Name

American Board of Family Practice

IN-TRAINING EXAMINATION
BOOK I: MULTIPLE-CHOICE QUESTIONS
TIME3 HOURS
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1. A 3-year-old white female is brought to your office because she is complaining of pain in her right
arm. Her mother tells you the pain began after she pulled her daughter by the arm while the girl
was fighting with her brother. You examine the child and diagnose nursemaids elbow.
You recommend which one of the following?
A)
B)
C)
D)

Manipulation of the forearm to reduce radial head subluxation

Long arm cast immobilization
Use of a sling for arm rest
A cock-up wrist splint

2. A 39-year-old African-American multigravida at 36 weeks gestation presents with a temperature

of 40.0 C (104.0 F), chills, backache, and vomiting. On physical examination, the uterus is
noted to be nontender. There is slight bilateral costovertebral angle tenderness. A urinalysis
reveals many leukocytes, some in clumps, as well as numerous bacteria.
Of the following, the most appropriate therapy at this time would be
A)
B)
C)
D)
E)

oral trimethoprim/sulfamethoxazole (Bactrim, Septra)

oral nitrofurantoin (Macrodantin)
oral levofloxacin (Levaquin)
intravenous doxycycline (Vibramycin)
intravenous ceftriaxone (Rocephin)

3. A painful thrombosed external hemorrhoid diagnosed within the first 24 hours after occurrence
is ideally treated by
A)
B)
C)
D)
E)

appropriate antibiotics
office banding
office cryotherapy
thrombectomy under local anesthesia
total hemorrhoidectomy

4. A 10-year-old female presents with a mildly itchy rash of 10 days duration. She had
streptococcal pharyngitis 2 weeks ago. A red, papular rash with scaling is present on the trunk
and proximal extremities. The lesions are 13 cm in diameter.
This presentation is most consistent with
A)
B)
C)
D)
E)

scarlet fever
guttate psoriasis
atopic dermatitis
scabies
erythema marginatum

5. An anxious and agitated 18-year-old white male presents to your office with a 2-hour history of
severe muscle spasms in the neck and back. He was seen 2 days ago in a local emergency
department with symptoms of gastroenteritis, treated with intravenous fluids, and sent home with
a prescription for prochlorperazine (Compazine) suppositories.
The best therapy for this problem is intravenous administration of
A)
B)
C)
D)
E)

atropine
diphenhydramine (Benadryl)
haloperidol (Haldol)
succinylcholine (Anectine)
carbamazepine (Tegretol)

6. A healthy 68-year-old white male comes to your office for a health maintenance visit. He tells
you he last saw a physician 6 years ago, and he recalls receiving a flu shot and a pneumonia
shot at that time.
According to current Centers for Disease Control (CDC) recommendations for giving
pneumococcal vaccine (Pneumovax) in the elderly, this patient should be revaccinated
A)
B)
C)
D)
E)

every 5 years
every 3 years
yearly
once
never

7. A 35-year-old white female comes to your office with a 3-month history of the gradual onset of
pain and tenderness in the wrists and hands. She also complains of 1 hour of morning stiffness.
She denies rash, fever, or skin changes. On physical examination she has symmetric swelling of
the proximal interphalangeal joints and metacarpophalangeal joints. Motion of these joints is
painful. She has no rash or mouth ulcers. Radiographs of the hands and wrists are negative, and
a chest film is unremarkable. Her CBC is normal, but the erythrocyte sedimentation rate is
elevated at 40 mm/hr. Latex fixation for rheumatoid factor is negative, and an antinuclear
antibody (ANA) test is negative.
The most likely diagnosis in this patient is
A)
B)
C)
D)
E)

rheumatoid arthritis
systemic lupus erythematosus
sarcoidosis
Lyme disease
calcium pyrophosphate deposition disease

8. Contraindications to thrombolytic therapy in acute stroke include which one of the following?
A)
B)
C)
D)

Age >80
Resolving transient ischemic attack
Blood glucose >200 mg/dL
Deficit present for >1 hour

9. Now that the blood supply is routinely screened for antibody to hepatitis C virus (HCV), what has
become the leading mode of transmission of HCV?
A)
B)
C)
D)
E)

Injection drug use

Sexual transmission
Perinatal maternal-child transmission
Occupational exposure of health-care workers
Household and day-care contact

10. A 33-year-old white female comes to your office accompanied by her spouse. In the last 9 months
she has withdrawn from a masters degree program and has requested a leave of absence from her
job as a teacher. Her husband says that she no longer will accept social engagements, and that she
was formerly highly active in church and teaching Sunday school, but has also withdrawn from
these activities. Her marriage remains strong, she sleeps well, and she continues independent
running and cycling.
Which one of the following would be appropriate as initial treatment?
A)
B)
C)
D)
E)

Lithium
Paroxetine (Paxil)
Haloperidol (Haldol)
Alprazolam (Xanax)
Trazodone (Desyrel)

11. A 70-year-old Asian male presents with hematochezia. He has stable vital signs. Lower
endoscopy is performed, but is unsuccessful due to active bleeding.
Which one of the following would be the next appropriate investigation?
A)
B)
C)
D)
E)

An abdominal CT scan
A barium enema
A technetium-99m blood pool scan
Exploratory laparotomy
A small-bowel radiograph

12. A 24-year-old primiparous female delivered a 4200-g (9 lb 4 oz) male infant after a prolonged
18-hour labor requiring oxytocin (Pitocin) augmentation. A vacuum-assisted delivery was
performed because of maternal exhaustion, and the mother required repair of a third degree
perineal laceration. Thirty minutes after you leave the delivery room, the delivery nurse calls you
urgently to report that the mothers blood pressure is 80 mm Hg systolic and that the bed is soaked
with blood.
The most likely cause of this problem is
A)
B)
C)
D)

occult cervical lacerations

uterine atony
uterine rupture
disseminated intravascular coagulopathy

13. A 75-year-old white male with well-controlled type 2 diabetes mellitus is scheduled for an
abdominal CT scan with oral and intravenous iodinated contrast. Which one of the following
medications should be withheld 48 hours before and after the procedure?
A)
B)
C)
D)
E)

Glyburide (Micronase, DiaBeta)

Glipizide (Glucotrol)
Acarbose (Precose)
Metformin (Glucophage)
Rosiglitazone (Avandia)

14. A 48-year-old unemployed house painter presents to the emergency department with a gradual
onset of lethargy and weakness. A physical examination is remarkable for 4+ pitting edema of
the lower extremities and a prominent abdomen.
Laboratory Findings
Serum sodium . . . . . . . . . . . . . . . .
Serum osmolality . . . . . . . . . . . . .
Urine sodium . . . . . . . . . . . . . . . .
Urine osmolality . . . . . . . . . . . . . .

122 mEq/L (N 135145)

260 mOsm/kg H2 O (N 280296)
5 mEq/L
250 mOsm/kg H2 O

The most likely diagnosis in this case is

A)
B)
C)
D)
E)

syndrome of inappropriate antidiuretic hormone (SIADH)

primary polydipsia
adrenal insufficiency
cirrhosis
salt-wasting nephropathy

15. Cutaneous larva migrans is transmitted via

A)
B)
C)
D)
E)

contaminated food
contaminated drinking water
aerosol inhalation
skin contact with soil
mosquitoes

16. For long-term therapy, the most effective control of heart rate in atrial fibrillation, both at rest and
with exercise, occurs with which one of the following?
A)
B)
C)
D)

Digitalis
$-Adrenergic blockers
Calcium channel blockers
Class 1A antiarrhythmics

17. Which one of the following statements about genital human papillomavirus (HPV) infection is
true?
A) Cervical cancer and genital warts result from the same HPV types
B) A single sexual encounter with a person infected with external genital warts carries a
low risk of infection
C) Direct culture of cervical lesions is the most accurate diagnostic method
D) The most important risk factor for acquiring HPV infection is a history of multiple
sexual partners
18. Assuming other appropriate measures are used (e.g., automatic antidecubitus mattresses, local
care, etc.), which one of the following represents the patient positioning most beneficial in the
care of a sacral decubitus ulcer?
A)
B)
C)
D)

Alternating right and left 30 (oblique) positions

Alternating right and left 90 (lateral) positions
Alternating lateral and oblique positions
Alternating supine, oblique, and lateral positions

19. Which vitamin deficiency is most likely in a child who is fed a strict vegetarian diet which
excludes meat, eggs, and dairy products?
A)
B)
C)
D)

Vitamin A
Vitamin B1
Vitamin B12
Vitamin C

20. An 18-year-old patient presents with his father for a pre-college physical examination. The
student plans to attend college in a nearby state and will live in a university-owned residence hall.
A review of his record shows that he received all of the currently recommended immunizations
on time throughout childhood.
The benefits of vaccination against which one of the following organisms should be discussed
during this visit?
A)
B)
C)
D)
E)

Measles
Tetanus
Pertussis
Meningococcus
Polio

21. A 62-year-old white female comes to see you for her annual pelvic examination. You find a
nontender, cystic left adnexal mass. The patient is asymptomatic and otherwise in good health,
and has no other pelvic abnormalities. Transvaginal ultrasonography demonstrates a 5-cm
septated left ovarian cyst. Her CA-125 level is 120 U/mL (N <35).
The best management option is to
A)
B)
C)
D)

repeat the clinical examination in 3 months

repeat the ultrasonography and CA-125 level in 3 months
repeat the ultrasonography every 3 months for 1 year
treat with estrogen plus progestin for 3 months, then repeat the ultrasonography and
CA-125 level
E) refer for surgical consultation
22. A 1-week-old white male is brought to your office because of irritability. The physical
examination is normal except for a suprapubic mass. When the mother is questioned, she tells you
that the infant has a dribbling urinary stream.
The most likely diagnosis is
A)
B)
C)
D)
E)

Wilms tumor
posterior urethral valves
urinary tract infection
spina bifida occulta involving the sacral plexus
horseshoe kidney

23. Which one of the following statements concerning insomnia is correct?

A) There is little correlation between insomnia and depression
B) Daytime drowsiness, excessive snoring, and confusion if awakened from sleep are
associated with restless legs syndrome
C) Getting up at the same time every day can increase the restfulness of sleep
D) Patients must take hypnotic drugs for a prolonged period to cure insomnia
E) Insomnia rarely occurs in the elderly

24. A 75-year-old white female develops deep-vein thrombosis of the left leg 1 week after hip surgery.
The patient is started on lowmolecular-weight heparin (Lovenox).
Daily monitoring while the patient is on lowmolecular-weight heparin should include which one
of the following?
A)
B)
C)
D)

Prothrombin time
Partial thromboplastin time
Fibrinogen levels
No routine coagulation tests

25. When considering therapy for the obese patient, one should know that the major component of
caloric expenditure is
A) dietary thermogenesis (the energy required for metabolism of food)
B) the basal metabolic rate (the amount of energy required to maintain metabolic
homeostasis)
C) physical activity
D) the negative-feedback response of growth hormone and cortisol to the ingestion of food
26. Which one of the following is the most appropriate screening test for vesicoureteral reflux in the
initial evaluation of a child with a urinary tract infection?
A)
B)
C)
D)
E)

Renal ultrasonography
Intravenous pyelography (IVP)
Voiding cystourethrography (VCUG)
A technetium-99m dimercaptosuccinic acid (DMSA) renal flow scan
Nuclear cystography

