1.

Block 1 part 1
1. 77yo F with 2-day hx of cramping abdominal pain, distension, N/V. T 99.4, BP
110/86, P 112, R 24/min. Cardiopulmonary exam wnl.BOWEL sounds are
High-pitched, abd xr shows air-fluid levels throughout small bowel and air in the
liver; no gas in colon or free air. Dx?
- Gallstone ileus

2. 67yo F with abd pain and copious vomiting for 24 hours. Two weeks ago, Rx
with warfarin for atrial fibrillation. Yesterday, INR was 6, and warfarin was
stopped. T 37C, BP 100/78, P 120, R 20/min. Abd distended, voluntary guarding
in epigastrium. No masses, organomegaly, or obvious hernias. Rectal exam wnl.
Negative FOBT. Hb decreased from 13 to 7.8. ECG wnl. Cause?
- Intramural hematoma of the proximal small bowel

3. 52yo F with decreased libido; this sx began 8 mo ago after TAH-BSO for
leiomyomata uteri and menorrhagia. Taking HRT with conjugated estrogen since
surgery. Exam shows moist, rugated vagina. Cause?
- Decreased androgens
(estrogen-->increased SBG-->decreased testosterone)

4. 57yo M for routine exam. Smokes 1 pack of cigarettes daily for 37 years. BP
180/112, P 82. Abd exam shows bruit in RUQ and no masses. Hct is 42%, serum
urea nitrogen concentration is 23, Cr is 1.4. Cause of bruit?
- Accumulation of lipids in the arterial wall

5. 3yo boy with 7-day history of fever and a painful swollen lymph node in his
groin. This is his 6th episode of lymph node swelling, which needed drainage and
abx. Had PNA at 12 months that reqd chest tube placement for drainage.
Maternal uncle died during childhood of infections. Patient is 5th percentile for
heightWEIGHT . T 38.5C. Labs show WBC 17k, 65% PMNS, 10% bands, 25%
lymphos. Gram stain of lymph node shows PMNs filled with bacteria; cultures
grow s. aureus. Mechanism?
- Impaired phagocytic oxidative mechanism

6. 5yo boy in ED 30 minutes after he fainted at home upon standing. Sx began

3d ago with diarrhea and vomiting. No UOP for 18hrs. T 37.5, BP 75/45, P 120.
Dry lips, tenting of the skin. Bowel sounds are hyperactive. IV bolus of NS
started, and bladder cath yields 5 mL urine. UA will show?
- Hyaline casts

7. 37yo F in ED, can't see out of her right eye since awakening 2 hours ago.
Painful eye movements. 20/200 in right eye, 20/20 in the left eye. Optic fundi are
normal. Left pupil reacts normally to light, right eye is poorly reactive to light.
Site of lesion?
- Right optic nerve

8. 32yo F with husband unable to conceive for 2 years. Menarche at age of 14

years, Menses irregular 35 - 50 day intervals and last 10 days, not painful.
Menstrual flow is normal. No Hx of illness, no meds,. OCPs for 16 years, d/c'd 2
years ago. Husbands sperm count wnl. Patient's BMI is 31. Physical shows acne
over face, shoulders, back. TSH, Free testosterone, DHEAS, LH, FSH, all wnl. Dx?
- PCOS

9. 27yo primigravid at 38 weeks' admited inLABOR . Pregnancy

uncomplicated, routine visit 2 days ago normal. Now, fetal heart tones cannot be
heard. U/S shows little amniotic fluid, fetal edema, no evidence of heartbeat.
After 90 min, delivers 3175-g stillborn infant; exam is normal except for mild
edema. Most appropriate immediate course of action?
- Recommend autopsy of the infant

10. 42yo M in ED for 2-hour history of confusion and difficulty walking. 10y Hx of
HTN noncompliant with meds. Drinks 6 to 12 beers daily for 10 years. T 37.5 C, P
90/min. Dysconjugate gaze and prominent nystagmus. Muscle strength is 5/5.
DTR diminished bilaterally. Decreased pinprick sensation over distal LE. Wide
based gait. Administration of which of the following is most appropriate?
- Vitamin B1 (thiamine)

