2008 Item Ult Choice

Name
American Board of Family Medicine
IN-TRAINING EXAMINATION
TIME4 HOURS
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Copyright 2008 The American Board of Family Medicine. All rights reserved.
1. A 30-year-old white male complains of several weeks of nasal stuffiness, purulent nasal
discharge, and facial pain. He does not respond to a 3-day course of trimethoprim/
sulfamethoxazole (Bactrim, Septra). Follow-up treatment with 2 weeks of amoxicillin/
clavulanate (Augmentin) is similarly ineffective.
Of the following diagnostic options, which one is most appropriate at this time?
A)
B)
C)
D)
Pulmonary function testing

Coronal CT of the sinuses
Culture and sensitivity testing of the discharge
Erythrocyte sedimentation rate
2. A 65-year-old male presents for a follow-up visit for severe depression. His symptoms have
included crying episodes, difficulty maintaining sleep, and decreased appetite. He has suicidal
ideations and states that he has a gun in his home. He also thinks his wife is having an affair,
but she is present and is adamant that this is not true. His symptoms have not been relieved by
maximum doses of sertraline (Zoloft), venlafaxine (Effexor), or citalopram (Celexa). He
currently is taking duloxetine (Cymbalta), which also has failed to relieve his symptoms.
Which one of the following would most likely provide the quickest relief of his symptoms?
A)
B)
C)
D)
Counseling
Bupropion (Wellbutrin)
Stopping duloxetine and starting an MAO inhibitor
Electroconvulsive therapy
3. A newborn male has a skin eruption on his forehead, nose, and cheeks. The lesions are mostly
closed comedones with a few open comedones, papules, and pustules. No significant erythema
is seen.
Which one of the following is the most likely diagnosis?
A)
B)
C)
D)
E)
Erythema toxicum neonatorum

Localized superficial Candida infection
Herpes simplex
Milia
Acne neonatorum
4. Regular breast self-examinations to screen for breast cancer

A)
B)
C)
D)
E)
are performed by most women in the United States

reduce mortality due to breast cancer
reduce all-cause mortality in women
are recommended by the U.S. Preventive Services Task Force
increase the number of breast biopsies performed
5. An 18-year-old female basketball player comes to your office the day after sustaining an
inversion injury to her ankle. She says she treated the injury overnight with rest, ice,
compression, and elevation. You examine her and diagnose a moderate to severe lateral ankle
sprain.
In addition to rehabilitative exercises, you advise
A)
B)
C)
D)
E)
a short-term cast
a posterior splint that allows no flexion or extension
a semi-rigid stirrup brace (Air-Stirrup)
an elastic bandage
no external brace or support
6. A 26-year-old female presents with a 1-year history of recurring abdominal pain associated with
intermittent diarrhea, 57 days per month. Her pain improves with defecation. There has been
no blood in her stool and no weight loss. Laboratory findings are normal, including a CBC,
chemistry profile, TSH level, and antibodies for celiac disease.
Which one of the following would be most appropriate at this point?
A)
B)
C)
D)
E)
Colonoscopy
An upper GI series with small-bowel follow-through
Abdominal CT with contrast
A gluten-free diet
Loperamide (Imodium)
7. Which one of the following is appropriate and effective treatment for genitourinary gonorrhea
in a 20-year-old male with a purulent urethral discharge?
A)
B)
C)
D)
E)
Amoxicillin, 3.5 g orally once

Ciprofloxacin (Cipro), 500 mg orally once
Ceftriaxone (Rocephin), 125 mg intramuscularly once
Doxycycline, 100 mg 2 times daily for 3 days
Erythromycin, 500 mg 4 times daily for 7 days
8. A 40-year-old male respiratory therapist presents for a health examination prior to hospital
employment. His history indicates that as a child he lived on a farm in Iowa, and his
examination is unremarkable, but a chest radiograph shows that both lung fields have BB-sized
calcifications in a miliary pattern. No other findings are noted. A PPD skin test is negative.
The findings in this patient are most likely a result of
A)
B)
C)
D)
E)
HIV infection
histoplasmosis
coccidioidomycosis
tuberculosis
cryptococcosis
2
9. A 68-year-old Mexican American female is brought to your office by her son with a complaint
of headaches. The patient speaks English adequately, but diverts her eyes to look at her son
when answering your questions.
Which one of the following is the most likely reason for this patient not making eye contact?
A)
B)
C)
D)
E)
Her son is overly controlling

She is a victim of abuse
She is being untruthful
She is showing respect to you
She is depressed
10. The pneumococcal polyvalent vaccine (Pneumovax 23) would be recommended for which one
of the following patients?
A)
B)
C)
D)
E)
A 1-year-old patient as a routine immunization

An 18-month-old patient diagnosed with cystic fibrosis
A 35-year-old patient recently diagnosed with HIV infection
A healthy 49-year-old patient
A healthy 75-year-old patient who received a dose 8 years ago
11. A 2-week-old female is brought to the office for a well child visit. The physical examination
is completely normal except for a clunking sensation and feeling of movement when adducting
the hip and applying posterior pressure.
Which one of the following would be the most appropriate next step?
A) Referral for orthopedic consultation
B) Reassurance that the problem resolves spontaneously in 90% of cases, and follow-up
in 2 weeks
C) Triple diapering and follow-up in 2 weeks
D) A radiograph of the pelvis
12. A 55-year-old male presents for an evaluation of heel pain. He has a relatively sedentary office
job, but exercises daily by jogging 3 miles. He has pain in the right heel at the medial aspect
of the calcaneus and is tender on examination. The pain is worse with the first few steps of the
morning.
Which one of the following would be the most appropriate initial treatment for this patient?
A)
B)
C)
D)
E)
Corticosteroid injection
Extracorporeal shockwave therapy
Surgical referral for bone spur removal
Nonweight bearing for 1 month
Stretching exercises for the Achilles tendon
13. A 50-year-old male with a history of methamphetamine abuse requests medication to treat this
problem. According to evidence-based studies, which one of the following would be most likely
to help this patient overcome methamphetamine dependence?
A)
B)
C)
D)
E)
Fluoxetine (Prozac)
Amlodipine (Norvasc)
Imipramine (Tofranil)
Bupropion (Wellbutrin)
Cognitive therapy
14. A 45-year-old white male undergoes a health screening at his church. He has a carotid Doppler
study, abdominal ultrasonography, heel densitometry, and a multiphasic blood panel. He
receives a report indicating that all of the studies are normal, but a 0.7-cm thyroid nodule was
noted. The TSH level is normal.
He schedules a visit with you and brings you the report. A neck examination and ENT
examination are normal, and you do not detect a nodule.
You recommend
A)
B)
C)
D)
E)
a radionuclide thyroid scan

T3, T4, and calcitonin levels
repeat ultrasonography in 612 months
a fine-needle biopsy
hemithyroidectomy
15. A 54-year-old female takes levothyroxine (Synthroid), 0.125 mg/day, for central hypothyroidism
secondary to a pituitary adenoma. The nurse practitioner in your office orders a TSH level,
which is found to be 0.1 mIU/mL (N 0.55.0).
Which one of the following would you recommend?
A)
B)
C)
D)
E)
Decrease the dosage of levothyroxine

Increase the dosage of levothyroxine
Order a free T4 level
Order a TRH stimulation test
Repeat the TSH level in 3 months
16. A 68-year-old African-American female is brought to your office by her daughter, who tells you
that her mother has recently been exhibiting short-term memory loss and confusion. For
example, she has difficulty remembering how to get dressed appropriately and sometimes forgets
to turn off the oven after using it. These symptoms developed fairly abruptly.
The patients medical problems include type 2 diabetes mellitus, hypertension,
hypercholesterolemia, and osteoarthritis. She had a stroke last year and has residual mild
hemiparesis.
A physical examination is normal except for mild hemiparesis. On cognitive testing she is able
to recall only one of three words, and all the numbers are on one side on the clock-drawing test.
Which one of the following types of dementia is most likely in this patient?
A)
B)
C)
D)
E)
Alzheimers disease
Dementia with Lewy bodies
Vascular dementia
Frontotemporal dementia
Multisystem atrophy
17. A 44-year-old female is distressed because of incontinence. She reports frequent episodes of an
immediate need to urinate, which cannot always be deferred. She admits to urinating more than
10 times a day, but denies any urine leakage with coughing, laughing, or straining.
Which one of the following is the most appropriate initial treatment for this patient?
A)
B)
C)
D)
E)
Solifenacin (Vesicare)
Oxybutynin (Ditropan XL)
Tamsulosin (Flomax)
Phenazopyridine (Pyridium)
Pelvic floor muscle training and bladder training
18. A 34-year-old female who delivered a healthy infant 18 months ago complains of a milky
discharge from both nipples. She reports that normal periods have resumed since cessation of
breastfeeding 6 months ago. She takes ethinyl estradiol/norgestimate (Ortho Tri-Cyclen) for
birth control. A complete review of systems is otherwise negative.
The most likely cause of the discharge is
A)
B)
C)
D)
a medication side effect

breast cancer
a hypothalamic tumor
hypothyroidism
19. A 60-year-old African-American female has a history of hypertension that has been well
controlled with hydrochlorothiazide. However, she has developed an allergy to the medication.
Successful monotherapy for her hypertension would be most likely with which one of the
following?
A)
B)
C)
D)
E)
Lisinopril (Prinivil, Zestril)

Hydralazine (Apresoline)
Clonidine (Catapres)
Atenolol (Tenormin)
Diltiazem (Cardizem)
20. In a patient who presents with symptoms of acute myocardial infarction, which one of the
following would be an indication for thrombolytic therapy?
A)
B)
C)
D)
E)
New-onset ST-segment depression

New-onset left bundle branch block
New-onset first degree atrioventricular block
New-onset Wenckebach second degree heart block
Frequent unifocal ventricular ectopic beats
21. Which one of the following preventive measures is recommended for nearly all international
travelers to developing countries?
A)
B)
C)
D)
E)
(-Globulin
Hepatitis A vaccine
Hepatitis B vaccine
Typhoid vaccine
Yellow fever vaccine
22. A 55-year-old male who has a long history of marginally-controlled hypertension presents with
gradually increasing shortness of breath and reduced exercise tolerance. His physical
examination is normal except for a blood pressure of 140/90 mm Hg, bilateral basilar rales, and
trace pitting edema.
Which one of the following ancillary studies would be the preferred diagnostic tool for
evaluating this patient?
A)
B)
C)
D)
E)
12-lead electrocardiography
Posteroanterior and lateral chest radiographs
2-dimensional echocardiography with Doppler
Radionuclide ventriculography
Cardiac MRI
23. A 45-year-old white male is admitted to the intensive-care unit after being pinned in a car wreck
for 2 hours. He has sustained several broken bones and crush injuries to both thighs. On
admission his urine is clear but the next morning it is burgundy colored. Some fresh urine is
drawn from his Foley catheter and sent for analysis, with the following results:
Specific gravity. . . . . . . . . .
pH.. . . . . . . . . . . . . . . . . .
Protein. . . . . . . . . . . . . . . .
Glucose. . . . . . . . . . . . . . .
Hemoglobin.. . . . . . . . . . . .
Urobilinogen. . . . . . . . . . . .
Bile. . . . . . . . . . . . . . . . . .
RBCs. . . . . . . . . . . . . . . . .
WBCs. . . . . . . . . . . . . . . .
Occasional hyaline casts
1.020
6.0
30 mg/dL (N 114)
negative
4+
0.1 Ehrlich Units (N 0.11.0)
negative
12/hpf
02/hpf
You immediately order a CBC which shows his hematocrit to have dropped 4 percentage points
overnight. Visual inspection of the serum shows it is clear.
The color of his urine is most likely due to
A)
B)
C)
D)
E)
myoglobinuria
hematuria from trauma to the urinary tract
a transfusion reaction with hemolysis of RBCs and free hemoglobin into the urine
hemoglobinuria resulting from reabsorption of hemoglobin from hematomas
acute porphyria provoked by trauma
24. A 44-year-old African-American female reports diffuse aching, especially in her upper legs and
shoulders. The aching has increased, and she now has trouble going up and down stairs because
of weakness. She has no visual symptoms, and a neurologic examination is normal except for
proximal muscle weakness. Laboratory tests reveal elevated levels of serum creatine kinase and
aldolase. Her symptoms improve significantly when she is treated with corticosteroids.
A)
B)
C)
D)
E)
Duchennes muscular dystrophy

Myasthenia gravis
Amyotrophic lateral sclerosis
Aseptic necrosis of the femoral head
Polymyositis
25. An asymptomatic 40-year-old male presents for a routine examination and is found to have a
total bilirubin level of 1.8 mg/dL (N 1.0) and an indirect bilirubin level of 1.3 mg/dL. He
drinks 36 beers/week. An examination and laboratory tests, including a CBC and serum liver
enzymes, are within normal limits.
Which one of the following is true regarding the diagnosis?
A)
B)
C)
D)
The most likely diagnosis is alcoholic liver disease

The most likely diagnosis is Dubin-Johnson syndrome
The most likely diagnosis is Gilbert syndrome
Ultrasonography of the liver and gallbladder are necessary to make a diagnosis
26. A 16-year-old female presents with a complaint of pelvic cramps with her menses over the past
2 years. She describes her periods as heavy, and says they occur once a month and last for 7
days, with no spotting in between. She has never been sexually active and does not expect this
to change in the foreseeable future. An abdominal examination is normal.
A)
B)
C)
D)
A pelvic examination
Ultrasonography
A TSH level
Naproxen prior to and during menses
27. A mother brings in her 2-month-old infant for a routine checkup. The baby is exclusively
breastfed, and the mother has no concerns or questions.
Which one of the following would you recommend at this time in addition to continued
breastfeeding?
A)
B)
C)
D)
E)
Iron supplementation
Vitamin D supplementation
A multivitamin
8 oz of water daily
4 oz of cereal daily
28. A 45-year-old male asks about using nicotine replacement therapy (NRT) to help him quit
smoking. You tell him that recent evidence shows that
A)
B)
C)
D)
E)
NRT usually doubles a smokers chance of quitting

NRT must be tapered off
NRT should be used for at least 6 months to be effective
nicotine patches are the most effective form of NRT
using combinations of NRT reduces the likelihood that a relapsed smoker will quit
29. Which one of the following medications should be discontinued in a patient with diabetic
gastroparesis?
A)
B)
C)
D)
E)
Exenatide (Byetta)
Benazepril (Lotensin)
Metformin (Glucophage)
Hydrochlorothiazide
Prochlorperazine maleate
30. Which one of the following antipsychotic medications is most likely to cause agranulocytosis?
A)
B)
C)
D)
Clozapine (Clozaril)
Aripiprazole (Abilify)
Risperidone (Risperdal)
Olanzapine (Zyprexa)
31. Which one of the following is associated with ulcerative colitis rather than Crohns disease?
A)
B)
C)
D)
E)
The absence of rectal involvement