27. An 18-year-old white nulliparous student comes to your office. She had unprotected intercourse
within the past 24 hours and does not want to become pregnant.
You explain all options, including nonintervention. She decides she does not want to be pregnant
and requests emergency contraception.
Of the following, which one would be the most appropriate, effective, and best tolerated for this
patient?
A)
B)
C)
D)

Diethylstilbestrol, 50 mg twice a day for 5 days

High-dose combination oral contraceptives, 2 pills now and 2 pills in 12 hours
Immediate insertion of an intrauterine device
Endometrial aspiration

28. Which one of the following is true regarding routine prenatal screening ultrasonography before
24 weeks gestation?
A)
B)
C)
D)
E)

It has been shown to reduce maternal mortality

It has been shown to reduce perinatal mortality
It has been associated with increased hearing abnormalities in infants
It has been associated with better Apgar scores in infants at 1 minute of life
It has not been proven to have any significant benefits

29. Once the diagnosis of anorexia nervosa is established, the most important initial goal of treatment
is
A) to prevent the patient from dying from complications of malnutrition
B) to treat the patients depression in order to prevent death by suicide
C) to rapidly correct problems with body image and performance-driven perfectionist
behavior, using intense psychotherapy
D) to correct dysfunctional family system dynamics that are at the heart of the problem,
using intense family therapy
30. A 45-year-old white male comes to your office with a 2-day history of pain and swelling in the
right testicle. He has no dysuria or urinary frequency, and denies any sexual contact except with
his wife. On examination you note tenderness in the right posterior aspect of the right testicle,
along with some swelling and erythema of the overlying scrotal skin.
Which one of the following is true regarding this situation?
The most likely etiologic agent is Chlamydia trachomatis
Immediate surgical referral is indicated
Anaerobic bacteria are the infecting agents in most cases
The patient should be treated symptomatically until results from a urethral culture are
available
E) Antibiotic therapy should include coverage for coliform bacteria
A)
B)
C)
D)

31. In which one of the following clinical situations would it be most appropriate to use a $-blocker
that has intrinsic sympathomimetic activity, such as acebutolol (Sectral) or pindolol (Visken)?
A) As a cardioprotective agent post myocardial infarction
B) In a hypertensive patient with symptomatic bradycardia while taking metoprolol
(Lopressor)
C) In a hypertensive patient with diabetes mellitus
D) In a hypertensive patient with asthma
E) To maintain sinus rhythm in a patient with chronic atrial fibrillation

32. For the past 3 days, an 11-year-old white male has had several small, circular lesions on the left
side of his lower forehead and nose, extending to the tip of the nose. On examination you note
grouped vesicles, several of which are scabbed. The patient also complains of burning pain in the
area of the lesions. He had a sore throat with a fever 5 days ago, but is now improved. His
stepfather reports he is up-to-date on immunizations, but a specific immunization record is not
available. His history and examination are otherwise unremarkable.
The most likely diagnosis is
A)
B)
C)
D)
E)

herpes zoster
undetected immune deficiency
primary herpes simplex type 1
impetigo
erythema multiforme

33. A 25-year-old white male exhibits a syndrome of fever, headache, myalgia, and aching joints 3
days after a summer camping trip. He subsequently develops a generalized maculopapular
eruption that initially involves the palms and soles and then becomes hemorrhagic. Splenomegaly
is noted. A protracted 3-week course of the illness occurs in spite of antibiotic therapy and is
followed by gradual resolution of the illness.
Which one of the following is the most likely diagnosis?
A)
B)
C)
D)
E)

Lyme arthritis
Systemic lupus erythematosus in exacerbation
Subacute immune complex disease
Gonococcemia
Rocky Mountain spotted fever

34. A 75-year-old male complains of pain with defecation, and loose stools. This problem seems to
have developed gradually over the last several months. His past medical history includes prostate
cancer treated with radiation therapy 5 years ago, hypertension, and osteoarthritis. Medications
include hydrochlorothiazide (HydroDIURIL), a $-blocker, and acetaminophen. On colonoscopy,
no polyps or cancer are found, but the rectal and sigmoid areas show pallor with friability and
telangiectasias.
The most likely diagnosis is
A)
B)
C)
D)
E)

familial angiodysplasia
Osler-Weber-Rendu syndrome
radiation proctitis
late-onset ulcerative colitis
sensitivity to acetaminophen breakdown products

35. Erythema infectiosum (fifth disease) is caused by which one of the following?
A)
B)
C)
D)
E)

Mycoplasma
Parvovirus B19
Herpes simplex virus
Streptococcus
An unknown virus

36. A 27-year-old female complains of palpitations. Your clinical evaluation finds no abnormalities.
You recommend that she discontinue her daily regimen of 34 cups of regular coffee.
Which one of the following symptoms is she most likely to develop?
A)
B)
C)
D)
E)

Anxiety
Depression
Headache
Fatigue
Flu-like illness

37. A 75-year-old white female presents with back pain of several months duration, which is
worsened by movement. Her examination is unremarkable except for mild pallor. She takes
furosemide (Lasix) for hypertension.
Laboratory Findings
Hemoglobin . . . . . . . . . . . . . . . . .
Serum creatinine . . . . . . . . . . . . . .
BUN . . . . . . . . . . . . . . . . . . . . . . .
Serum uric acid . . . . . . . . . . . . . . .
Serum calcium . . . . . . . . . . . . . . .
Total serum protein . . . . . . . . . . .
Globulin . . . . . . . . . . . . . . . . . .
Albumin . . . . . . . . . . . . . . . . . .
Serum IgG . . . . . . . . . . . . . . . . . . .
Urine . . . . . . . . . . . . . . . . . . . . . . .

10.0 g/dL (N 12.016.0)

2.0 mg/dL (N 0.61.5)
40 mg/dL (N 825)
8.0 mg/dL (N 3.07.0)
12.0 mg/dL (N 8.510.5)
9.8 g/dL (N 6.08.4)
6.1 g/dL (N 2.33.5)
3.7 g/dL (N 3.55.0)
3700 mg/dL (N 6391349)
positive for Bence-Jones protein

Which one of the following would be most appropriate at this point?

A)
B)
C)
D)
E)

Repeat the physical examination and laboratory evaluation every 6 months

Take the patient off the diuretic and repeat the laboratory evaluation in 1 month
Obtain a bone scan
Obtain a bone marrow examination
Begin therapy with tamoxifen (Nolvadex), 20 mg daily

10

38. A 40-year-old runner complains of gradually worsening pain on the lateral aspect of his foot. He
runs on asphalt, and has increased his mileage from 2 miles/day to 5 miles/day over the last 2
weeks. Palpation causes pain over the lateral 5th metatarsal. The pain is also reproduced when
he jumps on the affected leg. When you ask about his shoes he tells you he bought them several
years ago.
Which one of the following is the most likely diagnosis?
A)
B)
C)
D)

Ligamentous sprain of the arch

Stress fracture
Plantar fasciitis
Osteoarthritis of the metatarsal joint

39. You approach the administrator of your small-town hospital about the possibility of starting a
cardiac rehabilitation program. Which one of the following is true concerning such programs?
A)
B)
C)
D)
E)

Patients should have a baseline exercise stress test before starting cardiac rehabilitation
A standard exercise prescription is appropriate for all cardiac patients
Cardiac rehabilitation has no effect on coronary risk factors
Cardiac rehabilitation has no effect on exercise capacity
Coronary events are frequent in rehabilitation settings

40. A 5-month-old infant has had several episodes of wheezing, not clearly related to colds. The
pregnancy and delivery were normal; the infant received phototherapy for 1 day for
hyperbilirubinemia. He had an episode of otitis media 1 month ago. There is no chronic runny
nose or strong family history of asthma. He spits up small amounts of formula several times a
day, but otherwise appears well. His growth curve is normal. An examination is unremarkable
except for mild wheezing.
Which one of the following is the most likely diagnosis?
A)
B)
C)
D)
E)

Benign reactive airway disease of infancy

Cystic fibrosis
Unresolved respiratory syncytial virus infection
Early asthma
Gastroesophageal reflux

41. Which one of the following clinical presentations is most consistent with vitamin D deficiency
in the aged?
A)
B)
C)
D)
E)

Rapidly progressive osteoarthritis

Development of chronic bone pain and weakness in association with bone loss
Bleeding gums and fatigue
High-output cardiac failure with dermatitis and neuropathy
Diarrhea, dermatitis, and dementia

11

42. A 26-year-old white female presents to you 5 weeks after her last menstrual period with the
complaint of painless spotting for 2 days. She has not been using contraception and is trying to
conceive. She had regular menses until her last menstrual period, and a home pregnancy test was
positive 5 days ago. Her only previous pregnancy, 4 years ago, was electively terminated at 8
weeks gestation. Her past history is significant for an episode of presumed salpingitis treated with
intravenous antibiotics 2 years ago.
Physical Findings
Abdomen . . . . . . . . . . . . . . . . . . .
Vagina . . . . . . . . . . . . . . . . . . . . . .
Cervix . . . . . . . . . . . . . . . . . . . . . .
Bimanual . . . . . . . . . . . . . . . . . . . .

nontender
small amount of dark blood in the posterior
fornix
no active bleeding
uterus slightly enlarged, adnexa nontender,
no masses

Laboratory Findings
Urine pregnancy test . . . . . . . . . . .
$-hCG . . . . . . . . . . . . . . . . . . . . . .
Vaginal ultrasonography . . . . . . .

positive
1400 mIU/mL
3-mm sac with no definite fetal contents,
adnexa negative

The most appropriate action at this point is to

A)
B)
C)
D)

refer the patient for laparoscopy because of the possibility of ectopic pregnancy
perform dilatation and curettage
instruct the patient to return in 4 weeks
instruct the patient to call if she develops pain or increased bleeding; otherwise repeat
the $-hCG in 23 days
E) administer progesterone, 100 mg intramuscularly, and repeat the $-hCG in 23 days
43. Which one of the following is CONTRAINDICATED with circumcisions?
A)
B)
C)
D)

Local application of lidocaine 2.5%/prilocaine 2.5% cream (EMLA)

A penile block using 1% mepivacaine (Carbocaine)
A penile block using 1% lidocaine (Xylocaine)/epinephrine
A penile block using 0.25% bupivacaine (Sensorcaine)

44. What is the prevalence of microscopic carcinoma of the prostate among 80-year-old males
examined in autopsy studies?
A)
B)
C)
D)
E)

3%
10%
20%
40%
70%

12

45. For several years, a hypertensive 65-year-old female has been treated with hydrochlorothiazide
(HydroDIURIL), 25 mg/day; atenolol (Tenormin), 100 mg/day; and hydralazine (Apresoline),
50 mg 4 times/day. Her blood pressure has been well controlled on this regimen. Over the past
2 months she has experienced malaise, along with diffuse joint pains that involve symmetric sites
in the fingers, hands, elbows, and knees. A pleural friction rub is noted on examination.
Laboratory testing shows that the patient has mild anemia and leukopenia, with a negative
rheumatoid factor and a positive antinuclear antibody (ANA) titer of 1:640.
Which one of the following would be the most appropriate INITIAL treatment?
A) Discontinue the thiazide diuretic and switch to a loop diuretic such as furosemide
(Lasix)
B) Discontinue the hydralazine
C) Begin treatment with prednisone, 40 mg/day orally
D) Treat with hydroxychloroquine (Plaquenil), 400 mg/day
E) Obtain renal function studies and anticipate that a renal biopsy will be needed
46. A 27-year-old white male has been in rehabilitation for C6 complete quadriplegia. His health had
been good prior to a diving accident 2 months ago which caused his paralysis. The patient has
been catheterized since admission and his recovery has been steady. His vital signs have been
normal and stable.
The nurse calls and tells you that for the past hour the patient has experienced sweating,
rhinorrhea, and a pounding headache. His heart rate is 55/min and his blood pressure is 220/115
mm Hg. His temperature and respirations are reported as normal. There has been no vomiting
and his neurologic examination is unchanged.
The most likely diagnosis is
A)
B)
C)
D)
E)

cluster headache
autonomic hyperreflexia
sepsis
intracranial hemorrhage
progression of the spinal cord lesion

