Exam Section : Item 1 of 50 National Board of Medical Examiners Time Remaining:

■ Mark Medicine Self-Assessment 4 hr 59 min 56 sec

1. A 32-year-old woman comes to the office for a follow-up examination. Six weeks ago, she was diagnosed with sinusitis and began a
10-day course of amoxicillin-clavulanate therapy. She has occasional nonproductive cough; she otherwise feels well. During the past
6 years, she has had eight episodes of sinusitis treated with amoxicillin, amoxicillin-clavulanate, and azithromycin. One episode
required a 1-month course of amoxicillin therapy. The patient also has had two episodes of bacterial pneumonia during the past
3 years that resolved with moxifloxacin therapy. She currently takes no medications. Her maternal uncle died of pneumonia at the
age of 28 years. The patient is 163 cm (5 ft 4 in) tall and weighs 64 kg (140 lb); BMI is 24 kg/m 2• Vital signs are within normal limits.
Scattered rhonchi are heard over the right lower lung base. The remainder of the examination shows no abnormalities. Results of a
complete blood count, liver and kidney function testing, and HIV antibody serologic testing are within the reference ranges. A CT scan
of the paranasal sinuses shows mucosal thickening of the maxillary, sphenoid, and ethmoid sinuses. A CT scan of the chest shows
bronchial thickening and dilation of the bronchi in the lower lobe of the right lung. Which of the following is the most appropriate next
step in diagnosis?

0 A) Bone marrow biopsy

0 B) Bronchoalveolar lavage
0 C) Open lung biopsy
0 D) Quantitative serum immunoglobulin testing
0 E) Sputum culture for acid-fast bacilli

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Exam Section : Item 2 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 50 sec

2. An unconscious 37-year-old woman is brought to the emergency department after being found in an abandoned house. On arrival,
her temperature is 36°C (96.8°F), pulse is 100/min, respirations are 24/min, and blood pressure is 100/70 mm Hg. She is
unresponsive to painful stimuli. The remainder of the examination shows no abnormalities. Her serum creatinine concentration is 3
mg/dl, and blood alcohol concentration is 200 mg/dl. The remainder of the toxicology screening is negative. Urinalysis shows
pigmented casts. Serum studies are most likely to show which of the following?

0 A) Decreased phosphorus concentration

0 B) Decreased sodium concentration
0 C) Increased bicarbonate concentration
0 D) Increased calcium concentration
0 E) Increased creatine kinase activity

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Exam Section : Item 3 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 45 sec

3. A 62-year-old woman comes to the physician because she is concerned about her risk for osteoporosis. She has hypertension and
deep venous thrombosis. Current medications include metoprolol and warfarin. There is no personal or family history of fractures.
She does not smoke or drink alcohol. Her blood pressure is 132/82 mm Hg. Examination shows no abnormalities. A DEXA scan
shows findings consistent with osteoporosis. In addition to calcium and vitamin D supplementation, which of the following is the most
appropriate pharmacotherapy?

0 A) Alendronate
0 B) Calcitonin
0 C) Estrogen
0 D) lsoflavone
0 E) Raloxifene

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Exam Section : Item 4 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 41 sec

4. A 57-year-old homeless man is admitted to the hospital because of a 5-day history of moderate neck pain and fever. He has HIV
infection and hepatitis C. He takes no medications. He uses intravenous heroin three times weekly. He does not smoke cigarettes
and drinks alcohol occasionally. His temperature is 39.5°C (103.1 °F), pulse is 110/min, respirations are 22/min, and blood pressure is
112/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. There is no photophobia. The lungs are clear to
auscultation. Cardiac examination shows a regular rhythm; a grade 2/6 holosystolic murmur is heard best at the apex. The neck is
tender over the lower cervical spine with no warmth or erythema. Neurologic examination shows no focal findings. His
CD4+ T-lymphocyte count is 400/mm 3 (Normal<!:500), and HIV viral load is 75,000 copies/ml. A chest x-ray shows no abnormalities.
An x-ray of the cervical spine shows destructive changes in C5 and C6 and collapse of the intervening disc space. Which of the
following is the most likely mechanism of this patient's neck pain?

0 A) Contiguous spread of organism from adjacent soft-tissue process

0 B) Direct inoculation of the soft tissues of the neck
0 C) Granulomatous inflammation
0 D) Hematogenous dissemination of distant infection
0 E) Reactivation of latent organism

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Exam Section : Item 5 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 36 sec

5. A 67-year-old man comes to the physician for a routine health maintenance examination. He has no history of serious illness. Both of
his parents died of cerebral infarction in their 70s. He smokes one-half pack of cigarettes daily and drinks one 6-oz glass of wine
daily. He takes no medications. He is 178 cm (5 ft 10 in) tall and weighs 91 kg (200 lb); BMI is 29 kg/m 2. His temperature is
37°C (98.6°F), pulse is 78/min, and blood pressure is 170/95 mm Hg. The lungs are clear to auscultation. On cardiac examination, an
S 4 is heard at the cardiac apex. There are no murmurs. No bruits are heard over the neck. Neurologic examination shows no
abnormalities. Serum studies obtained after fasting show a glucose concentration of 140 mg/dl and cholesterol concentration of
250 mg/dl. Which of the following measures is most likely to decrease this patient's risk for cerebral infarction?

0 A) Cessation of smoking
0 B) Decreasing alcohol intake to 12 ounces weekly
0 C) A low-fat diet
0 D) Antihypertensive therapy
0 E) Hypoglycemic therapy

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Exam Section : Item 6 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 31 sec

6. A 57-year-old man comes to the physician because of a 3-day history

of a painful rash on his right index finger, low-grade fever, and swollen
lymph nodes in his right armpit. There is no family history of serious
illness. He drinks one alcoholic beverage daily. He does not smoke.
He works as a dentist. His temperature is 37.9°C (100.2°F}, pulse is
70/min, respirations are 12/min, and blood pressure is
130/84 mm Hg. A photograph of the right index finger is shown. There
is right axillary lymphadenopathy. Which of the following is the most
appropriate next step in management?