Transmural involvement of the colon
Segmental noncontinuous distribution of inflammation
Fistula formation
An increased risk of carcinoma of the colon
32. A 35-year-old male with a toothache presents to a local clinic for uninsured patients. On
examination you find a decayed left lower molar that is tender when tapped lightly, and
surrounding gingival inflammation and tenderness. There is no obvious mandibular swelling,
but he does have a tender submandibular lymph node. The earliest available dental appointment
is in 1 week. He has no allergies to medications.
Which one of the following would be the best antibiotic treatment for this patient?
A)
B)
C)
D)
E)
Doxycycline
Trimethoprim/sulfamethoxazole (Bactrim, Septra)
Clindamycin (Cleocin)
Ciprofloxacin (Cipro)
Cephalexin (Keflex)
33. A 22-year-old competitive cross-country skier presents with a complaint of not being able to
perform as well as she expects. She has been training hard, but says she seems to get short of
breath more quickly than she should. She also coughs frequently while exercising.
A review of systems is otherwise negative. Her family history is negative for cardiac or
pulmonary diseases. Her physical examination is completely normal, and pulmonary function
tests obtained before and after bronchodilator use are normal.
After you discuss your findings with the patient, she acknowledges that her expectations may be
too high, but can think of no other cause for her problem.
Which one of the following would be the next reasonable step?
A)
B)
C)
D)
An echocardiogram to look for cardiomyopathy or valvular dysfunction

Counseling regarding competition stress and athlete burnout syndrome
A sports medicine consultation to evaluate her training regimen
A trial of inhaled albuterol (Proventil) for exercise-induced bronchospasm
34. In a child, which one of the following is most likely to improve adherence to a chronic
medication regimen?
A) Adding a favorite flavor to bitter liquid medications
B) More frequent dosing of daily medication
C) Having only one person from the health-care team discuss the medication regimen
with the patient and his parents
D) Advising the parents to avoid giving rewards for following the regimen
E) Putting the parents in complete control of the dosing schedule
35. A 6-year-old female presents with a 24-hour history of dry cough, malaise, and a temperature
of 39.8C (103.6F). She received an influenza vaccination 7 days ago. A rapid influenza test
is positive for influenza A.
Which one of the following would be the best treatment option for this patient?
A)
B)
C)
D)
Oseltamivir (Tamiflu)
Amantadine (Symmetrel)
Rimantadine (Flumadine)
Zanamivir (Relenza)
10
36. A 64-year-old white male appears to be depressed 2 weeks after hospital discharge for a
myocardial infarction. He experienced short runs of ventricular tachycardia during his
hospitalization, and echocardiography revealed an ejection fraction of 40% at the time of
discharge, with no symptoms of heart failure. He has a history of depression in the past. His
current symptoms include depressed mood, sleep disturbance, feelings of hopelessness, and
anhedonia. He denies suicidal ideation.
A)
B)
C)
D)
Low-dose amitriptyline at bedtime

Sertraline (Zoloft)
Referral for electroconvulsive therapy
Referral for intense interpersonal psychotherapy
37. A 20-year-old female long-distance runner presents with a 3-month history of amenorrhea. A
pregnancy test is negative, and other blood work is normal. She has no other medical problems
and takes no medications.
With respect to her amenorrhea, you advise her
A)
B)
C)
D)
to increase her caloric intake

that this is a normal response to training
to begin an estrogen-containing oral contraceptive
to stop running
38. A 66-year-old male smoker is being evaluated for a persistent cough and difficulty breathing.
Spirometry confirms a fixed obstructive pathology with an FEV1 of about 50% of predicted for
size and age. His oxygen saturation is 89%90% on room air.
Which one of the following would be most effective to prevent worsening of this patients
condition?
A)
B)
C)
D)
E)
A combined inhaled corticosteroid and long-acting $-agonist

A long-acting anticholinergic agent
Long-term oral corticosteroids
Oxygen therapy
Smoking cessation
39. A 20-year-old female is seen for follow-up 6 weeks after delivery. Her pregnancy was
complicated by preeclampsia. Her examination is unremarkable.
This patient will be at increased risk for which one of the following in midlife?
A)
B)
C)
D)
E)
Breast cancer
Diabetes mellitus
Hypothyroidism
Kidney disease
Hypertension
11
40. A 65-year-old male presents with a 1-month history of problems passing urine. He says that his
bladder will feel full when he needs to urinate, but the urine stream is weak and his bladder does
not feel as if it has emptied completely. The symptoms have become increasingly severe over
the past week. Other symptoms include upper respiratory congestion for 3 days which he has
treated with an over-the-counter decongestant with some relief, constipation with no passage of
stool in the past 9 days, and increasing low back pain incompletely relieved with ibuprofen, with
associated weakness in both legs.
Examination shows a healthy-appearing male who is moderately overweight. He is afebrile and
vital signs are normal. There is no abdominal tenderness and no masses are detected. A rectal
examination reveals a large amount of hard stool in the rectum; a markedly enlarged (4+),
boggy, tender prostate gland; laxity of the anal sphincter; and numbness in the perianal area.
Urinalysis shows trace protein and 1020 WBCs/hpf. Ultrasonography shows a post-void
residual volume of 250 mL (normal for age <100).
Which one of the following must be done urgently in this patient?
A)
B)
C)
D)
Foley catheterization
Hospitalization for intravenous antibiotics
Digital disimpaction of the rectum, and Fleet enemas until clear
MRI of the lumbosacral spine
41. A 35-year-old African-American male has a blood pressure of 142/88 mm Hg, confirmed on
repeat measurements. A complete metabolic panel and urinalysis reveal a serum creatinine level
of 1.9 mg/dL (N 0.61.5) and 2+ protein in the urine.
Which one of the following would be the most appropriate initial treatment?
A)
B)
C)
D)
E)
ACE inhibitors
Aldosterone antagonists
$-Blockers
Calcium channel blockers
Diuretics
42. A 27-year-old male presents with what he thinks is a sinus infection. He has a 2-day history of
right maxillary pain associated with nasal congestion and clear rhinorrhea. The only significant
findings on examination are a low-grade fever and subjective tenderness with palpation over the
right maxillary sinus.
Which one of the following treatments is most supported by current evidence?
A)
B)
C)
D)
E)
Antihistamines
Oral decongestants
Topical vasoconstrictor sprays
Oral analgesics
Nasal lavage
12
43. Which one of the following skin infections should initially be treated with oral antifungal
therapy?
A)
B)
C)
D)
E)
Tinea capitis
Tinea corporis
Tinea cruris
Erythrasma
Mycosis fungoides
44. In a study to evaluate a test as a screen for the presence of a disease, 235 of the 250 people with
the disease had a positive test and 600 of the 680 people without the disease had a negative test.
Based on this data, the specificity of the test for the disease is
A)
B)
C)
D)
E)
235/250 = 94%
15/250 = 6%
600/680 = 88%
80/680 = 12%
15/80 = 19%
45. A 56-year-old African-American male has pain and tingling in the medial aspect of his ankle and
the plantar aspect of his foot. He jogs 3 miles daily and has no history of any injury. The
symptoms are aggravated by activity, and sometimes keep him awake at night. The only
findings on examination are paresthesias when a reflex hammer is used to tap just inferior to the
medial malleolus.
This patient probably has
A)
B)
C)
D)
E)
a stress fracture
a herniated nucleus pulposus at L5 or S1
plantar fasciitis
diabetic neuropathy
tarsal tunnel syndrome
46. A white male adolescent is concerned because he is the shortest boy in his class. His age is 14.3
years and his parents are of normal height. He has a negative past medical history and no
symptoms. On physical examination you note that he is 151 cm (59 in) tall. The average height
for his age is 165 cm. His weight is 43 kg (95 lb). His sexual maturity rating is 3 for genitalia
and 2 for pubic hair. A wrist radiograph shows a bone age of 12.2 years (the average height is
152 cm for this bone age).
On the basis of this evaluation you can tell the patient and his parents that
A)
B)
C)
D)
E)
he should have a growth hormone stimulation test

his adult height will be below average
his sexual development is about average for his age
he will begin to grow taller within a year or so
an underlying nutritional deficiency may be the cause of his short stature
13
47. Many of the changes that occur as part of aging affect pharmacokinetics. Which one of the
following is INCREASED in geriatric patients?
A)
B)
C)
D)
E)
Drug absorption
Glomerular filtration rate
Lean body mass
Volume of distribution of water-soluble compounds such as digoxin
Percentage of body fat
48. Which one of the following is safest for use in pregnancy (FDA category B or better)?
A)
B)
C)
D)

Nitrofurantoin (Macrodantin)
Gentamicin
49. Dizziness is most likely to have a serious etiology when it

A)
B)
C)
D)
E)
is associated with diplopia

is associated with intense nausea and vomiting
occurs when the patient rolls over in bed
occurs when the patient first arises in the morning
occurs after 2 minutes of hyperventilation
50. Which one of the following is most appropriate for the initial treatment of claudication?
A)
B)
C)
D)
Regular exercise
Chelation
Vasodilating agents
Warfarin (Coumadin)
51. A 72-year-old white male in otherwise good health complains of generalized pruritus that
worsens in the winter. The itching is most intense after he bathes. He recently noticed a rash
on his abdomen and legs as well. On examination you note poorly defined red, scaly plaques
with fine fissures on the abdomen. No eruption is present at other pruritic sites.
Which one of the following is the most likely cause of this problem?
A)
B)
C)
D)
E)
Stasis dermatitis
Lichen simplex chronicus
Xerosis
Rosacea
Candidiasis
14
52. In patients with breast cancer, the most reliable predictor of survival is
A)
B)
C)
D)
E)
estrogen receptor status

cancer stage at the time of diagnosis
tumor grade
histologic type
lymphatic or blood vessel involvement
53. You see a 20-month-old male approximately 1 hour after he had a generalized seizure that lasted
23 minutes according to his mother. His past medical history is unremarkable except for two
episodes of otitis media. On examination his temperature is 38.9C (102.0F), and he is awake,
interactive, and consolable, with obvious otitis media of the left ear. A neurologic examination
is unremarkable, and there are no meningeal signs.
A)
B)
C)
D)
Lumbar puncture
Electroencephalography
Neuroimaging studies
Serum levels of electrolytes, calcium, phosphate, and magnesium, plus a blood
glucose level and a CBC
E) No diagnostic studies at this time
54. A 75-year-old white female presents with severe pain of the carpometacarpal joint at the base
of her thumb. Examination of her hands also reveals hypertrophic changes of the distal
interphalangeal and proximal interphalangeal joints of her fingers.
These findings are most consistent with
A)
B)
C)
D)
E)
rheumatoid arthritis
gout
systemic lupus erythematosus
scleroderma
osteoarthritis
55. A 70-year-old male with a history of hypertension and type 2 diabetes mellitus presents with a
2-month history of increasing paroxysmal nocturnal dyspnea and shortness of breath with
minimal exertion. An echocardiogram shows an ejection fraction of 25%.
Which one of the patients current medications should be discontinued?
A)
B)
C)
D)
E)
Lisinopril (Zestril)
Pioglitazone (Actos)
Glipizide (Glucotrol)
Metoprolol (Toprol-XL)
Repaglinide (Prandin)
15
56. A 75-year-old male presents to the emergency department with a several-hour history of back
pain in the interscapular region. His medical history includes a previous myocardial infarction
(MI) several years ago, a history of cigarette smoking until the time of the MI, and hypertension
that is well controlled with hydrochlorothiazide and lisinopril (Prinivil, Zestril). The patient
appears anxious, but all pulses are intact. His blood pressure is 170/110 mm Hg and his pulse
rate is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no acute changes.
A chest radiograph shows a widened mediastinum and a normal aortic arch, and CT of the chest
shows a dissecting aneurysm of the descending aorta that is distal to the proximal abdominal
aorta but does not involve the renal arteries.
Which one of the following would be the most appropriate next step in the management of this
patient?
A)
B)
C)
D)
E)
Immediate surgical intervention

Arteriography of the aorta
Intravenous nitroprusside (Nitropress)
A nitroglycerin drip
Intravenous labetalol (Trandate)
57. An asymptomatic 3-year-old male presents for a routine check-up. On examination you notice
a systolic heart murmur. It is heard best in the lower precordium and has a low, short tone
similar to a plucked string or kazoo. It does not radiate to the axillae or the back and seems to
decrease with inspiration. The remainder of the examination is normal.
A)
B)
C)
D)
E)
Eisenmengers syndrome
Mitral stenosis
Peripheral pulmonic stenosis
Stills murmur
Venous hum
58. A 75-year-old female is admitted to the hospital with a change in mental status. The initial
workup includes a chemistry profile that reveals a plasma potassium level of 6.4 mEq/L (N
3.75.2).
Which one of the following should be given now to rapidly lower the plasma potassium level?
A)
B)
C)
D)
Corticosteroids
Albuterol
Furosemide (Lasix)
0.45% saline
16
59. Which one of the following is recommended for routine prenatal care?
A)
B)
C)
D)
E)
Hepatitis C antibody testing

Parvovirus antibody testing
Cystic fibrosis carrier testing
HIV screening
Examination of a vaginal smear for clue cells
60. Which one of the following confers the greatest risk for postoperative pulmonary complications
in noncardiothoracic surgery?
A)
B)
C)
D)
E)
Heart failure
Age 80
COPD
Cigarette use
Corticosteroid use
61. A 49-year-old female who takes multiple medications has a chemistry profile as part of her
routine monitoring. She is found to have an elevated calcium level. All other values on the
profile are normal, and the patient is not currently symptomatic. Follow-up testing reveals a
serum calcium level of 11.2 mg/dL (N 8.410.2) and an intact parathyroid hormone level of 80
pg/mL (N 1065).
Which one of the following should be discontinued for 3 months before repeat laboratory
evaluation and treatment?
A)
B)
C)
D)
E)
Lithium
Furosemide (Lasix)
Raloxifene (Evista)
Calcium carbonate
Vitamin D
62. A 32-year-old white male teacher is seen for a paroxysmal cough of 5 days duration. He tells
you that a student in his class was diagnosed with pertussis 3 weeks ago.
Which one of the following would be the best treatment?
A)
B)
C)
D)
E)
Amoxicillin
Azithromycin (Zithromax)
Cephalexin (Keflex)
Doxycycline
17
63. In the United States the most common form of child abuse is
A)
B)
C)
D)
physical abuse
emotional abuse
sexual abuse
child neglect
64. A 3-week-old infant is brought to your office with a fever. He has a rectal temperature of
38.3C (101.0F), but does not appear toxic. The remainder of the examination is within
normal limits.
Which one of the following would be the most appropriate management for this patient?
A) Admit to the hospital; obtain urine, blood, and CSF cultures; and start intravenous
antibiotics
B) Admit to the hospital and treat for herpes simplex virus infection
C) Follow up in the office in 24 hours and admit to the hospital if not improved
D) Order a CBC and urinalysis with urine culture, and send the patient home if the results
are normal
65. A 62-year-old male is admitted to the hospital with acute renal failure. A renal biopsy confirms
the diagnosis of acute interstitial nephritis (AIN). Infection and immune-associated causes are
ruled out, and you consider medications as a potential cause.
Which one of the following would be most likely to cause AIN?
A)
B)
C)
D)
E)
Chronic daily use of metoprolol (Lopressor)