11. 5yo girl brought to the physician 5 weeks before trip to Egypt. Immunizations
are up-to-date. Most appropriate ppx?
- Mefloquine

12. 32yo F w/ 10-day hx of persistent cough keeps her awake at night and worse
with physical activity, productive of white sputum in the morning. Sx began w/
URI 10 days ago. Smoked one pack of cigarettes daily for 16 years. Not in
distress but has a rasping cough. T 37.4 C, P 78/min, resp 12/min, BP 130/80. No
pharyngitis or facial tenderness. Scattered end-expiratory wheezes bilaterally.
Peak expiratory flow rate is mildly decreased. CXR wnl. Next step?
- Inhaled B2-adrenergic agonist

13. 14-mo girl with 14-hour history of irritability and episodes of drawing her
knees towards her chest. Vomited nonbilious fluid twice and had aBOWEL
MOVEMENT containing a small amount of blood. URI 2 weeks ago. Temp 38
C. Right-sided tenderness without guarding or rebound, bowel sounds present.
BRBPC. Abdominal xr wnl. Next step?
- Water-soluble contrast enema

14. 4 hours after c-section followed by tubal ligation, 37yo F G2P2 has dizziness
and confusion. 800 mL blood loss from surgery. Patient-controlled epidural
analgesia moderately effective for pain. BP now is 80/40 P 152, down from
120/72 and P 96 intraop. Breath sounds decreased bilaterally. No murmurs. Abd
distention/ tenderness, Bowel sounds absentIncision wnl. Hct is now 23% from
35%. Cause of hemodynamic changes?
- Epidural-related hypotension

15. 52yo M with 3-mo Hx of increased urinary volume & frequency at night. 6.8-
kgWEIGHT LOSS . Fam Hx of HTN, DMII. His nonfasting serum glucose is 280.
Which serum concentration is most likely to be increased?
- Insulin

16. 67yo M after CABG. Hx of HTN, CHF, hypercholesterolemia. Meds: morphine,

laxative, lisinopril, metoprolol, furosemide, and lovastatin. Urinary catheter in
place. Most appropriate next step to prevent iatrogenic complications in this
patient?
- Remove the urinary catheter

17. 6-mo G with poor feeding andLABORED breathing for 2 months.

Recurrent respiratory tract infections since birth. to-and-fro murmur in second
left intercostal space, a lous S2, bounding peripheral pulses, widened pulse
pressure. Dx?
- Patent ductus arteriosus

18. 37yo F progressive SOB for 5 years, and now SOB with mild exertion. Hx of
mitral stenosis secondary to rheumatic fever. Only med is HCTZ. Cardiac
examination shows an obvious opening snap in S2. A grade 3/6, late diastolic
murmur is heard at the apex. Right ventricular lift palpated along left sternal
border. Which is increased?
- Pulmonary artery pressure
 19. 27yo M 1 week hx of SOB with exertion, paroxysmal nocturnal dyspnea, and
swelling of his feet. No chest pain. Bad cold 1 month ago that resolved
spontaneously. BP 90/60, P 120/min. JVD to 8 cm, Bilateral basilar crackles are
heard. Cardiac exam shows diffuse, laterally displaced PMI. Normal S1 and S2
and an S3. 2+ pretibial edema bilaterally. ECG wnl. Echo will show?
- Diffuse hypokinesia and dilation of the ventricles

20. 18yo F routine exam. Menses at regular 28-day intervals. LMP 2 weeks ago.
Sexually active with 1 partner, use condoms inconsistently. GMah breast ca at 65
years, GPah colon ca at 72 years. Appropriate screening?
- Testing for Neisseria gonorrhoeae and Chlamydia trachomatis

21. 24yo M in by police 1 hour after ex-wife found him stubling around the yard.
BP 100/70 P 90/min. Pupils equal and reactive to light, the sclerae are injected.
He laughs without obvious reason, makes religious statements, and asks if there
is anthing to eat or drink. Mild paranoia. Next step?
- Observation in the emergency department

