10-13-2010, 04:04 PM
Hello Guys....
I have downloaded the offline version kaplan q bank from somewhere in the forum...And it has like 9 blocks for IM, 4 blocks for peds and 3 blocks for others each.. And on top of all this its written usmle practice test but not kaplan qbank..
So i am really confused whether to do that or not..Want to avoid other unwanted qs.If its Kaplan i will surely wanna give it a look..
Will be taking uworld subscription after that.
Any suggestion guys...
I am pasting the format of block 1 from IM...Those who have done this offline version please respond..
If anyone have kaplan q bank in pdf form anything,please send it to me
will appreciate this very much..
saisha.mle
Thanks
USMLE Step 2 Practice Test
Block 1
Name:
Instructions: Answer the questions below to the best of your ability. When you finish the test, click the Check button at the bottom to view the results.
1.A family physician cares for a family consisting of a 45-year old husband, 43-year-old wife and a 12-year-old daughter. The family reports that recently the 77-year-old maternal grandmother who lived with them died after a prolonged respiratory infection. Autopsy subsequently confirms that she had active pulmonary tuberculosis at the time of death. The organism tested sensitive to all anti-tuberculosis drugs. In responding to the grandmother's illness, which of the following is the most appropriate step in management?
A) Obtain leukocyte counts on all family members
B)Obtain sputum cultures for acid fast bacilli
C)Obtain chest computerized tomograms on all members
D)Place protein purified derivative (PPD) test on all members
E)Schedule bronchoscopy lavage for the adults
Normal Labs
2. A 57-year-old man comes to the emergency department because of excruciating pain in his right big toe. He describes the pain as so severe that it woke him from a deep sleep. He has no chronic medical conditions, does not take any medications, and denies any similar episodes in the past. He admits to a few "drinking binges" over the past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes (PMNs). Laboratory studies show: Serum
Leukocytes........16,000/mm3
Uric acid...........15 mg/dL
Calcium.............9 mg/dL
Which of the following is the most appropriate pharmacotherapy?
A Allopurinol
B Ceftriaxone
C Indomethacin
D Probenecid
E eSulfinpyrazone
Normal Labs 3. A 35-year-old woman arrives on the floor after an uneventful hysteroscopy to evaluate her long history of uterine fibroids. About 30 minutes after her arrival, she begins to complain of nausea and has two episodes of vomiting. The physician administers 0.625 mg of droperidol and 400 mg of acetaminophen by mouth. On follow-up evaluation, the patient's neck is involuntarily flexed to one side. She is alert, oriented, and conversant and has an otherwise normal neurologic examination. Which of the following is the most likely diagnosis?
A) Cerebral vascular accident
B)Conversion disorder
C) Dystonic reaction to droperidol
D) Munchausen syndrome
E) Seizure
Normal Labs 4. 4) A 50-year-old nurse consults a physician because of a rash above both her ankles. Physical examination demonstrates marked ankle edema with erythema, mild scaling, and brown discoloration of the overlying skin of the distal lower legs. Varicose veins are also noted. Which of the following is the most likely diagnosis?
A) Atopic dermatitis
B) Cellulitis
C)Lichen simplex chronicus
D)Nummular dermatitis
E)Stasis dermatitis
Normal Labs
5. An AIDS patient develops symptoms suggestive of a severe, persistent pneumonia with cough, fever, chills, chest pain, weakness, and weight loss. The patient does not respond to penicillin therapy, but goes on to develop very severe headaches. The presence of focal neurologic abnormalities leads the clinician to order a CT scan of the head. This demonstrates several metastatic brain abscesses. Biopsy of one of these lesions demonstrates beaded, branching, filamentous gram-positive bacteria that are weakly acid fast. Which of the following is the most likely causative organism?
A. Actinomyces
B. Aspergillus
C. Burkholderia
D. Francisella
E. Nocardia
Normal Labs
6. A 28-year-old patient with end-stage renal disease (ESRD) on continuous ambulatory peritoneal dialysis (CAPD) for two months presents with fever, abdominal pain and cloudy dialysis fluid. There is no diarrhea or vomiting and the pain has been present for about 12 hours. The patient has ESRD secondary to chronic glomerulonephritis, there is no history of diabetes, urinary infections or antibiotic use. Examination reveals a temperature of 38.9 C (102 F), and blood pressure of 110/70 mm Hg. The throat is clear, as are the lungs. Cardiac examination reveals a grade 2/6 systolic murmur. Abdominal examination reveals decreased bowel sounds with diffuse tenderness. There is mild rebound. There is no edema or skin rash. A complete blood count shows a leukocyte count of 14,200/mm3, hemoglobin is 12.5 g/dL. Peritoneal fluid is cloudy with 1,000 white blood cells, 85% of which are polymorphonuclear leukocytes. Gram's stain of fluid is negative. Cultures of blood and peritoneal dialysis fluid are taken. Which of the following is the most appropriate initial step in management?
A. Fluconazole
B. Immediate removal of dialysis catheter.
C. Intravenous vancomycin
D.Intravenous gentamicin
E.Oral ciprofloxacin
Normal Labs
7. A 54-year-old man presents for a periodic health examination. His family history is significant for his mother who died of a cerebrovascular accident at age 72, his father who died of a myocardial infarction at age 68, and a brother who developed sigmoid cancer at age 60. The patient is on no medications except for aspirin, 81 mg daily. His physical examination is unremarkable. The patient asks for a recommendation regarding current cancer screening. Which of the following is the most appropriate screening test for this patient?
A. Annual digital rectal examination and fecal occult blood testing
B. Flexible sigmoidoscopy
C. Flexible sigmoidoscopy and barium enema
D. Colonoscopy
E. Genetic testing for the p53 gene
Normal Labs
8. An AIDS patient under treatment with a nucleoside analog and a protease inhibitor comes to medical attention with complaints of leg weakness and incontinence. His vital signs are within normal limits. Physical examination reveals reduced strength in the lower extremities with accompanying mild spasticity. There is also diminished sensation in the feet and legs bilaterally. Lumbar puncture shows: Opening pressure.....100 mm H20
Cell count................5 lymphocytes/mm3
Glucose...................48 mg/dL
Proteins, total..........33 mg/dL
Gamma globulin.......8% total protein
Additional laboratory investigations show normal hematologic parameters, vitamin B12 within normal values, and negative serology for syphilis. MRI of the head fails to reveal any focal abnormality. Which of the following is the most likely diagnosis?
A. AIDS dementia complex
B. CMV polyradiculopathy
C. Cryptococcal meningoencephalitis
D. Vacuolar (HIV) myelopathy
E. Zidovudine-related toxicity
Normal Labs
9. A 45-year-old man is involved in an automobile accident and sustains severe injuries with considerable blood loss and hypotension. He is transferred from the emergency department to an intensive care unit, where he develops multiorgan failure. During the first 2 days in the intensive care unit, his plasma phosphate was within normal limits. Subsequently, it began to rise, eventually reaching 6.0 mg/dL. Failure of which of the following organs would most likely have this effect?
A. Heart
B. Kidneys
C. Liver
D. Lungs
E. Pancreas
Normal Labs
10. A 28-year-old woman is diagnosed with lupus nephritis, World Health Organization (WHO) type IV. She has a malar rash, diffuse arthritis, and edema. Her blood pressure is 190/110 mm Hg. Her creatinine is 2.1 mg/dL with a blood urea nitrogen of 28 mg/dL. Her urine reveals 25 red blood cells per hpf, and 3+ protein. One red blood cell cast is seen. A 24-hour urine collection reveals a protein of 11 grams with a creatinine of 1 gram. Which of the following would be the most appropriate management?
A. Oral azathioprine
B. Oral cyclophosphamide
C. Oral gold
D. Oral prednisone
E. Pulse IV cyclophosphamide
Normal Labs
11. A 48-year-old woman is seen by a clinician. She has a bright red, sharply demarcated, oozing and crusting rash involving one breast in the areola area. She has had this lesion for six months and states that it is slowly growing. The lesion does not respond to antibiotic ointment, antifungal ointment, or steroid ointment. This lesion is most likely related to which of the following conditions?
A. Breast cancer
B. Crohn disease
C. Gastric cancer
D. Rheumatoid arthritis
E. Systemic lupus erythematosus
Normal Labs
12. A recent article in a prominent medical journal explored the disparity of resource utilization between men and women. More men than women have major cardiac procedures, including catheterization, performed. This is thought to be because of which of the following reasons?
A. Fewer outcome studies have studied women with these disease
B. The incidence of cardiovascular disease is lower in women
C. Men have better health insurance
D. Men receive too many cardiovascular procedures
E. Provider attitudes has led to this situation
Normal Labs
13. A 43-year-old man presents with a 4-year history of joint pain. The distribution is asymmetric, involving the proximal and distal small joints of the right hand, the left knee, the ankle, and right elbow. Pain and morning stiffness are moderate. Physical examination reveals mild nail pitting, and the distal third interphalangeal joint is partially subluxated. X-rays of the hands show resorption of the distal end of the phalanx. The erythrocyte sedimentation rate (ESR) is elevated to 46 mm/hr, and rheumatoid factor is negative. Which of the following is the most likely diagnosis?
