1. Intubation

2. Chest x-ray

3. Pericardiocentesis

4. Chest decompression with a needle

5. Emergent thoracotomy

29. 19-year-old college student presents with a testicular mass, and after treatment he

returns for regular follow-up visits. Which of the following is the most useful serum marker for detecting

recurrent disease after treatment of nonseminomatous testicular cancer?

1. Carcinoembryonic antigen (CEA)

2. Human chorionic gonadotropin (hCg)

3. Prostate-specific antigen (PSA)

4. CA125

5. p53 oncogene

30. An 11-year-old girl presents to your office because of a family history of medullary carcinoma

of the thyroid. Physical examination is normal. Which of the following tests should you perform?

1. Urine vanillylmandelic acid (vma) level

2. Serum insulin level

3. Serum gastrin level

4. Serum glucagon level

5. Serum somatostatin level

31. 50-year-old man is incidentally discovered to have a low-grade mucosa-associated

lymphoid tissue (MALT) lymphoma on biopsy of the stomach during esophagogastroduodenoscopy for

dyspepsia. CT scans of the chest, abdomen, and pelvis demonstrate no evidence of enlarged regional

lymph nodes or distant metastases. Which of the following is the initial treatment of choice?

a. Total gastrectomy with esophagojejunostomy

b. Total gastrectomy with esophagojejunostomy and adjuvant chemotherapy

c. Chemotherapy

d. Steroids

e. Antibiotics

32. 53-year-old woman presents with bright red blood per rectum, increased abdominal

distention,and weight loss. She is found to have a large fungating mass 8 cm from the anal verge.

No other lesions are identified. Biopsy is consistent with invasive rectal adenocarcinoma. Endorectal

ultrasound shows invasion of the tumor into the perirectal fat and multiple enlarged lymph nodes. CT

scans of the chest, abdomen, and pelvis do not show any metastases. She would like to preserve her

sphincter if possible. Which of the following is the best treatment option for this patient given her

preferences?

a. Abdominoperineal resection

b. Neoadjuvant chemoradiation followed by low anterior resection

c. Neoadjuvant chemoradiation followed by abdominoperineal resection

d. Transanal excision followed by adjuvant chemoradiation

e. Neoadjuvant chemoradiation followed by transanal excision

33. A 57-year-old woman develops bony metastases 1 year after right modified radical

mastectomy for breast cancer. The tumor was estrogen receptor-negative, progesterone receptor-negative,

and Her-2/neu positive. Which of the following agents is indicated for treatment of her metastatic

disease?

a. Antiestrogen (Tamoxifen)

b. Selective estrogen receptor modulator (Raloxifene)

c. Monoclonal antibody (Trastuzumab)

d. Aromatase inhibitor (Anastrozole)

e. 5-fluorouracil

34. A 35-year-old woman with a history of previous right thyroidectomy for a benign thyroid

Nodule now undergoes completion thyroidectomy for a suspicious thyroid mass. Several hours postoperatively, she develops progressive swelling under the incision, stridor, and difficulty breathing. Orotracheal intubation is successful. Which of the following is the most appropriate next step?

a. Fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis

b. Administration of intravenous calcium

c. Administration of broad-spectrum antibiotics and debridement of the wound

d. Wound exploration

e. Administration of high-dose steroids and antihistamines

35. A 35-year-old woman presents with a lump in the left breast. Her family history is negative

forbreast cancer. On examination the mass is rubbery, mobile, and nontender to palpation. There are no

overlying skin changes and the axilla is negative for lymphadenopathy. An ultrasound demonstrates a

simple 1-cm cyst in the area of the palpable mass in the left breast. Which of the following represents the

most appropriate management of this patient?

a. Reassurance and reexamination

b. Immediate excisional biopsy

c. Aspiration of the cyst with cytologic analysis!

d. Fluoroscopically guided needle localization biopsy

e. Mammography and reevaluation of options with new information

36. A 55-year-old woman presents with a slow-growing painless mass on the right side of the

neck. A fine-needle aspiration of the nodule shows a well-differentiated papillary carcinoma. A complete

neck ultrasound demonstrates a 1-cm nodule in the right thyroid without masses in the contralateral lobe

or lymph node metastasis in the central and lateral neck compartments. With regards to this patient, which

of the following is associated with a poor prognosis?

a. Age

b. Sex

c. Grade of tumor

d. Size of tumor

e. Lymph node status

.