22. 32yo M mild tremulousness, increasing ANXIETY , and progressive fatigue

over the past 2 days. Taking lorazepam for acute anxiety since being robbed at
gunpoint 4 weeks ago; he stopped taking the meds 3 days ago. Hx of MVP,
seasonal allergies, and dysthymic disorder. Currently takes loratadine and
paroxetine. Explanation of sx?
- Discontinuation of lorazepam

23. 32yo F with lethargy and boredom since birth of her son 5 months ago.
Worries about her ability to care for him and has had frequent palpitations.
Unable to sleep after nighttime feedings. Stopped breastfeeing 1 month ago.
Son is healthy and wnl. VSS. Remembers 1/3 objects after 5 minutes.
SerumCHOLESTEROL is 265. Next step is measurement of which of the
following serum concentrations?
- Thyroid-stimulating hormone
orthopod, Jul 31, 2015

#2

2.orthopod
Block 1 part 2
24. 25yo F with 3-month hx of unexplained urge to eat a few tablespoons of
cornstarch daily. She has leiomyomata uteri, she is otherwise healthy. Physical
shows mild pallor. Neuro exam wnl. ECG shows tachycardia. Next step?
- Complete blood count

25. 20yo M routine health maintenance examination. 15-year hx of difficulty

relaxing his hands after tightly gripping objects or after shaking hands. Father
has cataracts and frontal baldness. Exam shows thin forearms. Moderate
weakness of hands. Dx?
- Myotonic muscular dystrophy

26. 57yo M in ED 30 minutes after found on floor, left hip pain andSHORTNESS
OF BREATH . Renal failure 2/2 ethylene glycol, missed last 2 dialysis rx. Meds:
amlodipine and doxazosin. T 37.5 C, BP 150/100, P 95/min. Crackles in the lung
bases. LLE is externally rotated. Labs: Na 135, Cl 102, K 7.1, HCO3 12. ABG on
4L/min of oxygen: pH 7.22, Pco2 31, Po2 61. ECG shows peaked T waves. It'll be
45 min before dialysis can be started. Next step?
- Intravenous calcium gluconate
27. 82yo F with 6-week Hx of increasing forgetfulness. Left the stove on when
she went to bed, difficulty remembering past events and seems unconcerned
about her memory lapses. Hx of similar symptoms 2 and 5 years ago that were
successfully treated with medication. Psychomotor retardation, flat affect =,
trouble repeating three numbers in sequence. BUN 25, Cr 1.7. Dx?
-MajorDEPRESSIVE disorder

28. 42-yo computer science professor brought in by husband. He reports she

believes aliens have been speaking to her, and she was upset when she turned
40 years old, and her sx have developed since that time. Fam Hx unknown.
Vermicular movements of the tongue and bilateral writhing motions of the upper
extremities. Moderate difficulty with memory and calculations. Dx?
- Huntington's disease

29. Program for the primary prevention of coronary artery disease implemented
in USA. Which measures involving the disease is most effective in monitoring the
program?
- Incidence

30. Previously healthy 10yo boy with 2-day hx of pruritic rash on arms and legs,
24 hours after played in wooded area. No fever. Pet cat at home. Severe
erythema and bullous lesions with discharge; there is a sharp line of
demarcation between the rash and the unaffected skin. Pic shown.
Recommendation to prevent recurrence?
- Avoidance of the wooded area

31. 15yo girl with 8-hour hx of difficulty breathing. Hx of asthma rx with oral
montelukast and inhaled salmeterol and fluticasone.HOSPITALIZED 3 times.
In moderate distress. Labored breathing, expiratory wheezes heard. Forgets to
take her meds and does not believe she needs it. Next step?
- Negotiate a contract regarding medication compliance

32. 70yo F increasing abdominal pain over the past 2 days. Renal failure, with
peritoneal dialysis for 18 months; last treatment was 2 hours ago. Appears toxic.
T 39 C, BP 140/90. Abdomen distended and diffusely tender to deep palpation
with rebound tenderness. WBC 18K, Next step?
- Gram stain of abdominal fluid

