American Board of Family Medicine

Name
American Board of Family Medicine
IN-TRAINING EXAMINATION
TIME4 HOURS
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Copyright 2011 The American Board of Family Medicine. All rights reserved.
1. A 30-year-old previously healthy male comes to your office with a 1-year history of frequent
abdominal pain, nonbloody diarrhea, and a 20-lb weight loss. He has no history of travel outside
the United States, antibiotic use, or consumption of well water. His review of systems is notable
for a chronic, intensely pruritic rash that is vesicular in nature. His review of systems is
otherwise negative and he is on no medications.
The most likely cause of his symptoms is
A)
B)
C)
D)
E)
lactose intolerance
irritable bowel syndrome
collagenous colitis
celiac sprue
Crohns disease
2. Which one of the following is an absolute contraindication to electroconvulsive therapy (ECT)?

A)
B)
C)
D)
E)
Age >80 years

A cardiac pacemaker
An implantable cardioverter-defibrillator
Pregnancy
There are no absolute contraindications to ECT
3. A 55-year-old female presents to an urgent-care facility with a complaint of weakness of several

weeks duration. She has no other symptoms. She has been healthy except for a history of
hypertension that has been difficult to control despite the use of hydrochlorothiazide, 25 mg
daily; lisinopril (Prinivil, Zestril), 40 mg daily; amlodipine (Norvasc), 10 mg daily; and
doxazosin (Cardura), 8 mg daily.
On examination her blood pressure is 164/102 mm Hg, with the optic fundi showing grade 2
changes. She has normal pulses, a normal cardiac examination, and no abdominal bruits. A CBC
is normal and a blood chemistry panel is also normal except for a serum potassium level of 3.1
mmol/L (N 3.55.5).
Which one of the following would be best for confirming the most likely diagnosis in this
patient?
A)
B)
C)
D)
E)
Magnetic resonance angiography of the renal arteries

A renal biopsy
24-hour urine for metanephrines
Early morning fasting cortisol
A plasma aldosterone/renin ratio
4. A 15-month-old male is brought to your office 3 hours after the onset of an increased respiratory
rate and wheezing. He has an occasional cough and no rhinorrhea. His immunizations are up
to date and he attends day care regularly. His temperature is 38.2C (100.8F), respiratory rate
42/min, and pulse rate 118 beats/min.
The child is sitting quietly on his mothers lap. His oxygen saturation is 94% on room air. On
examination you note inspiratory crackles in the left lower lung field. The child appears to be
well hydrated and the remainder of the examination, including an HEENT examination, is
normal. Nebulized albuterol (AccuNeb) is administered and no improvement is noted.
Which one of the following would be most appropriate in the management of this patient?
A)
B)
C)
D)
E)
Laboratory evaluation
Inpatient monitoring, with no antibiotics at this time
Hospitalization and intravenous ceftriaxone (Rocephin)
Close outpatient follow-up, with no antibiotics at this time
Oral high-dose amoxicillin (90 mg/kg/day), with close outpatient follow-up
5. For normal term infants, current practice is to introduce solid foods into the diet at what age?
A)
B)
C)
D)
E)
24 weeks
23 months
46 months
79 months
1 year
6. A 28-year-old male recreational runner has a midshaft posteromedial tibial stress fracture.
Although he can walk without pain, he cannot run without pain.
The most appropriate treatment at this point includes which one of the following?
A)
B)
C)
D)
E)
A short leg walking cast

A nonweight-bearing short leg cast
A nonweight-bearing long leg cast
An air stirrup leg brace (Aircast)
Low-intensity ultrasonic pulse therapy
7. A 59-year-old male reports decreases in sexual desire and spontaneous erections, as well as
reduced beard growth. The most appropriate test to screen for late-onset male hypogonadism is
A)
B)
C)
D)
E)
free testosterone
total testosterone
sex hormonebinding globulin
LH
FSH
8. A 68-year-old African-American female with primary hypothyroidism is taking levothyroxine

(Synthroid), 125 :g/day. Her TSH level is 0.2 :U/mL (N 0.55.0). She has no symptoms of
either hypothyroidism or hyperthyroidism.
Which one of the following would be most appropriate at this point?
A)
B)
C)
D)
E)
Continuing levothyroxine at the same dosage

Increasing the levothyroxine dosage
Decreasing the levothyroxine dosage
Discontinuing levothyroxine
Ordering a free T4
9. A 40-year-old female comes to your office with a 1-month history of right heel pain that she
describes as sharp, searing, and severe. The pain is worst when she first bears weight on the foot
after prolonged sitting and when she gets out of bed in the morning. It gets better with continued
walking, but worsens at the end of the day. She does not exercise except for being on her feet
all day in the hospital where she works as a floor nurse. She denies any history of trauma. An
examination reveals point tenderness to palpation on the plantar surface of the heel at the medial
calcaneal tuberosity.
Which one of the following should you recommend as first-line treatment?
A)
B)
C)
D)
E)
Taping/strapping
Over-the-counter heel inserts
Extracorporeal shock wave therapy
A corticosteroid injection
A fiberglass walking cast
10. A 3-year-old male presents with a 3-day history of fever and refusal to eat. Today his parents
noted some sores just inside his lips. No one else in the family is ill, and he has no significant
past medical history. He is up-to-date on his immunizations and has no known allergies.
On examination, positive findings include a temperature of 38.9C (102.0F) rectally,
irritability, and ulcers on the oral buccal mucosa, soft palate, tongue, and lips. He also has
cervical lymphadenopathy. The remainder of the physical examination is normal. The child is
alert and has no skin lesions or meningeal signs.
Which one of the following would be the most appropriate treatment?
A)
B)
C)
D)
E)
Ceftriaxone (Rocephin) intramuscularly

Nystatin oral suspension
Amoxicillin suspension
Acyclovir (Zovirax) suspension
Methotrexate (Trexall)
11. You see a 22-year-old female who sustained a right knee injury in a recent college soccer game.
She is a defender and executed a sudden cutting maneuver. With her right foot planted and her
ankle locked, she attempted to shift the position of her body to stop an oncoming ball and felt
her knee pop. She has had a moderate amount of pain and swelling, which began within 2 hours
of the injury, but she is most concerned about the loss of knee hyperextension.
Which one of the following tests is most likely to be abnormal in this patient?
A)
B)
C)
D)
Anterior drawer
Lachman
McMurray
Pivot shift
12. One of your patients has been diagnosed with monoclonal gammopathy of undetermined
significance (MGUS). Which one of the following is used to determine whether his condition
has progressed to multiple myeloma?
A)
B)
C)
D)
The length of time since the diagnosis of MGUS was made

The level of M protein
The percentage of plasma cells in bone marrow
Evidence of end-organ damage
13. A 60-year-old African-American male who has a 15-year history of diabetes mellitus reports a
1-week history of weakness of the lower left leg, giving way of the knee, and discomfort in the
anterior thigh. He has no history of recent trauma. A physical examination reveals decreased
sensation to pinprick and light touch over the left anterior thigh, and reduced motor strength on
hip flexion and knee extension. The straight leg raising test is normal.
The most likely cause of this condition is
A)
B)
C)
D)
E)
femoral neuropathy
diabetic polyneuropathy
meralgia paresthetica
spinal stenosis
iliofemoral atherosclerosis
14. Women who use low-dose estrogen oral contraceptives have a 50% lower risk of cancer of the
A)
B)
C)
D)
E)
breast
cervix
head and neck
lung
ovary
15. Which one of the following is most typical of polymyalgia rheumatica?

A)
B)
C)
D)
Headache and neck pain

A normal erythrocyte sedimentation rate
A dramatic response to corticosteroids
A lack of systemic symptoms and signs
16. A 53-year-old male presents for a routine well-care visit. He has no health complaints. His wife
has accompanied him, however, and is quite concerned about changes she has noticed over the
last 12 years. She says that he has become quite apathetic and seems to have lost interest in
his job and his hobbies. He has been accused of making sexually harassing comments and
inappropriate touching at work, and he no longer helps with household chores at home. He
often has difficulty expressing himself and his speech can lack meaning. The physical
examination is normal.
Based on the history provided by the wife, you should suspect a diagnosis of
A)
B)
C)
D)
E)
Alzheimers disease
major depressive disorder
frontotemporal dementia
dementia with Lewy bodies
schizophrenia
17. An 88-year-old male has been hospitalized for the past 3 days after being found on the floor of
his home by a neighbor and transported to the hospital by ambulance. He was cachectic and
dehydrated at the time of admission, with a serum albumin level of 1.9 g/dL (N 3.54.7). He
has received intravenous fluids and is now euvolemic. He began nasogastric tube feeding 2 days
ago and has now developed nausea, vomiting, hypotension and delirium.
Which one of the following is the most classic electrolyte abnormality with this condition?
A)
B)
C)
D)
E)
Hypocalcemia
Hypercalcemia
Hyperkalemia
Hypophosphatemia
Hyperphosphatemia
18. When prescribing an inhaled corticosteroid for control of asthma, the risk of oral candidiasis can
be decreased by
A)
B)
C)
D)
E)
using a valved holding chamber

limiting use of the inhaled corticosteroid to once daily
adding nasal fluticasone propionate (Flonase)
adding montelukast (Singulair)
adding salmeterol (Serevent)
19. A 45-year-old female presents with a 3-month history of hoarseness that is not improving. She
works as a high-school teacher.
The most appropriate management at this time would be
A)
B)
C)
D)
E)
voice therapy
azithromycin (Zithromax)
a trial of inhaled corticosteroids
a trial of a proton pump inhibitor
laryngoscopy
20. In adults, the most common cause of right heart failure is

A)
B)
C)
D)
myocarditis
left heart failure
pulmonic stenosis
ventricular septal defect
21. As the medical review officer for a local business, you are required to interpret urine drug tests.
Assuming the sample was properly collected and handled, which one of the following test results
is consistent with the history provided and should be reported as a negative test?
A) Diazepam (Valium) identified in an employee taking oxazepam prescribed by a physician
B) Morphine identified in an employee undergoing a prescribed methadone pain
management program
C) Morphine identified in an employee taking a prescribed cough medicine containing
codeine
D) Tetrahydrocannabinol above the threshold value in an employee who reports secondary
exposure to marijuana
E) Tetrahydrocannabinol identified in an employee taking prescribed tramadol (Ultram)
22. An 18-year-old male presents with a sore throat, adenopathy, and fatigue. He has no evidence
of airway compromise. A heterophil antibody test is positive for infectious mononucleosis.
Appropriate management includes which one of the following?
A)
B)
C)
D)
E)
A corticosteroid
An antihistamine
An antiviral agent
Strict bed rest
Avoidance of contact sports
23. A 65-year-old Hispanic male with known metastatic lung cancer is hospitalized because of
decreased appetite, lethargy, and confusion of 2 weeks duration. Laboratory evaluation reveals
the following:
Serum calcium. . . . . . . . . . . . . . . . . . . . . . . . .
Serum phosphorus. . . . . . . . . . . . . . . . . . . . . .
Serum creatinine. . . . . . . . . . . . . . . . . . . . . . .
Total serum protein. . . . . . . . . . . . . . . . . . . . .
Albumin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15.8 mg/dL (N 8.410.0)

3.9 mg/dL (N 2.64.2)
1.1 mg/dL (N 0.71.3)
5.0 g/dL (N 6.08.0)
3.1 g/dL (N 3.74.8)
Which one of the following is the most appropriate INITIAL management?

A)
B)
C)
D)
Calcitonin-salmon (Miacalcin) subcutaneously

Pamidronate disodium (Aredia) by intravenous infusion
Normal saline intravenously
Furosemide intravenously
24. A 35-year-old African-American female with symptomatic uterine fibroids that are unresponsive
to medical management prefers to avoid a hysterectomy. Which one of the following would be
a reason for preferring myomectomy over fibroid embolization?
A)
B)
C)
D)
E)
A desire for future pregnancy

Medical problems that increase general anesthesia risk
Religious objections to blood transfusion
The likelihood of a shorter hospital stay and recovery time
The minimal risk of fibroid recurrence
25. A 70-year-old African-American male undergoes routine sigmoidoscopy. He has a long history
of constipation, hypertension, and diet-controlled type 2 diabetes mellitus. The examination
reveals brown to black leopard spotting of the colonic mucosa.
You would now
A)
B)
C)
D)
E)
perform a metastatic workup

review his medications
prescribe oral corticosteroids
prescribe antibiotics and a proton pump inhibitor
check his stool for Clostridium difficile
26. The Valsalva maneuver will typically cause the intensity of a systolic murmur to increase in
patients with which one of the following conditions?
A)
B)
C)
D)
Aortic stenosis
Rheumatic mitral insufficiency
Valvular pulmonic stenosis
Hypertrophic obstructive cardiomyopathy
27. A 12-year-old male presents with left hip pain. He is overweight and recently started playing
tennis to lose weight. He says the pain started gradually after his last tennis game, but he does
not recall any injury. He is walking with a limp. On examination he is afebrile and has limited
internal rotation of the left hip.
What is the most likely cause of the hip pain?
A)
B)
C)
D)
E)
Septic arthritis
Juvenile rheumatoid arthritis
Transient synovitis
Slipped capital femoral epiphysis
Legg-Calv-Perthes disease
28. Which one of the following is associated with the use of percutaneous endoscopic gastrostomy
(PEG) tubes?
A)
B)
C)
D)
A reduced risk of aspiration pneumonia in patients with dysphagia