47. A 40-year-old white male is having rapid mood changes, and his speech is pressured and difficult
to interpret. These findings suggest
A)
B)
C)
D)
E)

obsessive-compulsive disorder
manic episode
paranoid schizophrenia
borderline personality
antisocial personality

13

48. A 70-year-old white female comes to your office for an initial visit. She has taken levothyroxine
(Synthroid), 0.3 mg/day, for the last 20 years. Although a recent screening TSH was fully
suppressed at <0.1 :U/mL, she claims that she has felt awful when previous physicians have
attempted to lower her dosage.
You explain that a serious potential complication of her current thyroid medication is
A)
B)
C)
D)
E)

adrenal insufficiency
carcinoma of the ovary
carcinoma of the thyroid
hip fracture
renal failure

49. You diagnose varicella in the two preschool children of a 28-year-old patient. She has no history
of having had the disease, and serology done in your office confirms her lack of immunity. A
pregnancy test is also negative and you tell her to return for a varicella vaccination, which she
does the following week.
She returns after 5 weeks because a home pregnancy test is now positive, and a pregnancy test in
your office is also positive. She is concerned about the effect of varicella vaccine on the fetus.
Which one of the following would be the most accurate advice?
A)
B)
C)
D)

There is little likelihood of a problem

She should receive varicella zoster immune globulin (VZIG) to protect the fetus
She has a high likelihood of having a spontaneous abortion
Women receiving varicella vaccine during the first trimester are likely to have children
with congenital varicella
E) Her risk of problems would be much higher in the second or third trimester
50. Of the following, the best laboratory study to evaluate nutritional status in an elderly patient is
A)
B)
C)
D)
E)

folate levels
iron studies
serum creatinine
serum albumin
serum electrolytes

51. Which one of the following is associated with a decreased risk for ovarian cancer?
A)
B)
C)
D)
E)

Use of fertility drugs

Use of oral contraceptives
Nulliparity
Postmenopausal hormone replacement therapy
Age >50

14

52. A 72-year-old white male diabetic presents with a 2-day history of dyspnea and decreased urine
output. Five days ago coronary angiography revealed the absence of coronary artery obstruction
and an ejection fraction of 40%. There has been no chest discomfort since that procedure. He
underwent abdominoperineal resection for anal cancer 3 years ago.
On examination his blood pressure is 180/92 mm Hg. Chest auscultation reveals basilar crackles.
His abdomen is round and nontender.
Laboratory Findings
Plasma creatinine . . . . . . . . . . . . .
BUN . . . . . . . . . . . . . . . . . . . . . . .
Glucose . . . . . . . . . . . . . . . . . . . . .
Potassium . . . . . . . . . . . . . . . . . . .
Sodium . . . . . . . . . . . . . . . . . . . . .
EKG . . . . . . . . . . . . . . . . . . . . . . .

3.3 mg/dL (N 0.61.5)

42 mg/dL (N 825)
184 mg/dL
5.6 mEq/L (N 3.55.0)
136 mEq/L (N 135145)
sinus rhythm without change

All current abnormal laboratory values were normal 7 days ago. Which one of the following
diagnostic tests would carry the greatest risk for this patient?
A)
B)
C)
D)
E)

Intravenous pyelography (IVP)

Catheterized urine for residual volume
A spiral CT scan
Ultrasonography of the kidneys and bladder
Fractional excretion of sodium

53. A 56-year-old African-American male with longstanding hypertension and a 30-pack-year

smoking history has a 2-day history of dyspnea on exertion. Physical examination is
unremarkable except for rare crackles at the bases.
Which one of the following serologic tests would be most helpful for detecting left ventricular
dysfunction?
A)
B)
C)
D)
E)

$-Natriuretic peptide (BNP)

Troponin-T
C-reactive protein (CRP)
D dimer
Cardiac interleukin-2

54. Prior to performing a peripheral nerve block of the median nerve at the level of the wrist, you
determine that the anesthetic effect should last for at least 2 hours.
The best agent for this purpose is
A)
B)
C)
D)

procaine (Novocain), 1.5% plain

lidocaine, 1.0% plain
bupivacaine (Marcaine), 0.25% plain
chloroprocaine (Nesacaine), 1.5% plain

15

55. In a day-care center for which you are the medical consultant, two children develop systemic
Haemophilus influenzae type b infections within the same month. You recommend prophylaxis
with which one of the following for all children and staff in the classroom?
A)
B)
C)
D)
E)

Ceftriaxone (Rocephin)
Chloramphenicol (Chloromycetin)
Trimethoprim/sulfamethoxazole (Bactrim, Septra)
Cefaclor (Ceclor)
Rifampin (Rifadin)

56. A healthy 72-year-old female comes to your office for a follow-up visit. She has hypertension
which is well controlled with an ACE inhibitor. Routine laboratory tests are normal except for
a serum calcium level of 10.8 mg/dL (N 8.510.5). A repeat calcium level is 11.1 mg/dL.
Which one of the following would be most appropriate at this point?
A)
B)
C)
D)

Radiographs of the hands

An osteocalcin level
An intact parathyroid hormone (PTH) level
Bone densitometry

57. You are treating a 50-year-old white male for diabetes mellitus and hyperlipidemia. At the time
of his initial presentation 1 year ago, his hemoglobin A1c was 8.0% (N 3.86.4), LDL 130 mg/dL,
HDL 28 mg/dL, and triglycerides 450 mg/dL. After treatment with metformin (Glucophage) and
high-dose simvastatin (Zocor), his most recent laboratory evaluation revealed a hemoglobin A1c
of 6.2%, LDL 95 mg/dL, HDL 32 mg/dL, and triglycerides 300 mg/dL.
The patient has not had any documented coronary or peripheral vascular disease. His family
history is positive for a myocardial infarction in his father at age 55. He is a nonsmoker. He has
a body mass index (BMI) of 28 and has been unable to lose weight. His blood pressure is well
controlled on enalapril (Vasotec).
What is the most appropriate management of his elevated triglycerides?
A) No specific treatment
B) Switch from metformin to a sulfonylurea such as glyburide (Micronase, DiaBeta) or
glipizide (Glucotrol)
C) Addition of a fibrate such as gemfibrozil (Lopid) or fenofibrate (Tricor)
D) Addition of cholestyramine (Questran)
58. Which one of the following is considered a normal change in sexual functioning as men age?
A)
B)
C)
D)
E)

The inability to maintain an erection to ejaculation

An increased need for direct tactile sensation to obtain or maintain an erection
The development of retrograde ejaculation
Decreased time between erections
Greater forcefulness of ejaculation

16

59. A 12-year-old white male asthmatic has an acute episode of wheezing. You diagnose an acute
asthma attack and prescribe an inhaled $2 -adrenergic agonist, but despite 12 hours of treatment
he continues to experience wheezing and shortness of breath.
Which one of the following is the most appropriate addition to acute outpatient management?
A)
B)
C)
D)
E)

Oral theophylline
Oral corticosteroids
An oral $2 -adrenergic agonist
Inhaled cromolyn
Inhaled corticosteroids

60. A 50-year-old white female comes to you because she has found a breast mass. You feel a firm,
fixed, nontender, 2-cm mass during your examination. No axillary nodes are palpable, nor is there
any nipple discharge. You send her for a mammogram, and then have one of your partners who
is skilled in fine-needle aspiration obtain cells for cytologic examination. The mammogram is
read as suspicious and the fine-needle cytology report reads, a few benign ductal epithelioid
cells and adipose tissue.
Which one of the following would be the most appropriate next step?
A)
B)
C)
D)
E)

A repeat mammogram in 3 months

Repeat fine-needle aspiration in 3 months
An excisional biopsy of the mass
Referral for breast irradiation
Referral to a surgeon for simple mastectomy

61. In assessing the nutritional status of an infant it is useful to know that birth weight is expected to
be regained within
A)
B)
C)
D)

5 days
14 days
21 days
28 days

62. A previously alert, otherwise healthy 74-year-old African-American male has a history of slowly
developing progressive memory loss and dementia associated with urinary incontinence and gait
disturbance resembling ataxia. This presentation is most consistent with
A)
B)
C)
D)

normal pressure hydrocephalus

Alzheimers disease
subacute sclerosing panencephalitis
multiple sclerosis

17

63. A 67-year-old female is concerned about osteoporosis. The study of choice for determining
whether or not she has osteoporosis is
A)
B)
C)
D)
E)

dual-energy x-ray absorptiometry (DEXA) of the hip and spine

a quantitative CT scan of the hip and spine
plain radiographs of the hip and spine
ultrasonography of the heel
a DEXA scan of the middle phalanx of the non-dominant hand

64. Within a 2-week period you see an unusually large number of patients of all ages who complain
of painless loss of central vision. You refer them appropriately to an ophthalmologist. The
feedback you get is that most of these persons have bilateral central scotomas caused by an
ophthalmoscopically visible macular defect.
Which one of the following events would most likely explain this problem?
A) A solar eclipse
B) A factory accident exposing persons over a wide area to dangerous levels of carbon
monoxide
C) A severe dust storm
D) The recent winner-take-all boxing tournament
E) The annual community Fourth of July picnic where lots of potato salad was consumed
65. A 65-year-old Hispanic male with known metastatic lung cancer is hospitalized because of
decreased appetite, lethargy, and confusion of 2 weeks duration. Laboratory evaluation reveals
the following:
Serum calcium . . . . . . . . . . . . . . .
Serum phosphorus . . . . . . . . . . . .
Serum creatinine . . . . . . . . . . . . . .
Total serum protein . . . . . . . . . . .
Albumin . . . . . . . . . . . . . . . . . .

15.8 mg/dL (N 8.410.0)

3.9 mg/dL (N 2.64.2)
1.1 mg/dL (N 0.71.3)
7.3 g/dL (N 6.08.0)
4.1 g/dL (N 3.74.8)

Which one of the following is the most appropriate INITIAL management?

