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* 1. A 69-year-old male presents with complaints of right groin pain that has progressively
worsened over the past year. On exam he has a decrease in internal and external rotation of the
right hip in comparison to the left hip. He complains that it hurts with movement. What imaging
study would be most appropriate?
A. AP/lateral films of the hip are the best test to see changes consistent with osteoarthritis
(narrowed joint space, osteophytes, lipping of marginal border). This is low cost and requires
less time than other studies in patients suspected to have osteoarthritis.
B. Bone scan is best for suspected infectious process or stress fracture or metastatic disease.
C. Computed tomography scan will show osteoarthritis but this is more expensive, inconvenient,
and exposes the patient to a higher dose of radiation.
D. Magnetic resonance image is better for visualizing soft tissue or fracture not seen on x-ray. It
also has greater expense and inconvenience.
Answer: A
* This question is required.
A. plain x-rays

B. bone scan

C. computed tomography

D. magnetic resonance imaging

* 2. A 45-year-old female presents with pain, stiffness and swelling in both hands for the
past 2 months; the pain is isolated to her metacarpophalangeal joints. The pain is present upon
waking and lasts for 3-4 hours often requiring over-the-counter pain medications. Further history
reveals low grade fever, malaise and an 8 lb. unintentional weight loss since her last appointment
4 months ago. What is the most likely diagnosis?
A. Gout most often has a sudden onset and typically targets one joint (great toe most commonly
[podagra]).
B. The pain and stiffness of osteoarthritis usually resolves after 1/2 -1 hour and is not associated
with fever, malaise, or weight loss.
C. Polymyalgia rheumatica usually presents with pain and stiffness in shoulders and hips lasting
weeks.
D Presentation of rheumatoid arthritis is usually symmetric polyarticular pain and stiffness
lasting >1hr that is present for greater than 6 weeks, along with fever, malaise, weight loss, and
anemia. It most commonly presents in the 4th or 5th decade and has a 3:1 female:male ratio.
Answer: D
* This question is required.
A. gout

B. osteoarthritis

C. polymyalgia rheumatica

D. rheumatoid arthritis

* 3. A 38-year-old female on chronic steroid therapy for systemic lupus erythematosus
(SLE) presents with pain in her hip when she walks. On exam the patient has pain with internal
and external rotation and extreme flexion. What diagnostic study would be most sensitive for
diagnosing the suspected condition?
A. Avascular necrosis is not seen well on plain x-ray in the early stages of the disease.
B. See D.
C. See D.
D. Although CT and bone scan can be used to diagnose avascular necrosis (AVN), MRI is the
best test to diagnose AVN in its early stages when treatment is more effective.
Answer: D
* This question is required.
A. AP/lateral x-ray of the hip

B. bone scan

C. CT scan of the hip

D. MRI scan of the hip

* 4. A 24-year-old white male presents with intermittent bilateral thigh and low back pain
over the past 6 months. The pain is present on waking but gets better with movement and use of
ibuprofen. Patient is afebrile. Radiography reveals bilateral sacroiliitis. What lab test is best to
help confirm the suspected diagnosis?
A. A CBC may reveal anemia but this is non-specific.
B. ESR will probably be elevated in all inflammatory diseases but it is non-specific.
C. HLA-B27 will be positive in 90% of white males and 50% of black males with ankylosing
spondylitis.
D. RF and CCP antibodies will be negative in most patients with ankylosing spondylitis.
Answer: C
* This question is required.
A. CBC

B. sedimentation rate

C. HLA-B27

D. rheumatoid factor

* 5. An 18-year-old female presents with left wrist pain after falling on her outstretched
hand. Exam reveals tenderness over the anatomical snuff box. X-rays of the left wrist are
negative for fracture. What is the recommended course of treatment at this time?
A. Long arm cast with follow up in 2 days is appropriate treatment for a Monteggia fracture.
B. Rest, ice, compression, elevation and NSAIDs are appropriate treatment for wrist sprain but a
scaphoid fracture must be ruled out with follow up x-ray one week later.
C. Short arm cast with follow up in 6 weeks is appropriate treatment for a distal radius fracture.
D. A long arm, thumb spica cast with follow up and repeat x-ray in one week is the correct
treatment for presumed scaphoid fracture.
Answer: D
* This question is required.
A. long arm cast with follow up in 2 days

B. rest, ice, compression, elevation and NSAIDs

C. short arm cast with follow up in 6 weeks

D. long arm, thumb spica cast with follow up in 1 week

* 6. A 36-year-old male construction worker presents with sudden onset of right buttock
and posterior thigh and lower leg pain. Patient reports numbness and tingling over the top of his
foot but no weakness. Exam reveals diminished patellar tendon reflex with slight weakness on
dorsiflexion of the great toe. Which of the following tests will help confirm the suspected
diagnosis?
A. Finkelstein's test is done by stressing the radial aspect of the wrist to see if it causes pain. It
helps with diagnosis of de Quervain's tenosynovitis.
B. Apprehension test determines possible dislocation of the shoulder.
C. Straight leg raise is positive when pain occurs in the affected leg when lifted to 60 degrees.
This helps confirm a herniated disc in the lumbar spine.
D. Thompson's test is done by squeezing the patient's calf muscle while the knee is 90 degrees,
foot should plantar flex. It is used to diagnosis Achilles tendon rupture.
Answer: C
* This question is required.
A. Finkelstein's test

B. apprehension test

C. straight leg raising test

D. Thompson's test

* 7. A 77-year-old female presents with pain and stiffness in the muscles of the shoulders
and hips for the last 3 weeks. Patient is unable to comb her hair secondary to pain. ESR is
72mm/hr. What other pathologic condition is commonly associated with the suspected
diagnosis?
A. Polymyalgia rheumatica and giant cell arteritis often exist together (about 50%) and it is
thought that they may be the same disease process. It is important to ask questions about
possible giant cell arteritis (headache, scalp tenderness, jaw claudication, amaurosis fugax or
diplopia) because, if untreated, it can cause permanent blindness.
B. Multiple myeloma may cause malaise, anemia and increased ESR. It typically presents with
bone pain.
C. Rheumatoid arthritis may present with pain and stiffness in joints and is often associated with
malaise, anemia and increased ESR.
D. Systemic lupus erythematosus (SLE) also may present with malaise, anemia, arthritis, and
increased ESR but often is associated with malar rash on the face.
Answer: A
* This question is required.
A. giant cell arteritis

B. multiple myeloma

C. rheumatoid arthritis

D. systemic lupus erythematosus

* 8. A 37-year-old female with history of systemic lupus erythematosus (SLE) X 16 years
presents with right sided groin pain. She is on multiple medications for her SLE including a
history of intermittent use of prednisone. On exam there is decreased internal rotation of the right
hip. What is the prognosis if the patient is not diagnosed and treated for her presenting
complaint?
A. The concern is that the patient has aseptic necrosis of her femoral head and cortisone
injections will not help with this problem.
B. Sometimes the hip pain can be referred to the knee but the resulting treatment would still be a
hip replacement if the problem is aseptic necrosis of the femoral head.
C. Aseptic necrosis progresses and eventually the femoral head collapses; the pain does not
resolve spontaneously.
D. If aseptic necrosis is not diagnosed early and treated it will eventually lead to severe hip pain
and deformity and the only treatment at that time is a hip replacement.
Answer: D
* This question is required.
A. chronic cortisone injections will be required in the hips

