A 35-year-old wood logger with no significant past medical history comes to the physician complaining of a 4-day history of

fevers, chills, severe headache, and diffuse aches and pains. He denies cough. After approximately 48 hours with these
symptoms, he developed a rash on the palms of his hands and the soles of his feet and on his wrists and anles. !ver the next
48 hours, the rash "egan to spread to his arms, legs, and trun. #he rash also changed from maculopapular in nature to
petechial. He is sexually active with his wife, and with shame he reports that he had a sexual encounter with a prostitute a
month ago, "ut used a condom. He owns a farm and raises cattle. He has a dog and a cat that live inside the house. $hysical
examination reveals a moderately %toxic% appearing man. His temperature is 3&.' ()'*.3 +,-, "lood pressure is ))'./' mm
Hg, pulse is ))3.min, and respirations are )5.min. He has a diffuse rash on his "ody, including his hands and feet as shown. He
does not have photopho"ia or nuchal rigidity. His heart is tachycardic without murmurs. #he remainder of his physical
examination is unremara"le. 0a"oratory results reveal a normal white count and liver function studies.
A 4'-year-old man presents with dysphagia.
He has difficulty and pain with swallowing
for the past 5 days. He also has "loody
diarrhea and an occasional fever, and he has
noticed eye floaters with no change in his
vision. !n further 1uestioning the patient
reports unintentional weight loss of *' l"s in
the past 3 months. $ast medical history
includes H23 infection diagnosed 5 years
ago. He has refused H23 medications.
$hysical examination reveals temperature of
38 .3+4 ( ) ') +,-, "lood pressure ) '8.5'
mm Hg, pulse &8.min, and respirations )/.min. He is cachectic. #here is no oral thrush or ulcers. ,unduscopic examinationt%6
reveals yellowish-white granules with perivascular exudates and hemorrhages. 4748 #-cell count is *5 cells.mm 3 . 9ndoscopy
reveals one large, shallow, 5-crn ulcer in the rnid-esophagus surrounded "y norrnal-armearing mucosa. :hich of the following
is the most armropriate pharmacologic therapy;
A. Acyclovir
<. Amphotericin <
4. ,lucona=ole
7. >anciclovir
9. $yrimethamine and sulfadia=ine
A /4-year-old woman comes to the emergency department "ecause of intermittent chest discomfort. ?he reports su"sternal
pressure that occasionally radiates to her left arm and lasts approximately ) ' minutes. ?he "egan noticing it when she waled
distances greater than ).* mile. ?he has a history of hypertension, dyslipidemia, and gout. ?he is currently taing a "a"y aspirin
daily. ?he has smoed one half pac of cigarettes daily for the past 45 years. $hysical examination shows a delayed carotid
upstroe and a systolic e@ection murmur heard "est at the second intercostal space at the right sternal "order. A soft ?* without
splitting and an ?4 are also present. 2f the patient is instructed to perform a hand-grip maneuver, which of the following effects
is most liely to "e seen;
A. 7ecrease the intensity of murmur
<. !uro=ie=6s sign
4. 2ncrease the intensity of murmur
:hich of the following is the most liely pathogen;
A. <artonella henselae
<. <orrelia "urgdorferi
4. 4oxiella "urnetii
7. 9hrlichia chaffeensis
9. AicBettsia ricBettsii
,. #reponema pallidum
7. Co change
9. #rigger a decrescendo murmur
An 85-year-old woman with a history of hypertension and hyperlipidemia comes to the physician for a routine health
maintenance examination. ?he has had difficulty dressing herself. putting shirts on. and "rushing her hair. ?he has also had
"ilateral shoulder and hip pain that lasts for approximately ) hour in the morning. ?he denies fevers, weight loss, weaness.
