Name

American Board of Family Medicine

IN-TRAINING EXAMINATION

TIME–4 HOURS

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1. Write your name in the blank at the top of the page.

2. Record your Program Number and ABFM Numberon the answer sheet, as shown in the sample on theright. Be sure to fill in both the boxes and thecircles.

3. Write your name, your program name, and the dateon the answer sheet.

Publication or reproduction in whole or in part is strictly prohibited.Copyright © 2012 The American Board of Family Medicine. All rights reserved.

��� SAMPLE ���

1. A 72-year-old white male develops a rapidly growing epithelial tumor just in front of his rightear. He states that it began as a firm red papule about 6 weeks ago. It is now 1.5 cm in diameterand has a horny plug in the center.

The most likely diagnosis is

A) Bowen’s diseaseB) basal cell carcinomaC) keratoacanthomaD) Kaposi’s sarcomaE) seborrheic keratosis

2. An 8-year-old male is brought to the emergency department with an acute asthma attack thatbegan 48 hours earlier. His mother initiated his asthma action plan when the attack began,starting oral prednisolone plus albuterol (Proventil, Ventolin) by metered-dose inhaler with aspacer every 3–4 hours. In the emergency department the child is alert, with a respiratory rateof 30 beats/min and an oxygen saturation of 94% on room air. He is audibly wheezing. Peakflow is 40% of the predicted value.

Which one of the following should you do next?

A) Continue the current albuterol treatment but switch to a nebulizerB) Administer high-dose albuterol via nebulizer every 20 minutes for 1 hourC) Administer intravenous corticosteroids within the first hourD) Administer magnesium sulfate intravenouslyE) Prescribe high-dose mucolytics and chest physiotherapy

3. A 56-year-old male with type 2 diabetes mellitus has normal cardiac and renal function but hasfailed to achieve adequate control of his diabetes with diet and multiple oral agents. His BMI is30.1 kg/m2 and his hemoglobin A1c level is 9.1%.

Which one of the following is most likely to be beneficial in combination with insulin and diettherapy in this patient?

A) Acarbose (Precose)B) Glimepiride (Amaryl)C) Metformin (Glucophage)D) Pioglitazone (Actos)E) Repaglinide (Prandin)

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4. You see a 78-year-old male in the hospital the day after his hip-replacement surgery. He has notvoided in the past 12 hours. A urethral catheter is placed and 500 mL of urine is removed fromhis bladder.

Which one of the following is most likely to improve the success rate of a voiding trial?

A) Using a specialized catheter coudé instead of a standard catheterB) Leaving the catheter in place for at least 2 weeksC) Immediately removing the catheter to prevent a urinary tract infectionD) Starting tamsulosin (Flomax), 0.4 mg daily, at the time of catheter insertionE) Starting antibiotic prophylaxis at the time of catheter insertion

5. A 22-year-old college student comes to your office to discuss her several-year history ofabdominal pain and constipation. It has gotten worse since she returned to school this fall. Shedescribes crampy pain and bloating that eases after defecation. Her bowel movements are firmand difficult to pass, and occur about every 3 days on average. Her symptoms have not includedvomiting, weight loss, blood in the stool, or melena. Her menses are regular and she is anotherwise healthy young woman. Her family history is negative for any gastrointestinal orgenitourinary diseases. On examination you find her abdomen to be soft and without masses,with no tenderness to palpation.

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

A) A therapeutic trial of increased soluble fiber intakeB) A therapeutic trial of lubiprostone (Amitiza)C) Abdominal ultrasonographyD) Abdominal CTE) Colonoscopy

6. Which one of the following is a proven strategy to reduce anterior cruciate ligament tears inhigh-school athletes?

A) The use of neoprene knee sleeves by all athletes competing in high-risk sportsB) Consistent inclusion of long-distance running in practice sessionsC) Structured exercises stressing balance, muscle strength, and proprioceptionD) Prohibiting girls from playing on boys’ sports teamsE) Increased enforcement of penalties involving dangerous plays

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7. A 70-year-old female presents with recurrent episodes of cough, voluminous sputum, anddyspnea. She is a nonsmoker and has never smoked, except for a few cigarettes in her teens.Her past, family, and occupational histories do not suggest a cause for pulmonary or liverdisease. Her examination is within normal limits except for the lung examination, which revealscrackles at both lung bases on auscultation. A chest radiograph shows nonspecific markings atboth bases.

The most appropriate next step in her workup would be

A) a PPD skin testB) high-resolution CTC) an �1-antitrypsin levelD) referral for bronchoscopy

8. A previously healthy 24-year-old female presents with a 10-day history of facial pain and fever.On examination she has tenderness over the maxillary sinus on the left.

Which one of the following would be most appropriate for treatment of this patient’s condition?

A) Intranasal saline flushesB) Intranasal antihistaminesC) Oral antihistaminesD) Oral antibioticsE) Reassurance only

9. A 50-year-old female presents with a 3-week history of a moderately pruritic rash, characterizedby flat-topped violaceous papules 3–4 mm in size. The lesions are located primarily on the volarwrists and forearms, lower legs, and dorsa of both feet. Ten days after the rash first appearedshe went to the emergency department and was treated for “possible scabies,” but the treatmenthas made little or no difference.

Which one of the following treatments is indicated at this time?

A) Clobetasol (Cormax, Temovate) 0.05% ointmentB) Permethrin 5% creamC) Tacrolimus (Protopic) 0.1% ointmentD) Triamcinolone 0.1% cream

10. Which one of the following children should be referred immediately for evaluation of speechdelay?

A) A 12-month-old who babbles but speaks no wordsB) An 18-month-old who does not understand action wordsC) A 2-year-old who has a vocabulary of 25 wordsD) A 2-year-old who is unable to follow three-step directionsE) A 3-year-old who has a vocabulary of 50 words

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11. A 23-year-old female presents with recurrent unprovoked epistaxis. The patient’s mother isknown to have hereditary hemorrhagic telangiectasia.

Contrast echocardiography is recommended to screen for which one of the following frequentlyassociated conditions?

A) Atrioseptal defectB) Ventricular septal defectC) Aortic root aneurysmD) Pulmonary arteriovenous malformationE) Myocardial perfusion defects

12. A 65-year-old male who has been in good health presents to your office with a 2-day history ofa sensation of pressure and hearing loss in his left ear. A physical examination and a thoroughneurologic examination are both unremarkable. Both tympanic membranes are normal. Anaudiogram shows a 30-decibel hearing loss at three consecutive frequencies in the left ear, withnormal hearing on the right. Placing a vibrating tuning fork in the midline of the foreheadreveals sound lateralizing to the right ear.

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

A) CTB) A CBC, metabolic profile, and thyroid studiesC) Nifedipine (Procardia)D) Acyclovir (Zovirax)E) Oral corticosteroids

13. Which one of the following is true concerning the use of hemoglobin A1c levels to diagnosediabetes mellitus?

A) A level >6.0% is diagnostic of diabetes mellitusB) Results can be misleading in patients with sickle cell diseaseC) The test is equally sensitive in African-Americans and whitesD) The test is useful to diagnose diabetes during pregnancy

14. A 50-year-old female presents for evaluation of dyspnea that tends to occur with exercise. Shehas a 40–pack-year history of smoking and has been diagnosed with exercise-induced asthma.She denies any other medical problems. You perform spirometry and find that the expiratoryloop is normal and that she has a flattened inspiratory loop.

What is the most likely diagnosis?

A) Vocal cord dysfunctionB) COPDC) AsthmaD) Restrictive lung disease

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15. A previously healthy 27-year-old female presents with dysuria and urinary urgency andfrequency. She also complains of right flank pain, fevers and chills, and nausea withoutvomiting. She has a decreased appetite, but has been able to drink liquids.

On examination she has a temperature of 38.4°C (101.2°F), a heart rate of 102 beats/min, anda blood pressure of 126/82 mm Hg. She has mild suprapubic tenderness and right costovertebralangle tenderness. A urinalysis shows microscopic pyuria, hematuria, and a positive leukocyteesterase test. Additional laboratory studies are notable for leukocytosis with a left shift, but areotherwise normal, including a negative pregnancy test. The patient does not have allergies to anyantibiotics.

Which one of the following would be most appropriate for this patient?

A) Outpatient management with oral amoxicillinB) Outpatient management with oral ciprofloxacin (Cipro)C) Outpatient management with oral nitrofurantoin (Macrodantin)D) Inpatient management with intravenous ceftriaxone (Rocephin)E) Inpatient management with intravenous levofloxacin (Levaquin)

16. An 82-year-old female is hospitalized for pneumonia and sepsis. She has advance directives inplace.

Should it become necessary, the patient’s decision-making capacity is determined by

A) the spouse or next of kinB) the attending physicianC) a consulting psychiatristD) the hospital ethics committeeE) a judge, at the request of hospital social services or the physician

17. A 67-year-old female presents with the inability to smell. She is in good health, and her onlymedical problem is osteoporosis, treated with alendronate (Fosamax). She says she has no sinusor nasal symptoms. A physical examination is normal including an ear, nose, and throatexamination.

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

A) Discontinuing the alendronateB) An anti-tissue transglutaminase antibody testC) A serum vitamin D levelD) MRI of the brain

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18. The American Heart Association recommends a goal blood pressure of �130/80 mm Hg forpatients with

A) heart failureB) pulmonary hypertensionC) atrial fibrillationD) angina pectorisE) chronic kidney disease

19. A 78-year-old female has chronic symptomatic orthostatic hypotension, likely related to diabeticautonomic dysfunction, which has failed to respond to nonpharmacologic treatment. Her currentmedications include metformin (Glucophage), 1000 mg twice daily; atorvastatin (Lipitor), 40 mgdaily; aspirin, 81 mg daily; and insulin glargine (Lantus), 24 units at bedtime.

Which one of the following would be the most effective therapy for her orthostatic hypotension?

A) Clonidine (Catapres)B) MidodrineC) PseudoephedrineD) TerbutalineE) Theophylline

20. A 34-year-old white female who works as an engineer for a major corporation complains offatigue, low energy, and a depressed mood. She states that she has felt this way for most of herlife. She feels depressed most of the time but denies any recent stresses or significant losses inher life. She reports that she is doing well at work and that she recently received a promotion. She has no interests other than her job and states that she has no happy thoughts and that herself-esteem is very low. She denies suicidal thoughts but states that she does not care if she dies. She has had no sleep disturbance, change in appetite, or difficulty concentrating. She is takingno medications and denies substance abuse. Results of a recent medical evaluation required byher employer were all normal, including a physical examination, EKG, multiple chemicalprofile, CBC, urinalysis, and TSH level.

Which one of the following is the most likely diagnosis?

A) Major depressionB) Dysthymic disorderC) Bipolar disorderD) CyclothymiaE) Adjustment disorder with depressed mood

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21. A 35-year-old female immigrant from a rural village in Southeast Asia visits your clinic shortlyafter arriving in the United States. She presents with a 1-week history of low-grade fever anda nonproductive cough, and has crackles but no signs of consolidation or pleural effusion onexamination. You order a chest radiograph and see several oval infiltrates, 1–2 cm in size.

Which one of the following is the most likely cause of these symptoms?

A) Ascaris lumbricoidesB) Enterobius vermicularis (pinworm)C) Taenia saginataD) Taenia solium E) Diphyllobothrium latum

22. A new first-time mother calls for advice on nipple pain with breastfeeding. She is 6 days postpartum after an uncomplicated delivery.

Which one of the following would be most effective?

A) Lanolin creamB) Expressed breast milkC) Tea bag compressesD) Hydrogel dressingE) Education on positioning

23. A previously healthy 29-year-old pediatric nurse has a 3-day history of malaise, arthralgias, anda nonpruritic rash. The rash is a faint, maculopapular, irregular, reticulate exanthem that coversher thighs and the inner aspects of her upper arms. Symmetric synovitis is present in severaldistal and proximal interphalangeal joints and in her metacarpophalangeal joints. Smalleffusions, warmth, and tenderness are noted in her left wrist and right elbow. No other jointsare affected.

The most likely cause of this problem is

A) varicella-zoster virusB) measles (rubeola) virusC) parvovirus B19D) adenovirusE) human immunodeficiency virus (HIV)

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24. For 2 weeks, a 62-year-old male with biopsy-documented cirrhosis and ascites has had diffuseabdominal 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), his bloodpressure is 100/60 mm Hg, and his heart rate is 92 beats/min and regular. Examination of theheart and lungs is normal. The abdomen is soft with vague tenderness in all quadrants. Thereis 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 the fluid for analysis. Which one ofthe following findings would best support the suspected diagnosis of spontaneous bacterialperitonitis?

A) pH <7.2B) Bloody appearanceC) Neutrophil count >250/mLD) Positive cytologyE) Total protein >1 g/dL

25. A 67-year-old female has a bone density study that indicates a T score of –3.5. You prescribealendronate (Fosamax) but at her next visit she says she cannot tolerate the side effects and asksabout other therapies.

Which one of the following has the best evidence for prevention of both vertebral fractures andhip fractures?

A) Calcitonin-salmon (Miacalcin)B) Raloxifene (Evista)C) Teriparatide (Forteo)D) Zoledronic acid (Reclast)

26. A 65-year-old Asian male with a long history of cigarette smoking presents with weakness,lethargy, and mental confusion. A physical examination is normal. There are no signs ofdehydration, edema, or pigmentary changes.

Laboratory Findings

Serum sodium� � � � � � � � � � � � � � � � � � � � � � � � � 122 mEq/L (N 135–145)Urine osmolality� � � � � � � � � � � � � � � � � � � � � � � 280 mOsm/kg H2O (N 50–1400)Plasma osmolality� � � � � � � � � � � � � � � � � � � � � � 260 mOsm/kg H2O (N 285–295)Urine sodium� � � � � � � � � � � � � � � � � � � � � � � � � � 25 mEq/LBUN� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4 mg/dL (N 8–25)Serum potassium� � � � � � � � � � � � � � � � � � � � � � � 4.1 mEq/L (N 3.5–5.0)

The most likely diagnosis is

A) sodium depletionB) syndrome of inappropriate secretion of antidiuretic hormone (SIADH)C) primary polydipsiaD) adrenal insufficiency

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27. A 38-year-old female has spontaneous rupture of the membranes with thick meconium just priorto delivery of a male infant at 40 weeks gestation. Oropharyngeal suctioning of the infant isperformed prior to delivery of the shoulders. Upon delivery the infant is noted to havespontaneous respirations, a heart rate of 120 beats/min, cyanosis of the hands and feet, and goodtone.

Which one of the following would be most appropriate in the immediate management of thenewborn?

