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thanks dolly for posting block 2 3 and 4......we are still missing block 1 however......can u post that again....or leave a link from the previous post.
thanks once again. and i really do think we should compile all of them with answers....let me know if you need any help with that.
you are amazing and Good luck is coming your way.... =)
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link to thread for blox 2,3,4 of form 2
i dont have block 1...
http://www.usmleforum.com/forum/message.php?id=136376
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link to thread for blox 2,3,4 of form 2
i dont have block 1...
http://www.usmleforum.com/forum/message.php?id=136376
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you really are a Doll!!! thanks =)
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you really are a Doll!!! thanks =)
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hi
wat software do u use to copy and paste nbme q
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hi
wat software do u use to copy and paste nbme q
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Blcok 1
1. A 50-year-old man with a 20-year history of type
2 diabetes
mellitus has had sensory neuropathy for 2 weeks.
Pulses are decreased at
the ankle. There is no peripheral edema. His serum
glucose levels have
been between 150 mg/dL and 200 mg/dL over the past 6
months. Which of
the following is the most effective measure to prevent
serious foot
infections?
A
) Use of support hose
B
) Use of well-fitted shoes
C
) Prophylactic antibiotics
D
) Daily aspirin and dipyridamole
E
) Decrease in serum glucose level
2. A 63-year-old woman comes to the emergency
department because of
palpitations for 1 hour. She was diagnosed with
hyperthyroidism 2
months ago but has not received treatment. Three
hours before arrival, she
drank two bottles of beer with dinner. Her blood
pressure is 90/60 mm
Hg, and pulse is 85/min and irregularly irregular.
Examination shows a
variation in intensity of S1. There is an absence of
a waves in the
venous pulse. An ECG is shown. Which of the
following is the most
likely cardiac rhythm disturbance?
A
) Atrial fibrillation
B
) Atrial flutter
C
) Multifocal atrial tachycardia
D
) Paroxysmal atrial tachycardia
E
) Second-degree atrioventricular block,
Wenckebach type
F
) Sick sinus syndrome
G
) Sinoatrial exit block, type II
H
) Torsades de pointes
I
) Wandering pacemaker
J
) Wolff-Parkinson-White syndrome
3. A 5-year-old girl is brought to the physician 30
minutes after
being bitten on the forearm by her cat. Examination
shows a small
puncture wound covered with dried blood. She is at
increased risk of
infection for which of the following reasons?
A
) Arm wounds are more susceptible to
infection
B
) Salivary enzymes in cats augment infection
C
) It is difficult to cleanse pathogens from this
wound
D
) The Staphylococcus species involved is
particularly virulent
E
) Young children are less able to resist infection
than adults
4. A 4-year-old girl is brought to the physician
because of pallor
and jaundice for 2 days. She had previously been
well, although she was
treated for jaundice with phototherapy for 2 weeks
while a newborn.
Her mother and two additional maternal relatives
underwent splenectomy
during childhood for unknown reasons. Examination of
the patient shows
jaundice. The spleen tip is palpated 4 cm below the
left costal margin.
Which of the following blood smear findings is most
likely to explain
this family's condition?
A
) Elliptocytes
B
) Howell-Jolly bodies
C
) Schistocytes
D
) Sickle cells
E
) Spherocytes
5. A sexually active 20-year-old woman has had
fever, chills,
malaise, and pain of the vulva for 2 days.
Examination shows a vulvar
pustule that has ulcerated and formed multiple
satellite lesions. Nodes are
palpated in the inguinal and femoral areas. A smear
of fluid from the
lesions establishes the diagnosis. Which of the
following is the most
likely causal organism?
A
) Chlamydia trachomatis
B
) Haemophilus ducreyi
C
) Neisseria gonorrhoeae
D
) Streptococcus pyogenes (group A)
E
) Treponema pallidum
6. A 5-year-old boy is brought to the physician 1
hour after
urinating bright red blood. He has been taking
ibuprofen since injuring his
right flank while wrestling with friends yesterday; he
also has been
taking penicillin for 3 days for streptococcal
pharyngitis. His
temperature is 36.7 C (98 F), blood pressure is 90/48
mm Hg, pulse is 108/min,
and respirations are 18/min. Examination shows purple
ecchymoses over
the shins and right flank; there is tenderness of the
right
costovertebral area. The abdomen is nontender.
Genital examination shows no
abnormalities. There is no edema. Urinalysis shows
gross blood;
microscopic examination shows 5“10 leukocytes/hpf and
erythrocytes that are too
numerous to count. Which of the following is the most
likely
explanation for this patient's hematuria?
A
) Acute pyelonephritis
B
) Ibuprofen-induced acute papillary necrosis
C
) Post-streptococcal glomerulonephritis
D
) Rhabdomyolysis
E
) Traumatic injury to the kidney
7. A 16-year-old girl comes to the physician for
her first prenatal
visit at 12 weeks' gestation. She has not had any
immunizations since
the age of 5 years. She has received the following
immunizations at the
recommended ages:
5 Diphtheria-tetanus-pertussis
3 Hepatitis B
1 Measles-mumps-rubella
4 Oral poliovirus
Examination shows no abnormalities. Which of the
following is the most
appropriate immunization to administer at this visit?
A
) Diphtheria-tetanus-pertussis
B
) Diphtheria (child)-tetanus toxoid
C
) Diphtheria (adult)-tetanus toxoid
D
) Haemophilus influenzae type b
E
) Hepatitis B
F
) Inactivated poliovirus
8. A 12-year-old boy is brought to the physician
because of
temperatures to 40.2 C (104.4 F), lethargy, and a
stiff neck for 2 days. A
diagnosis of pneumococcal meningitis is made, and the
child is admitted to
the hospital for antibiotic therapy. Serum studies 24
hours after
admission show:
Na+ 117 mEq/L
Cl“ 89 mEq/L
HCO3“ 25 mEq/L
Which of the following is the most likely explanation
for these
findings?
A
) Excessive cortisol release
B
) Hyperaldosteronism
C
) Inappropriate secretion of ADH (vasopressin)
D
) Increased production of leukotriene C4
9.
An asymptomatic 57-year-old man with a 3-year history
of type 2
diabetes mellitus comes for a routine follow-up visit.
Examination shows no
abnormalities. Serum studies show:
Aspartate aminotransferase
(AST, GOT) 76 U/L
Alanine aminotransferase
(ALT, GPT) 86 U/L
Iron 260 µg/dL
Total iron-binding capacity 300 µg/dL (N=250“450)
Ferritin 1200 ng/mL
Antinuclear antibody negative
Serologic testing for hepatitis is negative. Which of
the following is
the most appropriate next step in management?
A
) Corticosteroid therapy
B
) Interferon therapy
C
) Penicillamine therapy
D
) Chronic phlebotomy
E
) No therapy indicated
10. A 26-year-old man has had anxiety and insomnia
since he lost his
job 1 month ago. He also has had palpitations, daily
headaches, and
flatulence. He has no history of psychiatric
disorders. His mother has
a history of bipolar disorder, mixed, and his father
has alcoholism;
his younger sister had a history of drug abuse but has
been abstinent
from drugs for 3 years. Which of the following is the
most likely
diagnosis?
A
) Adjustment disorder
B
) Bipolar disorder, depressed
C
) Generalized anxiety disorder
D
) Major depressive disorder
E
) Post-traumatic stress disorder
A
) Acute toxic hepatitis
B
) Alcoholic hepatitis
C
) Cholangiocarcinoma
D
) Chronic idiopathic cirrhosis
E
) Common bile duct calculus
F
) Congestive hepatitis
G
) Gallstone pancreatitis
H
) Gilbert's syndrome
I
) Infectious hepatitis
J
) Intravascular hemolysis
K
) Primary biliary cirrhosis
11. A previously healthy 32-year-old man comes to
the emergency
department because of a 12-hour history of fatigue and
shortness of breath
at rest. He takes no medications. His temperature is
37 C (98.6 F),
blood pressure is 96/58 mm Hg, pulse is 110/min, and
respirations are
22/min. Examination shows scleral icterus and
conjunctival pallor.
There is no hepatosplenomegaly. Laboratory studies
show:
Hemoglobin 6.2 g/dL Serum
Leukocyte count 8800/mm3 Bilirubin, total 8.5 mg/dL
Reticulocyte count 16% Direct 1.5 mg/dL
Platelet count 245,000/mm3 Lactate dehydrogenase
1260 U/L
A
) Acute toxic hepatitis
B
) Alcoholic hepatitis
C
) Cholangiocarcinoma
D
) Chronic idiopathic cirrhosis
E
) Common bile duct calculus
F
) Congestive hepatitis
G
) Gallstone pancreatitis
H
) Gilbert's syndrome
I
) Infectious hepatitis
J
) Intravascular hemolysis
K
) Primary biliary cirrhosis
12. A 24-year-old third-year medical student comes
to the student
health clinic for evaluation of jaundice which he
noticed this morning.