0 A) Topical erythromycin
0 B) Topical hydrocortisone therapy
0 C) Oral acyclovir
0 D) Oral dicloxacillin
0 E) Oral prednisolone therapy
0 F) Incision and drainage

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Exam Section : Item 7 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 26 sec

7. A 52-year-old woman is brought to the emergency department by her husband because she says that she is having "the worst
headache of my life." It began abruptly while she was eating dinner 2 hours ago. She has a history of hypertension treated with
diuretics. She is lying quietly with her eyes closed. She has difficulty talking and concentrating because of the pain, but is fully
oriented. Her blood pressure is 180/98 mm Hg. Examination shows moderate nuchal rigidity. Cranial nerves, reflexes, and sensory
examination are normal. Examination of cerebrospinal fluid shows an opening pressure of 170 mm Hp, erythrocyte count of
86,000/mm 3, and leukocyte count of 5/mm 3. Which of the following is the most likely diagnosis?

0 A) Arterial hypertension
0 B) Epidural hematoma
0 C) Idiopathic intracranial hypertension
0 D) Meningitis
0 E) Migraine
0 F) Ruptured congenital aneurysm
0 G) Subdural hematoma

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Exam Section : Item 8 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 21 sec

8. A 4 7-year-old woman comes to the physician because of a 3-year history of progressive swelling of her left calf. Ten years ago, she
had a thrombus in her left leg and was treated with anticoagulants for 4 months. She currently takes no medications. Her pulse is
70/min, and blood pressure is 115/70 mm Hg. Examination shows mild edema and prominent varicose veins of the distal left lower
extremity. There is an 8-cm area of hyperpigmentation over the left ankle. Examination of the right lower extremity shows no
abnormalities. Peripheral pulses are normal. Ultrasonography of the lower extremities shows no abnormalities. Which of the following
is the most likely cause of this patient's edema?

0 A) Cellulitis
0 B) Obstruction of the iliac vein
0 C) Obstruction of lymph channels
0 D) Saphenous vein reflux
0 E) Valvular insufficiency of deep veins

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Exam Section : Item g of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 16 sec

9. A 62-year-old man comes to the physician because of a 2-week history of severe left ear pain. At the onset of pain, he flushed his ear
with water; the pain has become increasingly severe since then. He has no history of ear problems. He has a 30-year history of type
1 diabetes mellitus poorly controlled with insulin. Examination shows moist debris and edema of the left ear canal. Granulation tissue
is seen on the floor of the ear canal. Laboratory studies show:
Leukocyte count 18,000/mm 3
Segmented neutrophils 78%
Lymphocytes 22%
Erythrocyte sedimentation rate 100 mm/h
Serum glucose 450 mg/dL

Which of the following is the most likely diagnosis?

0 A) Acute mastoiditis
0 B) Acute otitis media
0 C) Angiocentric T-cell lymphoma
0 D) Chronic otitis media with effusion
0 E) Fungal otitis externa
0 F) Necrotizing otitis externa

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Exam Section: Item 10 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 12 sec

10. A previously healthy 57-year-old woman is admitted to the hospital for evaluation of a 3-week history of increasing fatigue,
constipation, urinary frequency, and increased thirst. She appears lethargic. Her pulse is 116/min, and blood pressure is
150/70 mm Hg. Examination shows dry mucous membranes. Serum studies show a calcium concentration of 15.2 mg/dl,
phosphorus concentration of 2.1 mg/dl, and parathyroid hormone concentration of 800 pg/ml. Which of the following is the most
likely explanation for this patient's polyuria and volume depletion?

0 A) Allergic interstitial nephritis

0 B) Central diabetes insipidus
0 C) Chronic pyelonephritis
0 D) Glycosuria
0 E) Hypertensive nephropathy
0 F) Nephrogenic diabetes insipidus

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Exam Section: Item 11 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 8 sec

11 . A 67-year-old man with type 2 diabetes mellitus is admitted to the hospital because of a 1-day history of fever and severe abdominal
pain. His only medication is glyburide. His temperature is 39°C (102.2°F). Abdominal examination shows moderate left lower
quadrant tenderness with guarding but no rebound. His serum creatinine concentration is 1.4 mg/dl. Urinalysis shows no
abnormalities. This patient should receive which of the following prior to a CT scan of the abdomen with intravenous contrast?

0 A) Atrial natriuretic peptide

0 B) Dopamine
0 C) Furosemide
0 D) Mannitol
0 E) 0.9% Saline

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Exam Section: Item 12 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 59 min 3 sec

12. A 62-year-old woman comes to the physician for a follow-up examination. She has chronic renal failure secondary to
glomerulonephritis. She has received hemodialysis three times weekly for 2 years. She is on a waiting list for a renal transplant.
Examination shows no abnormalities. Her serum calcium concentration is 8.2 mg/dl. Which of the following is the most likely
underlying mechanism of this patient's hypocalcemia?

0 A) Decreased absorption due to decreased serum 1,25-dihydroxycholecalciferol concentration

0 B) Decreased absorption due to decreased serum magnesium concentration
0 C) Decreased absorption due to increased serum ionized calcium concentration
0 D) Increased calcium binding by phosphate in the small bowel
0 E) Increased suppression of parathyroid hormone due to increased serum ionized phosphorus concentration

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Exam Section: Item 13 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 58 sec

13. A 47-year-old man with alcoholism is transferred from the hospital to a drug rehabilitation facility. On arrival, examination shows
hyperreflexia and a tremor in both hands when they are outstretched. His serum calcium concentration is 8.1 mg/dl. Which of the
following is the most likely additional serum electrolyte abnormality in this patient?

0 A) Hypochloremia
0 B) Hypokalemia
0 C) Hypomagnesemia
0 D) Hyponatremia
0 E) Hypophosphatemia

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Exam Section: Item 14 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 54 sec

14. A previously healthy 22-year-old woman comes to the physician because of a 2-day history of frequent pain with urination and
episodes of loss of urine. She has no history of similar symptoms, and she has not had pelvic pain or change in bowel function.
Menses occur at regular intervals and last 4 days; her last menstrual period was 10 days ago. Vital signs are within normal limits.
Abdominal examination shows no abnormalities. The external genitalia, vagina, and cervix appear normal. There is no cervical
motion or uterine tenderness, but the bladder is tender to palpation. Which of the following is the most appropriate next step in
management?