A) Intubation and tracheal suctioning below the vocal cordsB) Suctioning of the stomach to remove any swallowed meconiumC) Positive pressure ventilationD) Expectant management only

28. An 84-year-old female presents for follow-up of multiple chronic medical problems. She isusually accompanied by her daughter, who lives nearby, but today is brought in by her son anddaughter-in-law, who live out of town. They are supportive, but are insistent that the patient seea specialist for a problem that she has previously decided not to pursue further. The patientwants to avoid conflict but does not want to see any other physicians.

Which one of the following is the most appropriate way to deal with this situation?

A) Speak with the son and daughter-in-law privatelyB) Maintain neutrality and avoid triangulationC) Call the daughter to discuss the situationD) Try to talk your patient into seeing the specialistE) Schedule the appointment to appease the family, then cancel it later

29. A 50-year-old male presents to your office with erythroderma and fever. He has not had a sorethroat, rhinorrhea, cough, or urinary tract symptoms. His current medications include lisinopril(Prinivil, Zestril), atenolol (Tenormin), and allopurinol (Zyloprim). On examination he has ablood pressure of 110/90 mm Hg, a pulse rate of 90 beats/min, and a temperature of 38.6°C(101.5°F). The skin is remarkable for marked erythema over 90% of the body, with tendernessto touch. His mental status is clear and his neck is supple. Mildly tender adenopathy is noted inthe neck, axillae, and groin. He has no oral ulcerations or ocular symptoms.

A CBC shows a WBC count of 15,000/mm3 (N 4300–10,800) with 20% eosinophils. Ametabolic profile shows an AST (SGOT) level of 100 U/L (N 10–40) and an ALT (SGPT) levelof 110 U/L (N 10–55), but is otherwise normal.

Which one of the following is the most likely diagnosis?

A) Stevens-Johnson syndromeB) ErysipelasC) Red man syndromeD) Toxic shock syndromeE) Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)

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30. An unconscious 22-year-old male is brought into the emergency department. His respiratoryrate is 8/min, his pulse rate is 60 beats/min and regular, and his pupils are miotic.

The most likely cause of his condition is

A) organophosphate poisoningB) scopolamine overdoseC) narcotics overdoseD) benzodiazepine overdose

31. A 39-year-old male with a history of alcoholism presents to your office with complaints ofabdominal pain, vomiting, and nausea following a recent binge. He has eaten little since theonset of his symptoms 3 days ago. Laboratory findings suggest alcoholic ketoacidosis. His serumbicarbonate level is 16.3 mEq/L (N 22.0–26.0).

In addition to thiamine, what other treatment should be provided for this patient?

A) Bicarbonate and insulinB) Glucagon (GlucaGen) and hydrocortisoneC) Normal saline and glucoseD) N-acetylcysteine and pyridoxine (vitamin B6)

32. A previously normotensive 20-year-old primigravida is admitted to the hospital at 39 weeksgestation with a headache, a blood pressure of 170/110 mm Hg, and proteinuria. Which one ofthe following is the most effective agent for preventing eclamptic seizure while preparing forexpedited delivery?

A) BenzodiazepinesB) Fosphenytoin (Cerebyx)C) Magnesium sulfateD) Nimodipine

33. A 71-year-old white male with COPD and lung cancer is discharged from the hospital. Inaddition to a medical diagnosis, which one of the following criteria is used to determine whetherMedicare will pay for his home oxygen therapy?

A) Oxygen saturationB) PCO2

C) FEV1

D) The patient’s finances

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34. Which one of the following findings on examination of the head, oral cavity, and neck isassociated with diabetes mellitus?

A) Parotid enlargementB) Tooth erosionC) Diffuse melanin pigmentationD) Cobblestone oral mucosaE) Painful oral ulcers

35. A 53-year-old female is concerned about a skin lesion that has recently been changing in size andshape. On examination she is found to have a 7-mm, asymmetric, darkly pigmented lesion withsome color variegation and irregular borders.

Which one of the following skin biopsy techniques is most appropriate for confirming thediagnosis?

A) A shave biopsyB) Electrodesiccation and curettageC) Elliptical excisionD) Mohs surgery

36. A 22-year-old female in her second trimester of pregnancy presents with a 48-hour history ofa sore throat. She has also had coryza and a nonproductive cough. A physical examinationreveals a temperature of 37.3°C (99.2°F) and a blood pressure of 110/70 mm Hg. A HEENTexamination reveals tonsillar and pharyngeal erythema with no exudate. There is no adenopathy.Her chest is clear.

Which one of the following would be most appropriate for this patient?

A) Reassurance and symptomatic treatment onlyB) A routine throat cultureC) A rapid antigen detection test for StreptococcusD) Azithromycin (Zithromax) for 5 daysE) Penicillin V for 10 days

37. A 34-year-old female has a history of many years of diffuse pain, debilitating fatigue, anddisrupted sleep. You suspect she may have fibromyalgia. Laboratory tests and imaging studieshave been negative. She is confused about why she is in so much pain even though “everythingis normal.”

What do you tell her is currently thought to be the etiology of fibromyalgia?

A) Diffuse inflammation of soft tissuesB) A chronic viral infectionC) An exaggerated response to tactile stimuli by the central nervous systemD) A malfunction of pain receptors in the dermis, causing excess sensitivityE) A psychological disorder in which the patient imagines the pain

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38. A 12-year-old African-American male is brought to your office by his parents because he hasbeen limping for the past month. He says he has pain in the groin and knee, but the pain ispoorly localized. On examination he is noted to be obese, with normal findings on examinationof the knee. There is some decrease in internal rotation of the hip on the involved side. His gaitis antalgic.

The most likely cause of this problem is

A) unreported traumaB) aseptic necrosis of the femoral headC) reactive arthritisD) juvenile rheumatoid arthritisE) slipped capital femoral epiphysis

39. Of the following cardiovascular parameters, which one increases with normal aging?

A) Maximum heart rateB) Heart rate variabilityC) Left ventricular ejection fractionD) Arterial wall elasticityE) Blood pressure

40. A 68-year-old male with type 2 diabetes mellitus has failed to control his diabetes with diet andexercise. His most recent serum creatinine level was 1.9 mg/dL (N 0.6–1.5).

Which one of the following agents is most likely to cause symptomatic hypoglycemia in thispatient?

A) Glimepiride (Amaryl)B) Glipizide (Glucotrol)C) Glyburide (DiaBeta)D) Metformin (Glucophage)E) Repaglinide (Prandin)

41. A healthy 47-year-old female presents with a 3-day history of moderately severe low back painafter attempting to lift a heavy container of potting soil in her garden. She has no history of backproblems. Her pain is in the right lower back with radiation to the buttock. She denies urinaryor bowel incontinence, urinary retention, and numbness or tingling. A physical examinationconfirms low back muscular strain.

Which one of the following interventions has been shown to be beneficial in this situation?

A) Bed restB) Massage therapyC) Lumbar tractionD) PrednisoneE) Cyclobenzaprine (Flexeril)

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42. A 40-year-old male complains of a cough that has persisted for more than 3 months. He isotherwise asymptomatic. A chest radiograph and pulmonary function tests are normal.

Which one of the following is the most likely cause?

A) BronchiectasisB) TuberculosisC) SarcoidosisD) AsthmaE) Gastroesophageal reflux disease

43. A 45-year-old male asks you to evaluate his cardiovascular health status. He is currentlyasymptomatic, but wants to do everything he can to prevent heart disease and to understand hispotential cardiovascular risk. His Framingham score indicates that he is at low risk (10-year risk<6%), and his physical examination is normal.

He asks which laboratory and imaging tests he should have, and you recommend a lipid profile.According to the American College of Cardiology Foundation and the American HeartAssociation, which one of the following should also be recommended for this patient at thistime?

A) Lipoprotein and apolipoprotein levelsB) A C-reactive protein levelC) Measurement of cardiac calciumD) An ankle-brachial indexE) No further testing

44. In an adult who has a critical illness but no history of cardiac disease, the threshold fortransfusion of red blood cells should be a hemoglobin level of

A) 6 g/dLB) 7 g/dLC) 8 g/dLD) 9 g/dLE) 10 g/dL

45. A 67-year-old female hospitalized with pneumonia develops the rapid onset of dyspnea, pleuriticchest pain, tachypnea, and hypoxemia not responding to oxygen and requiring intubation. Aphysical examination is notable for rales throughout both lung fields with no peripheral edemanoted. A chest radiograph shows bilateral pulmonary infiltrates. Her BNP level is 90 ng/L.

Which one of the following is the most likely reason for her worsening clinical situation?

A) Heart failureB) Hypersensitivity pneumonitisC) Acute respiratory distress syndromeD) Pulmonary embolusE) Pneumothorax

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46. A 64-year-old male with a previous history of hypertension and atrial fibrillation presents withan acute onset of ataxia, headache, mild confusion, and restlessness. His only currentmedications are lisinopril (Prinivil, Zestril) and warfarin (Coumadin). On examination his bloodpressure is 160/100 mm Hg, pulse rate 86 beats/min, respirations 12/min, and temperature36.7°C (98.1°F). A CBC, serum electrolyte levels, and cardiac enzyme levels are normal. HisINR is 1.1. Noncontrast CT shows a cerebellar hemorrhage with a hematoma volume of 50 mL.

Which one of the following should be performed urgently?

A) Neurosurgical consultation for posterior cerebellar hematoma decompressionB) A reduction in blood pressure to 140/90 mm HgC) Administration of vitamin K, 10 mg intravenouslyD) Administration of mannitol (Osmitrol), 0.5–1.0 mg/kg intravenouslyE) Induction of hypothermia to achieve a body temperature of 34.4°C (94.0°F)

47. You prescribe enalapril (Vasotec) for a 68-year-old male with heart failure. At a follow-up visit6 weeks later the patient’s serum creatinine level is 2.5 mg/dL (N 0.6–1.5) and his serumpotassium level is 5.7 mEq/L (N 3.4–4.8). His baseline values were normal.

Which one of the following is a side effect of ACE inhibitors that is the most likely cause ofthese changes in renal function?

A) Toxicity to the proximal renal tubulesB) Impaired autoregulation of glomerular blood flowC) Microangiopathic arteriolar thrombosisD) RhabdomyolysisE) Interstitial nephritis

48. A 46-year-old African-American female sees you because of a history of excessive uterinebleeding and irregularity in her menstrual cycle. She has three children and had a tubal ligationafter her last delivery. A pelvic examination does not reveal any pathology to explain hersymptoms. Further laboratory evaluation indicates that she is mildly anemic. You perform anendometrial biopsy in the office that confirms your suspicion of endometrial hyperplasia withoutatypia.

Which one of the following is the treatment of choice for this patient?

A) Elective hysterectomyB) Hysteroscopic endometrial laser ablationC) High-dose oral estrogen supplementationD) Antifibrinolytic therapyE) Progestational drugs

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49. The diagnosis of Osgood-Schlatter disease (osteochondritis of the tibial tubercle apophysis) isbest made on the basis of findings from

A) the history and examinationB) evaluation by an orthopedic specialistC) radiographsD) ultrasonographyE) MRI

50. A 35-year-old primigravid schoolteacher awakens with a rash clinically consistent with varicellaearly in the 38th week of her pregnancy. She had a negative varicella titer early in herpregnancy. The clinical course is mild and all vesicles have either crusted over or healed 1 weeklater. She has an uncomplicated labor and vaginal delivery at 40 weeks gestation, and deliversa healthy-appearing male.

Of the following options, which one is the most appropriate initial management for the newborn?

A) Intravenously administered varicella immune globulinB) A weight-appropriate dose of intravenous acyclovir (Zovirax)C) Varicella vaccineD) Combination treatment with varicella vaccine, intravenous acyclovir, and varicella

immune globulinE) Close observation only

51. Traveler’s diarrhea can be effectively treated in the great majority of cases with which one ofthe following?

A) ErythromycinB) Penicillin VC) SulfacetamideD) Ciprofloxacin (Cipro)

52. The primary indication for joint replacement surgery in patients with osteoarthritis is

A) intractable painB) joint laxityC) limited range of motionD) recurrent subluxation

53. In a child, which one of the following findings on cardiac auscultation is most likely to beassociated with structural heart disease?

A) Increased murmur intensity with standingB) An early systolic murmurC) A murmur limited to a small areaD) An S2 with a variable split durationE) A musical or low pitch

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54. A 7-year-old white male is brought to your office about 5 hours after a dog bit him on theforearm. You examine the wound and decide not to suture it. His last tetanus immunizationbrought him up to date at 4 years of age.

Which one of the following is most appropriate?

A) Culture the woundB) Scrub the wound with povidone-iodine (Betadine) surgical scrubC) Irrigate the woundD) Administer tetanus immune globulin and DTaP immunization

55. A 50-year-old female is hospitalized with severe, diffuse abdominal pain without nausea orvomiting. Vital signs on admission include a pulse rate of 110 beats/min, a respiratory rate of35/min, and a temperature of 38.2°C (100.8°F). Laboratory findings include a WBC count of21,000/mm3 (N 4300–10,800) with 80% segmented neutrophils, and a serum amylase level of4000 U/L (N 53–123). CT of the abdomen is consistent with cholelithiasis and necrotizingpancreatitis without an abscess.

Which one of the following measures is best supported by evidence?

A) CorticosteroidsB) Placement of a nasogastric tubeC) Intravenous antibioticsD) Surgery if repeat CT shows development of a pseudocyst

56. In your role as team physician, you are attending a high-school basketball game. A playersuffers an inversion injury of her ankle while coming down after reaching for a rebound. Youexamine her immediately and diagnose a grade 2 ankle sprain.

Which one of the following is the most successful treatment for this injury?

A) Use of a weight-bearing short leg cast for 2 weeks, then progressively increased activityB) Non–weight bearing, with crutches and an elastic wrap for 2 weeksC) Ankle taping, an elastic wrap, and partial weight bearing for 6 weeksD) Icing, a gel or air splint, and mobilization within 48 hours

57. Which one of the following features in an elderly patient with cognitive problems is moresuggestive of depression than of Alzheimer’s disease?

A) A long duration of cognitive problemsB) A slow progression of cognitive problemsC) Delusions that are congruent with moodD) No past history of psychiatric problems

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58. You are considering adding sitagliptin (Januvia) to the regimen of a patient with type 2 diabetesmellitus. Which one of the following best describes the mechanism of action of this drug?