A)
B)
C)
D)
E)

Calcitonin (Calcimar) subcutaneously

Pamidronate disodium (Aredia) by intravenous infusion
Normal saline intravenously
Plicamycin (Mithramycin) intravenously
Furosemide (Lasix) intravenously

66. Which one of the following is consistent with spinal stenosis but not herniated vertebral disk?
A)
B)
C)
D)

Numbness
Muscle weakness
Pain relieved by sitting
Pain relieved by standing

18

67. A new drug treatment is shown to reduce the incidence of a complication of a disease by 50%.
If the usual incidence of this complication were 1% per year, how many patients with this disease
would have to be treated with this medication for 1 year to prevent one occurrence of this
complication?
A)
B)
C)
D)
E)

20
50
100
200
500

68. You are attending the delivery of a 34-year-old gravida 2 para 1 with no prenatal complications
who entered spontaneous labor at full term several hours ago. All fetal heart tones have been
reassuring. The head delivers in the occiput anterior position over a posterior midline episiotomy
without problems. However, the delivery stalls with the infants chin pressing against the
perineum. When there is a contraction or the mother attempts to push, the head descends slightly
and then returns to the same position.
After you call for additional assistance, which one of the following should you do first to facilitate
delivery?
A) Apply gradually increasing amounts of traction on the infants head
B) Ask an assistant to apply strong fundal pressure on the mothers abdomen
C) Deliberately fracture the infants anterior clavicle to free it from behind the mothers
pubis
D) Place the mothers knees and hips into extreme flexion onto the abdomen (McRoberts
maneuver)
E) Replace the infants head back inside the birth canal and prepare for immediate cesarean
section (Zavanelli maneuver)
69. A 32-year-old white female marathon runner presents with persistent pain and tenderness over the
pubic symphysis. With exercise, pain is noted in the lower abdomen and medial thighs. There
is no fever. A radiograph shows widening of the pubic symphysis.
What is the most likely diagnosis?
A)
B)
C)
D)

Osteomyelitis of the pubis

Stress fracture of the pubis
Osteitis pubis
Inguinal hernia

70. Physiologic changes in the elderly lead to which one of the following?
A)
B)
C)
D)

Resistance to dehydration
A tendency toward hypernatremia due to diminished thirst response
Lower than usual concentrations of medications distributed in body fluids
Greater than usual required dosages of medications

19

71. A 72-year-old woman cuts herself with a clean knife. The wound is 4 cm long on the volar
surface of the right forearm.
A reliable history of which one of the following would make tetanus toxoid UNNECESSARY at
this time?
A)
B)
C)
D)
E)

Tetanus toxoid 1 year ago

Tetanus toxoid 5 years ago
Tetanus toxoid 11 years ago
Tetanus toxoid 5 years ago and 3 tetanus toxoid shots over her lifetime
Tetanus toxoid 11 years ago and 3 tetanus toxoid shots over her lifetime

72. Which one of the following has proven most useful in preventing vertical transmission of HIV
infection from mother to neonate?
A)
B)
C)
D)
E)

Zidovudine (Retrovir) for both the mother and neonate

Vitamin A supplementation for both the mother and neonate
Vaginal cleansing with chlorhexidine
Minimizing the frequency of cesarean delivery
Breastfeeding for at least the first month of life

73. Travelers diarrhea can be effectively treated in the great majority of cases by a 3-day course of
A)
B)
C)
D)

erythromycin
penicillin V
sulfacetamide (Sultrin)
ciprofloxacin (Cipro)

74. A 28-year-old gravida 2 para 1 presents to the emergency department at 16 weeks gestation. She
has noted the sudden onset of dyspnea, pleuritic chest pain, and mild hemoptysis. Both calves are
mildly edematous and somewhat tender. A lung scan shows a high probability of pulmonary
emboli.
Which one of the following would be appropriate management at this time?
A) Placement of an inferior venous umbrella filter
B) Intravenous heparin for 510 days followed by subcutaneous heparin for the duration
of the pregnancy
C) Intravenous heparin for 510 days followed by warfarin anticoagulation
D) Warfarin therapy only, with the prothrombin time maintained at 1820 seconds (INR
2.03.0)
E) Aspirin, 81 mg/day throughout the pregnancy

20

75. A 72-year-old female is found to have a complex splenic mass on a CT scan done for another
reason. Because of concerns regarding possible malignancy and the potential for spontaneous
splenic rupture, an elective splenectomy is planned.
Which one of the following immunizations should be given prior to her surgery?
A)
B)
C)
D)
E)

Pneumococcal vaccine (Pneumovax)

MMR
Influenza vaccine
Tetanus vaccine
Yellow fever vaccine

76. In a patient taking a selective serotonin reuptake inhibitor (SSRI), addition of bupropion
(Wellbutrin) should be considered if the patient develops which one of the following side effects?
A)
B)
C)
D)

Dystonia
Nausea
Headache
Sexual dysfunction

77. A 53-year-old white female undergoes abdominal ultrasonography for suspected gallbladder
disease. A 3-cm thin-walled, fluid-filled cyst is seen on the left kidney.
Which one of the following would be most appropriate at this time?
A)
B)
C)
D)
E)

A renal contrast CT scan

Ultrasound-guided percutaneous aspiration/biopsy
An MRI scan of the retroperitoneum
Urology consultation for preoperative staging
No further intervention

78. A 3-month-old infant is brought to your office with small pustules on the soles of the feet and a
few similar lesions on the palms of her hands. Scabies is identified in scrapings of the lesions.
You should
A) prescribe 1% lindane (Kwell) to be applied from the neck down and left on for 812
hours
B) prescribe permethrin (Elimite) 5% cream to be applied to the entire body, including the
scalp
C) prescribe 10% crotamiton (Eurax) cream to be applied to the extremities and trunk for
24 hours
D) prescribe 6% sulphur in petrolatum to be applied for 24 hours
E) recommend that all family clothing be dry-cleaned to prevent recurrent infestation

21

79. A 75-year-old female presents with a 1-month history of pain in her hips and shoulders bilaterally,
accompanied by marked stiffness in the mornings. In addition, she reports a 4-lb weight loss and
fatigue. She denies fever, chills, sweats, nausea, vomiting, swallowing disturbances, or changes
in bowel habits. She specifically denies any visual symptoms or headache. Her physical
examination is unremarkable, except for changes suggestive of osteoarthritis in the knees and
hands. Laboratory testing reveals a hemoglobin level of 11.8 g/dL (N 13.016.0), a hematocrit
of 36% (N 4045), and an erythrocyte sedimentation rate of 84 mm/hr (N <20).
What is the most appropriate management at this point?
A) Begin prednisone, 60 mg daily, and refer for a temporal artery biopsy as soon as
possible
B) Begin prednisone, 60 mg daily, and plan to refer for a temporal artery biopsy if her
symptoms do not respond
C) Begin prednisone, 15 mg daily, with no plans for a biopsy
D) Begin a COX-2 inhibitor such as rofecoxib (Vioxx), with no plans for a biopsy
E) Refer for a temporal artery biopsy and wait for the results before starting drug therapy
80. You see a 23-year-old gravida 1 para 0 for her prenatal checkup at 38 weeks gestation. She
complains of severe headaches and epigastric pain. She has had an uneventful pregnancy to date
and had a normal prenatal examination 2 weeks ago. Her blood pressure is 140/100 mm Hg. A
urinalysis shows 2+ protein; she has gained 5 lb in the last week, and has 2+ pitting edema of her
legs.
The most appropriate management at this point would be
A) strict bed rest at home and reexamination within 48 hours
B) admitting the patient to the hospital for bed rest and frequent monitoring of blood
pressure, weight, and proteinuria
C) admitting the patient to the hospital for bed rest and monitoring, and beginning
hydralazine (Apresoline) to maintain blood pressure below 140/90 mm Hg
D) admitting the patient to the hospital, treating with parenteral magnesium sulfate, and
planning prompt delivery either vaginally or by cesarean section
81. The physician counseling a 4-year-old child about the death of a loved one should keep in mind
that children in this age group
A)
B)
C)
D)
E)

often feel no sense of loss

often believe they are somehow responsible for the death
should not attend a funeral
should usually be told the loved one is having a long sleep
usually accept the finality of death with little question

22

82. Use of the artificial sweetener aspartame (NutraSweet) is contraindicated in patients who have
A)
B)
C)
D)

galactosemia
homocystinuria
orotic aciduria
phenylketonuria

83. A 67-year-old Hispanic male comes to your office with severe periumbilical abdominal pain,
vomiting, and diarrhea which began suddenly several hours ago. His temperature is 37.0 C
(98.6 F), blood pressure 110/76 mm Hg, and respirations 28/min. His abdomen is slightly
distended, soft, and diffusely tender; bowel sounds are normal. Other findings include clear lungs,
a rapid and irregularly irregular heartbeat, and a pale left forearm and hand with no palpable left
brachial pulse. Right arm and lower extremity pulses are normal. Urine and stool are both
positive for blood on chemical testing. His hemoglobin level is 16.4 g/dL (N 13.018.0) and his
WBC count is 25,300/mm3 (N 430010,800).
The diagnostic imaging procedure most likely to produce a specific diagnosis of his abdominal
pain is
A)
B)
C)
D)
E)

intravenous pyelography (IVP)

sonography of the abdominal aorta
a barium enema
celiac and mesenteric arteriography
contrast venography

84. For 2 weeks, a 62-year-old male with biopsy-documented cirrhosis and ascites has had diffuse
abdominal discomfort, fever, and night sweats. His current medications are furosemide (Lasix)
and spironolactone (Aldactone). On examination, his temperature is 38.0 C (100.4 F), blood
pressure 100/60 mm Hg, heart rate 92 beats/min and regular. The heart and lung examination is
normal. The abdomen is soft with vague tenderness in all quadrants. There is no rebound or
guarding. The presence of ascites is easily verified. Bowel sounds are quiet. The rectal
examination is normal, and the stool is negative for occult blood.
You perform diagnostic paracentesis and send a sample of fluid for analysis. Which one of the
following findings would best establish the suspected diagnosis of spontaneous bacterial
peritonitis?
A)
B)
C)
D)
E)

pH <7.2
Bloody appearance
Neutrophil count >300/mL
Positive cytology
Total protein >1 g/dL

23

85. When evaluating a patient on chronic phenytoin (Dilantin) therapy for a seizure disorder, which
one of the following is a sign of toxicity?
A)
B)
C)
D)
E)

Peripheral neuropathy
Ataxia
Clonus
Ballistic movements
Photophobia

86. A 70-year-old white male whom you are treating for hypertension has several abnormal liver
function tests. He is a nondrinker and is not taking any prescription medications likely to cause
hepatotoxicity. However, during more extensive history taking, he tells you that he does use some
over-the-counter medications.
Which one of these is most likely responsible for the abnormal laboratory findings?
A)
B)
C)
D)
E)

Aspirin, used occasionally for headache

A fiber supplement taken to promote regular bowel habits
One long-acting niacin tablet per day
One 250-mg vitamin C tablet daily
Chewable simethicone after meals, almost daily

87. A 40-year-old African-American female presents to your office complaining of a persistent dry
cough for the last 3 months. This seemed to start with a bad chest cold. She went to an
urgent-care facility 6 weeks ago and the physician prescribed albuterol (Proventil, Ventolin) by
metered-dose inhaler empirically for presumed reactive airways disease. This did not help. Now
she also reports dyspnea on exertion that is noticeable when walking uphill. She has been taking
nitrofurantoin (Macrodantin) for chronic urinary tract infections, but has an otherwise negative
history. She works as a legal secretary.
On examination, she is tachypneic. There is no cyanosis or clubbing. Her lungs are clear. Her
height is 160 cm (63 in) and her weight is 60 kg (132 lb). Office pulmonary function tests reveal
a forced vital capacity (FVC) of 1.4 L (average 3.3) and a 1-second forced expiratory volume
(FEV1 ) of 1.6 L (average 2.8). An inhaled bronchodilator produces no improvement in these
numbers.
Which one of the following is the most likely cause of her problem?
A)
B)
C)
D)

Chronic asthma
Persistent coughing resulting from a viral respiratory illness
Cardiac disease
Interstitial lung disease

24

88. A 38-year-old white male wants to go to New Mexico to ski. In the past he has experienced
moderate symptoms of acute mountain sickness (AMS), including headache, nausea, shortness
of breath, and sleep disturbance. He has been otherwise healthy.
Which one of the following has been shown to be helpful in minimizing or preventing the
symptoms of AMS?
A)
B)
C)
D)
E)

