1

If you find an incorrect answer, or an answer that I have not included here, let me know, and I'll make the
change. A correct answer means that you correctly selected it on your version and it did not show up in your
'extended feedback.' You can discuss question topics here, or in a separate thread. Itll take some time to
transcribe all the questions, so Ill continue to edit/update/add questions over the next few days.
Block 2: Pg 7; Block 3: pg 13
Block 1 part 1
1. 22yo Primi admitted in labor. Pregnancy was complicated by 3 UTIs, the last one at 22 weeks gestation.
Shes now taking daily nitrofurantoin. Pt is otherwise healthy. Whats causing the recurrent UTIs?
- Urinary Stasis
2. 4yo boy with 3-day hx of cough, fever, runny nose. No wheezing, vomiting, or diarrhea. 75th %ile for
height, and 10th %ile for weight. T 37.5. Cap refill is 2 sec. Exam shows clear rhinorrhea. Breath sounds
normal. There is a media tab to view the cardiac exam. Dx?
- URI
3. 42yo woman with generalized weakness, lethargy, and double vision for 2 weeks. Chest X-ray shows upper
anterior mediastinal mass. Dx?
- Thymoma
4. 4mo old brought to ER after an apparent seizure. Pt has vomiting 6 times over the last 2 days, feeding
poorly, and sleeping more than usual. Pt is lethargic and afebrile. Anterior fontanel is tense, bilateral retinal
hemorrhages. Dx?
- Child abuse
5. 52yo man with excruciating pain/swelling of his great toe since undergoing appendectomy 10 days ago.
Celecoxib has provided no relief. Temp is 37.6. Exam shows red/swelling great toe and tender MTP joint.
Most appropriate next step?
- Indomethacin
6. During a sports physical, a healthy 14-yo boy has a BP of 150/90. Previous BP checks have been normal. 6
ft 2 in and weights 180 lb. BMI is 24. Exam is normal otherwise. Most appropriate next step?
- Repeat BP check in 4 weeks
7. 19yo man brought to ER by police after found standing in his neighbors living room in the middle of the
night. He is conscious but remains mute during questioning. Temp 37C, respirations 18/min, BP 160/95.
Exam shows bilateral nystagmus, constricted pupils, hypertonia, and decreased sensation to pinprick.
Substance?
- PCP
8. Officer investigates an outbreak of illness at a picnic. Onset of nausea and vomiting 3 to 4 hours after
attending the picnic. All those affected recover without Rx. Egg salad was the vehicle of transmission. What
is the factor most commonly contributing to an outbreak of this type?
- Inadequate refrigeration of implicated food
9. 2 days after beginning ACTH therapy for MS, a 47yo woman exhibits bizarre behavior. She is easily
angered and thinks the nurses are terrorists. Shes been pulling out her IV and walking down the halls at night.
Muscle strength in lower extremities is 2/5. On mental status exam, she is fidgety, labile affect, and is easily
distracted. Oriented to person, but not place or time. Most appropriate Rx?


- Haloperidol

10. 50yo F with 5-year Hx of metastatic breast cancer has SOB for 8 hours. Pulse 116/min, resp 32/min, BP
90/60. End-inspiratory crackles heard at base of both lungs. JVD present. Distant heart sounds. ABG shows:
pH 7.50; Pco2 28; Po2 78. XR shows cardiomegaly, ECG shows alternating QRS amplitude patterns. Echo
shows paradoximal motion of the interventricular septum and a pericardial effusion. Most appropriate next
step?
- Pericardial window.
11. 14 month boy brought in for well-child exam. Mother is worried because he is not yet walking on his own.
He will stand for several seconds before falling. He can empty raisins from a cup and tries to eat with a spoon.
25th %ile for length and 30th %ile for weight. Exam shows no abnormalities. Most appropriate next step?
- Reassurance
12. Asymptomatic 23yo M in for preemplyoment evaluation. Exam shows normal findings. PPD shows 16
mm of induration & erythema. He has had no previous PPD tests and hasnt been exposed to anyone with
active TB. XR shows no abnormalities. Sputum contains no acid fast bacilli. Most appropriate next step?
- Treat latent TB now
13. Previously healthy 26yo M in ER with SOB for 3 weeks and painful bumps on his legs for 1 week. T 38.2,
P 80/min, BP 140/85. Exam shows 2- to 3-cm tender, red nodules on anterior shins. CXR shows bilateral hilar
fullness. Which serum abnormalities is most likely in this patient?
- Increased calcium
14. 47yo F with fever, nausea, vomiting, and severe headache for 24 hours. T 39. Exam shows weakness of
right upper extremity and nystagmus, optic fundi cannot be visualized. Kernig sign is present. Most
appropriate next step in diagnosis?
- CT of head
15. 47yo F brought to ER 30 minutes after a MVC, unrestrained driver. Severe neck pain and mild chest and
abdominal pain. P 95/min, Respirations 20/min, and BP 120/80. Exam shows severe tenderness of the cervical
spine at C5. Bruise and mild tenderness over lower sternum and upper abdomen. Neuro exam is normal. CXR
is normal except for slightly widened mediastinum. Cervical spine XR shows C5 facet fracture. Abdominal
XR is normal. Most likely location of the life-threatening cardiovascular injury?
- Thoracic aorta
16. 18yo primi at 37 weeks gestation admitted in labor. Regular contractions every 3 minutes. Pregnancy
complicated by several episodes of genital herpes, most recent episode 6 weeks ago. No lesions or prodromal
symptoms since last episode. Vaginal exam shows no lesions. Membranes are intact. Fetal movement has
been appropriate. Cervix 100% effaced, 5cm dilated, vertex at -1 station. Most appropriate next step?
- Amniotomy and vaginal delivery
17. 4yo girl with 5lb weight loss during the last 2 months. No Hx of illness, on no medications, immunizations
up to date. 50th %ile for height, 25th %ile for weight. Occasional crackles over right middle lung field.
Intradermal testing with PPD, tetanus, and antigens for candida and trichophyton is nonreactive at 72 hours.
WBC count is 5100. Nucleic acid hybridization testing of gastric aspirates shows TB. Most likely
explanation?
- T lymphocyte dysfunction
18. 27yo F with 5 day history of headache, severe, diffuse abdominal pain, nausea, vomiting. Pain is
exacerbated by eating and relieved by vomiting. Vomitus originally had semisolid content with green fluid,