A) It increases glucagon levelsB) It slows inactivation of incretin hormonesC) It reduces the absorption of glucose in the gastrointestinal tractD) It reduces insulin resistance in skeletal muscleE) It reduces insulin resistance in the liver

59. Examination of a patient with COPD and a complaint of increased shortness of breath revealsdullness to percussion in the left lower lung field, with decreased fremitus and decreased breathsounds. This is most compatible with

A) pulmonary consolidationB) pleural effusionC) emphysematous bleb formationD) pneumothorax

60. In patients with mild to moderate allergic rhinitis, which one of the following is the mosteffective treatment?

A) First-generation antihistamines such as diphenhydramine (Benadryl)B) Second-generation antihistamines such as fexofenadine (Allegra)C) Montelukast (Singulair)D) Intranasal corticosteroidsE) Prednisone

61. A 58-year-old female presents with significant nausea and abdominal cramping 1 month afterbeginning lithium carbonate. Her symptoms have not been relieved by multiple doses ofantacids. A physical examination is remarkable only for the appearance of discomfort and aresting pulse rate of 92 beats/min.

You suspect lithium toxicity and advise her to discontinue the lithium immediately and submitblood samples for a lithium level and complete metabolic panel. When you review her resultsthat afternoon you find that her lithium level is in the mid-therapeutic range and the onlyabnormal laboratory findings are a calcium level of 13.0 mg/dL (N 8.8–10.0), an albumin levelof 3.0 g/dL (N 3.8–5.0), a BUN level of 35 mg/dL (N 7–18), and a creatinine level of 1.6mg/dL (N 0.6–1.2).

Of the options listed below, the best immediate intervention is

A) cinacalcet (Sensipar)B) furosemide (Lasix)C) glucocorticoidsD) intravenous saline infusionE) intravenous zoledronic acid (Zometa)

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62. A 57-year-old male with a BMI of 37.1 kg/m2 was found to have a fasting blood glucose levelof 115 mg/dL on a screening test. His mother and three siblings have type 2 diabetes mellitus.A follow-up hemoglobin A1c (HbA1c) level is 6.2%. Six months later, after lifestyleinterventions, the patient’s BMI is 35.5 kg/m2 and his HbA1c is 6.1%. On a lipid panel, histriglyceride level is 457 mg/dL and his HDL-cholesterol level is 32 mg/dL. His serum creatininelevel is 1.0 mg/dL (N 0.6–1.2). You consider the use of pharmacologic therapy.

Which one of the following would be the best initial medication?

A) Acarbose (Precose)B) Exenatide (Byetta)C) Glipizide (Glucotrol)D) Metformin (Glucophage)E) Pioglitazone (Actos)

63. A 16-year-old male comes to your office with a 1-month history of increasingly severe lowerback pain. He plays on his school’s soccer team, but denies any history of injury.Hyperextension is particularly painful, and now the pain occurs during normal daily activities.

Examination reveals a hyperlordotic posture, limited range of motion, and tight hamstrings. Theremainder of the examination is unremarkable.

Which one of the following should be done initially?

A) A complete blood profileB) Rheumatoid factor and HLA-B27 testingC) Plain radiographyD) MRIE) A radionuclide bone scan

64. A 2-year-old female visiting with her parents from Mexico presents with a 1-week history ofrepeated episodes of forceful coughing followed by emesis. Her immunization status isunknown. Her mother reports that a runny nose and “cold” preceded the onset of the cough. Thechild is currently afebrile and appears mildly ill; her lungs are clear.

Your management would include which one of the following?

A) Hospitalization for ribavirin aerosol therapyB) Reassurance that the cough will abate over the next weekC) Oral erythromycin therapy for 2 weeksD) Administration of immune serum globulin intramuscularly

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65. The fluid of choice for resuscitation after a significant burn injury is

A) lactated Ringer’s solutionB) hypertonic salineC) packed RBCsD) whole bloodE) 5% albumin

66. A 52-year-old male comes to your office with a 2-month history of hoarseness that began withthe onset of a head cold. His other symptoms resolved but the hoarseness has continued. He hassmoked for 32 years and drinks 4 beers per day, and has had gastroesophageal reflux disease(GERD) for several years.

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

A) Voice restB) LaryngoscopyC) Upper endoscopyD) Inhaled corticosteroidsE) High doses of a proton pump inhibitor

67. Four weeks after successful initial treatment of unilateral otitis media in a 2-year-old white maleenrolled in a local day-care center, you reevaluate the child. He is asymptomatic, but you detecta middle ear effusion in the affected ear. The tympanic membrane is otherwise normal.

The best management at this time would be

A) inflation of the eustachian tube by the Valsalva maneuverB) an antihistamine daily for 30 daysC) low-dose corticosteroids for 30 daysD) referral to an ENT specialistE) no further treatment, with reevaluation in 2 months

68. A previously healthy 26-year-old white male carpenter reports episodes of chest tightness anddyspnea. He states that he feels better on weekends.

He most likely has

A) hypersensitivity pneumonitisB) toxic pneumonitisC) byssinosisD) benign pleural effusionE) occupational asthma

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69. A 67-year-old female who is a recently retired college professor takes warfarin (Coumadin)because of chronic atrial fibrillation. She asks you about the possibility for self-management ofher anticoagulation using a portable monitor at home.

Which one of the following is true regarding self-management of anticoagulation therapycompared to standard monitoring?

A) It decreases the number of thromboembolic eventsB) It increases the number of bleeding eventsC) It increases all-cause mortalityD) It increases the patient’s level of anxietyE) When cost, complication rates, and mortality rates are considered, it is inferior to

standard monitoring

70. You are following a 60-year-old female for osteopenia. Which one of the following tests is bestfor assessing her vitamin D status?

A) 1,25-Dihydroxyvitamin DB) 24,25-Dihydroxyvitamin DC) 25-Hydroxyvitamin DD) Parathyroid hormoneE) Phosphate

71. A 45-year-old male presents to your office for a health maintenance visit. Other than mildfatigue, which he attributes to long hours at work and lack of exercise, he has no complaints.He is married, and says he takes no routine medications and does not smoke or drink. Hisexamination is unremarkable except for a BMI of 32.3 kg/m2. A CBC is unremarkable, but afasting metabolic profile shows a glucose level of 115 mg/dL, an AST (SGOT) level of 100 U/L(N 5–40), and an ALT (SGPT) level of 112 U/L (N 7–56). The remainder of the profile isnormal.

Which one of the following is the most likely cause of the abnormal laboratory findings?

A) Acetaminophen toxicityB) Hepatitis B or CC) Herbal preparations containing kavaD) Alcohol useE) Nonalcoholic fatty liver disease

72. A 60-year-old male is started on simvastatin (Zocor) for elevated cholesterol. He mentions thathe takes several herbal and dietary supplements.

Which one of the following should this patient be advised to avoid?

A) Ginkgo bilobaB) GinsengC) GarlicD) St. John’s wort

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73. Treatment with which one of the following antihypertensive medications may mimic the effectsof primary hyperparathyroidism?

A) Amlodipine (Norvasc)B) Doxazosin (Cardura)C) HydrochlorothiazideD) Lisinopril (Prinivil, Zestril)E) Metoprolol (Lopressor, Toprol-XL)

74. A 67-year-old female comes to your office to establish care after recently moving to yourcommunity. Her medical history includes hypertension, nonobstructive coronary artery disease,and heart failure, with an ejection fraction of 35% on an echocardiogram done last year. Shedoes not have diabetes mellitus or lung disease and she has never had a myocardial infarction.She tolerates her medications well and is active, walking about 2 miles daily. Her medicationsinclude aspirin, 81 mg daily; lisinopril (Prinivil, Zestril), 40 mg daily; and simvastatin (Zocor),40 mg daily.

Which one of the following possible additions to her medication regimen has the best evidencefor reducing mortality?

A) Clopidogrel (Plavix)B) Ezetimibe (Zetia)C) Losartan (Cozaar)D) Metoprolol succinate (Toprol-XL)E) Spironolactone (Aldactone)

75. An 85-year-old male is brought to your office by his family for a follow-up visit for Alzheimer’sdementia. His dementia has been present for 4 years. He has been experiencing increasingagitation and delusions over the past several weeks, and the family requests a medication to“calm him down.”

Which one of the following is indicated in this situation according to FDA guidelines?

A) Aripiprazole (Abilify)B) HaloperidolC) Olanzapine (Zyprexa)D) Risperidone (Risperdal)E) No antipsychotic drugs

76. Physicians are more likely than the general population to suffer from which one of thefollowing?

A) DepressionB) AlcoholismC) Prescription drug abuseD) Illicit drug abuse

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77. In symptomatic young children with Campylobacter enterocolitis that is refractory toconservative management, the preferred treatment is

A) erythromycinB) ciprofloxacin (Cipro)C) ampicillinD) trimethoprim (Primsol)E) metronidazole (Flagyl)

78. A 42-year-old male was admitted to the hospital yesterday for an extensive deep-vein thrombosisand treated with unfractionated heparin anticoagulation. The nurse alerts you that the patient hashad multiple episodes of passing moderate amounts of maroon blood per rectum. He has aprevious history of diverticulosis. He is hemodynamically stable.

The initial treatment of choice for this patient is

A) cryoprecipitateB) dabigatran (Pradaxa)C) protamine sulfateD) vasopressin (Pitressin)E) vitamin K

79. A 55-year-old nonsmoking male presents with a 2-month history of a nonproductive cough. Hehas no other respiratory tract symptoms, including dyspnea, and no history of fever. He takeshydrochlorothiazide and metoprolol succinate (Toprol-XL) for hypertension, and is otherwisehealthy. A physical examination, including vital signs with pulse oximetry, is unremarkable.

Which one of the following should you do next?

A) Discontinue metoprololB) Begin empiric antibiotic treatment for atypical pathogensC) Perform a complete spirometry evaluationD) Order a chest radiographE) Order CT of the chest with contrast

80. In neonatal resuscitation, chest compressions should begin if the heart rate drops below athreshold of

A) 120 beats/minB) 100 beats/minC) 80 beats/minD) 60 beats/minE) 40 beats/min

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81. According to the most recent American Diabetes Association guidelines, which one of thefollowing groups of patients with diabetes mellitus should take aspirin for primary preventionof cardiovascular events?

A) All patientsB) All patients over the age of 55C) Only those whose risk for cardiovascular disease events is >10%D) Only those whose risk for cardiovascular disease events is >20%

82. Which one of the following has the highest sensitivity and specificity for carpal tunnelsyndrome?

A) A positive Phalen maneuverB) Distal tingling with percussion (Tinel’s sign)C) A history of shaking the hand or flicking the wrist to alleviate nighttime pain (the flick

sign)D) Thenar atrophy

83. In patients with systolic heart failure, which one of the following �-blockers is best for reducingmortality and hospitalization rates?

A) Atenolol (Tenormin)B) Carvedilol (Coreg)C) Labetalol (Trandate)D) Nebivolol (Bystolic)

84. An 80-year-old male comes to your office for evaluation of neck stiffness with a sensation ofgrinding when turning his head. He has had this for several years, and has now developed dullaching in his arms and numbness in his fingers. He also has noted stiffness in his legs.Examination reveals that flexion of the neck results in a sensation that the patient says feels likean electric shock going down his back. You note some wasting of the intrinsic musculature ofthe hands, as well as hyperreflexia.

Which one of the following should you do now?

A) Order EMG of both upper extremitiesB) Order plain films of the cervical spineC) Order MRI of the cervical spineD) Refer for cervical corticosteroid injectionsE) Reevaluate the patient after 4 weeks of cervical bracing

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85. A full-term infant weighing 6 lb 8 oz at birth will typically weigh 20 lb at what age?

A) 6 monthsB) 9 monthsC) 12 monthsD) 15 monthsE) 18 months

86. One of your patients is planning to fly from Nebraska to Israel and asks about measures toprevent or reduce jet lag. Which one of the following is supported by the best evidence?

A) Melatonin should be started on the morning of departure and taken every morning for1 week

B) Melatonin should be taken nightly for 2–5 nights, beginning on the first night at thedestination

C) Melatonin will help only on the return flightD) A dose of caffeine equivalent to 3 cups of coffee should be taken every morning,

beginning on the morning of departure

87. A 13-year-old male with a history of mild intermittent asthma reports escalating use of hisshort-acting �-agonist inhaler. He routinely uses it at least 5–10 times per week for symptomrelief. He has been experiencing wheezing and chest tightness with only minimal exertion, andsometimes at rest, which is a new problem for him.

You recommend that he add which one of the following to his asthma medication regimen?

A) Intermittent use of an inhaled long-acting �-agonistB) Daily use of an inhaled long-acting �-agonistC) Daily use of an inhaled corticosteroidD) Daily use of an oral corticosteroidE) Daily use of an oral immunomodulator

88. A 14-year-old female is concerned because she is unable to gain weight. A review of systemsreveals intermittent diarrhea and chronic dermatitis previously diagnosed as eczema. Her pastand family histories are unremarkable. A laboratory workup is negative, including a completemetabolic profile, a TSH level, and a sweat chloride test. A stool sample is negative for WBCs,ova, and parasites.

Which one of the following is true regarding this patient?

A) She should be tested for IgA anti-tissue transglutaminaseB) She should be placed on a lactose-free dietC) She should be referred to an eating disorders specialistD) She should have a colonic mucosal biopsy

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89. A 48-year-old white male has experienced five episodes of right upper quadrant pain during thepast year. The most recent episode occurred 2 weeks ago. The episodes last 2–4 hours and areassociated with nausea and vomiting.

Which one of the following is most likely to provide an explanation for the patient’s symptoms?

A) A serum bilirubin levelB) An AST (SGOT) levelC) A plain film of the abdomenD) A HIDA scanE) Abdominal ultrasonography

90. A 4-year-old female is brought to your office with a 5-day history of a cough and low-gradefever. She appears mildly anxious but in no respiratory distress, and the physical examinationis notable for a temperature of 38.1°C (100.6°F), a respiratory rate of 44/min, and a spot O2

saturation of 94% with decreased breath sounds and fine crackles in the left lower lobe. Youdecide to prescribe amoxicillin. When you give the prescription to the mother she mentions thather 12-year-old son was given azithromycin (Zithromax) for pneumonia last year when he hadsimilar symptoms and findings, and she asks why the children were given different antibiotics.

What explanation would you give the mother for choosing amoxicillin?

A) Younger children are more likely to have gram-negative pathogensB) Younger children usually have more virulent bacteriaC) Younger children are less likely to have infections caused by atypical bacteria such as

MycoplasmaD) The half-life of azithromycin is shortened in children younger than 5 years

91. Effective therapy for myocarditis-induced dilated cardiomyopathy includes

A) ibuprofenB) lisinopril (Prinivil, Zestril)C) methotrexateD) oseltamivir (Tamiflu)E) prednisone

92. A 6-year-old male is brought to your office with a 1-day history of bloody diarrhea. The causeis determined to be enterohemorrhagic Escherichia coli, which is producing Shiga toxin.