A. Primary generalized osteoarthritis
B. Pseudogout
C. Psoriatic arthritis
D. Rheumatoid arthritis
Normal Labs
14. A 45-year-old man presents to a physician with complaints of weakness, fatigue, and feeling near fainting when he stands up quickly. Screening chemistry studies demonstrate sodium, 128 mEq/L; potassium, 5.2 mEq/L; bicarbonate, 17 mEq/L; and urea nitrogen, 45 mg/dL. The physician is considering Addison disease in his differential diagnosis. Which of the following features on physical examination would be most suggestive of this diagnosis?
A. Black freckles on the shoulders
B. Large, furrowed tongue
C. Many spider angiomas
D. Protruding eyeballs
E. Small glistening bumps on the lips
Normal Labs
15. A 71-year-old man presents to the emergency department with fever and cough. He has known hypercholesterolemia and is status post a right hemicolectomy for colon cancer. The patient states that he has had 3 days of fever to 102 F, cough productive of green sputum, as well as general malaise and weakness. His physical examination is remarkable for decreased breath sounds at the left base, left basilar egophony and dullness to percussion. A complete blood count reveals a leukocyte count of 15000/mm3. A chest radiograph reveals a left lower lobe infiltrate. Which of the following is the most important part of the history to ascertain prior to initiating therapy?
A. Influenza immunization status
B. Plasma lipid profile
C. Stage of the colon cancer
D. Social support structure for home therapy
E. Recently hospitalizations
Normal Labs
16. A 49-year-old woman presents to the office because of complaints of fatigue. She has had progressive exercise intolerance over the prior 6 months. On physical examination, she is pale and afebrile. Her blood pressure is 112/68 mm Hg, and her pulse is 88/min. Heart and lung examinations are normal except for a I/VI systolic flow murmur at the left sternal border. Routine laboratory results reveal hemoglobin of 8.3 g/dL, a mean corpuscular volume of 118 µL/m3, and a B12 of 82 pg/mL (normal >210 pg/mL). She undergoes a Schilling test, which reveals malabsorption of radiolabeled B12. Intrinsic factor is administered and the radiolabeled B12 is subsequently absorbed. Which of the following is the diagnosis?
A. Atrophic gastritis
B. Bacterial overgrowth
C. Chronic pancreatitis
D. Crohn disease
E. Gastric ulcer
Normal Labs
17. A 65-year-old woman consults a physician because of a 3-month history of weight loss, burning sensation of the tongue, fatigue, anorexia, and poorly localized abdominal pain. The woman appears pale to the physician. Intraoffice hematocrit is 35% with peripheral smear showing large erythrocytes and hypersegmented neutrophils. Serum folate is 2.4 ng/mL (normal greater that 1.9 ng/mL) and serum vitamin B12 is 100 pg/mL (normal 200-800 pg/mL). Stomach biopsy demonstrates chronic gastritis. Autoantibodies to which of the following are most likely involved in this patient's condition?
A. Basement membrane
B. Insulin receptor
C. Intrinsic factor
D. SS-B
E. TSH receptor
Normal Labs
18. A previously healthy 50-year-old woman comes to the physician because of double vision for three days. Her temperature is 37 C (98.6 F). The patient denies nausea or vomiting. Examination reveals ptosis and slight divergence of the right eye. Extraocular movements are limited in all directions, except laterally. The right pupil is larger than the left and poorly reactive to light. Examination of the fundus fails to reveal papilledema. Which of the following is the most likely underlying condition?
A. Aneurysm of the posterior communicating artery
B. Carcinoma of the right pulmonary apex
C. Diabetes mellitus
D. Giant cell arteritis
E. Syphilis
F. Systemic hypertension
Normal Labs
19. A patient with a history of chronic bacterial sinusitis presents to the emergency department with a very severe headache. While waiting to be seen, he develops a generalized grand mal seizure. Physical examination, after the seizure is over, demonstrates high fever, exophthalmos, papilledema, and nerve palsies of the VI and III cranial nerves on one side. Which of the following is the most appropriate next step?
A. Admit to the medical floor for monitoring of progression of symptoms
B. Emergency CT scan
C. Emergency exploratory surgery
D. Emergency ultrasound
E. Keep in emergency department for monitoring of progression of symptoms
Normal Labs
20. A 41-year-old man presents with complaints of mild intermittent heartburn after meals for the past 6 months. He has tried various over-the-counter antacids and H2 receptor antagonists with only minimal relief. He denies any dysphagia or odynophagia, and is otherwise in good health. He is concerned about the risk of developing cancer, because his father died of gastric cancer at age 49. His physical examination is unremarkable. Which of the following would be the most appropriate next step in management?
A. Avoidance of a high-protein diet
B. Avoidance of aspirin
C. Avoidance of acetaminophen
D. Elevation of the head of his bed
E. Increased consumption of carbohydrates
Normal Labs
21. A 40-year-old woman is brought to the emergency department following a suicide attempt with imipramine. Her fiancee found her unresponsive, with an empty bottle of the imipramine at her side. The imipramine had been his, and the prescription had been filled that morning. Her past medical history is significant for hypertension, atrial fibrillation, diabetes, and asthma. Her medications include furosemide, procainamide, glyburide, prednisone, and albuterol. She has no known drug allergies. She is afebrile, has a blood pressure of 100/60 mm Hg, pulse of 62/min, and respirations of 22/min. A gastric lavage yields multiple pill fragments. She is confused and somnolent, and has shallow respirations. Her physical examination is otherwise unremarkable. On an ECG, which of the following abnormalities would most likely reflect possible cardiac toxicity?
A. Left deviation of the QRS axis
B. Prolongation of the QRS interval
C. Shortening of the QT interval
D. ST segment depression
E. T wave inversion
Normal Labs
22. A 43-year-old bus driver presents to his gastroenterologist with complaints of difficulty swallowing solid foods. The evaluation demonstrates a smooth, tapered stricture of the distal esophagus, and biopsies reveal changes consistent with chronic esophagitis and fibrosis. The stricture is dilated with an endoscopic balloon dilator, and the patient's symptoms resolve. He reports that although he has had dysphagia for the past 2 months prior to the endoscopy, he rarely has heartburn and uses an over-the-counter antacid only occasionally. Which of the following is the most appropriate future management of this patient?
A. Famotidine
B. Lansoprazole
C. Magnesium hydroxide
D. Metoclopramide
E. No medication is necessary Normal Labs
23. A 23-year-old professional basketball player presents to the team physician 3 hours before game time complaining of abdominal pain. The symptoms began approximately 8 hours earlier in a diffuse fashion. Two hours later, he began feeling nauseated and vomited twice. Over the past 4 hours, the abdominal pain has become more severe and well localized in the right lower quadrant. His examination now reveals well-localized pain in the right lower quadrant inferolateral to the umbilicus. Which of the following is the most likely diagnosis?
A. Acute obstruction of the appendiceal lumen by a fecalith
B. Acute onset of ileocolitis
C. Acute onset of ischemic colitis
D. Acute Yersinia infection
E. Obstruction of the ileocecal valve by a mass
Normal Labs
24. A 31-year-old homeless woman is brought to the emergency department after being found face down on the street. The woman has a long history of admissions to the hospital for alcohol-related issues, including seizures, withdrawal, and hallucinations. Today, she was seen to fall in the street, have what were described as "convulsions" and then vomit. She remained face down in the street until the paramedics arrived. On physical examination, she has dry mucous membranes, a jugular venous pressure of less than 5 cm, and diffuse ecchymoses on her face, body, and breasts. Which of the following vitamins should be administered prior to volume resuscitation with IV fluids containing glucose?
A. Vitamin B1 (Thiamin)
B. Vitamin B3 (Niacin)
C. Vitamin B12 (Cobalamin)
D. Vitamin C
E. Vitamin K
Normal Labs
25. A 36-year-old man develops rapid mental status deterioration two days after sustaining a femoral fracture in a skiing accident. Physical examination shows multiple petechiae in the anterior chest and abdomen. On the third day, the patient lapses into coma and dies. Postmortem examination of the brain reveals numerous petechial hemorrhages in the corpus callosum and centrum semiovale. Which of the following is the most likely diagnosis?
A. Diffuse axonal injury
B. Fat embolism
C. Septic embolism
D. Systemic thromboembolism
E. Watershed infarction
Normal Labs
26. A 45-year-old man consults a physician because of dysuria. The patient is treated with antibiotics, but symptoms recur one week after antibiotic therapy is stopped. A different antibiotic is tried, but symptoms again recur after cessation of the antibiotic. Rectal examination demonstrates an enlarged prostate with areas of tenderness and fluctuance. Which of the following is the most likely diagnosis?