He has had no abdominal pain, itching, or weight
change. He takes no
medications. He describes recent anxiety over
anticipation of the
upcoming Step 2 examination. His temperature is 37 C
(98.6 F), blood
pressure is 120/80 mm Hg, pulse is 76/min, and
respirations are 12/min.
Examination shows no abnormalities except for scleral
icterus. Laboratory
studies show:
Hemoglobin 15 g/dL Serum
Leukocyte count 7000/mm3 Alkaline phosphatase 90
U/L
Platelet count 240,000/mm3 Aspartate
aminotransferase
Serum (AST, GOT) 23 U/L
Bilirubin, total 3.5 mg/dL Alanine aminotransferase
Direct 0.7 mg/dL (ALT, GPT) 27 U/L
A
) Adrenal cortex
B
) Adrenal medulla
C
) Aorta
D
) Renal arteries
E
) Renal glomeruli
F
) Thyroid gland
13. A 37-year-old woman with a 2-year history of
hypertension comes
for a follow-up examination; her hypertension has
worsened despite
treatment with a low-sodium diet and a ß-adrenergic
blocking agent. She
has a history of rheumatic fever and Graves' disease
treated with 131I.
Her blood pressure is 160/106 mm Hg, and pulse is
80/min. Serum
studies show:
Na+ 135 mEq/L
Cl“ 100 mEq/L
K+ 3.4 mEq/L
HCO3“ 26 mEq/L
Urea nitrogen (BUN) 12 mg/dL
Creatinine 0.8 mg/dL
Urinalysis is within normal limits. Renal
ultrasonography shows a left
kidney with a markedly irregular contour; it is 2.8 cm
smaller than the
right.
A
) Adrenal cortex
B
) Adrenal medulla
C
) Aorta
D
) Renal arteries
E
) Renal glomeruli
F
) Thyroid gland
14. A 27-year-old woman comes to the physician
because of muscle
weakness and cramps for 2 weeks. She has been taking
a ß-adrenergic
blocking agent for hypertension for 2 years. She had
chronic lymphocytic
thyroiditis (Hashimoto's disease) 1 year ago. Her
blood pressure is
160/108 mm Hg, and pulse is 60/min. Serum studies
show:
Na+ 140 mEq/L
Cl“ 110 mEq/L
K+ 2.2 mEq/L
HCO3“ 30 mEq/L
Urea nitrogen (BUN) 20 mg/dL
Creatinine 1 mg/dL
Magnetic resonance angiography of the abdomen shows
normal findings.
A 24-year-old man is hospitalized for treatment of
a posterior
dislocation of the right knee sustained in a
motorcycle collision. Six
hours after closed reduction, previously present
distal pulses in his foot
are absent, but the foot has remained warm. Which of
the following is
the most appropriate next step in management?
A
) Elevation of the limb and observation for 24
hours
B
) Nitroprusside therapy
C
) Sympathetic block
D
) Femoral arteriography
E
) Embolectomy with a Fogarty catheter through a
proximal arteriotomy
D
) Inflammation of the origin of the plantar fascia
A healthy 4-year-old girl is brought for a
well-child examination.
A grade 2/6 systolic ejection murmur is heard along
the upper left
sternal border. S2 is widely split and does not vary
with respiration. A
soft mid-diastolic murmur is heard along the lower
left sternal border.
Examination shows no other abnormalities. Which of
the following is
the most likely diagnosis?
A
) Aortic stenosis
B
) Atrial septal defect
C
) Coarctation of the aorta
D
) Mitral valve prolapse
E
) Patent ductus arteriosus
F
) Pulmonary stenosis
G
) Tetralogy of Fallot
H
) Transposition of the great arteries
I
) Ventricular septal defect
J
) Normal heart
18. A previously healthy 57-year-old woman comes to
the physician
because of three episodes of blurred vision in the
right eye over the
past 3 weeks; each episode lasts approximately 5
minutes. Retinal
examination shows a small refractile body at the
bifurcation of a retinal
artery. The remainder of the examination shows no
abnormalities. Which of
the following is the most appropriate next step in
diagnosis?
A
) Cerebral angiography
B
) Echocardiography
C
) Electroencephalography
D
) Duplex scan of the carotid arteries
E
) MRI of the brain
A 67-year-old woman comes to the physician for her
first influenza
virus vaccination. She has a history of untreated
hypertension. Her blood
pressure is 160/100 mm Hg, and pulse is 100/min.
Shortly after
administration of the influenza virus vaccine, she
develops shortness of
breath, hives, and angioedema. Which of the following
is most likely to
have prevented this reaction?
A
) Inquiry about an egg allergy
B
) Heterophile agglutination test
C
) Skin test with histamine reagent
D
) ß-Adrenergic blocking agent therapy
E
) Amantadine therapy
F
) Insulin therapy
G
) Rimantadine therapy
20. A 7-year-old girl is brought to the physician
because of a 2-day
history of fever, headache, sore throat, and swollen
glands. She does
not have a runny nose, congestion, or cough. She has
no allergies to
medications. Her temperature is 38.6 C (101.4 F),
blood pressure is
100/60 mm Hg, pulse is 120/min, and respirations are
16/min. Examination
shows a swollen, erythematous oropharynx with
tonsillar exudates. The
anterior cervical lymph nodes are enlarged and tender.
No other
abnormalities are noted. Which of the following is
the most likely causal
organism?
A
) Adenovirus
B
) Corynebacterium diphtheriae
C
) Group A streptococcus
D
) Haemophilus influenzae
E
) Mycoplasma pneumoniae
A 70-year-old nursing home resident is admitted to
the hospital
because of progressive obtundation over the past 2
days. He has
tachycardia, tachypnea, and hypotension. Bilateral
basilar crackles and an S3
gallop are heard on auscultation. Examination shows
jugular venous
distention and peripheral edema. Swan-Ganz
catheterization shows a cardiac
index of 1.8 L/min/m2 (N=2.5“4.2), a mean pulmonary
capillary wedge
pressure of 23 mm Hg (N=1“10), and markedly increased
systemic vascular
resistance. Which of the following is the most likely
diagnosis?
A
) Cardiogenic shock
B
) Hypovolemic shock
C
) Neurogenic shock
D
) Septic shock
22.
A 42-year-old man with alcoholism is brought to the
emergency
department by a friend because of fever and
progressive shortness of breath for
12 hours. His friend reports that they were eating
leftover chicken
and drinking beer earlier in the day when the patient
suddenly choked and
vomited. Six hours later, he developed sweating,
chills, and shortness
of breath. He has not had any subsequent nausea,
vomiting,
hematemesis, or abdominal pain. He has smoked two
packs of cigarettes daily for
22 years and drinks 12 to 18 beers daily. He is in
moderate respiratory
distress. His temperature is 39.3 C (102.8 F), blood
pressure is 90/60
mm Hg, pulse is 120/min, and respirations are 24/min.
Examination
shows no jugular venous distention. Breath sounds are
decreased halfway up
the left lung with increased dullness. Cardiac
examination shows a
normal S1 and S2; no murmurs are heard. There is no
abdominal tenderness.
Bowel sounds are hypoactive. X-ray films of the chest
show a left
pleural effusion and air in the mediastinum.
Thoracentesis is performed.
Laboratory studies show:
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Bands 10%
Lymphocytes 5%
Serum
Protein 6 g/dL
Lactate dehydrogenase 200 U/L
Pleural fluid
Leukocyte count 8000/mm3
Segmented neutrophils 98%
Monocytes 2%
Protein 4.2 g/dL
Amylase 140 U/L
Lactate dehydrogenase 180 U/L
Gram's stain
WBC present
Organisms none
Which of the following is the most likely diagnosis?
A
) Congestive heart failure
B
) Esophageal rupture
C
) Pancreatitis
D
) Pericarditis
E
) Tuberculosis
23. A 2-year-old girl with tricuspid atresia has
increasing
respiratory distress for 2 days. She has been
recovering uneventfully from an
operation 10 days ago to join systemic venous return
with pulmonary
arterial circulation. Over the past 4 days, she has
been weaned off
mechanical ventilation, started on oral feedings, and
is receiving chest
physiotherapy for atelectasis. Her temperature is
37.4 C (99.3 F), blood
pressure is 98/64 mm Hg, pulse is 120/min, and
respirations are 46/min.
Examination shows nasal flaring, grunting, and
intercostal retractions.
An x-ray film of the chest shows large bilateral
pleural effusions.
Thoracentesis yields 300 mL of whitish-yellow fluid.
The supernatant
remains uniformly opaque on centrifugation. Which of
the following is the
most likely cause of the pleural effusions?