3
and now only contains clear yellow fluid. Hx of Crohn dz treated with prednisone, tapered over the last 2
weeks, mesalamine, and azathioprine. LMP 7 weeks ago. Sex w/ 1 partner, use condoms inconsistently. Temp
38.4, P 120/min, Resp 22/min, BP 90/50. Dry oral mucosa, pale conjunctiva, distended abdomen, diffusely
tender and tympanic. Decreased bowel sounds. Pelvic exam is normal. Labs: HCT 31% WBC 15k, amylase
300, lipase 9. Dx?
- SBO
19. 37yo F with malaise, muscle aches, painful vulvar blisters, vaginal discharge, and dysuria for 3 days. Had
sex with new partner 7 days ago. T 38. Exam shows bilateral painful inguinal lymphadenopathy and
numerous 1-3 mm vesicles and ulcers on labia majora and minora, perineum, vulva, mons pubis. Next step in
diagnosing these lesions?
- Cx for herpes
20. 52yo F with personality change since death of close friend 2 weeks ago. Irritable, less sleep, speaks
rapidly, jumping from topic to topic. Shes had past episodes excessive sleeping, decreased energy, and loss
of interest, but never thought these symptoms were severe enough to seek medical attention. Mental status
exam shows loud, rapid speech, and flight of ideas. She says she is not sad, but rather uplifted by her friends
death. She hears her friends voice and communicates with her. Dx?
- Bipolar d/o
21. 6 hours after CABG, 62yo experiences drop in BP from 120/80 to 100/85. Urine output decreases from 60
to 10 mL/h, and cardiac output decreases from 6 to 3 L/min. Pulmonary artery diastolic pressure has
decreased . CXR shows widened mediastinum. Most appropriate next step?
-?
22. Homeless 66yo M with jaundice for 1 week. Eats irregularly, 20lb weight loss, over the past year. 20-year
Hx of alcoholism. Icteric sclerae, palmar erythema, and spider angiomata. Serum Mg is 0.8. Serum studies
most likely to show?
- Decreased Calcium
23. 24yo F with amenorrhea for 7 days. 8-year Hx of anorexia. Compared to other women her age, she has an
increased risk for?
- Osteoporosis
24. 62yo F with 3-mon Hx of difficulty swallowing solids and liquids, occasionally regurgitates undigested
food. Exam shows foul-smelling breath. Most appropriate next step in diagnosis?
- Barium Swallow
25. 24yo M with shortness of breath 2 days after ORIF of a midshaft femoral fracture. Abrasions over left
anterior chest wall. Initial CXR is normal. P 96/min, resp 24/min, BP 130/74. Exam shows petechial
hemorrhages of the conjunctivae and petechiae over the chest and upper extremities. ABG shows pH 7.48;
Pco2 30; pO2 56; HCO3 23. CXR now shows fluffy infiltrates in both lung fields. Dx?
- Fat embolism syndrome
26. 160yo F brought in by her mom requesting birth control. Mom wants to talk to doc alone because daughter
is staying out late, receiving many calls from several different boys, and wear tight clothing and excessive
makeup. Daughter confides many details of the dates to her. Father is furious and berates daughter, so mother
doesnt want to tell father about what is going on. On interview, she says she doesnt know why she is doing
this, but would like to understand. Most appropriate next step in management?
- Family therapy


27. 82yo F with metastatic breast cancer with low back pain and left thigh pain for 5 days despite taking 5
mg of morphine syrup q4 hours. She says morphine wears off after 2-3 hours. She is otherwise tolerating
morphine without side effects. Most appropriate next step in management?
- Increase the frequency of the dose to every 3 hours

28. 17yo F with 4-month history of persistent rash over face and upper back (photo). Which structure is
primarily involved in the development of this rash?
- Pilosebaceous follicles
29. 42M in ER, 6 hours after onset of severe flank pain. T 37C P 110/min, resp 12/min, BP 130/90.
Tenderness over RLQ of abdomen and costovertebral angle. UA shows 50-100 RBC and 3-5 wbc. 2 hours
after morphine, symptoms subside. In addition to analgesics, most appropriate next step in management?
- Discharge and encourage fluid intake
30. 72yo M with 3 month Hx of difficulty climbing stairs, arising from chair, and combing hair. 4-year Hx of
hypercholesterolemia treated with simvastatin. Cranial nerves intact. Tenderness to palpation over UE and
thighs. Strength 4+/5 in deltoid, biceps, triceps, hip flexor, and quads. DTR and sensation are normal. Most
likely location of the abnormality?
- Muscle
31. 72yo F with indigestion while walking uphill or briskly, relieved with rest. Sx are not related to eating and
not relieved by antacids. Most appropriate next step in management?
- Exercise stress test
32. 67yo M with 1 mo Hx of recatal bleeding. Passes bright red blood with bowel movements. No other Sx.
Hx of HTN and osteoarthritis. Current meds: losartan, metoprolol, amlodipine, and naproxen. Father had
colon cancer at age 70 and died at 74. 89yo mother had breast cancer 20 years ago and has survived. 183cm
tall, weighs 91kg; BMI 27. Vitals are wnl. Mass palpated in rectum, remainder of exam is wnl. Colonoscopy
shows ulcerating rectal mass, bx shows rectal cancer. Review of which clinical study is most useful in
developing treatment plan?
- RCTs
33. 6mo boy with diaper rash for 3 days. Otherwise healthy. Breast-feeds 6x a day. T 37.4C, P 100/min, resp
25/min. On exam, 2-cm crusted, popular, honey-colored lesion with clear discharge in left groin. Most
appropriate next step in management is topical application of?
- Mupirocin
34. 27yo M and wife unable to conceive for past 10 mo. Wife conceived from previous marriage, husband
with no children. Wifes menses and are normal, and her exam is wnl. Exam of husband shows ill-defined soft
masses palpated bilaterally, high in scrotum. Most likely cause of these masses?
- Bilateral varicoceles
35. 9yo boy with low back pain for 4 months, present throughout the day, but most severe when he awakens
and after physical activities. Pain described as dull ache. Walks with a stooped gait, but appears well. Exam
shows tenderness of right SI joint, paravertebral muscle spasm, decreased flexion at waist. Skin exam normal,
CK normal, ESR is increased. XR of spine shown. Dx?
- Ankylosing spondylitis
36. 15yo girl with low back pain for 2 mo, dull ache present all day and night, making it difficult to find
comfortable sleeping position. Hx of asthma for 2 years treated with prolonged courses of oral prednisone.
Cushingoid and hirsute appearance. Tenderness from T11 to L2 and paravertebral muscle spasm. CK and ESR