B. chronic knee pain requiring a total knee replacement

C. symptoms will resolve spontaneously in 2-4 weeks

D. chronic hip pain requiring a total hip replacement

* 9. A 39-year-old male presents with pain in the right shoulder after a fall 4 weeks ago.
The shoulder is most painful with overhead activities and at night when he sleeps on his right
side. On exam the patient has a positive drop arm sign; what does this mean?
A. Patient may also have pain with this test but the drop arm test evaluates strength. If the
patient just has pain, it is more likely rotator cuff tendinitis and not a tear.
B. This is also testing the rotator cuff but is not the drop arm sign.
C. The drop arm test is testing the strength of the supraspinatus and when a patient has a tear of
this muscle he/she is unable to sustain the arm at 90 degrees of abduction.
D. This would be testing strength of the biceps and not the rotator cuff.
Answer: C
* This question is required.
A. patient is able to hold the arm at 90 degrees but complains of pain

B. patient is unable to forward flex the arm to 90 degrees

C. patient is unable to hold the arm at 90 degrees of abduction

D. patient is unable to hold the arm at side and flex elbows to 90 degrees

* 10. An 82-year-old female is brought to the emergency room after falling in the shower.
Patient is complaining of left groin pain and difficulty moving her left leg. On exam her left leg
is externally rotated and is painful on flexion and rotation of the hip. What is the most likely
diagnosis?
A. Sacral fracture is common in patients with osteoporosis; however, it does not present with
groin pain or hip displacement.
B. This is a typical presentation of a hip fracture: elderly patient with recent trauma, pain on hip
range of motion, and leg externally rotated and shortened.
C. Pelvic fracture can result from a fall but the patient does not usually have pain on range of
motion of the hip. Patient will complain of pain with palpation of the pelvis.
D. Trochanteric bursitis usually presents with pain over the greater trochanter, buttock and
lateral thigh. Onset of pain is slow and bothers the patient at night and while walking.
Answer: B
* This question is required.
A. sacral fracture

B. fracture of the left hip

C. inferior pubic rami fracture

D. trochanteric bursitis of the left hip

* 11. A 3-week-old female presents for a well-baby visit. Her mother has no concerns at this
time. On exam, the left leg appears shorter than the right and the skinfolds in the groin are
asymmetric. Which of the following physical exam findings would best support the suspected
diagnosis?
A. Developmental dysplasia of the hip (DDH) is an anatomic condition and does not affect
muscle tone.
B. The vascular status is not compromised in DDH.
C. Patients may have a loss of abduction with DDH but flexion remains symmetrical.
D. A positive Barlow test indicates that the hip is unstable. It is manifest with a clunking sound
(subluxation) each time the maneuver is performed.
Answer: D
* This question is required.
A. diminished muscle tone bilaterally

B. diminished femoral pulses

C. loss of hip flexion

D. positive Barlow test

* 12. A 52-year-old black female presents with insidious onset of progressive weakness of
the large muscle groups X 2 weeks. She has had particular difficulty rising from a chair without
assistance. She denies pain or fever. Physical exam is normal. Creatine kinase is elevated; ESR is
normal. Which of the following is the best treatment option?
A. Acetaminophen is an analgesic with very limited anti-inflammatory properties.
B. Colchicine is used in the treatment of gout; it has troublesome GI side effects.
C. Immunoglobulins are used for some neurological disorders and may be useful in polymyositis
or dermatomyositis that is resistant to prednisone.
D. Prednisone beginning at 40-60 mg and then tapering over the next few weeks is the
recommended treatment for polymyositis.
Answer: D
* This question is required.
A. acetaminophen

B. colchicine

C. immunoglobulins

D. prednisone

* 13. A 32-year-old male presents with intermittent low back pain that does not radiate.
Patient plays golf on the weekends but does no other physical activity. Since college he has
gained 25 pounds. On exam there is no neurological deficit. What recommendations will best
help with this patient's back pain?
A. Bedrest is not recommended for low back pain. It is now recommended that patients continue
mild activity and get some guidance from a physical therapist. Muscle relaxants are ok but
should only be used for 2-3 days.
B. Reliance on a lumbar support may weaken the spine and abdominal muscles; it is better to
start a strengthening program with a physical therapist.
C. Starting a physical therapy program will teach the patient how to care for his back and give
him tips on correct lifting and twisting principles. It will allow him to participate in weekend
activities with less stress on his back. The NSAIDs will help with pain and inflammation and the
weight loss will lessen the stress on his back.
D. Patients with low back pain should not be encouraged to stop all activity; they should
continue with mild activity as tolerated. Narcotic pain medication just covers up the pain and, if
used, should only be for a few days.
Answer: C
* This question is required.
A. bed rest and muscle relaxants

B. lumbar support and non-steroidal anti-inflammatory drugs

C. physical therapy, weight loss and non-steroidal anti-inflammatory drugs

D. rest from weekend activity and use narcotic analgesic until pain resolves

* 14. A 23-year-old female presents with pain and clicking in her left knee after she twisted
it during a soccer game. Patient denies any instability and states it became swollen about 10
hours after the game. Exam reveals positive medial joint line tenderness and a positive balloon
sign. Patient is afebrile and able to bear weight on her leg. What is the best study to confirm the
suspected diagnosis?
A. Arthroscopy will confirm meniscal tear but is an invasive procedure and requires anesthesia
to perform; it should not be performed as a diagnostic measure.
B. CT scan is better for looking at the bones rather than the soft tissue.
C. MRI scan is the best test to look at the soft tissues in the knee and confirm a meniscal tear.
D. Plain x-ray will not provide any information on the soft tissues of the knee.
Answer: C
* This question is required.
A. arthroscopy of left knee

B. computed tomography of left knee

C. magnetic resonance imaging of left knee

D. plain x-rays of left knee

* 15. A 15-year-old male presents with pain in the right knee that wakes him up at night.
Two weeks ago he noticed a bump on his right lateral thigh. He denies history of trauma. Exam
reveals a firm, immobile bump over the right lateral femur. The knee exam is unremarkable. X-
ray reveals cortical destruction and a sunburst appearance of the distal lateral femur. What is the
most likely diagnosis?
A. A bone cyst is usually asymptomatic until there is a fracture of the bone (most common bone
involved is the humerus) and usually is seen in children (males > females) between the ages of 5-
15.
B. Chondrosarcoma is most common in males 30-55 years old and often is seen in the pelvis or
femur.
C. Plain x-ray in patients with multiple myeloma shows punched-out lesions. Multiple myeloma
is usually seen in patients over 50 years old.
D. This is the typical presentation of osteosarcoma; it is most often seen in young males and in
the long bones, often around the knee. It is the most common primary malignancy of bone.
Answer: D
* This question is required.
A. bone cyst

B. chondrosarcoma

C. multiple myeloma

D. osteosarcoma

* 16. A 28-year-old female presents with a recurrent bump on the dorsal aspect of her wrist.
She wants it removed because it "looks ugly." Exam reveals a firm, fluid-filled nodule that is
mobile and non-tender. What is the definitive treatment?
A. Aspiration is easy to do in the office and should be well tolerated by the patient. The patient
should be told that the cyst may return. Steroids are injected to reduce the chance of recurrence.
B. Incision with dissection and curettage is too painful to be done in the office and would require
general anesthesia.
C. Ganglion cysts may have been treated with a smack with a heavy book in the past but most
patients would not tolerate this treatment in the office.
D. Surgical excision is definitive. Removal of entire ganglion and all attachments is
recommended.
Answer: D
* This question is required.
A. aspiration with steroid injection