headaches. or difficulty with vision. 4urrent medications include hydrochlorothia=ide and pravastatin. :hich of the following
is the most appropriate next step in management;
A. <ilateral shoulder DA2 scan
<. 4omplete physical examination
4. 9lectromyography
7. Deasurement of erythrocyte sedimentation rate
9. Deasurement of serum rheumatoid factor
,. $rednisone "urst
A nurse calls you to as a"out a low calcium level. ?he is concerned a"out one of the patients on your service, a 48-year-old
alcoholic man admitted after "eing found stuporous in the par. #he patient6s mental status has improved with restarting his
lactulose and discharge is planned for tomorrow. His temperature is 35.' oc (&8./ +,-, "lood pressure is )48.8' mm Hg, pulse is
/*.min, and resr)ifations are *'.min. #he patient is alert and oriented and does not seem to "e in any distress. 9xamination
reveals temporal wasting, numerous chest wall spider angiomas. mild gynecomastia. and mared hepatosplenomegaly. #he
physical findings of shifting dullness and *8 flitting edema "ilaterally are also present. #he nurse is concerned "ecause the
patient6s total calcium level is 5.' mg.d0, and she wants to now what to do. :hich of the following is the most appropriate
management at this time;
A. Administer calcium car"onate, )-* g.day
<. Administer calcium gluconate, *'' mg (* ampules- stat
4. Administer vitamin 7 supplementation
7. 4hec al"umin level
9. 4hec magnesium level
A *)-year-old woman comes to the physician "ecause of a 3-month history of progressive a"dominal pain. ?he has a normal
appetite. 9xamination shows mild right lower 1uadrant a"dominal tenderness. $el3ic examination shows mild right adnexal
enlargement and tenderness. Erine human chorionic gonadotropin (h4>- is negati3e. A pel3ic unrasound shows a 3-cm,
heterogeneous hyperechoic lesion with cystic areas in the right adnexaF hair and calcifications re seen within the cystic areas.
#his patient is at greatest ris of mor"idity from which of the following;
' A. Hemolytic anemia
' <. 2nfection
' 4. Dalignant degeneration
' 7. Aupture
' 9. #or?2!n
A 44-year-old woman has a palpa"le nodule in the right lo"e of her thyroid gland. #he nodule measures * cm and is firm. #he
rest of the thyroid gland cannot "e felt and is not tender #he patient also descri"es palpitations. heat 2ntolerance. andGweight
loss despite her ravenous appetite. ?he is thin. fidgety. and constantly moving, with moist sin and a pulse of )'5.min. ?he has
no exophthalmos or preti"ial edema.Her #?H is reported as much lower than normal, and she has elevated levels of free #4.
:hich of the foll!:ing 2? the most appropriate next step )n diagnosis;
A. 9xploratory nec surgery
<. ,ine-needle aspiration (,CA- of the thyroid mass
4. DA2 scan of the pituitary gland
7. Ceedle core "iopsy of the thyroid mass
9. Aadlonuclide thyroid scan
A young lawyer is 2n psychotherapy "ecause he is depressed after his girlfriend lelt him. 2n the initial evaluation sessions he
tals a"out his accomplishments, and later on a"out his anger related to the recent "reaup. He complains of restlessness and
insomnia. #he therapist does not get to now anything a"out the relationship with the girlfnend, except that she was the most
sought-after woman in their law school class and that she pro"a"ly could not handle his success as a lawyer. 7uring the
sessions. the phy?ician notices that the patient goes on taling a"out himself and his successes and does not let the phy?ician
"rea in. :hich of the following is the most liely diagnosis;
A. Antisocial personality disorder
<. Histrionic personality disorder
4. Dania
7. Carcissistic personality disorder
9. $aranoid schi=ophrenia
A new"orn girl "orn to a healthy *&-year-old woman at 3) weeBs gestation is taBen to the neonatal intensive care unit "ecause
of respiratory distress. #he new"orn6s mother had routine prenatal care with negative serologies. #he vaginal delivery was
uncomplicated and Apgar scores were / and 5 at ) and 5 minutes. respectively, due to poor respiratory effort and decreased
tone. Her temperature is 3/.8. "lood wessure &'.5' mm Hg, pulse )3'.min, respirations /'.min, and "irth weight )/8' g. ?he is
transferred to the neonatal intensive care unit and placed on nasal continuous positive airway pressure (4$A$-. $eriodic
changes in "reathing are noted, with a"sent respiration of *' seconds duration with each episode while on continuous
positive airway pressure (4$A$-. Apneic episodes are associated with pulse &5.min and $a!* of 5'. $ulse returns to )4'.min
and $a!* to &5. "etween apneic episodes. :hich of the following is the most appropriate treatment;
A. <icar"onate
<. 7extrose
4. 9pinephrine
7. Caloxone
9. $heno"ar"ital
,. #heophylline
A 35-year-old man comes to the physician for a routine physical examination. He has a history or cardiac surgery in early
childhood. $hy?ical examination shows a systolic thnll GHlal ated at the left sternal "order, and a sort diastolic murmur is heard
in the "ase or the heart that increases with inspiration and decreases with the 3alsalva maneuver. #here 2? also an extra sound
heard after diastole and a :idely ?plit second heart sound :hich of the following is the most liely diagnosis;
A. Aortic regurgitation
<. Aortic stenosis
4. Ditral regurgitation
7. Ditral stenosis
9. $ulmonary regurgitation
,. $ulmonary stenosis
A. <lac frecles on the shoulders
<. 0arge, furrowed tongue
4. $rotruding eye"alls
7. ?mall glistening "umps on the lips
9. ?pider angiomas
A ).5-year-old girl is sent to a children6s hospital for evaluation following a nose"leed which was so severe as to re1uire nasal
pacing and transfusion of platelet concentrate?.:hen a "lood sample had "een drawn in the emergency room for serum
chemistry studies. the local hospital la"oratory had noted that the clot that formed was unusual in that it failed to retract.