33. 25yo F routine exam. Says that she is unhappy, unable to find a mate. She
feels so desperate when she is alone that she repeatedly calls or secretly follows
her former boyfriends. BMI 20. Physical shows well-healed superficial lacerations
on both wrists. She tells thePHYSICIAN that he seems like a man who would
always be available to her. Dx?
- Borderline personality disorder

34. 28yo F at 28 weeks' gestation reports excessive fatigability and dyspnea. BP

118/74, P 110. Cardiac apex not palpable. S1 is loud, sharp sound after S2. Low-
frequency diastolic murmur heard at apex increases in intensity before S1. Dx?
- Mitral stenosis

35. 4mo girl with birthmark on her arm increased in size over past several
weeks. 3 x 2-cm bright red, raised, soft, nontender, compressible patch. Next
step?
- No intervention is necessary

36. 32yo F with 1-year hx of severe dull pain in her lower back and buttocks.
Morning stiffness of lower back that lasts 1-2 hours. No hx of trauma. No heavy
lifting. Tenderness to palpation over SI joints bilaterally and decreased
flexion/extension of the lumbar spine. XR lumbosacral spine shows sclerosis of SI
joints. Labs will show?
- Histocompatibility human leukocyte antigen B27

37. 4yo boy in ED 20 minutes after MVC as an unrestrained passenger. On

arrival, BP 10/70, P 100, resp 32/min with grunting and retractions. Multiple
bruises over the chest. ABG on 40% oxygen shows: pH 7.38, Pco2 34, Po2 66.
CCXR 4 hours later shows diffuse infiltrates on the right side. Dx?
- Pulmonary contusion

38. 20-mo girl with fever and cough for 2 days. Has had several similar episodes
since the age of 4 months. 25th %ile for length and 5th %ile forWEIGHT . T 38
C, P 150/min. Mild clubbing. Wheezing and bilateral crackles are heard at the
lung bases. CXR shows streaky densities bilaterally with mild hyperinflation. Dx?
- Cystic fibrosis

39. 16yo boy with fever and cough with right-sided chest pain for 2 weeks.
Visited grandparents in Albania for 2 weeks. Thin, pale, T 38.2 C, P 76/min.
Shallow respirations with decreased breath sounds at the right lung base. CXR
shows right pleural effusion and hilar adenopathy. Dx?
- Pulmonary tuberculosis

40. 24yo F at 18 weeks' gestation. Increased BM over past 9 weeks; stools are
sometimes covered with mucus and blood. OTC antidiarrheal drugs has not
relieved her sx. Pregnancy otherwise uncomplicated. Erythematous, tender
nodules over the anterior surface of both lower extremities, some of the nodules
have violaceous hue. Rectal exam wnl. FHT audible by doppler. Dx?
- InflammatoryBOWEL disease

41. 18mo boy has not used his left arm since he fell while walking and holding
hands with his sister 2 hours ago. LUE at his side with his forearm pronated. No
tenderness, but restricted movement of the elbow. Intial step?
- Passive hypersupination of the forearm

42. 72yo M in ED after 5-minute episode of blindness in the right eye. Headache
and pain in the jaw with chewing. T 38.1, tender, nodular temporal arteries with
decreased pulses. ESR 92. Immediate step?
- Corticosteroid therapy

43. 2mo boy at well-child examination. Smiles spontaneously and vocalizes

without crying, but he does not appear to laugh or squeal. He will not work for a
toy out of his reach. Language and psychosocial development?
- Language development Normal; Psychosocial development normal

44. 67yo M in ED 1 hour after onset of vertigo, nausea, and imbalance. 20yr Hx
of HTN, BP 210/115. Small right pupil, mild right ptosis, and nystagmus.
Weakness of the right palate. Sensation to pinprick decreased over right side of
face and left extremities. Incoordination on finger-nose testing and heel-knee-
shin testing on the right. Artery occluded?
- Right vertebral

45. Two hours ago, 24yo M sudden onset of pain in the right side of his chest
that has becoe increasingly severe. Difficulty breathing. T, BP, P wnl. CXR shown.
Next step?
- Tube thoracostomy

