and serum electrolyte levels
are within normal limits. Which of the following is the most likely cause of this
condition?
A) Hypercoagulable state of pregnancy
B) Hyperuricemia
C) Peripheral artery aneurysm
D) Platelet embolus
E) Prolonged pressure on the vena cava during delivery
31. A 2-month-old boy is brought to the physician for a well-child examination. He

smiles spontaneously and vocalizes without crying, but he does not appear to laugh
or squeal. He will not work for a toy that is out of his reach. Which of the following is
the most appropriate assessment of language and psychosocial development?
Language Psychosocial
development development
A) Normal normal
B) Normal delayed
C) Delayed normal
D) Delayed delayed
32. A previously healthy 24-year-old woman comes to the physician because of a

low-grade fever and a nonproductive cough for 7 days. She has been able to
continue her daily activities. Her temperature is 37.7 C (99.9 F). A few scattered
inspiratory crackles are heard in the thorax. An x-ray film of the chest shows patchy
infiltrates in both lungs. Which of the following is the most appropriate initial
pharmacotherapy?
A) Amoxicillin
B) Cefaclor
C) Ciprofloxacin
D) Erythromycin
33. A 45-year-old woman comes to the emergency department because of shortness

of breath, chest pain, dizziness, and mild numbness and tingling around the lips for
2 hours. She says that she feels like she is going to die. She had three similar
episodes last week when she was vacationing at the Grand Canyon; the first episode
occurred while crossing a narrow bridge on a donkey. She takes a hypoglycemic
drug for type 2 diabetes mellitus, verapamil for hypertension, and sumatriptan as
needed for migraine. She is mildly diaphoretic and appears pale. Her blood pressure
is 130/90 mm Hg, pulse is 120/min, and respirations are 28/min. Serum glucose
level is 120 mg/dL. An ECG shows sinus tachycardia. Sublingual nitroglycerin
therapy does not relieve her symptoms and gives her a headache. The most
appropriate next step in management is administration of which of the following?
A) Haloperidol
B) Lorazepam
C) Oxygen
D) Sumatriptan
E) Verapamil
34. A 67-year-old man is brought to the emergency department 4 hours after the
onset of severe midlumbar back pain. He is anxious, pale, and diaphoretic. His
temperature is 37.1 C (98.8 F), blood pressure is 105/65 mm Hg, and pulse is
120/min. Examination shows no other abnormalities. X-ray films of the lumbar
spine show degenerative disc disease with calcifications anterior to the vertebral
bodies. Which of the following is the most likely diagnosis?
A) Aortoiliac occlusion
B) Herniated nucleus pulposus

C) Lumbar discitis
D) Lumbar strain
E) Pyelonephritis
F) Ruptured aortic aneurysm
G) Spinal stenosis
35. A 17-year-old boy is brought to the emergency department by his parents

because of bizarre behavior for 6 hours. Last night he was out with friends, and
since returning, he has been confused and has "trashed" his room. His blood
pressure is 165/95 mm Hg. He is hypervigilant, has little spontaneous speech, and is
disoriented to place and time. He appears catatonic but abruptly becomes assaultive
two times and needs to be restrained. Which of the following is the most likely
substance taken?
A) Cocaine
B) Ecstasy
C) LSD
D) Methaqualone
E) PCP
For each patient with back pain, select the most likely diagnosis.
A) Herniated disc
B) Lumbar spinal stenosis
C) Metastatic cancer
D) Muscle strain
E) Osteoporotic compression fracture
F) Sacroiliitis
G) Spinal epidural abscess
H) Spondylolisthesis
36. A 57-year-old woman is brought to the physician 2 days after the sudden onset
of severe low back pain; the pain does not radiate to the lower extremities. The pain
began when she was lifting her grandson. She does not have weakness or sensory
loss in the legs and has had no urinary incontinence. She has a 10-year history of
rheumatoid arthritis treated with prednisone. Her temperature is 37 C (98.6 F),
blood pressure is 130/60 mm Hg, and pulse is 64/min. Examination shows
deformities of the interphalangeal joints of the hands and exquisite tenderness to
percussion over the lumbar spine. Bilateral straight-leg raising to 80 degrees does
not increase the pain. Muscle strength and sensation are intact in the lower
extremities. Deep tendon reflexes are 2+ bilaterally. Babinski's sign is absent
bilaterally.
37. A previously healthy 32-year-old plumber comes to the physician because of a 3-

week history of constant, dull, low back pain that does not radiate to the extremities.
The pain began after he unloaded heavy equipment from his van. It increases with
activity and is temporarily relieved by bed rest and ibuprofen. Examination shows
tenderness to palpation over the lumbar paraspinal region bilaterally. The pain
increases with forward or lateral movements of the spine. Muscle strength and
sensation are intact in the lower extremities. Bilateral straight-leg raising to 80
degrees does not increase the pain. Deep tendon reflexes are 2+ bilaterally.
Babinski's sign is absent bilaterally.
38. A 72-year-old man comes to the physician because of a 2-month history of
urination twice nightly and occasional urinary frequency and urgency. He has a 15-
year history of type 2 diabetes mellitus now moderately well controlled with
glyburide. His father was diagnosed with prostate cancer at the age of 70 years, and
his sister died of complications from systemic lupus erythematosus. His blood
pressure is 135/86 mm Hg. Cardiopulmonary examination shows no abnormalities.
Abdominal examination shows no suprapubic fullness or tenderness. There is mild
enlargement of the prostate with no palpable nodules. His postvoid residual volume
is 10 mL. Serum studies show a urea nitrogen (BUN) level of 45 mg/dL and
creatinine level of 3.8 mg/dL. Urine dipstick shows 3+ protein. Which of the
following is most likely to have prevented progression of this patient's renal
disease?
A) Intermittent Foley catheterization
B) Intravenous mannitol therapy
C) Oral cyclophosphamide and prednisone therapy
D) Oral enalapril therapy
E) Oral finasteride therapy
F) Oral prednisone therapy only
G) Oral terazosin therapy
39. Two hours ago, a 24-year-old man had the sudden onset of pain in the right side
of his chest that has become increasingly severe. He is now having difficulty
breathing. His temperature, blood pressure, and pulse are normal. An x-ray film of
the chest is shown. Which of the following is the most appropriate next step in
management?
A) Bed rest and sedative therapy
B) Antibiotic therapy
C) Anticoagulant therapy
D) Tube thoracostomy
E) Immediate thoracotomy
40. A 21-year-old college student comes to the physician because of acne that
developed 4 days ago while she was taking her medical college admission test. She is
concerned about her appearance and plans to be in a wedding in 3 weeks. She has
had similar episodes that have resolved completely without treatment. Examination
shows acute acne over the face with a predominance of comedones and pustules.
There is no evidence of chronic scarring. Which of the following is the most
appropriate initial step in treatment?
A) Dietary restriction of chocolates and simple sugars
B) Dietary restriction of milk products
C) Topical acyclovir
D) Topical hydrocortisone cream
E) Topical retinoic acid
41. A 67-year-old woman comes for a routine health maintenance examination. She
exercises regularly. She is not sexually active. At her last visit 1 year ago, her serum
cholesterol level was 180 mg/dL, and fasting serum glucose level was 80 mg/dL; a
Pap smear and mammography showed normal findings. Two years ago, flexible
sigmoidoscopy showed no abnormalities. Today, she weighs 63 kg (140 lb) and is
165 cm (65 in) tall. Her blood pressure is 120/80 mm Hg. Examination shows no
abnormalities. Which of the following is the most appropriate screening test for this
patient?
A) Pap smear
B) Measurement of serum cholesterol level
C) Measurement of serum glucose level
D) Mammography
E) Flexible sigmoidoscopy
42. A 62-year-old man has had the gradual onset of fatigue and shortness of breath
over the past 3
years. There is striking jugular venous distention with a large wave occurring with
S2. The carotid upstroke is normal. Cardiac examination shows a lifting systolic
motion of the sternum and no palpable point of maximal impulse. A grade 3/6,
holosystolic, plateau-shaped murmur that is loudest on inspiration is heard at the
lower left sternal border. The liver is enlarged and tender, and the abdomen is
swollen with a fluid wave. There is marked ankle edema. Which of the following is
the most likely cause of the murmur?
A) Aortic stenosis
B) Mitral regurgitation
C) Mitral stenosis
D) Tricuspid regurgitation
E) Ventricular septal defect
43. A 24-year-old woman comes to the physician because of constant, severe pain in
her neck, shoulders, and back for 3 months. She has been unable to enjoy her usual
activities because of the pain. Use of over-the-counter ibuprofen and aspirin has not
relieved her symptoms. She has a history of irritable bowel syndrome. Examination
shows multiple tender spots over the neck, shoulders, and lumbar spine. Range of
motion of all joints is full. There is no evidence of synovitis. Fluorescent serum
antinuclear antibody and rheumatoid factor assays are negative. Which of the
A) Ankylosing spondylitis
B) Fibromyalgia
C) Polymyalgia rheumatica
D) Polymyositis
E) Seronegative rheumatoid arthritis

44. A 72-year-old man comes to the physician because of a 6-month history of mild
to moderate shortness of breath when climbing stairs. He had a myocardial
infarction 2 years ago and has had an ejection fraction of 35% since then. His only
medication is a β-adrenergic blocking agent. The lungs are clear to auscultation.
Cardiac examination shows an S4 gallop. There is no peripheral edema. Laboratory
studies are within normal limits. An ECG shows no acute changes. Which of the
following is the most appropriate pharmacotherapy?
A) α-Adrenergic blocking agent
B) Angiotensin-converting enzyme (ACE) inhibitor
C) Angiotensin2-receptor blocking agent
D) Nitrates
E) Thiazide diuretic
45. A 42-year-old woman comes to the physician because of a 3-month history of a

recurrent vivid dream that several men are assaulting her and her children. Upon
awakening, she is anxious and distressed by the frightening images. She realizes that
it is just a dream but is afraid to go back to sleep. She does not know why she is
having this particular dream because she has never been the victim of an assault.
She drinks two to three cups of coffee each morning. She does not use illicit drugs.
Physical examination shows no abnormalities. There is no evidence of depressed
mood or hallucinations. Laboratory studies are within normal limits. Which of the
A) Acute stress disorder
B) Nightmare disorder
C) Panic disorder
D) Sleep apnea
E) Sleep terror disorder