37. A 45-year-old woman presents with hypertension, development of facial hair, and a 7-cm suprarenal mass. Which of the following is the most likely diagnosis?

a. Myelolipoma

b. Cushing disease

c. Adrenocortical carcinoma

d. Pheochromocytoma

e. Carcinoid

38. A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

a. Hyperkalemia

b. Hypermagnesemia

c. Hypoglycemia

d. Hypophosphatemia

e. Hypochloremia

39. Following blunt abdominal trauma, a 12-year-old girl develops upper abdominal pain, nausea, and

vomiting. An upper gastrointestinal series reveals a total obstruction of the duodenum with a coiled spring

appearance in the second and third portions. In the absence of other suspected injuries, which of the

following is the most appropriate management of this patient?

a. Gastrojejunostomy

b. Nasogastric suction and observation

c. Duodenal resection

d. TPN (total parental nutrition) to increase the size of the retroperitoneal fat pad

e. Duodenojejunostomy

40. A 45-year-old woman is found to have suspicious appearing calcifications in the right breast on a

screening mammogram. Stereotactic biopsy of the calcifications shows lobular carcinoma in situ (LCIS).

On examination both breasts are dense without palpable masses. The neck and bilateral axilla are

negative for lymphadenopathy. Which of the following is the most appropriate management of this patient?

a. Frequent self breast examinations and yearly screening mammograms

b. Chemotherapy

c. Radiation

d. Right total mastectomy with sentinel lymph node biopsy

e. Bilateral modified radical mastectomy

41. A 36-year-old woman presents with palpitations, anxiety, and hypertension. Workup reveals a

pheochromocytoma. Which of the following is the best approach to optimizing the patient preoperatively?

a. Fluid restriction 24 hours preoperatively to prevent intraoperative congestive heart failure

b. Initiation of an α-blocker 24 hours prior to surgery

c. Initiation of an α-blocker at 1 to 3 weeks prior to surgery

d. Initiation of a β-blocker 1 to 3 weeks prior to surgery

e. Escalating antihypertensive drug therapy with β-blockade followed by α-blockade starting at least 1week prior to surgery

42. A 35-year-old woman presents with frequent and multiple areas of cutaneous ecchymosis. Workup

demonstrates a platelet count of 15,000/μL, evaluation of the bone marrow reveals a normal number of

megakaryocytes, and ultrasound examination demonstrates a normal-sized spleen. Based on the exclusion

of other causes of thrombocytopenia, she is given a diagnosis of immune (idiopathic) thrombocytopenic

purpura (ITP). Which of the following is the most appropriate treatment upon diagnosis?

a. Expectant management with close follow-up of platelet counts

b. Immediate platelet transfusion to increase platelet counts to greater than 50,000/μL

c. Glucocorticoid therapy

d. Intravenous immunoglobulin (IVIG) therapy

f. Referral to surgery for laparoscopic splenectomy

43. A 59-year-old woman presents with right lower quadrant pain, nausea, and vomiting. She undergoes

an uncomplicated laparoscopic appendectomy. Postoperatively, the pathology reveals a 2.5-cm mucinous

adenocarcinoma with lymphatic invasion. Staging workup, including colonoscopy, chest x-ray, and

computed tomography (CT) scan of the abdomen and pelvis, is negative. Which of the following is the

most appropriate next step in her management?

a. No further intervention at this time; follow-up every 6 months for 2 years

b. Chemotherapy alone

c. Neoadjuvant chemotherapy followed by right hemicolectomy

d. Ileocecectomy

e. Right hemicolectomy

44. A 41-year-old man complains of regurgitation of saliva and of undigested food. An esophagram

reveals a dilated esophagus and a bird’s-beak deformity. Manometry shows a hypertensive lower

esophageal sphincter with failure to relax with deglutition. Which of the following is the safest and most

effective treatment of this condition?

a. Medical treatment with sublingual nitroglycerin, nitrates, or calcium-channel blockers

b. Repeated bougie dilations

c. Injections of botulinum toxin directly into the lower esophageal sphincter

d. Dilation with a Gruntzig-type (volume-limited, pressure-control) balloon

e. Surgical esophagomyotomy

45. A 56-year-old previously healthy physician notices that his eyes are yellow and he has been losing

weight. On physical examination the patient has jaundice and scleral icterus with a benign abdomen.