0 A) Nitrofurantoin therapy
0 B) Oxybutynin therapy
0 C) Intermittent self-catheterization
0 D) Sacral nerve stimulation
0 E) Midurethral sling procedure

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Exam Section: Item 15 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 49 sec

15. A 27-year-old woman comes to the physician because of a 1-year history of fatigue. She first noted her fatigue after the birth of her
second child; pregnancy and delivery were uncomplicated. During both pregnancies, she was told she had anemia. Examination
shows no abnormalities. Laboratory studies show:
Hemoglobin 11 .6 g/dL
Mean corpuscular volume 66 µm 3
Reticulocyte count 0.3%

Hemoglobin electrophoresis shows:

Hemoglobin A 2 5% (N=2%-4%)
Hemoglobin F 2% (N=0o/o-2%)

Which of the following is the most likely diagnosis?

0 A) Autoimmune hemolytic anemia

0 B) Iron deficiency anemia
0 C) Lead poisoning
0 D) Sickle cell disease
0 E) Sideroblastic anemia
0 F) ~-Thalassemia trait

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Exam Section: Item 16 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 44 sec

16. A 27-year-old nulligravid woman comes to the physician because of a 4-month history of irregular menses. During this time, she has
had vaginal spotting so frequently that she does not know the dates of her actual menstrual periods. Previously, menses occurred at
regular 28-day intervals. She also reports increased hair growth over the face, chest, and lower abdomen. She has no history of
serious illness and takes no medications. Her blood pressure is 120/60 mm Hg. Physical examination shows coarse hair over the
upper lip, chin, and abdomen. Abdominal and pelvic examinations show no abnormalities. Her serum dehydroepiandrosterone
sulfate concentration is 75 µg/ml (N=0.5-5.4). An overnight dexamethasone suppression test shows no suppression of cortisol.
Which of the following is the most appropriate next step in management?

0 A) Measurement of fasting serum cortisol concentration

0 B) Measurement of serum potassium concentration
0 C) Ultrasonography of the pelvis
0 D) CT scan of the abdomen
0 E) MRI of the brain

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Exam Section: Item 17 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 39 sec

17. A 62-year-old man comes to the physician because of a 2-month history of increasing fatigue, weakness, malaise, and darkening of
his skin. During this period, he has had a 9-kg (20-lb) weight loss. He now has difficulty rising from a chair or climbing stairs. He has
smoked one pack of cigarettes daily for 40 years. He appears cachectic. His blood pressure is 160/98 mm Hg while sitting.
Examination shows hyperpigmentation of the skin and proximal muscle wasting and mild pitting edema at the ankles. His
hemoglobin concentration is 11 .5 g/dl, serum potassium concentration is 3.0 mEq/L, and serum glucose concentration is
130 mg/dl. Which of the following is the most likely diagnosis?

0 A) Adrenal insufficiency
0 B) Bronchial carcinoid
0 C) Hemochromatosis
0 D) Hyperthyroidism
0 E) Small cell carcinoma of the lung

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Exam Section: Item 18 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 34 sec

18. A 57-year-old woman comes to the physician because of fatigue over the past 6 months. She has had a decreased appetite and a
4.5-kg (10-lb) weight loss over the past year. She has not had nausea or vomiting, abdominal pain, changes in bowel movements,
diarrhea, or blood in the stool. She has a 2-year history of pruritus. She has hypertension treated with hydrochlorothiazide. She has
no known allergies. Her mother has Graves disease, her sister has systemic lupus erythematosus, and a paternal uncle has
hemochromatosis. Her pulse is 80/min and regular, respirations are 14/min, and blood pressure is 120/85 mm Hg. Examination
shows excoriations over the upper and lower extremities and trunk with no lesions. There are xanthomas around the eyelids.
Abdominal examination shows a liver span of 12 cm; there are no palpable masses or tenderness. Laboratory studies show:
Hemoglobin 12.5 g/dL
Leukocyte count 3500/mm 3
Platelet count 100,000/mm 3
Serum
Cholesterol 350 mg/dL
Total bilirubin 2.2 mg/dL
Alkaline phosphatase 450 U/L
AST 30 U/L
ALT 35 U/L

Ultrasonography of the abdomen shows hepatomegaly and no evidence of a biliary obstruction. There is a large gallstone in the
gallbladder and mild splenomegaly. Which of the following is most likely to suggest the diagnosis?

0 A) Serum antimitochondrial antibody assays

0 B) Serum antinuclear antibody assay
0 C) Serum hepatitis B surface antigen and antibody and core antibody assays
0 D) Oral cholecystography
0 E) HIDA scan
0 F) No further testing indicated

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Exam Section: Item 19 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 30 sec

19. A 25-year-old man comes to the physician 1 day after noticing pink-tinged urine. Two days ago, he had an upper respiratory tract
infection with a nonproductive, hacking cough; his symptoms are now resolved . He has not had pain, fever, or chills. He has no
history of serious illness. Current medications include over-the-counter cough syrup. He does not smoke, drink alcohol, or use illicit
drugs. His temperature is 37.1°C (98.?°F), pulse is 72/min, respirations are 12/min, and blood pressure is 114/68 mm Hg.
Examination shows no abnormalities. Urinalysis shows a pH of 5.5, 4+ blood, and greater than 50 RBC/hpf. His serum creatinine
concentration is 1.1 mg/dl, and serum complement concentration is within the reference range. Ultrasonography of the kidneys and
bladder shows no abnormalities. Which of the following is the most likely diagnosis?

