It was different
15. This patient and other women with severe preeclampsia, when compared with pregnant women without preeclampsia, will have a decrease in which of the following?
(A) response to pressor amines
(B) plasma volume
(C) total body sodium
(D) uric acid
(E) serum liver functions
16. A patient at 34 weeks’ gestation develops marked pruritus especially on her palms and soles, and mildly elevated liver function tests and elevated bile acids.
Which of the following diagnostic possibilities is most consistent with the clinical presentation?
(A) pancreatitis
(B) hyperthyroidism
(C) diabetes insipidus
(D) cholestasis of pregnancy
(E) progesterone allergy
17. You estimate that the pelvic outlet is adequate, but there may be a problem in the midpelvis. The interspinous diameter of a normal pelvis should be at least how many centimeters?
(A) 5
(B) 6–8
(C) 9–11
(D) 12
(E) The interspinous diameter is not a clinically important assessment
18. In a cephalic presentation, the position is determined by the relationship of what fetal part to the mother’s pelvis?
(A) mentum
(B) sacrum
(C) acromion
(D) occiput
(E) sinciput
19. A fetus presents in breech position and is delivered without assistance as far as the umbilicus. The
remainder of the body is manually assisted by the obstetrician. What is this called?
(A) version and extraction
(B) spontaneous breech delivery
(C) partial breech extraction
(D) total breech extraction
(E) Pipers to the aftercoming head
20. A 31-year-old infertility patient with regular ovulatory menstrual cycles has begun therapy with clomiphene citrate. Before she starts therapy, what information should you provide her regarding the medication?
(A) Typically, the timing of ovulation is increased by a week.
(B) Approximately 40% of patients will respond to clomiphene citrate with increased endometrial thickness.
(C) The risk of multiple gestation is 25%.
(D) Clomiphene citrate improves the fecundity rate principally through its effect on the endometrial lining.
(E) Risk and side effects of clomiphene citrate include nausea, hot flushes, weight gain, and mood swings.
21. In a young, obese, chronically anovulatory woman with an elevated LH:FSH (luteinizing hormone:follicle-stimulating hormone) ratio and polycystic-appearing ovaries, which of the following is the preferred initial method of ovulation induction?
(A) metformin
(B) human menopausal gonadotropins (hMGs)
(C) pulsatile gonadotropin-releasing hormone (GnRH)
(D) clomiphene citrate
(E) bromocriptine mesylate
22. A patient with hypogonadotropic hypogonadism desires ovulation. What is the initial treatment of choice?
(A) low-dose estrogen therapy
(B) hMG therapy
(C) bromocriptine mesylate
(D) cyclic progesterone
(E) clomiphene citrate
23. Different sex hormones have different effects on the cervical mucus. Which of the following statements accurately describes the effect of estrogen?
(A) It decreases the water content of cervical mucus.
(B) It decreases the palm-leaf crystallization pattern of mucus upon drying (ferning).
(C) It decreases formation of glycoprotein channels, which favor sperm penetration.
(D) It increases cervical mucus stretchability (spinnbarkeit).
(E) It increases the amount of potassium chloride in the cervical mucus.
24. A 31-year-old patient is preparing to start in vitro fertilization (IVF) because of obstructed fallopian tubes. On hysterosalpin-gogram (HSG), it is noted that she has large dilated hydrosalpinges present bilaterally. What should be your next step?
(A) The patient should begin her IVF treatment cycle.
(B) The patient should repeat the HSG to confirm the result.
(C) The patient should not be offered the opportunity to have IVF.
(D) Bilateral salpingectomies should be done prior to starting IVF.
(E) Her hydrosalpinges should be drained via transvaginal aspiration prior to starting IVF.
25. A 27-year-old azoospermic male undergoes a testicular biopsy revealing normal seminiferous tubules. He is diagnosed with hypogonadotropic hypogonadism and receives FSH and human chorionic gonadotropin (hCG) injections. What is the minimal time required before repeating the semen analysis
for spermatogenesis response?
(A) 15 days
(B) 30 days
(C) 60 days
(D) 90 days
(E) 120 days
26. A 43-year-old woman accompanied by her husband reports to you a history of pelvic adhesions and bilateral distal occlusion of both fallopian tubes with large hydrosalpinges. Both ovaries are buried in thick vascular adhesions. Adoption is not a consideration for the couple. What is the most appropriate
recommended therapy for this couple?