46.32yo F had pain during sexualINTERCOURSE . Vaginal dryness during sex

despite healthy libido. Gritty sensation in her eyes, three dental cavities, well-
controlled T1DM. Pelvic exam wnl, vaginal mucosa appears dry. Dx?
- Sjogren syndrome
Block 2 part 1

1. 16yo boy in ED 20 minutes after an episode of left arm shaking that lasted 3 minutes.
Over the past 2 days, Has had fever and emotional lability. T is 38.9, somnolent and
disoriented toPERSON , place, and time. Hct 34%, WBC 6k, platelets 280k. CSF shows:
WBCs 120 (20%, lymphos 80%), erythrocytes 300, glucose 60, protein 400. Cause?
- Viral infection

2. 25yo F 1 week before scheduled biopsy of mass in right breast. As infant, had four
operations for necrotizing enterocolitis. Does not smoke. Started job as
medicalASSISTANT 1 month ago. VSS. Patchy erythematous rash over the hands, 1.5-
cm firm, mobile, nontender mass in RUQ of right breast. Which is contraindicated during
operation?
- Latex products

3. 35yo M in ED for intractable nausea and vomiting of nonbilous fluid over past 48 hours.
Hx of duodenal ulcer disease treated with H2 receptor blocking agents. T 37C, BP 90/60, p
130/min. Serum findings?
- Na 140, Cl 80, K 2.5, HCO3 40

4. 24yo F with constant, severe pain in her neck, shoulders, and back for 3 months. OTC
ibuprofen and aspirin has not relieved her sx. Hx of IBS. Multiple tender spots over the
neck, shoulders, and lumbar spine. ROM of all joints is full. No synovitis. Flourescent serum
antinuclear antibody and rheumatoidFACTOR assays are neg. Dx?
- Fibromyalgia

5. 67yo M in ED 4 hours after severe midlumbar back pain. Anxious, pale, diaphoretic. T
37.1, BP 105/65, p 120/min. XR of lumbar spine show degenerative disc disease with
calcifications anterior to the vertebral bodies. Dx?
- Ruptured aortic aneurysm

6. 32yo M with 10-year hx of frequent sinus and pulmonary infections. Had an

anaphylactic reaction to a blood transfusion following MVC 3 years ago. T 37. Mild
erythema in posterior pharynx. Lungs clear. CBC and serum protein electrophoresis are
within normal limits. Cause of frequent infections?
- Selective IgA deficiency

7. 14yo boy with 2-year hx of increasing academic problems. Has always been hyperactive
and distractable, but he is failing ninth grade. Teachers say hyperactive in class. Macro-
orchidism. High forehead and long, protruding ears. Poor eye contact during exam. IQ of
70. Dx?
- Fragile X syndrome

8. 23yo F has pain, cramping, and swelling of the right calf 3 days after an uncomplicated
delivery. Right foot is wollen, and there is marked tenderness with dorsiflexion and
palpation of the right calf. CBC and serum electrolyte concentrations are normal. Cause?
- Hypercoagulable state of pregnancy

9. 20yo M in ED on a summer day 20 minutes after developing headache, nausea, and

unsteady gait while running the last 2 miles of a marathon. Confused and disoriented. T
40C, BP 100/60, P 155/min. Mechanism of condition?
- Inadequate dissipation of body heat

10. 62yo M with fatigue and SOB over the past 3 years. Striking jugular venous distention
with a large wave occurring with S2. Carotid upstroke is normal. Lifting systolic motion of
the sternum and no palpable point of maximal impulse. 3/6, holosystolic, plateau-shaped
murmur loudest on inspiration heard at the lower left sternal border.