B. incision with dissection and curettage

C. smack it with a heavy book

D. surgical excision

* 17. A 68-year-old female presents with 2-3 months of low back pain and tiredness in her
legs with walking. She states the pain is tolerable for about 2 blocks but then she has to stop and
sit down for a few minutes before she can continue. Exam reveals limited range of motion of her
lumbar spine with reproduction of her pain with extension of the lumbar spine. She also has
diminished ankle reflexes bilaterally. Motor strength is symmetric and strong in both lower
extremities. What is the suspected diagnosis?
A. Back strain usually is intermittent and is the result of trauma or overexertion.
B. Herniated disc can cause spinal stenosis in the degenerative spine but a more typical
presentation is after heavy lifting or twisting. It often only affects one side with more of a
radicular component.
C. Spinal stenosis is common in older adults with a history of osteoarthritis. It usually presents
with slow onset of pain and weakness that gets progressively worse. Symptoms get better with
rest or if they lean forward. Stenosis is caused by degeneration in the spine and pressure on the
nerves or their blood supply by osteophytes, facet hypertrophy, bulging discs or hypertrophy of
the ligamentum flavum.
D. Vertebral osteomyelitis presents with sudden onset of pain and would be isolated to the back.
It is commonly seen after spine surgery or in patients who are immunocompromised.
Answer: C
* This question is required.
A. back strain

B. herniated nucleus pulposis

C. spinal stenosis

D. vertebral osteomyelitis

* 18. A 21-year-old male presents with right ankle pain after twisting his ankle 2 times
during a basketball game. Exam reveals a contusion over the right lateral foot with pain over the
anterior talofibular ligament. Patient is able to weight bear on the ankle. What therapeutic
intervention is most appropriate?
A. Acetaminophen will alleviate the pain but would not help with inflammation.
B. Meperidine is too strong for an ankle sprain and has no anti-inflammatory properties.
C. Naproxen will help with the inflammation as well as the pain. This or another anti-
inflammatory medication would be the best choice.
D. Oxycodone is too strong for an ankle sprain and has no anti-inflammatory properties.
Answer: C
* This question is required.
A. acetaminophen

B. meperidine

C. naproxen

D. oxycodone

* 19. A patient complains of elbow pain. Exam reveals point tenderness over the medial
epicondyle. Which of the following physical exam maneuvers is likely to exacerbate the pain?
A. Repetitive elbow extension can cause triceps tendonitis but not medial epicondylitis.
B. Repetitive elbow flexion can cause biceps tendonitis.
C. Repetitive wrist extension usually causes lateral epicondylitis or tennis elbow.
D. Repetitive wrist flexion causes microtrauma leading to medial epicondylosis or golfer's elbow
due to the fact that the tendons that attach the muscles that flex the wrist are attached to the
medial epicondyle of the humerus. The old terminology, epicondylitis, is a misnomer; there is no
inflammation but rather degeneration.
Answer: D
* This question is required.
A. repetitive elbow extension against resistance

B. repetitive elbow flexion against resistance

C. repetitive wrist extension against resistance

D. repetitive wrist flexion against resistance

* 20. A 58-year-old female with type 2 diabetes X 12 years presents with a red, hot, swollen
knee x 12 hours. She is febrile at 102.3. The knee is erythematous and warm to touch with a
large effusion; range of motion is limited and painful. What is the most likely causative organism
for the suspected diagnosis?
A. B. burgdorferi is the causative organism in Lyme disease which is unlikely in this case. Lyme
typically causes a monoarticular or oligoarticular arthritis, most commonly affecting the knee,
and manifesting in stage 3 of the disease.
B. E. coli is the causative organism in about 5-10% of all cases of septic arthritis. It is more
common in IV drug users and immunocompromised persons.
C. N. gonorrhoeae is the most common causative organism in septic arthritis in patients less than
40 years old.
D. S. aureus is the most common cause of non-gonococcal septic arthritis (about 50% of all
cases). MRSA and group B strep are increasing in frequency.
Answer: D
* This question is required.
A. Borrelia burgdorferi

B. Escherichia coli

C. Neisseria gonorrhoeae

D. Staphylococcus aureus

* 21. A 13-year-old female presents with knee pain. She has recently started playing with 2
soccer teams and practices 4 times a week. She states the pain is worse during and after practice
and is mostly located over the anterior knee. The tibial tubercle is tender to palpation on exam.
What is the recommended treatment for the most likely diagnosis?
A. Osgood-Schlatter disease (OSD) is treated with activity modification, ice, NSAIDs and
stretching before workouts and is usually self-limited.
B. Knee immobilization is not recommended in the treatment of OSD.
C. NSAIDs, not opioid pain medications, are indicated in the treatment of OSD.
D. A steroid injection would not be indicated in OSD as it could lead to rupture of the tendon.
Answer: A
* This question is required.
A. activity modification

B. knee immobilizer during activity

C. oxycodone

D. steroid injection

* 22. A 69-year-old female presents after falling at a local drugstore when the automatic
door closed on her. She is unable to lift her arm. Swelling and ecchymosis are noted just below
the shoulder. X-ray reveals a non-displaced proximal humerus fracture without dislocation. What
is the initial recommended treatment for this patient?
A. An ORIF (open reduction internal fixation) is indicated in humerus fractures when there is
significant displacement or when the fracture is comminuted with more than 2 pieces of bone.
B. PT is indicated soon after the injury is sustained to prevent shoulder stiffening but not at
initial injury.
C. Sling immobilization is indicated in this type of fracture with early return to PT for passive
ROM exercises.
D. Shoulder replacement may be indicated in the future if avascular necrosis (AVN) develops but
not at presentation of this type of fracture.
Answer: C
* This question is required.
A. open reduction internal fixation (ORIF) of the shoulder

B. physical therapy

C. sling immobilization

D. total shoulder replacement

* 23. A 42-year-old male presents with a painful, swollen great toe. On exam, the toe is
tense, warm, erythematous and extremely tender. What is expected on examination of the
synovial fluid?
A. Inflammatory arthritis usually has 2,000-75,000 WBC/mcL.
B. Needle shaped crystals that are negatively birefringent are classically seen in gout which is
the most likely diagnosis in this scenario.
C. Gram-negative diplococci suggests a septic joint infected with N. gonorrhoeae.
D. Rhomboid shaped crystals that are positively birefringent are seen in pseudogout (calcium
pyrophosphate dihydrate) which can present like gout but usually affects the larger joints.
Answer: B
* This question is required.
A. 18000 WBC/mcL

B. needle shaped crystals that are negatively birefringent

C. positive stain for Gram-negative diplococci

D. rhomboid shaped crystals that are positively birefringent

* 24. A 49-year-old obese female presents with bilateral knee pain X 1 year. She states she
feels fine on waking in the morning but by the end of the day her knees hurt. Exam reveals
limited range of motion with mild crepitus on flexion. X-rays show some joint line narrowing but
no osteophytes or sclerosis of the bone. Which recommendation will provide the most long-term
benefit?
A. Corticosteroid injections are effective in reducing the need for oral pain medications but do
not offer long term relief or effect the progression of the disease.
B. NSAIDs will help with pain control but do not change the course of disease and have negative
side effects in many patients.
C. Total knee replacement provides symptomatic relief but is reserved for patients with more
severe disability.
D. Weight reduction will take some of the stress off this patient's knees and reduce pain. It can
also put off the need for a knee replacement possibly indefinitely.
Answer: D
* This question is required.
A. corticosteroid injection