A. Benign prostatic hyperplasia
B. Chronic nonbacterial prostatitis
C. Prostadynia
D. Prostatic abscess
E. Prostatic carcinoma
Normal Labs
27. A 31-year-old woman presents at the hospital for a pre-employment physical examination prior to beginning her year as a medical intern. She is sexually inactive and denies alcohol use. She had infectious mononucleosis while in college and received the recombinant hepatitis B vaccine before starting medical school. Which of the following would describe her hepatitis B serologic profile?
A. Hepatitis B surface antigen positive, core antibody positive, and surface antibody negative
B. Hepatitis B surface antigen negative, core antibody positive, and surface antibody positive
C. Hepatitis B surface antigen positive, core antibody negative, and surface antibody negative
D. Hepatitis B surface antigen negative, core antibody negative, and surface antibody positive
E. Hepatitis B surface antigen negative, core antibody negative, and surface antibody negative.
Normal Labs
28. A 57-year-old man presents to his physician for a preoperative evaluation. He has been a long-time patient in this office and has been treated for hypertension and gastritis. He has been scheduled for an elective open cholecystectomy in 2 days. He currently takes omeprazole for his gastritis and thiazide for his hypertension daily. He smokes two packs of cigarettes per day. His home blood pressure log shows that his systolic pressures range from 150 to 190 mm Hg, and his diastolic pressures range from 80 to 105 mm Hg, indicating that his blood pressure may be not adequately controlled for the surgical procedure. Which of the following medications is most appropriate in the perioperative period for added blood pressure control?
A. Captopril
B. Clonidine
C. Metoprolol
D. Nifedipine
E. Prazosin
Normal Labs
29. A 66-year-old man presents to the clinic complaining of progressively worsening shortness of breath and nonproductive cough over the past 2 years. He retired 1 year ago, after working as a rock miner for more than 30 years. He has no other significant past medical history. On physical examination, he is a thin man who appears tachypneic at rest. His lungs have reduced chest expansion and dry inspiratory rales in the upper lobes bilaterally. The remainder of his examination is normal. A chest x-ray film reveals multiple round opacities in the upper lobes accompanied by hilar lymphadenopathy with lymph node calcification. Which of the following is the most likely diagnosis?
A. Asbestosis
B. Aspergillosis
C. Cystic fibrosis
D. Silicosis
E. Tuberculosis
Normal Labs
30. A 55-year-old woman with a long-standing history of atrial fibrillation secondary to mitral regurgitation presents to the emergency department with a painful right foot. The patient reports that, over the past few hours, her foot has become more painful and now is nearly insensate. She describes the pain as burning and states that it is not relieved by any intervention. She takes coumadin, atenolol, digoxin, and aspirin. On physical examination, her pulse is irregularly irregular. Her lungs are clear, and she has a loud holosystolic murmur heard best at the apex. Her right foot is gray and cool to the touch and has poor capillary refill. Dorsalis pedis and posterior tibial pulses are absent on the right. Her prothrombin time is 14.4 seconds (INR 1.4). Which of the following is the most appropriate course of action?
A. Arrange for her to be seen by a vascular surgeon in the emergency department now
B. Arrange for her to be seen by a neurologist within the next few days
C. Arrange for her to undergo an MRI of the head that day
D. Ask her to make an appointment to be in seen in your office within 1 week
E. Instruct her to soak her leg in warm water and to place a fitted stocking on her affected leg
Normal Labs
31. A 50-year-old man is brought to the emergency department complaining of light-headedness. He has a history of lung cancer, which was diagnosed a month ago and found to be widely metastatic to the bone and pericardium. On physical examination, his blood pressure is 70/40 mm Hg, and his pulse is 100/min. His heart sounds are distant and soft. His ECG demonstrates low voltage, and electrical alternans is present. A chest x-ray film shows that the cardiac silhouette has a "water bottle" appearance.Which of the following is the most appropriate intervention in this patient?
A. Beta-blockers
B. Nonsteroidal anti-inflammatory drugs
C. Steroids
D. Pericardiocentesis
E. Cardiac catheterization
Normal Labs
32. A 62-year-old man with a 110 pack-year history of smoking presents with chest pain. He states that for the past few months, he has been getting chest "pressure" localized to the substernal region, radiating to the left arm on occasion. The pain occurs with mild exertion, but never at rest. He further states that when he gets the pain, it usually last about 5 minutes but goes away with rest. He reports that his exercise tolerance is moderate, and he gets dyspnea on exertion after a few blocks of walking. On physical examination, he has no chest wall tenderness to palpation, but a carotid bruit is heard, and his dorsalis pedis pulses are decreased. He has no history of coronary disease but his family history is significant for his father having a myocardial infarction at age 56. He denies chest pain at this time. In addition to ascertaining his other coronary risk factors, which of the following is the most appropriate diagnostic intervention?
A. Obtain a resting electrocardiogram
B. Schedule the patient for a cardiac echocardiogram
C. Schedule the patient for an exercise treadmill test
D. Schedule the patient for non-urgent coronary angiography
E. Schedule the patient for immediate coronary angiography
Normal Labs
33. A 35-year-old man comes to the physician for a health maintenance examination. He received blood transfusions for hypovolemic shock following a gunshot wound 10 years earlier. He is currently in good health, and physical examination is unremarkable. A serum chemistry panel shows: ALT 250 U/L
AST 140 U/L
Alkaline phosphatase 70 U/L
Serologic evaluation for viral hepatitis reveals positive antibodies to hepatitis C virus (HCV). A percutaneous liver biopsy shows marked portal inflammatory infiltrate disrupting the limiting plate of hepatic lobules. Which of the following is the incidence rate of this complication following HCV infection?
a) A. 5%
B. 10%
C. 20%
D. 40%
E. 80%
Normal Labs
34. A 71-year-old woman is admitted to the hospital for pneumonia. The patient presented to the hospital 2 days ago for cough and fever. She reported temperatures to 38.9 C (102 F) and a cough productive of green, copious sputum. She also reported pleuritic chest pain with deep inspiration. The initial examination revealed diminished breath sounds in the left lower lobe with dullness to percussion, and a chest radiograph revealed a dense left lower lobe infiltrate. Which of the following organisms is most likely responsible for her pneumonia?
A. Bordetella pertussis
B. Klebsiella pneumoniae
C. Mycoplasma pneumoniae
D. Pneumococcus
E. Staphylococcus aureus
Normal Labs
35. A 69-year-old woman presents to her physician of 3 years with progressive shortness of breath. The dyspnea was initially limited to exertion but has progressed to shortness of breath at rest. She has had intermittent cough but no fever. Her past medical history is significant for mild hypertension and seropositive rheumatoid arthritis. Which of the following aspect of her social history is the most important consideration to review at this point?
A. Alcohol history
B. Drugs of abuse history
C. Marital status
D. Occupation
E. Tobacco history
Normal Labs
36. A 42-year-old man presents for his annual physical examination. He was last seen 2 years ago for a periodic health examination and was in good health. He is on no medications. His past medical history is significant for a cholecystectomy 2 years ago and rheumatic fever at age 15. He has been smoking approximately ten cigarettes daily for the past 23 years. On physical examination, his blood pressure is 154/56 mm Hg, pulse is 68/min, and respirations are 14/min. He is afebrile. A head and neck examination is normal. His lungs are clear. He has a regular heart rhythm, with a II/IV blowing decrescendo diastolic murmur heard at the aortic area. His abdominal and rectal examinations are normal. Complete blood count, electrolytes, and thyroid function tests are normal. Which of the following is the most appropriate advice for this man regarding future preventive health maintenance?
A. Antibiotic prophylaxis before dental work
B. Annual chest x-ray film
C. Annual echocardiogram
D. Annual flexible sigmoidoscopy
E. Annual prostate specific antigen testing
Normal Labs
37. A 30-year-old man consults a physician at his wife's insistence because "his eyes are a little yellow all the time now". Screening chemistry studies show modest elevations of liver transaminases and total bilirubin 2.0 mg/dL, almost all of which is conjugated. The patient denies ever using alcohol. Viral hepatitis studies are negative. Liver biopsy shows hepatic fibrosis with normal iron levels and no evidence for alpha-1-antitrypsin deficiency. On further questioning about his general health, the patient reveals that he has had an unusually large number of bacterial pneumonias in his life. He has even had Pneumocystis pneumonia at one point. HIV testing at that time and repeated twice since has always been negative. A doctor at the time had commented that he seemed to have some trouble making neutrophils. T and B cell numbers are within normal limits. Antibody studies reveal the following: IgG total 200 mg/dL [normal 723-1685 mg/dL]
IgA 40 mg/dL [normal 81-463 mg/dL]
IgM 450 mg/dL [normal 48-271 mg/dL]
Which of the following is the most likely diagnosis?
A. Adenosine deaminase deficiency
B. Bruton's agammaglobulinemia
C. IgG subclass deficiency
D. Hyper IgM immunodeficiency
E. Selective IgA deficiency
Normal Labs
38. A 42-year-old man consults a physician because he has a "lump" on his forearm. Examination of the arm demonstrates a 3-cm diameter nodule protruding above the forearm surface. The lesion is covered with apparently normal skin and is soft and freely movable. It location appears to be subcutaneous. The lesion has been slowly growing over the past 2 years, and the patient has experienced no discomfort. He has consulted a physician at this time because his wife keeps pestering him to get something done about it. Which of the following is the most likely diagnosis?