wnl. XR shown. Dx?
- Compression fracture

37. 6yo boy with cramping abdominal pain & right-sided scrotal pain for 4 hours. Vomited once, Exam shows
distended abdomen. BS decreased, and deiffuse tenderness to palpation with involuntary guarding. Right
hemiscrotum discolored with swelling & tenderness superiorly. Left hemiscrotum is wnl. Most appropriate
next step in management?
- Operative procedure
38. 62yo F with SOB for 12 hours. 15y Hx of type 2 DM and 3y hx of chronic renal insufficiency. Meds
include insulin and captopril. T 38.2C, P 88/min, respt 16/min, BP 144/70. Exam shows no adenopathy.
Inspiratory crackles greater on right than left. Cardiac exam: discrete PMI, S1/S2 wnl, intermittent S4. Trace
pedal edema. Pulse ox on room air shows o2 sat of 90%. 13,000 leukocytes, creatinine is 2.2. CXR shows
patchy infiltrate in right midlung. Rx ith IV ceftriaxone and heparin is begun. She has poor oral intake, and
temp ranges from 37 38.4C, and BP range from 112/60 to 146/84. Glucose range from 140-320 despite
insulin control. 4 days later, Cr is 3.6. What could have prevented renal deterioration?
- IV fluids
39. 24yo W with intermittent double vision and drooping of the eyelids for 3 weeks and difficulty chewing
and swallowing for 1 week. Sx worse late in day. Eyelid ptosis worse on the right, weakness of abduction of
right eye, adduction of left eye, and eye closure. Weakness of forehead and mouth. Speech is nasal. DTR and
sensation are normal. Dx?
- decreased acetylcholine receptors
40. 37yo M with progressive weakness over the past 5 days, started at ankles and spread to proximal muscles
of lower extremities, hands, forearms, and face. Mild tingling of feet and fingers. Had URI 2 weeks ago.
Exam shows moderate weakness of facial muscles and muscles of extremities and marked weakness of distal
muscles of extremities. DTR absent, hypotonia of knees/ankles. SLT and vibration mildly decreased over feet.
Dx?
- Demyelination of axons? Could be incorrect. Answer is NOT E, loss of motor neurons
41. 32yo F abdominal pain, N/V for 6 hours. Cholesystectomy 2 years ago. Menses wnl, LMP 2 weeks ago.
No smoking/drinking. Appears acutely ill. T 37.4 resp 14/min, P 110/min BP 130/70 while supine, p 135 BP
90/60 when standing. Exam: guarding with rebound, BS decreased.
Labs: NA 146, K 3.3, Ca 8.9, T bili 1, alk phos: 120, AST 64 Amylase 1022.
Most appropriate next step to determine cause is measurement of?
- Triglycerides
42. 4yo boy with fatigue since viral illness 3 weeks ago. Pale for 1 week, gums bled yesterday when brushing.
Cervical, axillary, and inguinal adenopathy and hepatomegaly. Hb is 8, leukocytes 3000, platelets 30k. Most
appropriate next step in management?
- Bone marrow aspiration
43. 1 day after removal of large meningioma, 42yo F is comatose, intubated. Groans/moves extremities to
painful stimuli. T 37.2, p 96/min, resp 14/min, BP 110/72. Neuro exam shows no focal findings. Labs: Na
155, Cl 120, K 3.6, HCO3 24, urea nitrogen 16, Cr 0.8, Urine specific gravity 1.004. In last 24h, shes
received 2L IV 0.9% saline and had urine output of 6 L. Explanation for the hypernatremia?
- Diabetes insipidus
44. 82yo F with visual loss in left eye since awakening. HTN treated with Lisinopril, and takes daily aspirin.
Pupils are 2 mm bilaterally and reactive to light. Visual acuity is 20/30 on R and 20/400 on L. Fundoscopic


exam of L eye shows dilated retinal veins and widespread retinal hemorrhages intermixed with patches of
white exudate. R optic fundus wnl. Dx?
- central retinal vein occlusion

45. 47yo F with fatigue for 1 week. 10y Hx of type 2 DM Rx with short-acting insulin before each meal
needed and 12 U of intermediate acting insulin at bedtime. Over past week, glucose levels >250. BMI 27. T is
38.5C, P 90/min BP 110/70 when supine, P 120/min bp 90/40 when standing. Urine is pos for glucose, neg for
protein and ketones. UA shows 6-10 wbc and no RBC casts. Cause of postural hypotension?
- intravascular volume depletion
46. 18yo F with 3-day hx of fatigue and yellow eyes. Hx of anemia, but otherwise healthy. 16yo brother also
has anemia. T 36.7C, p 82/min, resp 14/min, BP 105/69. Scleral icterus, exam shows mildly tender 1-cm
cervical lymph nodes. Spleen tip palpated 3 cm below costal margin. Hb 8.6, MCHC 38%, retics 8%, Serum
T Billi 3. Negative coombs. Blood smear shown. What would have prevented symptoms?
- Splenectomy