B. NSAIDs

C. total knee replacement

D. weight loss

* 25. A 7-year-old female presents with pain in her left knee and right wrist X 8 weeks. Lab
evaluation reveals an increased ESR and CRP. Rheumatoid factor is negative and anti-CCP
antibody is positive. What is the first line treatment?
A. Corticosteroids are reserved for those patients with juvenile idiopathic arthritis (JIA) who
have severe involvement and systemic symptoms.
B. Methotrexate is used in patients who fail NSAID treatment for JIA.
C. NSAIDs are the first line treatment for children with JIA. Several are approved for use in
children including ibuprofen, naproxen, meloxicam (Mobic).
D. Narcotic analgesics are not recommended in the treatment of JIA.
Answer: C
* This question is required.
A. corticosteroids

B. methotrexate

C. naproxen

D. oxycodone

* 26. A 32-year-old presents with pain on the radial aspect of his wrist. It hurts most when
he lifts heavy objects. He has increased pain when the wrist is deviated laterally with the thumb
held within the palm. Which of the following is the first line treatment in this patient?
A. Aspiration is a treatment for a ganglion cyst which can cause pain and swelling at the site of
the lesion.
B. PT is not helpful in de Quervain's tenosynovitis.
C. Surgical release is considered if the patient does not respond to a steroid injection and
immobilization or when the constriction is severe causing the tendon to lock.
D. The presence of a positive Finkelstein's test indicates de Quervain's tenosynovitis. Steroid
injection and immobilization is recommended in the initial treatment of de Quervain's
tenosynovitis.
Answer: D
* This question is required.
A. aspiration

B. physical therapy

C. surgical release

D. steroid injection

* 27. A 41-year-old female presents with numbness in her thumb, index and middle fingers
and pain in her hand and forearm. She states the pain is worse when she spends a long time on
the computer. What physical exam finding will best help confirm the suspected diagnosis?
A. A Spurling test is done to assess for cervical radiculopathy. Although this will be negative, it
does not make the diagnosis of carpal tunnel syndrome (CTS).
B. A positive Tinel sign in expected in CTS.
C. A positive Finkelstein test is expected in de Quervain's tenosynovitis, not CTS.
D. A positive Phalen maneuver is expected in CTS and can help confirm the diagnosis.
Answer: D
* This question is required.
A. no pain with gentle neck hyperextension with head tilted to affected side

B. no pain or paresthesia with tapping over distal median nerve

C. pain on ulnar deviation with thumb grasped within the palm

D. pain with wrists held in flexion for > 60 seconds

* 28. A 27-year-old male presents with pain in the anterior shoulder. The pain is worse
when he tries to lift weights at the gym. He denies night pain and weakness of the shoulder. On
exam he has tenderness with direct palpation over the humeral head when the shoulder is held in
external rotation. What other physical exam finding will help confirm the suspected diagnosis?
A. Decreased sensation over the deltoid indicates damage to the axillary nerve. This is not seen
in bicipital tendonitis.
B. Pain with resisted supination of the forearm is seen in patients with bicipital tendonitis.
C. A positive drop arm test is seen in patients with suspected rotator cuff tears.
D. Weakness on internal rotation of the shoulder can indicate weakness of the subscapularis.
Answer: B
* This question is required.
A. decreased sensation over the deltoid

B. pain with resisted supination of the forearm

C. positive drop arm sign

D. weakness on internal rotation of the shoulder

* 29. A 28-year-old female presents after tripping and falling on her outstretched hand as
she tried to catch herself. She has pain in her wrist and she is unable to move it. Exam reveals a
dorsal angulation of the wrist; neurovascular status is intact. What is the most likely diagnosis?
A. A boxer fracture is usually seen after a patient punches something. It is a fracture of the 4th
and 5th metacarpal bones.
B. A Colles' fracture is a distal radius fracture that is dorsally displaced. The deformity that
results is often called a "silver fork deformity."
C. A Monteggia fracture is an injury where the radial head is dislocated and the ulnar shaft is
fractured.
D. A scaphoid fracture can result from a fall on an outstretched hand but would not result in the
classic "silver fork" deformity.
Answer: B
* This question is required.
A. boxer fracture

B. Colles' fracture

C. Monteggia fracture

D. scaphoid fracture

* 30. A 42-year-old male complains of a headache that has wakened him from sleep each of
the last 3 nights at 3 am. He states the pain is periorbital and feels like someone is stabbing him
in the eye with an ice pick. He also notes concurrent nasal congestion and tearing. The headache
resolves after about 2 hours without any treatment. He denies any past history of headaches.
What is the most likely diagnosis?
A. Cluster headaches usually present in middle aged males and are sudden in onset and often
periorbital in location. The pain can be associated with nasal congestion, rhinorrhea,
lacrimation, eye redness and Horner syndrome. It typically resolves within 15 minutes to 3
hours.
B. Migraine headache is more common than cluster headache and is usually unilateral and
throbbing. Migraine can be associated with an aura and can present with anorexia, nausea,
vomiting, photophobia, phonophobia and cognitive impairment. Episodes usually last from hours
to days.
C. Sinusitis usually presents with unilateral facial pressure, fullness and tenderness over the
cheek, and is often associated with nasal discharge.
D. Subarachnoid hemorrhage presents with severe, acute headache, often described as "the
worst headache of my life." It is usually associated with nausea, vomiting and loss of
consciousness.
Answer: A
* This question is required.
A. cluster headache

B. migraine headache

C. sinusitis

D. subarachnoid hemorrhage

* 31. A 60-year-old female with recent onset of recurrent TIAs is being evaluated for
surgical intervention. The benefits of this surgery would be most clear with which of the
following findings?
A. There is strong evidence to support endarterectomy for high-grade carotid stenosis (7099%)
especially when there is little evidence of atherosclerosis elsewhere. Operative treatment
(carotid thromboendarterectomy) reduces the risk of ipsilateral carotid stroke, especially when
transient ischemic attacks are of recent onset (<1 month).
B. Surgery is not indicated for mild stenosis.
C. Patients with vertebrobasilar disease/vertebrobasilar ischemic attacks are treated medically.
D. For patients with extensive vascular disease, vertebrobasilar disease, and lesions that are not
surgically accessible (intracranial lesions), medical treatment should be instituted.
Answer: A
* This question is required.
A. carotid artery stenosis of 75%

B. carotid artery stenosis of 35%

C. vertebrobasilar artery stenosis of 80%

D. vertebrobasilar and intracranial artery stenosis of 90%

* 32. A patient develops bilateral leg weakness that has progressed caudally and ascended
to both arms over 2 days. He received the influenza vaccination 6 days ago. The patient
complains of mild dyspnea but has a good forced vital capacity and a pulse oximetry of 97%.
Which of the following interventions is indicated?
A. This patient is exhibiting the manifestations of Guillain-Barre syndrome. Patients should be
admitted for monitoring; transfer to intensive care unit is indicated if the patient develops
declining respiratory status.
B. Dialysis is not useful in the treatment of Guillain-Barre.
C. Treatment with prednisone is ineffective and may prolong recovery time but intravenous
immunoglobulin (400 mg/kg/d for 5 days) may be helpful.
D. Intubation is recommended if the forced vital capacity reaches 15 mL/kg or the oxygen
saturation declines. However, this patient has good forced vital capacity and normal
oxygenation.
Answer: A
* This question is required.
A. admit the patient for close monitoring