$eripheral "lood smear o"tained "y finger puncture showed an appropriate num"er of normal-si=ed IGiatelets. all of which were
individual, without clumping. At the children6s hospital, it was noted that the child6s parents were cousins. ?pecial platelet
studies showed that the child6s platelet6s failed to aggregate with any physiologic aggregating agent, including a high
concentration of exogenous A7$. :hich of the following is the most liely diagnosis;
A. <ernard-?oulier syndrome
<. 4hedia-Higashi syndrome
4. Day-Hegglin anomaly
7. #hrom"asthenia
9. 3on :ille"rand disease
A *5-year-old man sustained multiple sta" wounds to the a"domen when he was mugged while @ogging in the par. #he assault
too place in the evening. He was dumped "y the attacers "ehind thic vegetation and was not found until the next morning .
9xploratory surgery reveals multiple small "owel and colonic lacerations. all of which are repaired. 2n the postoperative period
the patient has persistent hypotension. even though he has received ade1uate fluid infusion and his central venous pressure is
)* mm Hg. ,urther studies done with the help of a pulmonary artery catheter reveal high cardiac outiGut and low peripheral
resistance. :hich of the following is the most liely diagnosis;
' A. Adrenal insufficiency
' <. 4ardiogenic shoc
' 4. Hypovolemic shoc
' 7. Ceurogenic shoc
' 9. ?eptic shoc
A *'-year-old man is "rought to the emergency department "y his mother with nausea and vomiting. ?he reports he too 5'
ta"lets of 3*5-mg acetaminoiGhen / hours ago in a suicide attempt. His temperature is 35 .'+4 (&8./+,-, "lood pressure )35.8'
mm Hg, pulse )''.min. and respirations *'.min. !n physical examination he has mild a"dominal tenderness. ?erum
acetaminophen concentration is within toxic range, A?# is *5 2E.0, A0 # 3* 2E.0, and alaline phosphatase is 5/ 2E.0. :hich
of the following is the most appropriate next step in management;
A. Acetylcysteine treatment
<. Activated charcoal treatment
4. Admit and monitor for liver function a"normalities
7. >astric lavage
9. 2nduced vomiting
A. Anti-glomerular "asement mem"rane anti"odies
<. Anti-mitochondrial anti"odies
4.Anti-neutrophilic anti"odies
7 Anti-parietal cell anti"odies
9. Anti-smooth muscle anti"odies
A 3-year-old "oy is "rought to the physician for a well-child visit. #he parents state that he has "een well, "ut has lately lost his
appetite and seems a little moody. #hey attri"ute this to the fact that they moved in with the mother6s parents approximately /
months ago "ecause of financial restraints and the "oy has yet to "lend into the new environment. 2n addition, her parent6s
house is old and stuffy and needs renovating, which they started doing * months ago "y deplastering the walls in the "oy6s room
andre ainting it. #he child is in no acute distress "ut seems a little a athetic. He is in the twentieth percentile for weight and the
thirtieth percentile for height. 0a"oratory studies show thatthe red "lood cell count is *.&J)'K)* .0. :hich of the following is
the next "est step in management;
A. <lood transfusion
<. Administer calcium disodium edetate
4. 2ron supplementation
7. Aeassure the parents that improvement will ensue as the child ad@usts to the new environment
9. Aemove the child from his current environment
' A. Anti-nuclear anti"odies
' <. 9lectromyography
' 4. 0iver function tests
' 7. Dagnetic resonance imaging of spine and "ilateral lower legs
' 9. Duscle "iopsy
A *8-year-old patient who has end-stage renal disease (9?A7- on continuous am"ulatory peritoneal dialysis (4A$!- for *
months is "rought to the emergency department with fever. a"dominal pain. and cloudy dialysis fluid. Hfhere is no diarrhea or
vomiting and the pain has "een present for armroximately )* hours. Hfhe patient has 9?A7 secondary to chronic
glomerulonephritis .there is no history of dia"etes, urinary infections, or anti"iotic use. 9xamination reveals a temperature of