(A) gamete intrafallopian transfer (GIFT)
(B) IVF using her own eggs
(C) lysis of adhesions and surgical mobilization of the ovaries
(D) ovulation induction using gonadotropins with intrauterine inseminations
(E) IVF using donor eggs
27. During an ultrasound examination to harvest oocytes, the reproductive endocrinologist must be able to identify the position of the patient’s ovaries. Which landmark is most helpful in locating the ovaries?
(A) bladder
(B) cul-de-sac
(C) iliac vessels
(D) uterus
(E) rectum
28. A 33-year-old patient has incapacitating midline dysmenorrhea. Cyclic oral contraceptive pills previously had been unsuccessful and she gets only mild relief from analgesics. She wishes to retain her uterus in hope of becoming pregnant in the future. Which of the following current treatment options
may be helpful for dysmenorrhea but should be avoided because of reducing her chances of successful future pregnancy?
(A) diagnostic laparoscopy
(B) continuous oral contraceptive pills (OCPs)
(C) levonorgestrel-releasing intrauterine system (Mirena)
(D) endometrial ablation
(E) depo-lupron
29. A patient with two previable pregnancy losses has been told that she likely has an incompetent cervix. She asks you to tell her about this entity. Which of the following can you correctly tell her?
(A) It is associated with first-trimester spontaneous abortions.
(B) It is easily diagnosed by precise measurement of cervical resistance to dilatation.
(C) It is characterized by painless dilatation of the cervix after the first trimester of pregnancy.
(D) It is inherited as an autosomal recessive disease.
(E) It is primarily treated by medical therapy.
30. An 18-year-old woman presents for care because a condom broke during sexual intercourse. Coitus occurred 1 day ago when she was at midcycle. She does not wish to be pregnant and will terminate the pregnancy if menses does not occur. Regarding her fear of pregnancy, which is the most appropriate
next step in her management?
(A) advise her that unprotected midcycle coitus has a 5% risk of pregnancy
(B) prescribe intravaginal misoprostol (Cytotec)
(C) advise immediate douching
(D) prescribe a brief course of levonorgestrel
(E) advise her to await her next menses before taking any action
31. Over the years the estrogen component of the oral contraceptive pill has been dramatically decreased.
This has in turn minimized certain side effects. Reducing the estrogen content of OCs has resulted in an
increase in the rate of which of the following?
(A) pregnancy
(B) breakthrough bleeding (BTB)
(C) thromboembolic complications
(D) insulin resistance
(E) premenstrual symptoms
32. Conization of the cervix would be inappropriate in which of the following instances?
(A) when there is disparity between Pap smear and biopsy results
(B) when colposcopy is inadequate
(C) when microinvasion is diagnosed by biopsy
(D) when deeply invasive cancer is shown on a biopsy
(E) for treatment of biopsy-proven CIN III
33. If a nonhealing ulcer is seen on the cervix, it is best evaluated by which of the following?
(A) repeat examination
(B) Pap smear
(C) punch biopsy
(D) cone biopsy
(E) vaginal steroid cream
34. A patient has just been diagnosed with endometrial cancer by endometrial biopsy. During her
counseling regarding the disease, staging, management, and prognosis the patient is told that most
endometrial cancers are diagnosed as which of the following stages
(A) I
(B) II
(C) III
(D) IV
(E) recurrent
35. Ovarian neoplasms most commonly arise from which of the following cell lines?
(A) ovarian epithelium
(B) ovarian stroma
(C) ovarian germ cells
(D) ovarian sex cords
(E) metastatic disease
What nonpharmacologic treatments are available for the prevention of sudden cardiac death in patients with ischemic cardiomyopathy?
A. Ventricular assist device (VAD)
B. Implantable cardioverter defibrillator (ICD)
C. Biventricular pacemaker
D. Intra-aortic balloon pump (IABP)
Which of the following pharmacologic agents used in the management of heart failure lacks trial
data indicating a mortality benefit and does not prevent maladaptive ventricular remodeling?
A. ACE inhibitors or angiotensin receptor blockers (ARBs)
B. Spironolactone
C. Beta blockers
D. Digoxin
Which of the following statements incorrectly characterizes attributes of the medications to be con-
sidered for this patient?
A. Hydrochlorothiazide may exacerbate hypoglycemia (it was hypoglycemia)
B. Without a loading dose, the blood level of digoxin will plateau in 7 days
C. Oral bioavailability of loop diuretics varies little from drug to drug
D. Spironolactone has been associated with gynecomastia
E. Nonsteroidal anti-inflammatory drugs (NSAIDs) may cause diuretic Unresponsiveness
Which of the following statements regarding the clinical course of CHF and the prognosis of patients
with this condition is true
?