B. initiate dialysis immediately

C. initiate high doses of prednisone

D. intubate the patient to protect the airway

* 33. A patient gives a history of migraine headaches once or twice monthly since age 18.
She seeks advice on the management of her headaches. She usually has headaches just prior to
and during menstruation and, although ibuprofen is usually helpful, it does not always provide
relief. Which of the following is the best option for acute treatment for this patient?
A. Triptans are considered first line therapy for menstrual migraines.
B. Meperidine 100 mg intramuscularly is only indicated in rare instances when other analgesics
are not adequate. It would not be appropriate with this presentation.
C. Propranolol and verapamil can be used long term as prophylactic treatment. This is usually
reserved for patients who have severe migraines more than 2-3 times a month.
D. See C for explanation.
Answer: A
* This question is required.
A. sumatriptan

B. meperidine

C. propranolol

D. verapamil

* 34. A 45-year-old male whose father was recently diagnosed with Parkinson's disease is
concerned about the etiology of the disease and his own risks for developing Parkinson's disease.
Which of the following statements about the etiology of Parkinson's disease is most accurate?
A. The most common variety, idiopathic Parkinson's disease (paralysis agitans), begins most
often between 45 and 65 years of age.
B. Parkinsonism may rarely occur on a familial basis. The parkinsonian phenotype may result
from mutations of several different genes.
C. There is an approximately equal sex distribution in Parkinson's disease.
D. There is no prevalence of Parkinson's in any ethnic group.
Answer: B
* This question is required.
A. It most commonly presents between 30 and 40 years of age.

B. It may rarely occur on a familial basis.

C. Men are at greater risk than women.

D. People of northern European heritage are at greater risk.

* 35. A 30-year-old male presents with 7 day history of right-sided facial weakness. His
symptoms include right facial droop, weakness that includes his forehead and his eyelids, and
hyperacusis. Which of the following interventions will be most helpful for this patient?
A. Aspirin is helpful in TIA/CVA, but this patient has Bell palsy since a lower motor neuron
facial palsy is described.
B. Although earplugs may help alleviate the hyperacusis, Bell palsy does not result in permanent
hearing loss.
C. Artificial tears are essential in Bell palsy to prevent the eye from drying and corneal abrasion
from developing since the eyelid is weak and often cannot fully close.
D. There is no indication that any vitamin will impact the course of Bell palsy. Corticosteroids
may be helpful for general recovery but must be started within 5 days of symptom onset.
Answer: C
* This question is required.
A. aspirin

B. earplugs

C. artificial tears

D. vitamin B12

* 36. A patient presents actively seizing with a generalized tonic-clonic seizure that has
lasted for over 10 minutes. The patient has a long history of epilepsy and non-compliance with
his medication. After protecting the airway, obtaining IV access, and administering glucose,
which of the following is the most acceptable treatment?
A. Diazepam is a good short acting choice for initial seizure control, but carbamazapine is not a
first line agent for status epilepticus.
B. Although phenobarbital is an acceptable agent for status epilepticus, it is usually added after
a shorter acting IV or IM benzodiazepine has been initiated first. Ethosuximide is an
anticonvulsant normally used for absence seizures not tonic-clonic seizures.
C. Gabapentin is used for treatment of partial seizures, not status epilepticus. Prednisone has no
role in the treatment of seizures.
D. A benzodiazepine like diazepam or lorazepam is usually effective in halting seizures for a
brief period. Phenytoin is given intravenously at a rate of 50 mg/min to provide initiation of
long-term seizure control.
Answer: D
* This question is required.
A. diazepam with carbamazepine

B. ethosuximide with phenobarbital

C. gabapentin with prednisone

D. lorazepam with phenytoin

* 37. A 30-year-old female complains of fluctuating but progressive episodes of muscle
weakness, diplopia, ptosis and difficulty chewing and swallowing. The symptoms are made
worse by activity. On physical exam, muscle weakness is readily apparent and exacerbated by
repetitive movement. Sensory and reflex examination is completely normal. What diagnostic test
can generally best confirm the diagnosis?
A. A chest x-ray and CT scan may be obtained to look for a thymoma, which is often associated
with myasthenia gravis. However, these tests do not confirm the diagnosis.
B. See A for explanation.
C. The edrophonium or tensilon test demonstrates the muscle's response to short-acting
anticholinesterase. Myasthenia gravis is caused by autoantibodies binding to acetylcholine
receptors and causing local neuromuscular blockade. Using anticholinesterase temporarily
raises the amount of acetylcholine at the receptor site and improves symptoms. An assay of
serum for elevated levels of circulating acetylcholine receptor antibodies is useful because it has
a sensitivity of 8090% for the diagnosis of myasthenia gravis.
D. MRI will not be helpful since there is no brain lesion causing the symptoms; the problem is at
the muscle's acetylcholine receptor sites.
Answer: C
* This question is required.
A. chest x-ray

B. computed tomography scan

C. tensilon test

D. magnetic resonance imaging

* 38. A 55-year-old male presents for evaluation of a postural tremor of both hands and his
head for over three years. He reports his father and grandfather developed similar tremors in their
50s but were otherwise healthy. Which of the following findings will also likely be present in
this patient?
A. The most likely cause of this patient's tremor is benign essential tremor. Although a gait
disturbance is common in Parkinson's disease, no gait or balance disturbance is expected with
essential tremor.
B. A tremor that disappears when using the hands is a resting tremor which is more consistent
with Parkinson's disease.
C. This patient most likely has a history of benign essential tremor which typically improves after
drinking a small amount of alcohol. The age of onset, the areas involved, and the familial pattern
support this diagnosis.
D. The "pill rolling" tremor described is indicative of Parkinson's.
Answer: C
* This question is required.
A. tremor causes gait disturbance

B. tremor disappears when using his hands

C. tremor improves after drinking alcohol

D. tremor involves a rolling motion of the fingers

* 39. A 2 year-old is brought to the emergency department with signs of meningitis. Spinal
tap demonstrates the following: 100 mononuclear cells/mm3 (normal 0-5), glucose 80 (normal
45-85), protein 200 mg/dL (normal 15-45). What is the most likely etiology?
A. Bacterial meningitis is characterized by increased cell count, predominantly
polymorphonuclear (PMNs) cells, reduced glucose and elevated protein.
B. Fungal meningitis is characterized by a variable pleocytosis, reduced glucose, and elevated
protein.
C. Tuberculous meningitis is characterized by increased cell count, predominantly PMNs,
reduced glucose and elevated protein.
D. Viral meningitis is characterized by lower cell counts (10-100), predominantly monocytes,
normal or slightly elevated glucose and elevated protein.
Answer: D
* This question is required.
A. bacterial meningitis