Furosemide (Lasix)
Erythromycin
Acetazolamide (Diamox)
$-Blockers
Fluid restriction

89. Residential and occupational exposure to radon is most closely linked with the development of
A)
B)
C)
D)
E)

breast cancer
multiple myeloma
non-Hodgkins lymphoma
lung cancer
thyroid cancer

90. Which one of the following therapeutic agents is most appropriate for daily use in the prevention
of migraine headache?
A)
B)
C)
D)
E)

Dihydroergotamine (D.H.E. 45)

Amitriptyline (Elavil)
Sumatriptan (Imitrex)
Aspirin/caffeine/butalbital (Fiorinal)
Acetaminophen/hydrocodone bitartrate (Vicodin)

91. A 70-year-old white female who has been your patient for 10 years had an emergency
cholecystectomy 2 days ago. When you see her today while making rounds, she appears to be
confused. When you ask her how she is, she just stares at your stethoscope, and then says, That
snake may bite you. When you ask further questions she seems distracted and does not answer
the question asked. At times, she closes her eyes and seems to fall asleep unless questioned. She
does not know her daughter, who is in the room when you are.
Which one of the following additional observations would help you differentiate delirium from
dementia?
A) Her pulse, blood pressure, temperature, and respiratory rate are all normal
B) She cannot remember todays date or the day of the month, interpret proverbs, name the
president, or even remember your name
C) Her neurologic examination is normal, except for the noted mental status changes
D) Her mental status was normal before surgery, and on successive visits it fluctuates

25

92. A 1-year-old infant is brought to your office for a well child visit. A screening CBC reveals her
hemoglobin to be 10.5 g/dL (N 11.014.0) with a mean corpuscular volume of 69 :m3 (N 7084).
Which one of the following is the most likely cause of her anemia?
A)
B)
C)
D)
E)

Iron deficiency
Lead poisoning
Chronic liver disease
Hemolysis
Hypothyroidism

93. A 20-year-old white male states that he was physically abused by his natural parents, and as a
result of running away from home on several occasions was placed in a series of foster homes.
His schooling was sporadic, and he was frequently in trouble for truancy, vandalism, initiating
fights, and stealing. He dropped out of school at the age of 16, and during that year he was
arrested for car theft and driving while intoxicated. He has not worked at any job for more than
6 months, and has had frequent changes of address due to failure to pay rent and other financial
obligations. He brags that he has fathered three children by three different women, but has not
provided any support or made any contact with any of them since their pregnancies. He has used
several aliases, one of which he had printed on a business card listing his occupation as Barroom
Brawler and Superstud. IQ testing is normal and there is no history of a psychotic break.
The most accurate diagnosis of this patients condition is
A)
B)
C)
D)
E)

borderline personality disorder

unipolar manic disorder
antisocial personality disorder
abused child reaction formation
schizotypal personality disorder with psychoactive substance abuse

94. A 3-year-old child is brought to the emergency department with a barking cough, a hoarse voice,
and mild stridor. You diagnose acute laryngotracheitis.
Which one of the following treatments in the emergency department will reduce this childs
chance of subsequent hospitalization during this acute illness?
A)
B)
C)
D)
E)

Dexamethasone (Decadron)
Ceftriaxone (Rocephin)
Azithromycin (Zithromax)
2.5% racemic epinephrine
Placement in a mist tent

26

95. A 25-year-old married white female comes to your office for a routine examination. She
expresses some concern because she has not had a menstrual period in 6 months. She has been
trying to get pregnant for over 2 years without success. Examination shows an obese woman with
a central pattern to her obesity. She has a mild increase in facial hair, but the examination is
otherwise normal, although the pelvic examination is difficult to perform because of her obesity.
Her blood pressure is 138/90 mm Hg. A CBC, metabolic panel, and thyroid studies are all normal.
Other laboratory findings include the following:
Fasting glucose . . . . . . . . . . . . . . .
LDL cholesterol . . . . . . . . . . . . . .
HDL cholesterol . . . . . . . . . . . . . .
Triglycerides . . . . . . . . . . . . . . . . .
FSH . . . . . . . . . . . . . . . . . . . . . . . .
LH . . . . . . . . . . . . . . . . . . . . . . . . .

120 mg/dL (N 70110)

136 mg/dL
33 mg/dL
220 mg/dL
3.0 mU/mL (N 2.510.2)
15.0 mU/mL (N 1.912.5)

In addition to weight loss and exercise, which one of the following would improve her chances
for conception?
A)
B)
C)
D)
E)

Medroxyprogesterone (Provera), 10 mg/day for 14 days each month

Conjugated equine estrogens (Premarin) on days 1 through 10 each month
Metformin (Glucophage)
Niacin
Ginseng

96. You are treating an 18-year-old white male college freshman for allergic rhinitis. It is September
and he tells you that he has severe symptoms every autumn which impair his academic
performance. He has a strongly positive family history of atopic dermatitis.
Which one of the following medications is considered optimal treatment for this condition?
A)
B)
C)
D)

Intranasal glucocorticoids
Intranasal cromolyn sodium
Intranasal decongestants
Intranasal antihistamine

97. Hemoglobin A1c assays are INACCURATE in patients with

A)
B)
C)
D)
E)

secondary hypertension
morbid obesity
cor pulmonale
sickle cell disease
hypothyroidism

27

98. A 28-year-old gravida 2 para 2 notes bilateral milky discharge from her breasts. She delivered her
last child 2 years ago, and breastfed exclusively for 8 months and at night for a few more months.
She totally stopped breastfeeding several months ago, but she can still express milk from both
breasts daily. She takes no medications, and uses a diaphragm for contraception. The physical
examination is unremarkable except that a milky discharge is easily expressible from both nipples.
The most likely diagnosis is
A)
B)
C)
D)
E)

intraductal papillomatosis
mammary duct ectasia
empty sella syndrome
illicit drug ingestion
physiologic galactorrhea

99. You are caring for a 70-year-old male with widespread metastatic prostate cancer. Surgery,
radiation, and hormonal therapy have failed to stop the cancer, and the goal of his care is now
symptom relief. He is being cared for through a local hospice. Over the past few days he has been
experiencing respiratory distress. His oxygen saturation is 94% on room air and his lungs are
clear to auscultation. His respiratory rate is 16/min.
Which one of the following would be best at this point?
A)
B)
C)
D)

Morphine
Oxygen
Albuterol (Proventil, Ventolin)
Haloperidol (Haldol)

100. A 2-year-old white male is brought to your office by his mother, who says he has infected ant
bites. He was playing in his cousins yard yesterday in south Texas and cried when small brown
ants crawled on his feet and legs.
A physical examination is normal except for about 20 pustular-appearing lesions on erythematous
bases on his lower extremities. The lesions are 12 mm in size.
The most appropriate management of this problem is to
A)
B)
C)
D)
E)

prescribe an oral antibiotic that is active against Staphylococcus aureus

administer procaine penicillin intramuscularly
administer high doses of corticosteroids
recommend that the lesions be kept clean
report this case of child abuse to the authorities

28

101. A 7-year-old male with moderately severe atopic dermatitis has been treated with a variety of
moisturizers and topical corticosteroid preparations over the past year. The results have been less
than satisfactory.
Which one of the following topical medications is appropriate at this time?
A)
B)
C)
D)
E)

Mupirocin (Bactroban)
Terbinafine (Lamisil)
Penciclovir (Denavir)
Hydroquinone (Eldopaque, Eldoquin)
Tacrolimus (Protopic)

102. A 75-year-old white male complains of a tremor which has been progressive over the past 2 years.
The tremor interferes with writing, pouring liquids, and eating soup. He has no other medical
problems. He abstains from alcohol and tobacco products. Physical examination is remarkable
for an action tremor of the upper extremities and a head tremor. No rigidity or gait disorder is
noted.
Of the following agents, which one is most appropriate as initial drug therapy for this problem?
A)
B)
C)
D)
E)

Alprazolam (Xanax)
Clonazepam (Klonopin)
Carbamazepine (Tegretol)
Propranolol (Inderal)
Theophylline

103. During cardiac resuscitation performed on an adult by two people, the ratio of cardiac
compressions to respirations recommended by the American Heart Association is
A)
B)
C)
D)

5:1
3:2
10:1
15:2

104. In a 1-year-old, pneumococcal 7-valent conjugate vaccine (Prevnar) is preferred rather than
polyvalent pneumococcal vaccine (Pneumovax) because of which one of the following
advantages?
A)
B)
C)
D)
E)

It is available in an oral form

It is less expensive
It requires only one dose
It can be combined with MMR in a single injection
It is more immunogenic

29

105. Elevated levels of which one of the following are associated with atherosclerosis?
A)
B)
C)
D)

Vitamin B6
Vitamin B12
Folate
Homocysteine

106. A 49-year-old white female comes to your office complaining of painful, cold finger tips which
turn white when she is hanging out her laundry. While there is no approved treatment for this
condition at this time, which one of the following drugs has been shown to be useful?
A)
B)
C)
D)

Propranolol (Inderal)
Nifedipine (Procardia)
Ergotamine/caffeine (Cafergot)
Methysergide (Sansert)

107. A mother gives her 3-year-old child a cookie whenever he starts to whine. In behavioral terms,
she is using
A)
B)
C)
D)

positive reinforcement
negative reinforcement
extinction
bonding

108. Which one of the following would be considered first-line therapy for mild to moderately severe
psoriasis confined to the elbows and knees?
A)
B)
C)
D)

Phototherapy using ultraviolet B light

Methotrexate
Etretinate (Tegison)
Betamethasone dipropionate (Diprolene)

109. A 28-year-old white female consults you with a complaint of irregular heavy menstrual periods.
Her general physical examination, pelvic examination, and Papanicolaou test are normal and she
has a negative pregnancy test. A CBC and chemistry profile are also normal.
The next step in her workup should be
A)
B)
C)
D)
E)

endometrial aspiration
dilatation and curettage
LH and FSH assays
administration of estrogen
cyclic administration of progesterone for 3 months

30

110. In elderly patients with asymptomatic gallstones, which one of the following is an indication for
elective cholecystectomy because of the increased risk of gallbladder carcinoma?
A)
B)
C)
D)
E)

Multiple large stones

Choledochal stones with common duct dilatation
Chronic contracted gallbladder
Chronic calculous cholecystitis (porcelain gallbladder)
A history of gastric cancer

111. An epidemiologic study to determine possible correlates of testicular cancer is being developed.
A group of 100 men with testicular cancer has been identified, as well as a group of 100 men
without testicular cancer. The 200 men were asked to give an exhaustive accounting of their past
dietary habits to look for possible dietary differences between those with and those without
testicular cancer.
This epidemiologic study uses
A)
B)
C)
D)
E)

a case-control design
a cross-sectional design
a clinical series
a cohort design
an experimental design

112. The parents of a 20-month-old female bring her to your office because she has lost consciousness
twice recently. They describe two episodes where the child was crying vigorously then turned
purple and passed out. The child is an otherwise healthy product of a term delivery. There is
no history of head trauma and no family history of seizures or cardiac problems. The episodes are
not associated with fever or other symptoms. Physical examination of the child is normal.
Which one of the following would be most appropriate at this point?
A)
B)
C)
D)
E)