A. Arrhythmias cause the majority of deaths in patients with CHF
B. Signs of chronic right-sided heart failure portend a poorer prognosis
C. A persistent fourth heart sound portends a poorer prognosis
D. Annual mortality increases by 5% to 7% for each NYHA class (i.e., from class I to IV)
E. Once heart failure has developed, sex has no prognostic significance
A 55-year-old patient of yours presents for routine follow-up of CHF. An echocardiogram done 6 months ago showed a left ventricular ejection fraction of 20%. He feels quite well, has unlimited exercise tolerance while exercising on flat ground, and has dyspnea only with climbing more than two flights of stairs.His current regimen is enalapril, 40 mg/day, and furosemide, 40 mg b.i.d. On physical examination, hisblood pressure is 135/80 mm Hg, his pulse is 88 beats/min, and his respirations are normal. The rest ofhis examination is remarkable only for moderate obesity and 1+ pretibial edema. He has heard that medications called beta blockers could be helpful for people with heart trouble and wonders if he should be taking them.
Which of the following statements regarding beta-blocker use is true?
A. Beta blockers are contraindicated in patients with CHF
B. Beta blockers are contraindicated in this patient because his ejection fraction is so severely diminished
D. Beta blockers are not indicated in this patient because his blood pressure is already well controlled
E. Beta blockers are not indicated in this patient because his CHF is well controlled by his current therapy
F. Beta blockers are indicated in this patient
Which of the following statements regarding renovascular hypertension is true?
A.Renovascular hypertension is an exceptionally rare cause of hypertension in patients with treatment
resistant hypertension
B.Stenosing lesions of the renal circulation cause hypertension throughischemia-mediated activation of the renin-angiotensin-aldosterone system
C .Fibromuscular disease is an uncommon cause of renovascular hyper-
tension in patients of this age
D. Atheromatous disease and fibromuscular disease are equally frequent
causes of renovascular hypertension
Your nurse alerts you that a patient in your clinic has severely elevated blood pressure. The patient is a
45-year-old man without other significant medical history. The patient’s blood pressure is 220/125 mm
Hg; blood pressure measurements are essentially the same in both arms. The patient says that he is feel-
ing fine. He has had no symptoms of flushing, sweating, or headache, nor has he had visual changes,
focal weakness, numbness, chest pain, dyspnea, or decreased urine output. On examination, neurologic
status is normal. An S4 gallop and trace pretibial edema are noted. The lungs are clear to auscultation.
An ECG shows sinus rhythm with LVH. There is no evidence of ischemia or infarction.
How should you manage this patient?
A. Administer sublingual nifedipine, 10 mg
B. Administer atenolol, 50 mg, and follow up in 24 hours
C. Prescribe atenolol, 50 mg, and follow up in 1 week
D. Admit him to the intensive care unit for cardiac and blood pressure
monitoring and intravenous nitroprusside therapy
Which of the following is true regarding establishment and maintenance of normal sinus rhythm,
as compared with pharmacologic rate control?
A. Establishment and maintenance of sinus rhythm provides no survival advantage
B. Establishment and maintenance of sinus rhythm reduces thromboembolic risk
C. Establishment and maintenance of sinus rhythm improves the degree of symptomatic impairment
D. Conversion to normal sinus rhythm is rarely needed for patients withunstable angina, acute myocardial infarction, heart failure, or pulmonary edema
Which of the following is NOT a risk factor for cardioversion failure in this patient?
A. Duration of AF of longer than 1 year
B. Older age
C. Left atrial enlargement
D. Normal-sized heart
Which of the following is NOT an indication for implantation of a cardiac pacemaker?
A. Temporary pacing in the setting of acute myocardial infarction complicated by conduction abnormalities and hemodynamic instability
B. Resynchronization in the treatment of heart failure
C. Type I second-degree atrioventricular (AV) block in an asymptomatic athlete
D. Complete AV block
E. Neurocardiogenic syncope with significant bradycardia
A 56-year-old man presents to the emergency department with complaint of chest pain of 20 minutes’
duration. The pain is severe, crushing, substernal, and without radiation. He has associated nausea and
diaphoresis without vomiting. He has had no previous episodes of chest discomfort. He has not seen a
doctor for over 20 years and takes no medications. He has smoked two packs of cigarettes a day for the
past 35 years and has lived a sedentary lifestyle. His family history is remarkable for an MI in his father
at 49 years of age. Physical examination reveals a thin man, sitting upright, breathing rapidly on 2 L of
oxygen. His vital signs include the following: temperature, 98.8° F (37.1° C); pulse, 98 beats/min; respir
atory rate, 22 breaths/min; blood pressure, 150/95 mm Hg. Cardiac examination reveals normal rate and
rhythm without murmur, and neck veins are not elevated. Lungs are clear to auscultation. ECG shows
normal sinus rhythm with occasional premature ventricular contractions and ST segment elevations of
0.2 mV in leads II, III, and aVF.