Twice-daily use of ibuprofen for 2 weeks
Initiation of lisinopril (Prinivil, Zestril) therapy 1 week ago
A 5-day course of azithromycin (Zithromax) 6 months ago
Intermittent use of acetaminophen, up to 4 g/day
66. Patients with which one of the following conditions are at increased risk for complications from
electroconvulsive therapy for depression?
A)
B)
C)
D)
E)
Pregnancy
Seizure disorder
Cardiac pacemaker implantation
Depression unresponsive to oral medications
Recent cerebral hemorrhage
18
67. Which one of the following is the leading cause of death following bariatric surgery?
A)
B)
C)
D)
E)
Pulmonary embolism
Adult respiratory distress syndrome
Peritonitis secondary to an anastomotic leak
Sepsis related to a wound infection
Hemorrhage from an anastomotic ulcer
68. A 45-year-old female with rheumatoid arthritis has a hemoglobin level of 9.5 g/dL (N
11.516.0). Her arthritis is well controlled with methotrexate (Trexall). Further evaluation
reveals the following:
Hematocrit. . . . . . . . . . . .
Mean corpuscular volume.. .
Platelets. . . . . . . . . . . . . .
WBCs. . . . . . . . . . . . . . .
Differential. . . . . . . . . .
Serum iron. . . . . . . . . . . .
Total iron binding capacity. .
Iron saturation. . . . . . . . . .
Serum ferritin. . . . . . . . . .
Reticulocyte count.. . . . . . .
Stool guaiac.. . . . . . . . . . .
29.0% (N 35.047.0)
78 :m3 (N 8098)
230,000/mm3 (N 150,000400,000)
6900/mm3 (N 400011,000)
normal
15 :g/dL (N 50170)
150 :g/dL (N 4570)
10% (N 1550)
7 ng/mL (N 12150)
8109/L (N 10100)
negative 3
A) Evaluation for a source of blood loss
B) Hemoglobin electrophoresis to screen for thalassemia
C) Stopping the methotrexate and beginning an alternative treatment for rheumatoid
arthritis
D) No further evaluation
69. A 37-year-old female presents with concerns about difficulty initiating and maintaining sleep for
the past 34 months. She is irritable and feels fatigued and sleepy during the day. After further
evaluation, she is diagnosed with chronic insomnia. She asks about alternatives to hypnotic drug
treatments.
Which one of the following management options is best supported by current evidence?
A)
B)
C)
D)
E)
Diphenhydramine (Benadryl)
Cognitive behavior therapy
St. Johns wort
4 oz of red wine 30 minutes before bedtime
Vigorous aerobic exercise 3045 minutes before bedtime
19
70. A 59-year-old male reports nausea, vomiting, and progressive fatigue for the past few months.
At his last visit, 6 months ago, his blood pressure was poorly controlled and hydrochlorothiazide
was added to his $-blocker therapy. At this visit he appears moderately dehydrated on
examination. Laboratory testing reveals a serum calcium level of 12.5 mg/dL (N 8.010.0), a
BUN level of 36 mg/dL (N 620), and a creatinine level of 2.2 mg/dL (N 0.61.1). A CBC,
albumin level, and electrolyte levels are normal. His intact parathyroid hormone level is
reported a few days later, and is 60 pg/mL (N 1065).
What is the most likely cause of his hypercalcemia?
A)
B)
C)
D)
Renal failure
Hyperparathyroidism
Milk alkali syndrome
Sarcoidosis
71. A 55-year-old African-American male with osteoarthritis of the knees asks for advice on
improving the function of his knees and controlling arthritis pain. Which one of the following
would be appropriate advice?
A)
B)
C)
D)
E)
Topical capsaicin (Zostrix) applied twice daily will improve both pain and function
Glucosamine will improve both pain and function
A therapeutic exercise program will improve both pain and function
An intra-articular corticosteroid injection will provide at least 6 months of pain relief
NSAIDs will slow the progression of the disease
72. A 67-year-old smoker with a history of pulmonary tuberculosis at 22 years of age presents with
a 6-month history of increasing shortness of breath. On office spirometry his FVC is 60% of
predicted, his FEV1 is 80% of predicted, and his FEV1/FVC ratio is 0.8.
Which one of the following would be the most appropriate next step in his evaluation?
A) Refer to a pulmonary laboratory for static lung volume measurement and diffusion
studies
B) Perform a bronchodilator challenge test
C) Investigate for nonpulmonary causes for the patients symptoms
D) Order a PPD skin test
73. Which one of the following is true regarding temporomandibular joint disorder?
A)
B)
C)
D)
E)
Dental splints are the treatment of choice

Mandibular clicking is an essential diagnostic element
Ultrasonic phonophoresis with cortisone is the treatment of choice
The majority of cases resolve without treatment
MRI is preferred over CT to confirm the diagnosis
20
74. A 5-year-old white male has an itchy lesion on his right foot. He often plays barefoot in a city
park that is subject to frequent flooding. The lesion is located dorsally between the web of his
right third and fourth toes, and extends toward the ankle. It measures approximately 3 cm in
length, is erythematous, and has a serpiginous track. The remainder of his examination is within
normal limits.
Which one of the following is the most likely cause of these findings?
A)
B)
C)
D)
Dog or cat hookworm (Ancylostoma species)

Dog or other canid tapeworm (Echinococcus granulosus)
Cat protozoa (Toxoplasma gondii)
Dog or cat roundworm (Toxocara canis or T. mystax)
75. A 72-year-old male slipped on a rug in his kitchen and struck his right side against a counter.
He presents several days after the fall with a complaint of ongoing pain in his flank. He has a
history of chronic atrial fibrillation, which is treated with warfarin (Coumadin). His vital signs
are normal. A physical examination reveals tenderness to palpation along the posterior-lateral
chest wall and decreased breath sounds in the right base. Radiographs reveal two fractured ribs
on the right side and a moderately large pleural effusion in the right hemithorax. Laboratory test
results include a hemoglobin of 10.5 mg/dL (baseline 11.012.0 mg/dL) and a prothrombin time
of 33.5 seconds with an INR of 3.5.
Which one of the following would be the most appropriate management at this time?
A)
B)
C)
D)
E)
Evacuation of the pleural space

Prophylactic antibiotics
Open fixation of the ribs with control of bleeding
Symptomatic treatment and close follow-up
Use of a rib binder for 23 weeks
76. A 35-year-old female presents with pain in her neck, back, and shoulder, as well as a complaint
of poor sleep and fatigue. For the last 6 months she has experienced burning in her low back
that radiates to her buttocks, and she feels that her joints are swollen even though there is no
objective evidence of this. She also experiences morning stiffness that improves as the day
progresses.
A physical examination is unremarkable with the exception of palpation of 14 different tender
points above and below the diaphragm, including the upper border of the trapezius muscle, the
second rib space 3 cm lateral to the sternal border bilaterally, both lateral epicondyles, the upper
outer quadrants of both gluteal muscles, and the radial fat pad of both knees. Laboratory tests,
including a CBC, a chemistry profile, thyroid function tests, and an erythrocyte sedimentation
rate, all are within normal limits.
Which one of the following would be the most helpful treatment for this patient?
A)
B)
C)
D)
E)
Massage therapy
NSAIDs
Trigger-point injections
Corticosteroids
Cognitive-behavior therapy
21
77. A male infant is delivered by cesarean section because of dystocia due to macrosomia. Apgar
scores are 8 at 1 minute and 10 at 5 minutes. However, at about 1 hour of age he begins to have
tachypnea without hypoxemia. A chest radiograph shows diffuse parenchymal infiltrates and
fluid in the pulmonary fissures. The symptoms resolve without treatment within 24 hours.
The most likely diagnosis is
A)
B)
C)
D)
E)
transient tachypnea of the newborn

intracranial hemorrhage
laryngotracheomalacia
meconium aspiration syndrome
hyaline membrane disease
78. A 47-year-old male who lives at sea level attempts to climb Mt. Rainier. On the first day he
ascends to 3400 m (11,000 ft). The next morning he complains of headache, nausea, dizziness,
and fatigue, but as he continues the climb to the summit he becomes ataxic and confused.
Which one of the following is the treatment of choice?
A)
B)
C)
D)
E)
Administration of oxygen and immediate descent

Dexamethasone, 8 mg intramuscularly
Acetazolamide (Diamox), 250 mg twice a day
Nifedipine (Procardia), 10 mg immediately, followed by 30 mg in 12 hours
Helicopter delivery of a portable hyperbaric chamber
79. A 26-year-old female presents with a 2-month history of amenorrhea, nausea, and fluttering in
her chest. The fluttering feels similar to what she experienced 3 years ago when diagnosed with
Graves disease. At that time, she was successfully treated with medication, which she
discontinued after 18 months. Current laboratory tests reveal a positive hCG, a TSH of 0.03
:U/mL (N 0.45.0), and a free T4 of 4.0 :g/dL (N 0.82.0).
Which one of the following would be the most appropriate treatment in this situation?
A) 131I ablation
B) Propylthiouracil
C) Subtotal thyroidectomy
D) Methimazole (Tapazole)
22
80. Your patient is moving to another state and requests transfer of his medical records. Which one
of the following is true regarding this patients request?
A) The medical record should be released only with written permission from a patient or
legal representative
B) Although it is kept by the physician, the actual medical record is the property of the
patient
C) A physician may withhold medical record information that could cause undue stress
to a patient
D) In spite of a patient request, the physician may withhold information from a third party
E) A physician has the right to withhold the medical record until medical bills are paid
in full
81. A 32-year-old female who is an avid runner presents with knee pain. You suspect patellofemoral
pain syndrome.
Which one of the following signs or symptoms would prompt an evaluation for an alternative
diagnosis?
A)
B)
C)
D)
E)
Peripatellar pain while running

Knee stiffness with sitting
A popping sensation in the knee
Locking of the joint
A positive J sign (lateral tracking of the patella when moved from flexion to full
extension)
82. The parents of three children ask your advice about the need for fluoride supplementation in
order to prevent tooth decay. Which one of the following is true regarding current U.S.
Preventive Services Task Force guidelines for fluoride supplementation?
A) It is not recommended due to potential fluoride toxicity
B) Dental fluoride varnish is too toxic for routine use
C) Oral fluoride supplementation is recommended if the primary drinking water source
is low in fluoride
D) Fluoridated toothpaste provides adequate protection if used as soon as the child has
teeth
E) The need for fluoride supplementation is determined by serum fluoride levels
83. A 55-year-old male has New York Heart Association Class II heart failure. He becomes
dyspneic with significant exertion. His only medication is an ACE inhibitor.
Which one of the following additional medications has been shown to improve longevity in this
situation?
A)
B)
C)
D)
E)
Digitalis
Warfarin (Coumadin)
$-Blockers
Amiodarone (Cordarone)
Nondihydropyridine calcium channel blockers
23
84. A 22-year-old male with no previous history of shoulder problems is injured in a fall. He has
immediate pain and is unable to abduct his arm. He goes to the emergency department and an
MRI reveals an acute tear of the rotator cuff.
Which one of the following is the best initial treatment for this injury?
A)
B)
C)
D)
E)
Observation without treatment for 1 month

Immobilization for 1 month
Physical therapy for 1 month
Corticosteroid injection
Surgical repair
85. During a well child examination of a healthy-appearing 4-week-old white male born at term, his
mother questions you about a prominence in the left side of his scrotum, which she has noted
since his baths were begun. Your physical examination reveals an oblong, nontender,
nonreducible, light-transmitting mass closely adhered to or involving the testis.
You should recommend which one of the following?
A)
B)
C)
D)
Further observation
Sterile aspiration of the mass
Immediate surgery
Surgery in 34 months
86. An obviously intoxicated 50-year-old white male is brought to the emergency department after
the car he was driving hit a telephone pole. He has a fracture of the femur, and is confused and
uncooperative. His pulse rate is 120 beats/min, his blood pressure is 80/40 mm Hg, and his skin
is clammy. Initial physical examination of his abdomen does not indicate significant
intra-abdominal injury.
Which one of the following would be best for determining whether laparotomy is needed?
A)
B)
C)
D)
E)
CT of the abdomen
MRI of the abdomen
Upright and lateral decubitus radiographs of the abdomen
Contrast duodenography
Peritoneal lavage
87. One day after a nurse performs CPR on an emergency-department patient, she learns that the
patient had meningococcal meningitis. Which one of the following is the most appropriate
chemoprophylaxis for this condition?
A)
B)
C)
D)
E)
Penicillin G benzathine (Bicillin), 1.2 million units intramuscularly

Rifampin (Rifadin), 600 mg every 12 hours for 2 days
Oral prednisone, 40 mg daily for 5 days
Quadrivalent meningococcal vaccine
No prophylaxis
24
88. An asymptomatic 24-year-old white female comes to your office for a refill of oral contraceptive
pills. A speculum examination is normal with the exception of a slightly friable, welldemarcated, 1.4-cm raised lesion involving a portion of the cervix. All previous Papanicolaou
(Pap) tests have been normal and she has no history of abnormal bleeding or leukorrhea.
A) A Pap test, including a scraping of the erosion, with routine follow-up unless the
patient becomes symptomatic
B) A Pap test with follow-up in 3 months if results are normal
C) A Pap test and a colposcopically directed biopsy
D) A cone biopsy
E) Topical antibiotic cream
89. Which one of the following variables is the most important risk factor for being a victim of
domestic abuse?
A)
B)
C)
D)
E)
Educational background
Psychological problems
Race
Gender
Socioeconomic status
90. A 68-year-old female has an average blood pressure of 150/70 mm Hg despite appropriate
lifestyle modification efforts. Her only other medical problems are osteoporosis and mild
depression.
The most appropriate treatment at this time would be
A)
B)
C)
D)
E)
lisinopril (Prinivil, Zestril)

clonidine (Catapres)
propranolol (Inderal)
amlodipine (Norvasc)
hydrochlorothiazide
91. A 36-year-old female presents with the sudden onset of severe headache, nausea, and
photophobia. Her level of consciousness is progressively diminishing.
A)
B)
C)
D)
E)
Head CT without contrast

Head CT with contrast
Head MRI
Lumbar puncture
CT angiography
25
92. You see a patient for the first time who has AIDS and chronic hepatitis B. He is losing weight,
and in spite of adequate antiretroviral therapy, is becoming weaker, to the point of being
virtually bedridden. Because of ascites, low serum albumin, and elevated liver enzymes, you
suspect chronic hepatitis as the cause of his decline.
Which one of the following would be most likely to improve this patients condition?
A)
B)
C)
D)
E)
Antiviral drugs for hepatitis B