38.&+4 () '*.'+,- and "lood pressure of ))'.5' mm Hg. #he throat is clear. as are the lungs. 4ardiac examination reveals a
grade *./ systolic murmur. A"dominal examination reveals decreased "owel sounds with diffuse tenderness. there is mild
re"ound tenderness. #here is no edema or sin rash. A complete "lood count shows a leuocyte count of )4,*''.mm 3
hemoglo"in is )*.5 g.dl. $eritoneal fluid is cloudy with )''' white "lood cells, 85L of which are polymorphonuclear
leuocytes. >ram stain of the peritoneal fluid is negative. 4ultures of "lood and peritoneal dialysis fluid are taen. :hich of the
following is the most appropriate initial step in management;
A. ,lucona=ole
<. 2mmediate removal of dialysis catheter
4. 2ntraperitoneal administration of cefa=olin, together with cefta=idime
7. 2ntravenous gentamicin
9. !ral ciprofloxacin
A man who weighs /5 g ( )43 l"- has sustained second-and third-degree "urns over "oth of his lower extremities as a result of
his pants catching fire :hile lighting the "ar"e1ue 9xamination shortly thereafter reveals that virtually all of the sin- from
"oth groins to the tip of the toes. front and "ac- has "een "urned Dost of that appears to "e 3rd-degree "urn. "ut there may "e
some areas that are only second-degree. He has normal palpa"le pulses on "oth of his feet.$lans are made to wash all the
"urned areas in the operating room. "ut in addtion to that. which of the following should "e done durning the first hour of his
treatment;
' A. Administer ) liter of 23 Ainger6s lactate
' <. lntu"ate his trachea and place him on a respirator
' 4. $erform "ilateral escharotomies
' 7. $erform tracheostomy
' 9. ?tart parenteral nutrition
A 3/-year-old woman comes to the physician "ecause of "lurry vision and left-eye pain for 3 days. #he pain is worse with
movement of the eye. ?he has had no fever, history of eye trauma, or excessive lacrimation. Her medical history is
unremara"le. and she taes no medications. ?he has smoed a half pac of cigarettes daily for )5 years. Her temperature is
35.)c. #he examination shows decreased vision in the center of her left eye visual field and loss of color vision. #here
is a slow and diminished resiGonse to light in the left eye. #he !ptic disc is swollen. with a flame-shaped hemorrhage. :hich of
the following is the most appropriate diagnostic test;
' A. Anti-?mith anti"ody
' <. 4ere"ral angiography
'.4. 4omputeri=ed tomography of the or"it
' 7. 4omputeri=ed tomography of the sinuses
' 9. Dagnetic resonance imaging of the "rain
' A. 7ecreased "lood pressure, decreased 070, and decreased triglycerides
' <. 7ecreased "lood pressure, increased 070, and increased triglycerides
'.4. 2ncreased "lood pressure, decreased 070, and decreased triglycerides
' 7. 2ncreased "lood pressure, increased 070, and increased triglycerides
' 9. Co change in "lood pressure or lipid profile
A *8-year-old African American woman comes to the physician "ecause of chest pain for * days. ?he has "een otherwise in
good health. ?he does not drin alcohol, smoe. or tae medications. ?he denies any recent trauma to the chest. #here is no
family history of cardiovascular disease. Her pain is constant and 2s exacer"ated "y deep inspiration. Her temperature is 3/.5%4
(&8%,-. "lood pressure )*'.5' mm Hg, pulse /5)min, and respirations )4)rnin. $hysical examination 2s normal except for
tenderness on palpation of the third lett costochondral @unction. :hich of the following is the most appropriate next step in
management;
' A. 4hest x-rays
' <. 94> and echocardiographic studies
' 4. 0a"oratory studies to assess ris factors for atherosclerosis
' 7. Aeferral for psychiatric evaluation
' 9. Consteroidal ant)-)nftammatory drugs and rest
A /*-year-old man comes to the clinic seeing treatment for erectile dysfunction. He reports that over the last few years he has