A. Capillary hemangioma
B. Dermatofibroma
C. Intradermal nevus
D. Lipoma
E. Seborrheic keratosis
Normal Labs
39. A 45-year-old man undergoes a routine examination. While the physical examination is unrevealing, a hematocrit performed in the physician's office gives a value of 25%. Review of the peripheral smear reveals smaller-than-normal erythrocytes. The cells vary in size, and some have abnormal shapes. The cells do not appear paler than normal. Reticulocytes are decreased. Assuming that this patient has only a single cause for his anemia, which of the following is most likely to be seen on further evaluation?
A. Low iron
B. Low iron binding capacity
C. Low folate
D. Low mean corpuscular hemoglobin concentration (MCHC)
E. Low vitamin B12
Normal Labs
40. A 23-year-old African American man with AIDS is sent for work up of the nephrotic syndrome. His blood pressure is 140/82 mm Hg. He has 3+ edema in both legs. His risk factor for AIDS is IV heroin use. His creatinine is 2.0 mg/dL, and his urine reveals +3 protein, no blood. A kidney biopsy would most likely reveal which of the following?
A. Diabetic nephropathy
B. Focal glomerular sclerosis
C. IgA nephropathy
D. Membranous nephropathy
E. Nil disease
Normal Labs
41. A 57-year-old woman presents to her physician for follow-up of a fasting serum cholesterol level of 236 mg/dL. She is post-menopausal since age 52, and has been not been on hormone replacement therapy. She has a positive family history for coronary artery disease and she has smoked one-half pack of cigarettes per day for the past 20 years. During her last physical examination, a lipid profile was ordered, and she presents today for evaluation of those results. Which of the following lipid panels would most strongly suggest the need for pharmacologic therapy in this patient?
A. Total cholesterol 180 mg/dL, LDL cholesterol 140 mg/dL
B. Total cholesterol 184 mg/dL, LDL cholesterol 100 mg/dL
C. Total cholesterol 230 mg/dL, LDL cholesterol 100 mg/dL
D. Total cholesterol 245 mg/dL, LDL cholesterol 165 mg/dL
E. Total cholesterol 285 mg/dL, LDL cholesterol 100 mg/dL
Normal Labs
42. A 47-year-old man presents for follow up of his previous visit 2 weeks ago, when he was seen for evaluation of his duodenal ulcer. At that time, a test for Helicobacter pylori was performed. The patient was otherwise well but had been complaining of epigastric pain that was exacerbated by eating. An esophageal-gastroduodenoscopy revealed the presence of a duodenal ulcer, and biopsies were taken at that time. In addition, the patient was told that he needed to modify his diet, such as decreasing his coffee intake, and cutting his tobacco use. The patient returns today to discuss his test results, which were positive for the H. pylori organism. Which of the following is the most appropriate therapy at this time?
A. Amoxicillin orally
B. Bismuth, metronidazole, tetracycline, and omeprazole orally
C. Metronidazole orally
D. Omeprazole orally
E. Sucralfate orally
Normal Labs
43. A 33-year-old woman comes to the physician because of palpitations, restlessness, sweating, weight loss, and a tremor for the past 3 weeks. She does not drink coffee, tea, soda, or alcohol, and she does not smoke cigarettes. Her temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 90/min. Examination shows a fine tremor, lid lag and stare, and pretibial myxedema. The thyroid gland is diffusely enlarged, asymmetric, and lobular. A bruit is present over the gland. Laboratory studies show an undetectable level of thyroid-stimulating hormone, an increased level of thyroid hormones, and an increased radioactive iodine uptake (RAIU). The diagnosis of Graves' disease is made and the treatment options are discussed. The patient selects radioactive iodine therapy. This patient is at greatest risk for which of the following conditions?
A. Cholestasis
B. Granulocytopenia
C. Hypothyroidism
D. Recurrent laryngeal nerve damage
E. Thyroid carcinoma
Normal Labs
44. A 65-year-old man complains of increasing urinary frequency and dribbling at night. He has no past medical history and is on no medications. On physical examination, a digital rectal exam reveals a normal-sized prostate. The prostate-specific antigen (PSA) level is elevated at 15.4 ng/mL. Ultrasonography reveals a small hypoechoic area on the prostate measuring 6 × 8 mm in the right lobe. Which of the following is the most appropriate next step?
A. Administer leuprolide
B. Biopsy prostate lesion
C. Perform bone scan
D. Repeat PSA in 3 months
E. Scan pelvis and retroperitoneum
Normal Labs
45. The day after hunting and skinning wild rabbits, a hunter develops an inflamed papule on one finger. The papule rapidly enlarges and then bursts, releasing pus and forming a clean ulcer cavity productive of thin, colorless exudate. Several days later, the patient develops severe illness with atypical pneumonia and delirium. It is at this point that the patient seeks medical care. The regional lymph nodes of the axilla of the affected arm are enlarged. Reduced breath sounds and occasional rales are heard. Splenomegaly is noted. Blood studies show a mild leukocytosis. Which of the following is the most likely diagnosis?
A. Actinomycosis
B. Brucellosis
C. Melioidosis
D. Plague
E. Tularemia
Normal Labs
46. A 72-year-old man with a 25-year history of emphysema presents to his physician after he develops the acute onset of fevers, rigors, and a cough productive of green sputum. The symptoms gradually worsen over 36 hours and he presents to the emergency department. He has been taking a beclomethasone inhaler twice daily, an albuterol nebulizer treatment at home four times daily, and has been taking erythromycin for a recent bronchitis.
On physical examination he is 183 cm (6 feet) tall and
weighs 85 kg.
His temperature is 38.3 C (100.9 F), blood pressure is 162/92 mm Hg,
pulse is 94/min,
and respirations are 32/min. His lung examination reveals diffuse bilateral coarse rhonchi.
He uses his sternocleidomastoid muscles with each inspiration. An arterial blood gas reveals a pH of 7.20,
a pCO2 of 60 mm Hg,
and a pO2 of 52 mm Hg.
Over the next 2 hours, he becomes increasingly tachypneic, and his pCO2 rises to 74 mm Hg. The decision is made to intubate him at that point. Which of the following settings would be most appropriate for his tidal volume on the respirator?
A. 500 mL/breath
B. 600 mL/breath
C. 700 mL/breath
D. 850 mL/breath
E. 1000 mL/breath
Normal Labs
47. A 41-year-old man presents to his physician for a routine physical examination. He is a new to this office and brings his previous medical record with him. He has no significant past medical history but he does have a strong family history of cancer and heart disease. His father and his brother both had myocardial infarctions before age of 55, and his sister, mother, and aunt had breast cancer. He exercises regularly and eats well, with most of his diet being low in saturated fat and cholesterol. He smokes one pack of cigarettes per week. His review of systems is unremarkable. He is very anxious and would like only minimal interventions done because of his good health. Which of the following is an age-appropriate screening test in this patient?
A. Fasting lipid profile
B. Non-fasting total cholesterol level
C. Oral glucose tolerance test
D. Prostate examination
E. Sigmoidoscopy
Normal Labs
48. Two weeks after receiving an allogeneic bone marrow transplant for treatment of acute myelogenous leukemia, a 45-year-old man develops fever, intractable diarrhea, generalized rash, and non-productive cough. Chest x-ray films show bilateral interstitial infiltrates in the lung. The patient dies of overwhelming sepsis and multiorgan failure. Autopsy investigations reveal cytomegalovirus pneumonia, and extensive single cell necrosis in the intestinal epithelium and skin. This complication of bone marrow transplantation is principally mediated by which of the following cells?
A. B-lymphocytes of bone marrow graft
B. Leukemic cells
C. Natural killer cells of recipient
D. T-lymphocytes of bone marrow graft
E. T-lymphocytes of recipient
Normal Labs
49. A 25-year-old woman consults a dermatologist because of scaling skin since childhood. Physical examination demonstrates fine scaling of the back and extensor surfaces of the extremities. Involved areas also show horny plugs in the orifices of hair follicles. The flexor surfaces are uninvolved. Cracking of the skin is prominent on the palms and soles. The patient also has a history of atopy. Which of the following is the most likely diagnosis?
A. Epidermolytic hyperkeratosis
B. Ichthyosis vulgaris
C. Lamellar ichthyosis
D. X-linked ichthyosis
E. Xeroderma
Normal Labs
50. A 32-year-old woman has had a 15-year history of heartburn. Over the past 4 months, she has had difficulty swallowing large bites of solid food. She has no difficulty with soft foods or liquids, and she has not lost weight. Which of the following is the most likely explanation for her symptoms?
A. Adenocarcinoma in the lower third of the esophagus
B. Barrett's esophagus in the distal esophagus
C. Fibrosis and narrowing at the distal esophagus
D. Schatzki ring in the distal esophagus
E. Squamous carcinoma in the mid-third of the esophagus
Normal Labs
Note: Check your own answers before hitting the Check button below. When you click the Check button, a browser window will appear that contains a summary of your results.