Transcutaneous ultrasound of the abdomen demonstrates biliary ductal dilation without gallstones. Which

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

a. Esophagogastroduodenoscopy (EGD)

b. Endoscopic retrograde cholangiopancreatography (ERCP)

c. Acute abdominal series

d. Computed tomography (CT) scan

e. Positron emission tomography (PET) scan

46. A 22-year-old college student notices a bulge in his right groin. It is accentuated with coughing, but

is easily reducible. Which of the following hernias follows the path of the spermatic cord within the

cremaster muscle?

a. Femoral

b. Direct inguinal

c. Indirect inguinal

d. Spigelian

e. Interparietal

47. A 22-year-old woman presents with a painful fluctuant mass in the midline between the gluteal folds.

She denies pain on rectal examination. Which of the following is the most likely diagnosis?

a. Pilonidal abscess

b. Perianal abscess

c. Perirectal abscess

d. Fistula-in-ano

e. Anal fissure

48. A 62-year-old man has been noticing progressive difficulty swallowing, first solid food and now

liquids as well. A barium study shows a ragged narrowing just below the carinal level. Endoscopic

biopsy confirms squamous cell carcinoma. Which of the following provides the most accurate information

regarding the T stage of an esophageal carcinoma?

a. Computed tomography

b. Positron emission tomography

c. Magnetic resonance imaging

d. Endoscopic ultrasound

e. Bronchoscopy

49. 73-year-old woman presents to the emergency room complaining of severe epigastric pain

radiating to her back, nausea, and vomiting. CT scan of the abdomen demonstrates inflammation and

edema of the pancreas. A right upper quadrant ultrasound demonstrates the presence of gallstones in the

gallbladder. Which of the following is an important prognostic sign in acute pancreatitis according to

Ranson’s criteria?

a. Amylase level

b. Age

c. Total bilirubin level

d. Albumin level

e. Lipase level

Obstetrics & Gynecology

1. The clitoris is a major sensory sexual organ. Where does it get its major nerve supply from?

(A) lumbar spinal nerve

(B) pudendal nerve

(C) femoral nerve

(D) ilioinguinal nerve

(E) anterior gluteal nerve

2. How do nabothian cysts occur?

(A) Wolffian duct remnants

(B) blockage of crypts in the uterine cervix

(C) squamous cell debris that causes cervical irritation

(D) carcinoma

(E) paramesonephric remnants

3. Pelvic inflammatory disease (PID) occurs in women because of which of the following characteristics of the fallopian tube?

(A) It is a conduit from the peritoneal space to the uterine cavity.

(B) It is found in the utero-ovarian ligament.

(C) It has five separate parts.

(D) It is attached to the ipsilateral ovary by the mesosalpinx.

(E) It is entirely extraperitoneal.

4. Anterior vulvar cancer is most likely to spread primarily to which of the following lymph nodes?

(A) inguinal

(B) para-aortic

(C) obturator

(D) femoral

(E) ovarian

5. Which of the following pubertal events is not mediated by gonadal estrogen production and therefore would occur even in the absence of estrogen production?

(A) breast development

(B) menstruation

(C) pubic hair growth

(D) accelerated skeletal growth

(E) vaginal cornification

6. A 16-year-old girl is brought to clinic by her mother with concerns regarding the lack of any signs of puberty. The appearance of external genitalia is of a normal prepubertal female. Laboratory studies show markedly elevated FSH and LH levels. Which of the following causes of delayed puberty

accompanies elevated circulating gonadotropin levels?