Which one of the following is the most appropriate treatment?

A) Supportive treatment onlyB) Ciprofloxacin (Cipro)C) Clindamycin (Cleocin)D) DoxycyclineE) Trimethoprim/sulfamethoxazole (Bactrim, Septra)

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93. A 2-year-old male is brought to your office for a well child check. He was born with pectusexcavatum, which has progressed somewhat as he has grown. You and the parents are concernedabout the potential for abnormal cardiopulmonary function and body image issues as the childgrows.

Repair of mild to moderately symptomatic pectus excavatum ideally should be considered whenthe patient is

A) a toddlerB) preschool ageC) in elementary schoolD) an adolescent

94. Which one of the following outcomes is associated with hospital palliative care programs?

A) Shortened hospital staysB) Reduced use of nonphysician personnelC) Increased ICU utilizationD) Lower overall hospital costs

95. A 55-year-old female is concerned about variations in her heartbeat. She describes “fluttering,”“flip-flopping,” and sometimes “pounding” sensations in her chest, with occasional delaysbetween beats. Her symptoms are episodic, and have been occurring for several months. Theyhave not been present for the past week.

The patient’s family history is negative for thyroid disease, but she recalls some “heart trouble”in several family members that was accompanied by fainting spells, and at least one relative diedsuddenly. She takes no medications, has a negative psychiatric review of systems, and has anormal physical examination.

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

A) Reassurance that her symptoms are associated with a benign conditionB) A standard 12-lead EKGC) EchocardiographyD) Intermittent event (loop) cardiac monitoringE) Admission to a hospital-based cardiac monitoring unit

96. Which one of the following would disqualify a patient from being considered homebound, usingMedicare’s definition for the purpose of conducting a home visit?

A) Participating in a state-licensed adult day care programB) Regularly attending religious servicesC) Being able to leave home with help from another personD) Being able to leave home without help, but requiring occasional use of a cane

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97. You are discussing job-related exposure to human immunodeficiency virus (HIV) with yourcertified nursing assistants. Exposure to which one of the following from an HIV-positive patientwould require consideration of post-exposure prophylaxis?

A) Breast milkB) SalivaC) SweatD) UrineE) Feces

98. A 26-year-old gravida 3 at 29 weeks gestation presents with painless vaginal bleeding. A sterilespeculum examination reveals a small amount of blood in the cervix and dilation estimated at 1cm. A sonogram shows a complete placenta previa. Her blood pressure is normal, she is notorthostatic, and her hemoglobin level is 10.7 mg/dL (N 12.0–16.0). The fetal heart rate isaround 130 beats/min with good variability and no decelerations. No contractions are shown onthe tocometer.

In addition to hospital admission for monitoring, which one of the following would be mostappropriate?

A) MagnesiumB) Calcium channel blockersC) CorticosteroidsD) AntibioticsE) Urgent cesarean section

99. A 25-year-old previously healthy female presents to the urgent care clinic with swelling of herlips and tongue, wheezing, dyspnea, and urticaria that developed after she was stung by a wasp.Her only medication is atenolol (Tenormin), which she takes for migraine prophylaxis. Youimmediately administer epinephrine 1:1000 dilution subcutaneously, but the patient does notimprove even after two more injections 10 minutes apart. She continues to be hypotensivedespite administration of an intravenous normal saline bolus, intramuscular diphenhydramine,and nebulized albuterol (Proventil, Ventolin).

Which one of the following intravenous medications is most appropriate for treating this patient’shypotension?

A) AminophyllineB) DiphenhydramineC) EpinephrineD) Glucagon (GlucaGen)E) Hydrocortisone

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100. Which one of the following statements is consistent with current U.S. Preventive Services TaskForce recommendations for skin cancer screening for the adult general population with nohistory of premalignant or malignant lesions?

A) Whole-body examination should be conducted by a primary care provider every 3 yearsB) Whole-body patient self-examination should be performed every 6 monthsC) Benefits from screening have been established only for high-risk patientsD) The evidence is currently insufficient to determine whether early detection reduces

mortality and morbidity from skin cancerE) The harms of detection and early treatment outweigh the benefits

101. A 72-year-old female presents with a 2-month history of constipation. She says she has to strainto evacuate at least half the time and reports that her stools have become clay-like in consistencyand narrower in caliber. At least half the time she has the sensation that evacuation is notcomplete, and she has occasionally used manual maneuvers to complete evacuation. She had anormal colonoscopy 8 years ago.

An abdominal examination is normal, and stool with a clay-like consistency is palpated duringa rectal examination. No prolapse is seen with straining, and the anal wink is present. Screeninglaboratory tests indicate a mild microcytic, hypochromic anemia.

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

A) A trial of lactuloseB) Lifestyle modificationsC) Phosphosoda enemasD) ColonoscopyE) Pelvic floor muscle exercises

102. A 45-year-old male recently recovered from a second episode of left lower extremity cellulitis.He has onychomycosis on his left foot but is otherwise in good health.

Which one of the following treatments is best overall if eradication of the onychomycosis isnecessary?

A) Ciclopirox topical (Penlac Nail Lacquer)B) Oral fluconazole (Diflucan)C) Oral griseofulvin (Grifulvin V)D) Oral itraconazole (Sporanox)E) Oral terbinafine (Lamisil)

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103. Effective communication with patients from other countries requires knowledge ofcommunication styles within various cultures. Which one of the following is consistentlyappropriate for all patients from non–English-speaking countries?

A) Discouraging the use of family members as interpretersB) Expecting patients to make their own decisions regarding careC) Discussing test results with the patient onlyD) Maintaining eye contact with the patient

104. A 55-year-old male with type 1 diabetes mellitus is being treated in the wound care clinic for askin ulcer on his lower right leg. The ulcer is slow to improve. He comes to see you in the officebecause over the past 2 days his right knee has become swollen, red, warm, painful, and difficultto flex. When you examine him, his right knee is swollen, erythematous, indurated, and heldin full extension. Active and passive ranges of motion are limited. Areas of erythema andinduration continue to surround his leg ulcer. His WBC count is mildly elevated, but hiserythrocyte sedimentation rate and C-reactive protein level are normal.

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

A) Plain radiographsB) UltrasonographyC) MRID) ArthrocentesisE) Antinuclear antibody studies

105. In addition to fluid resuscitation, which one of the following is the recommended first-line agentfor the management of hypotension in a patient with sepsis?

A) AlbuminB) DopamineC) EpinephrineD) Norepinephrine (Levophed)E) Phenylephrine (Neo-Synephrine)

106. The husband of a 25-year-old white female consults you about his wife. Eighteen months ago,her last pregnancy was complicated by placental abruption, hemorrhagic shock, and the birth ofa stillborn infant. She did not lactate and has not menstruated since the delivery. Since that timeshe has become increasingly fatigued and apathetic and has noticed a marked decrease in herlibido.

Which one of the following is the most likely diagnosis?

A) Prolonged grief reactionB) Postpartum pituitary necrosisC) Postpartum depressionD) Iron deficiency anemia

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107. A 58-year-old postmenopausal female sees you for an initial health maintenance visit. Herexamination is normal and she has no complaints. You perform a Papanicolaou (Pap) test, whichshe has not had done in 15 years. The smear is read as “negative for intraepithelial lesion andmalignancy, benign endometrial cells present.”

What would be the most appropriate follow-up for this finding?

A) A repeat Pap test in 4–6 monthsB) A repeat Pap test in 1 yearC) HPV testingD) An endometrial biopsyE) Colposcopy and endocervical curettage

108. Which one of the following is most likely to cause hypoglycemia when used as monotherapy?

A) Acarbose (Precose)B) Exenatide (Byetta)C) Pioglitazone (Actos)D) Repaglinide (Prandin)E) Sitagliptin (Januvia)

109. During hospital rounds you are called to attend the resuscitation of one of your patients, achronic alcoholic with known esophageal varices secondary to hepatic cirrhosis, who justexperienced sudden massive hematemesis that resulted in aspiration and respiratory arrest.Endotracheal intubation and suctioning appear to improve her respiratory crisis momentarily,but her pulse quickly becomes too weak to palpate. After 20 minutes of resuscitative effort,cardiac monitoring fails to detect any cardiac electrical activity, no spontaneous respiratoryactivity is noted, and the process is halted.

When completing the death certificate for this patient, the diagnosis most appropriately listed asthe immediate cause of death is

A) cardiac arrestB) respiratory arrestC) upper gastrointestinal hemorrhageD) esophageal varicesE) cirrhosis of the liver

110. Which one of the following patients is eligible for the Medicare hospice benefit?

A) A patient with end-stage COPD with a life expectancy of 6 monthsB) A patient with amyotrophic lateral sclerosis with a life expectancy of 9 monthsC) A patient on hemodialysis with a life expectancy of 12 monthsD) A patient with stage IV breast cancer with a life expectancy of 18 months

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111. A 16-year-old male asthmatic with no other medical problems presents with a severe attack ofrespiratory distress and a peak expiratory flow rate <40%. After 1 hour of acute treatment hisrespiratory distress has resolved, but he complains of blurred vision.

Which one of the following therapeutic agents would be the most likely cause?

A) Nebulized albuterol (Proventil, Ventolin)B) Nebulized ipratropium bromideC) Nebulized levalbuterol (Xopenex)D) Subcutaneous terbutalineE) Intravenous methylprednisolone

112. A 77-year-old male presents for a periodic health evaluation. Your practice is organized as apatient-centered medical home, and this is the patient’s initial visit. His records indicate that hereceived all recommended screening tests and immunizations 4 years ago, and he asks whatscreening tests are necessary at his age.

The U.S. Preventive Services Task Force recommends that this patient be screened for whichone of the following?

A) Prostate cancerB) Colorectal cancerC) Abdominal aneurysmD) DementiaE) Depression

113. An 82-year-old white male consults you following several syncopal episodes that are clearlyorthostatic in nature. During the course of your evaluation you find that he has a large tongue,mild cardiomegaly, and findings suggestive of bilateral carpal tunnel syndrome.

The most likely diagnosis at this time is

A) pernicious anemiaB) cervical spondylosisC) amyloidosisD) cardiomyopathyE) polymyalgia rheumatica

114. Which one of the following is true concerning people in the United States who do not have healthinsurance?

A) Most uninsured people are members of a family with at least one working adultB) Most uninsured people who are employed full-time work for large companiesC) Most uninsured people who work part-time and have incomes below the poverty line are

eligible for MedicaidD) On average, uninsured people have as much access to routine health care as those with

insurance

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115. A 36-year-old male requests further testing for infertility. His female partner has undergone alltesting, and her results are normal. He has recently undergone a semen analysis, which revealedazoospermia. Suspecting hypogonadism, you evaluate morning levels of FSH and total serumtestosterone levels to help distinguish between primary and secondary causes.

Which one of the following would you expect with primary hypogonadism?

A) Normal levels of both FSH and testosteroneB) Low levels of both FSH and testosteroneC) Low FSH and increased testosteroneD) High FSH and low testosteroneE) High levels of both FSH and testosterone

116. A 32-year-old female presents with a history of recurring headaches. They are usually unilateral,last for 24–48 hours, have a pulsatile quality, and are associated with nausea. She sometimesexperiences photophobia as well. The patient describes the headaches as intense, usuallyrequiring her to limit her activities. She has tried several over-the-counter migraine medicationsthat have been minimally effective in aborting these headaches, and requests a prescription foran abortive therapy.

Which one of the following would be the best choice for first-line therapy?

A) AcetaminophenB) Acetaminophen/oxycodone (Percocet)C) Butalbital/aspirin/caffeine (Fiorinal)D) PrednisoneE) Sumatriptan (Imitrex)

117. A 24-year-old female presents to your office for a health maintenance evaluation. She mentionsthat she has had several episodes of indigestion after meals and started taking an over-the-counterproton pump inhibitor, which she feels has been helpful. She asks if it would be harmful to takethis medicine on a long-term basis.

You tell her that evidence has shown that continuing to take this medication will increase her riskfor which one of the following?

A) HypomagnesemiaB) Vitamin B12 deficiencyC) Clostridium difficile colitisD) Having a child with birth defects (if taken in the first trimester)E) Colon cancer

118. For adolescents with scoliosis, observation is always indicated for a curve below a threshold of

A) 20°B) 30°C) 40°D) 50°

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119. A 40-year-old male presents with a 3-month history of persistent low back pain and stiffness.He cannot recall any specific episode associated with the onset of the pain, and intermittentibuprofen has provided little benefit. The pain does not radiate into his legs. He has experiencedsimilar back pain before, but it had always resolved within 2 weeks with rest, cutting back onhis activities, and taking ibuprofen. During his third episode about a year ago MRI of hislumbosacral spine did not show any significant pathology.

When you examine the patient he describes mild, generalized discomfort with palpationthroughout his lumbosacral region, but has full range of motion of his back, normal deep tendonreflexes, and good muscle strength in his legs. The straight leg–raising test produces mild lowback discomfort but does not result in any leg pain.

Which one of the following treatment options has the best evidence for restoring function in thissituation?

A) AcupunctureB) Back schoolC) Back exercisesD) Spinal manipulationE) Epidural corticosteroid injection

120. A 63-year-old white male has been diagnosed with myasthenia gravis and is experiencingprogressive muscle weakness despite maximum pharmacotherapy. Which one of the followingsurgical options would be most likely to improve his condition?

A) ThyroidectomyB) Radioactive thyroid ablationC) AdrenalectomyD) Removal of a pituitary microadenomaE) Thymectomy

121. You are preparing to evaluate a patient in the emergency department. A BNP level was orderedby the physician from the previous shift who handed the patient over to you. The level isreported as 459 pg/mL. You have not yet interviewed or examined the patient.

Based upon the information you have at this point, which one of the following is true regardingthis patient?

A) The patient has diastolic heart failureB) The patient has systolic heart failureC) The patient has acute heart failureD) The patient does not have heart failureE) The patient’s diagnosis is uncertain

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122. A 45-year-old patient develops acute erythema and pain in the first metatarsophalangeal joint,the second such episode in 4 months. There is no apparent joint effusion. Results of a standardlaboratory profile are normal, including an erythrocyte sedimentation rate, CBC, liver enzymes,BUN/creatinine, electrolytes, calcium, and uric acid. A radiograph is read as normal.

The most likely diagnosis is

A) hydroxyapatite crystal diseaseB) Morton’s neuromaC) systemic lupus erythematosusD) acute gouty arthritis

123. A 73-year-old female presents with signs of an acute ischemic stroke, which began 2 hoursearlier. She has a National Institutes of Health Stroke Scale score of 14. Noncontrast head CTshows no sign of hemorrhage.