Explanations
I have downloaded the offline version kaplan q bank from somewhere in the forum...And it has like 9 blocks for IM, 4 blocks for peds and 3 blocks for others each.. And on top of all this its written usmle practice test but not kaplan qbank..
So i am really confused whether to do that or not..Want to avoid other unwanted qs.If its Kaplan i will surely wanna give it a look..
Will be taking uworld subscription after that.
Any suggestion guys...
I am pasting the format of block 1 from IM...Those who have done this offline version please respond..
If anyone have kaplan q bank in pdf form anything,please send it to me
will appreciate this very much..
saisha.mle
Thanks
USMLE Step 2 Practice Test
Block 1
Name:
Instructions: Answer the questions below to the best of your ability. When you finish the test, click the Check button at the bottom to view the results.
1.A family physician cares for a family consisting of a 45-year old husband, 43-year-old wife and a 12-year-old daughter. The family reports that recently the 77-year-old maternal grandmother who lived with them died after a prolonged respiratory infection. Autopsy subsequently confirms that she had active pulmonary tuberculosis at the time of death. The organism tested sensitive to all anti-tuberculosis drugs. In responding to the grandmother's illness, which of the following is the most appropriate step in management?
A) Obtain leukocyte counts on all family members
B)Obtain sputum cultures for acid fast bacilli
C)Obtain chest computerized tomograms on all members
D)Place protein purified derivative (PPD) test on all members
E)Schedule bronchoscopy lavage for the adults
Normal Labs
2. A 57-year-old man comes to the emergency department because of excruciating pain in his right big toe. He describes the pain as so severe that it woke him from a deep sleep. He has no chronic medical conditions, does not take any medications, and denies any similar episodes in the past. He admits to a few "drinking binges" over the past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes (PMNs). Laboratory studies show: Serum
Leukocytes........16,000/mm3
Uric acid...........15 mg/dL
Calcium.............9 mg/dL
Which of the following is the most appropriate pharmacotherapy?
A Allopurinol
B Ceftriaxone
C Indomethacin
D Probenecid
E eSulfinpyrazone
Normal Labs 3. A 35-year-old woman arrives on the floor after an uneventful hysteroscopy to evaluate her long history of uterine fibroids. About 30 minutes after her arrival, she begins to complain of nausea and has two episodes of vomiting. The physician administers 0.625 mg of droperidol and 400 mg of acetaminophen by mouth. On follow-up evaluation, the patient's neck is involuntarily flexed to one side. She is alert, oriented, and conversant and has an otherwise normal neurologic examination. Which of the following is the most likely diagnosis?
A) Cerebral vascular accident
B)Conversion disorder
C) Dystonic reaction to droperidol
D) Munchausen syndrome
E) Seizure
Normal Labs 4. 4) A 50-year-old nurse consults a physician because of a rash above both her ankles. Physical examination demonstrates marked ankle edema with erythema, mild scaling, and brown discoloration of the overlying skin of the distal lower legs. Varicose veins are also noted. Which of the following is the most likely diagnosis?
A) Atopic dermatitis
B) Cellulitis
C)Lichen simplex chronicus
D)Nummular dermatitis
E)Stasis dermatitis
Normal Labs
5. An AIDS patient develops symptoms suggestive of a severe, persistent pneumonia with cough, fever, chills, chest pain, weakness, and weight loss. The patient does not respond to penicillin therapy, but goes on to develop very severe headaches. The presence of focal neurologic abnormalities leads the clinician to order a CT scan of the head. This demonstrates several metastatic brain abscesses. Biopsy of one of these lesions demonstrates beaded, branching, filamentous gram-positive bacteria that are weakly acid fast. Which of the following is the most likely causative organism?
A. Actinomyces
B. Aspergillus
C. Burkholderia
D. Francisella
E. Nocardia
Normal Labs
6. A 28-year-old patient with end-stage renal disease (ESRD) on continuous ambulatory peritoneal dialysis (CAPD) for two months presents with fever, abdominal pain and cloudy dialysis fluid. There is no diarrhea or vomiting and the pain has been present for about 12 hours. The patient has ESRD secondary to chronic glomerulonephritis, there is no history of diabetes, urinary infections or antibiotic use. Examination reveals a temperature of 38.9 C (102 F), and blood pressure of 110/70 mm Hg. The throat is clear, as are the lungs. Cardiac examination reveals a grade 2/6 systolic murmur. Abdominal examination reveals decreased bowel sounds with diffuse tenderness. There is mild rebound. There is no edema or skin rash. A complete blood count shows a leukocyte count of 14,200/mm3, hemoglobin is 12.5 g/dL. Peritoneal fluid is cloudy with 1,000 white blood cells, 85% of which are polymorphonuclear leukocytes. Gram's stain of fluid is negative. Cultures of blood and peritoneal dialysis fluid are taken. Which of the following is the most appropriate initial step in management?
A. Fluconazole
B. Immediate removal of dialysis catheter.
C. Intravenous vancomycin
D.Intravenous gentamicin
E.Oral ciprofloxacin
Normal Labs
7. A 54-year-old man presents for a periodic health examination. His family history is significant for his mother who died of a cerebrovascular accident at age 72, his father who died of a myocardial infarction at age 68, and a brother who developed sigmoid cancer at age 60. The patient is on no medications except for aspirin, 81 mg daily. His physical examination is unremarkable. The patient asks for a recommendation regarding current cancer screening. Which of the following is the most appropriate screening test for this patient?
A. Annual digital rectal examination and fecal occult blood testing
B. Flexible sigmoidoscopy
C. Flexible sigmoidoscopy and barium enema
D. Colonoscopy
E. Genetic testing for the p53 gene
Normal Labs
8. An AIDS patient under treatment with a nucleoside analog and a protease inhibitor comes to medical attention with complaints of leg weakness and incontinence. His vital signs are within normal limits. Physical examination reveals reduced strength in the lower extremities with accompanying mild spasticity. There is also diminished sensation in the feet and legs bilaterally. Lumbar puncture shows: Opening pressure.....100 mm H20
Cell count................5 lymphocytes/mm3
Glucose...................48 mg/dL
Proteins, total..........33 mg/dL
Gamma globulin.......8% total protein
Additional laboratory investigations show normal hematologic parameters, vitamin B12 within normal values, and negative serology for syphilis. MRI of the head fails to reveal any focal abnormality. Which of the following is the most likely diagnosis?
A. AIDS dementia complex
B. CMV polyradiculopathy
C. Cryptococcal meningoencephalitis
D. Vacuolar (HIV) myelopathy
E. Zidovudine-related toxicity
Normal Labs
9. A 45-year-old man is involved in an automobile accident and sustains severe injuries with considerable blood loss and hypotension. He is transferred from the emergency department to an intensive care unit, where he develops multiorgan failure. During the first 2 days in the intensive care unit, his plasma phosphate was within normal limits. Subsequently, it began to rise, eventually reaching 6.0 mg/dL. Failure of which of the following organs would most likely have this effect?
A. Heart
B. Kidneys
C. Liver
D. Lungs
E. Pancreas
Normal Labs
10. A 28-year-old woman is diagnosed with lupus nephritis, World Health Organization (WHO) type IV. She has a malar rash, diffuse arthritis, and edema. Her blood pressure is 190/110 mm Hg. Her creatinine is 2.1 mg/dL with a blood urea nitrogen of 28 mg/dL. Her urine reveals 25 red blood cells per hpf, and 3+ protein. One red blood cell cast is seen. A 24-hour urine collection reveals a protein of 11 grams with a creatinine of 1 gram. Which of the following would be the most appropriate management?
A. Oral azathioprine
B. Oral cyclophosphamide
C. Oral gold
D. Oral prednisone
E. Pulse IV cyclophosphamide
Normal Labs
11. A 48-year-old woman is seen by a clinician. She has a bright red, sharply demarcated, oozing and crusting rash involving one breast in the areola area. She has had this lesion for six months and states that it is slowly growing. The lesion does not respond to antibiotic ointment, antifungal ointment, or steroid ointment. This lesion is most likely related to which of the following conditions?
A. Breast cancer
B. Crohn disease
C. Gastric cancer
D. Rheumatoid arthritis
E. Systemic lupus erythematosus
Normal Labs
12. A recent article in a prominent medical journal explored the disparity of resource utilization between men and women. More men than women have major cardiac procedures, including catheterization, performed. This is thought to be because of which of the following reasons?
A. Fewer outcome studies have studied women with these disease
B. The incidence of cardiovascular disease is lower in women
C. Men have better health insurance
D. Men receive too many cardiovascular procedures
E. Provider attitudes has led to this situation
Normal Labs
13. A 43-year-old man presents with a 4-year history of joint pain. The distribution is asymmetric, involving the proximal and distal small joints of the right hand, the left knee, the ankle, and right elbow. Pain and morning stiffness are moderate. Physical examination reveals mild nail pitting, and the distal third interphalangeal joint is partially subluxated. X-rays of the hands show resorption of the distal end of the phalanx. The erythrocyte sedimentation rate (ESR) is elevated to 46 mm/hr, and rheumatoid factor is negative. Which of the following is the most likely diagnosis?