0 A) Cystitis
0 B) lgA nephropathy
0 C) Nongonococcal urethritis
0 D) Postinfectious glomerulonephritis
0 E) Renal cell carcinoma

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Exam Section : Item 20 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 25 sec

20. An 82-year-old man with metastatic lung cancer is brought to the emergency department by his children because he has been
unresponsive for the past 24 hours. His family reports that he has become increasingly sleepy and confused over the past 2 weeks.
His lung cancer was diagnosed 3 years ago and initially treated with palliative radiation therapy to his chest and right femur. Nine
months ago, he and his oncologist agreed to discontinue treatment. He has had a 16-kg (35-lb) weight loss over the past 9 months.
He has lived in his son's house for the past 6 months and has received palliative care only. The patient has an advance directive
indicating that he does not want lifesaving treatment, and the son has stated that his father recently confirmed these wishes
verbally. His daughter, who lives out of state, disagrees with the plan to provide palliative care at home only and is concerned about
her father's weight loss. After a family meeting, both siblings now request that the physician switch to an aggressive treatment plan.
The patient appears cachectic but well groomed. He responds to painful stimuli only. He is 173 cm (5 ft 8 in) tall and weighs
52 kg (115 lb); BMI is 18 kg/m 2• His temperature is 37.8°C (100°F), pulse is 122/min, respirations are 34/min and shallow, and blood
pressure is 85/50 mm Hg. Serum studies show:
Na+ 142 mEq/L
Ca 2 + 13.2 mg/dl
Creatinine 2.8 mg/dl
Albumin 3 g/dl

Which of the following is the most appropriate next step?

0 A) Contact the hospital attorney

0 B) Contact the hospital ethics committee
0 C) Follow the advance directive
0 D) Perform lifesaving measures until the family issues can be resolved
0 E) Begin aggressive treatment

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Exam Section : Item 21 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 19 sec

21 . A 42-year-old African American woman comes to the physician because of a 4-week history of cough and fatigue. She has
long-standing hypertension well controlled with atenolol. Her blood pressure is 138/82 mm Hg. The lungs are clear to auscultation.
Serum studies show:
Ca 2 + 11 .8 mg/dl
Phosphorus 3.4 mg/dl
Globulin 4.8 g/dl
Parathyroid hormone, intact 7 pg/ml (N=10-65)
Parathyroid hormone-related protein 1.0 pmol/L (N<1 .3)

An x-ray of the chest shows several nodules throughout both lung fields. Which of the following is the most appropriate next step in
management?

0 A) Calcitriol therapy
0 B) Divalproex sodium therapy
0 C) Gallium nitrate therapy
0 D) Glucocorticoid therapy
0 E) Plicamycin therapy
0 F) Dialysis
0 G) Parathyroidectomy

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Exam Section : Item 22 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 14 sec

22. A 55-year-old man comes to the physician because of shortness of breath on exertion over the past 2 weeks. His last examination
was 38 years ago. He has smoked one pack of cigarettes daily for 30 years. His temperature is 36.7°C (98°F), pulse is 72/min,
respirations are 16/min, and blood pressure is 180/100 mm Hg. Jugular venous pressure is not increased. Crackles are heard at
both lung bases. Cardiac examination shows an S 4 gallop. Pulses are symmetric without bruits. There is no peripheral edema. His
fasting serum glucose concentration is 130 mg/dl, and fasting serum cholesterol concentration is 270 mg/dl. An x-ray of the chest
shows mild cardiomegaly and Kerley B lines. An ECG shows left ventricular hypertrophy. Echocardiography shows a thickened left
ventricle and an ejection fraction of 40% without segmental wall abnormalities. Which of the following is most likely to have
prevented the echocardiographic findings?

0 A) Adequate control of blood pressure

0 B) Adequate control of serum glucose concentrations
0 C) ~-Adrenergic agonist inhaler therapy
0 D) Low-cholesterol diet
0 E) Smoking cessation

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Exam Section : Item 23 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 9 sec

aVR V1 V4

llttlllfflffillfrnlllll
II aVL V2 VS

111 ■m m lflffl 1 111■

Ill aVF
111
V3 V6

•m1·t1-m■t111111rn 111 1
Lead V1 continuous

IIHI I!IW IlffllTilliffl Iii

23. A 42-year-old man is brought to the emergency department 30 minutes after the onset of severe chest pressure and nausea. He has
no history of serious illness and takes no medications. He has smoked three packs of cigarettes daily for 20 years. He is employed
as a truck driver and has a sedentary lifestyle. He appears anxious and diaphoretic. He is 180 cm (5 ft 11 in) tall and weighs
107 kg (235 lb); BMI is 33 kg/m 2. His pulse is 44/min and regular, and blood pressure is 160/94 mm Hg. Cardiopulmonary
examination shows no abnormalities. Peripheral pulses are normal. An ECG is shown. Which of the following is the most likely
cardiac rhythm?
0 A) Complete heart block
0 B) First-degree atrioventricular block
0 C) Mobitz type I (Wenckebach type) block
0 D) Mobitz type II block
0 E) Sinus bradycardia

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Exam Section : Item 24 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 5 sec

24. A previously healthy 25-year-old graduate student comes to the physician because of numbness of her left leg, stiffness of her right
leg, and urinary urgency. Examination shows increased tone and deep tendon reflexes in the right lower extremity. Babinski sign is
present on the right. Sensation to pinprick is decreased over the left lower extremity and below the level of T9 on the left. Sensation
to vibration and proprioception is intact. Gait testing shows stiffness and circumduction of the right lower extremity. This patient is
most likely to have a lesion at which of the following locations?

0 A) Brain stem
0 B) Cerebral hemispheres
0 C) Peripheral nerves
0 D) Spinal cord
0 E) No lesion (conversion reaction)

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Exam Section : Item 25 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 58 min 1 sec

25. A 38-year-old African American man with accelerated hypertension is admitted to the hospital. His blood pressure is 230/130 mm Hg
and he has grade Ill retinopathy. Serum creatinine concentration is 3.7 mg/dl. Antihypertensive therapy is begun. Twenty-four hours
later he develops oliguria, and 5 days later his serum creatinine concentration increases to 6.8 mg/dl. He has substernal chest pain
and a pericardia! friction rub. Which of the following is the most likely underlying cause of the pericardia! disease?