Reassurance
A CT scan of the brain
An EKG and chest radiograph
Measurement of serum glucose, electrolytes, and hematocrit
Echocardiography

113. When presenting with appendicitis, patients over the age of 65 are more likely than younger
patients to have which one of the following?
A)
B)
C)
D)
E)

WBC counts >15,000/mm3

Rebound tenderness
Guarding
Perforation
Fever

31

114. A 37-year-old white female who has had silicone breast implants for 17 years is concerned about
the risk of developing joint problems from the implants.
You discuss studies concerning risks of connective tissue disease in women who have silicone
breast implants and
A)
B)
C)
D)

recommend that she have her implants removed

recommend that she have her implants removed and replaced with saline implants
order laboratory testing to check for connective tissue disease
assure her that there is no increased risk of connective tissue disease in women with
silicone implants

115. The major problem with the use of continuous positive airway pressure (CPAP) for obstructive
sleep apnea is
A)
B)
C)
D)
E)

sneezing
dry mucous membranes
continued snoring
rhinorrhea
noncompliance

116. A 23-year-old female is informed by one of her sexual partners that he was recently treated for
gonorrhea. They have had unprotected intercourse on many occasions in the past few months.
Her last menstrual period was 6 weeks ago. Testing for chlamydial infection is negative, but her
gonococcal culture is positive and a pregnancy test is positive.
According to CDC guidelines, the best treatment plan for the gonococcal infection is
A)
B)
C)
D)

ofloxacin (Floxin), 400 mg orally

ceftriaxone (Rocephin), 125 mg intramuscularly in a single dose
azithromycin (Zithromax), 1 g orally in a single dose
doxycycline (Vibramycin), 100 mg orally twice a day for 7 days

117. A 4-year-old child returns to your clinic after 3 days of treatment for acute otitis media. She had
been taking amoxicillin, 40 mg/kg/day, and using acetaminophen and ibuprofen for pain and fever.
On examination, the child still has a bulging red tympanic membrane on the left, with a flat
tympanogram. She has continued to have a fever.
Which one of the following would be contraindicated?
A)
B)
C)
D)
E)

Amoxicillin/clavulanate (Augmentin) orally

Ceftriaxone (Rocephin) intramuscularly
Cefuroxime (Ceftin) orally
Ciprofloxacin (Cipro) orally
Clindamycin (Cleocin) orally

32

118. A 34-year-old white male letter carrier has developed progressively worsening dysphagia for
liquids and solids over the past 3 months. He says that he has lost about 30 lb during that time.
On examination, you note that he is emaciated and appears ill. His pulse rate is 98 beats/min,
temperature 37.8 C (100.2 F), respiratory rate 24/min, and blood pressure 95/60 mm Hg. His
weight is 45 kg (99 lb) and his height is 170 cm (67 in). His dentition is poor, and there is
evidence of oral thrush. His mucous membranes are dry.
You palpate small posterior cervical and axillary nodes. The heart, lung, and abdominal
examinations are normal. You promptly consult a gastroenterologist, who performs upper
endoscopy which reveals numerous small ulcers scattered throughout the esophagus with
otherwise normal mucosa.
As you continue to investigate, you take a more detailed history. Which one of the following
findings is most likely to be related to the patients problem?
A)
B)
C)
D)
E)

Intravenous drug use

Easy bruisability
A family history of esophageal cancer
Chest pain relieved by nitroglycerin
Recent travel to Russia

119. A 68-year-old white female is hospitalized for pneumonia. She appears acutely ill and slightly
lethargic. Her examination is consistent with right lower lobe pneumonia but is otherwise normal.
Her pulse rate is 90 beats/min and regular. Her weight is normal for height. Her TSH level is
9.0 :U/mL (N 1.05.0).
The most appropriate initial step for managing her thyroid abnormality is
A)
B)
C)
D)
E)

follow-up testing after discharge

free T4 and rT3 levels now
thyroid antimicrosomal antibody levels now
levothyroxine (Synthroid), 0.025 mg every day
levothyroxine, 0.1 mg every day

120. Which one of the following is considered a contraindication to the use of $-blockers for
congestive heart failure?
A)
B)
C)
D)

Mild asthma
Symptomatic heart block
New York Heart Association (NYHA) Class III heart failure
NYHA Class I heart failure in a patient with a history of a previous myocardial
infarction
E) An ejection fraction <30%

33

121. A 70-year-old white female complains of two episodes of urinary incontinence. On both
occasions she was unable to reach a bathroom in time to prevent loss of urine. The first episode
occurred when she was in her car and the second while she was in a shopping mall. She is
reluctant to go out because of this problem.
The most likely cause of her problem is
A)
B)
C)
D)

overflow incontinence
stress incontinence
urge incontinence
functional incontinence

122. Which one of the following historical features is specifically required for the diagnosis of adult
attention-deficit/hyperactivity disorder (ADHD)?
A)
B)
C)
D)
E)

Difficulty with maintaining attention and focus

Affective lability with frequent mood swings
Impulsivity and hyperactivity
Symptoms present since childhood
Sporadic episodes of symptoms

123. It would be most appropriate to WITHHOLD rabies prophylaxis for which one of the following?
A)
B)
C)
D)

A rat bite occurring in the patients basement

A bat bite sustained on a hiking trip
A dog bite from an unprovoked cocker spaniel not found for observation
A raccoon bite occurring on a hunting trip

124. You have diagnosed tardive dyskinesia in a 72-year-old white female with schizophrenia. She
resides in a nursing home and has been treated with haloperidol (Haldol), 1 mg twice a day, for
5 years. She also has a hiatal hernia.
Which one of the following statements is true regarding this patient?
A) The chances of symptom remission after withdrawal of the haloperidol are better than
for a younger patient
B) Quickly reducing the dosage of haloperidol will lead to prompt worsening of her tardive
dyskinesia
C) Long-term metoclopramide (Reglan) would be the best treatment for her hiatal hernia
D) Risperidone (Risperdal) would be more likely than haloperidol to cause tardive
dyskinesia

34

125. Which one of the following single-dose regimens is effective for treatment of uncomplicated
urethral or cervical infection caused by Chlamydia trachomatis?
A)
B)
C)
D)
E)

Azithromycin (Zithromax), 1 g orally

Doxycycline (Vibramycin), 200 mg orally
Amoxicillin, 2 g orally
Cefixime (Suprax), 400 mg orally
Metronidazole (Flagyl), 2 g orally

126. A 24-year-old male presents with a painless lump in the right testis that was recently discovered
by his sexual partner. The most useful initial diagnostic procedure is
A)
B)
C)
D)
E)

ultrasonography of the scrotum

a trans-scrotal biopsy of the lesion performed under local anesthesia in your office
a therapeutic trial of a quinolone antibiotic for 3 weeks to shrink the lesion
a $-hCG level
reassurance that benign lesions will generally regress, and reexamination in 46 weeks

127. A 25-year-old white male who has a poorly controlled major seizure disorder and a 6-week history
of recurrent fever, anorexia, and persistent, productive coughing visits your office. On physical
examination he is noted to have a temperature of 38.3 C (101.0 F), a respiratory rate of 16/min,
gingival hyperplasia, and a fetid odor to his breath. Auscultation of the lungs reveals rales in the
mid-portion of the right lung posteriorly.
Which one of the following is most likely to be found on a chest radiograph?
A)
B)
C)
D)
E)

Sarcoidosis
Miliary calcifications
A lung abscess
A right hilar mass
A right pleural effusion

128. During a health maintenance examination, a 14-year-old African-American male is noted to have
asymmetric breast enlargement with mild tenderness. The remainder of the physical examination
is normal.
The most appropriate management in this case is to
A)
B)
C)
D)
E)

reassure the patient and have him return in 6 months

order a chest radiograph
order serum estrogen and testosterone levels
order chromosomal studies
arrange for a biopsy

35

129. Which one of the following is consistent with current recommendations?

A)
B)
C)
D)

Giving influenza vaccine to all persons age 50 and over

Giving influenza vaccine to persons under age 65 only if they are at high risk
Advising all patients to receive influenza vaccine
Routinely giving pneumococcal vaccine whenever an initial influenza vaccination is
given

130. A 40-year-old male professional consults you about his recent onset of depression. He generally
feels well, but sometimes feels high and out of control. This is followed by significant
depression which usually remits after a long weekend of sleep at his cabin on the lake. He also
complains of persistent nasal congestion and a 10-lb weight loss. His psychiatric history is
negative, but he is suspicious and feels that people are against him. His mental status otherwise
reveals normal thought content and processes. His physical examination is normal except for
inflamed nares and enlarged nasal turbinates.
The most likely diagnosis is
A)
B)
C)
D)
E)

schizophrenia
generalized anxiety disorder
panic disorder
alcohol abuse
cocaine abuse

131. A 72-year-old white female has had annual Papanicolaou smears with normal findings for the past
30 years. She now finds it difficult and uncomfortable to undergo pelvic examinations because
of severe arthritis in both hips, as well as vaginal atrophy. She has not been sexually active since
the death of her husband 10 years ago.
What is the most appropriate approach to further screening for cervical neoplasia in this patient?
A) She should be screened every 35 years
B) She should undergo a test for the presence of human papillomavirus; if it is negative,
screening can be discontinued
C) She should undergo ultrasound examination of the pelvis every 35 years
D) Screening can be discontinued now
132. Which one of the following is true concerning breastfeeding?
A) The first feeding should take place a few hours after delivery when the mother is well
rested
B) Packets containing information about breastfeeding and samples of infant formula
should be provided when mothers go home from the hospital
C) Ointment containing vitamins A and D should be applied to prevent cracked nipples
D) When lactation is becoming established, infants should be weighed before and after a
feeding to determine whether they are getting enough milk
E) Breastfeeding mothers should be taught that milk supply depends on the amount of
suckling

36

133. Which one of the following is the best screening test for hereditary hemochromatosis?
A)
B)
C)
D)
E)

Hemoglobin
ALT (SGPT)
Serum transferrin saturation
Serum iron
Liver biopsy

134. A diabetic patient has a deep 23-cm dorsal foot ulcer, and you are concerned about the presence
of osteomyelitis. Which one of the following would be most cost-effective for evaluating this
problem?
A)
B)
C)
D)
E)

MRI
A CT scan
A bone scan
Probing for bone at the base of the ulcer
A CBC, erythrocyte sedimentation rate, and serum calcium level

135. A 60-year-old white female presents with pain in her left calf on walking. The pain does not go
away with continued walking, and is relieved by rest. She smokes one pack of cigarettes daily and
has type 2 diabetes mellitus which is only moderately controlled with oral agents. She has been
fairly noncompliant with dietary measures, and has not been interested in following your
recommendations regarding medication for her hyperlipidemia. She is unable to do many of the
things that she previously enjoyed doing, such as playing golf. Her ankle-brachial index at rest
on the left is 0.60 and on the right is 1.10.
Which one of the following is true regarding management of this patients peripheral vascular
disease?
A)
B)
C)
D)

In order to improve functional capacity, exercise training should be encouraged

Her goal LDL-cholesterol level is <130 mg/dL
Improved control of her diabetes with insulin will slow the progression of her disease
If she requires femoropopliteal bypass surgery, estrogen should be given postoperatively
for secondary prevention

136. An 85-year-old Hispanic female comes to your office for a routine annual visit. While reviewing
her medical history, you note that she began timolol (Timoptic) eye drops 3 months ago for the
treatment of glaucoma.
Which one of the following findings is most likely related to the eye drops?
A)
B)
C)
D)
E)