Appetite stimulation with topical androgens
Appetite stimulation with dronabinol (Marinol)
Liver transplantation
No treatment, with palliative care being the only appropriate management
93. Osteoporotic bone loss can be caused or accelerated by prolonged use of which one of the
following medications?
A)
B)
C)
D)
E)
Hydrochlorothiazide
Phenytoin
Raloxifene (Evista)
Diazepam (Valium)
Fluoxetine (Prozac)
94. A previously healthy 3-year-old male is brought to your office with a 4-hour history of
abdominal pain followed by vomiting. Just after arriving at your office he passes bloody stool.
A physical examination reveals normal vital signs, and guarding and tenderness in the right
lower quadrant. A rectal examination shows blood on the examining finger.
A)
B)
C)
D)
E)
Appendicitis
Viral gastroenteritis
Midgut volvulus
Meckels diverticulum
Necrotizing enterocolitis
95. A 36-year-old white female presents to the emergency department with palpitations. Her pulse
rate is 180 beats/min. An EKG reveals a regular tachycardia with a narrow complex QRS and
no apparent P waves. The patient fails to respond to carotid massage or to two doses of
intravenous adenosine (Adenocard), 6 mg and 12 mg.
The most appropriate next step would be to administer intravenous
A)
B)
C)
D)
E)
amiodarone (Cordarone)
digoxin (Lanoxin)
flecainide (Tambocor)
propafenone (Rhythmol)
verapamil (Calan)
26
96. A 56-year-old female has been on combined continuous hormone therapy for 6 years. This is
associated with a reduced risk for which one of the following?
A)
B)
C)
D)
E)
Bone fracture
Myocardial infarction
Stroke
Breast cancer
Venous thromboembolism
97. The parents of a 40-day-old infant bring her to your clinic because she has had a persistent fever
for the past 2 days with rectal temperatures between 38.1C (100.5F) and 38.9C (102.0F).
She has been fussy and wants to be held, but has been nursing well. She is crying when you
enter the room, and on examination she has good skin turgor and capillary refill. The
examination does not reveal any obvious source of infection. By the time you complete the
examination the infant is resting quietly in her fathers arms.
You obtain a CBC and urinalysis. The WBC count is 12,500/mm3 (N 500019,500) with an
absolute neutrophil count of 9500/mm3 (N 10009000). The urinalysis is within normal limits.
Which one of the following would be most appropriate at this time?
A) Home care and parental observation only, as long as the temperature remains under
39.0C (102.2F)
B) Home care and reevaluation in 24 hours
C) Oral antibiotics and reevaluation in 24 hours
D) A complete sepsis workup, including blood cultures, stool studies, a chest radiograph,
and cerebrospinal fluid studies
98. An asymptomatic 55-year-old male visits a health fair, where he has a panel of blood tests done.
He brings the results to you because he is concerned about the TSH level of 12.0 :U/mL (N
0.454.5). His free T4 level is normal.
Which one of the following is most likely to be associated with this finding?
A)
B)
C)
D)
E)
Atrial fibrillation
Reduced bone density
Systolic heart failure
Elevated LDL cholesterol
Type 2 diabetes mellitus
99. Which one of the following is an indication for a second dose of pneumococcal polysaccharide
vaccine in children?
A)
B)
C)
D)
E)
Cerebrospinal fluid leak

Cyanotic congenital heart disease
Sickle cell disease
Chronic bronchopulmonary dysplasia
27
100. A 62-year-old white male complains of fatigue and proximal extremity discomfort without any
localized joint pain. Which one of the following conditions is associated with a consistently
normal creatine kinase enzyme level at all phases of disease?
A)
B)
C)
D)
E)
Polymyalgia rheumatica
Polymyositis
Dermatomyositis
Drug-induced myopathy
Hypothyroid endocrinopathy
101. The daily intake of vitamins and minerals recommended by the Food and Nutrition Board varies
according to sex, age, and condition. The recommended daily allowance of vitamin D is
greatest for which one of the following?
A)
B)
C)
D)
E)
A
A
A
A
A
15-year-old
25-year-old
35-year-old
55-year-old
75-year-old
nonpregnant female
pregnant female
lactating female
female
female
102. Treatment for Helicobacter pylori infection will reduce or improve which one of the following?
A)
B)
C)
D)
The risk of peptic ulcer bleeding from chronic NSAID therapy

The risk of developing gastric cancer in asymptomatic patients
Symptoms of nonulcer dyspepsia
Symptoms of gastroesophageal reflux disease
103. The only antidepressant approved by the Food and Drug Administration for the treatment of
depression in children 817 years of age is
A)
B)
C)
D)
E)
venlafaxine (Effexor)
amitriptyline
lithium
paroxetine (Paxil)
fluoxetine (Prozac)
104. A 79-year-old male is admitted to the hospital because of a sudden inability to ambulate. He has
a past history of gout. On examination his temperature is 38.2C (100.8F) and he has bilateral
knee effusions. His WBC count is 14,000/mm3 with 82% segs. His serum uric acid level is 8.5
mg/dL (N <6.5).
A)
B)
C)
D)
E)
24-hour urine collection for uric acid

Arthrocentesis
Initiation of allopurinol
Initiation of antibiotics
Initiation of furosemide (Lasix)
28
105. A 3-year-old male is brought to your office because of ear pain. On examination you find a
round, plastic bead in the lower third of the ear canal close to the tympanic membrane. You
restrain the child and unsuccessfully attempt to remove the object despite several attempts, first
using water irrigation and then fast-acting glue on an applicator.
Which one of the following is the best option for removal?
A)
B)
C)
D)
A plastic loop curette through an otoscope

Referral for removal under anesthesia
Grasping with forceps
Applying acetone to dissolve the object
106. A 35-year-old female is planning a second pregnancy. Her last pregnancy was complicated by
placental abruption caused by a large fibroid tumor of the uterus, which is still present.
Which one of the following would be the most appropriate treatment for the fibroid tumor?
A)
B)
C)
D)
Myomectomy
Myolysis with endometrial ablation
Uterine artery embolization
Observation
107. A 36-year-old male presents with pain over the lumbar paraspinal muscles. He says the pain
began suddenly while he was shoveling snow.
Which one of the following is true regarding this patients injury?
A) Systemic corticosteroids speed recovery
B) Exercises specific to low back injuries speed recovery
C) Opioids have significant advantages for symptom relief when compared with NSAIDs
or acetaminophen
D) Continued activity rather than bed rest helps speed recovery
E) Trigger-point injections are superior to placebo in relieving acute back pain
108. A 55-year-old white male sees you for a routine annual visit. His fasting blood glucose level
is 187 mg/dL. Repeat testing 1 week later reveals a fasting glucose level of 155 mg/dL and an
HbA1c of 9.4%. His BMI is 30 kg/m2. He does not seem to have any symptoms of diabetes
mellitus.
In addition to lifestyle changes, which one of the following would you prescribe initially?
A)
B)
C)
D)
E)
Glyburide (DiaBeta, Micronase)
Rosiglitazone (Avandia)
Bedtime long-acting insulin (Lantus)
Bedtime long-acting insulin and rapid-acting insulin (Novolog) with each meal
29
109. A 75-year-old male is brought to your office by his wife, who states that he has had mental
difficulties in recent months, such as not being able to balance their checkbook or plan for his
annual visit with the accountant. He was able to capably perform these activities in the past.
She also tells you that he has reported seeing animals in the room with him that he can describe
vividly. He naps for 3 or more hours each day, and stares blankly for long periods of time. He
seems almost normal at times, but appears very confused at other times. This confusion seems
to come and go randomly. He also has been dreaming a lot, and has fallen more than once
recently. His only medication is aspirin, 81 mg/day.
On examination the patient walks slowly with a somewhat stooped posture and almost falls when
turning around. He has only minimal facial expressiveness. No tremor is noted, and the
remainder of the examination is normal. He is able to recall three words out of three, but clock
drawing is abnormal. Laboratory studies are normal, and a CT of the brain shows changes of
aging.
What type of dementia does this patient most likely have?
A)
B)
C)
D)
E)
Dementia with Lewy bodies

Dementia of Parkinsons disease
Alzheimers disease
Frontotemporal dementia
Vascular dementia
110. A 75-year-old patient with underlying chronic renal failure requires cardiac catheterization.
Which one of the following interventions is most likely to help prevent acute renal failure due
to contrast-induced nephropathy?
A)
B)
C)
D)
E)
Hydration with normal saline and mannitol

Hydration with sodium bicarbonate
Hydration plus a loop diuretic
Administering fenoldopam (Corlopam) prior to the procedure
Infusion of natriuretic peptides prior to the procedure
111. Which one of the following best defines the sensitivity of a diagnostic test for a particular
disease?
A)
B)
C)
D)
The tests accuracy in correctly identifying patients without the disease

The tests accuracy in correctly identifying patients with the disease
The difference between the false-positive and false-negative rates
A value calculated from the tests specificity
30
112. A 12-year-old female has a cough and slight shortness of breath on a daily basis. She is
awakened by the cough at least 3 nights per week.
Which one of the following would be the most appropriate treatment for this patient?
A)
B)
C)
D)
E)
Inhaled corticosteroids daily

An oral leukotriene inhibitor as needed
Oral prednisone daily
A short-acting $-agonist daily
A long-acting $-agonist daily
113. Which one of the following is associated with testosterone supplementation in men with
hypogonadism?
A)
B)
C)
D)
Muscle wasting
Polycythemia
Osteoporosis
An increased risk of benign prostatic hypertrophy
114. A 7-year-old male is hospitalized after sustaining abdominal trauma in an accident. The child
is conscious. His pulse rate is 150 beats/min, his systolic blood pressure is palpated at 60 mm
Hg, and his respiratory rate is 40/min. His hemoglobin level is 4.0 g/dL because of
trauma-related blood loss. His clinical condition is deteriorating despite an infusion of
intravenous volume expanders, but the parents are Jehovahs Witnesses and refuse to consent
to a blood transfusion because of their religious convictions. Your prognosis is that without a
blood transfusion the patient will die.
According to medical-legal precedent, which one of the following is correct?
A) The patient should receive the transfusion regardless of the parents wishes
B) The patient can be transfused regardless of the parents wishes once he becomes
asystolic
C) The parents may refuse the transfusion if they are in agreement
D) The parents may refuse the transfusion if the patient identifies himself as a Jehovahs
Witness
E) The parents may refuse the transfusion if there is a legally executed advance directive
115. When considering a diagnosis of pancreatitis, amylase levels
A)
B)
C)
D)
can help determine the severity of the disease

are less likely to be elevated in alcoholics
are more sensitive and specific than serum lipase levels
are less likely to be affected by nonpancreatic conditions such as renal insufficiency
31
116. Which one of the following is a significant side effect of varenicline (Chantix)?
A)
B)
C)
D)
E)
Facial hirsutism
Paroxysmal dysrhythmias
Pleurisy-like symptoms
Suicidal ideation
Insomnia
117. A middle-aged hairdresser presents with a complaint of soreness of the proximal nail folds of
several fingers on either hand, which has slowly worsened over the last 6 months. The nails
appear thickened and distorted. Otherwise she is healthy and has no evidence of systemic
disease.
Which one of the following would be the most effective initial treatment?
A) Soaking in a dilute iodine solution twice daily to cleanse and sterilize the nail beds
B) Oral amoxicillin/clavulanate (Augmentin) for up to 46 weeks
C) Topical betamethasone dipropionate (Diprolene) applied twice daily to the nail folds
for 34 weeks
D) Rheumatologic and autoimmune workups for HIV, hepatitis C, psoriasis, and
rheumatoid arthritis
118. A 15-year-old male presents for a routine evaluation. He has no complaints. He has a BMI of
30 kg/m2, which places him in the 97th percentile for his age. The remainder of his examination
is normal; however, a random blood glucose level is 162 mg/dL.
Which one of the following would be the most appropriate next step for this patient?
A)
B)
C)
D)
Obtain a fasting blood glucose level

Start metformin (Glucophage), 500 mg daily, and follow up in 4 weeks
Order a hemoglobin A1c level
Advise the patient to start a weight-loss program and follow up in 4 weeks
119. Which one of the following is true regarding the use of opiates in terminally ill patients?
A)
B)
C)
D)
E)
They are frequently addictive

They are indicated for relieving dyspnea
A medication contract is required by law
Respiratory depression is the first sign of excessive dosage
Gastrointestinal hypermotility is a common side effect
32
120. A 67-year-old male who recently had a screening colonoscopy presents for follow-up. During
the procedure, a mass was discovered in the sigmoid colon and a biopsy revealed a poorly
differentiated adenocarcinoma. When you tell the patient you have the test results and can
provide information about the prognosis, he says, To be honest, I can tell that the news is not
good, and I would rather not talk about it right now.
A)
B)
C)
D)
Relay the prognosis, but focus as much as possible on any positives

Discuss the prognosis with the patients wife, who is in the waiting room
Ask the patient if he would like to talk again at another time
Refer the patient to a support group
121. A 36-year-old female has been seen multiple times in the past several months for various
pain-related complaints. On each occasion, no physical or laboratory findings were found to
explain the symptoms. The patient is involved in a workers compensation case and could make
a significant amount of money if it is demonstrated that her physical complaints are related to
work conditions.
Which one of the following diagnoses characterizes her unexplained physical symptoms?
A)
B)
C)
D)
Somatization disorder
Conversion disorder
Hypochondriasis
Malingering
122. A 43-year-old male complains of difficulty washing his face and combing his hair with his right
hand. On examination a nodule, band, and slight contracture are noted in the palm proximal to
the fourth finger.
This patients symptoms are associated with which one of the following?
A)
B)
C)
D)
E)
Hyperparathyroidism
Diabetes mellitus
Hyperthyroidism
Hypothyroidism
Adrenal insufficiency
123. Which one of the following is the most likely cause of hearing loss in newborns?
A)
B)
C)
D)
E)
Intraventricular hemorrhage
Anomalies of the external ear canal
Congenital cholesteatoma
Genetic disorders
Infectious diseases
33
124. A 5-year-old female presents with a lesion on her forearm. It began as a red macule, turned into
a small vesicle that easily ruptured, then dried into a 1-cm honey-colored, crusted lesion seen
now.
Which one of the following would be the most appropriate therapy?
A)
B)
C)
D)
E)
Oral penicillin V
Oral erythromycin
Topical disinfectant (e.g., hydrogen peroxide)
Topical bacitracin
Topical mupirocin (Bactroban)
125. Which one of the following would be the most effective monotherapy for alcohol withdrawal
syndrome?
A)
B)
C)
D)
E)
Clonidine (Catapres)
Phenytoin (Dilantin)
Atenolol (Tenormin)
Phenobarbital
Chlordiazepoxide (Librium)
126. Which one of the following tests is most specific for diagnosing rheumatoid arthritis?
A)
B)
C)
D)
E)
Anti-cyclic citrullinated peptide (anti-CCP) antibody