Block 2 part 1

1. 37yo M with end-stage Duchenne muscular dystrophy. Life expectancy less than 6 months. Patient tells
physician that he is tired of living like this and requests a DNR with no further antibiotics. He has
considered this decision for 3 weeks, but has not discussed it with family. On mental status exam, he shows
sadness about his health, but has a normal thought process. He expresses no ambivalence about his decision.
Most appropriate next step in management?
- Determine if patient wants to discuss his decision with anyone else
2. 36yo G1P1 with heavy vaginal bleeding since delivery of placenta 15 minutes ago. Had vaginal delivery of
full term 4200g baby after 3-hour second stage of labor. P 110/min, BP 90/60. Fundus palpated 3 cm above
umbilicus. No evidence of genital tract injury. Placenta appears complete but torn. Dx?
- Uterine atony
3. 57yo F with factor XI and IgA deficiencies is scheduled to undergo resection for colon cancer. Preop HCT
is 24% and requires transfusion with 2 unites of PBRC. 3 minutes after beginning the first unit, patient
develops severe shortness of breath and urticarial with swelling of tongue and throat. She appears anxious. BP
90/60. Dx?
-Anaphylactic transfusion reaction
4. I DO NOT HAVE THIS QUESTION. IF SOMEONE KNOWS WHICH QUESTION IM MISSING,
PLEASE LET ME KNOW!
5. 32yo nulligravid with PCOS trying to conceive for 3 years. Menses occur at irregular intervals. She is 165
cm tall and weighs 100 kg. BMI is 37. Most appropriate Rx?
- Clomiphene
6. 25yo primigravid at 27 weeks gestation with severe contractions for 6 hours that have not resolved despite
changing positions and increasing fluid intake. Small amount of vaginal spotting the last time she voided.
External fetal monitoring shows contractions every 2 3 minutes and a fHR of 130/min with no decels.
Cervix is 1 cm dilated and 10% effaced. Fetal presenting part is high. During the next hour, she receives oral
hydration. Temp 37.2C, P 110/min, resp 16/min, BP 110/70. Lungs are clear, fundal height is 27 cm. Cervix is
now 1 2 cm dilated and 70% effaced; vertex at -2 station. Positive GBS culture. Most appropriate next step
in management?
-IM betamethasone
7. 37yo M with 6-month Hx of SOB and fatigue. SOB after walking 2 blocks. Sleeps 6 hours nightly but
doesnt feel well-rested. No smoking/drinking. Worked as teacher for 15 years. BMI is 59. P 86/min, resp
14/min, BP 146/92. Lungs clear, breath sounds are decreased. Normal cardiac exam. ABG shows pH 7.32,
Pco2 56, Po2 70. CXR is normal. Most likely cause of hypoxemia?
- Alveolar hypoventilation
8. 27yo asymptomatic HIV positive F requesting advice for immunization. All childhood immunizations up to
date. MMR 4 years ago, last tetanus vaccine 6 years ago. Hep B antibody was positive 3 weeks ago. CD4
count was 450 3 weeks ago. Which immunization is most appropriate?
-Pneumococcal vaccine
9. Afebrile 32yo F with cramping abdominal pain and watery stools for 4 days. Exam is normal. Her Hb is
12.5, and leukocyte count is 8500. Exam of stool shows no neutrophils. Organism?
- Enterotoxic E. Coli? Answer is NOT S. Aureus


8
10. 67yo M with uncontrollable nosebleed for 6 hours. No Hx of HTN and takes no meds. Smokes 1-2 packs
for 45 years. BP is 220/120. Exam shows lesion in left naris controlled with cauterization. Bilateral bruits over
flank. Rental arteriography shows 13 cm kidneys with single renal arteries. Ostial lesions of both kidneys that
occlude 85% of vessel orifice. After ACE inhibitor, BP drops to 140/80. Mechanism of response?
-No cleaving of C-terminal peptides on angiotensin I
11. 62yo F in for resection of ovarian tumor. 25 lb weight loss over past 2 months. Exam shows adnexal mass,
and no other abnormalities. Preop labs: Serum - BUN 80; Cr 5.7; Urine Glucose none; protein trace; WBC
0-2; RBC 0-2; Casts none; crystals none; bacteria none. Most appropriate next step to determine cause of
renal failure?
-Renal U/S
12. 57yo F with pain over left groin and anterior thigh for past year. Active range of motion of hip joint
reproduces pain. 20-degree hip flexion contracture. ESR is 20; pelvic XR shown; Dx?
- Osteoarthritis? Not Osteonecrosis
13. 32yo F with headache, joint pain, fatigue, fever for 2 weeks. 3 weeks ago, she had a bright red rash on
right calf for 7 days. No Hx of illness, no meds. T 37.7C. Physical normal except for pain on hyperextension
of knees. Neuro exam normal. Positive IgM antibody assay to Borrelia burgdoferi. Administration of which of
the following is most appropriate next step to prevent long-term complications of this disease?
-Amoxicillin
14. 17yo girl in MVC as unrestrained driver. Arrives on a backboard with C-collar. During attempts to
administer 100% O2, patient is combative. Facial trauma and open facial fractures. Chest severely bruised.
Makes gurgling sounds when she breathes. Most appropriate initial step in management?
-Cricothyrotomy? Answer is NOT Elevation of bed
15. 52yo F with 5-day Hx of abdominal pain, nausea, decreased appetite. Nine days ago, underwent lap
cholecystectomy for stones. Discharged 7 days ago. T 38.2, P 108/min, resp 20/min, BP 102/64. Exam shows
jaundice, RUQ tenderness. Bowel sounds present. Labs: Hb 12.2, HCT 36%, Leukocytes 17,200 BUN, 48;
Glucose 186; Cr 1.5; T bili 7.2; alk phos 251; AST 84. U/S is normal; Most appropriate next step in
management?
-ERCP
16. 32yo M with 3-month Hx of burning substernal chest pain and sour taste in his mouth. Sometimes
awakens at night with acidic liquid in his mouth. Nonproductive cough for 2 months. Smoked 1 pack daily for
14 years. Drinks 6 beers every week. BMI 31. Exam is otherwise normal. Most appropriate next step in
management?
- Trial of omeprazole therapy
17. 47yo M with 6-month Hx of progressive weakness that began in his right leg and gradually spread to his
other extremities. Mild difficulty swallowing solids and liquids. Exam shows atrophy of right quads and both
deltoid muscles and fasciculations in both quad muscles. Babinski sign present bilaterally. EMG and nerve
conduction studies are most likely to show?
- Fibrillation potentials in multiple muscles of multiple extremities
18. 22yo M exposed to unknown gas, now vomiting and has diarrhea. Pulse 96/min, resp 20/min, BP 115/65.
Exam shows miosis, copious oral secretions, rhinorrhea, and muscular fasciculations. Diffuse wheezing
bilaterally. Clothing is removed. While being washed, he has a generalized tonic-clonic seizure. Most
appropriate Rx?
- Atropine