Increased use of restraints
Improved nutritional status in nursing-home residents with dementia
Improved quality of life for patients with dementia
29. A 58-year-old white male comes to your office for follow-up after a recent bout of acute
bronchitis. He reports having a productive cough for several months. He gets breathless with
exertion and notes that every time he gets a cold it goes into my chest and lingers for months.
He has been smoking for 30 years. A physical examination is negative except for scattered
rhonchi. A chest radiograph done 4 months ago at an urgent care visit was negative except for
hyperinflation and flattened diaphragms.
Which one of the following would be best for making the diagnosis?
A)
B)
C)
D)
E)
A chest radiograph
CT of the chest
Peak flow measurement
Spirometry
A BNP level
30. A 50-year-old female presents with right eye pain. On examination, you find no redness, but
when you test her extraocular muscles she reports marked pain with eye movement.
This finding suggests that her eye pain is caused by
A)
B)
C)
D)
E)
an intracranial process
an ocular condition
a retinal problem
an orbital problem
an optic nerve problem
31. A 30-year-old female asks you whether she should have a colonoscopy, as her father was
diagnosed with colon cancer at the age of 58. There are no other family members with a history
of colon polyps or cancer.
You recommend that she have her first screening colonoscopy
A)
B)
C)
D)
E)
now and every 5 years if normal

now and every 10 years if normal
at age 40 and then every 5 years if normal
32. A 64-year-old African-American male presents with persistent pleuritic pain. The patient does
not feel well in general and has had a low-grade fever of around 100F (38C). His medications
include simvastatin (Zocor), lisinopril (Prinivil, Zestril), low-dose aspirin, spironolactone
(Aldactone), furosemide (Lasix), isosorbide mononitrate (Imdur), hydralazine, carvedilol
(Coreg), and nitroglycerin as needed.
A chest radiograph is normal and does not demonstrate a pneumothorax. Further evaluation rules
out pulmonary embolus, pneumonia, and myocardial infarction. A diagnosis of pleurisy is made.
Which one of the patients medications could be related to this condition?
A)
B)
C)
D)
E)
Hydralazine
Simvastatin
Lisinopril
Spironolactone
Carvedilol
33. A 30-year-old male presents to the emergency department with a sensation of a racing heart.
His history is significant for known Wolff-Parkinson-White syndrome (WPW). On examination
he is alert and in no severe distress. His blood pressure is 130/70 mm Hg, pulse rate 220
beats/min, and oxygen saturation 96%. An EKG reveals a regular, wide-complex tachycardia
with a rate of 220 beats/min. You determine that he is stable, the EKG is consistent with WPW,
and pharmacologic conversion is a safe initial therapy.
Which one of the following would be the treatment of choice?
A)
B)
C)
D)
Verapamil (Calan)
Adenosine (Adenocard)
Procainamide
Digoxin
34. Which one of the following is contraindicated in the second and third trimesters of pregnancy?
A)
B)
C)
D)
E)
Amoxicillin
Azithromycin (Zithromax)
Ceftriaxone (Rocephin)
Ciprofloxacin (Cipro)
Doxycycline
35. A 25-year-old medical student reads about the benefits of moderate alcohol consumption on lipid
levels and begins to drink 5 ounces of red wine a day, adding 100 calories to his diet. Assuming
that his diet and exercise levels stay the same, what effect will the additional 3000 calories a
month have on his body weight over the next 10 years?
A)
B)
C)
D)
They will have essentially no effect

His weight will increase by about 25 kg
His weight will increase slightly then stabilize
His normal caloric expenditure will decrease
36. You have just diagnosed mild persistent asthma in a 13-year-old African-American female.
Along with patient education, your initial medical management should be
A) a short-acting inhaled $-agonist to be used only as needed
B) a long-acting inhaled $-agonist daily
C) a low-dose inhaled corticosteroid daily, along with a short-acting inhaled $-agonist as
needed
D) a low-dose inhaled corticosteroid daily, along with a long-acting inhaled $-agonist daily
E) montelukast (Singulair) daily
37. Patients with rheumatoid arthritis should be screened for tuberculosis before starting which one
of the following medications?
A)
B)
C)
D)
E)
Gold
Hydroxychloroquine (Plaquenil)
Infliximab (Remicade)
Methotrexate (Rheumatrex)
Sulfasalazine (Azulfidine)
38. A 42-year-old male with a history of intravenous drug use asks to be tested for hepatitis C. The
hepatitis C virus (HCV) antibody enzyme immunoassay and recombinant immunoblot assay are
both reported as positive. The quantitative HCV RNA polymerase chain reaction test is negative.
These test results are most consistent with
A)
B)
C)
D)
very early HCV infection

current active HCV infection
a false-positive antibody test
past infection with HCV that is now resolved
10
39. A nursing-home resident is hospitalized, and shortly before she is to be discharged she develops
a skin ulcer, which proves to be infected with methicillin-resistant Staphylococcus aureus
(MRSA). Which one of the following is most important in terms of infection control when she
returns to the nursing home?
A)
B)
C)
D)
E)
Surveillance cultures of nursing-home residents living near the patient

Aggressive housekeeping in the patients room
Masks, gowns, and gloves for all those entering the patients room
Strict handwashing practices by all staff, visitors, and residents
Isolation of the patient in a room by herself
40. Metformin (Glucophage) should be stopped prior to which one of the following, and withheld
until 48 hours after completion of the test?
A)
B)
C)
D)
E)
An upper GI series
Abdominal ultrasonography
CT angiography
MRI of the brain
Colonoscopy
41. Which one of the following is most consistent with obsessive-compulsive disorder in adults?
A) Impulses related to excessive worry about real-life problems
B) A belief by the patient that obsessions are not produced by his or her own mind, but are
inserted thoughts
C) Recognition by the patient that the obsessions or compulsions are excessive or
unreasonable
D) Compulsions that bring relief to the patient rather than causing distress
E) Full remission with treatment
42. An 82-year-old resident of a local nursing home is brought to your clinic with fever, difficulty
breathing, and a cough productive of purulent sputum. The patient is found to have an oxygen
saturation of 86% on room air and a chest radiograph shows a new infiltrate. A decision is made
to hospitalize the patient.
Which one of the following intravenous antibiotic regimens would be most appropriate for this
patient?
A)
B)
C)
D)
E)
Levofloxacin (Levaquin)
Ceftriaxone (Rocephin) and azithromycin (Zithromax)
Ceftazidime (Fortaz, Tazicef) and levofloxacin
Ceftazidime and vancomycin
Ceftazidime, levofloxacin, and vancomycin
11
43. Which one of the following has the best evidence that it is safe for use in pregnancy?
A)
B)
C)
D)
E)
Alprazolam (Xanax)
Lithium
Bupropion (Wellbutrin)
Fluoxetine (Prozac)
Paroxetine (Paxil)
44. You examine an 11-month-old male who has had several paroxysms of abdominal pain in the
last 2 hours. The episodes last 12 minutes; the infant screams, turns pale, and doubles up.
Afterward, he seems normal. A physical examination is normal except for a possible fullness
in the right upper quadrant of the abdomen.
The most likely diagnosis is
A)
B)
C)
D)
E)
pyloric stenosis
choledochal cyst
Meckels diverticulum
intussusception
intestinal malrotation
45. A 62-year-old male with a history of prostate cancer and well-controlled hypertension presents
with severe osteoporosis. At 55 years of age he received prostate brachytherapy and androgen
deprivation for his prostate cancer and has been disease-free since. He presently takes lisinopril
(Prinivil, Zestril), 5 mg daily; alendronate (Fosamax), 70 mg weekly; calcium, 1000 mg daily;
and vitamin D, 1200 units daily. He has never smoked, exercises five times a week, and
maintains a healthy lifestyle. In spite of his lifestyle and the medications he takes, he continues
to have severe osteoporosis on his yearly bone density tests.
In addition to recommending fall precautions, which one of the following would you consider
next to treat his osteoporosis?
A)
B)
C)
D)
E)
Testosterone
Calcitonin
Teriparatide (Forteo)
Raloxifene (Evista)
Zoledronic acid (Reclast)
12
46. A 20-year-old white female presents with painful and frequent urination that has had a gradual
onset over the past week. She has never had a urinary tract infection. There is no associated
hematuria, flank pain, suprapubic pain, or fever. She says she has not noted any itching or
vaginal discharge. A midstream urine specimen taken earlier in the week showed significant
pyuria but a culture was reported as no growth. She has taken an antibiotic for 2 days without
relief. Her only other medication is an oral contraceptive agent.
Which one of the following is the most likely infectious agent?
A)
B)
C)
D)
Escherichia coli
Chlamydia trachomatis
Candida albicans
Staphylococcus saprophyticus
47. A previously healthy 82-year-old male is brought to your office by his daughter after a recent
fall while getting up to go to the bathroom in the middle of the night. The patient denies any
history of dizziness, chest pain, palpitations, or current injury. He has a history of bilateral
dense cataracts. On examination, he is found to have an increased stance width and walks
carefully and cautiously with his arms and legs abducted. A timed up-and-go test is performed,
wherein the patient is asked to rise from a chair without using his arms, walk 3 meters, turn,
return to his chair, and sit down. It takes the patient 25 seconds and he is noted to have an en
bloc turn.
Which one of the following is the most likely cause of this patients gait and balance disorder?
A)
B)
C)
D)
E)
Visual impairment
Cerebellar degeneration
Frontal lobe degeneration
Parkinsons disease
Motor neuropathy
48. A 17-year-old white female has a history of anorexia nervosa, and weight loss has recently been
a problem. The patient is an academically successful high-school student who lives with her
parents and a younger sibling. Her BMI is 17.4 kg/m2 . Her serum electrolyte levels and an
EKG are normal.
Which one of the following interventions is most likely to be successful?
A)
B)
C)
D)
E)
Family-based treatment
Adolescent-focused individual therapy
Fluoxetine (Prozac)
Phenelzine (Nardil)
Desipramine (Norpramin)
13
49. A 42-year-old male with well-controlled type 2 diabetes mellitus presents with a 24-hour history
of influenza-like symptoms, including the sudden onset of headache, fever, myalgias, sore
throat, and cough. It is December, and there have been a few documented cases of influenza
recently in the community.
The CDC recommends initiating treatment in this situation
A)
B)
C)
D)
on the basis of clinical symptoms alone

only if rapid influenza testing is positive
only if the diagnosis is confirmed by immunoassay testing
only if the diagnosis is confirmed by reverse transcriptase polymerase chain reaction
(PCR) assay
50. A 52-year-old male has had a chronic course of multiple vague and exaggerated symptoms for
which no cause has been found despite extensive testing. Which one of the following is the most
effective management approach for this patient?
A)
B)
C)
D)
E)
Reassure the patient that his symptoms are not real

Schedule the patient for regular appointments every 24 weeks
Prescribe opioids for the pain
Order additional diagnostic tests
Advise the patient to go to the emergency department if the symptoms occur after office
hours
51. Which one of the following patients should be advised to take aspirin, 81 mg daily, for the
primary prevention of stroke?
A)
B)
C)
D)
A 42-year-old male with a history of hypertension

A 72-year-old female with no chronic medical conditions
An 80-year-old male with a history of depression
An 87-year-old female with a history of peptic ulcer disease
52. A 12-month-old white female whom you have seen regularly for all of her scheduled well child
care is found to have a hemoglobin level of 9.0 g/dL (N for age 10.513.5). She started whole
milk at 9 months of age. She appears healthy otherwise and has no family history of anemia.
A CBC reveals a mild microcytic, hypochromic anemia with RBC poikilocytosis, but is
otherwise normal. The RBC distribution width is also elevated.
Of the following, the most appropriate next step would be to
A)
B)
C)
D)
E)
order tests for serum iron and total iron-binding capacity

order a serum ferritin level
order hemoglobin electrophoresis
prescribe oral iron
perform stool guaiac testing
14
53. Because of safety concerns, which one of the following asthma medications should be used only
as additive therapy and not as monotherapy?
A)
B)
C)
D)
E)
Inhaled corticosteroids
Leukotriene-receptor antagonists
Short-acting $2-agonists
Long-acting $2-agonists
Mast cell stabilizers
54. The mother of a 16-year-old male brings him to your office stating that she wants to find out if
he has Crohns disease. She says that both she and the childs aunt were diagnosed with this
condition by another physician with blood tests. The son tells you that for the past several
years his stool is intermittently loose and he has up to three bowel movements in a day. He says
he does not have fever, pain, hematochezia, weight loss, or any extraintestinal symptoms. A
physical examination is normal.
Which one of the following would be the most appropriate preliminary testing?
A)
B)
C)
D)
E)
A plain radiograph of the abdomen

CT of the abdomen and pelvis
An inflammatory bowel disease serologic panel
Colonoscopy with a biopsy
A CBC, serum chemistry panel, and erythrocyte sedimentation rate
55. A 3-day-old female developed a rash 1 day ago that has continued to progress and spread. The
infant was born at term after an uncomplicated pregnancy and delivery to a healthy mother
following excellent prenatal care. The infant was discharged 2 days ago in good health. She does
not appear to be irritable or in distress, and she is afebrile and feeding well. On examination,
abnormal findings are confined to the skin, including her face, trunk, and proximal extremities,
which have macules, papules, and pustules that are all 23 mm in diameter. Her palms and soles
are spared. A stain of a pustular smear shows numerous eosinophils.
Which one of the following is the most likely diagnosis?
A)
B)
C)
D)
E)
Staphylococcal pyoderma
Herpes simplex
Acne neonatorum
Erythema toxicum neonatorum
Rocky Mountain spotted fever
15
56. A 52-year-old Hispanic female with diabetes mellitus and stage 3 chronic kidney disease sees
you for follow-up after tests show an estimated glomerular filtration rate of 56 mL/min. Which
one of the following medications should she avoid to prevent further deterioration in renal
function?
A)
B)
C)
D)
E)
Lisinopril (Prinivil, Zestril)

Folic acid
Low-dose aspirin
Candesartan (Atacand)
Ibuprofen
57. The best drug treatment for symptomatic mitral valve prolapse is
A)
B)
C)
D)
E)
quinidine
propranolol (Inderal)
digoxin
procainamide
phenytoin (Dilantin)
58. A 52-year-old male with stable coronary artery disease and controlled hypertension sees you for
a routine visit and asks for advice regarding prevention of altitude illness for his upcoming trip
to Bhutan to celebrate his anniversary. His medical chart indicates that he had a reaction to a
sulfa drug in the past.
Which one of the following would be most appropriate?
A)
B)
C)
D)
Advise the patient to not make the trip

Recommend ginkgo biloba
Prescribe acetazolamide
Prescribe dexamethasone
59. Which one of the following is most commonly implicated in interstitial nephritis?
A)
B)
C)
D)
E)
NSAIDs
ACE inhibitors
Diuretics
Corticosteroids
Antibiotics
60. Which one of the following has been shown to be effective for improving symptoms of varicose
veins?
A)
B)
C)
D)
E)
Horse chestnut seed extract

Vitamin B12
Ephedra
Milk thistle
St. Johns wort
16
61. Breastfeeding a full-term, healthy infant is contraindicated when which one of the following
maternal conditions is present?
A)
B)
C)
D)
E)
Chronic hepatitis B infection