0 A) Collagen vascular disease

0 B) Pyogenic infection
0 C) Tuberculosis
0 D) Uremia
0 E) Viral infection

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Exam Section : Item 26 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 56 sec

26. A 37-year-old woman comes to the physician for a routine follow-up examination. She has mild, intermittent asthma treated with an
albuterol inhaler as needed. During the past 3 weeks, she has had three to four weekly episodes of shortness of breath and
wheezing that resolve with use of the inhaler. She has never required intubation for asthma. She is otherwise asymptomatic. She
has no other history of serious illness and takes no other medications. There are no known sick contacts. Her temperature is
36.?°C (98°F), pulse is 88/min, respirations are 16/min, and blood pressure is 118/64 mm Hg. Wheezes are heard bilaterally. An
x-ray of the chest shows no abnormalities. Which of the following is the most appropriate next step in pharmacotherapy?

0 A) Increase the dosage of albuterol to four times daily

0 B) Add fluticasone
0 C) Add salmeterol
0 D) Add theophylline
0 E) Add tiotropium

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Exam Section : Item 27 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 52 sec

27. During transfusion of a second unit of crossmatched packed red blood cells for lower gastrointestinal bleeding, a 67-year-old
woman has the onset of fever and chills. Six months ago, she had gastrointestinal bleeding and had no complications after
transfusion of 3 units of crossmatched packed red blood cells. She appears anxious. Her temperature is 39.2°C (102.6°F), pulse is
105/min, respirations are 14/min, and blood pressure is 135/75 mm Hg. Examination of the skin shows no abnormalities. The lungs
are clear to auscultation. Serum studies of a post-transfusion sample show no free hemoglobin. A direct antiglobulin (Coombs) test
is negative. The ABO blood groups of the patient and donor are verified, and a second crossmatch reconfirms compatibility. In
addition to intravenous administration of crystalloid solution, which of the following is the most appropriate pharmacotherapy?

0 A) Acetaminophen
0 B) Dantrolene
0 C) Epinephrine
0 D) Penicillin
0 E) Prednisone

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Exam Section : Item 28 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 47 sec

28. A 27-year-old woman comes to the physician because of a 3-month history of fatigue, heat intolerance, generalized anxiety, and
intermittent palpitations; she has had a 6.8-kg (15-lb) weight loss during this period . Her only medication is an oral contraceptive.
Her pulse is 104/min, respirations are 12/min, and blood pressure is 112/78 mm Hg. Examination shows a 2-cm, discrete, firm
nodule in the left lobe of the thyroid gland. There is no cervical adenopathy. Her serum thyroid-stimulating hormone concentration is
less than 0.3 µU/ml. Which of the following is the most likely diagnosis?

0 A) Graves disease
0 B) Medullary carcinoma of the thyroid gland
0 C) Papillary carcinoma of the thyroid gland
0 D) Riedel thyroiditis
0 E) Toxic adenoma of the thyroid gland
0 F) Toxic multinodular goiter

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Exam Section : Item 29 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 43 sec

29. An 87-year-old woman comes to the physician because of a 2-week history of constant, increasing abdominal pain. The pain is not
related to eating. She has had generalized itching for the past week. She underwent a cholecystectomy for gallstones at the age of
63 years. She is 168 cm (5 ft 6 in) tall and weighs 79 kg (175 lb); BMI is 28 kg/m 2. Her temperature is 37°C (98.6°F), pulse is
76/min, and blood pressure is 142/82 mm Hg. Examination shows excoriations on both upper extremities. Abdominal examination
shows mild epigastric tenderness. Results of a complete blood count are within the reference range. Serum studies show:
Total bilirubin 1.9 mg/dl
Alkaline phosphatase 305 U/L
AST 34 U/L
ALT 42 U/L
Amylase 56 U/L

Abdominal ultrasonography shows dilation of the common bile duct and pancreatic duct. The pancreas is poorly visualized because
of overlying bowel gas. Which of the following is the most likely cause of these findings?

0 A) Choledocholithiasis
0 B) Pancreatic adenocarcinoma
0 C) Primary biliary cirrhosis
0 D) Sclerosing cholangitis
0 E) Sphincter of Oddi dysfunction

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Exam Section : Item 30 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 38 sec

30. A 42-year-old woman comes to the office because of a 3-month history of progressive shortness of breath, cough, and intermittent
wheezing. Her cough usually is nonproductive but occasionally has produced white sputum. She is otherwise asymptomatic. Nine
months ago, she was intubated and mechanically ventilated for 2 weeks for management of Guillain-Barre syndrome. Her only
medication is a daily multivitamin. She has smoked one pack of cigarettes daily for 20 years. She smokes marijuana two times
monthly. She does not drink alcohol. Vital signs are within normal limits. Pulse oximetry on room air shows an oxygen saturation of
97%. High-pitched, end-expiratory wheezes are heard in the anterior aspect of the lungs. No crackles are heard. The remainder of
the examination shows no abnormalities. Which of the following is the most likely diagnosis?

0 A) Asthma
0 B) Guillain-Barre syndrome
0 C) Hypersensitivity pneumonitis
0 D) Paradoxic vocal cord motion
0 E) Tracheomalacia

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Exam Section : Item 31 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 34 sec

31 . A 47-year-old woman with hypertension comes to the physician for a follow-up examination. One month ago, her blood pressure
was 200/120 mm Hg, and daily treatment with an oral ACE inhibitor was started. Examination at that visit showed no other
abnormalities, and results of serum electrolyte concentrations and renal function studies were within the reference range. Her blood
pressure today is 170/90 mm Hg. Examination shows no other abnormalities. Her serum creatinine concentration is 2.5 mg/dl.
Which of the following is the most appropriate next step in management?

0 A) Measurement of plasma renin activity

0 B) Measurement of urine catecholamine concentration
0 C) Addition of thiazide diuretic therapy to the current regimen
0 D) Increase in the dose of ACE inhibitor
0 E) MR angiography of the renal arteries

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Exam Section : Item 32 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 28 sec

32. An otherwise healthy 41 -year-old woman comes to the physician

because of a lesion on the calf for 2 months. A photograph of the
lesion is shown. Which of the following is the most appropriate next
step in management?