Antinuclear antibody
Erythrocyte sedimentation rate
Serum complement levels
Anti-Sm antibody
127. You see a 9-month-old male with a 1-day history of cough and wheezing. He has previously
been healthy and was born after an uncomplicated term pregnancy. He is up to date on his
immunizations.
On examination his temperature is 38.6C (101.5F) and his respiratory rate is 30/min. He has
diffuse wheezing and his oxygen saturation on room air is 94%. Because it is midwinter, you
obtain a swab for influenza, which is negative. A chest radiograph shows peribronchiolar edema.
Appropriate management would include which one of the following?
A)
B)
C)
D)
E)
Supportive care only

Inhaled corticosteroids
Ribavirin (Rebetol)
Palivizumab (Synagis)
Supplemental oxygen
34
128. A 79-year-old male presents with left-sided hemiparesis. His previous medical history is
significant for long-standing hypertension and type 2 diabetes mellitus. On examination his blood
pressure is 220/130 mm Hg and his pulse rate is 96 beats/min. CT of the head shows no acute
bleeding. An EKG shows left ventricular hypertrophy with diffuse nonspecific changes.
Which one of the following would be most appropriate with regard to his blood pressure at this
time?
A)
B)
C)
D)
E)
Watchful waiting
Reduction of systolic blood pressure (SBP) to 190 mm Hg
Reduction of SBP to 170 mm Hg
129. A 25-year-old Hispanic male comes to the emergency department with the sudden onset of
moderate to severe right-sided chest pain and mild dyspnea. Vital signs are normal. A chest
film shows a loss of markings along the right lung margins, involving about 10%15% of the
lung space. The mediastinum has not shifted.
The best INITIAL treatment would be
A) strict bed rest
B) oxygen supplementation and close observation
C) decompression of the chest by insertion of a large-bore intravenous catheter into the
right second intercostal space at the midclavicular line
D) immediate chest tube insertion using a water seal
E) thoracotomy for wedge resection of pulmonary blebs
130. A 35-year-old white female complains of unilateral frontotemporal headaches. During these
episodes, which occur every 23 weeks, she becomes nauseated, sometimes to the point of
vomiting. The headaches are throbbing in character and last for 13 hours, often causing her
to leave work early. Relief is sometimes obtained with simple analgesics, but more often with
sleep or the passage of time.
On the basis of this history alone, the most likely diagnosis is
A)
B)
C)
D)
E)
sinusitis
a brain tumor
muscle tension headache
cluster headache
migraine headache
35
131. You see a 5-year-old white female with in-toeing due to excessive femoral anteversion. She is
otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly
concerned with the cosmetic appearance and possible future disability, and request that she be
treated.
You recommend which one of the following?
A)
B)
C)
D)
E)
Observation
Medial shoe wedges
Torque heels
Sleeping in a Denis Browne splint for 6 months
Derotational osteotomy of the femur
132. A 54-year-old white female has been taking amoxicillin for 1 week for sinusitis. She has
developed diarrhea and has had 68 stools per day for the past 2 days. Examination shows the
patient to be well hydrated with normal vital signs and a normal physical examination. The stool
is positive for occult blood, and a stool screen for Clostridium difficile toxin is positive.
The most appropriate treatment at this time would be
A)
B)
C)
D)
vancomycin (Vancocin) intravenously

metronidazole (Flagyl) orally
trimethoprim/sulfamethoxazole (Bactrim, Septra) orally
ciprofloxacin (Cipro) orally
133. Which one of the following decreases pain from infiltration of local anesthetics?
A)
B)
C)
D)
E)
Cooling the anesthetic solution

Using a 22-gauge needle rather than a 30-gauge needle
Infiltrating quickly
Infiltrating through surrounding intact skin
Adding sodium bicarbonate to the mixture
134. An outbreak of pediatric diarrhea has swept your community. You evaluate a 30-month-old
male who developed diarrhea yesterday. He is still breastfed. He is alert, his mucous
membranes are moist, and his skin turgor is good. He passes a liquid stool in your office.
Which one of the following would be the best advice with regard to his diet?
A)
B)
C)
D)
The mother should withhold breastfeeding

He should consume a normal age-appropriate diet, and continue breastfeeding
Fasting will promote intestinal mucosal recovery
Oral intake should be limited to clear fluids, bananas, rice, applesauce, and toast
(BRAT diet)
36
135. Which one of the following fetal ultrasound measurements gives the most accurate estimate of
gestational age in the first trimester (up to 14 weeks)?
A)
B)
C)
D)
E)
Femur length
Biparietal diameter
Abdominal circumference
Crown-rump length
Scapulo-sacral length
136. A 31-year-old healthy female is admitted to the hospital from the emergency department after
presenting with aching in her right shoulder and swelling in the ipsilateral forearm and hand.
The only precipitating event that she can recall is digging strenuously in the back yard to put in
a new garden.
Ultrasonography is remarkable for a thrombus in the axillosubclavian vein. She has no prior
history of clotting, takes no medications, and has no previous history of medical or surgical
procedures involving this extremity.
The most likely etiology for this patients condition is
A)
B)
C)
D)
a hypercoagulable state
a compressive anomaly in the thoracic outlet
use of injection drugs
Budd-Chiari syndrome
137. A frail 83-year-old male with a 10-year history of diabetes mellitus is admitted to a nursing
home. His blood glucose level, which he rarely checks, is typically over 200 mg/dL. His serum
creatinine level is 1.9 mg/dL. He also has had several episodes of heart failure. His current
medications include glipizide (Glucotrol), lisinopril (Prinivil, Zestril), and furosemide (Lasix).
Which one of the following would be most appropriate to add to this patients regimen to treat
his diabetes mellitus?
A)
B)
C)
D)
E)
The American Diabetes Association 1800-calorie/day diet

Pioglitazone (Actos)
Exenatide (Byetta)
Insulin glargine (Lantus)
138. According to the U.S. Preventive Services Task Force, which one of the following patients
should be screened for an abdominal aortic aneurysm?
A)
B)
C)
D)
E)
A 52-year-old male with type 2 diabetes mellitus

An asymptomatic 67-year-old male smoker with no chronic illness
A 69-year-old female with a history of coronary artery disease
A 72-year-old male with a history of chronic renal failure
A 75-year-old female with hypertension and hypothyroidism
37
139. A 72-year-old African-American male with New York Heart Association Class III heart failure
sees you for follow-up. He has shortness of breath with minimal exertion. The patient is
adherent to his medication regimen. His current medications include lisinopril (Prinivil, Zestril),
40 mg twice daily; carvedilol (Coreg), 25 mg twice daily; and furosemide (Lasix), 80 mg daily.
His blood pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular. Findings
include a few scattered bibasilar rales on examination of the lungs, an S3 gallop on examination
of the heart, and no edema on examination of the legs. An EKG reveals a left bundle branch
block, and echocardiography reveals an ejection fraction of 25%, but no other abnormalities.
Which one of the following would be most appropriate at this time?
A)
B)
C)
D)
E)
Increase the lisinopril dosage to 80 mg twice daily

Increase the carvedilol dosage to 50 mg twice daily
Increase the furosemide dosage to 160 mg daily
Refer for coronary angiography
Refer for cardiac resynchronization therapy
140. Which one of the following is a risk factor for acute pancreatitis?
A)
B)
C)
D)
E)
Gastroesophageal reflux disease

Intravenous drug abuse
Angiotensin receptor blocker use
Pyelonephritis
Gallstones
141. The most common cause of abnormal vaginal discharge in a sexually active 19-year-old female
is
A)
B)
C)
D)
E)
Candida albicans
Trichomonas vaginalis
Staphylococcus
group B Streptococcus
mixed vaginal flora
142. A 23-year-old female sees you with a complaint of intermittent irregular heartbeats that occur
once every week or two, but do not cause her to feel lightheaded or fatigued. They last only a
few seconds and resolve spontaneously. She has never passed out, had chest pain, or had
difficulty with exertion. She is otherwise healthy, and a physical examination is normal.
Which one of the following cardiac studies should be ordered initially?
A)
B)
C)
D)
E)
24-hour ambulatory EKG monitoring (Holter monitor)

30-day continuous closed-loop event recording
Echocardiography
An EKG
Electrophysiologic studies
38
143. A 55-year-old overweight male presents with a complaint of pain in the left big toe. He recently
started jogging 2 miles a day to try to lose weight, but has not changed his diet and says he
drinks 4 cans of beer every night. The pain has developed gradually over the last 2 weeks and
is worse after running.
An examination shows a normal foot with tenderness and swelling of the medial plantar aspect
of the left first metatarsophalangeal joint. Passive dorsiflexion of the toe causes pain in that
area. Plantar flexion produces no discomfort, and no numbness can be appreciated.
A)
B)
C)
D)
Sesamoid fracture
Gout
Mortons neuroma
Cellulitis
144. A 67-year-old female presents with progressive weakness, dry skin, lethargy, slow speech, and
eyelid edema. Of the following medications currently taken by this patient, which one is most
likely to be causing her symptoms?
A)
B)
C)
D)
E)
Donepezil (Aricept)
Lithium
Lisinopril (Prinivil, Zestril)
Alendronate (Fosamax)
145. Cows milk should be withheld from a childs diet until what age?
A)
B)
C)
D)
E)
4 months
6 months
9 months
12 months
15 months
146. Which one of the following should be avoided when treating pain in the elderly?
A)
B)
C)
D)
E)
Fentanyl (Sublimaze)
Hydrocodone
Meperidine (Demerol)
Morphine
Oxycodone (OxyContin)
39
147. A 47-year-old male with chronic kidney disease is being treated with epoetin alfa (Procrit). His
hemoglobin level is 11.3 g/dL (N 13.018.0).
Which one of the following would be most appropriate with regard to his epoetin alfa regimen?
A)
B)
C)
D)
Increase the dosage until the hemoglobin level is >12.0 g/dL

Increase the frequency of injections, using the same dose
Decrease the frequency of injections, using the same dose
Continue the current regimen
148. A 36-hour-old male is noted to have jaundice extending to the abdomen. He is breastfeeding
well, 10 times a day, and is voiding and passing meconium-stained stool. He was born by
normal spontaneous vaginal delivery at 38 weeks gestation after an uncomplicated pregnancy.
The mothers blood type is A positive with a negative antibody screen. The infants total serum
bilirubin is 13.0 mg/dL.
Which one of the following would be the most appropriate management of this infants jaundice?
A) Continue breastfeeding and supplement with water or dextrose in water to prevent
dehydration
B) Continue breastfeeding, evaluate for risk factors, and initiate phototherapy if at risk
C) Discontinue breastfeeding and supplement with formula until the jaundice resolves
D) Discontinue breastfeeding and supplement with formula until total serum bilirubin
levels begin to decrease
149. A 34-year-old female with menorrhagia is found to have iron deficiency anemia. Which one of
the following is true regarding the treatment of this problem with oral iron?
A)
B)
C)
D)
E)
An acidic environment enhances the absorption of iron from the gastrointestinal tract
Iron is absorbed better if taken with food
Diarrhea is a common complication
Iron supplementation can be discontinued once the hemoglobin reaches a normal level
Sustained-release formulations increase the total amount of iron available for
absorption
150. A 20-year-old female presents with a sudden onset of fever, chills, and headache of 2 days
duration, and now has a pink blanching rash. The rash covers most of her body, including the
palms of her hands and the soles of her feet, but not including her face. She recently returned
from a camping trip, but has had no recent contact with anyone who has been ill.
Which one of the following would be the most appropriate treatment for this patients symptoms?
A)
B)
C)
D)
E)
Doxycycline (Adoxa), 100 mg twice daily for 10 days

Azithromycin (Zithromax), 500 mg daily for 3 days
Cephalexin (Keflex), 500 mg twice daily for 10 days
Penicillin, 500 mg twice daily for 10 days
Reassurance
40
151. A previously healthy 27-year-old female has had a progressive decline in social and occupational
functioning over the past year, along with a withdrawal from activities. In addition, her family
notes that over the past 4 months she has had paranoid delusions, exhibited disorganized speech,
and heard voices. She has not had any major depressive or manic episodes.
A physical examination reveals a disheveled female with a flat affect, poor eye contact, and
loosely-associated speech. A toxicology screen and basic laboratory analysis are unremarkable.
She is not on any medications.
A)
B)
C)
D)
E)
Brief psychotic disorder

Delirium
Schizophrenia
Mood disorder with psychotic features
Delusional disorder
152. A 55-year-old white male sees you for follow-up after a recent lipid panel revealed no
improvement in his hyperlipidemia. His total cholesterol level is 275 mg/dL, with an
LDL-cholesterol level of 180 mg/dL, an HDL-cholesterol level of 35 mg/dL, and a triglyceride
level of 275 mg/dL. These numbers are similar to two previous lipid panels obtained over the
last several months, despite attempts at lifestyle changes. He has adequately treated essential
hypertension, with a blood pressure of 125/83 mm Hg. There is no history of diabetes mellitus
or tobacco use, and no family history of premature coronary heart disease.
A physical examination is unremarkable except for a BMI of 33 kg/m2 and a waist circumference
of 107 cm (42 in). His fasting blood glucose level is 107 mg/dL.
After discussion with the patient, you decide to start prescription drug therapy. The initial target
of this therapy should be to reach his goal level of
A)
B)
C)
D)
E)
LDL cholesterol
HDL cholesterol
non-HDL cholesterol
triglycerides
fasting blood glucose
153. Which one of the following is recommended for the treatment of cough and cold symptoms in
children younger than 2 years of age?
A)
B)
C)
D)
E)
Cough suppressants and humidified air

Intranasal decongestants
Nonsedating antihistamines and decongestants
Nasal saline with bulb suction
Antibiotics and hydration
41
154. The Current Procedural Terminology (CPT) code to document a patient encounter can be
determined by the amount of face-to-face time spent with the patient when
A) the office visit exceeds 1 hour
B) counseling or coordinating care accounts for more than 50% of the face-to-face time
spent with the patient
C) the intensity of the visit supports a higher code than is supported by the level of
history, examination, and medical decision making
D) a comprehensive history and examination or complex medical decision making is
conducted
E) considerable time is spent outside the office visit coordinating prior authorizations or
referrals on behalf of the patient
155. A 60-year-old male presents to the urgent care center with a fever and a productive cough. He
has a 40 pack/year history of cigarette smoking. In addition to lobar pneumonia on a chest
radiograph, there is an incidental finding of bilateral pleural plaques.
Which one of the following is the most likely cause of this finding?
A)
B)
C)
D)
E)
Coal dust
Silicon dust
Asbestos
Vinyl chloride
Radon
156. A 42-year-old female presents with a 2-day history of chest pain. She describes the pain as
sharp, located in the right upper chest, and worsened by deep breathing or coughing. She also
complains of shortness of breath. She was previously healthy and has no recent history of
travel. Her vital signs are normal.
A pleural friction rub is noted on auscultation of the lungs. The remainder of the examination
is normal. An EKG, cardiac enzymes, oxygen saturation, and a D-dimer level are all normal.
A)
B)
C)
D)
E)
No further testing
A chest radiograph
An antinuclear antibody test
Echocardiography
Pulmonary angiography
42
157. A male infant is delivered at 41 weeks gestation by spontaneous vaginal delivery. The amniotic
fluid is meconium stained. Apgar scores are 7 at 1 minute and 7 at 5 minutes. The baby is
noted to have respiratory distress from birth and is hypoxic by pulse oximetry. Respiration
improves with supplemental oxygen, as does the hypoxia, but does not return to normal.
Which one of the following would most likely be seen on a chest radiograph?
A)
B)
C)
D)
A normal heart and lungs