46. A 57-year-old man is brought to the emergency department 30 minutes after he
was found on the floor of his house; he has left hip pain and shortness of breath. He
has renal failure but has missed his last two dialysis treatments. His renal failure
was caused by inadvertent ingestion of ethylene glycol. His renal function did not
improve, and he is currently on the transplantation list. Medications include
amlodipine and doxazosin. On arrival, his temperature is 37.5 C (99.5 F), blood
pressure is 150/100 mm Hg, pulse is 95/min and regular, and respirations are
24/min. His breathing is rapid and deep. Crackles are heard in the lung bases.
Examination shows a soft abdomen. Bowel sounds are normal. The left lower
extremity is externally rotated. Laboratory studies show:
Serum
Na+ 135 mEq/L
Cl– 102 mEq/L
K+ 7.1 mEq/L
HCO3– 12 mEq/L
Arterial blood gas analysis on 4 L/min of oxygen by nasal cannula:

pH 7.22
PCO2 31 mm Hg
PO2 61 mm Hg
An ECG shows peaked T-waves. It will be at least 45 minutes before dialysis can be
started. Which of the following is the most appropriate next step in management?
A) Observation until dialysis is initiated
B) Intravenous calcium gluconate

C) Intravenous glucose and insulin
D) Intravenous 0.9% saline
E) Intravenous sodium bicarbonate
F) Rectal sodium polystyrene sulfonate (Kayexalate)
Section 3:--
1. A 26-year-old woman is brought to the emergency department because of marked

confusion for 2 hours; she also has had a flu-like illness for 3 days. Over the past 6
weeks, she has had increased fatigue, weakness, and nausea. She recently started
thyroid hormone replacement therapy for autoimmune thyroiditis; 1 week ago, her
serum thyroid-stimulating hormone level was 3 μU/mL. Her temperature is 38 C
(100.4 F), blood pressure is 80/40 mm Hg, and pulse is 140/min. She appears
confused and lethargic. Examination shows cool, mottled skin. There is generalized
hyperpigmentation, especially involving the palmar creases. The lungs are clear to
auscultation. Abdominal examination shows diffuse mild tenderness and no
rebound. Laboratory studies show:
Hemoglobin 10 g/dL
Eosinophils 20%
Lymphocytes 25%
Serum
Na+ 124 mEq/L
Cl– 92 mEq/L
K+ 6.4 mEq/L
HCO3– 16 mEq/L
An x-ray film of the chest and urinalysis show normal findings. An ECG shows sinus
tachycardia with peaked T waves. Which of the following is most likely to confirm
the primary cause of this patient's condition?
A) Measurement of pulmonary artery pressure
B) Measurement of right atrial pressure
C) Measurement of serum antithyroglobulin antibody level
D) Measurement of serum lactate dehydrogenase activity
E) Measurement of serum thyroid-stimulating hormone level
F) ACTH stimulation test
G) Dexamethasone suppression test
H) Blood cultures
I) Echocardiography
2. A 27-year-old man comes to the physician because of a 1-week history of

shortness of breath with exertion, paroxysmal nocturnal dyspnea, and swelling of
his feet. He has not had chest pain or palpitations. He has been healthy except for a
"bad cold" 1 month ago that resolved spontaneously after 10 days. His temperature
is 37 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 120/min, and respirations
are 24/min. Examination shows jugular venous distention to 8 cm. Bilateral basilar
crackles are heard. Cardiac examination shows a diffuse, laterally displaced point of
maximal impulse. There is a normal S1 and S2 and an S3. Examination shows 2+
pretibial edema bilaterally. An ECG shows no abnormalities. Echocardiography is
most likely to show which of the following?
A) Asymmetric septal hypertrophy

B) Bicuspid aortic valve with stenosis
C) Diffuse hypokinesia and dilation of the ventricles
D) Dyskinesia of the left ventricular apex
E) Mitral valve prolapse
3.
A 35-year-old man is brought to the emergency department because of intractable

nausea and vomiting of nonbilious fluid over the past 48 hours. He has a history of
duodenal ulcer disease treated with H2-receptor blocking agents. His temperature is
37 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 130/min, and respirations
are 10/min. Examination shows mild epigastric tenderness. Which of the following
are the most likely serum electrolyte findings?
Na+ Cl– K+ HCO3–

(mEq/L) (mEq/L) (mEq/L) (mEq/L)
A) 115 80 4.0 25
B) 140 80 2.5 40
C) 145 100 5.0 15
D) 150 105 2.5 25
E) 160 135 5.0 25
4. A 3-year-old boy is brought for a follow-up examination. He just completed a 10-

day course of amoxicillin that has not resolved his right ear pain. He appears
irritable. His temperature is 38.9 C (102 F). Examination shows downward and
lateral displacement of the right auricle with tenderness to palpation of the
posterior auricular area; his neck is supple. Which of the following is the most
appropriate next step in diagnosis?
A) Bone scan
B) CT scan of the head
C) Tympanometry
D) Lumbar puncture
E) Tympanocentesis
5. A 67-year-old man has had shortness of breath on exertion for 3 months; he has
had an 11.3-kg (25-lb) weight loss during this period. He has smoked two packs of
cigarettes daily for 25 years. He appears chronically ill. Examination shows
decreased breath sounds on the left; heart sounds are normal. An x-ray film of the
chest shows a large left-sided pleural effusion. Which of the following is the most
appropriate next step in diagnosis?
A) Bronchoscopy
B) Thoracoscopy
C) Closed pleural biopsy
D) Open pleural biopsy
E) Thoracentesis
6. A program for the primary prevention of coronary artery disease is implemented

in a community in the USA. Assuming that diagnostic procedures and detection
remain the same, which of the following measures involving the disease is most
effective in monitoring the program?
A) Case fatality
B) Hospitalization
C) Incidence
D) Mortality
E) Prevalence
7. A 77-year-old woman comes to the physician because of low back pain for 3
months. She has hypertension controlled with a calcium-channel blocking agent and
type 2 diabetes mellitus controlled with diet. Her vital signs are within normal
limits. Examination shows no spinal or costovertebral angle tenderness; straight-leg
raising produces pain in the low back at the L2–4 range. Knee jerk and ankle
reflexes are 2+ bilaterally. Babinski's sign is absent bilaterally. Urinalysis shows 5–
10 epithelial cells/hpf, 2–5 leukocytes/hpf, and few bacteria. Which of the following
is the most appropriate pharmacotherapy?
A) Acetaminophen
B) Gold
C) Methotrexate
D) Prednisone
E) Probenecid
8. A 32-year-old woman who is HIV positive has a CD4+ lymphocyte count of

800/mm3 (Normal ≥ 500). Her health maintenance regimen should include
immunization against which of the following pathogens?
A) Haemophilus influenzae type b
B) Hepatitis A
C) Influenza virus
D) Neisseria meningitidis
E) Streptococcus pyogenes (group A)
9. A 32-year-old woman comes to the physician because of bright red rectal bleeding
and severe stabbing pain with each bowel movement over the past 2 weeks. She has
blood-streaked stools, and there is blood on the toilet paper. Over the past 2
months, she has had mild constipation with no change in the caliber of the stool.
Examination shows a small anal fissure at the posterior midline. Rectal examination
is painful, but no abnormalities are detected except for a small amount of bright red
blood from the fissure. Which of the following is the most appropriate next step in
management?
A) Anesthetic ointment and stool softeners

B) Anal dilatation under anesthesia
C) Debridement and closure of the fissure under anesthesia
D) Surgical flaps
E) Lateral internal sphincterotomy
10. A 28-year-old nulligravid woman comes for a routine health maintenance
examination. She has had progressively severe dysmenorrhea over the past 6
months adequately controlled by nonsteroidal anti-inflammatory agents. Pelvic
examination shows a normal vagina and cervix. The uterus is retroverted and fixed,
and there is nodularity of the cul-de-sac. A 6-cm left adnexal mass is palpated.
Transvaginal ultrasonography shows a 7-cm septated adnexal mass. Four weeks
later, there is no change in the size of the adnexal mass. Which of the following is the
most appropriate diagnostic test?
A) Measurement of serum CA 125 level
B) Barium enema
C) CT scan of the pelvis
D) MRI of the pelvis
E) Laparoscopy
11. A 67-year-old woman is hospitalized because of abdominal pain and persistent

copious vomiting for 24 hours. Two weeks ago, she was hospitalized for treatment
of atrial fibrillation; after cardioversion to a normal sinus rhythm, she began
treatment with warfarin. Yesterday at a follow-up visit, her INR was 6, and her
medication was discontinued. She takes no other medications. Her temperature is
37 C (98.6 F), blood pressure is 100/78 mm Hg, pulse is 120/min and regular, and
respirations are 20/min. The abdomen is distended and moderately tender; there is
voluntary guarding in the epigastrium. There are no masses, organomegaly, or
obvious hernias. Rectal examination shows no abnormalities. Test of the stool for
occult blood is negative. Her hemoglobin level has decreased from 13 g/dL
yesterday to 7.8 g/dL today. An ECG shows a normal sinus rhythm. Which of the
following is the most likely explanation for this patient's abdominal symptoms?
A) Internal small-bowel herniation
B) Intestinal ischemia from a cardiac embolus
C) Intramural hematoma of the proximal small bowel
D) Intussusception of the small bowel
E) Malrotation of the small bowel
12. A 32-year-old man with alcoholism is brought to the emergency department by

friends because he has been unable to stand without support and has had "funny
eye movements"; they report that he has been drinking approximately 18 beers
daily over the past month and has been increasingly confused over the past 5 days.
He is awake and confused but is noncombative. His speech is slurred, and his breath
smells of alcohol. His temperature is 37.2 C (99 F), blood pressure is 180/60 mm Hg,
pulse is 110/min, and respirations are 18/min. Physical examination shows sixth
cranial nerve palsy, horizontal diplopia, strabismus, and an asymmetric horizontal-
gaze evoked nystagmus. Neurologic examination shows no focal weakness or
numbness. When helped up and told to walk, he has a broad-based, uncertain gait.
When asked how he arrived at the emergency department, he relates that "I drove
to this place to visit some friends." The most likely cause of these findings is a
deficiency of which of the following?
A) Folic acid
B) Magnesium
C) Vitamin B1 (thiamine)
D) Vitamin B12 (cyanocobalamin)
E) Zinc
13. A 32-year-old woman, gravida 2, para 2, comes to the physician because she has
been amenorrheic for 4 months. Examination shows a well-estrogenized vagina and
no evidence of virilization or other abnormalities. A serum pregnancy test is
negative. She is given medroxyprogesterone and has the onset of bleeding 3 days
later. Which of the following is the most likely cause of her condition?
A) Anovulation
B) Asherman's syndrome
C) Hypopituitarism
D) Menopause
E) Premature ovarian failure
14.
A previously healthy 47-year-old woman comes to the emergency department