0 A) Topical corticosteroid therapy

0 B) Oral dicloxacillin therapy
0 C) Cryotherapy with liquid nitrogen
0 D) Punch biopsy
0 E) Surgical excision
0 F) No treatment indicated

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Exam Section : Item 33 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 24 sec

33. A 77-year-old man with dementia, Alzheimer type, is brought to the physician because of a 1-week history of urinary incontinence.
He has had frequent loss of small amounts of urine, especially at night. Abdominal examination shows tenderness and a 10-cm
tender suprapubic mass. He can void spontaneously and has a poor urinary stream. Urinalysis shows 4 WBC/hpf and 1+ bacteria.
Which of the following is the most appropriate next step in management of this patient?

0 A) Observation
0 B) X-rays of the abdomen
0 C) CT scan of the abdomen and pelvis
0 D) Antibiotic therapy
0 E) Catheterization of the bladder

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Exam Section : Item 34 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 18 sec

34. A 57-year-old man comes to the physician for a routine examination. He feels well. He has rheumatoid arthritis, type 2 diabetes
mellitus, hypertension, and hyperlipidemia. Current medications include methotrexate, metformin, lisinopril, simvastatin, and 81-mg
aspirin. He drinks one to two glasses of wine each evening. His temperature is 37.2°C (98.9°F), pulse is 88/min, respirations are
16/min, and blood pressure is 138/78 mm Hg. Examination shows an abdominal bruit. Laboratory studies show:
Serum
Na+ 142 mEq/L
K+ 3.5 mEq/L
cI - 120 mEq/L
Hco3- 10 mEq/L
Urea nitrogen 22 mg/dL
Glucose 134 mg/dL
Creatinine 1.2 mg/dL
Urine pH 6.5

Which of the following is the most likely explanation for these findings?

0 A) Alcohol use
0 B) Diabetic ketoacidosis
0 C) Lactate production
0 D) Renal tubular acidosis
0 E) Salicylate intoxication

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Exam Section : Item 35 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 13 sec

35. A 37-year-old man comes to the physician because of difficulty swallowing for 6 days. He says that food becomes stuck in his
throat. Over the past 2 weeks, he has had low-grade fever and fatigue. He has had an 11 -kg (25-lb) weight loss over the past year.
He has smoked one pack of cigarettes daily for 20 years. He uses intravenous heroin. His temperature is 37.5°C (99.5°F), pulse is
100/min, and blood pressure is 110/78 mm Hg. Examination shows anterior and posterior cervical lymphadenopathy. There are thick
white plaques over the buccal mucosa and soft palate. The lungs are clear to auscultation. Which of the following is the most likely
cause of this patient's dysphagia?

0 A) Bacterial endocarditis
0 B) Esophageal cancer with nodal metastases
0 C) HIV infection with candidal esophagitis
0 D) Oral cancer with nodal metastases
0 E) Tertiary syphilis

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Exam Section : Item 36 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 8 sec

36. A 27-year-old woman is brought to the emergency department because of a 6-hour history of shortness of breath and nonproductive
cough. She has had similar episodes, which typically last 18 hours, two to three times weekly during the past 3 months. She is
asymptomatic when she runs outside for 45 minutes, five times weekly. She has not had chest pain. She has no history of serious
illness, and her only medication is an oral contraceptive. She does not smoke cigarettes. She smokes marijuana once monthly. She
moved to a new apartment building 4 months ago and she often uses the communal pool and hot tub. She appears to be in mild
respiratory distress. Her temperature is 37.9°C (100.2°F), pulse is 115/min, respirations are 26/min, and blood pressure is
110/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. She is not using accessory muscles of respiration.
Diffuse, fine crackles are heard prominently at the lung bases; no wheezes are heard . The remainder of the examination shows no
abnormalities. Which of the following is the most likely cause of this patient's symptoms?

0 A) Type of contraceptive use

0 B) Hot tub use
0 C) Illicit drug use
0 D) Swimming pool use
0 E) Type of exercise

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Exam Section : Item 37 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 57 min 3 sec

37. A 32-year-old homeless man is admitted to the hospital and placed in

respiratory isolation because of a 2-week history of fever, chills, and cough
productive of blood-tinged sputum. He also has had shortness of breath after
walking approximately 100 feet. He has had a 13.6-kg (30-lb) weight loss
during the past 6 months. He takes no prescription medications but has a
history of intravenous drug use. He is 168 cm (5 ft 6 in) tall and weighs
45 kg (100 lb); BMI is 16 kg/m 2. His temperature is 38.4°C (101 .1°F), pulse is
102/min, respirations are 24/min, and blood pressure is 102/68 mm Hg. He is
using accessory muscles of respiration . Pulse oximetry on room air shows an
oxygen saturation of 90%. Examination shows shotty cervical
lymphadenopathy. There is bilateral wasting of the temporal and
supraclavicular muscles. Diffuse crackles are heard throughout both lung
fields. His leukocyte count is 11 ,500/mm 3 (70% segmented neutrophils, 1%
eosinophils, 1% basophils, 25% lymphocytes, and 3% monocytes). A PPD skin
test is negative. A chest x-ray is shown. Which of the following is the most
likely diagnosis?
0 A) Aspiration pneumonia
0 B) Bronchiectasis
0 C) Sarcoidosis
0 D) Septic pulmonary embolism
0 E) Tuberculosis
0 F) Wegener granulomatosis

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Exam Section : Item 38 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 58 sec

38. A47-year-old woman comes to the physician for a health maintenance examination. She has mild hyperparathyroidism that does
not require treatment. She takes no medications. She does not exercise or eat meat or dairy products. She is 163 cm (5 ft 4 in) tall
and weighs 104 kg (230 lb); BMI is 40 kg/m 2. Examination shows no abnormalities. Which of the following is the strongest
predisposing factor for osteoarthritis in this patient during the next 10 years?