lost interest in sex. although he still loves his wife and does wish to have sex with her. He was ho ing a pill might stimulate his
erections. He has lost the desire to mastur"ate and has not had any recent nocturnal erections. He has no prior history of sexual
pro"lems or related diseases. $ast medical history is significant for osteoporosis (diagnosed after a recent radial fracture- and a
) '-year history of stage ) hypertension that has "een treated with meta rolol. A review of systems is unremara"le for
depressive symptoms or constitutional complaints. $hysical examination. including a thorough genitourinary examination. is
unremara"le. :hich of the following is the most appropriate next step in management;
' A. 7etermine the "ioavaila"le testosterone level
' <. 7iscontinue metoprolol
' 4. Aefer the patient for psychosocial evaluation
' 7. ?chedule an appointment with the patient6s wife
' 9. ?tart a trial of phosphodiesterase-? inhi"itor
' A. Acid-fast "acilli
' <. Atypical lymphocytes
' 4. <ilateral hllar adenopathy
' 7. 4alcifications on mammography
' 9. Dediastinal adenopathy
' ,. Epper lo"e cavitation
:hich of the following 2s the most appropriate next step in diagnosis;
' A. 4omputed tomography of the "rain
' <. 9lectroencephalography
' 4. 0um"ar puncture
' 7. ?erum glucose
' 9. Erine toxicology screen
A *'-year-old woman comes to the physician "ecause or left lower 1uadrant pain for * months that 2s now getting worse. ?he
has had no changes )n "owel or "ladder function ,ehe has no fevers or chills and no nausea,vomitlng, or diarrhea. #he pain is
intermittent and somet)mes feels lie a dull pressure plevic examination is significant for a left adnexal mass that is mildly
tender. Erine h4> is negative. $elvic ultrasound shows a 5-cm complex left adnexal mass :ith features consistent :ith a
"enign cystic teratoma. :hich or the following is the most appropriate next step in management;
' A. $ertorm hysteroscopy
' <. $ertorm laparotomy
' 4. $rescri"e the oral contraceptive pill
' '. Aepeat pelvic examination in ) year
' 9. Aepeat pelvic ultrasound in / wees
A /&-year-old woman comes to the physician "ecause of exertional chest pain for the past )8 months. ?he says that her chest
pain always occurs after she walBs * "locBs at a fast pace. ?he does not have the pain any other time. ?he has a history of
non-insulin-dependent dia"etes and hypertension. and has smoBed one pacB of cigarettes daily for the past 35 years. H3ital
signs are within normal limits. $hysical examination shows no a"normalities. An exercise stress test shows ?#-segment
deIGressions in leads 3) . 3*. and 33 after 4 minutes of exercise that is reversi"le with rest. A cardiac catheteri=ation shows
8'L stenosis of the woximal left main coronary artery. :hich of the following is the most appropriate treatment for this
patient;
' A. 2mmediately perform percutaneous "alloon angioplasty
' <. $rescri"e su"lingual nitroglycerin as needed for pain and a daily aspirin
' 4. Ae-examine her in / months and asB her to stop exercising until then
' 7. ?end her for coronary artery "ypass grafting
' 9. ?tart a "eta-"locBer and aspirin. and if symptoms persist, schedule coronary artery "ypass grafting
' A. Acyclovir alone
' <. Amphotericin < plus flucytosine
' 4. Ampicillin alone
' 7. 4eftriaxone alone
' 9. 4eftriaxone and ampicillin
' ,. 4eftriaxone and vancomycin
' >. 4eftriaxone. vancomycin. and ampicillin
' H. ?upportive care only
' 2. 3ancomycin alone
A 38-year-old man comes to the clinic complaining of a painful red eye. He worBs grinding industrial metal parts and is
worried that he may have some metal in his right eye. Mesterday afternoon at worB the patient "egan to suffer pain in his right
eye. #he pain progressed throughout the afternoon and evening and was severe enough to cause the patient difficulty sleeping.