Seropositive cytomegalovirus carrier state
Current tobacco smoking
Herpes simplex viral lesions on the breasts
Undifferentiated fever
62. What is the most common cause of erythema multiforme, accounting for more than 50% of
cases?
A)
B)
C)
D)
E)
Candida albicans
Herpes simplex virus
Mycoplasma pneumoniae
Penicillin therapy
Sulfonamide therapy
63. A 25-year-old male presents to your office for evaluation of pain in the right index finger that
has been present for the past 4 days. The pain has been getting progressively worse. On
examination the finger is swollen and held in a flexed position. The pain increases with passive
extension of the finger, and there is tenderness to palpation from the tip of the finger into the
palm.
Which one of the following is the most appropriate management of this patient?
A)
B)
C)
D)
E)
Surgical drainage and antibiotics

Antiviral medication
Oral antibiotics and splinting
Needle aspiration
Corticosteroid injection
64. An 81-year-old male with type 2 diabetes mellitus has a hemoglobin A1c of 10.9%. He is
already on the maximum dosage of glipizide (Glucotrol). His other medical problems include
mild renal insufficiency and moderate ischemic cardiomyopathy.
Which one of the following would be the most appropriate change in this patients diabetes
regimen?
A)
B)
C)
D)
Add metformin (Glucophage)

Add sitagliptin (Januvia)
Add pioglitazone (Actos)
Initiate insulin therapy
17
65. Which one of the following seafood poisonings requires more than just supportive treatment?
A)
B)
C)
D)
Ciguatera
Neurotoxic shellfish
Paralytic shellfish
Scombroid fish
66. A 22-year-old white female comes to your office complaining of dizziness. She was in her usual
good health until about 2 weeks before this visit, when she developed a case of gastroenteritis
that other members of her family have also had. Since that time she has been lightheaded when
standing, feels her heart race, and gets headaches or blurred vision if she does not sit or lie
down. She has not passed out but has been unable to work due to these symptoms. She is
otherwise healthy and takes no regular medications.
A physical examination is normal except for her heart rate, which rises from 72 beats/min when
she is lying or sitting to 112 beats/min when she stands. Her blood pressure remains unchanged
with changes of position. Routine laboratory tests and an EKG are normal.
What is the most likely cause of this patients condition?
A)
B)
C)
D)
E)
Myocarditis
A seizure disorder
Postural orthostatic tachycardia syndrome (POTS)
Systemic lupus erythematosus
Somatization disorder
67. Which one of the following is the greatest risk factor for abdominal aortic aneurysm (AAA)?
A)
B)
C)
D)
E)
Cigarette smoking
Diabetes mellitus
Hypertension
African-American race
Female gender
68. An asymptomatic 35-year-old female asks about having a thyroid test performed because
hypothyroidism runs in her family. You order the tests, which show a TSH level of 7.6 :U/mL
(N 0.45.1) and a free T4 level within the normal range.
Which one of the following is most likely in this patient?
A)
B)
C)
D)
E)
A euthyroid state
Primary hyperthyroidism
Secondary hyperthyroidism
Subclinical hypothyroidism
Overt hypothyroidism
18
69. Which one of the following tinea infections in children always requires systemic antifungal
therapy?
A)
B)
C)
D)
E)
Tinea cruris
Tinea corporis
Tinea capitis
Tinea pedis
Tinea versicolor
70. A 26-year-old female calls your office to inquire about the results of her recent Papanicolaou
(Pap) test. The report indicates the presence of atypical squamous cells of undetermined
significance (ASC-US), and her reflex HPV test is negative for high-risk HPV types. The patient
has never had an abnormal Pap test and has had three normal tests over the past 6 years. She is
a nonsmoker.
You advise the patient that the most appropriate next step would be to
A)
B)
C)
D)
E)
repeat the Pap test every 3 months for 1 year

repeat the Pap test in 6 months and 12 months
repeat the Pap test in 12 months
continue routine Pap tests, with the next test in 3 years
schedule colposcopy as soon as possible
71. You are asked to perform a preoperative evaluation on a 55-year-old white female with type 2
diabetes mellitus prior to elective femoralanterior tibial artery bypass surgery. She is unable
to climb a flight of stairs or do heavy work around the house. She denies exertional chest pain,
and is otherwise healthy.
Based on current guidelines, which one of the following diagnostic studies would be appropriate
prior to surgery because the results could alter the management of this patient?
A)
B)
C)
D)
E)
Pulmonary function studies

Coronary angiography
Carotid angiography
A dipyridamole-thallium scan
A hemoglobin A1c level
72. A 62-year-old male has been taking omeprazole (Prilosec) for over a year for gastroesophageal
reflux disease. He is asymptomatic and has had no problems tolerating the drug, but asks you
about potential side effects, as well as the benefits of continuing therapy.
It would be most accurate to tell him that omeprazole therapy is associated with which one of
the following?
A)
B)
C)
D)
E)
A decreased rate of hip fracture

Decreased vitamin B12 absorption
A reduced likelihood of pneumonia
A reduced likelihood of Clostridium difficile colitis
An increased likelihood of iron deficiency anemia
19
73. A 48-year-old white female comes to see you because of abnormal vaginal bleeding. Her
periods are lasting 35 days longer than usual, bleeding is heavier, and she has experienced
some intermenstrual bleeding. Her physical examination is unremarkable, except for a parous
cervix with dark blood at the os and in the vagina. She has no orthostatic hypotension, and her
hemoglobin level is 11.5 g/dL. A pregnancy test is negative.
Which one of the following is the most important next step in management?
A)
B)
C)
D)
Laboratory tests to rule out thyroid dysfunction

An endometrial biopsy
Oral contraceptives, 4 times a day for 57 days
Cyclic combination therapy with conjugated estrogens (Premarin) and medroxyprogesterone (Provera) each month
E) Administration of a gonadotropin-releasing hormone analog such as leuprolide acetate
(Eligard Lupron Depot)
74. A 75-year-old African-American male with no previous history of cardiac problems complains
of shortness of breath and a feeling of general weakness. His symptoms have developed over
the past 24 hours. On physical examination you find a regular pulse with a rate of 160
beats/min. You note rales to the base of the scapula bilaterally, moderate jugular venous
distention, and hepatojugular reflux. His blood pressure is 90/55 mm Hg; when he sits up he
becomes weak and diaphoretic and complains of precordial pressure. An EKG reveals atrial
flutter with 2:1 block.
Management at this time should include
A)
B)
C)
D)
E)
intravenous digoxin
intravenous verapamil (Calan, Isoptin)
amiodarone (Cordarone)
electrical cardioversion
insertion of a pacemaker
75. A 60-year-old male is referred to you by his employer for management of his hypertension. He
has been without primary care for several years due to a lapse in insurance coverage. During
a recent employee health evaluation, he was noted to have a blood pressure of 170/95 mm Hg.
He has a 20-year history of hypertension and suffered a small lacunar stroke 10 years ago. He
has no other health problems and does not smoke or drink alcohol. A review of systems is
negative except for minor residual weakness in his right upper extremity resulting from his
remote stroke. His blood pressure is 168/98 mm Hg when initially measured by your nurse, and
you obtain a similar reading during your examination.
In addition to counseling him regarding lifestyle modifications, which one of the following is the
most appropriate treatment for his hypertension?
A)
B)
C)
D)
E)
An angiotensin receptor blocker

A $-blocker
A calcium channel blocker
A thiazide diuretic/ACE inhibitor combination
No medication
20
76. With regard to the cardiovascular system, activation of the sympathetic branch of the autonomic
nervous system will cause a decrease in which one of the following?
A)
B)
C)
D)
E)
Heart rate
Coronary flow rate
Metabolic demand
Contractility of cardiac myocytes
The P-R interval
77. A 40-year-old female with chronic plaque psoriasis requests topical treatment. Which one of the
following topical therapies would be most effective and have the fewest adverse effects?
A)
B)
C)
D)
High-potency corticosteroids
Tazarotene (Tazorac)
Coal tar polytherapy
Anthralin
78. You have been treating a 43-year-old male for unipolar depression for 4 years. He has
developed treatment-resistant depression, and despite having a good initial response to an SSRI,
his symptoms are worsening. He has failed to improve despite escalated doses of multiple SSRIs
and SNRIs. He is currently taking citalopram (Celexa), 60 mg daily.
Of the following, the most effective adjunctive therapy would be augmentation with
A)
B)
C)
D)
lithium bicarbonate
high-dose triiodothyronine
an atypical antipsychotic, such as olanzapine (Zyprexa)
an anticonvulsant, such as gabapentin (Neurontin)
79. A 4-year-old is brought to the emergency department with abdominal pain and is noted to have
3+ proteinuria on a dipstick. Three days later the pain has resolved spontaneously, and a repeat
urinalysis in your office shows 2+ proteinuria with normal findings on microscopic examination.
A metabolic panel, including creatinine and total protein, is also normal.
A)
B)
C)
D)
Renal ultrasonography
A spot first morning urine protein/creatinine ratio
An antinuclear antibody and complement panel
Referral to a nephrologist
21
80. A 25-year-old male presents to your office with a 1-week history of neck pain with radiation to
the left hand, along with intermittent numbness and tingling in the left arm. His history is
negative for injury, fever, or lower extremity symptoms. Extension and rotation of the neck to
the left while pressing down on the head (Spurlings maneuver) exacerbates the symptoms. His
examination is otherwise normal. Cervical radiographs are negative.
A)
B)
C)
D)
E)
NSAIDs for pain relief

A trial of tricyclic antidepressants
Cervical corticosteroid injection
Cervical MRI
Referral to a spine subspecialist
81. A 21-year-old African-American female has been confused and delirious for 2 days. She has
no significant past medical history, and she is taking no medications. She recently returned from
a missionary trip to Southeast Asia.
During your initial examination in the emergency department, she has several convulsions and
rapidly becomes comatose. Her temperature is 37.9C (100.3F) and her blood pressure is
80/50 mm Hg. A neurologic examination shows no signs of meningeal irritation and a cranial
nerve evaluation is normal. There is a mild, bilateral, symmetric increase in deep tendon
reflexes. All other physical examination findings are normal.
Laboratory Findings
Hemoglobin. . . . . . . . . . . . . . . . . . . . . . . . . . .
Hematocrit. . . . . . . . . . . . . . . . . . . . . . . . . . . .
WBCs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Platelets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Serum bilirubin
Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Direct. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.0 g/dL (N 12.016.0)

20% (N 3646)
6500/mm3 (N 430010,800)
450,000/mm3 (N 150,000350,000)
5.0 mg/dL (N 0.31.1)
1.0 mg/dL (N 0.10.4)
The urine is dark red and positive for hemoglobin. CT of the brain shows neither bleeding nor
infarction.
A)
B)
C)
D)
vitamin B12 deficiency

malaria
ehrlichiosis
sickle cell anemia
22
82. While evaluating a stroke patient, you ask him to stick out his tongue. At first he is unable to
do this, but a few moments later he performs this movement spontaneously.
This defect is known as
A)
B)
C)
D)
apraxia
agnosia
expressive (Brocas) aphasia
astereognosis
83. When an interpreter is needed for a patient with limited English proficiency, which one of the
following should be AVOIDED when possible?
A)
B)
C)
D)
E)
Using mostly short sentences, with frequent pauses

Using diagrams and pictures
Addressing the patient in the second person (i.e., you)
Maintaining eye contact with the patient when speaking
Using an educated adult family member who is bilingual
84. A primigravida at 38 weeks gestation is concerned that her fetus is getting too large and wants
to know what interventions could prevent complications from a large baby. On examination her
uterine fundus measures 41 cm from the pubic symphysis. Ultrasonography is performed and
an estimated fetal weight of 4000 g (8 lb 13 oz) is reported.
Which one of the following management options is supported by the best evidence?
A)
B)
C)
D)
Induction of labor
Cesarean section
Awaiting spontaneous labor
Weekly ultrasonography to follow fetal growth
85. A 65-year-old female who is morbidly obese presents to your office with intertrigo in the axilla.
On examination you detect small, reddish-brown macules that are coalescing into larger patches
with sharp borders. You suspect cutaneous erythrasma complicating the intertrigo.
What would be the most appropriate topical treatment for this condition?
A)
B)
C)
D)
Cornstarch
A mild corticosteroid lotion
A high-potency corticosteroid lotion
Erythromycin
23
86. The CAGE-AID questionnaire is a tool for screening for

A)
B)
C)
D)
E)
depression
bipolar illness
substance abuse risk
psychosis
compatibility
87. You see a 6-year-old male for the third time in 3 months with a persistently painful hand
condition. He has been treated with oral amoxicillin, followed by oral trimethoprim/
sulfamethoxazole (Bactrim, Septra), with no improvement. A physical examination reveals
retraction of the proximal nail fold, absence of the cuticle, and erythema and tenderness around
the nail fold area. The thumb and second and third fingers are affected on both hands. The
patient is otherwise healthy.
First-line treatment for this condition includes
A)
B)
C)
D)
warm soaks three times a day

avoidance of emollient lotions
a topical corticosteroid cream
an oral antifungal agent
88. You see a 90-year-old male with a 5-year history of progressive hearing loss. The most
common type of hearing loss at this age affects
A)
B)
C)
D)
predominantly high frequencies

predominantly mid frequencies
predominantly low frequencies
all frequencies roughly the same
89. A 44-year-old female who suffers from obstructive sleep apnea complains of gradual swelling
in her legs over the last several weeks. Her vital signs include a BMI of 44.1 kg/m2, a
respiratory rate of 12/min, a blood pressure of 120/78 mm Hg, and an O2 saturation of 86% on
room air. An EKG and a chest radiograph are normal. Pulmonary function testing shows a
restrictive pattern with no signs of abnormal diffusion. Abnormal blood tests include only a
significantly elevated bicarbonate level.
Which one of the following treatments is most likely to reduce this patients mortality rate?
A)
B)
C)
D)
E)
ACE inhibitors
Routine use of nebulized albuterol (AccuNeb)
High-dose diuretic therapy
Continuous oxygen therapy
Continuous or bilevel positive airway pressure (CPAP or Bi-PAP)
24
90. A 38-year-old day-care worker consults you for a cold that wont go away. It began with a
runny nose, malaise, and a slight temperature elevation up to 100F (37.8C). She notes that
after 2 weeks she is now experiencing coughing fits, which are sometimes so severe that she
vomits. She has had no immunizations since her freshman year in college and does not smoke.
On examination you note excessive lacrimation and conjunctival injection. Her lungs are clear.
A)
B)
C)
D)
E)
Pertussis
Rhinovirus infection
Nonasthmatic eosinophilic bronchitis
Cough-variant asthma
Gastroesophageal reflux
91. A painful thrombosed external hemorrhoid diagnosed within the first 24 hours after occurrence
is ideally treated by
A)
B)
C)
D)
E)
appropriate antibiotics
office banding
office cryotherapy
thrombectomy under local anesthesia
total hemorrhoidectomy
92. Which one of the following is most characteristic of patellofemoral pain syndrome in adolescent
females?
A)
B)
C)
D)
Posterior knee pain