Which of the following interventions is NOT indicated for this patient at this time?
A. Morphine sulfate I.V.
B. Lidocaine
C. Aspirin
D. Metoprolol
E. Streptokinase
Which of the following findings would be most highly suggestive of significant ischemic heart disease
(IHD) on exercise ECG testing?
A. Chest discomfort before completion of the test
B. Hypertension during the test
C. An S3 heart sound during the test
D. A 0.5 mm ST segment depression during the test
A 67-year-old man with type 2 diabetes and a long history of cigarette smoking develops severe exer-
tional chest pain. Cardiac catheterization reveals three-vessel disease. Twenty-four hours later, he devel-
ops abdominal pain, painful toes, and a rash. On examination, he has purple discoloration of the sec-
ond and fourth toes on his right foot and a lacy rash on both legs. Laboratory results are as follows: Hb,
13; HCT, 39; WBC, 9.0; BUN, 26; and Cr, 1.8.
What is the most likely diagnosis for this patient?
A. Contrast nephropathy
B. Aortic dissection
C. Atheromatous emboli syndrome
D. Abdominal aortic aneurysmal rupture
Which of the following statements regarding DVT is true?
A. Thrombi confined to the calf are large and typically result in pulmonary venous thromboembolism (VTE)
B. The postthrombotic syndrome is a rare sequela of DVT and is associated with low morbidity
C. Most patients presenting with a new DVT have an underlying inherited thrombophilia
D. The most common cause of inherited thrombophilia associated with this illness is activated protein C resistance (factor V Leiden)
Which of the following statements regarding anticoagulation and thrombolysis for thromboembolism is true?
A. When using unfractionated heparin, the therapeutic range for the activated partial thromboplastin time (aPTT) is 2.5 to 3.5 times the normal value
B. Low-molecular-weight heparin (LMWH) is safe and effective for the treatment of
pulmonary thromboembolism
C. Because of a delay in achieving a therapeutic INR with lower doses, astarting dose of warfarin should be no less than 10 m
D. In contrast to other thrombolytic agents, recombinant tissue plasminogen activator (rt-PA) stimulates antibody production and can induce allergic reactions
Which of the following statements regarding adrenal insufficiency is true?
A. The most common cause of adrenal insufficiency in the United States is tuberculosis
B. The critical test for the diagnosis of chronic adrenal insufficiency is the cosyntropin test
C. Chronic secondary adrenal insufficiency is treated with hydrocortisone and fludrocortisone,
whereas chronic primary adrenal insufficiency is treated with hydrocortisone alone
D. In idiopathic or autoimmune adrenal insufficiency, CT of the abdomen shows enlarged adrenal glands
Which of the following statements regarding pheochromocytomas is true?
A. 90% of pheochromocytomas are malignant
B. Almost all patients with pheochromocytomas have episodic hypertension, making diagnosis difficult
in a single clinic visit
C. The incidence of pheochromocytoma is increased in patients with multiple endocrine neoplasia type 1
D. Treatment of pheochromocytoma is surgical; alpha blockade should be induced with
phenoxybenzamine, beginning 7 days before surgery
Which of the following statements regarding hyperaldosteronism is true?
A. The most common causes of secondary hyperaldosteronism are congestive heart failure and cirrhosis with ascites
B. Treatment of primary adrenal hyperaldosteronism is spironolactone
C. Patients with primary adrenal hyperaldosteronism usually present with hypertension,
hypokalemia, and metabolic acidosis
D. Diagnosis of primary adrenal hyperaldosteronism is confirmed by elevations in the levels of both renin and aldosterone
A 54-year-old woman comes to your clinic for a routine visit. She has no active complaints. Her medical history is positive only for mild asthma and arterial hypertension. Her only medications are albuterol, which she administers with a measured-dose inhaler as needed, and an angiotensin-converting enzyme
inhibitor. She smokes one pack of cigarettes a day. She has a strong family history of osteoporosis. Her
physical examination is unremarkable. You have a discussion with her regarding her risk of osteoporo-
sis, and you decide to obtain a dual-energy x-ray absorptiometry (DEXA) scan for screening. The results
show a T score of –2.6. Her creatinine and albumin levels are normal, her liver function tests are normal
except for a slightly elevated alkaline phosphatase level, and her calcium level is 11 mg/dl.
