Item: 1 of14 !

ll f' Mark <:1 t::>

Q. ld : 5965 [ Previous Next

6 The following vignette applies to the next 3 items.

7
A 29-year-old man comes to the emergency department complaining of palpitations, sw eating, and severe

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headache. His symptoms resolve spontaneously by the time he is evaluated. He has had at least 2 similar
episodes during the past 2 months. The patient's family history is unremarkable. He does not use tobacco,
alcohol, or illicit drugs. His primary care provider saw him after the first episode and prescribed an anxiolytic
12 medication. How ever, the patient felt drow sy at his job and stopped the medication. Physical examination
13 show s a thin man w ho appears anxious and diaphoretic. The thyroid is normal to palpation w ithout any
14 obvious nodules. His temperature is 36.7 C (98 F), blood pressure is 126/84 mm Hg, pulse is 86/min, and
respirations are 16/min. During his prior emergency department visit for an identical episode, his blood
pressure w as 150/ 100 mm Hg and pulse w as 120/min. The laboratory results at that time show ed normal
thyroid function tests.

Item 1 of 3

W hich of the follow ing is the most appropriate next step in management?

r A. Measure 24-hour fractionated urinary metanephrines and catecholamines

r B. Measure 24-hour urinary vanillylmandelic acid excretion
r C. Measure blood pressure in the office after 2 w eeks
r D. Start a beta blocker
r E. Start an alpha blocker
 ltem:2of14 !ll f' Mark <:1 t::>
Q. ld : 5966 [ Previous Next

6 Item 2 of 3
7
Endocrine studies yield results highly suspicious of a neuroendocrine tumor. W hich of the following is the

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best next step in management of this patient?

12
r A. Beta-blocking agent
13 r B. Chromogranin A measurement
14
r C. Metaiodobenzylguanidine scan
r D. MRI of the abdomen
r E. Removal of tumor
 ltem:3of14 !ll f' Mark <:1 t::>
Q. ld : 5967 [ Previous Next

6 Item 3 of 3
7
The patient is placed on appropriate preoperative medications and is taken for surgical removal of the tumor.

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During the procedure, he rapidly becomes hypotensive. His blood pressure falls from 110/89 mm Hg to 80/50
mm Hg. W hich of the follow ing is the most appropriate therapy for this patient's hypotension?

12
r A. Bolus of normal saline follow ed by continuous normal saline infusion
13
14 r B. Dobutamine infusion
r C. Dopamine infusion
r D. Intravenous colloid bolus
r E. Intravenous phentolamine bolus
 Item: 4 of 14 !ll f' Mark <:1 t::>
Q. ld : 5784 [ Previous Next

6 The following vignette applies to the next 2 items

7
A 66-year-old male w ith chronic rheumatoid arthritis is brought to the emergency department w ith fever, cough

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productive of yellow sputum, and confusion. He has had severe rheumatoid arthritis for the past twelve
years. He has been taking methotrexate, prednisone, and non-steroidal anti-inflammatory drugs as needed
for the last several years. Physical examination reveals an ill-appearing male w ith central fat deposition and
12 thin extremities. Joint deformities are consistent w ith advanced rheumatoid arthritis. His blood pressure is
13 73/40 mm Hg, heart rate is 123/min, temperature is 102 F (38.9 C) and respirations are 24/min. His oxygen
14 saturation by pulse oximetry is 92% on two liters of nasal canula oxygen . His mucous membranes appear
moist. There is no pallor or icterus. Lung examination reveals crackles over the left base. Laboratory
investigations reveal a WBC count of 22,000/mm'. His serum sodium is 131 mEq/L and BUN is 27 mg/dl.
His blood glucose level is 249 mg/dl. Chest x-ray show s a dense area of left low er lobe consolidation. EKG
show s sinus tachycardia w ith nonspecific ST-T w ave changes. A right-sided internal jugular vein catheter is
placed and a central venous pressure of 4 mmHg is recorded.