Pain exacerbated by walking on a flat surface
Inadequate hip abductor strength
A high rate of surgical intervention
93. A 52-year-old patient is concerned about a biopsy result from a recent screening colonoscopy.
Which one of the following types of colon polyp is most likely to become malignant?
A)
B)
C)
D)
E)
Hyperplastic polyp
Hamartomatous polyp
Tubular adenoma
Villous adenoma
Tubulovillous adenoma
94. Which one of the following treatments for diabetes mellitus reduces insulin resistance?
A)
B)
C)
D)
E)
Acarbose (Precose)
Sitagliptin (Januvia)
Repaglinide (Prandin)
Exenatide (Byetta)
Pioglitazone (Actos)
25
95. Which one of the following has been shown to be most effective for smokeless tobacco
cessation?
A)
B)
C)
D)
E)
Behavioral interventions
Mint snuff as a smokeless tobacco substitute
Bupropion (Wellbutrin)
The nicotine patch
Nicotine gum
96. An 81-year-old African-American female complains of increasing fatigue over the past several
months. She has also noticed that her skin and hair feel dry and that she often feels cold. She
also complains of intermittent swallowing difficulties. Her past medical history is significant for
long-standing coronary artery disease, for which she takes metoprolol (Lopressor). Her physical
examination is normal except for a resting pulse rate of 56 beats/min, dry skin, brittle hair, and
a slow relaxation phase of the deep tendon reflexes. Her serum TSH level is 63.2 :U/mL (N
0.55.0).
Which one of the following should you do now?
A)
B)
C)
D)
E)
Stop the metoprolol

Start levothyroxine (Synthroid)
Start liothyronine (Cytomel)
Start propylthiouracil
Refer for radioactive iodine ablation
97. Which one of the following is associated with vacuum-assisted delivery?

A)
B)
C)
D)
Lower fetal risk than with forceps delivery

More maternal soft-tissue trauma than forceps delivery
A reduced likelihood of severe perineal laceration compared to spontaneous delivery
An increased incidence of shoulder dystocia
98. A 21-year-old sexually active female presents with acute pelvic pain of several days duration.
A pelvic examination reveals right-sided tenderness and a general fullness in that area. In
addition to laboratory testing, you decide to order an imaging study.
Which one of the following is the best choice at this time?
A)
B)
C)
D)
E)
Transabdominal ultrasonography
Transvaginal ultrasonography
Contrast CT of the abdomen and pelvis
Hysteroscopy
Hysterosalpingography
26
99. A 27-year-old female presents to the emergency department with a complaint of bloody diarrhea
and abdominal cramping. A few days ago she ate a rare hamburger at a birthday party for her
4-year-old son. He ate hot dogs instead, and has not been ill. A stool specimen is positive for
Escherichia coli O:157.
Which one of the following should you do next?
A)
B)
C)
D)
Provide levofloxacin (Levaquin) prophylaxis to her close contacts

Monitor her liver enzymes
Monitor her renal function
Reassure her that her son is not at risk of illness
100. A 21-year-old female complains of bulging veins in her right shoulder region, along with
swelling and a tingling sensation in her right arm that has developed over the past 2 days.
There were no unusual events other than her regular workouts with her swim team.
Ultrasonography confirms an upper extremity deep-vein thrombosis of her right axillary vein.
A)
B)
C)
D)
E)
Intravenous heparin for 72 hours, followed by oral warfarin (Coumadin) for 3 months
Low molecular weight heparin (LMWH) subcutaneously for 5 days only
LMWH subcutaneously for at least 5 days, followed by oral warfarin for 3 months
LMWH subcutaneously for at least 5 days, followed by oral warfarin indefinitely
Oral warfarin for 3 months
101. A 75-year-old male consults you after his family expresses concern about his loss of interest in
his usual activities. They believe he has become increasingly withdrawn since the death of his
wife 8 months earlier. You note he has lost 8 kg (18 lb) since his last office visit 6 months
earlier. He does not drink alcohol. His physical examination is unremarkable for his age except
for a blood pressure of 105/70 mm Hg. Detailed laboratory studies, including thyroid function
tests, are all within normal limits.
He tells you he would be fine if he could just get some sleep.
Examination is normal, but he is obviously clinically depressed.
The most appropriate medication for his depression would be
A)
B)
C)
D)
E)
trazodone (Oleptro)
mirtazapine (Remeron)
bupropion (Wellbutrin)
amitriptyline
nortriptyline (Pamelor)
27
His Mini-Mental State
102. A 55-year-old female who has hypertension, hyperlipidemia, and osteoarthritis of the knees
develops acute gout and is found to have hyperuricemia. Discontinuation of which one of the
following medications may improve her hyperuricemia?
A)
B)
C)
D)
E)
Hydrochlorothiazide
Losartan (Cozaar)
Metoprolol (Lopressor)
Simvastatin (Zocor)
Acetaminophen
103. A patient with chronic kidney disease presents with chronic normocytic anemia with a
hemoglobin level of 7.8 g/dL. The best outcome is predicted if you raise the hemoglobin level
to
A)
B)
C)
D)
810 g/dL
1012 g/dL
1214 g/dL
>14 g/dL
104. A 25-year-old female sees you in the office for follow-up after a visit to the emergency
department for respiratory distress. She complains of several episodes of an acute onset of
shortness of breath, wheezing, coughing, and a choking sensation, without any obvious
precipitant. She has been on inhaled corticosteroids for 2 months without any improvement in
her symptoms. Albuterol (Proventil, Ventolin) does not consistently relieve her symptoms. She
is asymptomatic today.
Spirometry shows a normal FEV1, a normal FVC and FEV1/FVC ratio, and a flattened
inspiratory loop.
A)
B)
C)
D)
E)
globus hystericus
vocal cord dysfunction
asthma
anaphylaxis
COPD
105. In a patient with a sudden onset of dyspnea, which one of the following makes a pulmonary
embolus more likely?
A)
B)
C)
D)
E)
Fever >38.0C (100.4F)

Chest pain
Orthopnea
Wheezes
Rhonchi
28
106. A 2-year-old child stumbles, but his mother keeps him from falling by pulling up on his right
hand. An hour later the child refuses to use his right arm and cries when his mother tries to
move it.
A)
B)
C)
D)
E)
dislocation of the ulna

dislocation of the olecranon epiphysis
subluxation of the head of the radius
subluxation of the head of the ulna
anterior dislocation of the humeral head
107. You treat a 65-year-old white female for a clean minor laceration. Her chart reveals that she
has received two previous doses of tetanus toxoid. The last dose was 12 years ago.
Which one of the following is the preferred treatment?
A)
B)
C)
D)
E)
Reassurance that her tetanus immune status is adequate

Tetanus immune globulin (TIG) and tetanus toxoid (TT)
Tetanus toxoid only
Tdap
DTaP
108. A 45-year-old male has diabetes mellitus and hypertension. He has no other medical problems.
Which one of the following classes of medications is the preferred first-line therapy for the
treatment of hypertension in this patient?
A)
B)
C)
D)
E)
Potassium-sparing diuretics
ACE inhibitors
"-Receptor blockers
Calcium channel blockers
$-Blockers
109. A 73-year-old white female with a long history of rheumatoid arthritis has a normocytic
normochromic anemia. Her hemoglobin level is 9.8 g/dL (N 12.016.0) with decreased serum
iron, decreased total iron-binding capacity, and increased serum ferritin.
Which one of the following is the most appropriate treatment for this patient?
A)
B)
C)
D)
E)
Oral iron
Intramuscular iron dextran (DexFerrum, InFeD)
Treatment of the rheumatoid arthritis
Transfusion
Folic acid
29
110. Which one of the following would suggest that the sudden and unexpected death of a healthy
infant resulted from deliberate suffocation rather than sudden infant death syndrome?
A)
B)
C)
D)
E)
No previous history of apneic episodes

An age of 9 months
Mottled skin
Clenched fists
Blood-tinged froth in the mouth
111. The most appropriate advice for a 50-year-old female who has passed six calcium oxalate stones
over the past 4 years is to
A)
B)
C)
D)
E)
restrict her calcium intake

restrict her intake of yellow vegetables
increase her sodium intake
increase her dietary protein intake
take potassium citrate with meals
112. A 22-year-old female presents with lower right leg pain. She reports that it hurts when she
presses her shin. She has been training for a marathon over the past 4 months and has increased
her running frequency and distance. She now runs almost every day and is averaging
approximately 40 miles per week. She has little pain while at rest, but the pain intensifies with
weight bearing and ambulation. She initially thought the pain was from shin splints, but it has
intensified this week and she has had to shorten her usual running distances due to worsening
pain.
On examination you note tenderness to palpation over the anterior aspect of her mid-tibia. She
also has trace edema localized to the area of tenderness.
Which one of the following imaging studies should be performed first?
A)
B)
C)
D)
E)
Plain radiographs
CT
MRI
Ultrasonography
Bone scintigraphy
30
113. A 23-year-old white male is brought to the emergency department with slurred speech,
confusion, and ataxia. He works as an auto mechanic and has been known to consume alcohol
heavily in the past, but denies recent alcohol intake. He appears intoxicated, but no odor of
alcohol is noted on his breath. Abnormalities on the metabolic profile include a carbon dioxide
content of 10 mmol/L (N 2030). His blood alcohol level is <10 mg/dL (0.01%). A urinalysis
shows calcium oxalate crystals and an RBC count of 1020/hpf. Woods lamp examination of
the urine shows fluorescence. His arterial pH is 7.25.
A)
B)
C)
D)
Immediate hemodialysis
Gastric lavage
Administration of activated charcoal
Fomepizole (Antizol)
114. A 67-year-old white male with hypertension and chronic kidney disease presents with the recent
onset of excessive thirst, frequent urination, and blurred vision. Laboratory testing reveals a
fasting blood glucose level of 270 mg/dL, a hemoglobin A1c of 8.5%, a BUN level of 32 mg/dL,
and a serum creatinine level of 2.3 mg/dL. His calculated glomerular filtration rate is 28
mL/min.
Which one of the following medications should you start at this time?
A)
B)
C)
D)
Glipizide (Glucotrol)
Metformin (Glucophage)
Glyburide (DiaBeta)
Acarbose (Precose)
115. A 60-year-old male has a drug-eluting stent placed in his right coronary artery. He will require
treatment to prevent stent thrombosis, and once his initial treatment period is completed he will
be placed on aspirin, 75165 mg/day indefinitely.
Which one of the following is the preferred initial regimen for preventing stent thrombosis in
this situation?
A)
B)
C)
D)
E)
Aspirin/dipyridamole (Aggrenox) for 3 months

Aspirin, 162325 mg/day for 3 months
Aspirin, 162325 mg/day, plus clopidogrel (Plavix), both for 3 months
Aspirin, 162325 mg/day, plus clopidogrel, both for 12 months
Warfarin (Coumadin) for 3 months
31
116. A 57-year-old male executive sees you because of shaky hands. His tremor is most noticeable
when he is holding something or writing, and is more prominent in his hand than in his shoulder.
He has noticed that it seems better after a beer or two at social gatherings. He has no other
health problems. On examination you note a very definite tremor when he unbuttons his shirt.
His gait is normal and there is no resting tremor. He has a previous history of intolerance to
$-blockers.
Of the following, which medication would be the best choice for this patient?
A)
B)
C)
D)
Levodopa/carbidopa (Sinemet)
Amantadine (Symmetrel)
Primidone (Mysoline)
Lithium carbonate
117. Which one of the following is true regarding medical errors?