Which one of the following treatments is recommended and FDA approved for patients with thisproblem who have no contraindications?

A) Intravenous tissue plasminogen activator (tPA)B) Warfarin (Coumadin)C) Glycoprotein IIb/IIIa receptor antagonistsD) Aspirin and clopidogrel (Plavix)E) Heparin

124. Which one of the following jaundiced infants can be treated expectantly without a full workupfor pathologic causes?

A) A 12-hour-old term infant with a total bilirubin of 10 mg/dLB) A 1-day-old term infant with a total bilirubin of 20 mg/dLC) A 2-day-old term infant with a total bilirubin of 10 mg/dLD) A 1-week-old term infant with a total bilirubin of 25 mg/dL

125. Your laboratory reports a borderline low vitamin B12 level in an anemic patient. Which one ofthe following tests can confirm vitamin B12 deficiency?

A) LDHB) Methylmalonic acidC) Mean corpuscular volumeD) Serum ferritinE) Homocysteine

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126. A clinical trial reports that a new therapy is non-inferior to your usual choice of treatment. Youcan assume which one of the following?

A) The new treatment has proven efficacyB) A large placebo group was studiedC) The study was both double blind and placebo controlledD) The new therapy is not superior to what you are currently usingE) The new therapy is not less effective than what you are currently using

127. A 35-year-old white female schoolteacher presents with anxiety, fatigue, and insomnia. Thesymptoms began after a heart murmur was discovered on a routine physical examination. Anechocardiogram revealed mild mitral valve prolapse. A student at her school recently diedsuddenly on a school field trip because of undiagnosed idiopathic hypertrophic cardiomyopathyand the patient is now afraid she will die in a similar manner. She is anxious, sleepless, andfearful of physical activity. You perform a physical examination and EKG, with normal results.

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

A) Reassurance regarding the benign course of her conditionB) A stress testC) Clonazepam (Klonopin)D) Referral to a cardiologistE) Referral for group psychotherapy

128. A 37-year-old male returns for his first follow-up visit after being diagnosed with majordepression 4 weeks earlier. The patient is taking citalopram (Celexa), 20 mg/day. He istolerating the medication well and his energy level and sleep are improved, but he still complainsof anhedonia. He has no other health problems and takes no other medications.

The most reasonable management at this point is to

A) add aripiprazole (Abilify)B) increase the dosage of citalopramC) add bupropion (Wellbutrin)D) add levothyroxine (Synthroid)

129. You have recently diagnosed rheumatoid arthritis in a 49-year-old female. She has startedmethotrexate (Rheumatrex) for disease-modifying therapy.

You counsel her that she is at increased risk for various diseases related to her arthritis, but thatthe leading cause of death in patients with rheumatoid arthritis is

A) infectionB) cardiovascular diseaseC) lymphomaD) lung cancer

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130. A 25-year-old male graduate student develops an acute headache, fever, and rash while visitinghis parents during fall break. When he comes to the emergency department he has a widespreadpetechial rash and a stiff neck, and his blood pressure is 78/40 mm Hg. He is treated withappropriate empiric antibiotics, and the spinal fluid from a tap reveals a large number ofpolynuclear leukocytes and gram-negative diplococci.

What is the most appropriate treatment at this point?

A) Ceftriaxone (Rocephin)B) Rifampin (Rifadin)C) Ciprofloxacin (Cipro)D) AmoxicillinE) Doxycycline

131. While on vacation you get up for an early morning swim and find a young man face down in thehotel lap pool. He is flaccid and unresponsive when you pull him from the water. You are alone,there is no automated external defibrillator (AED) available, and the telephone is at the oppositeside of the room.

Which one of the following actions is most consistent with American Heart Association 2010guidelines for resuscitation?

A) Turning the victim on his side to drain upper airway fluid before starting CPRB) Performing the Heimlich maneuver before starting CPRC) Performing 10 minutes of CPR before activating emergency medical servicesD) Attempting ventilation before chest compressionE) Maintaining cervical spine immobilization with whatever is available

132. Which one of the following is most appropriate for the treatment of gonorrhea?

A) Azithromycin (Zithromax)B) Azithromycin plus ceftriaxone (Rocephin) C) Cefixime (Suprax)D) Ciprofloxacin (Cipro)

133. A 63-year-old male presents with increasing shortness of breath over the past year. He smokesa pack of cigarettes a day, and has done so since he was 18 years old. Your evaluation leads toa diagnosis of COPD.

Which one of the following interventions has been shown to slow the decline in lung functionin this situation?

A) Smoking cessationB) Regular use of an inhaled short-acting �2-agonistC) Regular use of an inhaled long-acting �2-agonistD) Regular use of an inhaled long-acting anticholinergic agentE) Regular use of oral corticosteroids

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134. A 25-year-old medical assistant presents with a 3-month history of a tremor that began shortlyafter the death of her husband. The tremor starts abruptly and then spontaneously remits. It isnot an action tremor and has no association with posture.

On examination you notice the tremor severity increases with questions calling attention to hertremor symptoms and lessens when she is distracted with questions about her hobbies andsummer plans. Her neurologic examination is completely normal, including no signs of dystonia,and she has no laboratory or radiologic evidence of disease. She denies taking any medicationsor using any substances that might cause a tremor. The patient also reports that the tremor doesnot improve with moderate alcohol consumption, and it did not respond to a trial of anti-tremormedications prescribed by another physician.

Based on your findings, you suspect this patient most likely has which type of tremor?

A) CerebellarB) DystonicC) EssentialD) ParkinsonianE) Psychogenic

135. Which one of the following is associated with testosterone replacement for men withhypogonadism?

A) OsteoporosisB) DepressionC) Reduced cognitive functionD) Increased fat depositionE) Infertility

136. A 70-year-old male sees you for a preoperative evaluation 3 days prior to iliofemoral bypasssurgery. He has a 54–pack-year history of cigarette smoking, and has a long-term history ofhypertension and peripheral vascular disease. His current medications include lisinopril (Prinivil,Zestril), hydrochlorothiazide, and low-dose aspirin. He has no past history of myocardialinfarction, diabetes mellitus, or hyperlipidemia.

His blood pressure is 156/84 mm Hg and his pulse rate is 80 beats/min. The cardiopulmonaryexamination is normal. Foot pulses are diminished but present bilaterally.

In order to reduce this patient’s risk of perioperative cardiac complications, which one of thefollowing is recommended prior to his surgery?

A) A pharmacologic cardiac stress testB) Discontinuation of aspirinC) Starting a �-blockerD) Starting enoxaparin (Lovenox)E) Starting a statin

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137. In counseling a 35-year-old female about smoking cessation, you find that her greatest concernis that she will gain weight. Among the following therapies, which one is most stronglyassociated with weight gain after smoking cessation?

A) Bupropion (Wellbutrin)B) Clonidine (Catapres)C) Varenicline (Chantix)D) Nicotine gum

138. You make a diagnosis of polymyalgia rheumatica in a 72-year-old female. This is a newdiagnosis for this patient and she has not received any treatment for this condition up to thispoint.

Which one of the following prednisone regimens would be the best initial treatment?

A) 15 mg daily with a slow taperB) 15 mg daily with a rapid taperC) 30 mg daily with a slow taperD) 30 mg daily with a rapid taperE) 60 mg daily with a rapid taper

139. An otherwise healthy 53-year-old male presents with acute shortness of breath and pleuritic chestpain. His O2 saturation on room air is 85%, and he is hemodynamically stable. The patientunderwent an appendectomy 2 weeks ago and his postoperative course was complicated by anabscess, which required a week-long hospital stay.

Which one of the following should be the initial test to further evaluate this patient?

A) D-dimerB) CT angiography of the chestC) Pulmonary angiographyD) Venous ultrasonography

140. A 52-year-old male presents with major depressive disorder. He reports a decrease in his libidoand is concerned about the impact of medication on his sex life.

Which one of the following antidepressants is least likely to cause sexual dysfunction?

A) Bupropion (Wellbutrin)B) Duloxetine (Cymbalta)C) Fluoxetine (Prozac)D) Mirtazapine (Remeron)E) Paroxetine (Paxil)

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141. A hospitalized 75-year-old white male with well-controlled type 2 diabetes mellitus is scheduledfor abdominal CT with oral and intravenous iodinated contrast. Which one of the followingmedications should be withheld for at least 48 hours after the procedure?

A) Acarbose (Precose)B) Glipizide (Glucotrol)C) Glyburide (Micronase, DiaBeta)D) Metformin (Glucophage)E) Rosiglitazone (Avandia)

142. An adult male has obvious gynecomastia, without galactorrhea, that has been present for the past10 years. A careful drug history, physical examination, and endocrine and malignancy workupsare negative. He wants the problem resolved.

Which one of the following is the treatment of choice?

A) Clomiphene (Clomid, Serophene)B) DanazolC) Tamoxifen (Soltamox)D) Topical testosterone (AndroGel)E) Surgery

143. A 46-year-old African-American male presents to your office with a 1-day history of the suddenonset of severe dizziness. His symptoms include a sensation of abnormal rotation of hisenvironment, as well as occasional headaches. He has felt nauseated but has not vomited. Onexamination he has resting nystagmus. There is no hearing loss, and a thorough neurologicexamination is otherwise normal. He is vertiginous in all positions.

Which one of the following is the most likely diagnosis?

A) Basilar artery migraine with vertigoB) Benign positional vertigoC) Vestibular neuronitisD) Meniere’s diseaseE) Eustachian tube dysfunction

144. A 48-year-old female has had no menses for the past 12 months. She complains of hot flashes,especially at night, which significantly interfere with sleep. She also complains of fatigue,decreased appetite, unrefreshed sleep, and feeling “down” 4 or 5 days per week. A physicalexamination and laboratory findings are unremarkable. The patient prefers not to take estrogenreplacement therapy.

Which one of the following medications would be appropriate for this patient?

A) Bupropion (Wellbutrin)B) Nortriptyline (Pamelor)C) Escitalopram (Lexapro)D) Imipramine (Tofranil)

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145. Which one of the following can cause a person’s normal hemoglobin level to be lower than thereference range?

A) HemochromatosisB) African-American ethnicityC) Cigarette smokingD) Living at a high altitude

146. When stratifying patient risk to determine whether an implantable cardioverter-defibrillator isindicated for the primary prevention of sudden cardiac death, which one of the following isassociated with the greatest risk?

A) Atrial fibrillationB) Heart failure, with an ejection fraction �35%C) Uncontrolled hypertensionD) Complete heart block

147. A 72-year-old male is hospitalized for pneumonia. During his hospitalization he developsdiarrhea due to Clostridium difficile infection. Appropriate antibiotics are prescribed.

What other measures should be taken to prevent the spread of infection in the hospital?

A) Contact precautions with gown and gloves plus handwashing with soap and waterB) Contact and respiratory precautions with gown, gloves, and face maskC) Use of hand sanitizers before and after patient contactD) Placing the patient in a reverse airflow room

148. A 23-year-old male comes to your office accompanied by his girlfriend to talk aboutattention-deficit disorder. He minimizes the concerns she raises, which include sleeping less(sometimes just 2–3 hours a night), rambling on tangentially during conversations, and beinghighly irritable. When you ask him about these observations, he agrees that they are true andreflect a change in his usual behavior. However, he explains that he is just becoming more socialand that his girlfriend is probably jealous of his new popularity. The patient has no familyhistory of attention-deficit disorder. His father died at a young age as a result of alcoholism. Hedenies stimulant use and a urine drug screen is negative.

Which one of the following mental disorders is most likely in this patient?

A) Attention-deficit disorderB) Attention-deficit/hyperactivity disorderC) Generalized anxiety disorderD) Major depressive disorderE) Bipolar disorder

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149. A 73-year-old white female sees you for a routine visit. The patient is on multiple medications,and on examination her blood pressure is 140/80 mm Hg and her heart rate is 75 beats/min. Shealso has a systolic heart murmur, osteoarthritic changes of the knees, and a trace of peripheraledema. Her free T4 level is elevated, and her TSH level is <0.01 �U/mL (N 0.5–5.0).

Which one of the following medications the patient is taking is most likely to cause abnormalthyroid hormone levels?

A) Amiodarone (Cordarone)B) DigoxinC) Enalapril (Vasotec)D) Furosemide (Lasix)E) Lithium

150. You are writing a prescription for amoxicillin for a 6-year-old female with acute otitis media.Her mother has had an anaphylactic reaction to penicillin in the past and is concerned that shemay have passed this trait down to her daughter. You reassure her that this is not usually thecase but warn her about potential signs of an allergic reaction.

Which one of the following is the most concerning early symptom of a dangerous drug reaction?

A) Tachycardia and elevated blood pressureB) Small, bright, erythematous macules diffusely over the trunkC) Pruritus around the mouth and on the palms of the hands and soles of the feetD) Eczematous patches in the antecubital and popliteal fossaeE) Diarrhea with blood on the tissue paper

151. A 52-year-old female presents with vulvovaginal dryness and pain with intercourse. She has notmenstruated for 6 months and denies hot flashes, insomnia, or other vasomotor symptoms. Shehas no past history of cancer or surgery. Her examination is consistent with vaginal atrophy.

Which one of the following is the recommended first-line treatment for this patient?

A) Oral estrogenB) Oral estrogen and progestogenC) Vaginal estrogenD) Vaginal estrogen and oral progestogen

152. A 1-year-old female has head lice. She has three siblings who have been treated unsuccessfullyfor this problem with permethrin (Nix).

Which one of the following would be the best alternative treatment for this child?

A) Benzyl alcohol lotion (Ulesfia)B) Malathion 0.5% lotion (Ovide)C) Permethrin cream rinseD) Pyrethrin shampoo (Pronto)E) Spinosad (Natroba)

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153. A 32-year-old female presents with complaints of moderate irritability and anxiety during theweek before nearly all of her menstrual periods. During this time she also has problems withweight gain and breast tenderness. She says she is her “usual happy self” at other times duringthe month. You diagnose premenstrual syndrome (PMS).

Which one of the following complementary and alternative therapies has been shown to behelpful in reducing the symptoms of this problem?

A) SaffronB) St. John’s wortC) SoyD) Pyridoxine (vitamin B6)E) Vitamin E

154. During a routine office visit, a 65-year-old female asks if she should be screened for carotidartery stenosis. The patient has a history of controlled hypertension and hypercholesterolemia,and a family history of stroke. Physical examination of the carotid artery is normal and thepatient is asymptomatic.