because of a 36-hour history of nausea, vomiting, and abdominal pain that radiates
to her back. Over the past 3 years, she has had intermittent episodes of cramping
abdominal pain 1 to 2 hours after meals; the pain lasts for several hours and
resolves spontaneously. She does not smoke and drinks one to two glasses of wine
each evening. There is a family history of coronary artery disease and hypertension.
Her temperature is 37 C (98.6 F), blood pressure is 100/60 mm Hg, pulse is
120/min, and respirations are 20/min. Abdominal examination shows moderate
epigastric and right upper quadrant tenderness with no guarding or rebound; bowel
sounds are decreased. Laboratory studies show:
Hematocrit 45%
Leukocyte count 9000/mm3 with a normal differential
Serum
Total bilirubin 1.5 mg/dL
Aspartate aminotransferase (AST, GOT) 78 U/L
Amylase 365 U/L
Lipase 1223 U/L (N=1–160)
Triglycerides 300 mg/dL
A) Acute cholecystitis
B) Alcoholic hepatitis
C) Alcoholic pancreatitis
D) Ascending cholangitis
E) Gallstone pancreatitis
F) Hepatitis A
G) Pancreatic cancer
H) Peptic ulcer disease
I) Triglyceride-induced pancreatitis
15. A healthy 37-year-old primigravid woman at 12 weeks' gestation comes for a

routine prenatal visit. The pregnancy was achieved by in vitro fertilization. She does
not use tobacco, alcohol, or drugs. She is a hematologist and works 10 to 12 hours
daily. Two previous ultrasonographies have shown a triplet gestation. She weighs
66 kg (145 lb) and is 178 cm (70 in) tall. Her blood pressure is 116/70 mm Hg, and
pulse is 72/min. Examination shows a uterus consistent in size with a 16-week
gestation. Her pelvis is normal-sized. This patient is at greatest risk for which of the
following?
A) Abruptio placentae
B) Hepatitis B
C) HIV infection
D) Preterm labor
E) Uterine rupture
16. A 67-year-old man is brought to the emergency department because of a 3-day

history of fever and headache. Five years ago, he underwent placement of a
mechanical aortic valve for treatment of sequelae of rheumatic fever. He appears ill.
His temperature is 40 C (104 F), blood pressure is 110/65 mm Hg, pulse is 110/min,
and respirations are 22/min. A grade 3/6, systolic ejection murmur is heard.
Neurologic examination shows mild left hemiparesis. Babinski's sign is present on
the left. There is no nuchal rigidity. This patient is at greatest risk for which of the
following complications?
A) Brain abscess
B) Carotid artery occlusion
C) Encephalitis
D) Hydrocephalus
E) Venous sinus thrombosis
17. A 67-year-old woman comes for a routine health maintenance examination. She
drinks 1 ounce of alcohol daily. Her blood pressure is 138/62 mm Hg, pulse is
76/min and regular, and respirations are 14/min. The lungs are clear to
auscultation. The remainder of the examination shows no abnormalities. Laboratory
studies show:
Hemoglobin 12.8 g/dL

Serum
Ca2+ 11.9 mg/dL
Phosphorus 2.8 mg/dL
Total protein 6.5 g/dL
Albumin 4.2 g/dL
Ionized calcium 5.8 mg/dL (N=4.5–5.1)

A) Measurement of serum alkaline phosphatase activity
B) Measurement of serum parathyroid hormone level
C) Measurement of serum vitamin D level
D) Serum and urine protein electrophoresis
E) X-ray film of the chest
F) Skeletal survey
G) Bone scan
For each patient with papilledema, select the most likely diagnosis.
A) Bacterial meningitis
B) Cerebral infarction
C) Cryptococcal meningitis
D) Glioblastoma multiforme
E) Herpes simplex encephalitis
F) Hypertensive encephalopathy
G) Idiopathic intracranial hypertension
H) Intracerebral hemorrhage
I) St. Louis encephalitis
18. A 25-year-old woman comes to the emergency department because of

increasingly severe bifrontal headaches over the past 6 months. During this period,
she has had transient episodes of blindness lasting 1 to 2 seconds. She has not had
nausea or vomiting. She has a long-standing history of difficulty losing weight. She
currently weighs 113 kg (250 lb) and is 152 cm (60 in) tall. Her blood pressure is
120/80 mm Hg. Visual field testing shows enlarged blind spots. The remainder of
the neurologic examination shows normal findings. A CT scan of the head with and
without contrast shows no abnormalities. Examination of the cerebrospinal fluid
shows:
Opening pressure 300 mm H2O

Glucose 70 mg/dL
Protein 25 mg/dL
WBC 1/mm3
RBC 0/mm3
Gram's stain and cultures are negative.
19. A 25-year-old man with a history of intravenous drug use comes to the
emergency department because of a progressive diffuse headache, generalized
malaise, and low-grade fever for 2 months. During this period, he has had a poor
appetite resulting in a 6.8-kg (15-lb) weight loss. His temperature is 38 C (100.4 F).
Examination shows ¬¬neck stiffness. Mental status examination shows no
abnormalities. Cranial nerve examination shows weakness of the lateral rectus
muscle on the right and bilateral papilledema. A CT scan of the head with and
without contrast shows moderate ventricular enlargement. Examination of
cerebrospinal fluid shows:
Opening pressure 220 mm H2O

Glucose 35 mg/dL
Protein 150 mg/dL
WBC 100/mm3
Lymphocytes 100%
RBC 1/mm
20. An asymptomatic 32-year-old woman comes for a routine health maintenance

examination. Her mother and sister have a history of low back pain and disc
herniation. The patient is a postal worker. She weighs 86 kg (190 lb) and is 165 cm
(65 in) tall. Her blood pressure is 130/78 mm Hg, pulse is 74/min, and respirations
are 16/min. Range of motion of the spine is normal and without pain. There is no
scoliosis or excessive kyphosis of the back. Which of the following is the most
effective strategy to decrease this patient's risk for developing low back pain?
A) Change in job
B) Limit physical activity
C) Stretching exercises
D) Weight-loss program
E) Nonsteroidal anti-inflammatory drug therapy

F) Prophylactic brace
21. Three days after being hospitalized for treatment of a hip fracture sustained in a
fall, a 62-year-old woman becomes acutely short of breath and coughs up a small
amount of blood-tinged sputum. She appears anxious. Her blood pressure is 110/70
mm Hg, pulse is 110/min, and respirations are 24/min. Examination shows no other
abnormalities. Arterial blood gas analysis on 40% oxygen by face mask shows:
pH 7.40
PCO2 38 mm Hg
PO2 70 mm Hg
Ventilation-perfusion lung scans show multiple segmental areas of mismatch on the

right. Which of the following is the most appropriate next step in management?
A) Pulmonary angiography
B) Dopamine therapy
C) Heparin therapy
D) Urokinase therapy
E) Intubation
22. A 24-year-old man is brought to the emergency department by police 1 hour

after his ex-wife found him stumbling around in the yard. His blood pressure is
100/70 mm Hg, pulse is 90/min, and respirations are 16/min. The pupils are equal
and reactive to light; the sclerae are injected. During the examination, he laughs
without obvious reason, makes religious statements, and asks if there is anything to
eat or drink. Mental status examination shows a broad range of affect; there is no
evidence of thought disorder except for mild paranoia. Which of the following is the
most appropriate next step in management?
A) Observation in the emergency department
B) Intramuscular administration of naloxone
C) Intravenous administration of 50% dextrose
D) Intravenous administration of lorazepam
E) Oral administration of chlorpromazine

23. A 17-year-old boy sustains a head injury and loses consciousness after diving
into a freshwater lake from a platform. After being submerged for 3 minutes, he is
rescued. He is initially cyanotic but then begins to cough and breathe spontaneously
after a 5-minute resuscitation. Over the next 36 hours, which of the following
complications is most likely?
A) Acute respiratory distress syndrome
B) Bacteremia
C) Bacterial pneumonia
D) Hypernatremia
E) Metabolic alkalosis
24. A 15-year-old boy is brought to the emergency department 30 minutes after

being involved in a motor vehicle collision. He was the unrestrained passenger. On
arrival, he is disoriented. His blood pressure is 80/40 mm Hg, pulse is 112/min, and
respirations are 24/min. There is no jugular venous distention. Examination of the
chest shows dullness to percussion and decreased breath sounds over the right
hemithorax. Which of the following is the most likely diagnosis?
A) Diaphragmatic rupture
B) Flail chest
C) Hemothorax
D) Massive aspiration
E) Pneumothorax
25. An 18-year-old man comes to the physician for an initial examination because of
a 3-year history of fatigue and migrating joint pain. He has brought a large folder
containing information about previous medical consultations, laboratory tests, and
x-ray films. He takes no medications. He weighs 50 kg (110 lb) and is 173 cm (68 in)
tall. Physical examination shows no other abnormalities. On mental status
examination, he is preoccupied with his symptoms. When asked about his mood, he
states that the future appears bleak, and that he is too tired to think about it. Which
A) Ask about further symptoms of obsessions and compulsions
B) Ask about sexual history including sexual orientation and practices

C) Ask about suicidal feelings
D) Ask about travel history over the past 6 months
E) Obtain a detailed exercise history
F) Measurement of serum Lyme (Borrelia burgdorferi) antibody level
G) Urine toxicology screening
26. An 80-year-old woman has had bleeding gums for 3 weeks. Her diet has
consisted of only tea and toast for 2 years. She appears thin and weak. Vital signs are
normal. Her gums are hypertrophied and exude blood with pressure. There are
ecchymoses of the inner thighs and small hemorrhages around the hair follicles. The
remainder of the examination shows normal findings. Supplementation with which
of the following vitamins is most likely to have prevented this condition?
A) A
B) B12 (cyanocobalamin)
C) C
D) D
E) E
27. A 30-year-old woman, gravida 2, para 1, is brought to the emergency

department in labor. An episiotomy is performed. Following delivery of the head,
the shoulders do not follow with the usual traction and maternal pushing. Which of
the following is the most appropriate next step in management?
A) Flexing the woman's knees toward her shoulders
B) More forceful traction and fundal pressure

C) Delivering the posterior arm
D) Rotating the head 180 degrees
E) Symphysiotomy
28
A 32-year-old man comes to the physician because of a 3-day history of low back
pain, urinary hesitancy, and pain with urination. He has had several similar episodes
over the past 3 years. He has not had any urethral discharge or recent sexual
contacts. His temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg.
The lungs are clear to auscultation; there is no costovertebral angle tenderness.
Abdominal examination shows no tenderness or masses. There is no tenderness to
palpation of the lower back. Straight-leg raising to 90 degrees is negative. There are
no motor or sensory deficits in the lower extremities. Rectal examination shows a
diffuse, minimally enlarged, tender prostate with no masses. Laboratory studies
show:
Serum prostate-specific antigen 6 ng/mL (N<4)

Urine
Specific gravity 1.020
Blood negative
Glucose negative
Ketones negative
Leukocyte esterase negative
Nitrites negative
A) Benign prostatic hypertrophy