A) Malpractice litigation is more common when physicians disclose errors to patients
B) The use of the word error should be avoided when disclosing mistakes to patients
C) Physicians in private practice are more likely to disclose errors to patients than
physicians employed by institutions or health care organizations
D) Patients prefer to receive apologies and explanations when an error has been made
E) It is ethically defensible to only disclose an error if the patient is aware there is a
problem
118. A 60-year-old female presents with a 1-year history of episodes of urinary incontinence. She
tells you that she will suddenly feel the need to urinate and can barely make it to the bathroom.
She occasionally loses urine before reaching the toilet. Her only medication is
hydrochlorothiazide, which she has been taking for many years for hypertension. On
examination, her vaginal mucosa is pale and somewhat dry. Minimal prolapse of her vaginal and
urethral areas is noted.
A)
B)
C)
D)
E)
Urodynamic testing
Referral for surgical evaluation
Oral estrogen
Oral anticholinergic therapy
Stopping the hydrochlorothiazide
32
119. A 42-year-old female brings you the results of a comprehensive metabolic profile obtained
through a health screening program offered by her employer. She fasted for 8 hours prior to
the test, and her blood glucose level was reported as 110 mg/dL. Her lipid values and her blood
pressure were normal, but her BMI is 30.5 kg/m2.
She currently views herself as relatively healthy and reports no symptoms consistent with
diabetes mellitus during your review of systems. Additional testing reveals a hemoglobin A1c of
6.3%.
Based on this data, which one of the following is most appropriate at this time?
A)
B)
C)
D)
E)
Order a C-peptide level

Order an islet cell antibody level
Recommend lifestyle modifications only
Start low-dose glyburide (DiaBeta) daily
Start low-dose insulin glargine (Lantus) daily
120. Which one of the following is consistent with spinal stenosis but not with a herniated vertebral
disk?
A)
B)
C)
D)
Numbness
Muscle weakness
Pain relieved by sitting
Pain relieved by standing
121. Which one of the following is a recommended treatment for presumptive methicillin-resistant
Staphylococcus aureus (MRSA) infection?
A)
B)
C)
D)
E)
Dicloxacillin
Levofloxacin (Levaquin)
Doxycycline
Cephalexin (Keflex)
122. A mother brings in her 2-week-old infant for a well child check. She reports that she is
primarily breastfeeding him, with occasional formula supplementation.
Which one of the following should you advise her regarding vitamin D intake for her baby?
A) Breastfed infants do not need supplemental vitamin D
B) As long as the baby is taking at least 16 oz of formula per day, he does not need
supplemental vitamin D
C) The baby should be given 400 IU of supplemental vitamin D daily
D) Intake of vitamin D in excess of 200 IU/day is potentially toxic
E) Vitamin D supplementation should not be started until he is at least 6 months old
33
123. A 60-year-old male is recovering from a nonQ-wave myocardial infarction. He has a

40-pack-year smoking history, currently smokes a pack of cigarettes per day, and has a strong
family history of coronary artery disease. Studies ordered by the cardiologist showed no
indication for any coronary artery procedures. His BMI is 27.5 kg/m2 and his blood pressure
is 130/70 mm Hg. Laboratory tests reveal a fasting blood glucose level of 85 mg/dL, a total
cholesterol level of 195 mg/dL, and an LDL-cholesterol level of 95 mg/dL.
Which one of the following secondary prevention measures would be LEAST likely to improve
this patients cardiovascular outcome?
A)
B)
C)
D)
E)
A weight reduction diet

A $-blocker
A statin
An antiplatelet agent
Smoking cessation
124. You have just diagnosed post-traumatic stress disorder in a 32-year-old male. You immediately
begin a program of patient education for him and his family, and connect them with a support
group. Since his symptoms are quite severe you decide to begin pharmacotherapy before
initiating trauma-focused psychotherapy.
Based on available evidence, which one of the following medications is the best INITIAL
treatment choice?
A)
B)
C)
D)
E)
Sertraline (Zoloft)
Amitriptyline
Phenelzine (Nardil)
Alprazolam (Xanax)
Haloperidol (Haldol)
125. You volunteer some of your time to provide services to athletes at a small liberal arts college that
has several NCAA Division II teams. When screening these athletes for health problems, you
would advise that students with uncontrolled stage 2 hypertension should not participate in
A)
B)
C)
D)
E)
rowing
soccer
tennis
fencing
baseball
34
126. A 36-year-old male presents to the emergency department with disorientation, tachycardia,
diaphoresis, and hypertension. According to his family, he has been consuming up to a fifth of
vodka daily but abruptly discontinued alcohol consumption 2 days ago. There is no history of
additional substance abuse and a urine drug screen is negative.
Which one of the following is most indicated in the management of this patient?
A)
B)
C)
D)
E)
An anticonvulsant
A typical antipsychotic
A benzodiazepine
A centrally-acting "2-agonist
Baclofen
127. A 54-year-old female has pain and swelling of the right knee. Examination of the synovial fluid
reveals a leukocyte count of 5000/mm3 , and crystals that appear as short, blunt rods, rhomboids,
and cuboids when viewed under polarized light.
A)
B)
C)
D)
E)
gonococcal arthritis
tuberculous arthritis
rheumatoid arthritis
pseudogout
gout
128. A 66-year-old male with type 2 diabetes mellitus is seen for a follow-up visit and has a
hemoglobin A1c of 6.7%. He is currently taking metformin (Glucophage), 1000 mg twice daily.
He has no history of coronary artery disease or heart failure.
A)
B)
C)
D)
E)
Continuing his current regimen

Increasing the metformin dosage
Adding a sulfonylurea
Adding a thiazolidinedione
Adding daily long-acting insulin
129. Which one of the following would most likely be found in a patient with giardiasis?
A)
B)
C)
D)
E)
Fecal leukocytosis
Mucus in the stool
Eosinophilia
Hematochezia
Foul-smelling flatus
35
130. A 12-year-old male is brought to your office with an animal bite. After talking with the patient,
you learn that he was bitten on his left hand as he attempted to pet a stray cat a little over 24
hours ago. He says that the bite was very painful, and that it bled for a few minutes. His parents
cared for the bite by rinsing it and covering it with a bandage. His chart indicates that he
received a tetanus shot last year.
On examination, the patient is afebrile with stable vital signs. The site is warm and tender to
light palpation, with surrounding erythema measuring approximately 3 cm in diameter.
Which one of the following is the most likely infectious agent in this situation?
A)
B)
C)
D)
E)
Candida albicans
Capnocytophaga canimorsus
Methicillin-resistant Staphylococcus aureus (MRSA)
Pasteurella multocida
Streptococcus pneumoniae
131. A 3-year-old toilet-trained female is brought to your office by her mother, who has noted a red
rash on the childs perineum for the last 5 days. The rash is pruritic and has been spreading.
The mother has treated the area for 3 days with nystatin cream with no obvious improvement.
The child has not used any other recent medications and has no significant past medical history.
Your examination reveals a homogeneous, beefy red rash surrounding the vulva and anus.
The most likely etiologic agent is
A)
B)
C)
D)
E)
Malassezia furfur
Escherichia coli
Haemophilus influenzae
Staphylococcus aureus
group A Streptococcus pyogenes
132. A 35-year-old male consults you about vague chest pain he developed while sitting at his desk
earlier in the day. The pain is right-sided and was sharp for a brief time when it began, but it
rapidly subsided. There was no hemoptysis and the pain does not seem pleuritic. His physical
examination, EKG, and oxygen saturation are unremarkable. A chest film shows a 10% right
pneumothorax.
Which one of the following should you do next?
A)
B)
C)
D)
Admit the patient to the hospital for observation

Admit the patient to the hospital for chest tube placement
Obtain a repeat chest radiograph in 2448 hours
Obtain an expiratory chest radiograph
36
133. Which one of the following provides the best evidence for a given therapeutic intervention?
A)
B)
C)
D)
An individual randomized, controlled trial

A prospective case-control study
A systematic review of cohort studies
A systematic review of randomized, controlled trials
134. A 46-year-old white female complains of a 3-month history of hoarseness and nocturnal
wheezing. On further questioning, she tells you that she has to clear her throat repeatedly and
feels like she has something stuck in her throat.
These symptoms are most likely related to
A)
B)
C)
D)
thyroid disease
gastroesophageal reflux disease
sinusitis
tracheal stenosis
135. A health-care worker repeatedly develops a rash on her hands after using latex gloves. The rash
is papular and pruritic, with vesicles. Latex allergy is confirmed by skin patch testing.
Which one of the following foods is most likely to provoke an allergic response in this patient?
A)
B)
C)
D)
E)
Avocados
Walnuts
Shellfish
Strawberries
Wheat
136. Which cardiac arrhythmia has been reported with high-dose methadone use?
A)
B)
C)
D)
E)
Atrial fibrillation
Paroxysmal supraventricular tachycardia
Third degree heart block
Torsades de pointes
Multifocal atrial tachycardia
37
137. A 17-year-old white female at 20 weeks gestation presents with a 2-day history of painful
vesicular lesions on her labia. This is the first time she has ever had this problem. Her last
sexual contact was 10 days ago. She has also had a low-grade fever, malaise, headache, and
mild, diffuse abdominal pain. On examination she has vesicles and erythematous papules on the
labia bilaterally. A few firm, tender inguinal nodes are also noted.
Which one of the following tests is most sensitive for confirming the diagnosis?
A)
B)
C)
D)
E)
A Papanicolaou smear of the lesions

Amniocentesis
Serologic studies
Viral polymerase chain reaction (PCR) testing
A Tzanck test
138. Outbreaks of dermatitis and folliculitis associated with swimming pools and hot tubs are often
caused by which one of the following?
A)
B)
C)
D)
E)
Listeria
Pseudomonas
Streptococcus
Shigella
Staphylococcus
139. A 40-year-old female presents with a complaint of fatigue. She says she is also concerned
because she has gained about 10 lb over the last several months. Physical examination reveals
no enlargement or other abnormalities of the thyroid gland. Laboratory testing reveals a TSH
level of 0.03 :U/mL (N 0.44.0) and a free T4 level of 1.0 :g/dL (N 1.55.5).
Which one of the following is the most likely cause of her problem?
A)
B)
C)
D)
E)
Malnutrition
Graves disease
Goiter
Hashimotos thyroiditis
Pituitary failure
140. A 45-year-old male sees you for a routine annual visit and is found to have atrial fibrillation,
with a ventricular rate of 7075 beats/min. He is otherwise healthy, and a laboratory workup
and echocardiogram are normal.
Which one of the following would be the most appropriate management?
A)
B)
C)
D)
E)
Aspirin, 325 mg daily

Warfarin (Coumadin), with a target INR of 2.03.0
Clopidogrel (Plavix), 75 mg daily
Amiodarone (Cordarone), 200 mg daily
Observation only
38
141. You are helping a hospice program manage the symptoms of a 77-year-old male with end-stage
colon cancer. He has required increasingly higher doses of his opioid medication to control
symptoms of pain and dyspnea.
In this situation, it should be kept in mind that which one of the following adverse effects of
opioids does NOT diminish over time?
A)
B)
C)
D)
E)
Constipation
Nausea
Mental status changes
Pruritus
Sedation
142. Of the following, which one causes the most deaths in the United States?
A)
B)
C)
D)
Colorectal cancer
Breast cancer
Prostate cancer
Lung cancer
143. A 28-year-old female consults you because of fatigue, arthralgias that are worse in the morning,
and painful, swollen finger joints. She is a high-school teacher. Her erythrocyte sedimentation
rate is 60 mm/hr and a test for rheumatoid factor is strongly positive.
The best choice for initial therapy would be
A)
B)
C)
D)
E)
prednisone
aspirin
naproxen (Naprosyn)
rituximab (Rituxan)
methotrexate (Rheumatrex)
144. Which one of the following treatments is most appropriate for a patient with uncomplicated acute
bronchitis?
A)
B)
C)
D)
E)
Amoxicillin
Amoxicillin/clavulanate (Augmentin)
Doxycycline
Supportive care only
39
145. A 60-year-old male presents with profound weakness after 3 days of watery, frequent diarrhea.
He has had no fever, bloody stool, or vomiting. His appetite has been poor. He has a history
of hypertension treated with chlorthalidone, 25 mg daily, and potassium chloride, 20 mEq twice
daily. Laboratory testing reveals a serum creatinine level of 2.0 mg/dL (N 0.61.5), a
potassium level of 6.5 mmol/L (N 3.44.8), and a BUN of 50 mg/dL (N 825). Baseline values
were normal.
Which one of the following is most likely to lower the serum potassium within 1 hour?
A)
B)
C)
D)
Regular insulin plus dextrose intravenously

Calcium chloride, 10% solution intravenously
Sodium polystyrene sulfonate (Kalexate) orally
Sodium polystyrene sulfonate rectally
146. A 40-year-old male with HIV infection presents to the emergency department with a 5-day
history of progressive cough and dyspnea on exertion. A chest radiograph shows bilateral diffuse
interstitial infiltrates. Arterial blood gas levels show an increased alveolar-arterial gradient and
a pO2 of 60 mm Hg. His CBC is normal but his CD4 count is 150/mm3.
In addition to trimethoprim/sulfamethoxazole (Bactrim, Septra), which one of the following
medications should be prescribed?
A)
B)
C)
D)
E)
Pentamidine (Pentam)
Dapsone
Atovaquone (Mepron)
Clindamycin (Cleocin) and primaquine
Corticosteroids
147. You have been asked to see a 75-year-old female who has just had hip surgery to correct a
fractured femoral neck. She has a 2-year history of diabetes mellitus treated with pioglitazone
(Actos), 30 mg daily, and metformin (Glucophage), 1000 mg twice daily. She is now fully alert
and has been able to eat her evening meal. A physical examination is normal except for her
being mildly overweight and having a bandage on her left hip. A CBC and chemistry profile
done earlier today were normal except for a serum glucose level of 200 mg/dL. Her hemoglobin
A1c at an office visit 2 weeks ago was 6.8%.
Which one of the following would be the best management of this patients diabetes at this time?
A)
B)
C)
D)
E)
Stop her usual medications and begin a sliding-scale insulin regimen

Stop the metformin only
Initiate an insulin drip to maintain glucose levels of 80120 mg/dL
Decrease the dosage of pioglitazone
Continue with her usual medication regimen
40
148. A 28-year-old white male comes to your office complaining of pain in the right wrist since
falling 2 weeks ago. On examination, he is tender in the anatomic snuffbox. A radiograph
reveals a nondisplaced fracture of the distal one-third of the carpal navicular bone (scaphoid).
Which one of the following is the most appropriate management at this time?
A)
B)
C)
D)
E)
A bone scan
Physical therapy referral
A Velcro wrist splint
A short arm cast
A thumb spica cast
149. You are caring for an 88-year-old female nursing-home resident with multiple comorbidities and
advanced Alzheimers disease. The patient has never completed advance directives and no longer
has the ability to make decisions. The family inquires about hospice services for this patient.
Which one of the following is true regarding this patient and hospice?
A)
B)
C)
D)
E)
Nursing-home residents are not eligible for hospice

The decision to enter hospice care is reversible
End-stage Alzheimers disease is not a qualifying diagnosis for hospice
Failure to complete advance directives by this patient prevents participation in hospice
The patient must have a life expectancy of less than 4 months to qualify for hospice
services
150. A 28-year-old male presents with the recent onset of intermittent urethral discharge accompanied
by dysuria. He is heterosexual, has no prior history of a sexually transmitted infection, and
acquired a new sexual partner a month ago. He has no regional lymphadenopathy or ulcers, and
gentle milking of the urethra produces no discharge. Evaluation of a first-void urine specimen,
however, reveals 15 WBCs/hpf. You treat him with oral azithromycin (Zithromax), 1 g in a
single dose, and ceftriaxone (Rocephin), 125 mg intramuscularly. Test results for gonorrhea,
Chlamydia, syphilis, HIV, and hepatitis B are negative.
He returns 2 months later because his urethral discharge has persisted. He reports no
relationships with a different sexual partner, and is confident that his current partner has only
had sexual contact with him. You repeat the previous tests and again treat him with oral
azithromycin.
According to CDC testing and treatment guidelines, which one of the following drugs should be
added to his treatment regimen?
A)
B)
C)
D)
E)
Metronidazole (Flagyl)
Ciprofloxacin (Cipro)
Trimethoprim/sulfamethoxazole (Bactrim, Septra)
Cefixime (Suprax)
41
151. Two doses of varicella vaccine are recommended for