19. 2 hours after repair of perforated gastric ulcer, 75yo W has multifocal PVCs. Hx of CHF treated with
Digoxin and diuretics. Most likely abnormal serum concentration?
- Decreased potassium
20. 55yo F with metastatic breast cancer admitted for confusion progressing to obtundation over past 24
hours. Barely arousable. Most likely abnormal serum concentration?
- Increased sodium
21. 57yo F with HTN in ER for 8-hour Hx of nausea, vomiting, diarrhea, abdominal pain, and weakness.
Slight blurred vision, double vision, dry mouth, and tingling and numbness of her legs. 32 hours ago,
consumed pork, shrimp, rice, and home-canned preserves. 1 week ago, had URI that resolved without
treatment. Current meds: Lisinopril and 81-mg aspirin. No smoking or drugs. T 36.9C, Pulse 64/min, resp
16/min, BP 124/72. Pulse ox shows O2 saturation of 94%. Pupils slightly dilated, sluggishly reactive. Mucous
membranes are dry. Normal cardiopulmonary exam. Weakness of oculomotor and facial nerves. Muscle
strength 4/5 in lower extremities. DTR 2+. Dx?
- Botulism
22. 75yo M with confusion and lethargy for 2 days. Was gardening on a 100F day before symptoms. 15-year
Hx of DM treated with glyburide and 25-y Hx of HTN treated with HCTZ. Underwent lap chole 6 weeks ago.
Smokes 1 pack daily and 2 drinks nightly. Traveled to Hawaii 2 months ago. T 41.5C, pulse 120/min, BP
90/60. Skin is hot and dry but not erythematous. Muscle tone decreased Serum CK is 8000, AST is 400.
Cause?
-Heat stroke
23. 4yo boy in ER for not using his left arm. No known injury to arm. Comfortable, but resists attempts to
move arm due to pain. Holds left UE with elbow flexed and forearm in pronation. No evidence of injury,
radial pulses normal. Sensation is full. Most appropriate next step in management?
- Supination of forearm with elbow in slight flexion
24. 37yo F with alcoholism in ICU for pancreatitis. During first 12 hours, vitals: Pulse 100-130/min; resp 2836/min; SBP 90-110. 14 liters of crystalloid solution infused to maintain urine output of 30 mL/h. She is
intubated for low O2 saturation. Lungs are clear. Pulmonary cath shows: Cardiac index 4.2L/min; CVP 11;
PCWP 10. ABG on FiO2 of 60% and PEEP of 10: pH 7.32; Pco2 38; Po2 78. CXR shows bilateral, diffuse,
hazy densities with cephalization of the pulmonary vasculature and perihilar fullness. Dx?
- ARDS
25. 43yo M with 3-day Hx of Temp 38.4C, left-sided chest pain, malaise, loss of appetite, and a cough
productive of yellow phlegm and SOB. Smoked 2 packs/day for 25y. He appears ill. Pulse 112/min, resp
22/min, BP 118/72. Crackles and wheezes at left base, breath sounds decreased. Increased tactile fremitus and
dullness to percussion at left base. CXR shown. Gram neg bacilli and leukocytes on stain. Dx?
- H. influenza
26. 32yo F at 16 weeks gestation with 6-hours of fever and waxing/waning consciousness. Only meds is
multivitamin with iron. T 38.3C. Neuro exam shows waxing/waning consciousness. HCT is 11%, platelets
52K, Cr is 3.5. Blood smear shows schistocytes. Dx?
- TTP