Item 1 of 2

W hich of the follow ing immediate measures is most likely to improve this patient's survival?

r A. Dobutamine infusion to systolic blood pressure of 90 mmHg

r B. Fluid resuscitation to central venous pressure of 12 mmHg
r C. Insulin therapy to blood glucose level of 150 mg/dL
r D. Non-invasive positive pressure ventilation
r E. Pulmonary artery catheterization to estimate left ventricular filling
 Item: 5 of 14 !ll f' Mark <:1 t::>
Q. ld : 5785 [ Previous Next

6 Item 2 of 2
7
The patient receives fluid resuscitation, broad-spectrum antibiotics, and is started on norepinephrine infusion.

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An intra-arterial catheter is placed for blood pressure monitoring. His central venous pressure is 14 mmHg,
blood pressure is 85/45 mmHg, and heart rate is 11 5/min. His oxygen saturation is 93% on two liters of nasal
canula oxygen . His urine output is 15 ml/hr. W hich of the follow ing best explains the hypotension in this
12 patient?
13
14
r A. Catecholamine-driven vasodilation
r B. Pulmonary hypertension
r C. Renal failure due to acute tubular necrosis
r D. Stress-induced cardiom yopathy
r E. Suppression of the pituitary-adrenal axis
 Item: 6 of 14 !ll f' Mark <:1 t::>
Q. ld : 5289 [ Previous Next

A 74-year-old male comes to the emergency department w ith rapid atrial fibrillation. He complains of
7 palpitations, dizziness, and shortness of breath . His past medical history is significant for hypertension, w hich
has been treated w ith hydrochlorothiazide for the past 12 years. He is not on any other medications. He
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denies any neck pain, fever, nausea, vomiting, abdominal pain, chest pain, motor w eakness, or loss of
consciousness. His family history is unremarkable. He denies any allergies. He lives w ith his w ife, and has
normal functional and instrumental activities of daily living. His heart rate is 120/min and irregular, and blood
12 pressure is 130/80 mmHg. Thyroid examination reveals a 3 em nodule in the right thyroid lobe. Other
13 systems are normal. EKG show s rapid atrial fibrillation. His labs are as follow s:
14
TSH < 0.01 iJU/ml (normal 0.35-5.0 iJU/ml)
FreeT4 3.3 iJU/ml (normal 0.8-1.8 iJU/ml)

Radioactive iodine uptake is 55% at 24 hours (normal 5-30%), and a scan show s an increased uptake in the
right lobe, w ith the rest of the thyroid gland show ing reduced uptake. W hat is the most likely cause of this
patient's atrial fibrillation?

r A. Toxic nodule
r B. Graves' disease
r C. Subacute thyroiditis
r D. Painless thyroiditis
r E. Surreptitious administration of levothyroxine
 Item: 7 of 14 !ll f' Mark <:l t::>
Q. ld : 5257 [ Previous Next

A 54-year-old female presented to the emergency room because of a rapid heartbeat. She has been having
recurrent atrial fibrillation w ithout a know n predisposing factor for the past six m onths. She has been
extensively investigated, including an echocardiogram and thyroid function tests in the past. All tests w ere
unrevealing. She w as started on amiodarone three m onths ago by her cardiologist and w as doing w ell. She is
also on atenolol 25 m g/d and aspirin 325 m g/d. She complains of mild episodic dizziness and palpitation . On
physical examination, her heart rate w as 130/min, irregular in the ER; how ever, after two doses of 5 m g
metoprolol, her heart rate is in the low 1OOs, and she appears to be hemodynamically stable. Laboratory tests
13 revealed normal CBC and basic metabolic panel. An EKG revealed rapid atrial fibrillation. Thyroid functions
14 are as follow s:

TSH 2.3 iJU/ml (0.35 to 5.0 iJU/ml is normal)

Total T4 15.6 IJg/dl (4-11 IJQ/dl is normal)
Total T3 88 ng/dl (80-180 ng/dl is normal)