A
) Chylothorax
B
) Congestive heart failure
C
) Empyema
D
) Pulmonary embolism
E
) Superior vena cava obstruction
24. A 23-year-old man is brought to the physician
by his mother
because he has heard a voice over the past month
telling him to hurt
himself. His mother says that her son has no friends
and is a lifelong
loner; since graduating from high school, he has been
unable to hold a job.
He admits to smoking marijuana occasionally and
drinking six beers
weekly. Examination shows a poorly groomed man with
poor eye contact. He
has a flat affect and limited facial expression. He
says he has no
intention of harming himself or others. Which of the
following is the
most appropriate next step in management?
A
) Schedule a follow-up visit in 4 weeks
B
) Prescribe oral risperidone and schedule a
follow-up visit in 2
weeks
C
) Admit him to the partial hospital program and
prescribe oral
lithium carbonate
D
) Admit him to the psychiatric unit for
detoxification
E
) Admit him to the psychiatric unit and prescribe
oral imipramine
A 23-year-old man is brought to the physician by his
mother because he
has heard a voice over the past month telling him to
hurt himself. His
mother says that her son has no friends and is a
lifelong loner; since
graduating from high school, he has been unable to
hold a job. He
admits to smoking marijuana occasionally and drinking
six beers weekly.
Examination shows a poorly groomed man with poor eye
contact. He has a
flat affect and limited facial expression. He says he
has no intention
of harming himself or others. Which of the following
is the most
appropriate next step in management?
A
) Schedule a follow-up visit in 4 weeks
B
) Prescribe oral risperidone and schedule a
follow-up visit in 2
weeks
C
) Admit him to the partial hospital program and
prescribe oral
lithium carbonate
D
) Admit him to the psychiatric unit for
detoxification
E
) Admit him to the psychiatric unit and prescribe
oral imipramine
25.
An 18-month-old boy is brought for a well-child
examination. He was
born at 37 weeks' gestation and weighed 2800 g (6 lb 3
oz). There were
no prenatal or perinatal complications. Developmental
history indicates
that he is able to run and walk up stairs while
holding his mother's
hand. He can hold a crayon but does not scribble
spontaneously. He is
at the 40th percentile for length and 50th percentile
for weight.
Examination shows a crude pincer grasp. Which of the
following is the most
appropriate assessment of fine and gross motor
development?
Fine Motor Gross Motor
Development Development
A
)
Delayed normal
B
)
Normal delayed
C
)
Delayed delayed
D
)
Normal normal
Five months after beginning fluoxetine to treat
obsessive-compulsive
disorder, a 19-year-old man states that he
discontinued his medication 2
months ago because he had begun to worry about taking
his medication
every day. His initial response to the medication was
good. His
symptoms have now returned, and his morning ritual of
cleaning and grooming
consumes so much time that his job is in jeopardy. In
addition to
education about the nature of his disorder and its
treatment, which of the
following is the most appropriate next step in
management?
A
) Tell the patient to schedule a return visit as
needed
B
) Offer to change the medication
C
) Request that the patient's parents supervise
administration of
medication
D
) Monitor the patient's compliance by weekly blood
tests
E
) Begin a trial of cognitive-behavior therapy
A 32-year-old woman comes to the physician because
of a 3-month
history of increasing pain and stiffness in her
wrists, hands, and ankles.
During this period, she also has had progressive
fatigue and morning
stiffness lasting 2 hours. She has a 1-year history
of rheumatoid
arthritis treated with naproxen. Examination shows
redness, swelling, and
warmth over the wrist, hand, and ankle joints
bilaterally. There are
nontender subcutaneous nodules over the extensor
surfaces of both elbows.
X-ray films of the hands show diffuse osteopenia and
erosions over
several of the distal metacarpal bones. Which of the
following is the most
appropriate pharmacotherapy?
A
) Add oral cyclophosphamide
B
) Add oral gold
C
) Add oral methotrexate
D
) Add oral penicillamine
E ) Switch to oral ibuprofen
28. A previously healthy 62-year-old man comes to
the physician
because of a 2-month history of progressive shortness
of breath and a mild
nonproductive cough. He does not smoke. He worked in
a foundry most
of his adult life before retiring 2 years ago. Vital
signs are within
normal limits. Crackles are heard at both lung bases
with no wheezes.
Cardiac examination shows an accentuated P2. The
remainder of the
examination shows no abnormalities. An x-ray film of
the chest shows
prominent interstitial markings at the lung bases.
Echocardiography shows
an ejection fraction of 55%. Pulmonary function
testing is most likely
to show which of the following?
A
) Decreased FEV1:FVC ratio
B
) Decreased maximal inspiratory effort
C
) Decreased total lung capacity
D
) Increased forced vital capacity
E
) Normal carbon monoxide diffusion capacity
29. A 55-year-old man is admitted to the hospital
because of
progressive shortness of breath for 10 days. He has a
history of chronic
venous stasis and deep venous thrombosis. He has been
treated with
warfarin since he had several pulmonary emboli 2 years
ago; he takes no other
medication. He has smoked two packs of cigarettes
daily for 30 years.
He weighs 109 kg (240 lb) and is 165 cm (65 in) tall.
Examination
shows jugular venous distention. Echocardiography is
most likely to show
which of the following?
A
) Left ventricular dilation
B
) Mitral stenosis
C
) Pericardial thickening and tamponade
D
) Right ventricular hypertrophy and dilation
E
) Tricuspid stenosis
30. A 32-year-old woman comes to the physician
because of weakness
of the lower extremities for 2 days. Three years ago,
she had pain and
partial loss of vision of the right eye; the vision
returned to normal
after 6 weeks. There is mild pallor of the right
optic disc. She has
impaired tandem gait. Babinski's sign is present
bilaterally. There
is mild spasticity of the lower extremities and mild
weakness of the
iliopsoas and hamstring muscles. Serum creatine
kinase activity is 50
U/L. Which of the following is the most likely
diagnosis?
A
) Amyotrophic lateral sclerosis
B
) Becker's muscular dystrophy
C
) Diffuse sensorimotor peripheral neuropathy
D
) Duchenne's muscular dystrophy
E
) Hyperkalemic periodic paralysis
F
) Hypokalemic periodic paralysis
G
) Multiple sclerosis
H
) Myasthenia gravis
I
) Myasthenic (Lambert-Eaton) syndrome
J
) Myotonic muscular dystrophy
K
) Polymyositis
L
) Pontine astrocytoma
M
) Pontine infarction
N
) Spinal cord tumor
O
) Transverse myelitis
31. A healthy 42-year-old man comes to the
physician for a life
insurance evaluation. He smoked one-half pack of
cigarettes daily for 20
years but quit 10 years ago. His father died of a
myocardial infarction
at the age of 65 years. The patient weighs 93 kg (205
lb) and is 178
cm (70 in) tall. His blood pressure is 160/110 mm Hg,
pulse is 96/min,
and respirations are 16/min. Physical examination,
ECG, and an x-ray
film of the chest show no abnormalities. Laboratory
studies are within
normal limits except for a serum cholesterol level of
206 mg/dL. Which of
the following is the greatest risk factor for cerebral
infarction in
this patient?
A
) Genetic profile
B
) History of smoking
C
) Hypercholesterolemia
D
) Hypertension
E
) Obesity
32. A previously healthy 56-year-old woman comes to
the physician
because of jaundice and dark urine for 3 weeks. She
has a 1-year history
of generalized pruritus. She takes no medications.
Examination shows
jaundice and several ecchymoses over the forearms and
thighs. The
liver and spleen are enlarged and nontender.
Laboratory studies show:
Prothrombin time 18 sec
Serum
Protein
Total 8.5 g/dL
Albumin 3.8 g/dL
Bilirubin
Total 5 mg/dL
Direct 2 mg/dL
Alkaline phosphatase 150 U/L
Alanine aminotransferase (ALT, GPT) 45 U/L
Antimitochondrial antibody assay is strongly positive.
A CT scan of
the abdomen shows hepatosplenomegaly. Endoscopic
retrograde
cholangiopancreatography shows no abnormalities.
Because of her condition, this
patient is at greatest risk for which of the following
deficiencies?
A
) Niacin
B
) Vitamin A
C
) Vitamin B2 (riboflavin)
D
) Vitamin B12 (cyanocobalamin)
E
) Vitamin C
33. An asymptomatic 52-year-old man comes for a
follow-up
examination 1 month after he passed renal calculi. He
has a history of renal
calculi 2 years ago. Serum uric acid and calcium
levels and urinary
oxalate excretion are within normal limits. Urinary
calcium excretion is
increased. In order to avoid recurrence of renal
calculi, which of the
following is the most appropriate pharmacotherapy for
this patient?
A
) Bicarbonate
B
) Calcium lactate
C
) Methenamine mandelate
D
) Probenecid
E
) Thiazide diuretic
34.