#he pain is descri"ed currently as %excruciating% and he is now too uncomforta"le to worB, drive, or read. He has washed his
eye numerous times, "ut has difficulty Beeping the affected eye open. 9xamination reveals an in@ected red eye with mild ciliary
flush, "ut without any discharge or corneal opacity. #he red reflex appears normal and the cham"er is well formed and the pupil
round. #he pupil is small and minimally reactive on the right, maBing proper funduscopic examination difficult, he has
photopho"ia in the affected eye. #here are no lid a"normalities or o"vious foreign "odies present. :hich of the following is the
most appropriate next step in the management;
' A. Administer topical dexamethasone
' <. Administer topical tetracaine
' 4. Administer topical to"ramycin
' 7. ,luorescein slit-lamp examination
' 9. $atch the eye and follow up in *4 hours
A /)-year-old man with a nown history of liver disease comes to see his physician complaining of anal discomfort and
spotting on completing defecation. His symptoms have "een intermittent for the past * months "ut have progressed over the
past * days. His discomfort is worse at the end of the day, and oftentimes is so uncomforta"le he finds himself leaning to one
side to avoid exacer"ating the pain. !n physical examination. his vital signs are normal. Anoscopy shows dilated and "leeding
veins "ulging into the lumen, "ut they do not prolapse out of the anal canal. ,lexi"le proctosigmoidoscopic examination shows
no other pathology. His next appointment is & months away. :hich of the following is the most appropriate next step in
management;
' A. $rescri"e ade1uate fluids, a high-fi"er diet. sit= "aths, and local anesthetics
' <. $rescri"e topical anti"iotics
' 4. $rovide reassurance and have the patient eep his appointment in & months
' 7. ?chedule excision of anal fissure under anesthesia
' 9. ?chedule excision of throm"osed hemorrhoid under anesthesia
A patient who 2s 2n shoc and has multiple traumatic in@uries 2s taen to the operating room for an exploratory laparotomy that
lasts 3 5 hours Dultiple "lood transfusions are adm)msteree). and several liters of Ainger6s lactate are mfuse42 during surgery.
At the second postoperative day, the patient develops confusion, ag)tat)on. lower extremty edema and cyanosis, and a"dominal
distension. #he a"dominal sutures are cutting through the sin around them. #he patienrs creatinine level has dou"led since
the surgery. wntch of the following treatments at the ttme of the lnitial surgical intervention could have prevented these
complications;
' A. Approximate the sBin only, using towel clips
' <. 4lose the a"domen with heavy retention sutures
' 4. >ive diuretics and close the a"domen in the usual way
' 7. 0eave the a"domen and its contents open to air
' 9. $r!32de temporary a"dominal closure :ith an a"sor"a"le mesh
' ,. use a"sor"a"le sutures only
A **-year-old woman. gravida *, para ) at 38 wees6 gestation. comes to the la"or and delivery floor "ecause of contractions.
?he had an uncomplicated prenatal course. Her previous o"stetric history is significant for a normal spontaneous vaginal
delivery at term 3 years ago. ?he has no medical history and has never had surgery. ?he taes prenatal vitamins and has no
nown drug allergies. !n pelvic examination, her cervix is 3 em dilated and 55L effaced, and the fetus is at -* station. ?he is
contracting every * minutes and the fetal heart rate is in the )4's with accelerations and no decelerations. A few minutes later
the patient experiences a large gush of fluid from the vagina and the fetal heart rate "ecomes "radycardic to the 5's per minute.