B) Cystitis
C) Epididymitis
D) Prostate cancer
E) Prostatitis
F) Pyelonephritis
G) Urolithiasis
29. A 16-year-old boy with neurofibromatosis is brought for a follow-up

examination. His uncle also has neurofibromatosis. He has a 1-year history of
headaches during which his parents say he appears pale. Six months ago, he
underwent operative treatment for an optic nerve glioma. His blood pressure is
164/105 mm Hg, pulse is 102/min, and respirations are 14/min. The thyroid glands
are not enlarged. No murmurs are heard, and radial pulses are equal. Abdominal
examination shows no abnormalities. Which of the following is the most likely cause
of this patient's high blood pressure?
A) Catecholamine-producing tumor
B) Carcinoma of the thyroid gland
C) Essential hypertension
D) Overproduction of aldosterone from an adrenal adenoma
E) Postsubclavian coarctation of the aorta
30. A 14-month-old girl is brought to the physician because of a 14-hour history of

irritability and episodes of drawing her knees toward her chest. During this period,
she has vomited nonbilious fluid twice and had a bowel movement containing a
small amount of blood. She had an upper respiratory tract infection 2 weeks ago.
She is listless except for intermittent episodes of discomfort. Her temperature is 38
C (100.4 F). Abdominal examination shows right-sided tenderness without guarding
or rebound; bowel sounds are present. Rectal examination shows bright red blood
and mucus. An x-ray film of the abdomen shows no abnormalities. Which of the
A) X-ray film of the upper gastrointestinal tract with contrast
B) Water-soluble contrast enema
C) Corticosteroid enemas
D) Admission to the hospital for total parenteral nutrition
E) Immediate laparotomy
31. An asymptomatic 47-year-old man comes for a preemployment examination. He

has never been hospitalized. He is a computer programmer, and he plays handball
once weekly. His maternal grandmother had type 2 diabetes mellitus, and a paternal
uncle had heart disease. The patient's blood pressure is 126/80 mm Hg.
Examination shows no abnormalities. His total serum cholesterol level is 225
mg/dL. Which of the following is the most appropriate next step in management?
A) Step 2 American Heart Association cardiac diet
B) Serum lipid studies while fasting
C) Exercise stress test
D) Oral cholestyramine and niacin therapy
E) Oral pravastatin therapy at bedtime

32. A 25-year-old woman comes to the physician because of a 3-month history of the
unexplained urge to eat a few tablespoons of cornstarch daily. The amount of
cornstarch ingested has increased gradually during this time. She has leiomyomata
uteri; she is otherwise healthy. Her weight is unchanged from her last visit 1 year
ago; she weighs 61 kg (135 lb) and is 168 cm (66 in) tall. Her blood pressure is
120/80 mm Hg, and pulse is 100/min. Physical examination shows mild pallor.
Neurologic examination shows no abnormalities. She is embarrassed about her
problem. She has no compulsive behavior or obsessive thoughts. An ECG shows
sinus tachycardia. Which of the following is the most appropriate next step in
management?
A) Psychiatric assessment
B) Complete blood count
C) Thyroid function studies
D) Urine toxicology screening
E) Admission to an eating disorders clinic
F) Antipsychotic therapy
G) Folic acid supplementation
H) Selective serotonin reuptake inhibitor therapy
33. A 30-year-old woman comes to the physician for a follow-up examination 4

months after starting treatment with lithium carbonate; during this period she has
had a 3.2-kg (7-lb) weight gain. Her medication was prescribed soon after the birth
of her son to treat racing thoughts, increased spending, and overtalkativeness; she
has had difficulty sleeping for more than 2 hours nightly. Her symptoms decreased
after 2 weeks of lithium carbonate therapy. She continues to take lithium carbonate
(300 mg three times daily). Her temperature is 37 C (98.6 F), blood pressure is
120/80 mm Hg, and pulse is 70/min. Examination shows normal findings. The most
appropriate next step is measurement of which of the following?
A) Fasting serum glucose level
B) Leukocyte count
C) Serum alkaline phosphatase activity
D) Serum creatinine level
E) Serum thyroid-stimulating hormone level
34. On a routine examination, a 2-year-old boy has a hemoglobin level of 10.5 g/dL,
hematocrit of 30%, and mean corpuscular volume of 72 μm3. He drinks four to five
8-oz bottles of milk daily. He maintains a regular diet but does not eat vegetables.
A) Folic acid deficiency
B) Iron deficiency
C) Sickle cell disease
D) Thalassemia
E) Vitamin B6 deficiency
35. A 57-year-old man is brought to the physician by his wife because his skin has
appeared yellow for 3 weeks. Examination shows jaundice and scleral icterus. His
total serum bilirubin level is 8 mg/dL with a direct component of 6.2 mg/dL. A CT
scan of the abdomen shows a large lesion in the head of the pancreas. When the
results are initially discussed, the patient says that he does not want to hear the
report, and his wife agrees to abide by his wishes. Which of the following is the most
appropriate course of action?
A) Withhold the results as the patient wishes
B) Contact the patient's children to discuss the results
C) Consult with the hospital ethics committee
D) Insist on telling the patient the results
E) Refer him to another physician
36. A previously healthy 52-year-old man comes to the physician because of a 3-

month history of increased urinary volume and increased urinary frequency at
night. He has had a 6.8-kg (15-lb) weight loss during this period despite no change
in appetite. His father has hypertension, and his mother has hypertension and type 2
diabetes mellitus. He currently weighs 95 kg (210 lb) and is 178 cm (70 in) tall. His
blood pressure is 160/85 mm Hg in both arms. Examination shows no other
abnormalities. His nonfasting serum glucose level is 280 mg/dL. Which of the
following serum levels is most likely to be increased in this patient?
A) Bicarbonate
B) Glucagon
C) HDL-cholesterol
D) Insulin
E) Ketones
37. Three days after hospitalization for heparin treatment of deep venous
thrombosis of a left superficial femoral vein, a 52-year-old woman has prolonged
bleeding from a venipuncture site. She had a pulmonary embolus 2 years ago. Her
temperature is 37.5 C (99.5 F). Examination shows multiple ecchymoses at the
venipuncture sites with oozing of fresh blood. Laboratory studies show:
Hemoglobin
10.5 g/dL
Platelet count
25,000/mm3
Prothrombin time
14 sec (INR=1.3)
Partial thromboplastin time
65 sec
Plasma fibrinogen
300 mg/dL (N=200–400)
Serum creatinine
1.1 mg/dL
A) Adverse drug reaction
B) Disseminated intravascular coagulation
C) Excessive blood loss from anticoagulation
D) Factor VIII deficiency
E) Factor IX deficiency
F) Immune thrombocytopenic purpura
G) Thrombotic thrombocytopenic purpura

38. A 37-year-old woman comes to the physician because of an itchy rash over her
trunk for 2 weeks. She has not had fever, chills, shortness of breath, chest pain, or
gastrointestinal symptoms. She has a history of recurrent urinary tract infections
and has been taking trimethoprim-sulfamethoxazole prophylaxis for the past year.
She is in mild distress. Her temperature is 37.5 C (99.5 F), blood pressure is 96/62
mm Hg, pulse is 78/min, and respirations are 14/min. Examination shows a
maculopapular erythematous rash over the trunk. Laboratory studies show:

Bands 1%
Eosinophils 15%
Lymphocytes 4%
Monocytes 8%
Serum
Urine
WBC 2/hpf
RBC 2/hpf
Which of the following is the most likely cause of these findings?
A) Eczema
B) Medication adverse effect
C) Staphylococcal skin infection
D) Streptococcal skin infection

E) Urinary tract infection
39. A 19-year-old primigravid woman at 34 weeks' gestation comes to the physician

for a routine prenatal visit. Her pregnancy has been uncomplicated. She has no
history of serious illness. She takes no medications and has no known allergies.
Examination shows a uterus consistent in size with a 34-week gestation. A routine
clean-catch urine culture grows greater than 100,000 colonies/mL of Escherichia
coli. Which of the following is the most appropriate pharmacotherapy?
A) Ampicillin
B) Ciprofloxacin
C) Clindamycin
D) Doxycycline
40. A 13-year-old girl is brought for a well-child examination. Menses have occurred
every other month since menarche 10 months ago. Her last menstrual period was 1
week ago. She is not sexually active. Sexual development is Tanner stage 3.
Examination shows no abnormalities. Which of the following is the most
A) Discussion of pregnancy prevention
B) Measurement of serum luteinizing and follicle-stimulating hormone levels
C) Urine β-hCG test
D) Pelvic examination
E) Estrogen therapy
F) Diagnostic laparoscopy
41. A 72-year-old man comes to the emergency department after a 5-minute episode
of blindness in the right eye. Over the past month, he has had headache and pain in
the jaw with chewing. His temperature is 38.1 C (100.6 F). Examination shows
tender, nodular temporal arteries with decreased pulses. His erythrocyte
sedimentation rate is 92 mm/h. Which of the following is the most appropriate
immediate step in management?
A) Carotid ultrasonography
B) Aspirin therapy
C) Cefotaxime therapy
D) Corticosteroid therapy
E) Temporal artery biopsy
42. A 42-year-old man comes for a routine health maintenance examination. There
is no family history of coronary artery disease, and he does not smoke. His weight is
appropriate for his height. His blood pressure is 120/80 mm Hg. Serum lipid studies
show a total cholesterol level of 190 mg/dL, HDL-cholesterol level of 40 mg/dL, and
triglyceride level of 150 mg/dL. Which of the following is the most appropriate next
step in management?
A) Recommend the Step 2 National Cholesterol Education Program diet
B) Measure serum LDL-cholesterol level now
C) Measure total serum cholesterol level in 5 years
D) Prescribe prophylactic aspirin
E) Begin treatment with lovastatin