A)
B)
C)
D)
adults under 60 years of age who develop shingles

all children with normal immune status
only immunocompromised individuals
only children between 12 months and 13 years of age
152. The FDA has imposed a black box warning on all thiazolidinediones, such as pioglitazone
(Actos). This warning addresses a contraindication to the prescription of these drugs in patients
with
A)
B)
C)
D)
E)
renal insufficiency
dementia
exposure to radiocontrast media
heart failure
respiratory failure
153. A 5-month-old female is brought in with a 1-day history of an axillary temperature of 100.6F
and mild irritability. Findings are normal on examination except for a runny nose and a
moderately distorted, immobile, red right eardrum. There is no history of recent illness or otitis
in the past.
The most appropriate management would be
A)
B)
C)
D)
E)
azithromycin (Zithromax) for 5 days

amoxicillin for 10 days
amoxicillin for 5 days
oral decongestants
observation and a repeat examination in 2 weeks
154. A previously healthy gravida 1 para 1 who is 3 weeks post partum complains of bilateral nipple
pain with breastfeeding. When she first started breastfeeding she had some soreness that went
away after repositioning with feeding. The current pain began gradually 3 days ago. It has been
worsening, inhibiting feeding, and is present between feedings. Examination of the breast is
notable for erythema and cracking of the areola.
The most likely cause is
A)
B)
C)
D)
E)
engorgement
mastitis
improper latch-on
eczema flare
Candida infection
42
155. An 8-year-old male presents with cervical lymphadenitis. He has a kitten at home and you are
concerned about cat-scratch disease. Which one of the following antibiotics is most appropriate
for treatment of Bartonella henselae infection?
A)
B)
C)
D)
E)
Ceftriaxone (Rocephin)
Doxycycline
Clindamycin (Cleocin)
156. The parents of a young child ask your advice about the need for fluoride supplementation in
order to prevent tooth decay. Which one of the following is true regarding current U.S.
Preventive Services Task Force guidelines for fluoride supplementation?
A) It is not recommended due to potential fluoride toxicity
B) Dental fluoride varnish is too toxic for routine use
C) Oral fluoride supplementation is recommended if the primary drinking water source is
low in fluoride
D) Fluoridated toothpaste provides adequate protection if used as soon as the child has teeth
E) The need for fluoride supplementation is determined by serum fluoride levels
157. An enlarged tongue is associated with which one of the following?
A)
B)
C)
D)
E)
Pellagra
Amyloidosis
Pernicious anemia
Xerostomia
Syphilis
158. A 3-year-old male is brought to your office by his parents because they are concerned about
three spells he has had in the past month. In each case, the child started crying when he was
prevented by a parent from doing something he wished to do. While crying, he suddenly
stopped breathing and his face and lips began to turn blue. After 3045 seconds he resumed
crying, his color returned to normal, and he showed no evidence of impairment.
A physical examination today is normal and the child is developmentally appropriate for his age.
A recent hemoglobin level was in the normal range.
Which one of the following should you do now?
A) Teach the parents age-appropriate disciplinary procedures to implement when the child
behaves in this manner
B) Reassure the parents that this is a benign condition and will resolve as the child gets
older
C) Order an EEG
D) Obtain appropriate laboratory studies to confirm the most likely diagnosis
E) Initiate treatment with valproic acid (Depakene)
43
159. A 36-year-old male complains of clear rhinorrhea, nasal congestion, and watery, itchy eyes for
several months. Tests in the past have suggested that he has an allergy to dust mites.
Which one of the following is most likely to provide the most relief from his symptoms?
A)
B)
C)
D)
E)
Oral antihistamines
An oral leukotriene-receptor antagonist
Intranasal antihistamines
Intranasal corticosteroids
Furnace filters and mite-proof bedding covers
160. A 57-year-old female is noted to have a serum calcium level of 11.1 mg/dL (N 8.910.5) on a
chemistry profile obtained at the time of a routine annual visit. The remainder of the chemistry
profile is unremarkable, including normal BUN and creatinine levels. She is otherwise healthy,
and is on no medications. On follow-up testing her calcium level is unchanged, a vitamin D
level is normal, and her parathyroid hormone level is elevated.
Which one of the following is the most likely cause of her hypercalcemia?
A)
B)
C)
D)
E)
Primary hyperparathyroidism
Secondary hyperparathyroidism
Tertiary hyperparathyroidism
Cancer metastatic to bone
Humoral hypercalcemia of malignancy
161. A 53-year-old female presents to the emergency department following a fall. She is found to
have an ankle fracture and a blood pressure of 160/100 mm Hg. She tells the emergency
department physician that she is not aware of any previous medical problems. A focused
cardiovascular examination is otherwise normal.
You are the patients regular physician, and the emergency physician calls your office for further
information about the blood pressure elevation. You confirm that this is a new problem.
Which one of the following would you ask the emergency physician to do?
A) Administer a dose of intravenous labetalol (Trandate) and ask the patient to follow up
in your office within the week
B) Administer nifedipine (Adalat, Procardia), 10 mg; discharge the patient once the blood
pressure falls to 140/90 mm Hg; and ask the patient to follow up with you tomorrow
C) Prescribe an appropriate antihypertensive agent and have the patient follow up with you
in a month
D) Order an EKG and chest radiograph, and ask the patient to see you in a week if the
results are normal
E) Perform no further evaluation of the hypertension, but ask the patient to follow up with
you within a month
44
162. A 23-month-old child is brought to your office with a 2-day history of a fever to 102F (39C),
cough, wheezing, and mildly labored breathing. He has no prior history of similar episodes and
there is no improvement with administration of an aerosolized bronchodilator.
Which one of the following is now indicated?
A)
B)
C)
D)
E)
Bronchodilator aerosol treatment every 6 hours

Corticosteroids
An antibiotic
A decongestant
Supportive care only
163. Contraindications to use of the levonorgestrel intrauterine system (Mirena) include which one
of the following?
A)
B)
C)
D)
E)
Nulliparity
A previous history of deep vein thrombosis
A previous history of endometriosis
Current pelvic inflammatory disease
Current breastfeeding
164. The best management of localized, well-differentiated prostate cancer in men older than 65 is
A)
B)
C)
D)
E)
radiation implants
external beam radiation therapy
watchful waiting
primary androgen deprivation therapy
robot-assisted prostatectomy
165. A 67-year-old Hispanic male comes to your office with severe periumbilical abdominal pain,
vomiting, and diarrhea, which began suddenly several hours ago. His temperature is 37.0C
(98.6F), blood pressure 110/76 mm Hg, and respirations 28/min. His abdomen is slightly
distended, soft, and diffusely tender; bowel sounds are normal. Other findings include clear
lungs, a rapid and irregularly irregular heartbeat, and a pale left forearm and hand with no
palpable left brachial pulse. Right arm and lower extremity pulses are normal. Testing reveals
the presence of blood in both his stool and his urine. His hemoglobin level is 16.4 g/dL (N
13.018.0) and his WBC count is 25,300/mm3 (N 430010,800).
The diagnostic imaging procedure most likely to produce a specific diagnosis of the abdominal
pain is
A)
B)
C)
D)
E)
intravenous pyelography (IVP)

sonography of the abdominal aorta
a barium enema
celiac and mesenteric arteriography
contrast venography
45
166. Which one of the following platelet counts is the threshold for prophylactic platelet transfusion
in most patients?
A)
B)
C)
D)
E)
10,000/:L
25,000/:L
40,000/:L
50,000/:L
100,000/:L
167. Which one of the following medications has the best evidence for preventing hip fracture?
A)
B)
C)
D)
E)
Ibandronate (Boniva)
Raloxifene (Evista)
Denosumab (Prolia)
Etidronate (Didronel)
Alendronate (Fosamax)
168. The sensitivity of a test is defined as

A) the probability of disease before a test is performed
B) the probability of disease after a test is performed
C) the percentage of patients with a positive test result who are confirmed to have the
disease
D) the percentage of patients with the disease who have a positive test result
E) the percentage of patients without the disease who have a negative test result
169. A 28-year-old female sees you with a complaint of irregular menses. She has not had a menstrual
period for 6 months. She is also concerned about weight gain, worsening acne, and dark hair
on her upper lip, chin, and periareolar region. She is also interested in becoming pregnant soon.
The patient tells you she has started an exercise program, which has helped with weight loss,
but she continues to have amenorrhea. She has a negative urine $-hCG test, a mild elevation in
free testosterone levels, and glucose intolerance.
Which one of the following would you consider initially for inducing ovulation?
A)
B)
C)
D)
E)
Insulin
Metformin (Glucophage)
Ethinyl estradiol/norgestimate (Ortho Tri-Cyclen)
Spironolactone (Aldactone)
46
170. The FDA issued a boxed warning describing an increased risk of tendinopathy and tendon
rupture associated with the use of which class of antibiotics?
A)
B)
C)
D)
E)
Macrolides
Aminoglycosides
Fluoroquinolones
Tetracyclines
Polypeptides
171. When added to compression therapy, which one of the following has been shown to be an
effective adjunctive treatment for venous ulcers?
A)
B)
C)
D)
E)
Warfarin (Coumadin)
Enoxaparin (Lovenox)
Clopidogrel (Plavix)
Pentoxifylline (Trental)
Atorvastatin (Lipitor)
172. A 75-year-old white male suffers an anteroseptal myocardial infarction. Four hours after
admission to the hospital his blood pressure is 65/40 mm Hg. A Swan-Ganz catheter is inserted
into the pulmonary artery, and the pulmonary capillary wedge pressure is found to be 8 mm Hg.
The best therapy in this instance is
A)
B)
C)
D)
E)
infusion of dopamine
infusion of 5% dextrose
infusion of normal saline
digoxin
furosemide (Lasix)
173. A 72-year-old male with COPD presents to the emergency department with an acute
exacerbation marked by increased sputum production and shortness of breath. His oxygen
saturation is 88% on room air and he has diffuse inspiratory and expiratory wheezes bilaterally.
In addition to oxygen and bronchodilators, which one of the following is most appropriate for
this patient?
A)
B)
C)
D)
E)
No additional treatments
Systemic corticosteroids only
Inhaled corticosteroids only
Systemic corticosteroids and antibiotics
Inhaled corticosteroids and antibiotics
47
174. A 42-year-old female with a history of alcoholism and binge drinking presents with a 3-hour
history of severe epigastric pain associated with nausea and vomiting. Her pain radiates to her
back and into her lower abdomen.
The patient appears to be in moderate distress due to pain. She is afebrile with a pulse rate of
110 beats/min and a blood pressure of 98/66 mm Hg. Her abdominal examination is remarkable
for epigastric tenderness, guarding, and mild abdominal distention. Laboratory evaluation
reveals a serum lipase level of 562 U/L (N 2251) and a serum amylase level of 317 U/L (N
36128).
You admit the patient to the hospital. Your treatment plan includes volume repletion, pain
control, and close monitoring of her hemodynamic status. After 48 hours of treatment, she is
hemodynamically stable. Her serum lipase level is now 168 U/L. She is awake and alert and
in no distress, but still requires parenteral pain medication.
Which one of the following is most appropriate for meeting her fluid and caloric needs at this
time?
A)
B)
C)
D)
D5 normal saline intravenously at a maintenance rate

Enteral feedings via nasogastric feeding tube
A low-fat diet orally and oral fluids ad libitum
Intravenous total parenteral nutrition
175. Which one of the following is effective for single-dose prophylaxis against Lyme disease after
an Ixodes scapularis tick bite?
A)
B)
C)
D)
E)
Amoxicillin
Cefuroxime (Ceftin)
Trimethoprim/sulfamethoxazole (Bactrim, Septra)
Doxycycline
176. A 63-year-old white male sees you for an initial visit and is accompanied by his daughter, who
is a patient of yours and scheduled the visit. The father recently relocated to be near the daughter
after his wife died. He has well-controlled type 2 diabetes mellitus, but is otherwise healthy.
Referring to the copy of the medical records they brought with them, the daughter notes that her
father has received influenza vaccine in 3 of the past 5 years, but she can find no documentation
that he ever had the pneumonia vaccine. She asks if he should receive it at this visit.
You advise them that he should receive pneumococcal vaccine
A)
B)
C)
D)
E)
annually, along with influenza vaccine

now and a repeat dose every 5 years
every 5 years starting at age 65
now and a repeat dose once at age 68
only once, at age 65
48
177. A 50-year-old Hispanic male has a solitary 5-mm pulmonary nodule on a chest radiograph. His
only medical problem is severe osteoarthritis. He quit smoking 10 years ago.
Which one of the following would be the most appropriate follow-up for the pulmonary nodule?
A)
B)
C)
D)
E)
Positron emission tomography (PET)

Chest CT
A repeat chest radiograph in 6 weeks
A repeat chest radiograph in 6 months
Referral for a biopsy
178. Early palliative care in patients with a terminal disease, including symptom management,
psychosocial support, and assistance with decision making, has been shown to
A)
B)
C)
D)
E)
shorten the time to death

increase aggressive end-of-life care
increase health care costs
decrease depressive symptoms
reduce the need for hospice
179. Which one of the following community health programs best fits the definition of secondary
prevention?
A)
B)
C)
D)
An antismoking education program at a local middle school

Blood pressure screening at a local church
A condom distribution program
Screening diabetic patients for microalbuminuria
180. A 4-month-old white male in respiratory distress is brought to the emergency department. On
examination, heart sounds include a grade 4/6 pansystolic murmur, best heard at the lower left
sternal border. He is acyanotic. A chest radiograph shows an enlarged heart and increased
pulmonary vascular markings, and an EKG shows combined ventricular hypertrophy.
Of the following, the most likely diagnosis is
A)
B)
C)
D)
E)
hypoplastic left heart syndrome (aortic valve atresia)

transposition of the great vessels
ventricular septal defect
tetralogy of Fallot
patent ductus arteriosus
49
181. A 55-year-old male sees you for a follow-up visit for hypercholesterolemia and hypertension.
He is in good health, does not smoke, and drinks alcohol infrequently. His medications include
a multiple vitamin daily; aspirin, 81 mg daily; lisinopril (Prinivil, Zestril), 10 mg daily; and
lovastatin (Mevacor), 20 mg daily. His vital signs are within normal limits except for a BMI of
33.4 kg/m2.
At todays visit his ALT (SGPT) level is 55 IU/L (N 1045) and his AST (SGOT) level is 44
IU/L (N 1037). The remainder of the liver panel is normal.
Which one of the following is the most likely cause of the elevation in liver enzymes?
A)
B)
C)
D)
E)
A side effect of lovastatin