10
27. 4 days after right hemicolectomy, 67yo F has leakage of serosanguineous fluid b/w incision staples; the
dressing is soaked. Meds include corticosteroids for COPD, T 37.5C, pulse 73/min, BP 140/90 Abdominal
exam shows distension with minimal incisional tenderness and no erythema. Dx?
- Wound dehiscence
28. Sexually active 24yo M with painful sores on his penis for the past 5 days. Theres lymphadenopathy. No
fever/chills. Lesions are shown. Dx?
-Genital herpes
29. 22yo F nulligravid for routine exam. Concerned about risk for ovarian cancer because her mother was
diagnosed at age 42. Doesnt know of anyone else in her family who has had acancer. No Hx of serious
illness, no meds, Menses normal, no smoking, occasional alcohol. Sexually active at 16. Uses condoms for
contraception. Plays tennis 2-3X a week. BMI is 21. Temp 37C, P 60/min, resp 20/min, BP 100/60. Physical
is normal. Most appropriate recommendation?
- Oral contraceptive therapy
30. 72yo M with SOB for 3 days. Hx of HTN and CAD. Receiving 2 L/min of O2 via nasal canula. Temp
37C, P 110/min, resp 20/min, BP 150/80. Bilateral crackles and wheezes. HCT is 28%, leukocyte count is
8000. Pulmonary artery cath shows cardiac index of 2 L/min (N = 2.5 4.2) and a pulmonary artery occlusion
pressure of 28. ABG shows pH 7.49; Pco2 30; Po2 58. Most appropriate next step in management?
- Diuretic therapy
31. Over the past 2 years, 67yo M with gradually progressive difficulty walking. Good health, no meds.
Smoked 1.5 packs per day X 50 years and 3 drinks per night. Wide-based gait and tends to reel from one side
to the other. Cannot walk more than three steps heel-to-toe in a straight line. Which would have prevented this
condition?
-Abstinence from alcohol
32. 15yo boy brought by mother for changes in behavior since he was transferred to new school 4 months ago.
He has become withdrawn, poor sleep, daytime fatigue, 10-lb weight loss, declining academic performance.
His maternal uncle and grandmother treated for depression. Denies alcohol or illicit drugs. Physical is normal.
Cooperative, but flat affect. Dx?
- Major depressive disorder
33. 11yo girl brought by parents for noticeable body odor. 3-month Hx of arguing and acting secretive at
home. Exam is normal except for mild facial acne. Sexual development is Tanner stage 2. Mental status exam
is normal. Most appropriate next step in management?
- Education about puberty for the child and parents
34. 50yo F with Hx of hypothyroidism has tingling in hands and feet and difficulty maintaining her balance
over last 2 months. Pale complexion, easy fatigability, and SOB. Labs show megaloblastic anemia. Anormal
Schilling test corrected by oral intrinsic factor. Whats causing her anemia?
-Atrophic gastritis
35. 12mo boy with 4-hour Hx of temp to 40.6C and irritability. Two previous infections during past 8 months:
pneumococcal bacteremia at age of 4 mo and periorbital cellulitis caused by H influenze type b at 7mo. All
immunizations were given. LP shows CSF with leukocytes of 500, 95% neutrophils. Gram stain shows gram
positive diplococci. Cell type involved in Dx?
- B lymphocyte


36. 12mo boy with persistent S. aureus abscess despite 2 weeks of cephalexin. 3rd infection since birth,
including inguinal abscess with S. aureus, pneumonia and empyema. Cell type involved in Dx?
- Neutrophil

11

37. 6 hours after undergoing left thoracotomy for coarctation of aorta, 10-day-old newborn is fussy and
irritable. Sedated and mechanically ventilated. Temp is 37.2C, pulse 160/min, resp 30/min, BP 110/70. Most
appropriate next step in management?
-Analgesic therapy
38. 42yo F with intermittent loss of urine over past 3 weeks. Sx only after voiding. Pelvic exam shows 3-cm,
midline, cystic, tender mass in the midthird of vagina. U/A is normal. Posvoid residual volume is 50 mL. Dx?
- Urethral diverticulum? Answer is NOT interstitial cystitis
39. 17yo boy unresponsive after using heroin at a party. He is obtunded. Temp is 35.9C, pulse 75/min, resp
6/min, BP 100/60. Administration of which of the following is most appropriate initial step?
-Naloxone
40. 27yo male stuck with needle while drawing blood from patient positive for hepatitis B antigen. Physician
was vaccinated against hep B 2 years ago. Labs show adequate antihepB antibodies. Most appropriate
management to prevent hep B infection in the physician?
- No treatment necessary
41. 32yo M with depression has sensation of insects crawling under his skin for 2 weeks. Initially treated for
scabies, but then told he had herpes zoster. Using acyclovir and topical scabies preparation, but Sx have
worsened, and he now sees tiny worms crawling out from his skin. Appears anxious but healthy. Scattered
excoriations over his face, head, abdomen, and upper and lower extremities. Lesions are punched-out sores on
a clean base. Tox screen most likely to show?
- Methamphetamine
42. 57yo M with mild left flank pain and intermittent blood in his urine for 3 days. No meds. He appears to be
in mild distress. Temp 37.2C, pulse 88/min, resp 12/min, BP 146/94. Mild left costovertebral angle
tenderness. Serum Ca is 10.9, phosphorus 2.3, intact parathyroid hormone is 1020 (N=10-65). Ct shows renal
calculi bilaterally. Cause of calculi?
- Increased urinary excretion of calcium
43. 27yo M brought to ER 30 minutes after a 10minute episode of loss of consciousness; during episode,
pulse 45/min, occurred while viewing body of his brother at the morgue. LOC was preceded by sweating and
light-headedness. Pulse is 100/min and regular, resp 12/min, BP 140/80. He hasnt eatin in 14 hours. Dx?
- Vasovagal syncope
44. 32yo M brought to ER after syncope while jogging. On arrival, he is alert and conversant. BP is 140/84.
Grade 3/6 systolic murmur at LSB, intensity increases when he stands from a squatting position. Explanation?
- Hypertrophic obstructive cardiomyopathy
45. 54yo M with weakness and numbness of the left upper and lower extremities for 1 week; he is now
asymptomatic. BP is 150/80. Carotid duplex shows 90% stenosis of right internal carotid. Serum cholesterol is
200. Most appropriate management to prevent subsequent stroke?
- Carotid endarterectomy
46. 8-hour-old newborn develops jaundice and respiratory distress. Born at 39 weeks following


uncomplicated pregnancy and delivery. He is pale and edematous. Hepatosplenomegaly and scattered
petechiae. Labs show Hb of 4, total bilirubin of 15, with a direct component of 0.3. Dx?
- Rh incompatibility