11. 5mo boy born at 37 weeks' gestation has had persistent wheezing since birth despite
rx with nebulized and oral bronchodilators and oral corticosteroids.DIET CONSISTS of
32 ounces of iron-fortified cow's milk-based formula daily. Appears nourished and happy.
Moderate relief of wheezing with extension of the neck. Mechanism of wheezing?
- Compression of the airway by a vascular ring

12. 32yo F in ED 30 minutes after MVC. Agitatied and has shortness of breath P 130/min,
BP 100/50, Breath sounds are absent on the right, and heart sounds are normal. X-ray of
the chest shows opacification of the right hemithorax. Dx?
- Hemothorax

13. 3mo boy with poor head control. Generalized hypotonia. Point of maximal impulse is at
the left anterior axillary line. Liver edge is palpated 4 cm below the right costal margin.
Spleen is not palpable. Dx?
- Glycogen storage disease type II (Pompe's disease)

14. 22yo F before beginning nursing school. No serious illness. Meds are loratadine for
seasonal allergies and an oral contraceptive. Received the three-dose series for hepatitis B
vaccine 3 years ago. Measles-mumps-rubella and tetanus-diptheria-acellular pertussis
immunizations are UTD. Had chickenpox 17 years ago.
Hep A IgG positive, Hep A IgM neg HBsag neg HBSAb neg, Hepatitis B core antibody neg,
Hepatitis C antibody negative. Next step?
- Administration of hepatitis B vaccine

15. 52yo Cantonese woman with husband and brother for follow-up 7 days after removal
of a 10-cm complex, solid, cystic adnexal mass. Patient insists to disclose results only to
her husband and not to her or to other family members. Appropriate course?
- Share the results with the husband only

16. 4yo boy with 3-day history of fever, cough, and runny nose. No wheezing, vomiting, or
diarrhea. At the 75th percentile for height and 10th percentile forWEIGHT . T37.5 C,
Capillary refill time is 2 seconds. Exam shows clear rhinorrhea. Cardiac exam in "Media
Player." Dx?
- Upper respiratory tract infection

17. 5-week-old boy with vomiting for 3 days. Switching from cow's milk-based formula to
soy and electrolyte solution has not helped. No yellow color to vomitus, but it is forceful
and occurs immediately after he has had 1 to 2 ounces of liquid. One mustard-colored
seedy stool daily. Explanation?
- Hypertrophic pyloric stenosis

18. 52yo F with difficulty sleeping through most the night and concentrating during the
day since son graduated from high school 2 months ago. Comment in their son's yearbook
implying that he is gay. She occasionally feelsSHORT OF BREATH and senses that her
heart is racing. Taken 2-week leave of absence from her job, avoids talking to family
members. Still enjoys going out but feels anxious when alone. No meds. Preoccupied with
her son's well-being. Dx?
- Adjustment disorder with anxiety

19. 4yo girl with fever and refusal to walk for 1 day. T 38.6C, p 120/min. Right knee is
erythematous and swollen. Right knee in flexion and resists any attempted movement of
her right leg. Next step?
- Arthrocentesis

20. 21yo F never been sexually active, no smoke or drugs. Two years ago, her mother
underwent a mastectomy for breast cancer at the age of 54 years. BMI 21. Screening test?
- Pap smear

21. 32yo F G2P2 been amenorrheic for 4 months. Well-estrogenized vagina and no
evidence of virilization. Pregnancy test negative. Is given medroxyprogesterone and has
 onset of bleeding 3 days later. Cause of her condition?
- Anovulation

22. 17yo boy with 2-day history of shortness of breath with minimal exertion, nausea,
weakness, and fatigue. Had urinary frequency and excessive thirst for the past 2 weeks.
Father and uncle have T2DM. BMI 22. P 92/min, BP 100/60 sitting, P 124/min SBP 80 while
standing. Serum studies show: Na 128, Cl 82, K 6.2, HCO3 10, Glucose 472,KETONES
positive. Explanation?
- InadequatePRODUCTION of insulin

23. 25yo F with increasingly severe bifrontal headaches over the past 6 months. Transient
episodes of blindness lasting 1 to 2 seconds. No nausea or vomiting, Weighs 250 lb. BP
120/80, Visual field testing shows enlarged blind sponts. CT normal. Cerebrospinal fluid
shows: Opening pressure 300, Glucose 70, Protein 25, WBC 1, RBC 0. Dx?
- Idiopathic intracranial hypertension