B. fungal meningitis

C. tuberculous meningitis

D. viral meningitis

* 40. A 37-year-old female presents with severe burning pain and swelling of her left hand.
She states she fractured her wrist 5 weeks ago and has been out of the cast and in a splint for 1
week. She reports severe burning pain even when the skin is lightly touched. Exam reveals
diffuse swelling of the hand, with dusky color and warmer temperature. Ultrasound is normal.
Which of the following has been shown to be effective in the treatment of the suspected
disorder?
A. Tricyclic antidepressants (TCAs) and gabapentin have been shown to be helpful in patients
with mild CRPS.
B. See A for explanation.
C. Oxycodone has not been shown to be helpful in patients with CRPS. NSAIDs and prednisone
have been shown to be more helpful with pain control.
D. Severe cases with edema and color change should be treated with prednisone for 2 weeks and
then tapered.
Answer: D
* This question is required.
A. gabapentin (Neurontin)

B. nortriptyline (Pamelor)

C. oxycodone

D. prednisone

* 41. A 28-year-old healthy female presents with a unilateral throbbing headache that is
associated with nausea, vomiting and photophobia. She states she has had similar episodes that
are associated with her menstrual cycle. Usually the pain resolves with 2 ibuprofen and lying in a
dark room, but today the pain only lessened slightly with the aforementioned treatment. What
would be the next step in treating this patient's headache?
A. 100% oxygen via non-rebreather mask is a treatment for cluster headache.
B. Massage is a recommended treatment for tension headache.
C. Prednisone is a recommended treatment for cluster headache and headache due to giant cell
arteritis.
D. Zolmitriptan (Zomig) is a selective serotonin receptor agonist and is recommended in the
treatment of migraine headache.
Answer: D
* This question is required.
A. 100% oxygen

B. massage

C. prednisone

D. zolmitriptan

* 42. A patient presents with a hand tremor. It is worse when he is taking an exam at school
but is much better after he has a few beers. He wants to know if he inherited it from his father.
What type of genetic inheritance can he be told he likely has?
A. Essential tremor exhibits an autosomal dominant inheritance.
B. See A.
C. See A.
D. See A.
Answer: A
* This question is required.
A. autosomal dominant

B. autosomal recessive

C. x-linked dominant

D. x-linked recessive

* 43. A 58-year-old male presents with right sided resting tremor and micrographia. He is
concerned about having Parkinson disease since it runs in his family. What additional finding on
physical exam would best support the suspected diagnosis?
A. Chorea movements are more often associated with Huntington disease.
B. Impairment of rapid alternating movements (slowing, rigidity) is one of many physical
findings commonly seen in Parkinson disease.
C. An inability to concentrate is often associated with depression which can be mistaken for
Parkinson disease. The two disorders may also coexist.
D. Kayser-Fleischer rings are associated with Wilson disease. It is usually distinguishable from
Parkinson disease by its earlier age of onset.
Answer: B
* This question is required.
A. chorea

B. impairment of rapid alternating movements

C. inability to concentrate

D. Keyser-Fleischer rings

* 44. A 78-year-old female with history significant for hypertension presents with drooping
of the right side of her face, weakness of right arm and an expressive dysphasia x 2 hours. What
is the first imaging study that should be ordered to determine the course of treatment in this
patient?
A. Carotid ultrasonography may be indicated in some cases but would not be the first study to be
done.
B. A CT scan (without contrast) is the first imaging study that should be ordered in this patient to
identify bleeding. It is important to determine if this patient is a candidate for thrombolytic
therapy which is best given within 3 hours of symptom onset.
C. An MR angiography may be indicated in some cases but would not be the initial study.
D. An MRI is more sensitive in outlining areas of damage; however, during the first 48 hours
after symptoms present, the CT scan is better for determining whether the stroke is ischemic or
hemorrhagic.
Answer: B
* This question is required.
A. carotid ultrasonography

B. CT scan

C. MR angiography

D. MRI scan

* 45. A 15-year-old presents to the emergency department after a helmet-to-helmet collision
during a football game today. He did not lose consciousness but admits to being confused for
about 5 minutes. He also has head pain, nausea and light sensitivity. He denies dizziness, loss of
balance, vomiting and amnesia. He denies any previous head injuries. Physical exam is
unremarkable. What is the appropriate treatment at this time?
A. Admission is not necessary in a patient who can be monitored by a responsible adult. In this
case CT scanning is not recommended because there was no loss of consciousness or force
neurologic deficits.
B. A cervical collar is not recommended in this patient as he has no complaints of neck pain.
C. The patient should not be cleared to play sports until all symptoms resolve and he has worked
up the post-concussion "6 step progression" program symptom free.
D. Physical and cognitive rest is the suggested treatment for a patient with acute concussion
symptoms.
Answer: D
* This question is required.
A. admission for serial CT scans

B. cervical collar and referral to a neurologist

C. no treatment, clear to play in next game

D. physical and cognitive rest

* 46. A 74-year-old female is brought in by her daughter who states her mother has
forgotten multiple doctor appointments recently even though they were on the calendar. The
daughter also found her mother walking around her complex trying to find her house after her
morning walk last week. Which of the following physical exam findings would most helpful to
confirm the suspected diagnosis?
A. Intelligence testing is not a sensitive method to screen for dementia. It is dependent on prior
experience and education. Change in cognitive ability and mental status over time is key to the
diagnosis.
B. The combination of the 3-item recall and clock draw test constitute the "mini-cognitive test"
which is a validated screening method for early dementia.
C. Vibratory sense and strength testing are part of the neurological exam but are not key in
diagnosing dementia.
D. See C.
Answer: B
* This question is required.
A. intelligence testing

B. recall three words after 5 minutes

C. strength testing

D. vibratory testing at distal sites

* 47. A 34-year-old female with multiple sclerosis that has been in remission for 3 years
presents with weakness of her lower extremities, numbness and tingling in her toes, and double
vision. Which of the following would best hasten her recovery?
A. Azathioprine and methotrexate may help arrest the course of secondary progressive multiple
sclerosis but are not used in the relapsing-remitting type of the disease.
B. High dose steroids have been shown to hasten the recovery of relapses in multiple sclerosis.
C. See A.
D. Plasmapheresis may be effective in multiple sclerosis patients with relapses that are not
responsive to steroids.
Answer: B
* This question is required.
A. azathioprine (Imuran)

B. corticosteroids

C. methotrexate

D. plasmapheresis

* 48. A 10-year-old male presents with his parents who have concerns about his constant
outbursts. They state he calls out at odd times but does not seem to be aware he is doing it. He
also seems to shrug his shoulders every few minutes even when he has not been asked a
question. His parents are worried because he does not seem to have any close friends at school
and his teachers are starting to label him as a troublemaker. What is the most likely diagnosis?
A. Attention deficit hyperactivity disorder (ADHD) is associated with a triad of symptoms:
impulsivity, inattention and hyperactivity.
B. Complex partial seizures can begin with a convulsive jerk but are always followed by
impaired consciousness.
C. Tourette syndrome initially presents with motor tics (80%) or phonic tics (20%) although
ultimately it becomes a combination of the two. Symptoms are usually first noticed in childhood
before the age of 15 years.
D. Obsessive compulsive disorder (OCD) is characterized by recurring thoughts or fears that
cause anxiety and is alleviated by ritualistic performance of an action to allay the fear. Patients
are aware that the obsessions/compulsions are recognized as absurd.
Answer: C
* This question is required.
A. attention deficit hyperactivity disorder