A. Primary generalized osteoarthritis
B. Pseudogout
C. Psoriatic arthritis
D. Rheumatoid arthritis
Normal Labs
14. A 45-year-old man presents to a physician with complaints of weakness, fatigue, and feeling near fainting when he stands up quickly. Screening chemistry studies demonstrate sodium, 128 mEq/L; potassium, 5.2 mEq/L; bicarbonate, 17 mEq/L; and urea nitrogen, 45 mg/dL. The physician is considering Addison disease in his differential diagnosis. Which of the following features on physical examination would be most suggestive of this diagnosis?
A. Black freckles on the shoulders
B. Large, furrowed tongue
C. Many spider angiomas
D. Protruding eyeballs
E. Small glistening bumps on the lips
Normal Labs
15. A 71-year-old man presents to the emergency department with fever and cough. He has known hypercholesterolemia and is status post a right hemicolectomy for colon cancer. The patient states that he has had 3 days of fever to 102 F, cough productive of green sputum, as well as general malaise and weakness. His physical examination is remarkable for decreased breath sounds at the left base, left basilar egophony and dullness to percussion. A complete blood count reveals a leukocyte count of 15000/mm3. A chest radiograph reveals a left lower lobe infiltrate. Which of the following is the most important part of the history to ascertain prior to initiating therapy?
A. Influenza immunization status
B. Plasma lipid profile
C. Stage of the colon cancer
D. Social support structure for home therapy
E. Recently hospitalizations
Normal Labs
16. A 49-year-old woman presents to the office because of complaints of fatigue. She has had progressive exercise intolerance over the prior 6 months. On physical examination, she is pale and afebrile. Her blood pressure is 112/68 mm Hg, and her pulse is 88/min. Heart and lung examinations are normal except for a I/VI systolic flow murmur at the left sternal border. Routine laboratory results reveal hemoglobin of 8.3 g/dL, a mean corpuscular volume of 118 µL/m3, and a B12 of 82 pg/mL (normal >210 pg/mL). She undergoes a Schilling test, which reveals malabsorption of radiolabeled B12. Intrinsic factor is administered and the radiolabeled B12 is subsequently absorbed. Which of the following is the diagnosis?
A. Atrophic gastritis
B. Bacterial overgrowth
C. Chronic pancreatitis
D. Crohn disease
E. Gastric ulcer
Normal Labs
17. A 65-year-old woman consults a physician because of a 3-month history of weight loss, burning sensation of the tongue, fatigue, anorexia, and poorly localized abdominal pain. The woman appears pale to the physician. Intraoffice hematocrit is 35% with peripheral smear showing large erythrocytes and hypersegmented neutrophils. Serum folate is 2.4 ng/mL (normal greater that 1.9 ng/mL) and serum vitamin B12 is 100 pg/mL (normal 200-800 pg/mL). Stomach biopsy demonstrates chronic gastritis. Autoantibodies to which of the following are most likely involved in this patient's condition?
A. Basement membrane
B. Insulin receptor
C. Intrinsic factor
D. SS-B
E. TSH receptor
Normal Labs
18. A previously healthy 50-year-old woman comes to the physician because of double vision for three days. Her temperature is 37 C (98.6 F). The patient denies nausea or vomiting. Examination reveals ptosis and slight divergence of the right eye. Extraocular movements are limited in all directions, except laterally. The right pupil is larger than the left and poorly reactive to light. Examination of the fundus fails to reveal papilledema. Which of the following is the most likely underlying condition?
A. Aneurysm of the posterior communicating artery
B. Carcinoma of the right pulmonary apex
C. Diabetes mellitus
D. Giant cell arteritis
E. Syphilis
F. Systemic hypertension
Normal Labs
19. A patient with a history of chronic bacterial sinusitis presents to the emergency department with a very severe headache. While waiting to be seen, he develops a generalized grand mal seizure. Physical examination, after the seizure is over, demonstrates high fever, exophthalmos, papilledema, and nerve palsies of the VI and III cranial nerves on one side. Which of the following is the most appropriate next step?
A. Admit to the medical floor for monitoring of progression of symptoms
B. Emergency CT scan
C. Emergency exploratory surgery
D. Emergency ultrasound
E. Keep in emergency department for monitoring of progression of symptoms
Normal Labs
20. A 41-year-old man presents with complaints of mild intermittent heartburn after meals for the past 6 months. He has tried various over-the-counter antacids and H2 receptor antagonists with only minimal relief. He denies any dysphagia or odynophagia, and is otherwise in good health. He is concerned about the risk of developing cancer, because his father died of gastric cancer at age 49. His physical examination is unremarkable. Which of the following would be the most appropriate next step in management?
A. Avoidance of a high-protein diet
B. Avoidance of aspirin
C. Avoidance of acetaminophen
D. Elevation of the head of his bed
E. Increased consumption of carbohydrates
Normal Labs
21. A 40-year-old woman is brought to the emergency department following a suicide attempt with imipramine. Her fiancee found her unresponsive, with an empty bottle of the imipramine at her side. The imipramine had been his, and the prescription had been filled that morning. Her past medical history is significant for hypertension, atrial fibrillation, diabetes, and asthma. Her medications include furosemide, procainamide, glyburide, prednisone, and albuterol. She has no known drug allergies. She is afebrile, has a blood pressure of 100/60 mm Hg, pulse of 62/min, and respirations of 22/min. A gastric lavage yields multiple pill fragments. She is confused and somnolent, and has shallow respirations. Her physical examination is otherwise unremarkable. On an ECG, which of the following abnormalities would most likely reflect possible cardiac toxicity?
A. Left deviation of the QRS axis
B. Prolongation of the QRS interval
C. Shortening of the QT interval
D. ST segment depression
E. T wave inversion
Normal Labs
22. A 43-year-old bus driver presents to his gastroenterologist with complaints of difficulty swallowing solid foods. The evaluation demonstrates a smooth, tapered stricture of the distal esophagus, and biopsies reveal changes consistent with chronic esophagitis and fibrosis. The stricture is dilated with an endoscopic balloon dilator, and the patient's symptoms resolve. He reports that although he has had dysphagia for the past 2 months prior to the endoscopy, he rarely has heartburn and uses an over-the-counter antacid only occasionally. Which of the following is the most appropriate future management of this patient?
A. Famotidine
B. Lansoprazole
C. Magnesium hydroxide
D. Metoclopramide
E. No medication is necessary Normal Labs
23. A 23-year-old professional basketball player presents to the team physician 3 hours before game time complaining of abdominal pain. The symptoms began approximately 8 hours earlier in a diffuse fashion. Two hours later, he began feeling nauseated and vomited twice. Over the past 4 hours, the abdominal pain has become more severe and well localized in the right lower quadrant. His examination now reveals well-localized pain in the right lower quadrant inferolateral to the umbilicus. Which of the following is the most likely diagnosis?
A. Acute obstruction of the appendiceal lumen by a fecalith
B. Acute onset of ileocolitis
C. Acute onset of ischemic colitis
D. Acute Yersinia infection
E. Obstruction of the ileocecal valve by a mass
Normal Labs
24. A 31-year-old homeless woman is brought to the emergency department after being found face down on the street. The woman has a long history of admissions to the hospital for alcohol-related issues, including seizures, withdrawal, and hallucinations. Today, she was seen to fall in the street, have what were described as "convulsions" and then vomit. She remained face down in the street until the paramedics arrived. On physical examination, she has dry mucous membranes, a jugular venous pressure of less than 5 cm, and diffuse ecchymoses on her face, body, and breasts. Which of the following vitamins should be administered prior to volume resuscitation with IV fluids containing glucose?
A. Vitamin B1 (Thiamin)
B. Vitamin B3 (Niacin)
C. Vitamin B12 (Cobalamin)
D. Vitamin C
E. Vitamin K
Normal Labs
25. A 36-year-old man develops rapid mental status deterioration two days after sustaining a femoral fracture in a skiing accident. Physical examination shows multiple petechiae in the anterior chest and abdomen. On the third day, the patient lapses into coma and dies. Postmortem examination of the brain reveals numerous petechial hemorrhages in the corpus callosum and centrum semiovale. Which of the following is the most likely diagnosis?
A. Diffuse axonal injury
B. Fat embolism
C. Septic embolism
D. Systemic thromboembolism
E. Watershed infarction
Normal Labs
26. A 45-year-old man consults a physician because of dysuria. The patient is treated with antibiotics, but symptoms recur one week after antibiotic therapy is stopped. A different antibiotic is tried, but symptoms again recur after cessation of the antibiotic. Rectal examination demonstrates an enlarged prostate with areas of tenderness and fluctuance. Which of the following is the most likely diagnosis?