43. A 28-month-old boy has a history of cyanosis since birth with episodes of
syncope. Examination shows cyanosis and clubbing. The lungs are clear to
auscultation. There is a right ventricular heave, a systolic click, a single S2, and a
grade 3/6 systolic murmur. Which of the following is the most likely diagnosis?
A) Bicuspid aortic valve
B) Coarctation of the aorta
C) Mitral stenosis
D) Patent ductus arteriosus
E) Tetralogy of Fallot
44. A healthy 18-year-old woman comes for a routine health maintenance

examination. Menses occur at regular 28-day intervals. Her last menstrual period
was 2 weeks ago. She is sexually active with one partner, and she and her partner
use condoms inconsistently for contraception. Her maternal grandmother was
diagnosed with breast cancer at the age of 65 years, her paternal grandfather was
diagnosed with colon cancer at the age of 72 years, and her maternal grandfather
died of a myocardial infarction at the age of 66 years. Examination shows no
abnormalities. Which of the following is the most appropriate screening test for this
patient?
A) Complete blood count
B) Fasting serum lipid studies
C) Test of the stool for occult blood
D) Testing for Neisseria gonorrhoeae and Chlamydia trachomatis
E) Urinalysis
For each child with fever and cough, select the most likely diagnosis.
A) α1-Antitrypsin deficiency
B) Cystic fibrosis
C) Pneumothorax
D) Pulmonary alveolar proteinosis
E) Pulmonary aspergillosis
F) Pulmonary hemorrhage
G) Pulmonary tuberculosis
45. A 20-month-old girl is brought to the physician because of fever and cough for 2
days. She has had several similar episodes since the age of 4 months. Three months
ago, she and her family visited her grandmother in Finland for 2 weeks. She is at the
25th percentile for length and 5th percentile for weight. She appears thin and pale.
Her temperature is 38 C (100.4 F), pulse is 150/min, and respirations are 40/min.
Examination shows mild clubbing. Wheezing and bilateral crackles are heard at the
lung bases. An x-ray film of the chest shows streaky densities bilaterally with mild
hyperinflation.
46. A previously healthy 16-year-old boy is brought to the physician because of

fever and cough with right-sided chest pain for 2 weeks. Six months ago, he visited
his grandparents in Albania for 2 weeks. He weighs 54 kg (120 lb) and is 173 cm (68
in) tall. He appears thin and pale. His temperature is 38.2 C (100.8 F), pulse is
76/min, and respirations are 36/min. Examination shows shallow respirations with
decreased breath sounds at the right lung base. An x-ray film of the chest shows a
right pleural effusion and hilar adenopathy.
_________________________________________________________________________________________________
_________________________________
Section 4:--
1. A previously healthy 52-year-old man comes to the emergency department

because of hiccups for 1 week. He has smoked two packs of cigarettes daily for 30
years. He does not drink alcohol. He is alert and oriented. His temperature is 37 C
(98.6 F), blood pressure is 150/95 mm Hg, pulse is 70/min, and respirations are
12/min. Physical and neurologic examinations show no abnormalities. His serum
sodium level is 120 mEq/L. An x-ray film of the chest shows a right hilar mass.
Which of the following is the most appropriate next step in treatment?
A) Bisphosphonate therapy
B) Calcitonin therapy
C) Calcium therapy
D) Dexamethasone therapy
E) 5% Dextrose in 0.225% saline therapy
F) 5% Dextrose in 0.45% saline therapy
G) 5% Dextrose in water therapy
H) Fluid restriction
I) Hydrocortisone therapy
J) Lactated Ringer's solution
K) Mannitol therapy
L) Potassium therapy
M) 0.9% Saline therapy
N) 3% Saline therapy
O) Sodium bicarbonate therapy
2. A 67-year-old man comes to the physician because of a 6-month history of double

vision, slurred speech, and difficulty swallowing liquids. Initially, his symptoms
were intermittent but now occur daily and are worse at the end of the day. Over the
past week, he has had shortness of breath with exertion. He has pernicious anemia
treated with monthly vitamin B12 (cyanocobalamin) injections and autoimmune
thyroid disease currently treated with thyroid replacement therapy. Examination
shows bilateral ptosis and disconjugate gaze. There is bilateral facial weakness and
hypernasal speech. The tongue is weak, and the gag reflex is reduced. Muscle
strength is 4/5 in the proximal muscles of the upper and lower extremities. Deep
tendon reflexes are 2+ diffusely. Babinski's sign is absent. Sensory examination
shows no abnormalities. A CT scan of the chest is shown. Which of the following is
the most likely diagnosis of this patient's intrathoracic lesion?
A) Aspiration pneumonia
B) Bronchogenic carcinoma
C) Lung metastasis
D) Sarcoidosis
E) Thymoma
F) Thyroid carcinoma
3. A 32-year-old man receiving intensive chemotherapy for Hodgkin's disease has a

temperature of 39 C (102.2 F). His respirations are 40/min. Widespread crackles are
heard in all lung fields. An x-ray film of the chest shows a diffuse alveolar and
interstitial pattern. Which of the following is the most likely causal organism?
A) Aspergillus species
B) Candida albicans
C) Coccidioides immitis
D) Pneumocystis carinii
E) Streptococcus pneumoniae
4. A 20-year-old African American man with sickle cell disease comes to the
physician because of a 1-week history of shortness of breath on exertion, fatigue,
and generalized weakness. He has had no fever, chills, night sweats, or cough
productive of sputum. His only medication is oxycodone for joint pain. He weighs 68
kg (150 lb) and is 168 cm (66 in) tall. His temperature is 36.7 C (98 F), blood
pressure is 120/70 mm Hg, pulse is 76/min, and respirations are 18/min.
Examination shows no abnormalities. Laboratory studies show:
Hematocrit 20%
Reticulocyte count 1.8%
Which of the following is the most likely mechanism for these findings?
A) Adverse drug reaction
B) Atrophy of gastric mucosa

C) Bacterial overgrowth in the small intestine
D) Increased demand for folic acid
E) Increased demand for vitamin B12 (cyanocobalamin)
F) Malabsorption
G) Vitamin B1 (thiamine) deficiency
5. A 44-year-old woman comes to the emergency department 2 days after being

discharged from the hospital for abdominal pain; an exploratory laparoscopy
showed no abnormalities. Over the past 5 years, she had been admitted to the
hospital numerous times for the evaluation of a variety of symptoms; all work-ups
had been negative. Her temperature is 39.2 C (102.6 F). Examination shows a
reddened, indurated laparoscopic wound. She is admitted to the hospital and given
intravenous antibiotics. On the second hospital day, a nurse witnesses the patient
rubbing saliva into her laparoscopy site. Which of the following is the most likely
diagnosis?
A) Adjustment disorder with disturbance of conduct

B) Conduct disorder
C) Conversion disorder
D) Factitious disorder
E) Hypochondriasis
F) Major depressive disorder
G) Oppositional defiant disorder
H) Somatization disorder
6. A 37-year-old woman is brought to the emergency department because she has

been unable to see out of her right eye since awakening 2 hours ago. She states that
any movement of the eye is painful. Examination shows visual acuity of 20/200 in
the right eye and 20/20 in the left eye. The optic fundi are normal. The left pupil
reacts normally to light. The right pupil is poorly reactive to direct light. The
remainder of the eye examination shows no abnormalities. Which of the following is
the most likely site of the lesion?
A) Left optic nerve
B) Left optic radiation
C) Left optic tract
D) Left visual cortex

E) Optic chiasm
F) Retina
G) Right optic nerve
H) Right optic radiation
I) Right optic tract
J) Right visual cortex
For each patient with peripheral nerve dysfunction, select the most likely site of
nerve injury.
A) Axillary nerve
B) Cervical nerve root at the cervical foramen
C) Long thoracic nerve
D) Median nerve above the elbow
E) Median nerve at the elbow
F) Median nerve at the wrist
G) Musculocutaneous nerve above the elbow
H) Musculocutaneous nerve at the elbow
I) Musculocutaneous nerve at the wrist
J) Radial nerve above the elbow
K) Radial nerve at the elbow
L) Radial nerve at the wrist
M) Suprascapular nerve
N) Thoracodorsal nerve
O) Ulnar nerve above the elbow
P) Ulnar nerve at the elbow
Q) Ulnar nerve at the wrist
7. A previously healthy 42-year-old carpenter comes to the physician because of a 6-

month history of pain and numbness in his dominant hand that awakens him at
night. He describes numbness in his long and index fingers after driving for
extended periods of time. Examination shows minimal atrophy of the thenar
muscles. There is normal sensation to light touch on the little finger and the palm of
the right hand. Sensation to light touch is decreased at the tip of the thumb, index
finger, and long finger. X-ray films of the right elbow and wrist show no
abnormalities.
For each patient with peripheral nerve dysfunction, select the most likely site of
nerve injury.
A) Axillary nerve
B) Cervical nerve root at the cervical foramen
C) Long thoracic nerve
D) Median nerve above the elbow
E) Median nerve at the elbow
F) Median nerve at the wrist
G) Musculocutaneous nerve above the elbow
H) Musculocutaneous nerve at the elbow
I) Musculocutaneous nerve at the wrist
J) Radial nerve above the elbow
K) Radial nerve at the elbow
L) Radial nerve at the wrist
M) Suprascapular nerve
N) Thoracodorsal nerve
O) Ulnar nerve above the elbow
P) Ulnar nerve at the elbow
Q) Ulnar nerve at the wrist
8. A previously healthy 37-year-old man comes to the physician because of a 2-

month history of pain in the forearm and little finger of his dominant hand; he has
been working as a receptionist for 6 months. He describes numbness in his little
finger and weakness of his grip. There is decreased sensation to light touch at the tip
of the little finger. Paresthesias are elicited with compression of the cubital tunnel.
9. A 3-month-old boy is brought for a well-child examination. He has poor head

control. Examination shows generalized hypotonia. The point of maximal impulse is
at the left anterior axillary line. The liver edge is palpated 4 cm below the right
costal margin. The spleen is not palpable. Which of the following is the most likely
diagnosis?
A) Congenital muscular dystrophy
B) Glycogen storage disease, type II (Pompe's disease)
C) GM1 gangliosidosis
D) Infant botulism
E) Ventricular septal defect
10. Over the past 3 months, a 30-year-old woman has had intermittent episodes of
headache, palpitations, sweating, and irritability. Her blood pressure is 150/100
mm Hg while supine and 149/100 mm Hg while standing, and pulse is 90/min while
supine and 110/min while standing. Examination shows no abnormalities except for
pallor. Which of the following is the most likely location of this patient's lesion?
A) Adrenal gland
B) Brain
C) Heart
D) Kidney
E) Thyroid gland
11. A 19-year-old man is brought to the emergency department 45 minutes after

sustaining a single, large stab wound to the right upper quadrant of the abdomen.
He is obtunded. His blood pressure is 60/palpable mm Hg, and pulse is 148/min.
Breath sounds are equal bilaterally. Examination shows a 4-cm laceration in the
right upper quadrant in the midclavicular line. The abdomen is distended. Which of
the following is the most appropriate next step in management?
A) X-ray films of the abdomen and pelvis