0 A) Calcium deficiency
0 B) Hyperparathyroidism
0 C) Lack of exercise
0 D) Obesity
0 E) Vitamin D deficiency

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Exam Section : Item 39 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 53 sec

39. A 47-year-old man is admitted to the hospital for treatment of alcoholic pancreatitis. He is currently receiving intravenous
0.9% saline, intravenous morphine, oral lorazepam for alcohol withdrawal, and multiple vitamins. He has no known allergies. He has
smoked one pack of cigarettes daily for 25 years. He drinks one fifth of vodka daily. He frequently has sexual intercourse with
prostitutes. On examination, he is diaphoretic. His temperature is 37.4°C (99.3°F), pulse is 88/min, respirations are 18/min, and
blood pressure is 150/84 mm Hg. Examination shows no lymphadenopathy. The abdomen is distended with epigastric tenderness. A
photograph of the genitalia is shown. There is a lesion under the prepuce. The lesions over the penile shaft are tender, but the lesion
over the glans penis is nontender. Serum rapid plasma reagin is negative. Which of the following is the most appropriate
pharmacotherapy for the lesion on this patient's glans penis?
0 A) Acyclovir
0 B) Azithromycin
0 C) Ciprofloxacin
0 D) Doxycycline
0 E) Penicillin

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Exam Section : Item 40 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 46 sec

40. A 77-year-old man with alcoholism is brought to the emergency department after his landlord found him unconscious in his
apartment on a hot summer day. No history is available. On arrival, he is obtunded but is responsive to painful stimuli. His
temperature is 40°C (104°F), pulse is 120/min, respirations are 20/min, and blood pressure is 90/60 mm Hg. Examination shows
warm , dry skin and dry mucous membranes. The pupils are equally round and reactive to light; ocular movements are intact. The
neck is supple. No evidence of trauma is noted. Neurologic examination shows no focal findings. Laboratory studies show:
Hematocrit 33%
Leukocyte count 13,500/mm 3
Platelet count 75,000/mm3
Prothrombin time 13 sec
Partial thromboplastin time 50 sec
Serum
Na+ 149 mEq/L
cI - 110 mEq/L
K+ 5.4 mEq/L
HC0 3- 20 mEq/L
Urea nitrogen 60 mg/dL
Glucose 50 mg/dL
Creatinine 3.5 mg/dL
Bilirubin (total) 4 mg/dL
AST 150 U/L
Creatine kinase 550 U/L
Blood alcohol 0 mg/dL
Urinalysis
Blood 2+
Protein 1+
WBC 1- 2/hpf
RBC 1-2/hpf
Casts few granular

An x-ray of the chest and CT scan of the head show no abnormalities. Which of the following is the most likely diagnosis?

0 A) Delirium tremens
0 B) Heat stroke
0 C) Neuroleptic malignant syndrome
0 D) Subarachnoid hemorrhage
0 E) Thyroid storm
0 F) Wernicke-Korsakoff syndrome

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Exam Section: Item 41 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 41 sec

41. A 32-year-old man comes to the emergency department because of swelling of his left hand and redness of his left forearm, wrist,
and hand after being involved in a grease fire while working at a restaurant yesterday. After emptying the fryers, a small amount of
grease splattered and left small burns on his arms. He does not take any medications. He has a history of "abnormal liver tests" and
condylomata acuminata. He has had multiple sexual partners during the past 10 years and does not use condoms. His temperature
is 38.8°C (101 .9°F), pulse is 112/min, respirations are 14/min, and blood pressure is 138/68 mm Hg. A photograph of the left upper
extremity is shown. There is no crepitus or fluctuance. Cardiopulmonary examination shows no abnormalities. Laboratory studies
show a leukocyte count of 18,000/mm 3 with a left shift. X-rays of the left hand show diffuse soft-tissue edema. Which of the following
is the most likely diagnosis?
0 A) Brown recluse spider bite
0 B) Disseminated gonococcal infection
0 C) Erysipelas
0 D) Fasciitis
0 E) Gout
0 F) Lymphangitis
0 G) Sporotrichosis

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Exam Section : Item 42 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 35 sec

42. A 52-year-old woman comes to the physician for a routine health maintenance examination. She feels well. She has a 3-year history
of type 2 diabetes mellitus and hypertension. Current medications include metformin and lisinopril. Her pulse is 68/min, and blood
pressure is 116/74 mm Hg. Examination shows no abnormalities. Laboratory studies show a hemoglobin A 1cof 6.4%, serum
creatinine concentration of0.7 mg/dl, and serum LDL-cholesterol concentration of 112 mg/dl. Which of the following is the most
appropriate next step in pharmacotherapy?

0 A) Add rosiglitazone to her current regimen

0 B) Add simvastatin to her current regimen
0 C) Increase the dosage of lisinopril
0 D) Increase the dosage of metformin
0 E) No change in therapy is indicated

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Exam Section : Item 43 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 29 sec

43. A previously healthy 72-year-old man is brought to the emergency department because of a 1-day history of episodic memory loss,
dizziness, and double vision and a 2-hour history of burning pain in his left great toe. During the past 2 months, he has had a
moderate itching sensation over his legs. On arrival , he is conscious and oriented to person, place, and time. His temperature is
37.4°C (99.3°F), pulse is 75/min and regular, and blood pressure is 170/80 mm Hg. Examination shows bluish-red discoloration of
the left great toe. There is no pain on movement of the toe. On cardiac examination, no murmurs or gallops are heard. The spleen
tip is palpated 3 cm below the left costal margin. Neurologic examination shows no focal findings. Laboratory studies show:
Hemoglobin 18.5 g/dL
Hematocrit 62%
Leukocyte count 13,000/mm 3
Platelet count 420,000/mm 3
Serum
Urea nitrogen 22 mg/dL
Creatinine 1.2 mg/dL
Ferritin 14 ng/mL
Uric acid 12.9 mg/dL

Which of the following interventions will most rapidly correct this patient's visual and memory disturbances?