W hat is the m ost likely explanation of this patient's thyroid function tests?

r A. Euthyroid sick syndrome

r B. Graves' disease
r C. Amiodarone-effect on thyroid functions
r D. Atenolol-effect on thyroid functions
r E. Aspirin-effect on thyroid functions
 ltem:8of14 !ll f' Mark <:l t::>
Q. ld : 6159 [ Previous Next

6
7 A 60-year-old w oman is brought to the emergency department follow ing a motor vehicle accident. She hit a

tr
car from her side and claims that she did not see another car coming tow ards her. This accident took place
at a small intersection w ith little traffic. Her past medical history is significant for Cushing's disease and an
intra-abdominal operation 15 years ago for the disease. Physical examination show ed a tanned female w ith
normal vital signs. She has a few abrasions on her face and chest. Ophthalmologic examination reveals
12 bitemporal hemianopsia . Her injuries are managed appropriately.
13
14 Item 1 of 2

W hat is the next best step in the management of this patient?

r A. X-ray of the skull

r B. MRI of the brain
r C. CT angiogram
r D. W aters' view
r E. Slit lamp examination
 ltem:9of14 !ll f' Mark <:l t::>
Q. ld: 6160 [ Previous Next

6 Item 2 of 2
7

~
What is the most likely diagnosis?

r A. Prolactinoma
12 r B. Nelson's syndrome
13
14
r C. Craniopharyngioma
r D. Low -grade astrocytoma
r E. Empty sella syndrome
 Item: 10of14 !ll f' Mark <:l t::>
Q. ld : 5343 [ Previous Next

6 The following vignette applies to the next 2 items

A 31 -year-old diabetic male presents to the emergency department because of abdominal discomfort,
nausea, and vomiting. The patient states that he has not been feeling w ell for the past two days and has been
vomiting intractably. He stopped taking his regular dose of insulin because he w as unable to "hold anything
dow n". His initial labs are positive for serum ketones and show a blood glucose of 360 mg/dl. In the
12 emergency room, he w as started on intravenous normal saline w ith potassium and insulin infusion. Five
13 hours after his admission to the intensive care unit, the patient states that he feels better. His labs show the
14 follow ing:
Hematocrit 37%
WBC 11 ,400/cmm, normal differential
Platelets 240,000/cmm

Sodium 139 mEql dL

Potassium 3.6 mEq/dL
Bicarbonate 14 mmoi/L
Chloride 98 mmoi/L
BUN 24 mg/dl
Creatinine 1.3 mg/dl
Blood glucose 180 mg/dl

Item 1 of 2

W hat is the next best step in the management of this patient?

r A. Continue normal saline and decrease the insulin infusion rate

r B. Continue normal saline, and start administering insulin subcutaneously
r C. Continue the same regimen until blood sugar is below 120 mgldl
r D. Decrease the insulin infusion rate, and change the fluid to D5 1/2 NS w ith potassium
r E. Stop intravenous fluids, start oral feeding and subcutaneous insulin
 Item: 11 of14 !ll f' Mark <:l t::>
Q. ld : 5344 [ Previous Next

6 Item 2 of 2

Ten hours after the admission, the patient feels better. He says that he is hungry. He has not had any
vomiting over the last several hours and his abdominal discomfort has subsided. He is currently on an insulin
drip and intravenous 0 5 1/2 NS infusion with potassium . His most recent labs are the following:
Sodium 141 mEq/dL
12 Potassium 3.8 mEq/dL
13 Bicarbonate 18 mmoi/L
14 Chloride 112 mmoi/L
BUN 14 mg/dl
Creatinine 0.9 mg/dl
Blood glucose 154 mg/dl

Which of the following is the most appropriate next step in managing this patient?