!n examination. the cervix feels approximately 5 cm in diameter and a pulsating segment of um"ilical cord can "e felt in the
vagina. :hich of the following is the most appropriate next step in management;
' A. 4ontinue expectant management
' <. Danually push the cord "ac into the uterus
' 4. !"tain a "iophysical profile
' 7. $erform an emergency cesarean delivery
' 9. #ocolysis with Dg?!4
' A. Administer atropine
' <. Administer dopamine
' 4. Administer proper vaccination
' 7. $lace the patient on a *4-hour Holter monitor
' 9. #ransvenous pacemaBer
' A. <isphosphonate
' <. 4alcitonin
' 4. Hydrochlorothia=ide
' 7. 23 normal saline
' 9. !ral calcium car"onate
' ,. Delphalan immediately
' >. $rednisone immediately
' H. 23 furosemide
A *-year-old girl is "rought to the emergency department "y her parents "ecause of a severe cough with sputum, fever, and
rapid "reathing. #he cough "egan ) month ago with sputum and has "ecome persistent. ?he has a history of prolonged
neonatal @aundice and two episodes of "ronchiolitis at ages 5 and )3 months. Her temperature is 3&, "lood pressure is &'./4 mm
Hg, pulse is &'.min. respirations are *8.min. and oxygen saturation on room air is 88L. $hysical examination is pertinent for
nasal polyps and coarse "reath sounds that are heard on auscultation of the chest. 4hest radiograph shows hyperinflation with
patchy consolidations. ?he is "elow the fifth percentile for "oth height and weight. :hich of the following is the next "est step
in management;
' A. >enetic testing
' <. Histopathologic analysis of the nasal polyps
' 4. 23 cefta=idirne with to"ramycin
' 7. 23 levofloxacin
' 9. !ral trirnethoprim-sulfamethoxa=ole
' ,. $ilocarpine iontophoresis test
' A. 4hange his oral hypoglycemic agent to metformln
' <. $rescri"e lntracavernous prostaglandin in@ections
' 4. $rescr)"e oral sildenafil
' 7. $rescri"e testosterone supplementation
' 9. Aecommend 2ntensive couples psychotherapy
A )*-year-old girl with a history of asthma is "rought to the emergency department "y her parents "ecause of whee=ing and
difficulty "reathing for the past 4 hours. Her parents report that she has "een using an al"uterol inhaler more fre1uently without
any improvement in her symptoms. ?he has nocturnal symptoms twice weely and has "een getting short of "reath easily. ?he
has never "een intu"ated "ut has "een "rought to the emergency department 3 times in the past )* months for acute asthma
exacer"ations. 2n the emergency center you treat her respiratory distress and she responds to therapy. #he patient is ready for
discharge. :hich of the following treatments is most appropriate for maintenance therapy;
' A. Anticholinergic agent
' <. 4romolyn sodium
' 4. 2nhaled corticosteroid
' 7. 0ong-term "ronchodilator
' 9. Cedocromil sodium
A *-year-old "oy 2s "rought to the emergency department "ecause of a *-day history of fever to 3&.'+4 ( ) '*.*.,-, irrita"ility,
and redness and tenderness of the sBin. #he parents state that there were two small, fluid-filled lesions that "roe open with
pressure on the "oy6s left arm 5 days ago. His temperature 2s 38.8 and pulse is )*5.min. 9xamination shows diffuse
red papules that are rough to the touch distri"uted around the eyes, mouth, and antecu"ital fossa. #here are two "ullae on the
right lower extremity. #here is a separation of the epidermis wtth the application of lateral pressure at the edge of one of the
"ullae. :hich or the following is the most appropriate pharmacotherapy;
' A. Amoxicllin orally
' <. Ampicillin 2ntravenously
' 4. 4eftriaxone 2ntramuscularly
' 7 4iprofloxacin intravenously
' 9. 9rythromycin orally
' ,. oxacillin 2ntravenously
A 44-year-old woman, gravida 4, para 3, at 8 wees6 gestation comes to the physician for her first prenatal visit. ?he has mild
nausea and vomiting "ut no other complaints. Her o"stetric history is significant for 3 full-term. normal vaginal deliveries of
normal infants. ?he has no medical or surgical history and taes no medications. $hysical examination reveals an 8-wee-si=ed
uterus, "ut is otherwise unremara"le. ?he wishes to have chromosomal testing of the fetus and wants to have chorionic villus
sampling performed. as she did with her last pregnancy. 4ompared with amniocentesis. chorionic villus sampling may place the
patient at greater ris for which of the following;
' A. Accessory placental lo"e
' <. ,etal lim" defects
' 4. Dem"rane rupture
' 7. Dental retardation
' 9. Did-second-trimester a"ortion
A 3-wee-old "oy is "rought to the physician "ecause of a )-wee history of forceful vomiting. He has "een vomiting after
almost every feeding. #he vomitus contains mostly undigested formula and is non"ilious. 9xamination shows dry oral mucosa.