A. Benign prostatic hyperplasia
B. Chronic nonbacterial prostatitis
C. Prostadynia
D. Prostatic abscess
E. Prostatic carcinoma
Normal Labs
27. A 31-year-old woman presents at the hospital for a pre-employment physical examination prior to beginning her year as a medical intern. She is sexually inactive and denies alcohol use. She had infectious mononucleosis while in college and received the recombinant hepatitis B vaccine before starting medical school. Which of the following would describe her hepatitis B serologic profile?
A. Hepatitis B surface antigen positive, core antibody positive, and surface antibody negative
B. Hepatitis B surface antigen negative, core antibody positive, and surface antibody positive
C. Hepatitis B surface antigen positive, core antibody negative, and surface antibody negative
D. Hepatitis B surface antigen negative, core antibody negative, and surface antibody positive
E. Hepatitis B surface antigen negative, core antibody negative, and surface antibody negative.
Normal Labs
28. A 57-year-old man presents to his physician for a preoperative evaluation. He has been a long-time patient in this office and has been treated for hypertension and gastritis. He has been scheduled for an elective open cholecystectomy in 2 days. He currently takes omeprazole for his gastritis and thiazide for his hypertension daily. He smokes two packs of cigarettes per day. His home blood pressure log shows that his systolic pressures range from 150 to 190 mm Hg, and his diastolic pressures range from 80 to 105 mm Hg, indicating that his blood pressure may be not adequately controlled for the surgical procedure. Which of the following medications is most appropriate in the perioperative period for added blood pressure control?
A. Captopril
B. Clonidine
C. Metoprolol
D. Nifedipine
E. Prazosin
Normal Labs
29. A 66-year-old man presents to the clinic complaining of progressively worsening shortness of breath and nonproductive cough over the past 2 years. He retired 1 year ago, after working as a rock miner for more than 30 years. He has no other significant past medical history. On physical examination, he is a thin man who appears tachypneic at rest. His lungs have reduced chest expansion and dry inspiratory rales in the upper lobes bilaterally. The remainder of his examination is normal. A chest x-ray film reveals multiple round opacities in the upper lobes accompanied by hilar lymphadenopathy with lymph node calcification. Which of the following is the most likely diagnosis?
A. Asbestosis
B. Aspergillosis
C. Cystic fibrosis
D. Silicosis
E. Tuberculosis
Normal Labs
30. A 55-year-old woman with a long-standing history of atrial fibrillation secondary to mitral regurgitation presents to the emergency department with a painful right foot. The patient reports that, over the past few hours, her foot has become more painful and now is nearly insensate. She describes the pain as burning and states that it is not relieved by any intervention. She takes coumadin, atenolol, digoxin, and aspirin. On physical examination, her pulse is irregularly irregular. Her lungs are clear, and she has a loud holosystolic murmur heard best at the apex. Her right foot is gray and cool to the touch and has poor capillary refill. Dorsalis pedis and posterior tibial pulses are absent on the right. Her prothrombin time is 14.4 seconds (INR 1.4). Which of the following is the most appropriate course of action?
A. Arrange for her to be seen by a vascular surgeon in the emergency department now
B. Arrange for her to be seen by a neurologist within the next few days
C. Arrange for her to undergo an MRI of the head that day
D. Ask her to make an appointment to be in seen in your office within 1 week
E. Instruct her to soak her leg in warm water and to place a fitted stocking on her affected leg
Normal Labs
31. A 50-year-old man is brought to the emergency department complaining of light-headedness. He has a history of lung cancer, which was diagnosed a month ago and found to be widely metastatic to the bone and pericardium. On physical examination, his blood pressure is 70/40 mm Hg, and his pulse is 100/min. His heart sounds are distant and soft. His ECG demonstrates low voltage, and electrical alternans is present. A chest x-ray film shows that the cardiac silhouette has a "water bottle" appearance.Which of the following is the most appropriate intervention in this patient?
A. Beta-blockers
B. Nonsteroidal anti-inflammatory drugs
C. Steroids
D. Pericardiocentesis
E. Cardiac catheterization
Normal Labs
32. A 62-year-old man with a 110 pack-year history of smoking presents with chest pain. He states that for the past few months, he has been getting chest "pressure" localized to the substernal region, radiating to the left arm on occasion. The pain occurs with mild exertion, but never at rest. He further states that when he gets the pain, it usually last about 5 minutes but goes away with rest. He reports that his exercise tolerance is moderate, and he gets dyspnea on exertion after a few blocks of walking. On physical examination, he has no chest wall tenderness to palpation, but a carotid bruit is heard, and his dorsalis pedis pulses are decreased. He has no history of coronary disease but his family history is significant for his father having a myocardial infarction at age 56. He denies chest pain at this time. In addition to ascertaining his other coronary risk factors, which of the following is the most appropriate diagnostic intervention?
A. Obtain a resting electrocardiogram
B. Schedule the patient for a cardiac echocardiogram
C. Schedule the patient for an exercise treadmill test
D. Schedule the patient for non-urgent coronary angiography
E. Schedule the patient for immediate coronary angiography
Normal Labs
33. A 35-year-old man comes to the physician for a health maintenance examination. He received blood transfusions for hypovolemic shock following a gunshot wound 10 years earlier. He is currently in good health, and physical examination is unremarkable. A serum chemistry panel shows: ALT 250 U/L
AST 140 U/L
Alkaline phosphatase 70 U/L
Serologic evaluation for viral hepatitis reveals positive antibodies to hepatitis C virus (HCV). A percutaneous liver biopsy shows marked portal inflammatory infiltrate disrupting the limiting plate of hepatic lobules. Which of the following is the incidence rate of this complication following HCV infection?
a) A. 5%
B. 10%
C. 20%
D. 40%
E. 80%
Normal Labs
34. A 71-year-old woman is admitted to the hospital for pneumonia. The patient presented to the hospital 2 days ago for cough and fever. She reported temperatures to 38.9 C (102 F) and a cough productive of green, copious sputum. She also reported pleuritic chest pain with deep inspiration. The initial examination revealed diminished breath sounds in the left lower lobe with dullness to percussion, and a chest radiograph revealed a dense left lower lobe infiltrate. Which of the following organisms is most likely responsible for her pneumonia?
A. Bordetella pertussis
B. Klebsiella pneumoniae
C. Mycoplasma pneumoniae
D. Pneumococcus
E. Staphylococcus aureus
Normal Labs
35. A 69-year-old woman presents to her physician of 3 years with progressive shortness of breath. The dyspnea was initially limited to exertion but has progressed to shortness of breath at rest. She has had intermittent cough but no fever. Her past medical history is significant for mild hypertension and seropositive rheumatoid arthritis. Which of the following aspect of her social history is the most important consideration to review at this point?
A. Alcohol history
B. Drugs of abuse history
C. Marital status
D. Occupation
E. Tobacco history
Normal Labs
36. A 42-year-old man presents for his annual physical examination. He was last seen 2 years ago for a periodic health examination and was in good health. He is on no medications. His past medical history is significant for a cholecystectomy 2 years ago and rheumatic fever at age 15. He has been smoking approximately ten cigarettes daily for the past 23 years. On physical examination, his blood pressure is 154/56 mm Hg, pulse is 68/min, and respirations are 14/min. He is afebrile. A head and neck examination is normal. His lungs are clear. He has a regular heart rhythm, with a II/IV blowing decrescendo diastolic murmur heard at the aortic area. His abdominal and rectal examinations are normal. Complete blood count, electrolytes, and thyroid function tests are normal. Which of the following is the most appropriate advice for this man regarding future preventive health maintenance?
A. Antibiotic prophylaxis before dental work
B. Annual chest x-ray film
C. Annual echocardiogram
D. Annual flexible sigmoidoscopy
E. Annual prostate specific antigen testing
Normal Labs
37. A 30-year-old man consults a physician at his wife's insistence because "his eyes are a little yellow all the time now". Screening chemistry studies show modest elevations of liver transaminases and total bilirubin 2.0 mg/dL, almost all of which is conjugated. The patient denies ever using alcohol. Viral hepatitis studies are negative. Liver biopsy shows hepatic fibrosis with normal iron levels and no evidence for alpha-1-antitrypsin deficiency. On further questioning about his general health, the patient reveals that he has had an unusually large number of bacterial pneumonias in his life. He has even had Pneumocystis pneumonia at one point. HIV testing at that time and repeated twice since has always been negative. A doctor at the time had commented that he seemed to have some trouble making neutrophils. T and B cell numbers are within normal limits. Antibody studies reveal the following: IgG total 200 mg/dL [normal 723-1685 mg/dL]
IgA 40 mg/dL [normal 81-463 mg/dL]
IgM 450 mg/dL [normal 48-271 mg/dL]
Which of the following is the most likely diagnosis?
A. Adenosine deaminase deficiency
B. Bruton's agammaglobulinemia
C. IgG subclass deficiency
D. Hyper IgM immunodeficiency
E. Selective IgA deficiency
Normal Labs
38. A 42-year-old man consults a physician because he has a "lump" on his forearm. Examination of the arm demonstrates a 3-cm diameter nodule protruding above the forearm surface. The lesion is covered with apparently normal skin and is soft and freely movable. It location appears to be subcutaneous. The lesion has been slowly growing over the past 2 years, and the patient has experienced no discomfort. He has consulted a physician at this time because his wife keeps pestering him to get something done about it. Which of the following is the most likely diagnosis?