What is the most appropriate step to take next in the treatment of this patient?
A. Start bisphosphonate, calcium, and vitamin D, and reassess in 6 Months
B. Measure the parathyroid hormone (PTH) level with a two site immunoradiometric assay
(IRMA, or so-called intact PTH) and assess 24-hour urinary calcium output
C. Order CT scans of the chest and abdomen to look for an occult malignancy
D. Start hormone replacement therapy with estrogens and progestins
Which of the following descriptions is characteristic of irritable bowel syndrome?
A. Painless diarrhea that occurs during the day or night
B. Abdominal pain with defecation and an altered bowel habit
C. Painless, chronic watery diarrhea of moderate severity
D. Diarrhea associated with postprandial flushing and a drop in blood pressure
A 32-year-old woman presents as a walk-in patient in the emergency department. She complains of nau-
sea and diarrhea that began early that evening. She reports that she ate a sandwich at a fast-food estab-
lishment for lunch, and she began experiencing symptoms several hours later. She denies seeing blood
in the stool. She reports no similar experiences in the past; she has no recent travel history, nor has she
had any contacts with sick persons. She was treated with a 3-day course of antibiotics for an upper uri-
nary tract infection 2 months ago and is otherwise healthy.
Which organism is the most likely cause of this patient’s acute diarrheal illness?
A. Campylobacter jejuni
B. Salmonella enteritidis
C. Staphylococcus aureus
D. C. difficile
A 26-year-old man presents with intermittent crampy abdominal pain, diarrhea without noticeable
blood, and weight loss of 15 lb over 10 months. The bowel symptoms, including the diarrhea, wake him
from sleep. On a few occasions, he has had fevers, nausea, and vomiting. The patient is an architect, and
he describes his work as being stressful; he resumed smoking cigarettes a year ago. His older brother has
had similar symptoms but has not yet been evaluated. On examination, the patient is a slender man with
normal vital signs. He has an oral aphthous ulcer and poorly localized lower abdominal to midabdomi-
nal tenderness without peritoneal signs. Anal and rectal examinations are normal, and a stool guaiac test
is negative. Stool leukocytes are present. The hematocrit is 34%. Results of examination with flexible
sigmoidoscopy are normal.
Which of the following is the most likely diagnosis for this patient?
A. Irritable bowel syndrome
B. Acute appendicitis
C. Crohn disease
D. Ulcerative colitis
E. Colon cancer
Which of the following statements regarding nutritional support is true?
A. Enteral nutrition is less likely to cause infection than parenteral nutrition
B. Parenteral nutrition has consistently been shown to result in a decrease in mortality,
compared with standard care
C. The use of oral supplements in hospitalized elderly patients has been shown to be harmful
D. Parenteral nutrition is the preferred mode of nutrition in cancer patients because of
its lower incidence of infections
Which of the following laboratory findings is the most easily monitored immediate effect of erythro-
poietin therapy?
A. An increase in the reticulocyte count
B. An increase in the mean corpuscular volume
C. An increase in the hemoglobin level
D. An increase in the mean corpuscular hemoglobin level
Which of the following statements about megaloblastic anemia is false?
Absorption of cobalamin in the small intestine is dependent on proteins produced in the
mouth and stomach
Megaloblastic erythropoiesis is characterized by defective DNA synthesis and arrest at the G2 phase, with impaired maturation and a buildup of cells that do not synthesize DNA and
that contain anomalous DNA
C. In most patients with severe cobalamin deficiency, the neurologic examination is normal
D. Cobalamin deficiency is treated with parenteral cobalamin therapy
Which of the following statements regarding autoimmune hemolytic anemia is true?
A. Autoimmune hemolytic anemia typically results in intravascular hemolysis
B. Autoimmune hemolytic anemia may be idiopathic or secondary to disorders such as systemic lupus erythematosuchronic lymphocytic leukemia (CLL), HIV infection, or hepatitis C infection
C. Most patients with autoimmune hemolytic anemia are cured with steroid therapy
D. Splenectomy is curative for those patients who do not respond to simple steroid therapy
A 60-year-old man presents with complaints of headache, light-headedness, blurry vision, and fatigue;
these symptoms have been increasing over the past month. He reports that he has felt weak and has not
had much energy. He also reports generalized itching, which usually occurs after he takes a hot shower.
Physical examination reveals facial plethora. His spleen is palpable 2 cm below the left costophrenic
angle. Laboratory results reveal the following: Hb, 18; Hct, 61; platelets, 500,000; leukocytes, 17,000.