Which one of the following is consistent with U.S. Preventive Services Task Force andAmerican Heart Association recommendations regarding carotid artery ultrasonography for thispatient?

A) She does not need screening ultrasonography at this timeB) She should have one-time screening ultrasonography nowC) She should have routine screening ultrasonography now and every 5 yearsD) She should have routine screening ultrasonography now and every 10 years

155. A 35-year-old white female comes to your office with a 3-month history of the gradual onset ofpain and tenderness in her 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 swellingof the proximal interphalangeal joints and metacarpophalangeal joints. Motion of these joints ispainful. She has no rash or mouth ulcers. Radiographs of the hands and wrists are negative, anda chest film is unremarkable. A CBC is normal, but the erythrocyte sedimentation rate iselevated at 40 mm/hr. Latex fixation for rheumatoid factor is negative, and an antinuclearantibody (ANA) test is negative.

The most likely diagnosis in this patient is

A) rheumatoid arthritisB) systemic lupus erythematosusC) sarcoidosisD) Lyme diseaseE) calcium pyrophosphate deposition disease

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156. A 68-year-old female with a previous history of multiple medical problems presents to youroffice with dizziness. She describes this dizziness as an “off-balance” or “wobbly” feeling. Shehas not had a sensation of spinning or motion, or loss of consciousness. She is not anxious ordepressed. She takes the following medications:

Lovastatin (Mevacor), 20 mg daily for hypercholesterolemiaMetoprolol succinate (Toprol-XL), 25 mg dailyChlorthalidone, 12.5 mg dailyLisinopril (Prinivil, Zestril), 20 mg daily for hypertensionSertraline (Zoloft), 25 mg daily for menopausal symptomsAlendronate (Fosamax), 70 mg weeklyCalcium, 600 mg 2 times dailyVitamin D, 1000 units daily for osteoporosisOxybutynin (Ditropan XL), 10 mg daily for overactive bladderAcetaminophen, 1000 mg 2 times daily for osteoarthritisMeclizine (Antivert, Bonine), 25 mg 3 times daily as needed for dizzinessCyclobenzaprine (Flexeril), 5 mg 3 times daily as needed for muscle spasmZolpidem (Ambien), 5 mg at bedtime as needed

A physical examination is normal, including a neurologic examination, and the patient has anormal gait. There is no evidence of peripheral neuropathy, and Romberg testing is normal.There is no orthostatic decrease in blood pressure. The Dix-Hallpike maneuver is negative. ACBC, chemistry profile (CMP), TSH level, and vitamin B12 level are normal.

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

A) A 24-hour heart monitorB) A tilt table testC) Carotid ultrasonographyD) Medication reductionE) Increasing the dosage of sertraline to 50 mg daily

157. A 54-year-old male presents to your office with a chief complaint of vomiting and diarrhea,along with stomach cramps. He has not noticed blood in his stool or vomit.

His symptoms began in the middle of the night, approximately 4 hours after he ate at a localdelicatessen. He has not been out of the country and has not eaten any exotic foods or foods thatare not part of his normal diet. His vital signs include a temperature of 37.0°C (98.6°F), a pulserate of 90 beats/min, and a blood pressure of 130/80 mm Hg.

Which one of the following organisms is implicated in this patient’s presumed case of foodpoisoning?

A) Staphylococcus aureusB) Clostridium botulinumC) Campylobacter jejuniD) Enterohemorrhagic Escherichia coli

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158. A 45-year-old male with type 1 diabetes mellitus receives a corticosteroid injection forosteoarthritis of the left knee. Which one of the following is true regarding monitoring of hisblood glucose levels?

A) Glucose levels should be closely monitored for 48 hoursB) Glucose levels should be closely monitored for 7 daysC) Glucose levels should be closely monitored for 14 daysD) No additional monitoring is necessary

159. A 14-year-old male with Tanner stage 1 pubic hair has prepubertal-size testes. His height is atthe 3rd percentile. The physical examination is otherwise unremarkable.

Which one of the following additional findings would be most consistent with constitutional delayof growth and puberty?

A) Impairment of the sense of smellB) Delayed bone ageC) Elevated LH and FSHD) Elevated thyrotropinE) Elevated prolactin

160. A 52-year-old African-American male sees you for a routine visit. His only medical problem ishypercholesterolemia. Because you wish to initiate a statin, you order a liver profile with thefollowing results:

Total bilirubin� � � � � � � � � � � � � � � � � � � � � � � � � 2.0 mg/dL (N 0.0–1.0)Direct bilirubin� � � � � � � � � � � � � � � � � � � � � � � � 0.2 mg/dL (N 0.0–0.4)Albumin� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4.0 g/dL (N 3.5–5.0)LDH� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 250 U/L (N 45–90)AST (SGOT)� � � � � � � � � � � � � � � � � � � � � � � � � � 25 U/L (N 7–27)ALT (SGPT)� � � � � � � � � � � � � � � � � � � � � � � � � � 15 U/L (N 1–21)Alkaline phosphatase� � � � � � � � � � � � � � � � � � � � 25 U/L (N 13–39)

Which one of the following would best explain these results?

A) Alcoholic hepatitisB) SteatohepatitisC) Chronic hepatitis CD) HemolysisE) Gilbert’s syndrome

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161. A 44-year-old female has recently lost her best friend to ovarian cancer. She has no familyhistory of cancer in her siblings, parents, or grandparents. She requests screening for ovariancancer. Her physical examination, including a pelvic examination, is normal.

According to current guidelines, which one of the following would be best for this patient?

A) CA-125 testingB) CA-125 testing and ovarian ultrasonographyC) Ovarian ultrasonography aloneD) CT of the pelvisE) No screening

162. A pregnant 32-year-old gravida 2 para 1 develops an acute deep-vein thrombosis in the left lowerextremity during the third trimester. The patient had a cesarean delivery with her first pregnancyand wants to breastfeed.

Which one of the following is the treatment of choice?

A) Low molecular weight heparinB) Unfractionated heparinC) Warfarin (Coumadin)D) A vena cava filter

163. A 40-year-old male presents with a new rash. On examination you note multipleerythematous-to-yellow dome-shaped papules on the extensor surfaces of his extremities, on hisbuttocks, and on his hands. The papules are tender and pruritic. A biopsy reveals foamymacrophages and dermal extracellular lipids.

This patient’s rash is associated with

A) endocarditisB) systemic vasculitisC) a viral infection of the skinD) hypertriglyceridemiaE) urticaria

164. For most patients, which one of the following is the most effective treatment for anemia ofchronic disease?

A) Elemental ironB) ErythropoietinC) PrednisoneD) Optimal management of the underlying disorderE) Combined therapy with oral iron, vitamin B12, folic acid, and erythropoietin

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165. Which one of the following interventions for bed-wetting in children should be recommendedas initial therapy?

A) Waking a child during the night and carrying him or her to the toiletB) Restriction of fluids during the dayC) An enuresis alarmD) Imipramine (Tofranil)E) Oxybutynin (Ditropan)

166. Which one of the following is a contraindication to the use of combined hormonalcontraceptives?

A) A family history of breast cancer in a first degree relativeB) Rheumatoid arthritis treated with immunosuppressionC) Morbid obesityD) Migraine headaches with auraE) Ovarian cancer

167. A 5-month-old child begins to cough and wheeze. He has no previous history of respiratoryproblems, although he has had upper respiratory symptoms for the past 2 days. On physicalexamination you note tachypnea and mild intercostal retractions and wheezes.

The most likely diagnosis is

A) asthmaB) bronchiolitisC) croupD) pertussisE) pneumonia

168. Which one of the following cardiac arrhythmias is associated with antipsychotic use?

A) Third degree heart blockB) Paroxysmal atrial tachycardiaC) Atrial fibrillationD) Ventricular fibrillation (torsades de pointes)E) Wolff-Parkinson-White syndrome

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169. A 16-year-old female has had foot pain for the past 3 weeks. She has no known history oftrauma, but is participating in cross-country running events for her high school and hassignificantly increased her training schedule over the past 2 months. An examination revealstenderness at the base of the fifth metatarsal, but no swelling. Radiographs are negative, but aradionuclide bone scan shows increased uptake in the proximal portion of the fifth metatarsal.

Which one of the following would be most appropriate?

A) A reduced training schedule for 1 monthB) A DXA scan to evaluate bone mineral densityC) A wooden cast shoeD) Ice and NSAID therapy onlyE) Referral to an orthopedist

170. You are treating a 68-year-old male for COPD, hypertension, systolic heart failure, andcoronary artery disease. You are considering adding a �-blocker but you are concerned that itcould affect his COPD.

Which one of the following options would be most appropriate for this patient?

A) Metoprolol tartrate (Lopressor), 12.5 mg twice dailyB) Nadolol (Corgard), 20 mg dailyC) Sotalol (Betapace), 40 mg twice dailyD) Timolol, 5 mg dailyE) Avoiding �-blocker use

171. A 77-year-old white female complains of fatigue and mild dyspnea with exertion. After athorough evaluation you conclude that she has early heart failure. She has no edema or evidenceof volume overload, and echocardiography reveals an ejection fraction of 34%.

Which one of the following would be most appropriate as INITIAL treatment?

A) DigoxinB) Furosemide (Lasix)C) HydrochlorothiazideD) Isosorbide dinitrateE) Lisinopril (Prinivil, Zestril)

172. For a 1-year-old patient, pneumococcal 13-valent conjugate vaccine (Prevnar) is preferred ratherthan polyvalent pneumococcal vaccine (Pneumovax) because of which one of the followingadvantages?

A) It is available in an oral formB) It is less expensiveC) It requires only one doseD) It can be combined with MMR in a single injectionE) It is more immunogenic

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173. A 49-year-old female with type 1 diabetes mellitus presents to your office with a 1-week historyof a red, hot, swollen foot. She recalls twisting her ankle when stepping off a curb the daybefore the swelling began. She denies fever or significant pain. She has difficulty walking dueto stiffness in the foot.

On examination you find the patient is in no distress. Her temperature is 36.7°C (98.1°F), bloodpressure 144/82 mm Hg, and heart rate 80 beats/min. Her right foot is edematous,erythematous, and excessively warm. Monofilament testing reveals significant impairment ofsensation of both feet. She has restricted range of motion of the right ankle and foot comparedto the left. No skin lesions are present. Dorsalis pedis pulses are brisk and symmetric. Aradiograph of the right foot is normal.

Laboratory Findings

Hemoglobin A1c� � � � � � � � � � � � � � � � � � � � � � � � 8.2%Capillary blood glucose�� � � � � � � � � � � � � � � � � 213 mg/dLHematocrit� � � � � � � � � � � � � � � � � � � � � � � � � � � � 37.2% (N 36.0–46.0)WBCs� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11,000/mm3 (N 4300–10,800)Platelets� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 350,000/mm3 (N 150,000–350,000)Erythrocyte sedimentation rate� � � � � � � � � � � � 30 mm/hr (N 1–25)

Which one of the following is the most likely diagnosis?

A) OsteomyelitisB) OsteoarthritisC) Acute goutD) Charcot foot

174. A 37-year-old male returns for follow-up after an episode of nephrolithiasis. He passed a 3-mmcalcium oxalate stone and requests information about preventing further stones.

You would advise that he

A) drink up to 2 L of water/dayB) increase his consumption of meats and grainsC) increase the level of fructose in his dietD) restrict foods high in oxalate, such as spinach and rhubarb

175. When discussing end-of-life issues with patients, physicians may inadvertently send the wrongmessage. Which one of the following has the greatest potential to be misinterpreted by a patient?

A) “We can offer many options to control your symptoms”B) “If you become extremely ill, would you like to be put on artificial life support?”C) “The cancer has not responded to the treatment as we had hoped”D) “We want to provide coordinated care with a team of professionals to help you remain

comfortable”E) “It is time to consider withdrawal of care”

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176. A 32-year-old secretary complains of wrist pain at rest and when holding a pen. She says it feelslike her thumb locks up at times. On examination you note tenderness on the radial side of herright wrist. A radiograph shows multiple sesamoid bones around her first metacarpophalangealjoint.

You suspect

A) rheumatoid arthritisB) carpal joint arthritisC) de Quervain’s tenosynovitisD) cervical radiculopathyE) carpal tunnel syndrome

177. A 45-year-old female presents to your office with a complaint of hair loss. Examination revealsthinning of the hair over the central superior portion of the scalp. Her frontal hairline ispreserved. There are no oval patches of baldness and no scarring. She has a history of hirsutism,infertility, irregular menses, and cystic acne. Her testosterone, dehydroepiandrosterone sulfate,and prolactin levels are normal, as are thyroid and iron levels.

Of the following, which one would be most appropriate for treatment of this patient’s hair loss?

A) Oral estrogenB) Oral corticosteroidsC) Topical corticosteroidsD) Finasteride (Propecia)E) Topical minoxidil (Women’s Rogaine)

178. Tourette’s syndrome is associated with which one of the following comorbidities?

A) Cardiac arrhythmiasB) Partial or complex seizuresC) HypertensionD) Attention-deficit disorderE) Hypothyroidism

179. An overweight 42-year-old female complains of foot pain. Which one of the following wouldbe most suggestive of plantar fasciitis?

A) A sudden onset of ecchymosis and plantar heel painB) Sharp, stabbing pain with palpation of the medial plantar calcaneal areaC) Posterior medial ankle painD) Burning pain in the medial plantar region

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180. Which one of the following is most consistent with the rash of infantile seborrheic dermatitis?

A) Sparing of the diaper areaB) An onset after 6 months of ageC) Pruritus at the time of onsetD) Resolution within weeks to monthsE) Progression to atopic dermatitis

181. A 38-year-old white female who complains of abdominal pain insists that she be referred forsurgical evaluation. She has a history of multiple unexplained physical symptoms that began inher late teenage years. She is vague concerning past medical evaluations, but a review of herthick medical chart reveals multiple normal blood and imaging tests, several surgical proceduresthat have failed to alleviate her symptoms, and frequent requests for refills of narcoticanalgesics.

This history is most compatible with which one of the following?

A) HypochondriasisB) MalingeringC) Panic disorderD) Generalized anxiety disorderE) Somatization disorder

182. A concerned father brings his 20-month-old daughter to see you because of the overnight onsetof a “barky” cough along with hoarseness, a runny nose, and a fever to 100.8°F. She is anotherwise healthy child who is up to date on her vaccinations. During the course of the visit youobserve her to be coughing intermittently, and on examination you note clear lungs withoccasional stridor and no retractions. She is not tachypneic or tachycardic. Her oxygensaturation is 95% on room air.

Appropriate medical management of this patient includes which one of the following?