Gallbladder disease
Hepatitis A
Alcoholic liver disease
Metabolic syndrome
182. A 67-year-old female is admitted to the hospital with severe community-acquired pneumonia.
Her urine should be tested for which one of the following antigens?
A)
B)
C)
D)
E)
Chlamydia
Mycoplasma
Legionella
Haemophilus influenzae
Pseudomonas
183. A 22-year-old male presents to your office with a 2-hour history of a painful right scrotal mass.
The physical examination raises concerns that the patient may have testicular torsion.
The imaging study of choice would be
A)
B)
C)
D)
E)
a plain film
color duplex Doppler ultrasonography
CT
MRI
a nuclear scan
184. A 22-year-old male has acute low back pain without paresthesias or other neurologic signs.
There is no lower extremity weakness.
Which treatment has been shown to be of most benefit initially?
A)
B)
C)
D)
Complete bed rest for 2 weeks

Bed rest plus local injection of corticosteroids
A low-back strengthening program
Resumption of physical activity as tolerated
50
185. A 68-year-old female is being monitored in the hospital after elective surgery. On her third
postoperative day she suddenly develops hypoxia, fever, tachycardia, and hypotension. You
institute high-rate intravenous fluids and empiric antibiotics. However, approximately 2 hours
into this therapy, her blood pressure remains at 80 mm Hg systolic with sluggish urine output.
Which one of the following hormones should be assessed at this time?
A)
B)
C)
D)
E)
Aldosterone
Catecholamines
Cortisol
Renin
TSH
186. In order to be eligible for Medicare hospice benefits, a patient must be entitled to Medicare Part
A and
A)
B)
C)
D)
E)
be essentially bedridden
have a life expectancy of 6 months or less
have a hematologic or a solid tumor malignancy
have a caregiver in the home who is present at least 50% of the time
have documentation of a do-not-resuscitate (DNR) order
187. A 7-year-old female with a history of asthma is brought to your office for a routine follow-up
visit. She has a history of exercise-induced asthma, but also has had exacerbations in the past
that were unrelated to exercise. In the past month, she has premedicated herself with albuterol
(Proventil, Ventolin) with a spacer before recess 5 days/week as usual. She has also needed her
albuterol to treat symptoms (wheezing and/or shortness of breath) once or twice per week and
had one exacerbation requiring medical treatment in the past year. She has had no nighttime
symptoms. Albuterol as needed is her only medication.
After reinforcing asthma education, which one of the following would be most appropriate?
A)
B)
C)
D)
E)
Referral to an asthma specialist

Addition of a low-dose inhaled corticosteroid
Addition of a long-acting $-agonist
Elimination of premedication with albuterol, restricting use to an as-needed basis
No changes to her regimen
188. A young woman in labor at term develops frank eclampsia. What is the best choice of
anticonvulsant to treat her condition?
A)
B)
C)
D)
E)
Phenytoin (Dilantin)
Diazepam (Valium)
Topiramate (Topamax)
Lamotrigine (Lamictal)
Magnesium sulfate
51
189. Which one of the following is associated with a history of sexual abuse in females?
A)
B)
C)
D)
Lifelong functional gastrointestinal disorders

Lifelong headache disorders
Obesity
Recurrent syncope
190. Of the following, the greatest risk for developing colon cancer is associated with a personal
history of
A)
B)
C)
D)
E)
tobacco use
ulcerative colitis
villous adenoma
familial adenomatous polyposis
colon cancer in a first degree relative
191. An 82-year-old white male suffers from chronic low back pain. He is on warfarin (Coumadin)
for chronic atrial fibrillation, tamsulosin (Flomax) for benign prostatic hyperplasia, and
famotidine (Pepcid) for gastroesophageal reflux disease.
Which one of the following analgesic medications would have the least potential for adverse side
effects?
A)
B)
C)
D)
E)
The lidocaine patch (Lidoderm)

Hydrocodone/acetaminophen
Nortriptyline (Pamelor)
Duloxetine (Cymbalta)
Celecoxib (Celebrex)
192. Which one of the following is recommended for routine prenatal care?
A)
B)
C)
D)
E)
Hepatitis C antibody testing

Parvovirus antibody testing
Cystic fibrosis carrier testing
HIV screening
Examination of a vaginal smear for clue cells
193. At the 18-month visit, which one of the following is the most specific sign of autism?
A)
B)
C)
D)
E)
Delayed or odd use of language

Repetitive behaviors
Stereotypic movements
Delayed attainment of social skill milestones
Self-injurious behaviors
52
194. A 55-year-old male presents with a 2-year history of persistent, worsening neck stiffness. Over
the past month, the stiffness has been associated with left thumb tingling.
After completing a thorough history and physical examination, which one of the following
studies would be the most appropriate next step in further evaluating the patients complaints?
A)
B)
C)
D)
E)
Lateral neck radiography

A cervical spine series
Neck MRI
CT myelography
Diskography
195. You are initiating treatment for a patient being admitted to the hospital with a new diagnosis of
pulmonary embolus. Low molecular weight heparin and warfarin (Coumadin) are started
immediately.
When can the low molecular weight heparin be stopped?
A)
B)
C)
D)
E)
When the INR is 2.0

When the INR is 2.0 for 24 hours
After 4 days, if the INR is 2.0
After 4 days, if the INR has been 2.0 for 24 hours
After 5 days, if the INR has been 2.0 for 24 hours
196. A 70-year-old retired engineer who is an avid runner asks you about his slow, progressive
decrease in exercise performance. He says he realizes he is getting older, but is in good health
and is curious as to why this is happening.
You tell him that there are multiple physiologic changes associated with aging that lower exercise
performance, including a decrease in
A)
B)
C)
D)
cardiac output
systolic blood pressure
pulse pressure
residual lung volume
197. Which one of the following reduces the incidence of atopic dermatitis in children?
A)
B)
C)
D)
E)
Exclusive breastfeeding until the infant is 4 months of age

Prenatal ingestion of probiotics by the mother
Delayed introduction of solid food until after 6 months of age
Application of emollients
Early exposure to dust mites
53
198. An 8-year-old male is brought to your office for evaluation of recurrent headaches. His mother
explains that the headaches occur at least twice a week and often require him to miss school.
The patient says he sometimes feels nauseated and that being in a dark room helps. His mother
states that she had migraines as a child. The childs only other medical issue is constipation.
A head CT ordered by another physician was negative.
Which one of the following would be best for preventing these episodes?
A)
B)
C)
D)
E)
Sumatriptan (Imitrex)
Ibuprofen
Carbamazepine (Tegretol)
Propranolol (Inderal)
Amitriptyline
199. A 12-year-old Hispanic female develops fever, knee pain with swelling, diffuse abdominal pain,
and a palpable purpuric rash. A CBC and platelet count are normal.
Her long-term prognosis depends on the severity of involvement of the
A)
B)
C)
D)
E)
gastrointestinal tract
heart
liver
kidneys
lungs
200. According to the Beers criteria, a list of drugs that should be avoided in geriatric patients, which
one of the following NSAIDs should be avoided in older patients due to its higher rate of adverse
central nervous system effects?
A)
B)
C)
D)
E)
Indomethacin
Ibuprofen
Diclofenac sodium
Etodolac
Celecoxib (Celebrex)
201. Which one of the following treatments for type 2 diabetes mellitus often produces significant
weight loss?
A)
B)
C)
D)
E)
Exenatide (Byetta)
Pioglitazone (Actos)
Insulin detemir (Levemir)
Insulin lispro (Humalog)
54
202. A 7-year-old female is brought to your clinic by her mother, who has concerns about her
behavior. For the last 2 months, the patient has resisted going to school. Each school morning
she complains of not feeling well and asks to stay home. When forcibly taken to school she cries
and begs to go home. Once at home she is playful and engages in normal activities. She also
resists attending her usual swimming lessons in the evenings. She has frequent nightmares in
which one of her parents dies.
After a thorough history and physical examination rule out an underlying medical condition, you
diagnose the patient with
A)
B)
C)
D)
E)
separation anxiety disorder

generalized anxiety disorder
acute stress disorder
panic disorder with agoraphobia
social phobia
203. In patients with pes anserine bursitis, tenderness is most likely to be noted
A)
B)
C)
D)
E)
over the medial epicondyle

over the lateral pelvic/hip region
over the medial proximal tibia
just posterior to the medial malleolus
just distal to the lateral malleolus
204. The results of a given study are reported as achieving significance at a p-value of <0.05 (the
5% level). True statements about this finding include which one of the following?
A) There is a 5% likelihood of the results having occurred by chance alone
B) If the study were replicated 100 times, 95 studies would repeat this finding and 5 would
not
C) The confidence interval is 0%10%
D) The null hypothesis has a 5% chance of being true
E) The $ (type II) error is <5%
205. A 23-year-old female comes to your office 6 days after giving birth to her first child by cesarean
section. Her pregnancy was complicated by preeclampsia. During the history she reports brief
crying spells, irritability, poor sleep, and nervousness. Her husband notes that even the littlest
thing can set her off. She has a history of major depression 2 years ago that resolved with
psychotherapy and SSRI treatment. She and her husband are concerned that she may be suffering
from postpartum depression.
Which one of the following is the greatest risk factor for postpartum depression in this patient?
A)
B)
C)
D)
Operative delivery
First pregnancy and delivery
Preeclampsia
A previous history of depression
55
206. A 40-year-old businessman has recently been diagnosed with irritable bowel syndrome after
extensive testing by his gastroenterologist. His predominant symptoms are diarrhea and pain.
Which one of the following has been shown to be helpful in controlled trials?
A)
B)
C)
D)
E)
Probiotics such as yogurt and buttermilk

Insoluble fiber such as wheat bran, corn bran, and defatted flaxseed
Soluble fiber such as psyllium (ispaghula)
Turmeric
Peppermint oil
207. A 32-year-old white female presents with a 6-week history of increasing headache, which she
now describes as severe. The only abnormal finding on examination is a BMI of 32.4 kg/m2.
A neurologic examination is normal. CT of the head is normal and a lumbar puncture is
remarkable only for increased cerebrospinal fluid pressure. There is no history of trauma or
hypercoagulable disorder.
Management should be directed toward preventing which one of the following?
A)
B)
C)
D)
E)
Visual loss
Hearing loss
Vertigo
A cerebrovascular accident
Cerebral herniation
208. The U.S. Preventive Services Task Force recommends which one of the following regarding
general screening for COPD?
A)
B)
C)
D)
E)
A routine chest radiograph for screening patients over 50 with a history of tobacco use
Spirometry for screening patients over 50 with a history of tobacco use
Arterial blood gas analysis for patients over 60 with a history of tobacco use
Peak flow measurement for office screening for COPD
No routine screening for COPD with spirometry
209. A 27-year-old female presents with 2 weeks of generalized pruritus. She had previously been
in good health except for a laparoscopic cholecystectomy 3 weeks earlier. She has had
intermittent right upper quadrant abdominal pain since the surgery, and has occasionally taken
acetaminophen with hydrocodone for pain relief. Her examination is remarkable only for
questionable scleral icterus.
A)
B)
C)
D)
hydrocodone allergy
liver toxicity from acetaminophen
retained common duct stone
acute hepatitis
56
210. Regular breast self-examinations to screen for breast cancer

A)
B)
C)
D)
E)
are performed by most American women

reduce mortality due to breast cancer
reduce all-cause mortality in women
are recommended by the U.S. Preventive Services Task Force
increase the number of breast biopsies performed
211. Actinic keratosis is a precursor lesion to

A)
B)
C)
D)
E)
keratoacanthoma
nodular melanoma
superficial spreading melanoma
basal cell carcinoma
cutaneous squamous cell carcinoma
212. In the elderly, the risk of heat waverelated death is highest in those who
A)
B)
C)
D)
have COPD
have diabetes and are insulin dependent
have a functioning fan, but not air conditioning
are homebound
213. Which one of the following is a criterion for gastric bypass surgery, according to
recommendations of the National Institutes of Health?
A)
B)
C)
D)
E)
A Framingham risk score >25%

Severe insulin resistance
Failed pharmacotherapy
Clearance by a mental health professional
A BMI >30 kg/m2 with comorbidities
214. A 66-year-old male has hypertension that has become difficult to manage after several years of
good control on a stable medical regimen. On evaluation, his BUN level is 40 mg/dL (N 825)
and his serum creatinine level is 2.1 mg/dL (N 0.61.5).
Which one of the following tests would be best to evaluate this patient for renovascular
hypertension?
A)
B)
C)
D)
Duplex Doppler ultrasonography

CT angiography
Aortography
Captopril (Capoten) renography
57
215. A 24-year-old primigravida has nausea and vomiting associated with pregnancy. Which one of
the following is recommended by the American Congress of Obstetricians and Gynecologists
(ACOG) as first-line therapy?
A)
B)
C)
D)
E)
Droperidol (Inapsine)
Ondansetron (Zofran)
Prochlorperazine
Metoclopramide (Reglan)
Doxylamine (Unisom) and vitamin B6
216. A 45-year-old white male develops disabling tremulousness, loss of voice, and a marked sense
of forceful and rapid heartbeat whenever he must speak to a large group.
Which one of the following drugs is likely to be of most value in enabling him to give
presentations at sales and stockholders meetings?
A)
B)
C)
D)
E)
Desipramine (Norpramin)
Propranolol (Inderal)
Alprazolam (Xanax)
Amantadine (Symmetrel)
Buspirone (BuSpar)
217. A 2-year-old white male is seen for a well child visit. His mother is concerned because he is
not yet able to walk. The routine physical examination, including an orthopedic evaluation, is
unremarkable. Speech and other developmental landmarks seem normal for his age.
Which one of the following tests would be most appropriate?
A)
B)
C)
D)
E)
A TSH level
Random urine for aminoaciduria
Phenylketonuria screening
A serum creatine kinase level
Chromosome analysis
218. An 80-year-old female is being started on warfarin (Coumadin) for atrial fibrillation. According
to the American College of Chest Physicians guidelines, the initial dose in this patient should
NOT exceed
A)
B)
C)
D)
E)
2.5 mg
5 mg
7.5 mg
10 mg
12.5 mg
58
219. Over the past year, a 32-year-old white female has experienced increasing hair growth on her
chin and chest, acne, and irregular menstrual periods. She takes no medications.
Which one of the following would be the most appropriate course of action at this point?
A)
B)
C)
D)
E)
Empiric treatment with metformin (Glucophage)