Which of the following is the most appropriate diagnosis for this patient?
A. Gaisböck syndrome (relative polycythemia)
B. Pickwickian syndrome
C. Polycythemia vera
D. Acute myeloid leukemia
E. Chronic myeloid leukemia
Which of the following statements about blood components is true?
A. Whole blood transfusion would be preferable to red cell transfusion in this patient
B. Leukocyte reduction reduces febrile transfusion reactions
C. Cryoprecipitate consists of albumin and platelets
D. Single-donor platelet transfusions carry a higher risk of blood-borne infection than platelet concentrates
Which of the following statements regarding transfusion complications is true?
Immediate hemolytic reactions are the result of an anamnestic response to an antigen to
which the recipient is already sensitized
Delayed hemolytic reactions occur during primary sensitization and can be as severe as
immediate hemolytic reactions
Until the cause of the hemolytic transfusion reaction is identified, the patient may only receive
type O red cells or AB plasma
Fever without signs of hemolysis can be managed with acetaminohen; no further laboratory workup is necessary
A 63-year-old multiparous woman is receiving packed red cells to treat symptomatic anemia after hip
replacement surgery. Fifteen minutes into the transfusion, she has rigors. On physical examination, she
appears anxious and diaphoretic; her temperature is 102.2° F (39° C); the rest of her examination is
normal.
What is the first step in the diagnosis and management of this transfusion reaction?
A. Administer acetaminophen or meperidine for symptomatic relief
B. Draw blood for culturing
C. Stop the transfusion
D. Send the untransfused blood back to the blood bank for analysis
Which of the following statements about ITP is false?
A. ITP is associated with splenomegaly
B. ITP is associated with HIV infection, acute viral illnesses, and some autoimmune diseases
C. Patients with platelet counts over 50,000/µl do not routinely require treatment
D. Treatment is indicated for patients with platelet counts below 20,000 to 30,000/µl or for those
whose platelet count is less than 50,000/µl
Which of the following tests would be helpful in the acute setting to determine the cause of her sus-
pected hypercoagulable state?
A. Protein S level
B. Protein C level
C. Factor V Leiden (it was protein c resistance)
D. AT-III level
A 26-year-old man presents with new-onset left lower extremity swelling and pain of 6 hours’ duration.
He takes no medications and has no history of trauma, immobilization, or prior thrombosis. His family
history is remarkable for two “blood clots” in his mother. Compression ultrasonography confirms occlu-
sive thrombus in the left superficial femoral vein.
Which of the following is the most appropriate sequence of interventions for this patient?
Start heparin and warfarin immediately, send tests for the hypercoagulable state before warfarin reaches therapeutic levels, and discontinue heparin after the international normalized ratio
(INR) reaches therapeutic levels
B. Send tests for the hypercoagulable state, then start heparin and warfarin concurrently, and discontinue heparin after 5 days’ overlap
C. Send tests for the hypercoagulable state, then start heparin and warfarin concurrently, and discontinue heparin when the INR reaches therapeutic levels
D. Start heparin and warfarin immediately, discontinue heparin after 5 days’ overlap, and evaluate for
The hypercoagulable state after warfarin therapy is completed
E. Evaluate for the hypercoagulable state, but no anticoagulation is indicated for superficial thrombophlebitis
A 68-year-old man presents with new onset of right-sided DVT without apparent risk factors. Therapy is
initiated, and the possibility of underlying cancer is raised. You are consulted regarding appropriate eval-
uation for occult malignancy.
What would you recommend for this patient?
A. Careful history, physical examination, routine blood counts and chemistries,
chest x-ray (CXR), fecal occult blood testing (FOBT), andprostate-specific antigen (PSA); if these are not revealing, no further
evaluation is necessary
B. Careful history, physical examination, routine blood counts and chemistries, CXR, FOBT, and PSA; if these are not revealing, proceed with colonoscopy
C. Careful history, physical examination, routine blood counts and chemistries, CXR, FOBT, and PSA; if these are not revealing, proceed with CT scan of the chest, abdomen, and pelvis
D. Careful history, physical examination, routine blood counts and
chemistries, CXR, FOBT, and PSA; if these are not revealing, proceed
with bone scan
A 68-year-old man is evaluated for symptoms of fever, weight loss, and dyspnea on exertion. Physical
examination reveals a new diastolic murmur and stigmata of peripheral emboli. He is admitted to the
hospital for further evaluation and management of endocarditis. A cardiac echocardiogram shows a
1 cm aortic valve vegetation, and two of two blood cultures subsequently grow Streptococcus bovis that
is susceptible to penicillin.