Fluid in the pulmonary fissures
Homogeneous opaque infiltrates with air bronchograms
Patchy atelectasis
158. The risk of heat waverelated death to elderly patients is highest in those who
A)
B)
C)
D)
have COPD
have diabetes and are insulin-dependent
have a functioning fan, but not air conditioning
are homebound
159. A 16-year-old white male is seen for a preparticipation sports examination. His height is 183
cm (72 in), his weight is 64 kg (141 lb), and he appears to have long arms. A physical
examination reveals a high arched palate, kyphosis, myopia, and pectus excavatum.
Which one of the following valvular abnormalities is most likely in this patient?
A)
B)
C)
D)
E)
Mitral stenosis
Pulmonic stenosis
Aortic stenosis
Aortic insufficiency
Bicuspid aortic valve
160. A 26-year-old gravida 2 para 1 presents at 30 weeks gestation with a complaint of severe itching.
She has excoriations from scratching in various areas. She says that she had the same problem
during her last pregnancy, and her medical records reveal a diagnosis of intrahepatic cholestasis
of pregnancy.
Elevation of which one of the following is most characteristic of this disorder?
A)
B)
C)
D)
E)
(-Glutamyltransferase (GGT)
Bile acids
Direct bilirubin
Indirect bilirubin
Prothrombin time
43
161. A 3-year-old male was treated for acute otitis media last month. His mother brings him in for
follow-up because she believes his hearing has not been normal since then. He attends day care
and has had several upper respiratory infections.
On examination the tympanic membranes are not inflamed, but the membrane is retracted on the
right side. Tympanography produces a normal peak (type A) on the left side, but a flat tracing
(type B) on the right side.
Which one of the following would be the most appropriate recommendation?
A)
B)
C)
D)
E)
Audiometry
Observation with follow-up
An antihistamine/decongestant combination
Intranasal corticosteroids
Systemic corticosteroids
162. A 42-year-old previously healthy white female presents to your office with her third episode of
abdominal pain. This episode began 2 hours ago, and the pain is improving. She describes
colicky right upper quadrant and epigastric pain. On examination you note mild right upper
quadrant tenderness, with otherwise unremarkable findings. Renal function tests are normal.
A)
B)
C)
D)
E)
KUB films
Ultrasonography of the right upper quadrant
Abdominal CT with intravenous contrast
Abdominal CT with intravenous and oral contrast
MRI of the abdomen
163. A 66-year-old female presents for a preoperative evaluation prior to elective podiatric surgery.
She has no complaints other than her foot problem, and says she feels well. On examination she
has an irregularly irregular heart rate with a 2/6 holosystolic murmur. An EKG reveals atrial
fibrillation with a rate of 110 beats/min. Echocardiography shows mild to moderate mitral
regurgitation and a dilated left atrium, but is otherwise normal.
Which one of the following is the most appropriate initial treatment for this patient?
A)
B)
C)
D)
E)
Digoxin, 0.125 mg/day

Quinidine gluconate, 324 mg 3 times daily
Atenolol (Tenormin), 25 mg/day
Sustained-release nifedipine (Adalat, Procardia), 180 mg/day
Unfractionated heparin sodium, 5000 units subcutaneously 3 times daily
44
164. A 45-year-old white male consults you because of a painless, circular, 1-cm white spot inside
his mouth, which he noticed 3 days ago. You are treating him with propranolol (Inderal) for
hypertension, and you know him to be a heavy alcohol user. After a careful physical
examination, your tentative diagnosis is leukoplakia of the buccal mucosa. You elect to observe
the lesion for 2 weeks. On the patients return, the lesion is still present and unchanged in
appearance.
The best course of management at this time is to
A)
B)
C)
D)
E)
reassure the patient and continue to observe

discontinue propranolol
treat with oral nystatin
order a fluorescent antinuclear antibody test
perform a biopsy of the lesion
165. A 54-year-old white male presents with drooping of his right eyelid for 3 weeks. On
examination, he has ptosis of the right upper lid, miosis of the right pupil, and decreased
sweating on the right side of his face. Extraocular muscle movements are intact.
In addition to a complete history and physical examination, which one of the following would
be most appropriate at this point?
A)
B)
C)
D)
E)
A chest radiograph
MRI of the brain and orbits
131
I thyroid scanning
A fasting blood glucose level
An acetylcholine receptor antibody level
166. Which one of the following most increases insulin sensitivity in an overweight patient with
diabetes mellitus?
A)
B)
C)
D)
Acarbose (Precose)
NPH insulin
167. A 32-year-old farmer comes to your office because of an upper respiratory infection. While he
is there he points out a lesion on his forearm that he first noted approximately 1 year ago. It is
a 1-cm asymmetric nodule with an irregular border and variations in color from black to blue.
The patient says that it itches and has been enlarging for the past 2 months. He says he is so
busy that he is not sure when he can return to have it taken care of.
In such cases the best approach would be to
A)
B)
C)
D)
E)
perform a punch biopsy and have the patient return if the biopsy indicates pathology
perform a shave biopsy and recheck in 2 months for signs of recurrence
use electrocautery to destroy the lesion and the surrounding tissue
perform an elliptical excision as soon as possible
freeze the site with liquid nitrogen
45
168. A 3-week-old male is brought to your office because of a sudden onset of bilious vomiting of
several hours duration. He is irritable and refuses to breastfeed, but stools have been normal.
He was delivered at term after a normal pregnancy, and has had no health problems to date. A
physical examination shows a fussy child with a distended abdomen. Radiography of the
abdomen shows a double bubble sign.
A)
B)
C)
D)
E)
Infantile colic
Necrotizing enterocolitis
Hypertrophic pyloric stenosis
Intussusception
Midgut volvulus
169. In a preadolescent athlete, sudden death from a blunt injury to the chest (commotio cordis) is
most likely to occur in which one of the following situations?
A)
B)
C)
D)
E)
A pitcher is struck by a line drive

A basketball player is struck by the ball
A chest-to-chest collision occurs during a soccer game
Hockey players skate into each other
A football player is struck by the shoulder pad of a lineman
170. The blood pressure goal for a patient who has uncomplicated diabetes mellitus is
A)
B)
C)
D)
E)
140/80
130/80
120/80
110/80
110/70
mm
mm
mm
mm
mm
Hg
Hg
Hg
Hg
Hg
171. A 70-year-old female consults you about osteoporosis treatment. Two years ago her T score was
2.6, and she began taking risedronate (Actonel), 35 mg/week. Her BMI is 24 kg/m2, she takes
appropriate doses of calcium and vitamin D, and she takes walks almost every day. Her current
T score is 2.5, and she is concerned about the minimal change in spite of therapy. She has
never had a fracture, but asks if more could be done to reduce her fracture risk.
A)
B)
C)
D)
E)
Continue current treatment

Stop risedronate and start alendronate (Fosamax)
Stop risedronate and start teriparatide (Forteo)
Add raloxifene (Evista)
Order a bone biopsy to evaluate bone architecture
46
172. The American College of Obstetricians and Gynecologists and the American Academy of
Pediatrics support the advance provision of drugs and instructions for emergency contraception
to sexually active women, so that they have ready access to them if they are needed. The
evidence shows that advance provision of emergency contraception
A)
B)
C)
D)
E)
decreases pregnancy rates on a population level

decreases the time from unprotected sex to use of emergency contraception
decreases contraception use by the patient prior to sexual activity
increases rates of sexually transmitted infection
increases rates of unprotected intercourse
173. Which one of the following causes of anemia is associated with a normal red cell distribution
width?
A)
B)
C)
D)
E)
Vitamin B12 deficiency

Iron deficiency
$-Thalassemia trait
Sideroblastic anemia
Myelofibrosis
174. The intranasal live, attenuated influenza vaccine would be appropriate for which one of the
following?
A)
B)
C)
D)
E)
A
A
A
A
A
5-year-old female who is otherwise healthy

12-year-old male who has a history of severe persistent asthma
21-year-old female who has a history of Guillain-Barr syndrome
24-year-old female who is 24 weeks pregnant
55-year-old healthy male who requests influenza vaccine
175. Osmotic demyelination can result when which one of the following is corrected too rapidly?
A)
B)
C)
D)
E)
Hypocalcemia
Hypoglycemia
Hypomagnesemia
Hypokalemia
Hyponatremia
176. Information derived from which one of the following provides the best evidence when selecting
a specific treatment plan for a patient?
A)
B)
C)
D)
Meta-analysis
Prospective cohort studies
Expert opinion
Consensus guidelines
47
177. A 60-year-old female is admitted to the hospital with pneumonia 1 week after her discharge
following elective colorectal surgery. Her initial stay was 5 days and she had no complications.
She had no signs of infection until 2 days ago when she developed a temperature of 39.1C
(102.4F), a cough with yellow sputum, and hypoxia. She has no abdominal pain or diarrhea.
Her pulse rate is slightly elevated to 96 beats/min, and her blood pressure is unchanged from
baseline. A chest radiograph confirms a left lingular infiltrate. Methicillin-resistant
Staphylococcus pneumonia is rare in this institution.
Of the following antibiotic regimens, which one would be the best initial treatment for this
patient?
A)
B)
C)
D)
E)
Ampicillin/sulbactam (Unasyn)
Ceftazidime sodium (Fortaz) and gentamicin
Ceftriaxone (Rocephin) and azithromycin (Zithromax)
Clarithromycin (Biaxin)
Levofloxacin (Levaquin)
178. A 70-year-old female with type 2 diabetes mellitus is admitted to the hospital with a 4-week
history of fever, anorexia, and weight loss. Two blood cultures are positive for Streptococcus
bovis.
In addition to being treated for the infection, she should be evaluated for which one of the
following?
A)
B)
C)
D)
E)
B-cell lymphoma
T-cell lymphoma
Multiple myeloma
Lung cancer
Colorectal cancer
179. A 45-year-old male sees you for follow-up after a pre-employment physical examination reveals
blood in his urine. He brings a copy of a urinalysis report that shows 35 RBCs/hpf. He has
not seen any gross blood himself. He is asymptomatic, is on no medications, and does not
smoke. You perform a physical examination, with normal findings. A repeat urinalysis
confirms the presence of red blood cells but is otherwise normal.
A)
B)
C)
D)
E)
Observation and reassurance

A repeat urinalysis in 6 months
Urine cytology only
Ultrasonography of the kidneys and urine cytology only
Ultrasonography of the kidneys, urine cytology, and cystoscopy
48
180. A generally healthy 35-year-old female has mild generalized anxiety, but is not depressed. She
does not want to take a prescription medication, and asks if an herbal or dietary supplement
might be helpful.
Which one of the following botanical medications has the best clinical evidence of potential
benefit for anxiety disorders when used for a short time (up to 24 weeks)?
A)
B)
C)
D)
E)
St. Johns wort

Valerian
Passionflower
Kava
Chamomile
181. A 67-year-old male sees you for knee pain from osteoarthritis. It has not responded to his usual
treatment, and you treat him with an intra-articular corticosteroid injection. It is mid-November,
and he tells you that he has not received the influenza vaccine this year. He has also never
received pneumococcal vaccine. He has a history of allergic rhinitis, treated with intranasal
corticosteroids.
Which one of the following is true regarding pneumococcal vaccine and influenza vaccine for
this patient?
A) The immunizations should be administered at least 4 weeks apart
B) Administration of both immunizations should be delayed 4 weeks because of
immunosuppression
C) Administration of influenza vaccine should be delayed for 4 weeks because it is a live
attenuated vaccine
D) Administration of pneumococcal vaccine should be delayed for 4 weeks because it is
contraindicated with simultaneous intra-articular corticosteroids
E) It is acceptable to administer both immunizations at this visit
182. A 70-year-old male sees you because of slowly increasing problems with COPD. He has had
frequent exacerbations requiring emergency department visits. He currently uses a tiotropium
(Spiriva) inhaler once a day, as well as an albuterol (Proventil) inhaler, 2 puffs 4 times a day as
needed. An examination shows decreased breath sounds throughout, and an oxygen saturation
of 92%. Spirometry shows he has severe COPD (stage III); his FEV1/FVC ratio is 65% of
predicted and his FEV1 is 45% of predicted.
The most reasonable change in treatment would be to add
A)
B)
C)
D)
oxygen, 2 L/min while sleeping

inhaled fluticasone (Flovent), 2 puffs twice daily
oral low-dose prednisone daily
oral theophylline (Uniphyl) twice daily
49
183. Which one of the following is true regarding medication dosage adjustments for patients with
chronic kidney disease?
A) Loading doses should usually be adjusted
B) Adjustments typically are not necessary until the glomerular filtration rate is <20
mL/min/1.73m2
C) A normal serum creatinine value indicates that no adjustment is necessary
D) Serum drug levels are usually required for making adjustments
E) A reduction of dose, an increase in dosing interval, or both may be necessary
184. A 6-month-old Hispanic female has had itching and irritability for 45 weeks. There is a family
history of atopy and asthma. Physical examination reveals an excoriated dry rash bilaterally
over the antecubital and popliteal fossae, as well as some involvement of the face.
In addition to maintenance therapy with an emollient, which one of the following topical
medications would be appropriate first-line treatment for flare-ups in this patient?
A)
B)
C)
D)
E)
A calcineurin inhibitor such as pimecrolimus (Elidel)

An anesthetic
An antihistamine
An antibiotic
A corticosteroid
185. A 60-year-old male who has a 5-year history of diabetes mellitus is found to have an elevated
creatinine level that has increased from 1.5 mg/dL to 2.0 mg/dL over the past year. His current
medications include lisinopril (Prinivil, Zestril) to control blood pressure and proteinuria. He
is aware that tight control of his blood glucose will help prevent the progression of renal disease,
but wants to know what else he can do to preserve renal function.
Which one of the following would be the most appropriate recommendation for this patient?
A)
B)
C)
D)
E)
Add an angiotensin receptor blocker (ARB)