CT of the adrenal glands
Laboratory testing
Brain MRI
Pelvic ultrasonography
220. You have diagnosed type 2 diabetes mellitus in a 64-year-old male. He has no known coronary
heart disease.
You recommend lowering his LDL-cholesterol to below a threshold of
A)
B)
C)
D)
E)
190 mg/dL
160 mg/dL
130 mg/dL
100 mg/dL
70 mg/dL
221. A 56-year-old white male reports lower leg claudication that occurs when he walks
approximately one block, and is relieved by standing still or sitting. He has a history of diabetes
mellitus and hyperlipidemia. His most recent hemoglobin A1c level was 5.9% and his
LDL-cholesterol level at that time was 95 mg/dL. Current medications include glyburide
(DiaBeta), metformin (Glucophage), simvastatin (Zocor), and daily aspirin. He stopped
smoking 1 month ago and began a walking program. A physical examination is normal, except
for barely palpable dorsalis pedis and posterior tibial pulses. Femoral and popliteal pulses are
normal. Noninvasive vascular studies of his legs show an ankle-brachial index of 0.7 bilaterally,
and decreased flow.
Which one of the following would be most appropriate for addressing this patients symptoms?
A)
B)
C)
D)
E)
Fish oil
Warfarin (Coumadin)
Cilostazol (Pletal)
Dipyridamole (Persantine)
Clopidogrel (Plavix)
59
222. A mother calls for advice regarding her 2-year-old son. She found an open container of
immediate-release diltiazem (Cardizem) on the floor, with some spilled and partially chewed
tablets, and estimates that her son opened the container about 90 minutes ago. He does not
appear to be in any distress.
Which one of the following would you advise her to do?
A)
B)
C)
D)
Administer syrup of ipecac at home and observe

Transport the child to the emergency department for gastric lavage
Transport the child to the emergency department for administration of activated charcoal
Transport the child to the emergency department for administration of activated charcoal
and a cathartic
E) Transport the child to the hospital for admission to the pediatric intensive-care unit for
observation
223. A 55-year-old white male comes to your office with weakness and a headache. He also
describes an annoying pruritus that occurs frequently after he takes a hot shower. The physical
examination is remarkable for the presence of an enlarged spleen. He has a hemoglobin level
of 21 g/dL (N 1216) and a hematocrit of 63% (N 3648). To confirm your clinical diagnosis,
you obtain additional studies.
Which one of the following would be most consistent with the most likely diagnosis in this
patient?
A)
B)
C)
D)
A low serum erythropoietin level

A low platelet count
A low arterial oxygen concentration
An elevated carboxyhemoglobin level
224. A previously healthy 73-year-old male is admitted to the intensive-care unit after an emergency
appendectomy. He does well until the evening, when he suddenly appears confused. His speech
is rambling and incoherent, and he is disoriented to person, place, and time. His wife says he
was sleepy but otherwise acting normal 2 hours ago.
On examination he has normal vital signs and no fever. Other than the cognitive changes and
some mild peri-incisional tenderness the examination is normal. Serum electrolytes, a CBC,
arterial blood gases, and a routine chemistry panel are normal.
The most likely cause for his altered sensorium is
A)
B)
C)
D)
E)
sepsis
acute psychosis
dementia with Lewy bodies
delirium
ischemic stroke
60
225. A 75-year-old male develops a mild Clostridium difficile infection and is treated with 10 days
of metronidazole (Flagyl), 500 mg orally 3 times daily. The diarrhea recurs 10 days after he
completes the course of treatment.
A)
B)
C)
D)
E)
Repeat the course of metronidazole

Repeat the course of metronidazole and add vancomycin
Administer vancomycin intravenously
Prescribe loperamide (Imodium), 4 mg twice daily as needed
Prescribe a probiotic
226. Which one of the following, when confirmed with a repeat test, meets the diagnostic criteria for
diabetes mellitus?
A)
B)
C)
D)
E)
A fasting blood glucose level of 120 mg/dL

A 2-hour value of 180 mg/dL on an oral glucose tolerance test
A random glucose level of 180 mg/dL in a patient with symptoms of diabetes mellitus
A positive urine dipstick for glucose
A hemoglobin A1c of 7.0%
227. Screening for osteoporosis should be done in which one of the following groups?
A)
B)
C)
D)
Postmenopausal women
Women over age 50 with a BMI 30 kg/m2
Men over age 50 with type 2 diabetes mellitus
Men over age 70
228. In patients with chronic renal insufficiency and hypertension, the target blood pressure should
be
A)
B)
C)
D)
<110/70 mm Hg
<120/80 mm Hg
<130/80 mm Hg
<140/90 mm Hg
229. A 59-year-old male with known cirrhosis is beginning to show some lower abdominal distention.
Ultrasonography confirms your suspicion that he has developed moderate ascites for the first
time.
Which one of the following is recommended as the initial treatment of choice for this condition?
A)
B)
C)
D)
E)
Chlorthalidone
Spironolactone (Aldactone)
Furosemide (Lasix)
Ramipril (Altace)
Large-volume paracentesis
61
230. About a month after returning from the Middle East, an American soldier develops a papule on
his forearm that subsequently ulcerates to form a shallow annular lesion with a raised margin.
The lesion shows no signs of healing 3 months after it first appeared. He has no systemic
symptoms.
A)
B)
C)
D)
E)
leishmaniasis
schistosomiasis
malaria
trypanosomiasis
syphilis
231. Which one of the following organisms is NOT killed by alcohol-based hand disinfectants?
A)
B)
C)
D)
E)
Methicillin-resistant Staphylococcus aureus (MRSA)

Methicillin-sensitive Staphylococcus aureus
Pseudomonas aeruginosa
Klebsiella pneumoniae
Clostridium difficile
Items 232240: Refer to Pictorial Atlas insert, center of book.

232. A 53-year-old male presents with a 1-day history of swelling in his upper arm, shown in Figure
1. The swelling appeared after a sudden painful pop as he was lifting a heavy box. A physical
examination reveals a soft to firm, nontender mass in the anterior aspect of the arm, and
weakness of forearm supination. Shoulder radiographs are normal.
A)
B)
C)
D)
Acute anterior shoulder dislocation

Lateral epicondylitis
Biceps tendinitis
Biceps tendon rupture
233. One week after returning from a Caribbean vacation, a 43-year-old female presents to a walk-in
clinic with a complaint of redness and itching on the sole of her foot, shown in Figure 2. She
recalls experiencing a stinging sensation in the same area while she was wading in the surf on
the day before she was to return home, but was unable to see any sign of injury immediately
following the incident. Since her return the itching has intensified and the red area has enlarged.
The most likely cause of this condition is a
A)
B)
C)
D)
E)
filarial nematode
jellyfish
hookworm
roundworm
tapeworm
62
234. An 80-year-old white male is admitted to the hospital with an acute myocardial infarction. He
is given an antiarrhythmic for ventricular ectopic beats. During monitoring in the coronary care
unit, he develops the rhythm shown on the EKG in Figure 3.
This rhythm is best described as
A)
B)
C)
D)
ventricular flutter
ventricular fibrillation
ventricular tachycardia
torsades de pointes
235. A 7-year-old male complains of left shoulder pain after a bicycle accident. The neurovascular
evaluation is normal. A radiograph is shown in Figure 4.
The best management for his condition is
A)
B)
C)
D)
E)
chest radiography and frequent vital sign observation

internal fixation under general anesthesia
Steinmanns pin fixation under local anesthesia
sending the patient home in a sling and swathe
a modified shoulder spica cast
236. A 68-year-old white female with a several-year history of well-controlled essential hypertension
and a history of acute myocardial infarction 2 years ago is brought to the emergency department
complaining of sudden, painless, complete loss of vision in her left eye that began 1 hour ago.
Her vital signs are stable, and her blood pressure is 148/90 mm Hg. Her corrected visual acuity
is: leftabsent, with no light perception; right20/30. The external eye examination is entirely
unremarkable. A retinal examination reveals the findings shown in Figure 5.
A)
B)
C)
D)
E)
acute narrow-angle glaucoma

optic neuritis
retinal hemorrhage
central retinal artery occlusion
central retinal vein occlusion
237. The pruritic lesions on the arm shown in Figure 6 are typical of
A)
B)
C)
D)
E)
poison ivy dermatitis

brown recluse spider bites
bedbug bites
Hymenoptera stings
molluscum contagiosum
63
238. A 23-year-old female with a history of systemic lupus erythematosus presents with a 48-hour
history of vague left precordial pain. Serum markers for acute cardiac injury are normal. An
EKG performed in the emergency department is shown in Figure 7.
Which one of the following would be best at this point for determining the cause of the patients
chest pain?
A)
B)
C)
D)
E)
Cardiac angiography
Echocardiography
An erythrocyte sedimentation rate
A CBC
An antinuclear antibody titer
239. A 26-year-old male presents with hand pain. He tells you he was out drinking with friends last
night and does not remember sustaining any injuries. On examination, there is diffuse swelling
and tenderness across the dorsal and lateral aspects of the hand. Radiographs are shown in
Figures 8 and 9.
A)
B)
C)
D)
E)
A wrist extension splint

A molded finger splint
An ulnar gutter splint
A short arm cast
Surgical pin fixation
240. A 27-year-old female radiology technician developed an area of redness over the left
interscapular region while visiting a friend in Paris last week. The rash has progressed to include
the area shown in Figure 10 and the patient says it itches. She recalls feeling somewhat tired and
achy once she arrived in Paris but attributed this to jet lag. She denies any other systemic
symptoms. Your examination reveals no significant findings except for the rash.
Of the following, which one is most consistent with this patients history and examination?
A)
B)
C)
D)
E)
Guttate psoriasis
Tinea versicolor
Radiation dermatitis
Cutaneous T-cell lymphoma
Pityriasis rosea
END OF BOOK
Please check the top of your answer sheet to insure that your
Program Number and ABFM Number are filled in correctly.
64
GENERAL INSTRUCTIONS
Each of the questions or incomplete statements in this book is followed by four or five answers or
completions. Select the ONE that is BEST in each case. You are advised to respond to all items. Even
though you may be in doubt about the correct answer, selecting the choice that you consider to be the best
will maximize the likelihood of your examination scores reflecting the breadth of your knowledge.
You may make preliminary notes or calculations in the test book, but credit is given only for answers
marked on the answer sheet. Only one choice should be marked for each response set. Double answers
are treated as wrong answers. After you have decided upon the best answer, completely fill in the circle
containing the corresponding letter on the answer sheet. Use only the pencil that was supplied with the
examination; do not use a pencil with hard lead or a ballpoint or felt-tipped pen. Make no stray marks on
your answer sheet. Do not fold or damage the answer sheet.
If you wish to change an answer, erase your first mark completely and mark your new choice. Take
care in marking your answers since SOME ITEMS HAVE FEWER THAN 5 OPTIONS.
This book contains a pictorial atlas for use with questions 232240. It may be removed from the book for
easier handling.
EXAMPLE
1. To which one of the following systems of the body does the heart belong?
A)
B)
C)
D)
E)
Digestive
Circulatory
Central nervous
Endocrine
Musculoskeletal
DO NOT BREAK THE SEAL UNTIL YOU ARE TOLD TO DO SO.

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2. Which one of the following is an absolute contraindication to electroconvulsive therapy (ECT)?

Age >80 years

3. A 55-year-old female presents to an urgent-care facility with a complaint of weakness of several

Magnetic resonance angiography of the renal arteries

A short leg walking cast

8. A 68-year-old African-American female with primary hypothyroidism is taking levothyroxine

Continuing levothyroxine at the same dosage

Ceftriaxone (Rocephin) intramuscularly

The length of time since the diagnosis of MGUS was made

15. Which one of the following is most typical of polymyalgia rheumatica?

Headache and neck pain

using a valved holding chamber

20. In adults, the most common cause of right heart failure is

15.8 mg/dL (N 8.410.0)

Which one of the following is the most appropriate INITIAL management?

Calcitonin-salmon (Miacalcin) subcutaneously

A desire for future pregnancy

perform a metastatic workup

A reduced risk of aspiration pneumonia in patients with dysphagia

now and every 5 years if normal

They will have essentially no effect

very early HCV infection

Surveillance cultures of nursing-home residents living near the patient

on the basis of clinical symptoms alone

Reassure the patient that his symptoms are not real

A 42-year-old male with a history of hypertension

order tests for serum iron and total iron-binding capacity

A plain radiograph of the abdomen

Lisinopril (Prinivil, Zestril)

Advise the patient to not make the trip

Horse chestnut seed extract

Chronic hepatitis B infection

Surgical drainage and antibiotics

Add metformin (Glucophage)

repeat the Pap test every 3 months for 1 year

Pulmonary function studies

A decreased rate of hip fracture

Laboratory tests to rule out thyroid dysfunction

An angiotensin receptor blocker

NSAIDs for pain relief

7.0 g/dL (N 12.016.0)

vitamin B12 deficiency

Using mostly short sentences, with frequent pauses

86. The CAGE-AID questionnaire is a tool for screening for

warm soaks three times a day

predominantly high frequencies

Posterior knee pain

Stop the metoprolol

97. Which one of the following is associated with vacuum-assisted delivery?

Lower fetal risk than with forceps delivery

Provide levofloxacin (Levaquin) prophylaxis to her close contacts

His Mini-Mental State

Fever >38.0C (100.4F)

dislocation of the ulna

Reassurance that her tetanus immune status is adequate

No previous history of apneic episodes

restrict her calcium intake

Aspirin/dipyridamole (Aggrenox) for 3 months

117. Which one of the following is true regarding medical errors?

Order a C-peptide level