A. Capillary hemangioma
B. Dermatofibroma
C. Intradermal nevus
D. Lipoma
E. Seborrheic keratosis
Normal Labs
39. A 45-year-old man undergoes a routine examination. While the physical examination is unrevealing, a hematocrit performed in the physician's office gives a value of 25%. Review of the peripheral smear reveals smaller-than-normal erythrocytes. The cells vary in size, and some have abnormal shapes. The cells do not appear paler than normal. Reticulocytes are decreased. Assuming that this patient has only a single cause for his anemia, which of the following is most likely to be seen on further evaluation?
A. Low iron
B. Low iron binding capacity
C. Low folate
D. Low mean corpuscular hemoglobin concentration (MCHC)
E. Low vitamin B12
Normal Labs
40. A 23-year-old African American man with AIDS is sent for work up of the nephrotic syndrome. His blood pressure is 140/82 mm Hg. He has 3+ edema in both legs. His risk factor for AIDS is IV heroin use. His creatinine is 2.0 mg/dL, and his urine reveals +3 protein, no blood. A kidney biopsy would most likely reveal which of the following?
A. Diabetic nephropathy
B. Focal glomerular sclerosis
C. IgA nephropathy
D. Membranous nephropathy
E. Nil disease
Normal Labs
41. A 57-year-old woman presents to her physician for follow-up of a fasting serum cholesterol level of 236 mg/dL. She is post-menopausal since age 52, and has been not been on hormone replacement therapy. She has a positive family history for coronary artery disease and she has smoked one-half pack of cigarettes per day for the past 20 years. During her last physical examination, a lipid profile was ordered, and she presents today for evaluation of those results. Which of the following lipid panels would most strongly suggest the need for pharmacologic therapy in this patient?
A. Total cholesterol 180 mg/dL, LDL cholesterol 140 mg/dL
B. Total cholesterol 184 mg/dL, LDL cholesterol 100 mg/dL
C. Total cholesterol 230 mg/dL, LDL cholesterol 100 mg/dL
D. Total cholesterol 245 mg/dL, LDL cholesterol 165 mg/dL
E. Total cholesterol 285 mg/dL, LDL cholesterol 100 mg/dL
Normal Labs
42. A 47-year-old man presents for follow up of his previous visit 2 weeks ago, when he was seen for evaluation of his duodenal ulcer. At that time, a test for Helicobacter pylori was performed. The patient was otherwise well but had been complaining of epigastric pain that was exacerbated by eating. An esophageal-gastroduodenoscopy revealed the presence of a duodenal ulcer, and biopsies were taken at that time. In addition, the patient was told that he needed to modify his diet, such as decreasing his coffee intake, and cutting his tobacco use. The patient returns today to discuss his test results, which were positive for the H. pylori organism. Which of the following is the most appropriate therapy at this time?
A. Amoxicillin orally
B. Bismuth, metronidazole, tetracycline, and omeprazole orally
C. Metronidazole orally
D. Omeprazole orally
E. Sucralfate orally
Normal Labs
43. A 33-year-old woman comes to the physician because of palpitations, restlessness, sweating, weight loss, and a tremor for the past 3 weeks. She does not drink coffee, tea, soda, or alcohol, and she does not smoke cigarettes. Her temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 90/min. Examination shows a fine tremor, lid lag and stare, and pretibial myxedema. The thyroid gland is diffusely enlarged, asymmetric, and lobular. A bruit is present over the gland. Laboratory studies show an undetectable level of thyroid-stimulating hormone, an increased level of thyroid hormones, and an increased radioactive iodine uptake (RAIU). The diagnosis of Graves' disease is made and the treatment options are discussed. The patient selects radioactive iodine therapy. This patient is at greatest risk for which of the following conditions?
A. Cholestasis
B. Granulocytopenia
C. Hypothyroidism
D. Recurrent laryngeal nerve damage
E. Thyroid carcinoma
Normal Labs
44. A 65-year-old man complains of increasing urinary frequency and dribbling at night. He has no past medical history and is on no medications. On physical examination, a digital rectal exam reveals a normal-sized prostate. The prostate-specific antigen (PSA) level is elevated at 15.4 ng/mL. Ultrasonography reveals a small hypoechoic area on the prostate measuring 6 × 8 mm in the right lobe. Which of the following is the most appropriate next step?
A. Administer leuprolide
B. Biopsy prostate lesion
C. Perform bone scan
D. Repeat PSA in 3 months
E. Scan pelvis and retroperitoneum
Normal Labs
45. The day after hunting and skinning wild rabbits, a hunter develops an inflamed papule on one finger. The papule rapidly enlarges and then bursts, releasing pus and forming a clean ulcer cavity productive of thin, colorless exudate. Several days later, the patient develops severe illness with atypical pneumonia and delirium. It is at this point that the patient seeks medical care. The regional lymph nodes of the axilla of the affected arm are enlarged. Reduced breath sounds and occasional rales are heard. Splenomegaly is noted. Blood studies show a mild leukocytosis. Which of the following is the most likely diagnosis?
A. Actinomycosis
B. Brucellosis
C. Melioidosis
D. Plague
E. Tularemia
Normal Labs
46. A 72-year-old man with a 25-year history of emphysema presents to his physician after he develops the acute onset of fevers, rigors, and a cough productive of green sputum. The symptoms gradually worsen over 36 hours and he presents to the emergency department. He has been taking a beclomethasone inhaler twice daily, an albuterol nebulizer treatment at home four times daily, and has been taking erythromycin for a recent bronchitis.
On physical examination he is 183 cm (6 feet) tall and
weighs 85 kg.
His temperature is 38.3 C (100.9 F), blood pressure is 162/92 mm Hg,
pulse is 94/min,
and respirations are 32/min. His lung examination reveals diffuse bilateral coarse rhonchi.
He uses his sternocleidomastoid muscles with each inspiration. An arterial blood gas reveals a pH of 7.20,
a pCO2 of 60 mm Hg,
and a pO2 of 52 mm Hg.
Over the next 2 hours, he becomes increasingly tachypneic, and his pCO2 rises to 74 mm Hg. The decision is made to intubate him at that point. Which of the following settings would be most appropriate for his tidal volume on the respirator?
A. 500 mL/breath
B. 600 mL/breath
C. 700 mL/breath
D. 850 mL/breath
E. 1000 mL/breath
Normal Labs
47. A 41-year-old man presents to his physician for a routine physical examination. He is a new to this office and brings his previous medical record with him. He has no significant past medical history but he does have a strong family history of cancer and heart disease. His father and his brother both had myocardial infarctions before age of 55, and his sister, mother, and aunt had breast cancer. He exercises regularly and eats well, with most of his diet being low in saturated fat and cholesterol. He smokes one pack of cigarettes per week. His review of systems is unremarkable. He is very anxious and would like only minimal interventions done because of his good health. Which of the following is an age-appropriate screening test in this patient?
A. Fasting lipid profile
B. Non-fasting total cholesterol level
C. Oral glucose tolerance test
D. Prostate examination
E. Sigmoidoscopy
Normal Labs
48. Two weeks after receiving an allogeneic bone marrow transplant for treatment of acute myelogenous leukemia, a 45-year-old man develops fever, intractable diarrhea, generalized rash, and non-productive cough. Chest x-ray films show bilateral interstitial infiltrates in the lung. The patient dies of overwhelming sepsis and multiorgan failure. Autopsy investigations reveal cytomegalovirus pneumonia, and extensive single cell necrosis in the intestinal epithelium and skin. This complication of bone marrow transplantation is principally mediated by which of the following cells?
A. B-lymphocytes of bone marrow graft
B. Leukemic cells
C. Natural killer cells of recipient
D. T-lymphocytes of bone marrow graft
E. T-lymphocytes of recipient
Normal Labs
49. A 25-year-old woman consults a dermatologist because of scaling skin since childhood. Physical examination demonstrates fine scaling of the back and extensor surfaces of the extremities. Involved areas also show horny plugs in the orifices of hair follicles. The flexor surfaces are uninvolved. Cracking of the skin is prominent on the palms and soles. The patient also has a history of atopy. Which of the following is the most likely diagnosis?
A. Epidermolytic hyperkeratosis
B. Ichthyosis vulgaris
C. Lamellar ichthyosis
D. X-linked ichthyosis
E. Xeroderma
Normal Labs
50. A 32-year-old woman has had a 15-year history of heartburn. Over the past 4 months, she has had difficulty swallowing large bites of solid food. She has no difficulty with soft foods or liquids, and she has not lost weight. Which of the following is the most likely explanation for her symptoms?
A. Adenocarcinoma in the lower third of the esophagus
B. Barrett's esophagus in the distal esophagus
C. Fibrosis and narrowing at the distal esophagus
D. Schatzki ring in the distal esophagus
E. Squamous carcinoma in the mid-third of the esophagus
Normal Labs
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