B) Angiography
C) Contrast study of the wound tract
D) CT scan of the abdomen
E) CT scan of the chest
F) Laparoscopy
G) Peritoneal lavage
H) Laparotomy
I) Local wound exploration
12. A 52-year-old woman comes to the physician because of decreased libido; this
symptom began 8 months ago, after she underwent a total abdominal hysterectomy
and bilateral salpingo-oophorectomy for leiomyomata uteri and menorrhagia. She
has been taking hormone replacement therapy with conjugated estrogen since the
operation. Examination shows a moist, rugated vagina. Which of the following is the
most likely cause of these findings?
A) Decreased androgens
B) Decreased estrogen
C) Decreased follicle-stimulating hormone (FSH)
D) Decreased luteinizing hormone (LH)
E) Decreased progesterone
F) Decreased prolactin
G) Increased androgens
H) Increased estrogen
I) Increased FSH
J) Increased LH
K) Increased progesterone
L) Increased prolactin
13. A 7-day-old newborn is brought for a well-child examination. He was born at

home. His mother has taken acetaminophen for perineal discomfort. The newborn is
breast-feeding well. He is at the 75th percentile for length and weight. Examination
shows no abnormalities. After vaccination with hepatitis B, he has prolonged
bleeding at the injection site. There is no family history of excessive bleeding.
Laboratory studies show:
Hemoglobin 16 g/dL
Bands 2%
Lymphocytes 50%
Prothrombin time 20 sec (INR=1.6)
Partial thromboplastin time 60 sec
Which of the following is the most likely mechanism for these findings?
A) Autoimmunization
B) Bacterial toxic effect
C) Factor VIII deficiency
D) Factor IX deficiency
E) Immunoglobulin deficiency
F) Iron deficiency
G) Pharmacologic effect
H) Viral toxic effect
I) Vitamin deficiency J) Zinc deficiency
14. A 67-year-old man with long-standing signs and symptoms of congestive heart
failure is admitted to the hospital because of progressive shortness of breath.
Examination shows no other abnormalities. An x-ray film of the chest shows
cardiomegaly, cephalization of blood vessels, and a right-sided pleural effusion.
Which of the following sets of pleural fluid findings is most likely in this patient?
Leukocyte Segmented
Protein Glucose count neutrophils Monocytes
(g/dL) (mg/dL) (/mm3) (%) (%)
A) 2.5 10 10,000 50 50
B) 2.5 90 2000 60 40
C) 3.8 40 30,000 80 20
D) 4.5 60 10,000 20 80
E) 4.5 90 2000 50 50
15. For 8 weeks, a 52-year-old man with a 5-year history of type 2 diabetes mellitus
has had deep burning pain in the ball of his right foot and big toe when the foot is
raised above chest level. He also has cramping in his right calf when he walks more
than 50 feet. He has smoked two packs of cigarettes daily for 30 years. Femoral
pulses are palpable; pedal pulses are absent. Which of the following is the most
likely diagnosis?
A) Aortoiliac stenosis
B) Femoral popliteal stenosis
C) Mononeuropathy
D) Vasculitis
E) Venous stasis
16. A 1-year study of a new drug to treat hypertension is conducted. One hundred
patients with hypertension are enrolled; 50 patients are given the new drug and
another 50 patients are given hydrochlorothiazide. All patients completed the trial.
One noted unexpected effect is increased growth of scalp hair which occurred in
those taking the new drug, a nonstatistically significant difference (p>0.10). This
effect has also been reported in studies of other similar drugs in the new therapeutic
class. The investigators of the study concluded that the new drug did not cause hair
growth. Which of the following features of this study is most likely to affect the
validity of this conclusion?
A) Differential follow-up
B) Lead time bias

C) Length of the study
D) Sample size
E) Self-selection
17. A 38-year-old woman, gravida 2, para 1, at 38 weeks' gestation has had no fetal
movement for 36 hours. Her prenatal course, prenatal tests, and fetal growth have
been normal. Fetal heart tones are heard by Doppler. Which of the following is the
most appropriate next step in management?
A) Routine prenatal visit in 1 week
B) Maternal hydration
C) Nonstress test
D) Immediate induction of labor
E) Amniocentesis
18. A healthy 7-year-old boy is brought to the physician 1 week after he was
exposed for several hours to a child with chickenpox. The patient and his healthy
sister have not had chickenpox. They have not received varicella vaccine. Which of
the following is the most appropriate management for the patient and his sister at
this time?
A) Administer acyclovir as prophylaxis
B) Administer immune globulin, intravenously
C) Administer aspirin therapy if vesicles appear
D) Advise the parents to keep the siblings home from school to prevent exposing
their classmates
E) Inform the parents that a vesicular rash may appear at any time over the next 2
weeks
19. A 6-year-old boy is brought to the physician by his mother because of

progressive visual loss over the past year. Over the past 2 years, he has had
deterioration of his hearing, speech, writing, and intellectual performance. His
maternal uncle had similar symptoms. Visual acuity is 20/200 bilaterally.
Funduscopic examination shows optic atrophy. His hearing is markedly impaired.
There is weakness and spasticity of all extremities. Deep tendon reflexes are
extremely hyperactive. Babinski's sign is present bilaterally. On mental status
examination, he is not oriented to place, year, month, or the names of his siblings. An
MRI of the brain shows marked symmetric white matter disease involving all lobes.
Diagnostic studies are most likely to show which of the following?
A) Abnormally decreased serum cholesterol level
B) Acanthocytes on blood smear
C) An excess of very long chain fatty acids
D) Normal nerve conduction studies
E) Vitamin E deficiency
20. A 22-year-old primigravid woman at 16 weeks' gestation is brought to the

emergency department because of progressive shortness of breath over the past 48
hours. Her temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is
100/min, and respirations are 24/min. Scattered wheezes are heard. Pelvic
examination shows a uterus that extends to the umbilicus. Fetal heart tones are
absent. Her hematocrit is 32%, leukocyte count is 11,000/mm3, and serum β-hCG
level is 300,000 mIU/mL. Pulse oximetry on room air shows an oxygen saturation of
92%. An x-ray film of the chest shows multiple round densities throughout all lung
fields. Which of the following is the most likely diagnosis?
A) Bacterial pneumonia
B) Choriocarcinoma
C) Pulmonary embolism
D) Tuberculosis E) Viral pneumonia
21. A 42-year-old man comes to the physician because of progressive swelling of the
legs over the past 2 months. He has a history of stage IIA Hodgkin's disease treated 1
year ago with radiation therapy to the neck and chest. His temperature is 37 C (98.6
F), blood pressure is 102/80 mm Hg, pulse is 110/min, and respirations are 22/min.
Examination shows jugular venous distention that increases with inspiration. The
lungs are clear to auscultation. Cardiac examination shows a nondisplaced point of
maximal impulse; heart sounds are distant. An early diastolic sound is heard at the
apex. Abdominal examination shows mild distention with shifting dullness. The liver
is pulsatile, and its edge is palpated 4 cm below the right costal margin. There is 2+
peripheral edema extending up to the knees. Which of the following is the most
likely mechanism of this patient's increased central venous pressure?
A) Constrictive pericarditis
B) Cor pulmonale
C) Left-sided congestive heart failure
D) Mitral stenosis
E) Tricuspid stenosis
22. A 5-year-old boy is brought to the emergency department 30 minutes after he

fainted at home after standing up from a sitting position. His symptoms began 3
days ago with diarrhea and vomiting. He has had no urine output for 18 hours. He is
alert but quiet. His temperature is 37.5 C (99.5 F), blood pressure is 75/45 mm Hg,
pulse is 120/min, and respirations are 28/min. Examination shows dry lips and
tenting of the skin. There is no abdominal tenderness. Bowel sounds are
hyperactive. The remainder of the examination shows no abnormalities. His
capillary refill time is 5 seconds. Intravenous bolus doses of 0.9% saline are
administered. Bladder catheterization yields 5 mL of urine. Urinalysis is most likely
to show which of the following?
A) Blood
B) Erythrocyte casts
C) Hyaline casts
D) Leukocyte casts
E) Oxalate crystals
23. A 2-year-old boy is brought to the physician because of fever and cough for 2
days. He had Streptococcus pneumoniae meningitis at the age of 1 year, S.
pneumoniae bacteremia at the age of 18 months, and pneumonia at the age of 22
months. Two maternal uncles died before the age of 2 years from "infection." His
temperature is 39.8 C (103.6 F), pulse is 150/min, and respirations are 60/min.
Examination shows subcostal retractions on inspiration. Laboratory studies show:
Hemoglobin 10 g/dL
Bands 20%
Lymphocytes 8%
Monocytes 2%
Serum
IgA <5 mg/dL
IgG 30 mg/dL
IgM <5 mg/dL
An x-ray film of the chest shows an infiltrate in the left upper lobe. Which of the
A) Reexamination in 12 weeks
B) Prednisone therapy only
C) Prednisone, vincristine, doxorubicin, asparaginase, and methotrexate therapy
D) Zidovudine (AZT), lamivudine (3TC), and ritonavir therapy
E) Intravenous immunoglobulin infusion
F) Bone marrow transplantation
G) Thymus transplantation
24. A previously healthy 13-year-old girl is brought to the physician because of a 2-

month history of intermittent abdominal pain and loose stools. She has had a 2.3-kg
(5-lb) weight loss during this period due to a decreased appetite, but she drinks up
to 1 liter of fruit juice daily. At her last visit 9 months ago, she was at the 50th
percentile for height and the 50th percentile for weight. She is now at the 50th
percentile for height and the 10th percentile for weight. Her temperature is 37.8 C
(100 F), pulse is 80/min, and respirations are 18/min. Examination shows no other
abnormalities. Test of the stool for occult blood is positive. Laboratory studies show:
Hemoglobin 8.5 g/dL

Lymphocytes 35%
Monocytes 10%
Erythrocyte sedimentation rate 75 mm/h
Serum
Na+ 139 mEq/L

Cl– 101 mEq/L
K+ 3.2 mEq/L
HCO3– 23 mEq/L
Glucose 73 mg/dL
A barium enema shows patches of ulcerations along the proximal colon with reflux
of dye into the terminal ileum. Which of the following is the most appropriate next
step in management?
A) Eliminate fruit juice from the patient's diet
B) Switch to a gluten-free diet
C) H2- receptor blocking agent therapy
D) Prednisone and aminosalicylate therapy
E) Bowel resection
25. An asymptomatic 57-year-old man comes to the physician for a routine health
maintenance examination. He has smoked one pack of cigarettes daily for 37 years.
His blood pressure is 180/112 mm Hg, and pulse is 82/min. Abdominal examination
shows a bruit in the right upper quadrant and no masses. His hematocrit is 42%,
serum urea nitrogen (BUN) level is 23 mg/dL, and serum creatinine level is 1.4
mg/dL. Which of the following is the most likely cause of this patient's bruit?
A) Accumulation of lipids in the arterial wall
B) Hypertrophy of the arterial wall media
C) Infiltration of arterial wall by giant cells
D) Infiltration of round cells in the arterial wall
E) Reflex vasodilation
26. An otherwise healthy 4-month-old girl is brought to the physician because of a