0 A) Aspirin therapy
0 B) Heparin therapy
0 C) Hydroxyurea therapy
0 D) Infusion of 0.9% saline
0 E) Phlebotomy

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Exam Section : Item 44 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 23 sec

44. A previously healthy 27-year-old woman comes to the physician because of a 3-month history of low-grade fever, fatigue, and
intermittent diarrhea. She has had one episode of blood in her stool and a 4.5-kg (10-lb) weight loss during this time. She takes no
medications. Her father has hypertension, and her older sister has irritable bowel syndrome. The patient does not smoke. She
drinks one to two glasses of wine monthly. Her temperature is 37.3°C (99.2°F), pulse is 88/min, respirations are 20/min, and blood
pressure is 102/60 mm Hg. Abdominal examination shows diffuse tenderness and no rebound; bowel sounds are increased. Rectal
examination shows normal sphincter tone. Test of the stool for occult blood is positive. Which of the following is the most likely
diagnosis?

0 A) Celiac disease
0 B) Crohn disease
0 C) Cytomegalovirus colitis
0 D) Giardiasis
0 E) Irritable bowel syndrome

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Exam Section : Item 45 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 18 sec

45. A 37-year-old woman comes to the physician because of a 3-week history of a rash over her left wrist. She first noticed the rash
after she started wearing a new watch, but the rash has not resolved since she stopped wearing the watch 3 days ago. She has a
2-year history of hypertension treated with atenolol. She is wearing perfume today. Examination of the left wrist shows erythematous
papules. There are several nevi over the chest and abdomen. The skin is diffusely dry and flakes easily. Which of the following is
the most likely cause of this patient's symptoms?

0 A) Adverse effect of atenolol

0 B) Allergic reaction to perfume
0 C) Dry skin
0 D) Exposure to nickel
0 E) Impaired T-lymphocyte response

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Exam Section : Item 46 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 12 sec

46. A 67-year-old man comes to the emergency department because of a 3-month history of a mass in his right groin that intermittently
appears and disappears spontaneously; over the past 3 hours, the mass has become increasingly painful, and he has not been able
to make it disappear. He also has had a decreased urinary stream and terminal dribbling with urination. He has smoked one pack of
cigarettes daily for 45 years. He has a daily nonproductive morning cough. Abdominal examination shows no distention or
tenderness. There is a nonreducible right groin mass; the testes are normal. Which of the following is the most appropriate next step
in management?

0 A) CT scan of the abdomen with contrast

0 B) Fine-needle aspiration biopsy
0 C) Cystoscopy and urodynamic studies
0 D) Incision and drainage
0 E) Immediate groin exploration

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Exam Section : Item 47 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 6 sec

4 7. A 42-year-old woman comes to the physician 2 hours after the onset of headache and light-headedness. Her symptoms began
approximately 10 minutes after she ate mahimahi (dolphinfish), reheated rice, a lettuce salad, an unrefrigerated cream puff, and
unwashed raspberries. She appears slightly flushed. Which of the following is most likely to have prevented her symptoms?

0 A) Not eating the mahimahi

0 B) Refrigerating the cream puff
0 C) Thoroughly reheating the rice
0 D) Washing the lettuce
0 E) Washing the raspberries

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Exam Section : Item 48 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 56 min 1 sec

48. Twenty-four hours after nearly drowning, a 24-year-old man in the

intensive care unit has not regained consciousness. He was resuscitated
at the scene and was intubated and mechanically ventilated en route to
the emergency department. In the emergency department, his Po 2 was
80 mm Hg on an F10 2 of 30%. An x-ray of the chest showed no
abnormalities. Now, his temperature is 37.2°C (99°F), pulse is 90/min,
and blood pressure is 121/60 mm Hg. His respirations are 14/min on the
ventilator. Examination shows no edema. Coarse airway sounds are
heard on auscultation; there are no crackles. Heart sounds are distant
with no gallops. Laboratory studies show:
Leukocyte count 8500/mm 3
Segmented neutrophils 80%
Lymphocytes 20%
Serum creatinine 1.2 mg/dL

Arterial blood gas analysis on an F10 2 of 100% and a positive

end-expiratory pressure of 20 cm Hp shows:
7.42
38 mm Hg
60 mm Hg

An x-ray of the chest is shown. Which of the following is the most likely
cause of this patient's current x-ray findings?

0 A) Acute respiratory distress syndrome

0 B) Bronchiolitis obliterans
0 C) Congestive heart failure
0 D) Diffuse interstitial pneumonia
0 E) Idiopathic interstitial fibrosis

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Exam Section : Item 49 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 55 min 53 sec

49. A 37-year-old man is brought to the emergency department 2 hours after he was involved in a motor vehicle collision in which he
was the unrestrained driver of a car without an air bag. He has smoked two packs of cigarettes daily for 15 years. On arrival, he has
severe chest pain that is most severe on inspiration. He is 173 cm (5 ft 8 in) tall and weighs 113 kg (250 lb); BMI is 38 kg/m 2. His
pulse is 130/min, respirations are 28/min, and blood pressure is 130/80 mm Hg. Examination shows an ecchymosis over the
anterior chest; there is no evidence of fractures. The lungs are clear to auscultation. An x-ray of the chest shows interstitial infiltrates
of the lungs bilaterally. Which of the following is the most likely cause of this patient's respiratory symptoms?

0 A) Fat embolism
0 B) Flail chest
0 C) Pulmonary contusion
0 D) Pulmonary edema
0 E) Pulmonary thromboembolism

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Exam Section : Item 50 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Medicine Self-Assessment 4 hr 55 min 48 sec

50. A 27-year-old woman with systemic sclerosis (scleroderma) comes to the physician because of a 4-month history of progressive
shortness of breath. Examination shows decreased lung expansion, neck vein distention, and a parasternal heave; diffuse
inspiratory crackles are heard on auscultation. She has 3+ pedal edema bilaterally. Which of the following is the most likely
diagnosis?

0 A) Angioedema
0 B) Superior vena cava obstruction
0 C) Biventricular heart failure
0 D) Cirrhosis of the liver
0 E) Cor pulmonale
0 F) Idiopathic membranous nephropathy
0 G) Lymphedema
0 H) Myxedema
0 I) Venous insufficiency

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