12


Block 3 part 1

13

1. 15yo girl with finger pain and swelling for 6 months. Appears well nourished, erythema over the cheeks.
Minimal redness, tenderness, and swelling around proximal interphalangeal joints of the hands. Labs show Hb
10.3; leukocytes 2500; C3 27 (N=72-120); ANA positive 1:60; RF negative; Urine blood 1+, protein 4+, RBC
30-50. Dx?
- SLE
2. 14yo boy with 6-month Hx of left knee pain exacerbated by activity. No Hx of injury. He has grown 3
inches over the past 6 months. His older brother had similar Sx at the age of 13 years. Normal gait, ROM is
normal. Tenderness over left tibial tubercle. No joint effusion, knee joint is stable. Mechanism?
- Repeated microfracture at the tendon insertion
3. For 12 hours, 25yo F G2P1 at 20 weeks has severe epigastric pain that radiates to the back. Vomited once.
Temp 37.8C, pulse 92/min, BP 120/80. Fundus is nontender, fundal height is 21 cm. FHR is 138/min. HCT is
42%, leukocyte 9000, platelets 220k. Most appropriate next step in management?
- Measurement of serum amylase activity
4. 21yo primi at 37 weeks with mild epigastric pain and moderate headache for 24 hours. Temp 37C, BP
150/98. Fundus nontender, fundal height is 36 cm. FHR is 130/min. DTR are 3+, urine protein is 3+. Most
appropriate next step in management?
- Measurement of platelet count
5. 3 days after total hip replacement, 50yo M is unable to move his legs and has urinary incontinence. Sx
began immediately following removal of epidural catheter inserted for pain control. His meds include
ketorolac, enoxaparin, and morphine. Dx?
- epidural hematoma
6. 47yo M with 9-mo Hx of constipation and 2-mo hx of blood in stool. Sx partially relieved by stool
softeners and laxatives. Has hypercholesterolemia rx with atorvastatin, and had appendectomy at age 26.
Vitals normal. Cardiopulmonary, abdomen exam normal. Rectal exam shows external hemorrrhoids. Positive
occult blood test. HCT is 35%. Most appropriate next step in management?
- Colonoscopy
7. 67yo M with fatigability & generalized weakness for 3 mo and chest pain for 1 mo, which is worse on deep
inspiration. He appears slightly pale. Tenderness over left 8th and 9th ribs. HCT 28%. SPEP and UPEP show
monoclonal spike. BM biopsy shows greater than 50% plasma cells. CXR shows 1.5cm areas of radiolucency
in 8th/9th ribs. He's most susceptible to infection with?
- S. Pneumoniae
8. 4 CAGE questions are used to screen for alcoholism. If the number of "yes" responses needed for test to be
positive is decreased to one, how will it effect sensitivity and specificity?
- Increase sensitivity, decrease specificity


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9. 32yo F with asthma and 3-mo Hx of progressive cough. Initially, nonproductive cough every 2-3 days.
For the past month, cough occurred daily and has been productive of thick yellow sputum/tinged w/ blood. 1mo Hx of SOB after walking two blocks. Meds include albuterol and budesonide inhalers, used more
frequently over the past month. No smoking. Today, in mild resp. distress. T 37C, P 88/min, resp 17/min, BP
110/65. Pulse ox: O2 sat 93%. Scattered end-expiratory wheezes bilaterally with corase rhonchi at bases.
Labs: HCT 42%, WBC 10k (67% PMNs, 8% eosinophils, 25% lymphos). platelets 160k, serum IgE 1250.
CXR shows linear atelectasis at bases and thickened airways with irregular cystic opacities. Dx?
- Allergic bronchopulmonary aspergillosis
10. 62yo M with intermittent painless rectal bleeding for 3 weeks. Hx of angina and taking inhaled
corticosteroids for COPD. Smoked 1.5 packs daily for 45 years. Vitals normal. Crackles and wheezes
bilaterally. Heart sounds normal. Rectal exam shows palpable mass 2-3 cm inside anal verge. Anoscopy
shows 5-cm ulcerated mass, bx shows adenocarcinoma. Most appropriate next step in management?
- Colonoscopy to the cecum
11. 62yo M brought in 30 min after onset of severe chest pain. Tearing sensation in midchest radiating to his
back. P 104/min, resp 24/min, BP 200/120 in RUE and 180/100 in LUE. Decreased left brachial pulse. Grade
2/6 diastolic decrescendo murmur at RSB. CXR shows widened mediastinum. Most appropriate initial
pharmacotherapy?
- IV labetalol
12. 37yo F G3P3. Exam shows 3-cm, nontender, fluctuant mass involving left posterior vulva underlying the
mucosa of the vestibule and external to the hymenal ring. Dx?
- ??? I know the answer is NOT vestibular gland cyst, and probably NOT a bartholin duct cyst (which would
be tender)
13. 18yo F with fever, mild nonproductive cough, sore throat, general malaise, and anorexia for 5 weeks.
Exudative pharyngitis with a whitish membrane, cervical LAD, and splenomegaly. Dx?
- EBV
14. 42yo M scheduled to undergo MRI for hemoptysis and abnormal CXR. During MRI, he yells to get out,
and appears pale. No chest pain or SOB, but had tunnel vision and tingling in his fingers while in the machine.
Hx of hypothryroidism Rx with levothyroxine and occasional heartburn rx with rantidine. P 104/min, resp
22/min and shallow, BP 140/09. No evidence of paranoia. Most appropriate next step in management?
- Lorazepam therapy
15. 72yo M hospitalized because of dyspnea for 6 weeks. Hx of type 1 DM and angina. Meds include insulin
and warfarin. During past 4 months, was hospitalized once for DVT and another time for PE. Exam shows
JVD, ascites, pitting pretibial edema. CXR shows mild cardiomegaly and no pulmonary edema. Cause?
- Cor pulmonale
16. 24yo F primi at 38 weeks' gestation admitted in labor. Spontaneous ROM 2 hrs ago. Contractions are
moderate and occur every 5-6 min. Was treated at 20 wks with ampicilin for GBS UTI. Temp 37C, p 82/min,
resp 18/min, BP 122/74. Cervix 2 cm dilated and 80% effaced; vertex at -1 station. Most appropriate rx to
prevent GBS infection in the newborn?
- ?? Answer is NOT 'No prophylaxis indicated' so it might be IV penicillin G