birthmark on her arm that has increased in size over the past several weeks.
Examination shows a 3 x 2-cm, bright red, raised, soft, nontender, compressible
patch over the left forearm. Which of the following is the most appropriate next step
in management?
A) Topical corticosteroid therapy
B) Biopsy
C) Laser therapy
D) Excision
E) No intervention is necessary
27. A 7-year-old girl is brought to the physician in September because of fever and
sore throat for 1 day. She is in the third week of second grade. Her temperature is
38.6 C (101.5 F). Examination shows an erythematous pharynx and slightly enlarged
tonsils without exudate. There is no significant cervical lymphadenopathy. A rapid
test for group A streptococcus is negative. Which of the following is the most
A) Monospot test
B) Throat culture
C) Intramuscular penicillin therapy
D) Oral erythromycin therapy
E) Oral penicillin therapy
For each patient with weakness, select the most appropriate test to establish the
cause of the condition.
A) Brain stem auditory evoked potentials
B) Carotid ultrasonography
C) Chromosomal analysis for trinucleotide repeat
D) Electroencephalography
E) Electromyography and nerve conduction studies
F) MRI of the spine
G) Muscle biopsy
H) Repetitive nerve stimulation
I) Somatosensory evoked potentials
J) SPECT scan
K) Temporal artery biopsy
L) Visual evoked potentials
28. A 57-year-old man is brought to the emergency department 6 hours after the
onset of weakness of his right face, arm, and leg. Three days ago, he had an episode
of sudden visual loss in his left eye that he describes as "a shade coming down." The
episode resolved completely within 10 minutes. He has hypertension and type 2
diabetes mellitus, both poorly controlled with lisinopril and glyburide. Examination
shows expressive aphasia and right lower facial droop. There is moderate weakness
on the right, worse in the upper extremity than the lower extremity. Deep tendon
reflexes are 3+ in the right extremities and 2+ in the left extremities. Babinski's sign
is present on the right. Sensory examination shows no abnormalities.
For each patient with weakness, select the most appropriate test to establish the
cause of the condition.
A) Brain stem auditory evoked potentials
B) Carotid ultrasonography
C) Chromosomal analysis for trinucleotide repeat
D) Electroencephalography
E) Electromyography and nerve conduction studies
F) MRI of the spine
G) Muscle biopsy
H) Repetitive nerve stimulation
I) Somatosensory evoked potentials
J) SPECT scan
K) Temporal artery biopsy
L) Visual evoked potentials
29. A previously healthy 27-year-old woman is brought to the emergency

department because of a 2-day history of weakness of her arms and legs and
numbness of her hands and feet and a 4-hour history of mild shortness of breath
while supine. The weakness began in her feet and has progressed to involve the
hands. She describes a sensation of "electrical shocks" extending from the buttocks
to the feet. Today, she tripped and fell several times and was unable to button
clothes or hold utensils. Three weeks ago, she had a mild upper gastrointestinal
illness that resolved within 5 days. Her respirations are 20/min and shallow. There
is mild facial weakness; cranial nerves are otherwise intact. Muscle strength in the
upper and lower extremities is 4/5 proximally and 2/5 distally. There is areflexia.
Babinski's sign is absent bilaterally. Sensation to vibration is slightly decreased at
the fingers and toes.
30. A 72-year-old man comes to the physician with his wife because of chronic
abdominal pain and headaches for 4 months. His wife states that he has become
more forgetful over the past 6 months. He has a history of gout. He has smoked one
pack of cigarettes daily for 50 years and drinks 10 oz of homemade whiskey daily.
He takes no medications. His temperature is 36.8 C (98.3 F), blood pressure is
160/98 mm Hg, pulse is 74/min, and respirations are 16/min. Neurologic
examination shows mild short-term memory loss and decreased sensation to
pinprick in the distal extremities. He has an ataxic gait. There are gouty tophi on the
dorsal aspect of the left elbow. Laboratory studies show:
Hematocrit 33%
Serum
Glucose 90 mg/dL
Creatinine 2 mg/dL
Uric acid 14 mg/dL

A) Measurement of blood lead level
B) Measurement of serum porphobilinogen level
C) CT scan of the abdomen
D) MRI of the brain
E) Carbidopa-levodopa therapy
31. A county health officer investigates an outbreak of illness among persons

attending a church picnic. The illness is characterized by the onset of nausea and
vomiting 3 to 4 hours after attending the picnic. All affected persons recover
without specific therapy. The investigation implicates egg salad as the vehicle of
transmission. This episode is consistent with a foodborne outbreak caused by which
of the following?
A) Clostridium perfringens
B) Giardia lamblia
C) Salmonella species
D) Staphylococcus aureus
32. A 62-year-old woman comes to the physician because of generalized weakness

for 2 weeks. She has a 20-year history of arthritis of the hands treated with aspirin
and acetaminophen. She had two episodes of urinary tract infections 5 and 11 years
ago, respectively. Examination shows no abnormalities except for Heberden's nodes
on the hands. Laboratory studies show:
Erythrocyte sedimentation rate 15 mm/h
Serum
Na+ 136 mEq/L

Cl– 100 mEq/L
K+ 4.9 mEq/L
HCO3– 20 mEq/L
Creatinine 4 mg/dL
Urine
Protein 1+
WBC 2–4/hpf
RBC none
Bacteria none
Squamous epithelial cells occasional
Granular casts occasional
Renal ultrasonography shows no abnormalities. Which of the following is most

likely to have prevented this condition?
A) Periodic PPD skin testing
B) Screening for autoimmune causes of glomerulonephritis
C) Periodic renal ultrasonography
D) Avoidance of analgesics
E) Suppressive antibiotic therapy for treatment of urinary tract infections

33. A 60-year-old man comes to the physician because of increasing shortness of
breath for 1 week; it occurs at rest and is exacerbated by exertion. He has not had
chest pain. He has smoked two packs of cigarettes daily for 40 years. Between the
ages of 18 and 30 years, he worked in a warehouse with exposed bare insulation; for
the past 15 years, he has driven a taxi. Medications include ipratropium bromide
and albuterol metered-dose inhalers. His temperature is 37 C (98.6 F), blood
pressure is 170/95 mm Hg, pulse is 100/min, and respirations are 24/min. Anterior
and posterior diffuse wheezes are heard. Cardiac examination shows no murmurs.
There is mild pretibial edema. An x-ray film of the chest shows calcified pleural
plaques on the right hemidiaphragm and a 2-cm pleural-based mass. With regard to
the findings on the x-ray film, which of the following is most likely to have prevented
this patient's condition?
A) Appropriate immunizations
B) Different occupation
C) Different medications
D) Hypertension screening
E) Smoking cessation
34. A previously healthy 67-year-old man is admitted to the hospital because of

lethargy, confusion, muscle cramps, and decreased appetite for 7 days. He appears
ill. His temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is
98/min, and respirations are 20/min. Breath sounds are diminished at the right
lung base. Neurologic examination shows no abnormalities except for lethargy.
Serum studies show:
Na+ 114 mEq/L

K+ 4.3 mEq/L
Creatinine 1 mg/dL
Thyroid-stimulating hormone 4.1 μU/mL
An x-ray film of the chest shows a 2-cm nodule in the right lower lobe and
mediastinal adenopathy. A biopsy specimen of the nodule is most likely to show
which of the following?
A) Adenocarcinoma
B) Clear cell carcinoma
C) Mesothelioma
D) Small cell carcinoma
E) Squamous cell carcinoma
35. A 62-year-old woman comes to the physician because of bloating and cramping
abdominal pain and intermittent diarrhea over the past 5 years. Her symptoms have
increased over the past month since she started a new diet that emphasizes yogurt
and cottage cheese as low-fat sources of calcium and protein. Vital signs are within
normal limits. Abdominal examination shows diffuse tenderness to palpation with
no rebound tenderness; there are no masses or organomegaly. Bowel sounds are
increased. Test of the stool for occult blood is negative. Which of the following is the
best explanation for this patient's diarrhea?
A) Impaired intestinal motility

B) Inflammatory process
C) Malabsorption
D) Secretory process
36. A 52-year-old woman comes to the physician because of a 3-month history of

intermittent bloody discharge from the right breast. She does not perform regular
monthly breast self-examinations. She has a 3-year history of major depressive
disorder treated with fluoxetine. Examination of the breasts shows no
abnormalities. No masses are noted on palpation. Serosanguineous fluid can be
expressed from the nipple of the right breast by pressing on the left side of the
areola. Which of the following is the most likely diagnosis?
A) Cystosarcoma phyllodes
B) Fat necrosis
C) Fibroadenoma
D) Fibrocystic changes of the breast
E) Galactorrhea
F) Hyperprolactinemia
G) Intraductal papilloma
H) Mastitis
I) Paget's disease of the breast
37. A 6-month-old girl is brought to the physician because of poor feeding and
labored breathing for 2 months. She has had recurrent respiratory tract infections
since birth. Examination shows a to-and-fro murmur in the second left intercostal
space, a loud S2, bounding peripheral pulses, and a widened pulse pressure. Which
of the following is the most likely diagnosis?
A) Atrial septal defect (ostium primum type)
B) Atrial septal defect (ostium secundum type)
C) Atrioventricular canal
D) Coarctation of the aorta
E) Hypoplastic left heart syndrome
F) Patent ductus arteriosus
G) Tetralogy of Fallot
H) Transposition of the great arteries
I) Tricuspid atresia
J) Ventricular septal defect

38. A 70-year-old man comes to the physician because of urinary hesitancy and
frequency for 9 months. His temperature is 37.5 C (99.5 F). Examination shows a
circumcised penis with no urethral discharge. Testicular examination shows no
abnormalities. Rectal examination shows an enlarged rubbery prostate that is
nontender to palpation. Urinalysis shows many leukocytes and no erythrocytes.
Gram's stain of urine shows gram-negative rods. Which of the following is the most
likely cause of this patient's condition?
A) Infection of the epididymis
B) Infection of the prostate
C) Infection of the urethra
D) Neurogenic bladder
E) Outflow obstruction of the bladder
39. A 32-year-old woman comes to the physician because of lethargy and boredom
since the birth of her son 5 months ago. She worries about her ability to care for him
and has had frequent palpitations. She is unable to fall back asleep after nighttime
feedings. She stopped breast-feeding 1 month ago. Her son is healthy, and growth
and development are normal for his age. Her blood pressure is 122/80 mm Hg,
pulse is 58/min, and respirations are 18/min. Physical examination shows no
abnormalities. She remembers one out of three objects after 5 minutes. Her serum
cholesterol level is 265 mg/dL. The most appropriate next step in diagnosis is
measurement of which of the following serum levels?
A) Cortisol
B) Estrogen
C) Progesterone
D)Prolactin
E) Thyroid-stimulating hormone
40. The genetic disease institute at a university hospital has developed a rapid
screening test for a serious but treatable inherited metabolic disorder. Although this
disorder is predominantly found in a particular ethnic group, it is also found
sporadically throughout the entire population. The screening test has a sensitivity of
95% and a specificity of 90%. When used in an ethnically prescreened population
where the prevalence of this disorder is 30%, the positive predictive value is 80%
and the negative predictive value is 96%. The institute proposes to use this
screening test on the general population where the prevalence of this disease is
0.1%. Which of the following is the most likely result of this screening program?
A) Negative predictive value decreases
B) Positive predictive value decreases
C) Sensitivity decreases
D) Specificity decreases
41. A 32-year-old woman comes to the physician because of a 1-year history of

increasingly severe dull pain in her lower back and buttocks. She also has had
morning stiffness of the lower back that lasts for 1 to 2 hours. There is no history of
trauma. Her job does not require heavy lifting. Her blood pressure is 110/70 mm
Hg, pulse is 68/min and regular, and respirations are 16/min. Cardiopulmonary
examination shows no abnormalities. There is tenderness to palpation over the
sacroiliac joints bilaterally and decreased flexion and extension of the lumbar spine.
An x-ray film of the lumbosacral spine shows sclerosis of the sacroiliac joints.
Laboratory studies are most likely to show which of the following findings in this
patient?
A) Decreased erythrocyte sedimentation rate
B) Histocompatibility human leukocyte antigen B27
C) Increased serum antinuclear antibody titer
D) Increased serum carcinoembryonic antigen (CEA) level
E) Positive serum rheumatoid factor
42. A 6-month-old boy is brought to the physician because of respiratory distress for
1 day. He had a persistent dry cough 3 days ago. He has not had a fever or nasal
discharge, but he has had chronic watery stools. He is at the 50th percentile for
height and 10th percentile for weight. He appears ill and is in respiratory distress.
His temperature is 37 C (98.6 F), pulse is 140/min, and respirations are 78/min.
Pulse oximetry shows an oxygen saturation of 70% while breathing room air.
Examination shows white plaques on the mucous membranes of his mouth and
diffuse adenopathy. There are intercostal retractions, and diffuse crackles are heard
throughout all lung fields. In addition to oxygen and antibiotic therapy, which of the
A) Stool culture for bacterial pathogens