Maintain blood pressure at 140/90 mm Hg or less
Follow a high-protein, low-fat diet
Use erythropoietin therapy to keep the hemoglobin level above 14 g/dL
Add a calcium channel blocker
186. A 65-year-old female develops gram-negative septicemia from a urinary tract infection. Despite
the use of fluid resuscitation she remains hypotensive, with a mean arterial pressure of 50 mm
Hg.
Which one of the following would be the most appropriate treatment for this patient?
A)
B)
C)
D)
E)
Vasopressin (Pitressin)
Phenylephrine (Neo-Synephrine)
Epinephrine
Norepinephrine (Levophed)
Low-dose dopamine
50
187. A 3-year-old female is brought to your office for a health maintenance examination, and her
father expresses concern about her vision. Her visual acuity is 20/20 bilaterally on a tumbling
E visual acuity chart. With both eyes uncovered during a cover/uncover test, the corneal light
reflex in the right eye is medial to the pupil when focused on a fixed point, but the light reflex
in the left eye is almost centered in the pupil. When the left eye is covered, the right eye moves
quickly inward to focus on the fixed point, and the corneal light reflex is centered in the pupil.
When the left eye is uncovered, the right eye returns to its original position. When you cover
the right eye, no left eye movement is noted.
A)
B)
C)
D)
E)
Strabismus
Amblyopia
Cataract
Esotropia
Heterophoria
188. A 32-year-old white male undergoes an emergency splenectomy after a motor vehicle accident.
Which one of the following should he receive after the surgery?
A)
B)
C)
D)
Pneumococcal vaccine and meningococcal vaccine

Pneumococcal vaccine alone
Meningococcal vaccine alone
No immunizations
189. You see a 17-year-old female for a routine visit. She tells you she has been sexually active for
3 years and that her partners have used condoms, but not consistently. She has never had a
Papanicolaou (Pap) test. You provide counseling regarding contraception and sexually
transmitted diseases, and perform a gynecologic examination, including a Pap test. The results
of the test are reported as atypical squamous cells of undetermined significance (ASC-US).
According to the American Society for Colposcopy and Cervical Pathology, which one of the
following would be most appropriate with regard to the abnormal smear?
A)
B)
C)
D)
E)
A repeat Pap test in 36 months

A repeat Pap test in 12 months
HPV DNA testing
Colposcopy
Loop electrical excisional procedure (LEEP)
51
190. A 32-year-old African-American female presents with a 3-day history of fever, cough, and
shortness of breath. She has been healthy otherwise, except for a sinus infection 2 months ago
treated with amoxicillin. She does not appear toxic. A chest radiograph reveals an infiltrate in
the right lower lobe, consistent with pneumonia.
Which one of the following would be the best choice for antibiotic treatment?
A)
B)
C)
D)
E)
High-dose amoxicillin
Azithromycin (Zithromax)
Doxycycline
Levofloxacin (Levaquin)
Cefuroxime axetil (Ceftin)
191. Which one of the following drugs used to treat rheumatoid arthritis can delay the progression
of the disease?
A)
B)
C)
D)
E)
Aspirin
Ibuprofen
Indomethacin (Indocin)
Capsaicin (Zostrix)
Hydroxychloroquine (Plaquenil)
192. Current thinking regarding infantile colic is that the cause is

A)
B)
C)
D)
E)
malabsorption
overfeeding
excessive air swallowing
unknown
parental anxiety
193. A 40-year-old female comes to your office for a routine examination. She has been in good
health and has no complaints other than obesity. Her mother is diabetic and the patient has had
a child that weighed 9 lb at birth. Her examination is negative except for her obesity. A fasting
glucose level is 128 mg/dL, and when repeated 2 days later it is 135 mg/dL.
A)
B)
C)
D)
Diagnose type 2 diabetes mellitus and begin diet and exercise therapy
Begin an oral hypoglycemic agent
Order a glucose tolerance test
Tell the patient that she has impaired glucose homeostasis but is not diabetic
52
194. A 60-year-old male with a right-sided pleural effusion undergoes thoracentesis. Analysis of the
pleural fluid reveals a protein level of 2.0 g/dL and an LDH level of 70 U/L. His serum protein
level is 7.0 g/dL (N 6.08.3) and his serum LDH level is 200 U/L (N 100105).
Based on these findings, which one of the following is the most likely diagnosis?
A)
B)
C)
D)
E)
Heart failure
Pulmonary embolism
Tuberculous pleurisy
Malignancy
Bacterial pneumonia
195. A 57-year-old male with severe renal disease presents with acute coronary syndrome. Which
one of the following would most likely require a significant dosage adjustment from the standard
protocol?
A)
B)
C)
D)
E)
Enoxaparin (Lovenox)
Metoprolol (Lopressor)
Carvedilol (Coreg)
Clopidogrel (Plavix)
Tenecteplase (TNKase)
196. Which one of the following sleep problems in children is most likely to occur during the second
half of the night?
A)
B)
C)
D)
Confusional arousals
Sleepwalking
Sleep terrors
Nightmares
197. Which one of the following is a risk factor for osteoarthritis of the hip?
A)
B)
C)
D)
E)
Low bone mass

Young age
Participation in swimming
Hyperthyroidism
Obesity
198. Patients with obstructive sleep apnea have an increased risk for
A)
B)
C)
D)
E)
chronic renal failure

hypertension
hypokalemia
hypothyroidism
sepsis
53
199. A 45-year-old male was admitted to the hospital for nausea resulting from chemotherapy for
colon cancer. He has no other chronic diseases and takes no routine medications. He was
mildly dehydrated on admission and has been receiving intravenous fluids (D5 -normal saline
with potassium chloride) at slightly higher than maintenance rates through an indwelling port for
the last 24 hours. The nausea is being controlled by antiemetics, and his condition is improving.
Results of routine blood work at the time of admission and from the following morning are
shown below.
Glucose
BUN
Creatinine
Sodium
Potassium
Chloride
Total CO2
Admission
Following Morning
109 mg/dL (N 65110)
371 mg/dL
13 mg/dL (N 721)
9 mg/dL
0.9 mg/dL (N 0.61.6)
0.9 mg/dL
143 mmol/L (N 136144)
129 mmol/L
3.7 mmol/L (N 3.65.1)
6.6 mmol/L
110 mmol/L (N 101111)
108 mmol/L
20 mmol/L (N 2232)
22 mmol/L
A)
B)
C)
D)
E)
Start an intravenous insulin drip

Order blood work taken from a peripheral vein
Restrict the patients free water intake
Switch from normal saline to hypertonic saline
Treat with diuretics
200. A 79-year-old male has psychosis secondary to dementia associated with Parkinsons disease.
After exhausting all other options you decide to prescribe an antipsychotic agent.
Which one of the following would be the best choice in this situation?
A)
B)
C)
D)
E)
Haloperidol
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Thioridazine
201. A 53-year-old male presents for follow-up after a routine screening colonoscopy. He is healthy
and takes no medications, and his family history is negative for colon cancer. During a
thorough, relatively easy colonoscopy to the cecum, two rectal polyps measuring 0.7 mm were
removed, both of which were found to be hyperplastic on pathologic analysis.
His next surveillance colonoscopy should be in
A)
B)
C)
D)
E)
1 year
3 years
5 years
7 years
10 years
54
202. A 35-year-old male with a previous history of kidney stones presents with symptoms consistent
with a recurrence of this problem. The initial workup reveals elevated serum calcium.
Which one of the following tests would be most appropriate at this point?
A)
B)
C)
D)
E)
Serum calcitonin
24-hour urine for calcium and phosphate
Serum phosphate and magnesium
Serum parathyroid hormone
Spot urine for microalbumin
203. A 60-year-old male presents with an acute onset of pain and swelling in the right big toe. He
can recall no mechanism of injury. He has hypertension which is well controlled with
hydrochlorothiazide. On examination the area around the toe is slightly warm.
Which one of the following should be AVOIDED in this patient at this time?
A)
B)
C)
D)
E)
Allopurinol (Zyloprim)
Colchicine
NSAIDs
Prednisone
Aspiration of the joint
204. Which one of the following is true regarding the schedule for administering rotavirus vaccine?
A)
B)
C)
D)
The first dose should be given prior to 12 weeks of age

The vaccine should be given at 2 months, 6 months, and 12 months of age
A catch-up vaccination can be administered up to 3 years of age
The minimum time between doses is 2 weeks
205. A 35-year-old female sees you because she has lost her voice. She has had no recent upper
respiratory infection symptoms, cough, or heartburn, and she has not done anything that would
strain her voice. Examination of the head and neck appear normal. A review of her chart shows
this has happened before, but an ear, nose, and throat evaluation found no abnormalities. She
also has been seen numerous times in the past few years for headaches, chest pains, abdominal
pains, rectal pressure, and vaginal symptoms. Despite several workups and referrals, no definite
cause has been found and the symptoms persist.
Which one of the following would be the most reasonable plan of action?
A)
B)
C)
D)
Test for food allergies

Begin low-dose lorazepam (Ativan)
Begin a 6-week trial of a proton pump inhibitor
Schedule frequent office visits
55
206. Of the following, which one causes the most deaths in the United States?
A)
B)
C)
D)
Colorectal cancer
Breast cancer
Prostate cancer
Lung cancer
207. A 24-year-old female with a past history of asthma presents to the emergency department with
an asthma exacerbation. Treatment with an inhaled bronchodilator and ipratropium (Atrovent)
does not lead to significant improvement, and she is admitted to the hospital for ongoing
management. On examination she is afebrile, her respiratory rate is 24/min, her pulse rate is
92 beats/min, and oxygen saturation is 92% on room air. She has diffuse bilateral inspiratory
and expiratory wheezes with mild intercostal retractions.
Which one of the following should be considered in the acute management of this patient?
A)
B)
C)
D)
E)
Chest physical therapy

Inhaled fluticasone/salmeterol (Advair)
Oral azithromycin (Zithromax)
Oral prednisone
Oral theophylline
208. A 69-year-old male has a 4-day history of swelling in his left leg. He has no history of trauma,
recent surgery, prolonged immobilization, weight loss, or malaise. His examination is
unremarkable except for a diffusely swollen left leg. A CBC, chemistry profile, prostatespecific antigen level, chest radiograph, and EKG are all normal; however, compression
ultrasonography of the extremity reveals a clot in the proximal femoral vein. He has no past
history of venous thromboembolic disease.
In addition to initiating therapy with low molecular weight heparin, the American College of
Chest Physicians recommends that warfarin (Coumadin) be instituted now and continued for at
least
A)
B)
C)
D)
1 month
3 months
6 months
12 months
209. Which one of the following community health programs best fits the definition of secondary
prevention?
A)
B)
C)
D)
A smoking education program at a local middle school

A blood pressure screening at a local church
A condom distribution program
Screening diabetic patients for microalbuminuria
56
210. A 33-year-old white female presents with tremor and a history of weight loss. On examination
she is found to have mild, regular tachycardia and exophthalmos. Laboratory tests confirm
hyperthyroidism.
Which one of the following treatments has been found to potentially worsen ophthalmopathy?
A)
B)
C)
D)
E)
Radioactive iodine
Propylthiouracil
Methimazole (Tapazole)
Thyroid hormone replacement plus propylthiouracil
Thyroidectomy
211. A 24-year-old gravida 1 para 1 who is 2 weeks post partum complains of double vision,
shortness of breath, and almost dropping her baby while trying to hold her. She says her
symptoms worsen as the day progresses. She has no family history of neurologic or muscular
illness. A physical examination is normal except for unilateral ptosis and 4/5 proximal weakness
of both arms. Breath sounds are generally decreased.
Routine blood tests, including TSH and creatine kinase levels, are normal. A chest radiograph
and an MRI of the brain and cervical spine are also normal.
Of the following, this presentation is most consistent with
A)
B)
C)
D)
E)
fibromyalgia syndrome
Sheehans syndrome (postpartum hypopituitarism)
polymyositis
myasthenia gravis
stroke
212. A 65-year-old white male comes to your office with a 0.5-cm nodule that has developed on his
right forearm over the past 4 weeks. The lesion is dome shaped and has a central plug. You
schedule a biopsy but he does not return to your office for 1 year. At that time the lesion
appears to have healed spontaneously.
A)
B)
C)
D)
E)
benign lentigo
lentigo maligna
basal cell carcinoma
squamous cell carcinoma
keratoacanthoma
57
213. A 56-year-old white male presents with a 2-week history of intermittent pain in his left leg. The
pain usually occurs while he is walking and is primarily in the calf muscle or Achilles region.
Sometimes he will awaken at night with cramps in the affected leg. He has no known risk
factors for atherosclerosis.
Which one of the following would be the best initial test for peripheral vascular occlusive
disease?
A)
B)
C)
D)
E)
Ankle-brachial index
Arterial Doppler ultrasonography
Arteriography
Magnetic resonance angiography (MRA)
Venous ultrasonography
214. Which one of the following is the most common cause of hypertension in children under 6 years
of age?
A)
B)
C)
D)
E)
Essential hypertension
Pheochromocytoma
Renal parenchymal disease
Hyperthyroidism
Excessive caffeine use
215. You see a patient with a serum sodium level of 122 mEq/L (N 135145) and a serum osmolality
of 255 mOsm/kg H2O (N 280295). Which one of the following would best correlate with a
diagnosis of syndrome of inappropriate antidiuresis?
A)
B)
C)
D)
E)
Fractional excretion of sodium <1%

Elevated urine osmolality
Elevated serum glucose
Elevated BUN
Low plasma arginine vasopressin
216. An overweight 13-year-old male presents with a 3-week history of right lower thigh pain. He
first noticed the pain when jumping while playing basketball, but now it is present even when
he is just walking. On examination he can bear his full weight without an obvious limp. There
is no localized tenderness, and the patella tracks normally without subluxation. Internal rotation
of the hip is limited on the right side compared to the left.
Based on the examination alone, which one of the following is the most likely diagnosis?
A)
B)
C)
D)
E)
Avascular necrosis of the femoral head (Legg-Calv-Perthes disease)

Osteosarcoma
Meralgia paresthetica
Pauciarticular juvenile rheumatoid arthritis
Slipped capital femoral epiphysis
58
217. A 60-year-old male has moderate anemia, with a suggestion of hemolysis on a peripheral blood
smear. Which one of the following patterns would be consistent with the presence of hemolysis?
A)
B)
C)
D)
E)
Elevated LDH, decreased haptoglobin, elevated indirect bilirubin

Elevated LDH, elevated haptoglobin, decreased indirect bilirubin
Decreased LDH, elevated haptoglobin, elevated indirect bilirubin
Decreased LDH, decreased haptoglobin, elevated indirect bilirubin
Decreased LDH, decreased haptoglobin, decreased indirect bilirubin
218. Good evidence supports which one of the following measures for reducing the risk of
postoperative pulmonary complications after major abdominal surgery?
A)
B)
C)
D)
Avoidance of preoperative systemic corticosteroids

Use of an incentive spirometer
Antibiotic prophylaxis for 48 hours
Postoperative total parenteral nutrition
219. A 9-month-old male is brought to your office by his mother because of concerns about his
eating. She states that he throws tantrums while sitting in his high chair, dumps food on the
floor, and refuses to eat. She has resorted to feeding him cookies, crackers, and juice, which
are all he will eat. A complete physical examination, including a growth chart of weight,
length, and head circumference, is normal.
A) Use disciplinary measures to force the child to eat a healthy breakfast, lunch, and
dinner
B) Leave the child in the high chair until he has eaten all of the healthy meal presented
C) Play feeding games to encourage consumption of healthy meals or snacks
D) Skip the next meal if the child refuses to eat
E) Provide healthy foods for all meals and snacks, and end the meal if the child refuses
to eat
220. An 83-year-old female presents with pain, swelling, and erythema of her left knee, as well as
some swelling and pain in her right wrist. She first noticed this problem last night before going
to bed. She is generally healthy and takes no medications. She has not been sexually active
since being widowed 15 years ago, and she currently lives with her sister. She states that she
developed pain and swelling in her left ankle 2 years ago that lasted only a couple of days and
resolved spontaneously. Blood testing shows a very elevated erythrocyte sedimentation rate but
a normal rheumatoid factor and uric acid level.
A)
B)
C)
D)
E)
Gonococcal arthritis
Gout
Pseudogout (calcium pyrophosphate disease)
Rheumatoid arthritis
Rupture of the anterior cruciate ligament
59
221. Which one of the following is true about end-of-life care?