Bronchospasm
Elevated serum creatinine
Hirsutism
Leukopenia
New-onset atrial fibrillation

37

137. A 70-year-old African-American male who has been hospitalized for 2 weeks for congestive
heart failure develops severe, persistent diarrhea. For the past 3 days he has had abdominal cramps
and profuse semi-formed stools without mucus or blood.
The patients current medications include captopril (Capoten), digoxin, furosemide (Lasix),
subcutaneous heparin, spironolactone (Aldactone), and loperamide (Imodium). He has coronary
artery disease, but has been relatively pain free since undergoing coronary artery bypass surgery
4 years ago. An appendectomy and cholecystectomy were performed in the past, and the patient
has since been free of gastrointestinal disease.
On physical examination his blood pressure is 100/80 mm Hg, pulse 100 beats/min and regular,
and temperature 37.0 C (98.6 F). He has mild jugular venous distention and crackles at both lung
bases. Examination of his heart is unremarkable, although there is 1+ dependent edema. His
abdomen is diffusely tender without masses or organomegaly. Rectal examination is normal.
The results of routine laboratory tests, including a CBC, chemistry profile, EKG, and urinalysis,
are all normal. The stool examination shows numerous white blood cells.
Of the following, the most likely diagnosis is
A)
B)
C)
D)
E)

viral gastroenteritis
Clostridium difficile colitis
ulcerative colitis
gluten-sensitive enteropathy (celiac sprue)
digoxin toxicity

138. Which one of the following represents an advantage of injectable medroxyprogesterone acetate
(Depo-Provera)?
A)
B)
C)
D)
E)

There is a general lack of menstrual irregularities

It is not causally linked with thromboembolic events
There is no weight gain
There is no measurable effect on blood lipid levels
The cost is half that of generic combination oral contraceptives

139. A 6-month-old white male is brought to your office because he has blisters in his diaper area.
You find large bullae filled with cloudy yellow fluid. Some of the blisters have ruptured and the
bases are covered with a thin crust.
Which one of the following is most appropriate in the management of this condition?
A)
B)
C)
D)

Use of a topical antifungal agent

Treating diapers with a vinegar rinse to remove residual ammonia
A course of penicillin to prevent acute glomerulonephritis
A course of a penicillinase-resistant penicillin or a cephalosporin

38

140. According to evidence-based guidelines of the American College of Obstetricians and

Gynecologists (ACOG), which one of the following is an indication for hysterectomy for
leiomyoma?
A)
B)
C)
D)
E)

Difficulty making a diagnosis of ovarian cancer because of nonpalpable adnexa

A desire to avoid increased surgical morbidity due to continued uterine enlargement
Persistent, severe pelvic discomfort caused by myomas
Prophylaxis for possible future symptoms
Prophylaxis for malignant leiomyosarcoma

141. Which one of the following is a contraindication to immunization with MMR?

A)
B)
C)
D)
E)

The patient had a tuberculosis skin test (PPD) within the previous 2 days
A household member of the patient has an immunodeficiency
The mother of the patient is pregnant
The patient is pregnant
The patient is breastfeeding her newborn infant

142. A 73-year-old white male who is otherwise in good health noted a sudden shower of flashing
lights before his left eye a few hours ago. He has never had this symptom before.
The most likely diagnosis is
A)
B)
C)
D)
E)

migraine syndrome
retinal detachment
vitreous floaters
central retinal vein thrombosis
temporal lobe tumor

143. Combination oral contraceptives would be contraindicated in which one of the following?
A)
B)
C)
D)
E)

A 25-year-old female whose body mass index is >30

A 26-year-old female with migraine headaches without focal neurologic symptoms
A 28-year-old smoker
A 30-year-old female with a previous history of deep venous thrombosis
A 42-year-old nonsmoker

144. Total parenteral nutrition is most appropriate for patients

A)
B)
C)
D)

with poorly functioning gastrointestinal tracts who cannot tolerate enteral feeding
who cannot swallow because of an esophageal motility problem
who refuse to eat
in whom maintenance nutrition is desired for a short period following recovery from
surgery

39

145. Which one of the following would be most likely to have secondary hypertension?
A) A 39-year-old white male who weighs 119 kg (262 lb) and whose blood pressure is
142/94 mm Hg
B) A 48-year-old African-American female with left ventricular hypertrophy on echocardiography whose blood pressure is 162/98 mm Hg
C) A 62-year-old African-American male with a strong family history of hypertension
D) A 78-year-old white female with abdominal bruits whose blood pressure is
182/102 mm Hg
E) An 88-year-old white male with hemiparesis due to a previous stroke whose blood
pressure is 192/88 mm Hg
146. A 91-year-old white male presents with a 6-month history of a painless ulcer on the dorsum of the
proximal interphalangeal joint of the second toe. Examination reveals a hallus valgus and a rigid
hammer toe of the second digit. His foot has mild to moderate atrophic skin changes and the
dorsal and posterior tibial pulses are absent.
Appropriate treatment includes which one of the following?
A)
B)
C)
D)

Surgical correction of the hammer toe

Custom-made shoes to protect the hammer toe
Bunionectomy
A metatarsal pad

147. A 10-year-old male comes in for follow-up of his attention-deficit/hyperactivity disorder (ADHD).
At the time of his last visit 1 month ago he was taking methylphenidate (Ritalin) once daily each
morning. At that time his mother reported that he did extremely well in class during the morning,
but by the end of the day he was having problems with inattentiveness. This carried over into
difficulties concentrating on homework after school. These problems were affecting his grades
and causing distress to him and his mother. The child expressed a desire not to have to take
medicine during the school day. You switched his medicine at that visit to a long-acting form of
methylphenidate (Concerta).
At this visit the mother reports that her son is now doing well through the entire school day and
is able to get his homework done. However, she notes that his appetite at dinner has decreased
and that he has lost 2 lb. She also reports that it is somewhat more difficult for him to fall asleep.
What is the most appropriate management at this point?
A) Have him take the medication at bedtime
B) Reassure the mother and reevaluate in 1 month
C) Add a dose of a tricyclic antidepressant such as nortriptyline (Aventyl, Pamelor), to be
taken with the evening meal
D) Switch him to a selective serotonin reuptake inhibitor (SSRI) such as paroxetine (Paxil)

40

148. A 42-year-old white female has a 2-month history of vaginal itching. Another physician
prescribed three courses of antifungal therapy, but the condition persists. The patient says there
has been no discharge, and there are no skin lesions anywhere else. The physical examination is
remarkable only for a lacy white rash on the labia minora.
Which one of the following is the most likely diagnosis?
A)
B)
C)
D)
E)

Atrophic vaginitis
Lichen planus
Contact dermatitis
Chronic candidiasis
Vaginal adenosis

149. A 62-year-old male with a previous history of hypertension, smoking, and hypercholesterolemia
comes to your office after being seen in the emergency department with an episode of dysarthria
and weakness on the left side of his body. Physical examination reveals a right carotid bruit.
Carotid ultrasonography shows 70%80% stenosis of the right carotid artery, which is confirmed
by magnetic resonance angiography.
In addition to management of risk factors, which one of the following is appropriate?
A)
B)
C)
D)

Long-term aspirin therapy

Aspirin plus clopidogrel (Plavix)
Warfarin (Coumadin)
Carotid endarterectomy

150. A 38-year-old male is admitted to the hospital after being found lying on the floor unconscious
from a drug overdose. The next morning, he is alert and complains of constant pain in the anterior
aspect of his left leg. On examination, you note pain with passive stretching, pain with palpation
anteriorly, and a slightly decreased dorsalis pedis pulse on the left. There is no edema or
erythema. Radiographs of the lower extremity are normal.
Which one of the following would you do now?
A)
B)
C)
D)
E)

Recommend rest, ice, and elevation, along with physical therapy

Begin empiric intravenous antibiotics
Order duplex doppler ultrasonography of the left leg
Order impedance plethysmography of the left leg
Obtain immediate surgical consultation

41

151. A 37-year-old white male comes to your office for evaluation of multiple complaints. He has seen
three other physicians but has been dissatisfied with their treatment. He states that he has been
in poor health for most of his adult life, and lists the following complaints: difficulty swallowing,
palpitations, shortness of breath, impotence, difficulty urinating, vomiting, diarrhea, bloating,
muscle weakness, joint pains, dizziness, fainting, poor vision, and headaches. A thorough
physical examination reveals no physical cause for any of his complaints. He sleeps well and has
not lost any weight recently.
The most likely diagnosis is
A)
B)
C)
D)
E)

panic attacks
conversion disorder
masked depression
somatization disorder
hysteria

152. An 84-year-old male with advanced dementia develops a fever, mental status changes, and
bacteremia. No other history is available.
What is the most likely source of his infection?
A)
B)
C)
D)
E)

A urinary tract infection

Pneumonia
Cholecystitis
Diverticulitis
Cellulitis

153. A 35-year-old male consults you about a vague chest pain he developed while sitting at his desk
earlier in the day. The pain is right-sided and was sharp for a brief time when it began, but it
rapidly subsided. There was no hemoptysis and the pain does not seem pleuritic. His physical
examination, EKG, and oxygen saturation are unremarkable. A chest film shows a 10% right
pneumothorax.
Which one of the following is true in this situation?
A)
B)
C)
D)
E)

He is likely to be an overweight smoker with a chronic cough

Rupture of subpleural bullae would be an unlikely cause of his problem
Outpatient observation with a repeat chest radiograph in 24 hours is indicated
A chest tube should be placed expeditiously
After treatment his probability of recurrence is less than 15%

42

154. A 32-year-old white female comes to see you because of moderately severe pelvic pain that has
been present for several years and is worse with menses. She describes the pain as bilateral, deep
in the pelvis, and intermittently cramping and steady. She has never been pregnant, although she
has not been using any contraception during the 6 years she has been married. She is not
interested in fertility at this time. She has no history of previous sexually transmitted disease, IUD
use, or abdominal or pelvic surgery. She currently uses ibuprofen, 600 mg 34 times a day as
needed, with moderate pain relief. She is a nonsmoker.
Physical examination reveals a blood pressure of 120/70 mm Hg and normal findings on
examination of the heart, lungs, and abdomen. The vagina and cervix are normal in appearance.
Bimanual examination reveals a normal-sized uterus and adnexa with no masses, but mild
tenderness on palpation of the posterior uterus and posterior cul-de-sac. Recent screening
laboratory work was normal, including a CBC, thyroid function tests, lipid levels, and liver
function tests.
What is the most appropriate management at this time?
A) Referral for hysterosalpingography
B) Prescribing a COX-2 inhibitor such as rofecoxib (Vioxx) or celecoxib (Celebrex) to be
used instead of ibuprofen
C) Starting her on an oral contraceptive containing both estrogen and progesterone
D) Starting her on danazol (Danocrine), 600 mg/day
155. Compared to forceps, which one of the following is a potential advantage of the vacuum extractor
in an assisted vaginal delivery?
A)
B)
C)
D)

It can be used in patients with incomplete cervical dilatation

The incidence of cephalohematoma is lower
It causes less maternal genital trauma
There is a higher rate of successful vaginal delivery

156. A healthy 24-year-old male presents with a sore throat of 2 days duration. He reports mild
congestion and a dry cough. On examination, his temperature is 37.2 C (99.0 F). His pharynx
is red without exudates, and there are no anterior cervical nodes. His tympanic membranes are
normal, and his chest is clear.
You would do which one of the following?
A)
B)
C)
D)