B) Urinalysis
C) HIV testing
D) Quantitative measurement of immunoglobulins
E) Nitroblue tetrazolium testing
F) Platelet morphology evaluation
G) Tympanocentesis
43. A 42-year-old man is brought to the physician by his wife because of a 2-month
history of staring spells that last 1 to 2 minutes each. During episodes, he also
smacks his lips and picks at his shirt collar. Four years ago, he was comatose for 2
weeks after sustaining a head injury in a motorcycle collision; he required 6 months
of rehabilitation. He reports that, over the past year, he has had intermittent
episodes of smelling burnt rubber that occur approximately every 2 weeks. He hears
an intense hissing sound during these episodes. Examination shows no
abnormalities. Which of the following is the most likely diagnosis?
A) Absence seizures
B) Complex partial seizures
C) Transient ischemic attack
D) Tourette's disorder
E) Limbic encephalopathy
44. A 47-year-old woman is admitted to the hospital for evaluation of a 2-week

history of increased irritability and racing thoughts. Her family reports that she
argues with anyone who does not agree with her. She has been talking incessantly at
a rapid rate and pacing around the house. She says that, for years, she has been
hearing the voice of God telling her that she has been chosen for a special mission.
She has barely slept for the past week, waiting to hear further messages from God.
She is disheveled and dehydrated. Serum studies show:
Na+ 137 mEq/L
Cl– 96 mEq/L
K+ 3.8 mEq/L
HCO3– 22 mEq/L
Glucose 68 mg/dL
Mental status examination shows disorganized thoughts and flight of ideas. She is
agitated and has difficulty staying seated. She is too distractible to perform cognitive
tests. Toxicology screening is negative. Which of the following is the most likely
diagnosis?
A) Acute renal failure
B) Borderline personality disorder
C) Diabetes insipidus
D) Narcissistic personality disorder
E) Schizoaffective disorder
F) Schizoid personality disorder
45. A 20-year-old man comes for a routine health maintenance examination. He has
a 15-year history of difficulty relaxing his hands after tightly gripping objects or
after shaking hands. His father has cataracts and frontal baldness. Examination
shows thin forearms. There is moderate weakness of the hands and difficulty
releasing after gripping with his hands. Which of the following is the most likely
diagnosis?
A) Amyotrophic lateral sclerosis
B) Cervical spondylosis
C) Multiple sclerosis
D) Myasthenia gravis
E) Myasthenic (Lambert-Eaton) syndrome
F) Myotonic muscular dystrophy
G) Polymyalgia rheumatica
H) Polymyositis
I) Progressive neuropathic (peroneal) muscular atrophy
46. A 47-year-old man is admitted to the hospital after threatening to harm a radio
announcer he believed was broadcasting his thoughts. Over the past 20 years, he
has had multiple psychiatric hospitalizations for threatening people who he
believed were plotting against him, trying to control his mind, or causing him to
hear voices by implanting devices in his head. Past symptoms improved with
neuroleptic therapy; after discharge, he discontinued the medication and his
symptoms worsened. Which of the following is the most appropriate
pharmacotherapy to decrease this patient's risk for future hospitalization?
A) Clozapine
B) Fluphenazine hydrochloride
C) Haloperidol decanoate
D) Risperidone
E)Trifluoperazine hydrochloride
___________________________________________________________________
Answers:
NBME CK form 1
block 1
cbbbc fdajh cagcf cbfed bdbed daabb ecaab debed cacea d
block 2
ddadd efegc edbec dgahh bbeeb cdeaa adbfe eddde ddbbb b
block 3
fcbbe cacae ccced abgcd caacc caeab bbeba dabaa dcedb g
block 4
heddd gfpda hhibd dcecb aceda eabea ddedc gfeeb bcbef c
NBME FORM 1 ANSWERS

BLOCK 1
1- C
2 -B
3 -B
4- B
5 -C
6 -F
7- D
8 -B
9 -H
10 -
11-C / B ?
12- A
13- G
14 –C
15- F
16-C
17- B
18- F
19- E
20 –D
21- B
22-D / C ?
23-B
24-E
25-D
26-D
27-A
28-A
29-B
30- B
31- E / D
32-C
33-C
34-A
35-B
36-D
37-E
38-B
39-E
40-D
41-C
42-A
43-C
44-E
45-A
46-D
block 2
1-b
2-d?
3-a
4-d
5-d
6-e
7-f
8-e / next ? c
9-g??
10-c
11-e
12-d
13-B/ d??
14-e
15-c
16- D
17- G
18- E
19- H
20- K
21- B
22- B
23- E
24- E
25- E
26- C
27- B
28- E
29- A
30- A
31- A
32- C / D
33- B
34- F
35- E
36- E
37- D
38- D
39- D
40- E
41- D
42- D / E
43- B
44- B
45- B
46- B
BLOCK 3
1F
2C
3B
4B
5E
6C
7A
8 C OR E ( if strept pyogens is the same as strept pneumonia then its E)
9A
10 E
11 C
12 C
13 A
14 E
15 D
16.a
17.b?g?
18.g
19.a?c?
20.b?d?
21.c
22.a
23.a
24.c
25.a?b?
26.c
27.a?b?
28.e?g?
29.a
30.b
31 B
32 B
33 E
34 B
35 A
36 D
37 A
38 B (why such a low bp in this patient,)?
39 E
40 B
41 D
42 C
43 E
44 D
45 B
46 G
BLOCK 4
1-A
2-E
3-E
4-B
5-A
6-E
7-D
8-D
9-C
10-A
11-B
12-C
13-B
14-D
15-A
16-B
17-A
18-C
19-E
20-E
21-A
22-D
23-B
24-C
25-B
26-A
27-D
28-G
29-E
30-E
31-F
32-E
33- E
34-A
35-A
36-E
37-D
38-A
39-C
40-A
41-B
42-B
43-E
44-A
45-I
46-C

Form 1

Uploaded by

Form 1

Uploaded by

NBME Form 1 Step 2

A ) X-ray films of the abdomen

B ) Comparison of abdominal fluid amylase with serum amylase activity

C ) Gram's stain of abdominal fluid

D ) Ultrasonography of the abdomen

E ) CT scan of the abdomen and pelvis

2. A 5-year-old girl is brought to the physician because of temperatures to 40 C (104

3. A 40-year-old man is brought to the emergency department 1 hour after a high-

A ) Inadequate administration of fluids

E ) Traumatic rupture of the aorta

A ) Anemia secondary to infection

C ) Gastrointestinal blood loss

D ) Sickle cell disease

5. An 87-year-old nursing home resident with dementia, Alzheimer's type, is

A ) Decreased airway elasticity

D ) Decreased thyroid function

E ) Diastolic cardiac dysfunction

F ) Impaired cardiac response to exercise

G ) Impaired T-lymphocyte function

I ) Increased lung compliance

J ) Renal salt wasting

6. A 27-year-old woman comes to the physician because of feelings of anxiety about

B ) Anxiety disorder due to a general medical condition

D ) Generalized anxiety disorder

E ) Panic disorder with agoraphobia

7. A previously healthy 44-year-old woman, gravida 4, para 4, comes to the

8. One day after an uncomplicated spontaneous vaginal delivery, a 23-year-old

9. An 82-year-old woman is brought to the physician by her granddaughter because

A ) Acute stress disorder

B ) Dementia, Alzheimer's type

F ) Hepatolenticular degeneration (Wilson's disease)

I ) Major depressive disorder

J ) Multi-infarct (vascular) dementia

O ) Schizophrenia, catatonic type

10. A 42-year-old computer science professor is brought to the physician by her

11. A 5-month-old boy is brought for a follow-up examination. He was born at 37

A ) Allergic reaction to cow's milk

B ) Aspiration of a foreign body

C ) Compression of the airway by a vascular ring

D ) Concurrent upper respiratory tract infection

E ) Persistent immaturity of lungs

12. An 18-month-old boy is brought to the emergency department because he has

A ) Passive hypersupination of the forearm

B ) Application of figure-of-8 strap

C ) Administration of analgesics and application of ice

D ) Aspiration of the elbow joint

A ) Acute cerebral edema

B ) Decreased absorption of cerebrospinal fluid

C ) Dilation of cerebral arteries

D ) Intracranial mass lesion

E ) Obstruction of lateral sinus

F ) Obstruction of superior vena cava

G ) Obstruction of cerebrospinal fluid flow

H ) Overproduction of cerebrospinal fluid

A ) Repeat measurement of MSAFP level

D ) Amniocentesis for measurement of α-fetoprotein level

E ) Amniocentesis for chromosomal analysis

15. A 28-year-old man is brought to the emergency department by police because of

C ) Depressive disorder not otherwise specified

16. A 6-year-old girl is brought to the physician because of a 4-week history of

A) Increased potassium and sodium bicarbonate intake

B) Decreased sodium and daily calorie intake

D) Strict fluid restriction

17. A previously healthy 62-year-old man comes to the emergency department

B) CT scan of the abdomen

18. A previously healthy 3-month-old girl is brought to the emergency department

Ca2+ 5.6 mg/dL

Capillary blood gas analysis on 100% oxygen:

D ) Destruction of CD4+ T lymphocytes

E ) Developmental arrest of maturation of B lymphocytes

F ) Dysmorphogenesis of the third and fourth pharyngeal pouches

H ) Impaired phagocytic oxidative metabolism

A) Acute respiratory distress syndrome

B) Parasympathetic nervous system

D) Presynaptic neuromuscular junction

E) Sympathetic nervous system