(A) chronic illness

(B) gonadal dysgenesis

(C) hypothalamic tumors

(D) Kallmann syndrome

(E) malnutrition

7. Even after menopause, most women have circulating estrogen. In high enough levels, this can promote the development of endometrial cancer. It mainly originates from the aromatization of which of the following?

(A) androstenedione to estradiol by ovarian granulosa cells

(B) androstenedione to estrone by ovarian thecal cells

(C) androstenedione to estrone by adipose tissue

(D) estradiol to estrone by adipose tissue

(E) testosterone to estradiol by adipose tissue

8. Most state-of-the-art serum pregnancy tests have a sensitivity for detection of β-human chorionic gonadotropin (β-hCG) of 25 mLU/ mL. Such tests would diagnose pregnancy as early as which of the

following?

(A) 5 days after fertilization

(B) 24 hours after implantation

(C) day of the expected (missed) menses

(D) 5 weeks’ gestation age by menstrual dating

(E) 6 weeks’ gestation age by menstrual dating

9. A 21-year-old G1 now P1 just delivered after a prolonged induction of labor due to being postdates. After the placental delivery she continues to bleed excessively. Your initial intervention to address this bleeding is to activate the normal physiologic mechanisms. Which of the following is the most

important hemostatic mechanism in combating postpartum hemorrhage?

(A) contraction of interlacing uterine muscle bundles

(B) fibrinolysis inhibition

(C) increased blood-clotting factors in pregnancy

(D) intramyometrial vascular coagulation due to vasoconstriction

(E) markedly decreased blood pressure in the uterine venules

10. The physiologic changes of pregnancy can alter many of the common laboratory tests. During the evaluation of a patient with tachycardia, hypertension, and headache you are considering both hyperthyroidism versus an atypical preeclampsia and draw the following laboratory tests. To correctly interpret the results, it is necessary to distinguish between normal versus abnormal changes during pregnancy. Which of the following would normally be expected to increase during pregnancy?

(A) alanine aminotransferase (ALT)

(B) aspartate aminotransferase (AST)

(C) hematocrit

(D) plasma creatinine

(E) thyroxine-binding globulin (TBG)

11. Worldwide, which of the following is the most common problem during pregnancy?

(A) diabetes

(B) preeclampsia

(C) heart disease

(D) urinary tract infection (UTI)

(E) iron-deficiency anemia

12. A pregnant woman not previously known to be diabetic, who is at 26 weeks’ gestation, had a routine 50-g (GTT) with a 1-hour blood glucose value of 144 mg/dL. A follow-up 100-g, 3-hour oral GTT revealed plasma values of fasting blood sugar of 102; 1 hour, 180; 2 hours, 162; and 3 hours, 144. You should do which of the following?

(A) begin American Diabetes Association (ADA) diet and daily glucose monitoring

(B) repeat the GTT in early or mid-third trimester

(C) start oral hypoglycemic agents in the diet

(D) perform an immediate Contraction Stress Test (CST)

(E) treat the patient as one with normal gestation

13. There is good evidence that a woman who gave birth to an infant with a neural tube defect (NTD) can substantially reduce the risk of recurrence by taking periconceptional folic acid supplementation. What is the recommended dose?

(A) 0.4 mg

(B) 0.8 mg

(C) 1.0 mg

(D) 4 mg

(E) 8 mg

14. A 28-year-old G2P0 at 39 weeks is in early labor. She is 2 cm dilated and 90% effaced, with contractions every 4 to 5 minutes. The fetal heart tones are reassuring. Her nurse steps out for a moment and returns to find her having a seizure. The nurse administers a 4-g magnesium bolus. The seizure stops. The fetal heart tone variability is flat, but there are no decelerations. What would your next therapies be aimed at?

(A) reducing edema with diuretics

(B) giving hypotensive agents until the blood pressure is 110/70 mm Hg

(C) giving 3 g of magnesium sulfate every 3 hours

(D) prepare for immediate delivery by cesarean section

(E) keeping the patient free of convulsions, coma, and acidosis