A 57-year-old woman is brought to the emergency
department because of
abdominal pain for 12 hours. Over the past 3 hours,
the pain has become
severe and generalized. Over the past month, she has
had mild upper
abdominal discomfort that is relieved by eating. She
has a history of
recurrent migraines treated with sumatriptan as
needed. Her temperature
is 38.2 C (100.8 F), blood pressure is 170/95 mm Hg,
and pulse is
110/min. Abdominal examination shows mild distention;
there is marked
rigidity with diffuse tenderness. Bowel sounds are
absent. Rectal
examination shows no abnormalities; test of the stool
for occult blood is
negative. Laboratory studies show:
Hematocrit 36%
Leukocyte count 16,500/mm3
Serum
Na+ 145 mEq/L
Cl“ 106 mEq/L
K+ 3.8 mEq/L
HCO3“ 19 mEq/L
Urea nitrogen (BUN) 32 mg/dL
Which of the following is the most appropriate next
step in diagnosis?
A
) X-ray films of the abdomen while supine and
standing
B
) Abdominal ultrasonography
C
) Upper gastrointestinal series with contrast
D
) HIDA scan
E
) Fiberoptic endoscopy of the upper
gastrointestinal tract
35. An 18-year-old man comes to the physician
because of itchy
lesions on his penis for 2 weeks and itching around
his wrists and ankles
for 1 week. He is sexually active and does not
consistently use condoms.
Examination shows scattered, crusted lesions on the
penis and no
significant inguinal lymphadenopathy. There are
excoriated papules on the
wrists and ankles, a few papules between the fingers,
and excoriations
along the belt line. Which of the following is the
most likely
diagnosis?
A
) Disseminated primary herpes simplex
B
) Eczema
C
) Scabies
D
) Secondary syphilis
E
) Vasculitis
36. An asymptomatic 62-year-old man comes for a
follow-up visit.
One month ago, he had acute cystitis treated with
ciprofloxacin. At his
initial visit, a urine culture grew Klebsiella
pneumoniae. He has a
2-year history of chronic prostatitis and has had four
episodes of
cystitis over the past year. His temperature is 36.9
C (98.4 F).
Examination, including prostate examination, shows no
abnormalities. Which of
the following is the most appropriate measure to
prevent recurrent
episodes of cystitis in this patient?
A
) Trimethoprim-sulfamethoxazole prophylaxis
B
) Insertion of a Foley catheter
C
) Total prostatectomy
D
) Transurethral prostatectomy
E
) No treatment is available
37. A 32-year-old woman comes for a routine health
maintenance
examination. Examination shows a bloody discharge
from the nipple of her
left breast. There is no palpable mass. On
questioning, she says that
she never noted the discharge and does not perform
breast
self-examinations. Which of the following is the most
likely diagnosis?
A
) Breast abscess
B
) Breast cyst
C
) Breast hematoma
D
) Fibroadenoma
E
) Fibrocystic changes of the breast
F
) Intraductal adenoma
38. A 35-year-old woman is brought to the physician
by her husband
because of increasing memory loss and involuntary
"dancing" movements
over the past 6 weeks. She has had difficulty
remembering things,
particularly recent events. She has had no
disturbances in sleep or appetite.
Her medical history is unremarkable. She does not
remember her mother
who died 25 years ago, but her father told her that
her mother had
similar symptoms several years before her death.
Neurologic examination
shows involuntary choreiform movements. She has a
childlike affect. She
describes her mood as good. On recall testing, she
can remember one out
of three objects after 3 minutes with distraction; she
cannot remember
the other objects with prompting. She cannot remember
the date of her
marriage or her previous address. The most likely
cause of these
symptoms is a lesion at which of the following
locations?
A
) Caudate nucleus
B
) Parietal lobe
C
) Prefrontal lobe
D
) Putamen
E
) Temporal lobe
39. A 67-year-old man comes to the physician
because of insomnia for
2 years. He goes to bed at 11:00 PM after taking a
bath but does not
fall asleep until midnight. He usually wakes up twice
each night: once
around 3:00 AM to void and again at 6:00 AM. He stays
in bed until his
alarm goes off at 7 AM. He is concerned because he
used to sleep 8
hours daily. He recently retired from his job as an
attorney. He takes
no medications. He drinks one beer with lunch 3 days
each week and one
glass of wine with dinner each evening. He walks 1
mile daily after
dinner. Physical examination shows no abnormalities.
His mood is
neutral, and cognition is intact. Urine toxicology
screening is negative.
Which of the following is the most likely cause of
this patient's
symptoms?
A
) Advanced sleep phase syndrome
B
) Alcohol abuse
C
) Delayed sleep phase syndrome
D
) Major depressive disorder
E
) Melatonin deficiency
F
) Poor sleep hygiene
G
) Normal aging
40. An asymptomatic 37-year-old woman comes for a
follow-up
examination 1 year after receiving a renal transplant.
Current medications
include felodipine, enalapril, cyclosporine,
pravastatin, and penicillin
G. She appears well. Her temperature is 36.8 C (98.2
F), blood
pressure is 160/95 mm Hg, pulse is 80/min, and
respirations are 12/min.
Examination shows no other abnormalities. Which of
the following
medications is the most likely cause of this patient's
hypertension?
A
) Cyclosporine
B
) Enalapril
C
) Felodipine
D
) Penicillin G
E
) Pravastatin
41. A 4080-g (9-lb) male newborn is delivered at
term to a
32-year-old woman, gravida 2, para 1. Apgar scores
are 8 and 9 at 1 and 5
minutes, respectively. Examination in the delivery
room shows fracture of
the right clavicle. Which of the following is the
most likely sequela
of this condition?
A
) Correction only with casting
B
) Correction only with physical therapy
C
) Left-hand dominance
D
) Permanent nerve damage
E
) Spontaneous healing without treatment
42. A 22-year-old man with schizoaffective disorder
is brought to
the emergency department 2 hours after the sudden
onset of neck and back
pain. The symptoms began after taking one of his
medications for his
psychiatric disorder. The dosage was increased
yesterday, but he does
not recall the names of either of his medications. He
has no other
history of serious illness. Physical examination
shows rigid contraction
of the neck and back muscles with arching. On mental
status
examination, he is alert and cooperative and hears a
faint voice that tells him to
wash windows. He is oriented to person, place, and
time. Which of the
following medications is most likely responsible for
this patient's
symptoms?
A
) Clozapine
B
) Haloperidol
C
) Lithium carbonate
D
) Trazodone
E
) Valproic acid
43. A 52-year-old woman, gravida 3, para 3, comes
to the physician
because of irregular vaginal bleeding over the past 2
months. She has
hypertension treated with enalapril and type 2
diabetes mellitus well
controlled with diet. Menopause occurred 2 years ago.
Her maternal aunt
had breast cancer at the age of 70 years. The patient
weighs 88 kg
(195 lb) and is 160 cm (63 in) tall. Examination
shows no other
abnormalities. An endometrial biopsy specimen shows
adenocarcinoma. Which of
the following is the most significant predisposing
factor for this
patient's endometrial cancer?
A
) Heredity
B
) Hypertension
C
) Parity
D
) Type 2 diabetes mellitus
E
) Weight
44. A 67-year-old man is brought to the emergency
department 2 hours
after the onset of weakness and double vision. He has
hypertension and
hyperlipidemia treated with metoprolol, captopril, and
atorvastatin.
His blood pressure is 190/106 mm Hg. Neurologic
examination shows
left-sided facial weakness including the forehead.
There is palsy of left
conjugate gaze, and the left eye fails to adduct on
right gaze.
Vertical eye movements are intact. Muscle strength is
3/5 in the right upper
and lower extremities. Deep tendon reflexes are
brisk, and Babinski's
sign is present on the right. Which of the following
is the most
likely location of this patient's lesion?
A
) Bilateral thalamic
B
) Left frontal
C
) Left pontine
D
) Right caudate
E
) Right midbrain
45. Six weeks after spontaneous drainage of an anal
abscess, a
32-year-old man has persistent blood-stained purulent
fluid on his
underwear. He has not had significant anal pain since
drainage of the boil.
Bowel movements are normal. Which of the following is
the most likely
diagnosis?
A
) Anal fissure
B
) Fistula in ano
C
) Pruritus ani
D
) Thrombosed external hemorrhoids
E
) Thrombosed internal hemorrhoids
46. A previously healthy 14-year-old girl is
brought to the
physician because of a 2-day history of fever and pain
and swelling of the
right knee. She remembers injuring the knee while
playing soccer last
week, but she was able to finish the game. She has no
history of rash or
joint pain. Her sister has inflammatory bowel
disease. The patient's
temperature is 39 C (102.2 F), blood pressure is
110/80 mm Hg, pulse is
95/min, and respirations are 20/min. Examination of
the right knee
shows swelling, tenderness, warmth, and erythema;
range of motion is
limited. Which of the following is the most
appropriate next step in
management?