A) Inhaled albuterol (Proventil, Ventolin)B) Inhaled epinephrineC) Oral azithromycin (Zithromax)D) Oral dexamethasoneE) Oral oseltamivir (Tamiflu)

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183. A 75-year-old male complains of loose stools and pain with defecation. This problem seems tohave developed gradually over the last several months. His past medical history includes prostatecancer treated with radiation therapy 5 years ago, hypertension, and osteoarthritis. Hismedications include hydrochlorothiazide, a �-blocker, and acetaminophen. Colonoscopy isnegative for polyps and cancer, but the rectal and sigmoid areas show pallor with friability andtelangiectasia.

The most likely diagnosis is

A) familial angiodysplasiaB) Osler-Weber-Rendu syndromeC) radiation proctitisD) late-onset ulcerative colitisE) sensitivity to acetaminophen breakdown products

184. A 40-year-old female with chronic asthma presents for a 6-month follow-up visit. For the pastyear she has done very well on fluticasone/salmeterol (Advair), 250/50 �g, except for when shehad to use an albuterol (Proventil, Ventolin) inhaler for 2 days because of cold symptoms 5months ago.

The most reasonable change to this patient’s medication regimen would be to

A) add montelukast (Singulair)B) replace fluticasone/salmeterol with fluticasone (Flovent)C) replace fluticasone/salmeterol with budesonide/formoterol (Symbicort)D) replace fluticasone/salmeterol with tiotropium (Spiriva)

185. A 52-year-old African-American female has a chest radiograph after a PPD test is equivocal.She is a schoolteacher, and a child in her classroom has been confirmed as a TB contact. Theradiograph shows large bilateral hilar nodes. She has recently been diagnosed with psoriaticarthritis on the basis of a scaly skin rash and arthralgias. A physical examination also revealsnodular skin lesions on her shins, and scattered, slightly enlarged lymph nodes.

Which one of the following would be the most appropriate next step for confirming thediagnosis?

A) A lymph node biopsyB) An antinuclear antibody testC) CT angiography of the chestD) Pulmonary function testsE) An echocardiogram

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186. Most of the gait disturbances identified in geriatric patients in the outpatient primary care settingare related to which one of the following?

A) Sensory ataxiaB) Parkinson’s diseaseC) OsteoarthritisD) Multiple strokesE) Myelopathy

187. A 23-year-old female becomes pregnant while using a copper T 380A intrauterine device(ParaGard) for contraception. Ultrasonography indicates an estimated gestational age of 8 weeksand confirms the location of the intrauterine device (IUD) within the uterus. A speculumexamination shows the string coming through the cervix.

Which one of the following is the best management strategy?

A) Remove the IUD nowB) Remove the IUD during the second trimesterC) Remove the IUD after 37 weeks gestationD) Remove the IUD when the patient goes into laborE) Leave the IUD in place until delivery

188. A 20-year-old white male states that he was physically abused by his natural parents, and as aresult of running away from home on several occasions he was placed in a series of fosterhomes. 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 yearhe was arrested for car theft and driving while intoxicated. He has not worked at any job formore than 6 months, and has had frequent changes of address due to failure to pay rent and otherfinancial obligations. He brags that he has fathered three children by three different women, buthas not provided any support or made any contact with any of them since their pregnancies. Hehas used several aliases, one of which he had printed on a business card listing his occupationas “Barroom Brawler and Superstud.” IQ testing is normal and there is no history of a psychoticbreak.

The most accurate diagnosis of this patient’s condition is

A) borderline personality disorderB) unipolar manic disorderC) antisocial personality disorderD) abused child reaction formationE) schizotypal personality disorder with psychoactive substance abuse

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189. You see a 75-year-old male for his Medicare annual wellness visit. Which one of the followingsatisfies the Medicare requirement for vision screening?

A) Questioning the patient about vision changesB) Use of the Amsler grid to detect age-related macular degenerationC) Use of the Snellen eye chart to evaluate visual acuityD) Use of an ophthalmoscope to detect cataractsE) Use of tonometry to detect glaucoma

190. Which one of the following combination hormonal contraceptives is most effective in obesewomen?

A) The etonogestrel/ethinyl estradiol vaginal ring (NuvaRing)B) The norelgestromin/ethinyl estradiol transdermal patch (Ortho Evra)C) Oral norethindrone/ethinyl estradiol (Aranelle, Brevicon)D) Oral levonorgestrel/ethinyl estradiol (Aviane, Seasonale)E) Oral drospirenone/ethinyl estradiol (Ocella, Yaz)

191. An asymptomatic 30-year-old female has developed hypertension that has been difficult tocontrol despite the use of hydrochlorothiazide, lisinopril (Prinivil, Zestril), atenolol (Tenormin),and hydralazine. She sees you for a follow-up visit, and her blood pressure is 165/98 mm Hg.The examination is otherwise unremarkable, including cardiac auscultation and distal pulses. HerCBC, TSH level, complete metabolic panel, and urinalysis are all normal.

Which one of the following tests would be best to confirm the most likely diagnosis?

A) An aldosterone/renin ratioB) A renal biopsyC) 24-hour urinary free cortisolD) 24-hour urinary total metanephrinesE) CT angiography

192. A 17-year-old female comes to your office with an 8-month history of amenorrhea. Menarcheoccurred at age 12 and her menses were regular until the past year. The patient’s vital signs arein the normal range for her age except for a BMI of 16.1 kg/m2 (below the third percentile forage). She is a high-school senior who dances with the local ballet company. She practices danceseveral hours a day and works out regularly. She admits that she follows a strict 800-calorie/daydiet to keep in shape for ballet.

You order a CBC, a complete metabolic profile, a urine �-hCG level, FSH and LH levels, anda TSH level. Which one of the following is also recommended as part of the workup?

A) An EKGB) Pelvic ultrasonographyC) Abdominal/pelvic CTD) A DXA scanE) A nuclear bone scan

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193. To decrease stroke risk in patients undergoing coronary artery bypass grafting (CABG) whohave concomitant carotid stenosis, current evidence supports which one of the following?

A) Carotid endarterectomy at the same time as CABGB) Postoperative �-blockersC) Postoperative aspirinD) Postoperative statins

194. With regard to screening mammography, which one of the following is lower in women 40–49years of age compared to women age 50 and older?

A) Radiation riskB) The false-positive rateC) The false-negative rateD) The absolute risk reduction for breast cancer mortality

195. In otherwise healthy, nonsmoking, previously unimmunized 65-year-olds, current Centers forDisease Control and Prevention recommendations for immunization with pneumococcal vaccine(Pneumovax) recommend administration of the vaccine

A) yearlyB) every 3 yearsC) every 5 yearsD) onceE) only for patients who are immunocompromised

196. A 67-year-old female sees you for a routine follow-up visit for hypertension. Her chemistryprofile and other laboratory studies are normal except for a serum calcium level of 10.9 mg/dL(N 8.4–10.4). This result is confirmed on repeat testing and is elevated when adjusted for heralbumin level.

Her current medications are lovastatin (Mevacor), 20 mg daily for hypercholesterolemia, andlisinopril (Prinivil, Zestril), 10 mg daily for hypertension. Her medical history is otherwisenegative. Her parathyroid hormone level is 74 pg/mL (N 15–75), her serum creatinine level is1.1 mg/dL (N 0.6–1.5), and her 25-hydroxyvitamin D level is 26 ng/mL (N 14–60).

Which one of the following is the most likely diagnosis?

A) Primary hyperparathyroidismB) Occult malignancyC) SarcoidosisD) Paget’s disease of boneE) Hypervitaminosis D

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197. A 7-year-old male is brought to your office by his mother because she is concerned about hisability to focus and stay still in school all day. She has paperwork from school and home,including his report card, Connor Rating Scales, behavioral screening, IQ tests, and performancetesting. Your evaluation leads to a diagnosis of attention-deficit/hyperactivity disorder (ADHD)with no apparent comorbidities. As you discuss management options the mother expressesconcern because her parents tell her that medications for ADHD are overprescribed andaddictive. She asks you for further guidance.

After providing the mother with comprehensive educational material, which one of the followingwould you recommend as first-line treatment?

A) Cognitive-behavioral therapyB) Atomoxetine (Strattera)C) Bupropion (Wellbutrin)D) Clonidine (Catapres)E) Methylphenidate (Ritalin LA, Concerta)

198. A 65-year-old male has complaints of insomnia and fatigue. His past medical history issignificant only for hypertension and osteoarthritis. His physical examination is normal exceptfor a blood pressure of 145/90 mm Hg and a heart rate of 105 beats/min. He has a normal BMI,does not smoke or drink alcohol, and denies any pain or chest pressure. He has not changed hisdaily exercise routine or diet, and has not traveled recently. Routine blood work is normal exceptfor a TSH level of 0.3 �U/mL (N 0.5–5.0).

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

A) Order a repeat TSH level and instruct the patient to fast beforehandB) Order a thyroglobulin levelC) Order free T3 and free T4 levelsD) Order a 24-hour radioactive iodine uptake testE) Begin treatment with levothyroxine (Synthroid)

199. A 50-year-old male presents to your office with recurrent irritative voiding symptoms that areaccompanied by testicular, perineal, and low back discomfort. He also reports occasional distalpenile pain. Four months ago he visited another physician because of a similar episode. He wastold then that he had a urinary tract infection, based on a positive urine culture that grewEscherichia coli, and was given a prescription for an antibiotic to take for 2 weeks. Hissymptoms improved but never completely resolved. On examination the patient is afebrile. Hisprostate is slightly enlarged, boggy, and moderately tender.

Which one of the following is the most appropriate management step at this time?

A) A prostate-specific antigen level prior to initiating treatmentB) Transrectal ultrasonography of the prostate prior to initiating treatmentC) Ciprofloxacin (Cipro)D) Tamsulosin (Flomax)E) High-dose oral ampicillin

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200. A 46-year-old male admits to consuming at least 4 alcoholic drinks a day. He states that hedoesn’t think his alcohol use is a problem, and that he has read that drinking helps keep the hearthealthy.

The cardiovascular effects of this level of alcohol use include

A) a decrease in blood pressure while drinkingB) a decreased risk for acute coronary eventsC) an increased risk of valvular diseaseD) an increased risk of heart failureE) no apparent effect on stroke risk

201. A 22-year-old female has a 4-month history of suprapubic pain, urinary frequency, urinaryurgency, dysuria, and dyspareunia. She has been empirically treated with antibiotics for aurinary tract infection despite the fact that multiple urine tests have been negative for infectionor other abnormalities. You suspect the patient has interstitial cystitis.

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

A) Fluoxetine (Prozac)B) IbuprofenC) Nitrofurantoin (Macrobid)D) Pentosan polysulfate sodium (Elmiron)E) Trimethoprim/sulfamethoxazole (Bactrim, Septra)

202. Which one of the following is a risk factor for depression during pregnancy?

A) High socioeconomic statusB) NonsmokingC) Age over 25D) A family history of hyperthyroidismE) Childhood abuse

203. A 62-year-old female presents with painful lesions at both corners of her mouth characterizedby redness, scaling, and deep cracks. The cracks sometimes bleed when she opens her mouth.She has treated them with bacitracin/neomycin/polymyxin B ointment (Neosporin) but says ithas not helped.

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

A) A biopsy of the lesionsB) An anticandidal medicationC) BacitracinD) Vitamin B12

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204. A 40-year-old male presents with right eye pain and redness. There is no history of trauma orinjury.

Which one of the following should be done initially?

A) IrrigationB) Funduscopic examinationC) Visual acuity testingD) Fluorescein stainingE) Application of a local anesthetic

205. While vacationing, a 27-year-old white male was exposed to poison ivy. Between 48 and 72hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his armsand neck. He began treating himself with an over-the-counter topical hydrocortisone cream, andwhen the eruption did not improve after 24 hours of treatment he sought help from the localemergency department. He was given oral methylprednisolone (Medrol Dosepak), starting with24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, andvesiculation, involving extensive areas of his arms, neck, and face.

The most appropriate management at this time would be to

A) prescribe a superpotent topical corticosteroidB) repeat the oral methylprednisolone treatmentC) begin diphenhydramine (Benadryl), 4 times a dayD) begin high-dose oral prednisone and taper over 2 weeksE) discontinue all medications and recommend cool compresses

206. A 56-year-old male sees you for a health maintenance visit. He inquires about the options forcolon cancer screening. He has not had any screening tests performed in the past and has nopersonal or family history of colon cancer. You tell him that there are several alternatives, butaccording to the U.S. Preventive Services Task Force, recommendations regarding the optimalscreening intervals vary by test. He opts for fecal occult blood testing.

You recommend he repeat this test at which one of the following intervals?

A) YearlyB) Every 5 yearsC) Every 7 yearsD) Every 10 yearsE) Never, if the results are negative

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207. Which one of the following is the leading cause of death among adolescents age 12–19 in theUnited States?

A) AccidentsB) SuicideC) HomicideD) CancerE) Heart disease

208. An 80-year-old female who lives independently at home is admitted to the hospital with acutepyelonephritis. When she is taken to her hospital room she is incontinent, unsteady whenwalking, and somewhat disoriented. Her past medical history includes hypertension withevidence of diastolic dysfunction on echocardiography and asymptomatic glucose intolerance.

Which one of the following orders would be appropriate for this patient?

A) TelemetryB) Continuous pulse oximetryC) Foley catheter placementD) A regular dietE) Bed rest

209. A 70-year-old male sees you because his left leg feels tender and swollen. Questioning revealsthat a few days ago he returned from a long road trip with his wife, and that they had spentseveral days driving to visit relatives. On examination there is marked asymmetry between hisleft calf and his right calf; there is also a slight discoloration around the area of his left calfwhere it is most tender.

You suspect the edema may be due to a deep-vein thrombosis (DVT). The patient has nopersonal or family history of blood clots. Further investigation reveals a high pretest probabilityscore on the Wells Clinical Prediction Rule test for DVT.

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

A) D-dimerB) Contrast venographyC) Compression ultrasonographyD) Helical CTE) MRI

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210. A 45-year-old female with type 1 diabetes mellitus currently takes NPH insulin (Humulin,Novolin) twice a day. She expresses a desire to change to insulin glargine (Lantus). Her diabeteshas always been well controlled, and her current hemoglobin A1c of 7.4% is typical for her.

Which one of the following is most likely to be reduced if this change is made?

A) Quality of lifeB) Hemoglobin A1c

C) Morbidity from all causesD) Treatment costsE) Her risk for hypoglycemia

211. A 52-year-old female sees you for the first time to establish care for her stable COPD. Sincelosing her insurance 4 months ago she has been off all medications except for a short-actingbronchodilator. She stopped smoking 2 years ago. She has a frequent, chronic cough and isdyspneic when climbing stairs. Pulmonary function testing reveals an FEV1 of 55%. Her O2

saturation is 90% on room air.