After appropriate management of this patient's endocarditis, the patient should undergo which of
the following?
A. Glucose tolerance test
B. Chest radiograph to screen for lung cancer
C. Upper endoscopy
D. Colonoscopy
E. No specific further evaluation is warranted
A 65-year-old man with poorly controlled diabetes underwent transurethral resection of the prostate
2 days ago. Today he presents with a complaint of scrotal pain. On physical examination, the patient is
somnolent but arousable. His temperature is 101.7° F (38.7° C), his blood pressure is 100/70 mm Hg,
and his pulse is 120 beats/min. His scrotum is markedly swollen, erythematous, and exquisitely tender.
What is the best step to take next in the treatment of this patient?
A. Immediate institution of broad-spectrum antibiotics
B. Immediate institution of broad-spectrum antibiotics and hyperbaric
oxygen therapy
C. Immediate surgical exploration and resection without regard to
reconstruction
D. Immediate surgical exploration and resection with caution with
regard to future reconstruction
Which of the following statements about septic (bacterial) arthritis is true?
A. Local inoculation of organisms into the joint space is the most com-
mon route of acquisition
B. HIV-infected patients are at increased risk
C. Patients with underlying joint disease (e.g., rheumatoid arthritis) are
at increased risk
D. The finger joints are the most commonly involved site
E. Most cases are polyarticular
A 57-year-old man presents for evaluation of a left lower extremity ulcer. He has a history of hyperten-
sion and poorly controlled type 2 diabetes mellitus. The lesion began approximately 4 weeks ago in the
absence of any known trauma. The patient reports experiencing subjective fevers, chills, and malaise
over the past few days. On physical examination, the patient’s temperature is 100.4° F (38° C). A non-
tender stage 3 ulceration of the plantar surface is noted on the patient’s left first metatarsal, with sur-
rounding erythema and mild discharge.
Which of the following statements regarding osteomyelitis in this patient is true?
A. The most likely reason for osteomyelitis in this patient is hematogenous seeding
B. Prolonged antibiotic therapy alone cures the majority of these patients
C. Infections are rarely polymicrobial
D. Vascular insufficiency impairs wound healing and allows bacterial proliferation
which of the following statements about subacute bacterial endocarditis (SBE) is
true?
A. Vegetations of more than 5 mm in size are associated with an increased risk of embolization
B. In most patients with SBE, blood cultures will be positive in the absence of previous antibiotic use
C. Over 50% of patients with SBE are afebrile
D. Physical examination findings frequently include clubbing and splenomegaly
A 34-year-old air-conditioning repairman is admitted to the hospital because of respiratory distress. He
reports fever, chills, a mildly productive cough, myalgias, headache, and nausea. Physical examination
shows a toxic-appearing man in moderate respiratory distress. His temperature is 102.2° F (39.0° C); his
heart rate is 120 beats/min; his blood pressure is 124/78 mm Hg; and his respiratory rate is 24
breaths/min. Crackles at both lung bases with diffuse wheezes are noted. Laboratory data show pro-
found leukocytosis with a left shift and a serum sodium level of 126 mEq/L. He is admitted to hospital
for treatment of community-acquired pneumonia.
Which of the following is the best antibiotic regimen for this patient?
A. Penicillin
B. Clindamycin
C. Gentamicin
D. Azithromycin or levofloxacin
Which of the following makes the diagnosis of spontaneous bacterial peritonitis (SBP) unlikely?
A. Absence of fever
B. Absence of elevated peripheral WBCs
C. Absence of abdominal pain or tenderness on examination
D. Gram stain of ascitic fluid revealing no organisms
E. PMN count in the ascitic fluid < 250 cells/mm3
Which of the following CSF profiles is most compatible with acute Streptococcus pneumoniae meningitis?
A. Normal glucose level, normal total protein level, normal cell count
B. Decreased glucose level; increased total protein level; increased cell count with a
neutrophilic predominance
C. Normal glucose level; increased total protein; increased cell count with a lymphocytic predominance
D. Decreased glucose level; increased total protein level; increased cell count with a lymphocytic predominance
E. Normal glucose level; increased total protein level; increased cell count with a red cell predominance
A 68-year-old woman is now in the intensive care unit after taking an excess of propranolol. Her
pulse is 35 beats/min, her blood pressure is 65/35 mm Hg, she is unresponsive, and her skin is mottled.
Therapeutic options for this patient include which of the following?
A. Dopamine drip
B. Intravenous glucagon
C. Isoproterenol drip
D. Epinephrine drip
E. Intravenous glucagon and epinephrine drip
Which of the following statements regarding delirium in the elderly patient is false?