A
) X-ray film of the right knee
B
) Gastrointestinal series with small-bowel
follow-through
C
) Nuclear scan of the right knee
D
) MRI of the right knee
E
) Antibiotic therapy
F
) Arthrocentesis
Posts: 3,675,937
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Blcok 1
1. A 50-year-old man with a 20-year history of type
2 diabetes
mellitus has had sensory neuropathy for 2 weeks.
Pulses are decreased at
the ankle. There is no peripheral edema. His serum
glucose levels have
been between 150 mg/dL and 200 mg/dL over the past 6
months. Which of
the following is the most effective measure to prevent
serious foot
infections?
A
) Use of support hose
B
) Use of well-fitted shoes
C
) Prophylactic antibiotics
D
) Daily aspirin and dipyridamole
E
) Decrease in serum glucose level
2. A 63-year-old woman comes to the emergency
department because of
palpitations for 1 hour. She was diagnosed with
hyperthyroidism 2
months ago but has not received treatment. Three
hours before arrival, she
drank two bottles of beer with dinner. Her blood
pressure is 90/60 mm
Hg, and pulse is 85/min and irregularly irregular.
Examination shows a
variation in intensity of S1. There is an absence of
a waves in the
venous pulse. An ECG is shown. Which of the
following is the most
likely cardiac rhythm disturbance?
A
) Atrial fibrillation
B
) Atrial flutter
C
) Multifocal atrial tachycardia
D
) Paroxysmal atrial tachycardia
E
) Second-degree atrioventricular block,
Wenckebach type
F
) Sick sinus syndrome
G
) Sinoatrial exit block, type II
H
) Torsades de pointes
I
) Wandering pacemaker
J
) Wolff-Parkinson-White syndrome
3. A 5-year-old girl is brought to the physician 30
minutes after
being bitten on the forearm by her cat. Examination
shows a small
puncture wound covered with dried blood. She is at
increased risk of
infection for which of the following reasons?
A
) Arm wounds are more susceptible to
infection
B
) Salivary enzymes in cats augment infection
C
) It is difficult to cleanse pathogens from this
wound
D
) The Staphylococcus species involved is
particularly virulent
E
) Young children are less able to resist infection
than adults
4. A 4-year-old girl is brought to the physician
because of pallor
and jaundice for 2 days. She had previously been
well, although she was
treated for jaundice with phototherapy for 2 weeks
while a newborn.
Her mother and two additional maternal relatives
underwent splenectomy
during childhood for unknown reasons. Examination of
the patient shows
jaundice. The spleen tip is palpated 4 cm below the
left costal margin.
Which of the following blood smear findings is most
likely to explain
this family's condition?
A
) Elliptocytes
B
) Howell-Jolly bodies
C
) Schistocytes
D
) Sickle cells
E
) Spherocytes
5. A sexually active 20-year-old woman has had
fever, chills,
malaise, and pain of the vulva for 2 days.
Examination shows a vulvar
pustule that has ulcerated and formed multiple
satellite lesions. Nodes are
palpated in the inguinal and femoral areas. A smear
of fluid from the
lesions establishes the diagnosis. Which of the
following is the most
likely causal organism?
A
) Chlamydia trachomatis
B
) Haemophilus ducreyi
C
) Neisseria gonorrhoeae
D
) Streptococcus pyogenes (group A)
E
) Treponema pallidum
6. A 5-year-old boy is brought to the physician 1
hour after
urinating bright red blood. He has been taking
ibuprofen since injuring his
right flank while wrestling with friends yesterday; he
also has been
taking penicillin for 3 days for streptococcal
pharyngitis. His
temperature is 36.7 C (98 F), blood pressure is 90/48
mm Hg, pulse is 108/min,
and respirations are 18/min. Examination shows purple
ecchymoses over
the shins and right flank; there is tenderness of the
right
costovertebral area. The abdomen is nontender.
Genital examination shows no
abnormalities. There is no edema. Urinalysis shows
gross blood;
microscopic examination shows 5“10 leukocytes/hpf and
erythrocytes that are too
numerous to count. Which of the following is the most
likely
explanation for this patient's hematuria?
A
) Acute pyelonephritis
B
) Ibuprofen-induced acute papillary necrosis
C
) Post-streptococcal glomerulonephritis
D
) Rhabdomyolysis
E
) Traumatic injury to the kidney
7. A 16-year-old girl comes to the physician for
her first prenatal
visit at 12 weeks' gestation. She has not had any
immunizations since
the age of 5 years. She has received the following
immunizations at the
recommended ages:
5 Diphtheria-tetanus-pertussis
3 Hepatitis B
1 Measles-mumps-rubella
4 Oral poliovirus
Examination shows no abnormalities. Which of the
following is the most
appropriate immunization to administer at this visit?
A
) Diphtheria-tetanus-pertussis
B
) Diphtheria (child)-tetanus toxoid
C
) Diphtheria (adult)-tetanus toxoid
D
) Haemophilus influenzae type b
E
) Hepatitis B
F
) Inactivated poliovirus
8. A 12-year-old boy is brought to the physician
because of
temperatures to 40.2 C (104.4 F), lethargy, and a
stiff neck for 2 days. A
diagnosis of pneumococcal meningitis is made, and the
child is admitted to
the hospital for antibiotic therapy. Serum studies 24
hours after
admission show:
Na+ 117 mEq/L
Cl“ 89 mEq/L
HCO3“ 25 mEq/L
Which of the following is the most likely explanation
for these
findings?
A
) Excessive cortisol release
B
) Hyperaldosteronism
C
) Inappropriate secretion of ADH (vasopressin)
D
) Increased production of leukotriene C4
9.
An asymptomatic 57-year-old man with a 3-year history
of type 2
diabetes mellitus comes for a routine follow-up visit.
Examination shows no
abnormalities. Serum studies show:
Aspartate aminotransferase
(AST, GOT) 76 U/L
Alanine aminotransferase
(ALT, GPT) 86 U/L
Iron 260 µg/dL
Total iron-binding capacity 300 µg/dL (N=250“450)
Ferritin 1200 ng/mL
Antinuclear antibody negative
Serologic testing for hepatitis is negative. Which of
the following is
the most appropriate next step in management?
A
) Corticosteroid therapy
B
) Interferon therapy
C
) Penicillamine therapy
D
) Chronic phlebotomy
E
) No therapy indicated
10. A 26-year-old man has had anxiety and insomnia
since he lost his
job 1 month ago. He also has had palpitations, daily
headaches, and
flatulence. He has no history of psychiatric
disorders. His mother has
a history of bipolar disorder, mixed, and his father
has alcoholism;
his younger sister had a history of drug abuse but has
been abstinent
from drugs for 3 years. Which of the following is the
most likely
diagnosis?
A
) Adjustment disorder
B
) Bipolar disorder, depressed
C
) Generalized anxiety disorder
D
) Major depressive disorder
E
) Post-traumatic stress disorder
A
) Acute toxic hepatitis
B
) Alcoholic hepatitis
C
) Cholangiocarcinoma
D
) Chronic idiopathic cirrhosis
E
) Common bile duct calculus
F
) Congestive hepatitis
G
) Gallstone pancreatitis
H
) Gilbert's syndrome
I
) Infectious hepatitis
J
) Intravascular hemolysis
K
) Primary biliary cirrhosis
11. A previously healthy 32-year-old man comes to
the emergency
department because of a 12-hour history of fatigue and
shortness of breath
at rest. He takes no medications. His temperature is
37 C (98.6 F),
blood pressure is 96/58 mm Hg, pulse is 110/min, and
respirations are
22/min. Examination shows scleral icterus and
conjunctival pallor.
There is no hepatosplenomegaly. Laboratory studies
show:
Hemoglobin 6.2 g/dL Serum
Leukocyte count 8800/mm3 Bilirubin, total 8.5 mg/dL
Reticulocyte count 16% Direct 1.5 mg/dL
Platelet count 245,000/mm3 Lactate dehydrogenase
1260 U/L
A
) Acute toxic hepatitis
B
) Alcoholic hepatitis
C
) Cholangiocarcinoma
D
) Chronic idiopathic cirrhosis
E
) Common bile duct calculus
F
) Congestive hepatitis
G
) Gallstone pancreatitis
H
) Gilbert's syndrome
I
) Infectious hepatitis
J
) Intravascular hemolysis
K
) Primary biliary cirrhosis
12. A 24-year-old third-year medical student comes
to the student
health clinic for evaluation of jaundice which he
noticed this morning.
He has had no abdominal pain, itching, or weight
change. He takes no
medications. He describes recent anxiety over
anticipation of the
upcoming Step 2 examination. His temperature is 37 C
(98.6 F), blood
pressure is 120/80 mm Hg, pulse is 76/min, and
respirations are 12/min.