B. complex partial seizures

C. Gilles de la Tourette syndrome

D. obsessive compulsive disorder

* 49. A 20-year-old is brought to the office by her mother who is concerned that her
daughter, who has always been shy, has experienced increased timidity and obvious anxiety
whenever she is made to leave the house. The patient describes a sense of fear accompanied by
palpitations, dyspnea, and tremor. All symptoms abate at home. What is the most likely
diagnosis?
A. Agoraphobia, rooted in a fear of being in places where it may be difficult to escape, manifests
as a fear of public areas or open places. This patient's symptoms come on acutely with the fear
of entering the public space.
B. Bipolar disorder is characterized by mood swings that interfere with the patient's ability to
function.
C. Generalized anxiety disorder manifests with similar symptoms but lacks the correlation with
specific events.
D. Panic attacks are specific anxiety reactions, typically associated with a specific event or
situation. Agoraphobia is a specific subset of panic attack.
Answer: A
* This question is required.
A. agoraphobia

B. bipolar disorder

C. generalized anxiety disorder

D. panic attacks

* 50. A 23-year-old male describes sudden episodes of dyspnea, palpitations, and dizziness.
He describes a choking sensation and feelings of impending doom. The episodes start and stop
unexpectedly, last approximately 10-12 minutes, and leave the patient fatigued. ECG is normal.
What is the recommended treatment for acute episodes?
A. Benzodiazepines, namely lorazepam or alprazolam, are the recommended first line treatment
for the acute symptoms of panic attacks.
B. Beta blockers are effective for stage fright, but not so effective in acute panic attacks,
although they may be used as adjunctive therapy with an antidepressant for long term
management.
C. Antidepressants, particularly SSRIs, are the first line choice for sustained treatment against
panic attacks.
D. Valproate and other antiseizure medications may be helpful for sustained treatment in
patients who do not respond to other medications.
Answer: A
* This question is required.
A. lorazepam

B. propranolol

C. sertraline

D. valproate

* 51. A 16-year-old female ballet dancer presents with her mother who is concerned about
significant weight loss in her daughter. On exam, she appears emaciated, and her vitals show
hypotension and bradycardia. Which of the following is expected on laboratory testing?
A. Hypomagnesemia, metabolic acidosis, and thrombocytopenia are rare lab abnormalities with
anorexia nervosa.
B. Hypokalemia, leukopenia, increased cortisol, low T3, and elevated cholesterol are commonly
found in anorexia.
C. See A.
D. See A.
Answer: B
* This question is required.
A. hypomagnesemia

B. hypokalemia

C. metabolic acidosis

D. thrombocytopenia

* 52. A person is described as superstitious and suspicious. He lacks interpersonal interest
and has become socially withdrawn and eccentric. Which personality disorder does this patient
most likely have?
A. The antisocial person is selfish, callous, impulsive and promiscuous. The individual is unable
to learn from experience and usually end up with legal problems.
B. Histrionic persons are dependent, seductive, and egocentric.
C. The narcissistic person also lacks interest in others but this lack of interest is due to
exhibitionism and preoccupation with self.
D. The schizotypal person is suspicious of others and has limited interpersonal ability. The
individual becomes socially isolated and exhibit eccentric or odd behavior.
Answer: D
* This question is required.
A. antisocial

B. histrionic

C. narcissistic

D. schizotypal

* 53. A patient is described by his spouse as hyperactive with elated mood and involvement
in several new activities. At first he enjoyed his new found popularity but in the past week the
patient has become irritable and sometimes aggressive with others. His employer is concerned
that he is becoming difficult to work with on the job. Last night he was brought home by a
neighbor who states that he was disrupting the town hall meeting and accusing the mayor of
abuse of power. What is the best choice for long-term treatment for this patient?
A. High-potency benzodiazepines (eg, clonazepam) are recommended as alternative or
adjunctive control of acute behavior.
B. Haloperidol is an alternative medication if symptoms do not respond to atypical
antipsychotics or lithium.
C. Lithium was the first truly effective antimanic medication and is still popular; however, due to
side effects and complex pharmacodynamics, other atypical antipsychotics may be first choice. A
chronic medication is needed for this patient; however, more importantly, he needs acute
medication at this time.
D. The atypical antipsychotics, such as olanzapine or risperidone, are effective for management
of the agitation and acute psychosis of mania. They are also first-line treatment for chronic
management.
Answer: D
* This question is required.
A. clonazepam

B. haloperidol

C. lithium

D. olanzapine

* 54. A 68-year-old presents 7 weeks after her husband's unexpected death. She now
complains of inability to sleep. She appears angry and irritable and describes feelings of
excessive worry, guilt, and discouragement. She denies suicidal or homicidal ideation. What is
the best treatment?
A. Adjunctive group or family therapy may be helpful in adjustment disorders, especially if the
adjustment disorder is causing difficulty with relationships.
B. Although a short course of sleep aids, such as zolpidem (Ambien) may be helpful in the short
term, they should not be used long term and should not be used as monotherapy.
C. Individual supportive psychotherapy and time constitute the management of adjustment
disorders. Adjustment disorders are defined as occurring less than 3 months after a life event,
affecting social function, and associated with guilt.
D. Medication with antidepressants is rarely indicated in acute adjustment disorder.
Answer: C
* This question is required.
A. family therapy

B. zolpidem

C. supportive psychotherapy

D. selective serotonin reuptake inhibitor (SSRI)

* 55. A patient is admitted through the emergency department with an elevated blood
alcohol level. He is acutely paranoid and admits to auditory hallucinations which are telling him
everyone is out to kill him. He is oriented and displays no abnormal motor signs. What is the
treatment of choice?
A. Clonidine is a centrally acting alpha adrenergic agonist that can be used as needed in
withdrawal syndromes.
B. Benzodiazepines are the treatment of choice for withdrawal symptoms, but not for psychosis
which this patient is displaying.
C. Haloperidol is the treatment of choice for alcoholic psychosis.
D. Phenytoin is an anti-seizure medication.
Answer: C
* This question is required.
A. clonidine

B. diazepam

C. haloperidol

D. phenytoin

* 56. A 19-year-old female has a history of binge eating and hoarding food in her dorm
room. She is 5'0" and weighs 118 pounds which is 2 pounds more than last month. Which of the
following physical exam findings is most likely to be found in this patient?
A. Dental caries are common in bulimia; the acidic or bilious vomit is caustic to enamel.
Patients may also have lesions on the knuckles due to self-induced vomiting.
B. Hirsutism is found in patients with polycystic ovarian syndrome or other sex hormone
disorders. Lanugo, a finer hair found on the face, shoulders or the back, may be found in long
term anorexia.
C. Loss of body fat is characteristic of anorexia; bulimics are of normal weight or even
somewhat higher.
D. Eating disorders result in bradycardia.
Answer: A
* This question is required.
A. dental caries