In addition to the short-acting inhaled bronchodilator, recommended maintenance monotherapyfor this patient would be either an inhaled long-acting anticholinergic agent or an inhaled

A) corticosteroidB) long-acting �-agonistC) mast-cell stabilizerD) antihistamine

212. A 62-year-old female presents to your office because of painless rectal bleeding. Over the pastseveral months she has occasionally noted blood on the toilet tissue and in her stool after bowelmovements. She also reports periodic anal itching and discharge, and protrusion of rectal tissueduring bowel movements that resolves spontaneously. She had a normal colonoscopy at age 50.

An abdominal examination is normal and a digital rectal examination is not painful and no massis palpated. However, her stool is positive for occult blood. Anoscopy demonstrates dilatedpurplish-blue veins above the dentate line.

Which one of the following has the best evidence for reducing symptoms in this situation?

A) Sitz bathsB) Fiber supplementationC) Topical 1% hydrocortisoneD) Topical diltiazem (Cardizem)E) Topical lidocaine cream (LidaMantle)

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213. Which one of the following reflects the percentage of patients with a disease who have a positivetest for the disease in question?

A) Likelihood ratioB) SensitivityC) SpecificityD) Positive predictive valueE) Negative predictive value

214. Patients with which one of the following platelet disorders should be hospitalized and treatedemergently?

A) Drug-induced thrombocytopeniaB) Congenital thrombocytopeniaC) Gestational thrombocytopeniaD) Thrombotic thrombocytopenic purpuraE) Thrombocytopenia associated with Lyme disease

215. A 12-year-old male presents to the office with a 2-day history of fever, myalgias, andrhinorrhea. He is otherwise healthy, and you suspect influenza.

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

A) Symptomatic treatment onlyB) Diagnostic testing to confirm influenza infectionC) Oseltamivir (Tamiflu)D) Amantadine (Symmetrel)E) Antibiotics to prevent bacterial coinfection

216. A 40-year-old male with diabetes mellitus has the following fasting lipid profile:

Total cholesterol� � � � � � � � � � � � � � � � � � � � � � � 204 mg/dLTriglycerides� � � � � � � � � � � � � � � � � � � � � � � � � � 223 mg/dLLow-density lipoprotein (LDL)�� � � � � � � � � � � 112 mg/dLHigh-density lipoprotein (HDL)� � � � � � � � � � � 42 mg/dL

The patient is currently on simvastatin (Zocor), 40 mg, for management of his dyslipidemia.Which one of the following would be most appropriate?

A) Continuing the current medication regimenB) Increasing the dosage of simvastatin C) Switching to atorvastatin (Lipitor)D) Adding gemfibrozil (Lopid)

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217. An obese 32-year-old female has not conceived after more than 4 years of unprotectedintercourse. You perform an appropriate workup and diagnose polycystic ovary syndrome.

Of the following, the most effective management for her infertility would be

A) spironolactone (Aldactone)B) luteinizing hormoneC) basal body temperature monitoringD) clomiphene (Clomid)E) bromocriptine (Parlodel)

218. A patient has fatigue and joint pain and is concerned about the possibility of systemic lupuserythematosus (SLE) after reading about this condition on the Internet. After taking a briefhistory you decide that further evaluation is appropriate.

In addition to the history and physical findings, which one of the following laboratory findingswould most support the diagnosis of SLE?

A) An abnormal C-reactive protein levelB) An erythrocyte sedimentation rate of 48 mm/hrC) A positive antimicrosomal antibody testD) A positive test for antiphospholipid antibodiesE) A positive test for rheumatoid factor

219. A 54-year-old female presents with a new onset of headaches. She rates her pain as severe andreports that the headaches frequently awaken her in the early morning. The patient has a historyof hypertension and stage 4 chronic kidney disease. Her glomerular filtration rate is 24 mL/min.

You suspect the patient has a brain tumor and order gadolinium-enhanced MRI of the head.Which one of the following is the patient at high risk for developing with the use of gadoliniumcontrast?

A) Nephrogenic systemic fibrosisB) Anaphylaxis to contrast dyeC) DermatomyositisD) Focal seizuresE) Hypertensive crisis

220. You suspect mild Pneumocystis jiroveci pneumonia in a patient whose past medical history issignificant for HIV infection. He has not been compliant with his disease management and is noton any medications.

What is the recommended treatment for this patient’s pneumonia?

A) Azithromycin (Zithromax)B) Clindamycin (Cleocin)C) Rifampin (Rifadin)D) Trimethoprim/sulfamethoxazole (Bactrim, Septra)

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221. A 66-year-old white female presents to your office for a routine physical examination. Hermedical problems include hypertension, diabetes mellitus, hypercholesterolemia, andgastroesophageal reflux, all controlled with medications. A bone density study is consistent withosteopenia. She is taking a multivitamin and calcium carbonate, 1200 mg daily.

Which one of her medications would reduce her calcium carbonate absorption?

A) Atorvastatin (Lipitor)B) HydrochlorothiazideC) Lisinopril (Prinivil, Zestril)D) Metformin (Glucophage)E) Omeprazole (Prilosec)

222. A 3-year-old male is brought to your office by his father for evaluation of 5 days of knee painand fever up to 101.6°F. There was no known trauma preceding these symptoms. The pain andfever respond well to oral acetaminophen but continue to recur 4 hours after each dose.

On examination the child appears well and is afebrile. He had a dose of acetaminophen about2 hours ago. There are no signs of upper respiratory infection. Examination of the knee revealsno redness, warmth, or swelling, and you see no other skin changes. He has full range of motionof both the knee and hip without pain. You note tenderness to firm palpation of the proximaltibia. He is able to bear weight and walk but refuses to jump due to anticipation of pain in hisknee. Plain films of the knee are normal.

The next step in the evaluation of this patient should include which one of the following?

A) Close monitoring at homeB) A CBC, a C-reactive protein level, and an erythrocyte sedimentation rateC) Ultrasonography of the hipD) Knee joint aspirationE) MRI of the knee

223. A 58-year-old female with diabetes mellitus complains of 2 years of right shoulder pain, whichis worse with activity. There has been no trauma. She tells you one of her friends had a similarproblem and was treated successfully with “some sort of shock wave treatments.”

Which one of the following diagnoses is most likely to be successfully treated withextracorporeal shock wave therapy?

A) Calcific tendinitisB) GoutC) Partial rotator cuff tearD) Frozen shoulderE) Hooked acromion

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224. A 24-year-old female presents with a 10-day history of cough productive of green sputum. Herpast medical history is unremarkable and she is up to date on all immunizations. The patient’stemperature is 37.2°C (98.9°F), blood pressure 127/76 mm Hg, pulse rate 89 beats/min,respiratory rate 24/min, and O2 saturation 95% on room air. Her physical examination isunremarkable except for a loose cough.

Which one of the following is best supported by evidence for management of this patient’scondition?

A) A macrolide antibiotic such as azithromycin (Zithromax)B) An oral corticosteroid such as prednisoneC) An inhaled �-agonist such as albuterol (Proventil, Ventolin)D) An expectorant such as guaifenesinE) Reassurance that symptoms will likely resolve on their own within 3 weeks

225. You are managing a patient who is critically ill and is being placed on a ventilator. Managementshould include which one of the following to reduce the occurrence of ventilator-associatedpneumonia?

A) Continuous sedationB) Nasotracheal intubationC) Metoclopramide (Reglan) prophylaxisD) Elevation of the head of the bedE) Initiation of tube feedings within 24 hours

226. Which one of the following has good evidence of effectively improving borderline personalitydisorder?

A) SSRIsB) Second-generation antipsychoticsC) Omega-3 fatty acidsD) No currently available pharmacotherapy

227. A 32-year-old gravida 2 para 1 with long-standing untreated hypertension presents at 8 weeksgestation for prenatal care. Her physical examination is normal except for a blood pressure of156/114 mm Hg.

Which one of the following would be most appropriate as initial treatment?

A) Labetalol (Trandate)B) Lisinopril (Prinivil, Zestril)C) Losartan (Cozaar)D) Metoprolol (Lopressor, Toprol-XL)E) Nifedipine, immediate release (Procardia)

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228. A 26-year-old male presents to the emergency department with a fever, and he appears acutelyill. After a previously undocumented grade 3 murmur is detected on examination, a transthoracicechocardiogram is ordered and reveals a 1.5-cm vegetation on the tricuspid valve.

Which one of the following is the most likely causative organism?

A) Cardiobacterium hominisB) Enterococcus faecalisC) Pseudomonas aeruginosaD) Staphylococcus aureusE) Streptococcus viridans

229. A neurologically intact 77-year-old female presents with severe low back pain following a fall2 days ago that caused her to land on her buttocks. A radiograph of her lower spine shows acompression fracture of L3 with a loss of about 50% of the vertebral body height.

Which one of the following is most appropriate at this point?

A) Referral for kyphoplastyB) Referral for vertebroplastyC) Back bracingD) Bed restE) Calcitonin-salmon (Miacalcin)

230. Which one of the following is the most common cause of death for African-American males inthe United States?

A) Heart diseaseB) StrokeC) CancerD) Accidental injuriesE) Homicide

231. A 45-year-old female has an alkaline phosphatase level that is twice the normal level on achemistry panel ordered for evaluation of pruritus. Other tests of liver function are withinnormal limits, including bilirubin and ALT (SGPT) levels, and repeat testing 2 months latershows no change. A �-glutamyltransferase level is also significantly elevated, as is anantimitochondrial antibody titer. Hepatic ultrasonography is unremarkable.

Which one of the following diagnoses is most likely?

A) Primary biliary cirrhosisB) Paget’s disease of the boneC) SarcoidosisD) CholedocholithiasisE) Drug-induced cholestasis

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232. A 19-year-old sexually active female comes to your office for a routine checkup. She isgenerally healthy with no chronic conditions and does not smoke.

For this patient, screening for which one of the following is supported by the best evidence?

A) HypercholesterolemiaB) Cervical cancerC) Chlamydia infectionD) HPV infectionE) Intimate partner violence

233. You see a 72-year-old male for follow-up after his third hospital admission for heart failurewithin the past 4 months. He is a widower and lives alone, but he wants to talk about options forin-home nursing care. He is accompanied today by his sister and his neighbor. This is the firsttime you have seen the patient.

Which one of the following is the best choice regarding your interactions with the three of them?

A) Construct a family genogram to determine how to proceed with the patient’s careB) Speak privately with the sister and neighbor to determine possible ulterior motivesC) Determine the reason each person is present todayD) Discuss the patient’s health information freely, as he willingly brought the neighbor and

sister along

Items 234–240: Refer to Pictorial Atlas insert, center of book.

234. An 80-year-old male presents with a 4-hour history of generalized abdominal pain, vomiting,and fever to 101°F. On examination you note normal cardiovascular findings, generalizedmoderate abdominal tenderness, absent bowel sounds, and a normal rectal examination.

Figure 1 shows a diagnostic abdominal film, which suggests

A) a leaking abdominal aortic aneurysmB) toxic megacolonC) small bowel obstructionD) diverticulitisE) a perforated viscus

235. The EKG shown in Figure 2 reveals

A) sinus tachycardiaB) paroxysmal atrial tachycardiaC) multifocal atrial tachycardiaD) atrial fibrillationE) atrial flutter

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236. A 37-year-old previously healthy male presents with a 1-week history of a painful swollen areaon his left eye, associated with redness (see Figure 3). He complains of dull aching in the eyethat radiates to his ipsilateral temple. He denies any ocular discharge or vision changes. Hisvisual acuity is normal.

Which one of the following is the most appropriate first step in managing this patient’scondition?

A) A topical mydriatic agentB) A topical cycloplegic agentC) A topical antibioticD) An oral NSAIDE) An oral antibiotic

237. The most likely diagnosis of the condition shown in the radiographs in Figure 4 is

A) dislocation of the trapeziumB) dislocation of the scaphoidC) dislocation of the lunateD) fracture of the distal radiusE) fracture of the distal ulna

238. A 28-year-old white male alcoholic presents with a 4-week history of fever, malaise, cough,sputum production, and weight loss. Twelve hours ago his cough increased and he noted frankblood in his sputum, along with a foul taste. Sputum is obtained for routine culture. A chestradiograph is shown in Figure 5.

Which one of the following diagnostic procedures should be performed prior to the initiation oftherapy?

A) A culture of expectorated sputumB) An open lung biopsyC) Immediate bronchoscopyD) Transtracheal aspiration

239. A 58-year-old African-American male presents to the emergency department with a 6-hourhistory of substernal pain. He has a previous history of hypertension. His blood pressure dropsto 60 mm Hg systolic after three sublingual nitroglycerin tablets. His EKG is shown in Figure6.

In addition to nitrate side effects, which one of the following should be the first diagnosticconsideration?

A) Right ventricular infarctionB) Pericarditis with tamponadeC) Papillary muscle ruptureD) Ventricular free wall ruptureE) Ventricular septal rupture

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240. During a follow-up visit for a 72-year-old white female with type 2 diabetes mellitus, herdaughter asks you to treat the lesions shown in Figure 7. These lesions bother the patient andshe complains of itching, especially at night.

The most likely diagnosis is

A) chronic, reactive scabies infestationB) eczema craquelé (xerotic eczema)C) neurodermatitisD) necrobiosis lipoidicaE) lichen sclerosus

END OF BOOK

Please check the top of your answer sheet to insure that yourProgram Number and ABFM Number are filled in correctly.

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GENERAL INSTRUCTIONS

Each of the questions or incomplete statements in this book is followed by four or five answers orcompletions. Select the ONE that is BEST in each case. You are advised to respond to all items. Eventhough you may be in doubt about the correct answer, selecting the choice that you consider to be the bestwill 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 answersmarked on the answer sheet. Only one choice should be marked for each response set. Double answersare treated as wrong answers. After you have decided upon the best answer, completely fill in the circlecontaining the corresponding letter on the answer sheet. Use only the pencil that was supplied with theexamination; do not use a pencil with hard lead or a ballpoint or felt-tipped pen. Make no stray marks onyour 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. Takecare in marking your answers since SOME ITEMS HAVE FEWER THAN 5 OPTIONS.

This book contains a pictorial atlas for use with questions 234–240. It may be removed from the book foreasier handling.

EXAMPLE

1. To which one of the following systems of the body does the heart belong?

A) DigestiveB) CirculatoryC) Central nervousD) EndocrineE) Musculoskeletal

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