Examination shows no abnormalities except for scleral
icterus. Laboratory
studies show:
Hemoglobin 15 g/dL Serum
Leukocyte count 7000/mm3 Alkaline phosphatase 90
U/L
Platelet count 240,000/mm3 Aspartate
aminotransferase
Serum (AST, GOT) 23 U/L
Bilirubin, total 3.5 mg/dL Alanine aminotransferase
Direct 0.7 mg/dL (ALT, GPT) 27 U/L
A
) Adrenal cortex
B
) Adrenal medulla
C
) Aorta
D
) Renal arteries
E
) Renal glomeruli
F
) Thyroid gland
13. A 37-year-old woman with a 2-year history of
hypertension comes
for a follow-up examination; her hypertension has
worsened despite
treatment with a low-sodium diet and a ß-adrenergic
blocking agent. She
has a history of rheumatic fever and Graves' disease
treated with 131I.
Her blood pressure is 160/106 mm Hg, and pulse is
80/min. Serum
studies show:
Na+ 135 mEq/L
Cl“ 100 mEq/L
K+ 3.4 mEq/L
HCO3“ 26 mEq/L
Urea nitrogen (BUN) 12 mg/dL
Creatinine 0.8 mg/dL
Urinalysis is within normal limits. Renal
ultrasonography shows a left
kidney with a markedly irregular contour; it is 2.8 cm
smaller than the
right.
A
) Adrenal cortex
B
) Adrenal medulla
C
) Aorta
D
) Renal arteries
E
) Renal glomeruli
F
) Thyroid gland
14. A 27-year-old woman comes to the physician
because of muscle
weakness and cramps for 2 weeks. She has been taking
a ß-adrenergic
blocking agent for hypertension for 2 years. She had
chronic lymphocytic
thyroiditis (Hashimoto's disease) 1 year ago. Her
blood pressure is
160/108 mm Hg, and pulse is 60/min. Serum studies
show:
Na+ 140 mEq/L
Cl“ 110 mEq/L
K+ 2.2 mEq/L
HCO3“ 30 mEq/L
Urea nitrogen (BUN) 20 mg/dL
Creatinine 1 mg/dL
Magnetic resonance angiography of the abdomen shows
normal findings.
A 24-year-old man is hospitalized for treatment of
a posterior
dislocation of the right knee sustained in a
motorcycle collision. Six
hours after closed reduction, previously present
distal pulses in his foot
are absent, but the foot has remained warm. Which of
the following is
the most appropriate next step in management?
A
) Elevation of the limb and observation for 24
hours
B
) Nitroprusside therapy
C
) Sympathetic block
D
) Femoral arteriography
E
) Embolectomy with a Fogarty catheter through a
proximal arteriotomy
D
) Inflammation of the origin of the plantar fascia
A healthy 4-year-old girl is brought for a
well-child examination.
A grade 2/6 systolic ejection murmur is heard along
the upper left
sternal border. S2 is widely split and does not vary
with respiration. A
soft mid-diastolic murmur is heard along the lower
left sternal border.
Examination shows no other abnormalities. Which of
the following is
the most likely diagnosis?
A
) Aortic stenosis
B
) Atrial septal defect
C
) Coarctation of the aorta
D
) Mitral valve prolapse
E
) Patent ductus arteriosus
F
) Pulmonary stenosis
G
) Tetralogy of Fallot
H
) Transposition of the great arteries
I
) Ventricular septal defect
J
) Normal heart
18. A previously healthy 57-year-old woman comes to
the physician
because of three episodes of blurred vision in the
right eye over the
past 3 weeks; each episode lasts approximately 5
minutes. Retinal
examination shows a small refractile body at the
bifurcation of a retinal
artery. The remainder of the examination shows no
abnormalities. Which of
the following is the most appropriate next step in
diagnosis?
A
) Cerebral angiography
B
) Echocardiography
C
) Electroencephalography
D
) Duplex scan of the carotid arteries
E
) MRI of the brain
A 67-year-old woman comes to the physician for her
first influenza
virus vaccination. She has a history of untreated
hypertension. Her blood
pressure is 160/100 mm Hg, and pulse is 100/min.
Shortly after
administration of the influenza virus vaccine, she
develops shortness of
breath, hives, and angioedema. Which of the following
is most likely to
have prevented this reaction?
A
) Inquiry about an egg allergy
B
) Heterophile agglutination test
C
) Skin test with histamine reagent
D
) ß-Adrenergic blocking agent therapy
E
) Amantadine therapy
F
) Insulin therapy
G
) Rimantadine therapy
20. A 7-year-old girl is brought to the physician
because of a 2-day
history of fever, headache, sore throat, and swollen
glands. She does
not have a runny nose, congestion, or cough. She has
no allergies to
medications. Her temperature is 38.6 C (101.4 F),
blood pressure is
100/60 mm Hg, pulse is 120/min, and respirations are
16/min. Examination
shows a swollen, erythematous oropharynx with
tonsillar exudates. The
anterior cervical lymph nodes are enlarged and tender.
No other
abnormalities are noted. Which of the following is
the most likely causal
organism?
A
) Adenovirus
B
) Corynebacterium diphtheriae
C
) Group A streptococcus
D
) Haemophilus influenzae
E
) Mycoplasma pneumoniae
A 70-year-old nursing home resident is admitted to
the hospital
because of progressive obtundation over the past 2
days. He has
tachycardia, tachypnea, and hypotension. Bilateral
basilar crackles and an S3
gallop are heard on auscultation. Examination shows
jugular venous
distention and peripheral edema. Swan-Ganz
catheterization shows a cardiac
index of 1.8 L/min/m2 (N=2.5“4.2), a mean pulmonary
capillary wedge
pressure of 23 mm Hg (N=1“10), and markedly increased
systemic vascular
resistance. Which of the following is the most likely
diagnosis?
A
) Cardiogenic shock
B
) Hypovolemic shock
C
) Neurogenic shock
D
) Septic shock
22.
A 42-year-old man with alcoholism is brought to the
emergency
department by a friend because of fever and
progressive shortness of breath for
12 hours. His friend reports that they were eating
leftover chicken
and drinking beer earlier in the day when the patient
suddenly choked and
vomited. Six hours later, he developed sweating,
chills, and shortness
of breath. He has not had any subsequent nausea,
vomiting,
hematemesis, or abdominal pain. He has smoked two
packs of cigarettes daily for
22 years and drinks 12 to 18 beers daily. He is in
moderate respiratory
distress. His temperature is 39.3 C (102.8 F), blood
pressure is 90/60
mm Hg, pulse is 120/min, and respirations are 24/min.
Examination
shows no jugular venous distention. Breath sounds are
decreased halfway up
the left lung with increased dullness. Cardiac
examination shows a
normal S1 and S2; no murmurs are heard. There is no
abdominal tenderness.
Bowel sounds are hypoactive. X-ray films of the chest
show a left
pleural effusion and air in the mediastinum.
Thoracentesis is performed.
Laboratory studies show:
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Bands 10%
Lymphocytes 5%
Serum
Protein 6 g/dL
Lactate dehydrogenase 200 U/L
Pleural fluid
Leukocyte count 8000/mm3
Segmented neutrophils 98%
Monocytes 2%
Protein 4.2 g/dL
Amylase 140 U/L
Lactate dehydrogenase 180 U/L
Gram's stain
WBC present
Organisms none
Which of the following is the most likely diagnosis?
A
) Congestive heart failure
B
) Esophageal rupture
C
) Pancreatitis
D
) Pericarditis
E
) Tuberculosis
23. A 2-year-old girl with tricuspid atresia has
increasing
respiratory distress for 2 days. She has been
recovering uneventfully from an
operation 10 days ago to join systemic venous return
with pulmonary
arterial circulation. Over the past 4 days, she has
been weaned off
mechanical ventilation, started on oral feedings, and
is receiving chest
physiotherapy for atelectasis. Her temperature is
37.4 C (99.3 F), blood
pressure is 98/64 mm Hg, pulse is 120/min, and
respirations are 46/min.
Examination shows nasal flaring, grunting, and
intercostal retractions.
An x-ray film of the chest shows large bilateral
pleural effusions.
Thoracentesis yields 300 mL of whitish-yellow fluid.
The supernatant
remains uniformly opaque on centrifugation. Which of
the following is the
most likely cause of the pleural effusions?
A
) Chylothorax
B
) Congestive heart failure
C
) Empyema
D
) Pulmonary embolism
E
) Superior vena cava obstruction
24. A 23-year-old man is brought to the physician
by his mother
because he has heard a voice over the past month
telling him to hurt
himself. His mother says that her son has no friends
and is a lifelong
loner; since graduating from high school, he has been
unable to hold a job.