B. hirsutism

C. loss of body fat

D. tachycardia

* 57. A 22-year-old African-American female presents complaining of being "nervous" all
the time. She is graduating from college soon and worries constantly about finding a job,
finances, paying back her loans, and whether or not she should apply to graduate school. She
admits to being "restless," finding it difficult to concentrate, and having problems going to sleep.
For the most likely condition, how long must her symptoms be present at a minimum in order to
make the diagnosis?
A. See C.
B. See C.
C. Patients with generalized anxiety disorder (GAD) worry greatly about life situations (e.g.,
finances, health, social acceptance, jobs, relationships, etc.). It cannot be diagnosed if the
symptoms occur in conjunction with another illness (e.g., major depression, schizophrenia),
when it occurs with other psychiatric conditions, such as panic disorder or OCD, or if the
symptoms are related to a substance (drugs, medications) or medical condition (e.g.,
hyperthyroidism). For diagnosis, the patient must have at least 3 of the following: restlessness,
easy fatigability, poor concentration, irritability, muscle tension, or sleep disturbance. These
symptoms must persist most days for at least 6 months.
D. See C.
Answer: C
* This question is required.
A. 1 month

B. 3 months

C. 6 months

D. 12 months

* 58. A 45-year-old female presents for a routine follow-up visit with her primary care
provider. Embarrassed to mention it previously, she now admits to an intense fear of spiders,
which has worsened recently as she has moved into an older historic home. When was the most
likely onset of her diagnosis?
A. The onset of specific phobias (e.g., animals, storms, heights, death, flying, etc.) begins in
childhood (usually before age 12). Specific phobias are more common in women.
B. Social phobias (fear of humiliation in social settings) begin during adolescence or young
adulthood (usually before age 25).
C. See A.
D. See A.
Answer: A
* This question is required.
A. childhood

B. adolescence

C. young adulthood

D. middle age

* 59. A 9-year-old male with no significant past medical history is brought to the
neurologist's office for an evaluation. As young as age 6, he exhibited inattention in school,
fidgeting, and talking incessantly. His parents are concerned about his behavior and performance
in school. What diagnostic test would be most helpful at this time?
A. CT scan would be indicated if the child displayed focal findings or there was suspicion of a
mass lesion.
B. Connors questionnaire is the most commonly used method to screen for ADHD.
C. Quantitative MRI has been used in research studies and may show either size reductions or
asymmetry in the basal ganglia, cerebellum, and prefrontal cortex in patients with ADHD.
However, this is not done in routine practice.
D. Patients with autism show impairment in social interaction and communication and
restrictive repetitive patterns.
Answer: B
* This question is required.
A. computed tomography

B. Connors questionnaire for parents and teachers

C. magnetic resonance imaging

D. M-CHAT (modified checklist for autism in toddlers)

* 60. A 2-year-old boy is brought to neurology due to concerns of language delays (i.e.,
word formation, speaking sentences) and impaired social interaction. On exam, he appears
withdrawn and detached. For the most likely condition, which of the following tests would be
diagnostic?
A. There are no specific biological markers identified as yet that make the diagnosis of autism.
B. EEG abnormalities may be seen in patients with autism, but they are not diagnostic.
C. MRI studies have found structural and functional abnormalities in the brain, but such findings
are not pathognomonic for autism.
D. There is no diagnostic study for autism at this time. Diagnosis is based on history and
psychosocial observations.
Answer: D
* This question is required.
A. biological markers

B. EEG

C. MRI

D. none of the above

* 61. A morbidly obese sedentary 24-year-old female presents for evaluation. History
reveals that she regularly eats an unreasonable amount of food from the dollar menu at fast-food
restaurants several times a day. Which of the following is the most likely diagnosis?
A. This patient engages in regular binge eating without any compensatory purging. Binge-eating
disorder occurs in about 25% of people with morbid obesity.
B. While there is evidence for regular binge eating, there is nothing in the history to indicate
other inappropriate compensatory behaviors (i.e. excessive fasting, exercise, self-induced
vomiting, laxative abuse).
C. Hypothyroidism is not correlated with excess eating patterns.
D. Polycystic ovary syndrome is characterized by obesity, hirsutism, and infertility. Excess food
consumption is not seen.
Answer: A
* This question is required.
A. binge-eating disorder

B. bulimia nervosa

C. hypothyroidism

D. polycystic ovary syndrome

* 62. A 40-year-old female presents with complaints of depressed mood for most of the day.
Her husband states that she feels down more days than not, and this has been going on for almost
3 years. She complains of fatigue, hypersomnia, and feeling hopeless. She denies any previous
medical or psychiatric history, and any associated stressors. Which of the following would be the
best initial pharmacologic treatment option?
A. See B.
B. MAOIs, SSRIs, and TCAs are all effective treatments. However, because dysthymic patients
with milder symptoms are less likely to tolerate medication side effects, initial treatment should
be with an SSRI. SSRIs have less anticholinergic and sedating adverse effects and the benefit of
less weight gain as well.
C. Lithium is not indicated for patients with dysthymic disorder. It is a treatment option for
patients with bipolar disorder.
D. See B.
Answer: B
* This question is required.
A. desipramine (TCA)

B. fluoxetine (SSRI)

C. lithium

D. phenelzine (MAOI)

* 63. A 23-year-old female exhibits inappropriate seductive/provocative behavior. She also
becomes uncomfortable in social situations where she is not the center of attention. Her
relationships are typically strained as she considers them to be more intimate than they really are.
Otherwise, she feels well. Which of the following would be the most effective treatment
modality?
A. There is little, if any, evidence that pharmacologic therapy is helpful for histrionic personality
disorder symptoms unless there is an associated major depressive or anxiety disorder.
B. Desensitization is effective against specific phobias.
C. Group therapy may be helpful, especially if the members have similar symptoms. Such a
group makeup can provide a mirror for the patient's emotional/social interactions. Because of
their need for approval from others, such patients may be more likely to tolerate confrontations
to avoid rejection.
D. See A.
Answer: C
* This question is required.
A. antipsychotics

B. desensitization

C. group therapy

D. SSRIs

* 64. A 25-year-old white male presents with bizarre behavior with apparent hallucinations,
delusions, and abnormal emotions. Medical or drug-induced causes are ruled-out. He is started
on a pharmacologic treatment; six weeks later he shows a coarse resting tremor and excessive
blinking. He is also complaining of sudden painful muscular contractions. With which of the
following was he most likely treated?
A. Aripiprazole, clozapine and risperidone are atypical antipsychotics which usually produce
mild metabolic side effects.
B. See A.
C. Typical (also called "first generation" or "conventional") antipsychotics commonly cause
neuroleptic side effects such as tardive dyskinesia as described in this scenario.
D. See A.
Answer: C
* This question is required.
A. aripiprazole (Abilify)

B. clozapine (Clozaril)

C. haloperidol (Haldol)

D. risperidone (Risperdal)

* 65. A new patient presents to the office for an initial routine physical exam. He has no
medical complaints, is happily married and has a satisfying job. Subsequent exam is completely
normal. However, the patient relates recurring concerns that he is being watched or followed by
a group that wishes to harm him. Which of the following is the best treatment choice?
A. Chlorpromazine (Thorazine), fluphenazine (Prolixin) and haloperidol (Haldol) are typical or
conventional antipsychotics with a higher risk of extrapyramidal symptoms.
B. See A.
C. See A.
D. The treatment of delusional disorder is heavily based on the use of antipsychotic medications,
especially the atypical or second-generation ones due to reduced side effect profile. Risperidone
(Risperdal) is a second-generation or atypical antipsychotic.
Answer: D
* This question is required.
A. chlorpromazine (Thorazine)

B. fluphenazine (Prolixin)

C. haloperidol (Haldol)

D. risperidone (Risperdal)