In medically ill patients, delirium is most commonly associated with acute infections, hypoxemia, hypotension, and the use of psychoactive medications
By definition, delirium can be an acute or chronic disorder
Medications frequently associated with delirium include antiarrhythmic agents, tricyclic antidepressants, neuroleptics, gastrointestinal medications, and antihistamines
Patients with delirium can have perceptual disturbances such as hallucinations and can have a fluctuating level of alertness
A 49-year-old man was referred from a walk-in clinic when he was discovered to have a blood glucose
level of 246 mg/dl during evaluation of an acute GI syndrome. Subsequently, a diagnosis of diabetes was
confirmed by a finding of fasting blood glucose values of 190 mg/dl and 176 mg/dl, measured when the
patient was not ill. Overall, this patient's clinical picture is consistent with type 2 diabetes. He has not
received medical treatment or been evaluated for many years but reports being in generally good health.
Which of the following is the most reasonable approach for evaluating this patient's renal status?
A. Perform 24-hour urine collection, obtain an estimate of his creatinine clearance,
and measure total protein excretion
B. Measure the albumin-creatinine ratio on a spot urine sample
C. Defer specific assessment because he has just been diagnosed, and diabetic nephropathy is
unlikely to have developed
D. Measure serum BUN and creatinine concentrations
E. Perform renal ultrasound
A 52-year-old woman presents to the emergency department after experiencing 4 days of worsening men-
tal status. She has not seen a doctor in over 20 years. Her medical history is unremarkable. She takes no
medications. Physical examination shows a somnolent, obese woman with dry mucous membranes. The
neurologic examination is nonfocal. Results of laboratory studies are as follows: sodium concentration,
128 mEq/L; potassium concentration, 4.5 mEq/L; chloride concentration, 94 mEq/L; serum glucose level,
810 mg/dl; renal function, normal.
Which of the following would be the most appropriate intervention in the care of this patient?
A. Fluid restriction and loop diuretics
B. Administration of hypertonic saline
C. Administration of normal saline and insulin
D. Demeclocycline
A 45-year-old man with a history of alcohol abuse is brought to the emergency department after being
found lying on the floor of his apartment by a neighbor. On examination, he is unresponsive and
appears dehydrated. Initial blood work reveals a hematocrit of 41%, a BUN of 60 mg/dl, and a creatinine
level of 3.2 mg/dl. Creatine kinase and lactose dehydrogenase (LDH) levels are elevated at 12,000 U/L
and 475 U/L, respectively. Urinalysis shows reddish urine with a specific gravity of 1.020; dipstick assay
shows 3+ blood and 1+ protein. Microscopic examination of urine sediment demonstrates 0 to 2 red cells
and 0 to 5 white cells per high-powered field; hyaline casts are also observed.
The urinary findings are suggestive of which of the following conditions?
A. Acute glomerulonephritis
B. Hemoglobinuria
C. Allergic interstitial nephritis
D. Myoglobinuria
A 45-year-old man presents for a routine examination. His history is remarkable for a bleeding peptic
ulcer at age 30 that required transfusion of several units of packed red blood cells. He has been without
peptic symptoms since then. He consumes no alcohol. His physical examination reveals a blood pres-
sure of 154/98 mm Hg, confirmed on several occasions, but is otherwise not remarkable. His laboratory
evaluation was remarkable for ALT and AST levels that were 2.5 times normal and a dipstick that was
positive for blood and protein.
What should be the next step in this patient's management?
A. Referral for a liver biopsy
B. Renal arteriogram
C. Helicobacter pylori antibody testing
D. Serum renin measurement
E. Serum antibody testing for hepatitis C
A 21-year-old woman of Peruvian descent presents with hypertension, fatigue, and microscopic hema-
turia. A renal biopsy demonstrates glomerulonephritis secondary to focal segmental glomerulosclerosis
(FSGS).
Which of the following would be the most appropriate step to take next in the treatment of this
patient's disease?
A. Renal dialysis
B. Cyclosporine
C. Prednisone
D. Cyclophosphamide
E. Captopril
A 45-year-old man presents with acute onset of flank pain and hematuria. He gives a history of several
months of increasing peripheral edema in his lower extremities. His urinary protein-to-creatinine ratio
is 3.9.
What would be the best step to take next in this patient's management?
A. Renal ultrasound and duplex scan
B. Gram-negative antimicrobial therapy
C. Intravenous furosemide
D. Rapid-sequence intravenous pyelogram
E. ASO titer
Psychiatry