He admits to smoking marijuana occasionally and
drinking six beers
weekly. Examination shows a poorly groomed man with
poor eye contact. He
has a flat affect and limited facial expression. He
says he has no
intention of harming himself or others. Which of the
following is the
most appropriate next step in management?
A
) Schedule a follow-up visit in 4 weeks
B
) Prescribe oral risperidone and schedule a
follow-up visit in 2
weeks
C
) Admit him to the partial hospital program and
prescribe oral
lithium carbonate
D
) Admit him to the psychiatric unit for
detoxification
E
) Admit him to the psychiatric unit and prescribe
oral imipramine
A 23-year-old man is brought to the physician by his
mother because he
has heard a voice over the past month telling him to
hurt himself. His
mother says that her son has no friends and is a
lifelong loner; since
graduating from high school, he has been unable to
hold a job. He
admits to smoking marijuana occasionally and drinking
six beers weekly.
Examination shows a poorly groomed man with poor eye
contact. He has a
flat affect and limited facial expression. He says he
has no intention
of harming himself or others. Which of the following
is the most
appropriate next step in management?
A
) Schedule a follow-up visit in 4 weeks
B
) Prescribe oral risperidone and schedule a
follow-up visit in 2
weeks
C
) Admit him to the partial hospital program and
prescribe oral
lithium carbonate
D
) Admit him to the psychiatric unit for
detoxification
E
) Admit him to the psychiatric unit and prescribe
oral imipramine
25.
An 18-month-old boy is brought for a well-child
examination. He was
born at 37 weeks' gestation and weighed 2800 g (6 lb 3
oz). There were
no prenatal or perinatal complications. Developmental
history indicates
that he is able to run and walk up stairs while
holding his mother's
hand. He can hold a crayon but does not scribble
spontaneously. He is
at the 40th percentile for length and 50th percentile
for weight.
Examination shows a crude pincer grasp. Which of the
following is the most
appropriate assessment of fine and gross motor
development?
Fine Motor Gross Motor
Development Development
A
)
Delayed normal
B
)
Normal delayed
C
)
Delayed delayed
D
)
Normal normal
Five months after beginning fluoxetine to treat
obsessive-compulsive
disorder, a 19-year-old man states that he
discontinued his medication 2
months ago because he had begun to worry about taking
his medication
every day. His initial response to the medication was
good. His
symptoms have now returned, and his morning ritual of
cleaning and grooming
consumes so much time that his job is in jeopardy. In
addition to
education about the nature of his disorder and its
treatment, which of the
following is the most appropriate next step in
management?
A
) Tell the patient to schedule a return visit as
needed
B
) Offer to change the medication
C
) Request that the patient's parents supervise
administration of
medication
D
) Monitor the patient's compliance by weekly blood
tests
E
) Begin a trial of cognitive-behavior therapy
A 32-year-old woman comes to the physician because
of a 3-month
history of increasing pain and stiffness in her
wrists, hands, and ankles.
During this period, she also has had progressive
fatigue and morning
stiffness lasting 2 hours. She has a 1-year history
of rheumatoid
arthritis treated with naproxen. Examination shows
redness, swelling, and
warmth over the wrist, hand, and ankle joints
bilaterally. There are
nontender subcutaneous nodules over the extensor
surfaces of both elbows.
X-ray films of the hands show diffuse osteopenia and
erosions over
several of the distal metacarpal bones. Which of the
following is the most
appropriate pharmacotherapy?
A
) Add oral cyclophosphamide
B
) Add oral gold
C
) Add oral methotrexate
D
) Add oral penicillamine
E ) Switch to oral ibuprofen
28. A previously healthy 62-year-old man comes to
the physician
because of a 2-month history of progressive shortness
of breath and a mild
nonproductive cough. He does not smoke. He worked in
a foundry most
of his adult life before retiring 2 years ago. Vital
signs are within
normal limits. Crackles are heard at both lung bases
with no wheezes.
Cardiac examination shows an accentuated P2. The
remainder of the
examination shows no abnormalities. An x-ray film of
the chest shows
prominent interstitial markings at the lung bases.
Echocardiography shows
an ejection fraction of 55%. Pulmonary function
testing is most likely
to show which of the following?
A
) Decreased FEV1:FVC ratio
B
) Decreased maximal inspiratory effort
C
) Decreased total lung capacity
D
) Increased forced vital capacity
E
) Normal carbon monoxide diffusion capacity
29. A 55-year-old man is admitted to the hospital
because of
progressive shortness of breath for 10 days. He has a
history of chronic
venous stasis and deep venous thrombosis. He has been
treated with
warfarin since he had several pulmonary emboli 2 years
ago; he takes no other
medication. He has smoked two packs of cigarettes
daily for 30 years.
He weighs 109 kg (240 lb) and is 165 cm (65 in) tall.
Examination
shows jugular venous distention. Echocardiography is
most likely to show
which of the following?
A
) Left ventricular dilation
B
) Mitral stenosis
C
) Pericardial thickening and tamponade
D
) Right ventricular hypertrophy and dilation
E
) Tricuspid stenosis
30. A 32-year-old woman comes to the physician
because of weakness
of the lower extremities for 2 days. Three years ago,
she had pain and
partial loss of vision of the right eye; the vision
returned to normal
after 6 weeks. There is mild pallor of the right
optic disc. She has
impaired tandem gait. Babinski's sign is present
bilaterally. There
is mild spasticity of the lower extremities and mild
weakness of the
iliopsoas and hamstring muscles. Serum creatine
kinase activity is 50
U/L. Which of the following is the most likely
diagnosis?
A
) Amyotrophic lateral sclerosis
B
) Becker's muscular dystrophy
C
) Diffuse sensorimotor peripheral neuropathy
D
) Duchenne's muscular dystrophy
E
) Hyperkalemic periodic paralysis
F
) Hypokalemic periodic paralysis
G
) Multiple sclerosis
H
) Myasthenia gravis
I
) Myasthenic (Lambert-Eaton) syndrome
J
) Myotonic muscular dystrophy
K
) Polymyositis
L
) Pontine astrocytoma
M
) Pontine infarction
N
) Spinal cord tumor
O
) Transverse myelitis
31. A healthy 42-year-old man comes to the
physician for a life
insurance evaluation. He smoked one-half pack of
cigarettes daily for 20
years but quit 10 years ago. His father died of a
myocardial infarction
at the age of 65 years. The patient weighs 93 kg (205
lb) and is 178
cm (70 in) tall. His blood pressure is 160/110 mm Hg,
pulse is 96/min,
and respirations are 16/min. Physical examination,
ECG, and an x-ray
film of the chest show no abnormalities. Laboratory
studies are within
normal limits except for a serum cholesterol level of
206 mg/dL. Which of
the following is the greatest risk factor for cerebral
infarction in
this patient?
A
) Genetic profile
B
) History of smoking
C
) Hypercholesterolemia
D
) Hypertension
E
) Obesity
32. A previously healthy 56-year-old woman comes to
the physician
because of jaundice and dark urine for 3 weeks. She
has a 1-year history
of generalized pruritus. She takes no medications.
Examination shows
jaundice and several ecchymoses over the forearms and
thighs. The
liver and spleen are enlarged and nontender.
Laboratory studies show:
Prothrombin time 18 sec
Serum
Protein
Total 8.5 g/dL
Albumin 3.8 g/dL
Bilirubin
Total 5 mg/dL
Direct 2 mg/dL
Alkaline phosphatase 150 U/L
Alanine aminotransferase (ALT, GPT) 45 U/L
Antimitochondrial antibody assay is strongly positive.
A CT scan of
the abdomen shows hepatosplenomegaly. Endoscopic
retrograde
cholangiopancreatography shows no abnormalities.
Because of her condition, this
patient is at greatest risk for which of the following
deficiencies?
A
) Niacin
B
) Vitamin A
C
) Vitamin B2 (riboflavin)
D
) Vitamin B12 (cyanocobalamin)
E
) Vitamin C
33. An asymptomatic 52-year-old man comes for a
follow-up
examination 1 month after he passed renal calculi. He
has a history of renal
calculi 2 years ago. Serum uric acid and calcium
levels and urinary
oxalate excretion are within normal limits. Urinary
calcium excretion is
increased. In order to avoid recurrence of renal
calculi, which of the
following is the most appropriate pharmacotherapy for
this patient?
A
) Bicarbonate
B
) Calcium lactate
C
) Methenamine mandelate
D
) Probenecid
E
) Thiazide diuretic
34.