15
17. 27yo M with 2-month history of a rash on his face, neck, and torso. Rash began with couple tiny spots,
and now there are more than 100. Exam shows 2-8 mm flesh-colored papules with central umbilication over
face, neck, back, and chest. Dx with molluscum contagiousum is made. In addition to Rx, most appropriate
intervention?
- HIV antibody testing
18. 14yo boy with sickle cell trait with 1-day hx of severe pain in left thigh and knee. Unable to bear weight.
No swelling, locking, or catching. 6 days ago, twisted his knee playing basketball. Knee XR was taken
(shown), and he was was given NSAIDS, ice, and crutches. His sx had improved for 3 days. BMI 32. Temp
37C, BP 110/70. Joint line tenderness of the knee, no effusion. ROM of left hip limited by pain. WBC 8k,
ESR 10. Most appropriate next step in management?
- XR of the left hip
19. 70yo F with peeling, scaling, and cracking of the right nipple for 2 months. Breast exam shows no masses,
and mammography shows no masses or calcifications. Dx?
- ?? Not eczema, so I'm assuming it's Paget disease of the breast
20. 40yo F with few drops of yellow discharge from her left nipple while performing a breast selfexamination 4 days ago. No spontaneous discharge, only when squeezing. No masses, and mammography
shows no masses or calcifications. Dx?
- Physiologic discharge
21. 3 hours after repair of leaking AAA, 72yo F has following hemodynamic findings by pulmonary artery
cath:
Cardiac index: 1.2L/min
MAP: 55 (N = 80-90)
PCWP: 30 (N=5-16)
CVP: 28 (N=5-8)
Pulmonary arterial pressure: 55/35
IV dopamine begun intraoperatively. Surgery complicated by hypotension, metabolic acidosis, and oliguria.
ECG shows supraventricular and ventricular arrhythmias, each causing hypotension. Cause of these
hemodynamic findings?
- Cardiogenic shock
22. 67yo M with aching in the calves while walking during the past 2 months, relieved by rest. Decreased
pedal pulses. Symptoms due to narrowing of?
- femoropopliteal arteries
23. 16yo girl comatose next to a suicide note. Unresponsive. Temp 37.2C, p 100/min, resp 28/min, BP 100/66.
Pupils reactive to light; doll's eye reflex present. Labs: Na 140, Cl 104, K 3.5, HCO3 6. ABG: pH 7.32, Pco2:
12; Po2: 92. What substance had she used in her suicide attempt?
- Aspirin
24. 72yo M with decreased UOP 2 days after Rx for cholecystitis. UOP has been 15 mL/h for 3 hours. On
admission, results showed gram neg bacteremia and DIC. CUrrently receiving IV fluids, cefoxitin, and
gentamicin. Temp 38.5C, Pulse 110/min, resp 24/min, BP 90/64. Mild RUQ tenderness. Serum Cr increased
from 1.5 2 days ago to 3. Urinalysis findings?
- ?? It's NOT A, but could be D: Blood 1+, Protein 1+, RBC 0-5, WBC 0-5, Casts pigmented granular, Other
microscopic findings renal tubular epithelial cells. ATN due to gentamicin.


16
25. 27yo primi F at 39 weeks' admitted in labor. spontaneous ROM 1 hour ago. Cervix was 3 cm dilated
and vertex at -1 station. Point A on labor curve shown, FHR tracing shows recurrent late decels and decreased
variability. Most appropriate next step in management?
- Cesarean delivery
26. 24yo F with pain in th eleft hemithorax for 2 days; the pain began after she moved heavy furniture. The
pain is worse with inspiration. She has used an oral contraceptive for 16 years and smoked 1 pack daily for 18
yrs. Pulse 110/min, resp 24/min, BP 110/70. Lungs clear, tenderness to palpation lateral to the sternum on the
left. Cardiac exam normal. Dx?
- Costochondritis
27. Missing this question
28. 37yo F with 1-year hx of irregular menses, occurring at irregular 3-month intervals and lasted for 10 days
with moderately heavy flow. No hx of illness and no meds. BMI 24, Temp 37.1C, pulse 70/min, resp 12/min,
BP 90/50. Visual field test shows outer field deficits bilaterally. Milky white discharge from both breasts.
Stool for occult blood is neg. Prolactin concentration is 40 ng/mL. MRI of the brain shows pituitary
microadenoma. Most appropriate next step in management?
- Bromocriptine therapy
29. Five days after open splenectomy for ITP, 57yo F has SOB. Only med is morphine. Temp 37.3C, p
80/min, resp 20/min, BP 120/80. Surgical wound appears normal. BS decreased at left lung base. WBC
15.6K, platelets 112k, amylase is 90U/L. Most appropriate next step in management?
- CXR
30. 19yo African American man with 9-month Hx of watery diarrhea associated with abdominal cramps and
bloating. Has occasionally had diarrhea after meals since age of 12, but has been worse since he started
college 1 year ago. Exam shows no abnormalities. Cause of diarrhea?
- ?? Answer is NOT "immunologic damage to the microvilli of the bowl," so I'm assuming it's " Digestive
enzym deficiency"
31. 42yo F left eye is red since she awoke 4 hours ago. NO changes in vision and no trauma. NO meds. BP
110/70. Left eye is shown. Visual acuity 20/20 in both eyes, pupils equal and reactive. Most appropriate next
step in management?
- Reassurance
32. 72yo M for follow-up exam 4 weeks after 10-day quinolone Rx for UTI. Has been drinking 12 to 15
glasses of water daily to prevent another infection. 30-year hx of schizoaffective d/o. On Reisperidone.
Oriented to person but not to place or time. P 80/min, BP 128/60, with no orthostatic changes. Exam shows
dry oral mucosa and no JVD. Lungs clear. No peripherla edema. Muscle strength 5/5, sensation intact.
Reflexes 1+ bilaterally. Labs: Na 122, K 4, Cl 94, HCO3 22, BUN 16, Cr 1.1; Urine: blood neg, glucose neg,
protein neg, sodium 20, osmolality 200. Cause of hyponatremia?
- Psychogenic polydipsia