depressed anterior fontanelle, and capillary refill of 3 to 4 seconds. A"dominal examination shows a *-cm mass in the
epigastrium. #he remainder of the examination is unremara"le. :hich of the following electrolyte findings will most liely "e
seen;
'A. High pH, high $4!* ,low $!*, high "icar"onate,low chloride
' <. High pH. low $4!* . high "icar"onate
' 4. High pH, low $4!* low "icar"onate
' 7. 0ow pH, low $4!* high $!* low "icar"onate, low chloride
' 9. Cormal pH. normal $4! * normal $! * normal "icar"onate. normal chloride
A //-year-old dia"etic man presents to the emergency department via am"ulance with shortness or "reath or the past * hours
he has experienced dyspnea at rest and has "een cough)ng u sputum. He denies chest pain.His vita) signs are temperature
35.*%, (&8.&%4-, ulse )*4.mln,6and "lood pressure )5/.&4 mm Hg. !n physical examination the patient is lying down and in
distress. Aespirations are **.min. He is una"le to complete the sentences. An electrocardiogram 2s normal. :hat is the next "est
step in management;
' A. Assist the patient into a sitting position
' <. 7o"utamine
' 4. 7opamine
' 7. 9chocardiography
' 9. Hydrala=ine
' ,. DE>A scan
' >. ?ynchroni=ed cardioversion
' H. 3erapamil
A 34-year-old woman 2s "rought to the emergency department "y her hus"and "ecause of the sudden onset of palflitations
while resting. ?he also complains of shortness of "reath and has mild chest pressure. ?he is currently taing a multDtamin
supplement and oral contraceptives. Her "lood pressure is ))'.5) mm Hg, pulse is )53.min, and respirations are )&.min. ?he
appears anxious $hysical examination shows no carotid "ruits or Gugular venous distention. 0ungs are clear to auscultation. Co
a"normal heart sounds are heard. Her a"domen is soft and nontender, and there is no clu""ing, cyanosis, or edema. An 94>
shows a narrow complex tachy4ardia at a rate of )55.mln A carotid massage is performed :hich ot the following mechanisms
"est explains how the carotid massage :ill help control thi? patient6s condition;
' A. 2ncreased conduction in the $urin@e fi"er system
' <. 2ncrease 2n A3 conduction delay
' 4. 2ncrease 2n A3 conduction velocity transmission
' 7. Dodulating atrial myocyte electrical conduction
' 9. Aeducing the refractory time of sinusal action potentials
A 3-year-old "oy who has recently emigrated from Dexico with his family is "rought to the emergency department "ecause of a
high-grade temperature. difficulty "reathing. difficulty speaing. and irrita"ility that "egan overnight. He has no history of
chronic medical conditions and taes no medication. He received some vaccinations in Dexico "ut his mother is unsure which
ones. His temperature is 3&.5 . "lood pressure )'*./* mm Hg, pulse )45.min. and respirations 3/.min. !n physical
examination the patient is noted to "e drooling and appears to "e in moderate respiratory distress. Auscultation of the chest
reveals a soft. whistling sound during expiration. and intercostal and su"costal retractions are present. :hich of the following
is the most appropriate initial step in management;
' A. Administer anti"iotics
' <. Administer anti-inflammatory drugs
' 4. 9xamine the oropharynx
' 7. !rder a chest x-ray
' 9. 2nsert endotracheal tu"e
' ,. $erform throat swa" for culture
' >. Aeassure the mother and advise rest
' H. ?end for a "lood culture
A )/-year-old girl comes to the physician "ecause of a *-year history of %pimples% on her face, "ac, and chest that do not
improve with over-the-counter "en=oyl peroxide. ?he states that the num"er of red, tender nodules on the chees and chin
increases during menses. Her menses are irregular, and her last menstrual period was 5 wees ago. ?he taes no other
medications. ?he weighs )'/ g (*34 l"- and is )5' em (/5 in- tall. $hysical examination shows deep inflammatory nodules,
pustules. and comedones on the face, chest. and "ac. #here are sparse. coarse. IGigmented hairs on the upIGer liIG and chin
and thinning of the hair at the ternIGies. Erine pregnancy test is negative. :hich of the following is the most appropriate next
step in diagnosis;
' A. 4# scan of the head
' <. 0uteini=ing hormone (0H- level
' 4. #rial of oral contraceptives
' 7. Nuantitative human chorionic gonadotropin (h4>- level
' 9. #ransvaginal ultrasound