r A. Continue insulin drip and give subcutaneous insulin

r B. Continue insulin drip and add bicarbonate to IV fluids
r C. Stop insulin drip and give subcutaneous insulin
r D. Stop insulin drip and place the patient on sliding scale insulin coverage
r E. Taper insulin drip over the next six hours
 Item: 12of14 !ll f' Mark <:l t::>
Q. ld : 5617 [ Previous Next

A 68-year-old Caucasian female is brought to the emergency room after she w as found in her apartment
obtunded w ith a fingerstick glucose level of 34 mg/dl. Tw o ampules of intravenous 50% dextrose are
administered en route to the hospital. Her past medical history is significant for severe depression, type 2
diabetes mellitus, and osteoarthritis. Her home medications include glyburide and sertraline. Her blood
pressure is 155/93 mmHg and her heart rate is 122/min. On examination in the ER, the patient is obtunded
and diaphoretic. W hile she is being examined, she has an episode of generalized tonic-clonic seizures. A
repeat blood glucose level is 33 mg/dl. Tw o ampules of intravenous 50% dextrose are given and the patient
13 is started on 10% dextrose infusion. W hich of the follow ing is the best additional therapy for this patient?
14

r A. Exenatide
r B. Metoprolol
r C. Octreotide
r D. Pentazocine
r E. Sitagliptin
 Item: 13of14 !ll f' Mark <:1 t::>
Q. ld : 5986 [ Previous Next

6 A 40-year-old man is brought to the emergency department for sudden onset of headaches, diaphoresis, and
7 loss of consciousness. His wife states that he w as previously in his usual state of health. His past medical
history is unremarkable. He w orks as a physician assistant and does not smoke or drink alcohol. On
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physical examination, the patient is diaphoretic and comatose. His fingerstick blood glucose level is 45
mg/dl. The patient is given 50% dextrose intravenously and then regains consciousness. He says that he is
currently dealing with a great deal of w ork- and relationship-related stress.

12

14
Laboratory test results on the blood sample drawn prior to dextrose administration are as follow s:
Blood glucose
Serum insulin
C-peptide level
42 mg/dl
Elevated
Elevated
Proinsulin Elevated

Which of the following is the best next step in management of this patient?

r A. 72-hour fasting test

r B. Abdominal CT scan
r C. Examine the patient for needle marks
r D. Mixed-meal challenge test
r E. Oral hypoglycemic agent screen
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2 Item: 14 of 14 !II f' Mark <:1 t::>
Q. ld : 5463 [ Previous Next

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6
A 47-year-old Mexican-American w oman comes to the emergency room because of severe w eakness and
fatigue. She has w ell-controlled diabetes mellitus type 2 and asthma . She previously smoked one pack of
cigarettes daily for 15 years. She quit smoking 10 years ago. She does not use alcohol or drugs. Her
7
medications include glyburide, metformin, albuterol, and fluticasone metered dose inhalers. Her temperature
is 37.8 C (100 F), blood pressure is 102/61 mmHg, pulse is 106/min and respirations are 32/min.
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Examination reveal no pulmonary or cardiac abnormalities. The patient laboratory tests show the follow ing:

CBC
12

--
Hb 14.1 g/dL
13
Ht 52%
Platelet count 350,000/cmm
Leukocyte count 9,000/cmm
Segmented neutrophils 63%
Lymphocytes 29%
Monocytes 8%

Serum chemistry
Serum Na 150 mEq/L
Serum K 4.5 mEq/L
Chloride 105 mEq/L
Bicarbonate 12 mEq/L
BUN 25 mg/dL
Serum Creatinine 1.1 mg/dL
Calcium 9.4 mg/dL
Glucose 185 mg/dL
Am ylase 80 U/L

W hich of the follow ing is the most appropriate course of action?

r A. Administer insulin and intravenous (IV) hydration, and order ABG.

r B. Order a chest x-ray and start antibiotics.
r C. Start Albuterol nebulizations and oxygen therapy.
r D. Order ABG and lactic acid levels.
r E. Order ketone levels and urinalysis.