A 57-year-old woman is brought to the emergency
department because of
abdominal pain for 12 hours. Over the past 3 hours,
the pain has become
severe and generalized. Over the past month, she has
had mild upper
abdominal discomfort that is relieved by eating. She
has a history of
recurrent migraines treated with sumatriptan as
needed. Her temperature
is 38.2 C (100.8 F), blood pressure is 170/95 mm Hg,
and pulse is
110/min. Abdominal examination shows mild distention;
there is marked
rigidity with diffuse tenderness. Bowel sounds are
absent. Rectal
examination shows no abnormalities; test of the stool
for occult blood is
negative. Laboratory studies show:
Hematocrit 36%
Leukocyte count 16,500/mm3
Serum
Na+ 145 mEq/L
Cl“ 106 mEq/L
K+ 3.8 mEq/L
HCO3“ 19 mEq/L
Urea nitrogen (BUN) 32 mg/dL
Which of the following is the most appropriate next
step in diagnosis?
A
) X-ray films of the abdomen while supine and
standing
B
) Abdominal ultrasonography
C
) Upper gastrointestinal series with contrast
D
) HIDA scan
E
) Fiberoptic endoscopy of the upper
gastrointestinal tract
35. An 18-year-old man comes to the physician
because of itchy
lesions on his penis for 2 weeks and itching around
his wrists and ankles
for 1 week. He is sexually active and does not
consistently use condoms.
Examination shows scattered, crusted lesions on the
penis and no
significant inguinal lymphadenopathy. There are
excoriated papules on the
wrists and ankles, a few papules between the fingers,
and excoriations
along the belt line. Which of the following is the
most likely
diagnosis?
A
) Disseminated primary herpes simplex
B
) Eczema
C
) Scabies
D
) Secondary syphilis
E
) Vasculitis
36. An asymptomatic 62-year-old man comes for a
follow-up visit.
One month ago, he had acute cystitis treated with
ciprofloxacin. At his
initial visit, a urine culture grew Klebsiella
pneumoniae. He has a
2-year history of chronic prostatitis and has had four
episodes of
cystitis over the past year. His temperature is 36.9
C (98.4 F).
Examination, including prostate examination, shows no
abnormalities. Which of
the following is the most appropriate measure to
prevent recurrent
episodes of cystitis in this patient?
A
) Trimethoprim-sulfamethoxazole prophylaxis
B
) Insertion of a Foley catheter
C
) Total prostatectomy
D
) Transurethral prostatectomy
E
) No treatment is available
37. A 32-year-old woman comes for a routine health
maintenance
examination. Examination shows a bloody discharge
from the nipple of her
left breast. There is no palpable mass. On
questioning, she says that
she never noted the discharge and does not perform
breast
self-examinations. Which of the following is the most
likely diagnosis?
A
) Breast abscess
B
) Breast cyst
C
) Breast hematoma
D
) Fibroadenoma
E
) Fibrocystic changes of the breast
F
) Intraductal adenoma
38. A 35-year-old woman is brought to the physician
by her husband
because of increasing memory loss and involuntary
"dancing" movements
over the past 6 weeks. She has had difficulty
remembering things,
particularly recent events. She has had no
disturbances in sleep or appetite.
Her medical history is unremarkable. She does not
remember her mother
who died 25 years ago, but her father told her that
her mother had
similar symptoms several years before her death.
Neurologic examination
shows involuntary choreiform movements. She has a
childlike affect. She
describes her mood as good. On recall testing, she
can remember one out
of three objects after 3 minutes with distraction; she
cannot remember
the other objects with prompting. She cannot remember
the date of her
marriage or her previous address. The most likely
cause of these
symptoms is a lesion at which of the following
locations?
A
) Caudate nucleus
B
) Parietal lobe
C
) Prefrontal lobe
D
) Putamen
E
) Temporal lobe
39. A 67-year-old man comes to the physician
because of insomnia for
2 years. He goes to bed at 11:00 PM after taking a
bath but does not
fall asleep until midnight. He usually wakes up twice
each night: once
around 3:00 AM to void and again at 6:00 AM. He stays
in bed until his
alarm goes off at 7 AM. He is concerned because he
used to sleep 8
hours daily. He recently retired from his job as an
attorney. He takes
no medications. He drinks one beer with lunch 3 days
each week and one
glass of wine with dinner each evening. He walks 1
mile daily after
dinner. Physical examination shows no abnormalities.
His mood is
neutral, and cognition is intact. Urine toxicology
screening is negative.
Which of the following is the most likely cause of
this patient's
symptoms?
A
) Advanced sleep phase syndrome
B
) Alcohol abuse
C
) Delayed sleep phase syndrome
D
) Major depressive disorder
E
) Melatonin deficiency
F
) Poor sleep hygiene
G
) Normal aging
40. An asymptomatic 37-year-old woman comes for a
follow-up
examination 1 year after receiving a renal transplant.
Current medications
include felodipine, enalapril, cyclosporine,
pravastatin, and penicillin
G. She appears well. Her temperature is 36.8 C (98.2
F), blood
pressure is 160/95 mm Hg, pulse is 80/min, and
respirations are 12/min.
Examination shows no other abnormalities. Which of
the following
medications is the most likely cause of this patient's
hypertension?
A
) Cyclosporine
B
) Enalapril
C
) Felodipine
D
) Penicillin G
E
) Pravastatin
41. A 4080-g (9-lb) male newborn is delivered at
term to a
32-year-old woman, gravida 2, para 1. Apgar scores
are 8 and 9 at 1 and 5
minutes, respectively. Examination in the delivery
room shows fracture of
the right clavicle. Which of the following is the
most likely sequela
of this condition?
A
) Correction only with casting
B
) Correction only with physical therapy
C
) Left-hand dominance
D
) Permanent nerve damage
E
) Spontaneous healing without treatment
42. A 22-year-old man with schizoaffective disorder
is brought to
the emergency department 2 hours after the sudden
onset of neck and back
pain. The symptoms began after taking one of his
medications for his
psychiatric disorder. The dosage was increased
yesterday, but he does
not recall the names of either of his medications. He
has no other
history of serious illness. Physical examination
shows rigid contraction
of the neck and back muscles with arching. On mental
status
examination, he is alert and cooperative and hears a
faint voice that tells him to
wash windows. He is oriented to person, place, and
time. Which of the
following medications is most likely responsible for
this patient's
symptoms?
A
) Clozapine
B
) Haloperidol
C
) Lithium carbonate
D
) Trazodone
E
) Valproic acid
43. A 52-year-old woman, gravida 3, para 3, comes
to the physician
because of irregular vaginal bleeding over the past 2
months. She has
hypertension treated with enalapril and type 2
diabetes mellitus well
controlled with diet. Menopause occurred 2 years ago.
Her maternal aunt
had breast cancer at the age of 70 years. The patient
weighs 88 kg
(195 lb) and is 160 cm (63 in) tall. Examination
shows no other
abnormalities. An endometrial biopsy specimen shows
adenocarcinoma. Which of
the following is the most significant predisposing
factor for this
patient's endometrial cancer?
A
) Heredity
B
) Hypertension
C
) Parity
D
) Type 2 diabetes mellitus
E
) Weight
44. A 67-year-old man is brought to the emergency
department 2 hours
after the onset of weakness and double vision. He has
hypertension and
hyperlipidemia treated with metoprolol, captopril, and
atorvastatin.
His blood pressure is 190/106 mm Hg. Neurologic
examination shows
left-sided facial weakness including the forehead.
There is palsy of left
conjugate gaze, and the left eye fails to adduct on
right gaze.
Vertical eye movements are intact. Muscle strength is
3/5 in the right upper
and lower extremities. Deep tendon reflexes are
brisk, and Babinski's
sign is present on the right. Which of the following
is the most
likely location of this patient's lesion?
A
) Bilateral thalamic
B
) Left frontal
C
) Left pontine
D
) Right caudate
E
) Right midbrain
45. Six weeks after spontaneous drainage of an anal
abscess, a
32-year-old man has persistent blood-stained purulent
fluid on his
underwear. He has not had significant anal pain since
drainage of the boil.
Bowel movements are normal. Which of the following is
the most likely
diagnosis?
A
) Anal fissure
B
) Fistula in ano
C
) Pruritus ani
D
) Thrombosed external hemorrhoids
E
) Thrombosed internal hemorrhoids
46. A previously healthy 14-year-old girl is
brought to the
physician because of a 2-day history of fever and pain
and swelling of the
right knee. She remembers injuring the knee while
playing soccer last
week, but she was able to finish the game. She has no
history of rash or
joint pain. Her sister has inflammatory bowel
disease. The patient's
temperature is 39 C (102.2 F), blood pressure is
110/80 mm Hg, pulse is
95/min, and respirations are 20/min. Examination of
the right knee
shows swelling, tenderness, warmth, and erythema;
range of motion is
limited. Which of the following is the most
appropriate next step in
management?
A
) X-ray film of the right knee
B
) Gastrointestinal series with small-bowel
follow-through
C
) Nuclear scan of the right knee
D
) MRI of the right knee
E
) Antibiotic therapy
F
) Arthrocentesis
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And this is form 1 of NBME, I guess.
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