A) Physicians underestimate life expectancies
B) Most physicians are comfortable with their level of education in palliative care and
pain control
C) Most patients who qualify for hospice care receive services early in the course of their
illness
D) Most terminal patients want their lives prolonged as much as possible
E) Most terminal patients express a desire for a sense of control
222. A 4-year-old white male is brought to your office in late August. His mother tells you that over
the past few days he has developed a rash on his hands and sores in his mouth. On
examination you note a vesicular exanthem on his hands, with lesions ranging from 3 to 6 mm
in diameter. The oral lesions are shallow, whitish, 4- to 8-mm ulcerations distributed randomly
over the hard palate, buccal mucosa, gingiva, tongue, lips, and pharynx. Except for a
temperature of 37.4C (99.3F), the remainder of the examination is normal.
A)
B)
C)
D)
E)
herpangina
hand, foot, and mouth disease
aphthous stomatitis
herpetic gingivostomatitis
streptococcal pharyngitis
223. Of the following dietary factors recommended for the prevention and treatment of cardiovascular
disease, which one has been shown to decrease the rate of sudden death?
A)
B)
C)
D)
E)
Increased
Increased
Increased
Increased
Moderate
intake of plant protein

intake of omega-3 fats
intake of dietary fiber and whole grains
intake of monounsaturated oils
alcohol consumption (1 or 2 standard drinks per day)
224. Late decelerations on fetal monitoring are thought to indicate which one of the following?
A)
B)
C)
D)
E)
Fetal head compression

Umbilical cord compression
Fetal sleep
Uterine hypotonus
Uteroplacental insufficiency
60
225. A 72-year-old male presents with unintentional weight loss of 25 lb over the last 6 months. His
history, including a nutritional assessment, is unremarkable, as is his physical examination. His
current medications include mirtazapine (Remeron) for depression and hydrochlorothiazide for
hypertension.
A)
B)
C)
D)
E)
Order a CBC, chemistry panel, stool for occult blood, and TSH
Refer for immediate colonoscopy and esophagogastroduodenoscopy
Schedule CT of the chest, abdomen, and pelvis
Start megestrol (Megace) to promote weight gain
Discontinue mirtazapine
226. An 18-year-old male seen in your office is found to be overweight and to have acanthosis
nigricans. Both of his parents have a history of diabetes mellitus. His fasting plasma glucose
level is 111 mg/dL (N <100).
Which one of the following is the correct diagnosis?
A)
B)
C)
D)
Prediabetes
Maturity-onset diabetes of the young
227. The manager of a local chicken processing plant asks about arranging screening tests for his 100
employees. Several are smokers, and one individual was recently found to have lung cancer.
He asks what the best and most cost-effective way to screen for this would be.
Based on randomized, controlled trials and recommendations by the U.S. Preventive Services
Task Force, you would advise
A)
B)
C)
D)
E)
annual chest radiographs

annual sputum cytology
both sputum cytology and chest radiographs annually
annual spiral CT
no screening for asymptomatic individuals
228. The mother of an 11-month-old male asks about the viral gastroenteritis vaccine. You advise
that it is
A)
B)
C)
D)
E)
routinely given at the 12-month visit

associated with an increased risk for intussusception
initiated at 612 weeks of age
indicated only for immunocompromised children
indicated only for children attending day care
61
229. A previously healthy 20-month-old female is brought to the urgent-care clinic during the evening
with a barking cough. On examination her rectal temperature is 37.9C (100.2F), respiratory
rate 18/min, heart rate 120 beats/min, and O2 saturation 94%. She has stridor, with mild
substernal retractions only when her temperature was taken.
A)
B)
C)
D)
Dexamethasone, 0.6 mg/kg orally or intramuscularly as a single dose

Guaifenesin/pseudoephedrine elixir orally until symptoms improve
Azithromycin (Zithromax) orally for 5 days
Observation in the clinic, and if there is improvement, a 5-day course of
dexamethasone
230. A patient with end-stage renal failure is found to be anemic. You suspect a vitamin B12
deficiency, but testing reveals that her vitamin B12 level is low normal.
Which one of the following laboratory test results would confirm a diagnosis of vitamin B12
deficiency?
A)
B)
C)
D)
E)
Low epogen
Low folic acid
High methylmalonic acid (MMA)
Low homocysteine
A normal peripheral smear
231. In addition to calcium and vitamin D supplementation, patients who are beginning long-term
treatment with prednisone (3 months at a dosage 5 mg/day) should also receive
A)
B)
C)
D)
E)
bisphosphonate therapy
calcitonin
estrogen replacement therapy
recombinant human parathyroid hormone
raloxifene (Evista)
Items 232240: Refer to Pictorial Atlas insert, center of book.

232. A 55-year-old female develops pain in her chest while getting her hair done and arrives at the
emergency department within 15 minutes. Her blood pressure is elevated, but other vital signs
are normal. An EKG taken a few minutes after her arrival is shown in Figure 1.
Based on the EKG, which one of the following is the most likely diagnosis?
A)
B)
C)
D)
E)
Pulmonary embolism
High lateral wall ischemia
Acute inferior myocardial infarction
Right bundle branch block
Atrial flutter
62
233. A 27-year-old female office worker presents with the inflamed lesion shown in Figure 2. She
is in good health otherwise and takes only iron supplements and oral contraceptives. She has
not had any recent illnesses, but she states that she may have had a similar lesion as a teenager.
A)
B)
C)
D)
E)
Orf virus infection

Herpes simplex
Herpes zoster nasociliary infection
Staphylococcal infection
Contact dermatitis from cosmetics
234. A 53-year-old male presents with a 2-week history of passing frequent, small, formed stools that
contain mucus and streaks of blood. He says he has not had diarrhea. He recently traveled to
Mexico. Figure 3 shows findings seen on anoscopy.
A)
B)
C)
D)
Empiric therapy for giardiasis

Testing for Clostridium difficile
Rectal cultures for Chlamydia, gonorrhea, and HSV-2
Referral to a colorectal surgeon
235. A 60-year-old male presents with a 3-day history of abdominal pain and urinary urgency. He
also complains of chills, fatigue, and decreased appetite. His temperature is 38.4C (101.2F)
orally, his pulse rate is 96 beats/min, and his blood pressure is 126/84 mm Hg. On physical
examination he is tender in the left lower quadrant, and a rectal examination reveals a normal
sized, nontender prostate gland. A urinalysis reveals 510 WBCs/hpf and 510 RBCs/hpf. A
CBC reveals a normal hemoglobin and hematocrit, with a WBC count of 15,000/mm3 and 85%
neutrophils. A CT scan of the abdomen is shown in Figure 4.
A)
B)
C)
D)
E)
Acute prostatitis
Colon cancer
Appendicitis
Diverticulitis
Pyelonephritis
63
236. A middle-aged male comes to the emergency department after a single, brief episode of
pressure-like chest pain on exertion that was relieved by rest. He is asymptomatic on arrival.
His EKG is shown in Figure 5. While awaiting results of cardiac enzyme studies, he has a
second episode of similar chest discomfort and a second EKG is performed (Figure 6).
When considering both EKGs, which one of the following would be the most appropriate
interpretation?
A)
B)
C)
D)
E)
Left ventricular hypertrophy and strain

Early repolarization
Old inferior myocardial infarction
Acute anterior ischemia
Uninterpretable due to artifact
237. A 7-year-old male is brought to your office after hurting his hand when he fell on a wet kitchen
floor. He is unable to describe the mechanism of injury. On examination the maximal point of
tenderness is at the third metacarpal-phalangeal joint, which also has some generalized swelling
but no ecchymosis. Range of motion is limited in this joint due to pain. A radiograph of the
hand is shown in Figure 7.
A)
B)
C)
D)
E)
Boxers fracture
Greenstick fracture
Salter type II fracture
Spiral fracture
No abnormality
238. A 24-year-old generally healthy female presents with a rash that developed quickly over her
extremities and trunk earlier in the day (see Figure 8). The lesions started as round
erythematous macules, but over the course of a few hours have evolved. Some of the areas that
were affected initially have already cleared. The affected skin is mildly pruritic, but she has no
other symptoms or physical findings. Her mucous membranes are normal.
Which one of the following would be the most appropriate first-line treatment for this patients
condition?
A)
B)
C)
D)
E)
An oral antibiotic
An oral antihistamine
Oral corticosteroids
Topical corticosteroids
A topical antifungal agent
64
239. A 60-year-old white male is noted to have a rocking motion of his precordium, associated with
mild heart failure, about 3 months after an acute anterior myocardial infarction. He denies any
current chest pain. His EKG is shown in Figure 9.
A)
B)
C)
D)
E)
pericarditis
ruptured papillary muscle
pulmonary embolus
left ventricular aneurysm
left ventricular hypertrophy
240. A 34-year-old male presents with a 10-lb weight loss, subjective fever, chills, and a cough for
the past 6 weeks. The cough has gradually worsened and now produces blood-tinged,
foul-tasting mucus. His medical history includes poorly controlled type 1 diabetes mellitus that
has resulted in several instances of symptomatic hypoglycemia over the past year. He smokes
cigarettes, but only on social occasions when he has a drink.
On examination he has a temperature of 38.9C (102.0F), a harsh cough, significant dental
caries and periodontal disease, and normal breath sounds and chest resonance. Laboratory
studies indicate the presence of mild leukocytosis with a left shift, moderately elevated blood
glucose, and minimally elevated BUN and creatinine. A sputum Gram stain indicates mixed
flora. A chest radiograph is shown in Figure 10.
Of the following choices, which one would be the best empirical treatment while awaiting the
results of cultures, testing for acid-fast bacilli, and a tuberculin test?
A)
B)
C)
D)
A four-drug antitubercular regimen

Clindamycin (Cleocin)
Doxycycline plus a fluoroquinolone
END OF BOOK
Please check the top of your answer sheet to insure that your
Program Number and ABFM Number are filled in correctly.
65
GENERAL INSTRUCTIONS
Each of the questions or incomplete statements in this book is followed by four or five answers or
completions. Select the ONE that is BEST in each case. You are advised to respond to all items. Even
though you may be in doubt about the correct answer, selecting the choice that you consider to be the best
will maximize the likelihood of your examination scores reflecting the breadth of your knowledge.
You may make preliminary notes or calculations in the test book, but credit is given only for answers
marked on the answer sheet. Only one choice should be marked for each response set. Double answers
are treated as wrong answers. After you have decided upon the best answer, completely fill in the circle
containing the corresponding letter on the answer sheet. Use only the pencil which was supplied with the
examination; do not use a pencil with hard lead or a ball-point or felt-tipped pen. Make no stray marks
on your answer sheet. Do not fold or damage the answer sheet.
If you wish to change an answer, erase your first mark completely and mark your new choice. Take
care in marking your answers since SOME ITEMS HAVE FEWER THAN 5 OPTIONS.
This book contains a pictorial atlas for use with questions 232240. It may be removed from the book for
easier handling.
EXAMPLE
1. To which one of the following systems of the body does the heart belong?
A)
B)
C)
D)
E)
Digestive
Circulatory
Central nervous
Endocrine
Musculoskeletal
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Pulmonary function testing

Erythema toxicum neonatorum

4. Regular breast self-examinations to screen for breast cancer

are performed by most women in the United States

Amoxicillin, 3.5 g orally once

Her son is overly controlling

A 1-year-old patient as a routine immunization

a radionuclide thyroid scan

Decrease the dosage of levothyroxine

a medication side effect

Lisinopril (Prinivil, Zestril)

New-onset ST-segment depression

Duchennes muscular dystrophy

The most likely diagnosis is alcoholic liver disease

NRT usually doubles a smokers chance of quitting

The absence of rectal involvement

An echocardiogram to look for cardiomyopathy or valvular dysfunction

Low-dose amitriptyline at bedtime

to increase her caloric intake

A combined inhaled corticosteroid and long-acting $-agonist

he should have a growth hormone stimulation test

Trimethoprim/sulfamethoxazole (Bactrim, Septra)

49. Dizziness is most likely to have a serious etiology when it

is associated with diplopia

estrogen receptor status

Immediate surgical intervention

Hepatitis C antibody testing

Chronic daily use of metoprolol (Lopressor)

Dental splints are the treatment of choice

Dog or cat hookworm (Ancylostoma species)

Evacuation of the pleural space

transient tachypnea of the newborn

Administration of oxygen and immediate descent

Peripatellar pain while running

Observation without treatment for 1 month

Penicillin G benzathine (Bicillin), 1.2 million units intramuscularly

lisinopril (Prinivil, Zestril)

Head CT without contrast

Antiviral drugs for hepatitis B

Cerebrospinal fluid leak

The risk of peptic ulcer bleeding from chronic NSAID therapy

24-hour urine collection for uric acid

A plastic loop curette through an otoscope

Dementia with Lewy bodies

Hydration with normal saline and mannitol

The tests accuracy in correctly identifying patients without the disease

Inhaled corticosteroids daily

can help determine the severity of the disease

Obtain a fasting blood glucose level

They are frequently addictive

Relay the prognosis, but focus as much as possible on any positives

Anti-cyclic citrullinated peptide (anti-CCP) antibody

Supportive care only

vancomycin (Vancocin) intravenously

Cooling the anesthetic solution

The mother should withhold breastfeeding

The American Diabetes Association 1800-calorie/day diet

A 52-year-old male with type 2 diabetes mellitus

Increase the lisinopril dosage to 80 mg twice daily

Gastroesophageal reflux disease