Treat with analgesics and supportive care

Treat with azithromycin (Zithromax)
Perform a throat culture and begin treatment with penicillin
Perform a rapid strep test

43

157. Which one of the following would support a diagnosis of carpal tunnel syndrome?
A)
B)
C)
D)

Absence of symptoms at night

Numbness in the fourth and fifth digits
Wasting of the thenar compartment
Provocation of symptoms by sustained wrist extension

158. Which one of the following is true regarding prenatal risk assessment for trisomy 21 (Down
syndrome)?
A) The majority of pregnant women with a positive triple screen on maternal serum
screening have a fetus with trisomy 21
B) Maternal serum screening should be regarded as an alternative to amniocentesis in
women over the age of 35
C) Amniocentesis is performed at an earlier gestational age than chorionic villus sampling
D) An elevated second-trimester maternal serum "-fetoprotein level indicates increased risk
for trisomy 21
E) Seventy percent of trisomy 21 pregnancies occur in women younger than 35 years of age
159. Which one of the following is true regarding dysthymic disorder?
A)
B)
C)
D)

Antidepressant medications are not helpful in the management of this problem

The prognosis for eventual remission is generally excellent
There is a strong association with other psychiatric and medical conditions
The onset is typically abrupt following an identifiable life stress

160. A 24-year-old mother is discharged from the hospital with her baby 24 hours after an
uncomplicated labor and delivery. The baby was delivered at term, and this is her first child. You
receive a call from the mother the next day because she is concerned that the baby looks a little
orange.
Which one of the following bilirubin levels would prompt phototherapy?
A)
B)
C)
D)

6 mg/dL at 30 hours
12 mg/dL at 48 hours
21 mg/dL at 72 hours
18 mg/dL at 96 hours

44

161. A 52-year-old menopausal female sees you because she had vaginal bleeding for 3 days in the
preceding month. Since developing hot flushes 12 months ago, she has taken conjugated equine
estrogens (Premarin), 0.9 mg/day. You perform an endometrial biopsy and the pathologist reports
a histologic diagnosis of adenomatous hyperplasia with atypia.
At this point, which one of the following would be most appropriate?
A) Convert the patient to cyclic combined hormone replacement therapy by adding
medroxyprogesterone acetate (Provera), 10 mg/day on days 1 through 14 of each month,
while continuing the daily estrogen
B) Convert the patient to continuous combined hormone replacement therapy by adding
medroxyprogesterone acetate, 5 mg/day, while continuing the estrogen
C) Discontinue the estrogen and observe for recurrence of bleeding
D) Discontinue the estrogen and prescribe medroxyprogesterone acetate, 20 mg/day for the
next 3 months, then repeat the endometrial biopsy
E) Arrange for surgical dilatation and curettage
162. A 75-year-old otherwise healthy white female states that she has passed out three times in the last
month while walking briskly during her daily walk with the local senior citizens mall walkers
club. This history would suggest which one of the following as the etiology of her syncope?
A)
B)
C)
D)
E)

Vasovagal syncope
Transient ischemic attack
Orthostatic hypotension
Atrial myxoma
Aortic stenosis

163. A football player sustains a finger injury in a preseason scrimmage. He reports getting his finger
caught in another team members jersey. His right ring finger is tender on the volar surface, and
is swollen around the distal interphalangeal joint. He is unable to flex at the distal interphalangeal
joint, but can flex at the proximal interphalangeal joint and at the metacarpophalangeal joint.
Radiographs do not show any bony abnormality.
You would now
A)
B)
C)
D)
E)

splint his finger in a slightly flexed position and urgently refer him to a hand surgeon
splint his finger in a slightly flexed position and have him return in 1 week
splint his finger in an extended position and have him return in 1 week
splint his finger in a hyperflexed position and have him return in 1 week
cast his finger in a comfortable position and have him return in 1 week

45

164. In an 80-year-old homebound female with constipation not adequately responding to increased
fluid and psyllium (Metamucil) supplementation, the safest stimulant laxative to add to her
regimen is
A)
B)
C)
D)
E)

senna
phenolphthalein
castor oil
bisacodyl
Milk of Magnesia

165. A 43-year-old African-American male is hospitalized for treatment of a deep venous thrombosis
of the right leg extending to the mid-thigh. His baseline platelet count on admission is
250,000/mm3 (N 150,000450,000). On the day of admission he is started on heparin and
warfarin (Coumadin). He shows steady clinical improvement, and discharge is planned for the
fifth hospital day. On the morning he is to be discharged, laboratory results show therapeutic
values for both prothrombin time and partial thromboplastin time, but his platelet count is
45,000/mm3 .
Which one of the following would be most appropriate at this time?
A)
B)
C)
D)
E)

Stop the heparin but continue the warfarin

Stop the warfarin but continue the heparin
Stop the heparin and warfarin and substitute a lowmolecular-weight heparin
Stop the heparin and warfarin and start a non-heparin anticoagulant
Discharge the patient, as clinical improvement has occurred

166. Which one of the following best describes vaginismus?

A)
B)
C)
D)

Dyspareunia caused by a structurally small vagina

A voluntary contraction of the vaginal muscles to prevent penetration
An involuntary contraction of the vaginal and pelvic floor muscles
A condition associated with general sexual and orgasmic inhibition

167. Potential complications of long-term therapy with lithium include which one of the following?
A)
B)
C)
D)
E)

Tardive dyskinesia
Agranulocytosis
Acquired nephrogenic diabetes insipidus
Hyperprolactinemia
Hypertension

46

168. About a month after returning from the Middle East, an American soldier develops a papule on
his forearm that subsequently ulcerates to form a shallow annular lesion with a raised margin. The
lesion shows no signs of healing 3 months after it first appeared. He has no systemic symptoms.
The most likely diagnosis is
A)
B)
C)
D)
E)

leishmaniasis
schistosomiasis
malaria
trypanosomiasis
syphilis

169. A 28-year-old white female complains of fatigue, stiffness, and a diffuse aching in her neck,
shoulders, and back for several months. She is not sleeping well.
A thorough physical examination is unremarkable except for tenderness over the upper trapezius,
second costochondral junctions, lateral epicondyles, and medial knees. A CBC, erythrocyte
sedimentation rate, and rheumatoid factor are unremarkable.
Which one of the following is the most appropriate management at this time?
A) Prescribe amitriptyline (Elavil), 1025 mg every night at bedtime, along with exercise
aimed at improving her overall level of fitness
B) Prescribe a 2-week course of a short-acting sedative-hypnotic such as triazolam
(Halcion), 0.25 mg every night at bedtime
C) Schedule electromyography and nerve conduction studies to rule out neuropathies
D) Refer the patient to a rheumatologist for suspected seronegative rheumatoid arthritis
170. A 40-year-old sedentary white male with a family history of stroke sees you for a health
maintenance visit. His blood pressure averages 150/100 mm Hg over several visits. His LDL
cholesterol level is 170 mg/dL.
Which one of the following would have the greatest impact on decreasing his future risk of stroke?
A)
B)
C)
D)

Reducing his blood pressure to normal levels

Reducing his LDL cholesterol level to <130 mg/dL
Aspirin, 81 mg daily
A program of regular physical exercise

47

171. A 17-year-old white female has had no menstrual period for the last 6 months. She has no
significant previous medical history, but admits to a history of irregular periods since menarche
at age 14. A urine pregnancy test is negative and a physical examination is unremarkable.
The most appropriate initial workup of this patient would include which one of the following?
A)
B)
C)
D)
E)

Reassurance and reevaluation in 1 month

Measurement of serum FSH and LH
Administration of conjugated estrogens
Administration of medroxyprogesterone
A CT scan of the brain

172. Which one of the following is a major risk factor for prostate cancer?
A)
B)
C)
D)
E)

Asian ethnicity
A family history of prostate cancer
Age <50
Urinary hesitancy and nocturia
Uncontrolled diabetes mellitus

173. In differentiating early Parkinsons disease from variants such as drug-induced parkinsonism,
progressive supranuclear palsy, and multiple system atrophy, which one of the following is the
most important clue?
A)
B)
C)
D)
E)

A resting tremor
Bradykinesia
Rigidity
Gait difficulty
Loss of postural reflexes

174. A 16-year-old white female experiences the sudden onset of tender, bleeding gums, malodorous
breath, and a bad taste in her mouth. On examination she is febrile and has cervical
lymphadenopathy and tachycardia. Her mouth has marginal punched-out, crater-like depressions
of the interdental gingival papillae and gingival margins that are covered with a gray
pseudomembranous slough.
The drug of choice for treating this condition is
A)
B)
C)
D)
E)

acyclovir (Zovirax)
penicillin
clotrimazole troche (Mycelex)
ketoconazole (Nizoral)
prednisone

48

Items 175180: Refer to Pictorial Atlas insert, center of book.

175. The arrhythmia shown in Figure 1 is often an adverse response to
A)
B)
C)
D)
E)

quinidine
digoxin
phenytoin (Dilantin)
propranolol (Inderal)
diltiazem (Cardizem)

176. A 35-year-old white female complains of a 2-day history of influenza-like symptoms. Her left
tympanic membrane is shown in Figure 2.
The best management at this time would be
A)
B)
C)
D)

reassurance that this is an old scar from a previous infection

referral to an otolaryngologist for surgery
a 10-day course of amoxicillin
a topical antibiotic/corticosteroid suspension placed in the ear canal 3 times/day until
symptoms resolve

177. An 8-year-old female is brought to your office because of a rash on her legs and buttocks. One
week ago she had an upper respiratory infection. The rash began as small spots which have
coalesced. On examination, she is afebrile and looks well. She has a nonpalpable rash noted on
the legs and buttocks (Figure 3). Her platelet count is 210,000/mm3 (N 140,000400,000).
Which one of the following is LEAST likely to be a complication of this patients illness?
A)
B)
C)
D)

Hematuria
Colicky abdominal pain
CNS bleeding
Arthritis of the knees and ankles

178. A 56-year-old white female nursing-home patient with diabetes mellitus is brought to the hospital
emergency department with the expanding, painful skin discoloration shown in Figure 4. She has
recently been hospitalized due to diabetic ketoacidosis and she developed a painful sinus infection
during that hospitalization. She has been treated with cefaclor (Ceclor), 250 mg orally 3 times a
day.
The most likely diagnosis is
A)
B)
C)
D)

ecthyma gangrenosum
necrobiosis lipoidica diabeticorum
clostridial sinusitis with myonecrosis
mucormycosis

49

179. The most likely diagnosis of the condition shown in the radiographs in Figure 5 is
A)
B)
C)
D)
E)

dislocation of the trapezium

dislocation of the scaphoid
dislocation of the lunate
fracture of the distal radius
fracture of the distal ulna

180. A 70-year-old white female has a long history of recurring cardiac arrhythmias. She comes to the
emergency department with a 1-hour history of weakness and rapid heart beat. Her lungs are clear
and she denies chest pain. Her blood pressure is 110/60 mm Hg. An EKG is shown in Figure 6.
Of the following, the most appropriate immediate management would be
A)
B)
C)
D)
E)

cardioversion
cardiac pacing
adenosine (Adenocard)
bretylium (Bretylol)
lidocaine (Xylocaine)

END OF BOOK
Please check the top of your answer sheet to insure that your
Program Number, Resident Number, and Residency Year are filled in correctly.

50

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 175180. 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

DO NOT BREAK THE SEAL UNTIL YOU ARE TOLD TO DO SO.