Block 2 part 2

24. 25yo M history of intravenous drug use comes to ED with progressive diffuse headache,
generalized malaise, and low-grade fever for 2 months. Poor appetite resulting in 6.8-kgWEIGHT
LOSS T 38C. Neck stiffness. Weakness of the lateral rectus muscle on the right and bilateral
papilledema. CT without contrast shows moderate ventricular enlargement. Cerebrospinal fluid
shows: Opening pressure 220, Glucose 35, Protein 150, WBC 100 (Lymphos 100%), RBC 1. Dx?
- Cryptococcal meningitis

25. 37yo F with itchy rash over her trunk for 2 weeks. No fever, chills,SHORTNESS OF BREATH ,
chest pain, or GI symptoms. Hx of recurrent urinary tract infections and has eben taking
trimethoprim-sulfamethxazole prophylaxis for the past year (Bactrim). T 37.5C, BP 96/62, P 78/min,
Maculopapular erythematous rash over the trunk. Labs show. WBC 10.5K (PMN 72%, Eosinophils
15%, lymphs 4%, monocytes 8%). BUN 12, Cr 0.9, Cause of these findings?
- Medication adverse effect

26. Four weeks after low c section for cephalopelvic disproportion, 27yo F G1P1 with pulling feeling
on the right side of her incision for the past 4 days, exacerbated by movement. Within the past 2
weeks, has initiated excercise regiment, resumed sexual activity, has been breast-feeding. BMI 29. T
37C. Breast engorgement, Abdomen is soft and nontender without rebound in the right and left upper
quadrants. Surgical wound is clean, dry, and intact. Uterus nontender on bimanual exam. Next step?
- Reassurance

27. 42yo F with 3-month history of recurrent vivid dream that several men are assaulting her and her
children. Anxious and distressed by the images, afraid to go back to sleep. Never been the victim of
an assault. Drinks coffee each morning. No drugs, Physical normal. No evidence ofDEPRESSED
mood or hallucinations. Dx?
- Nightmare disorder

28. 8yo girl with type 1DIABETES MELLITUS in ED 10 minutes after MVC. Reported bilateral thigh
pain, but then she stopped talking, closed her eyes, and became unresponsive to voice; responds to
noxious stimuli with brief grimaces and no withdrawal. Bp 40/palpable P 148/min. Air entry is
symmetric. Pupils equal and react to light. HCT 37%. Next step?
- Infusion of 0.9% saline

29. 37yo M in ED 6 hours after the onset of constant, increasingly severe abdominal pain and nausea.
Symptoms awoke him from sleep, and he has vomited once since that time. No meds, alcohol, or
illicit drugs. In acute stress and lying in the fetal position. T 37.8 C, BP 108/68, P 112/min. Lungs
clear. Rigid abdomen; bowel sounds are absent. Labs show> Hb 14, WBC 18.2k, platelets 150k, BUN
34, Cr 1.9, Total bilirubin 1.2. X-ray of the chest shows small amount of free air under the left
diaphragm. Antibiotics and fluids is begun. Next step?
- Laparotomy

30. 7yo girl with fever and sore throat for 1 day. In the third week of second grade. T 38.6 C.
Erythematous pharynx and slightly enlarged tonsils without exudate. No significant cervical
lymphadenopathy. Rapid test for group A streptococcus is negative. Next step?
- Throat culture

31. 62yo F with generalized weakness for 2 weeks. 20-year history of arthritis of the hands treated
with aspirin and acetaminophen. Two episodes of urinary tract infections 5 and 11 years ago.
Heberden's nodes on the hands. Labs show: ESR 15, Na 136, Cl 100, K 4.9, HCO3 20, BUN 41, Cr 4.
Urine shows: Protein 1+, WBC 2-4, RBC none, bacteria none, Swuamous epithelial cells occasional,
Granular casts occasional. Renal ultrasonography normal. Which is mostly likely to have prevented
this condition?
- Avoidance of analgesics

32. 87yo nursing home resident withDEMENTIA , Alzeimer's type, with progressive lethargy and
decreased appetite for 3 days. Had flu0like illness followed by deep cough 1 week ago. Hospitalized
once for bacterial pneumonia. T 38.6 C, BP 110/60, P 123/min. Dry mucous membranes. No
adenopathy. Crackles are heard in the right lung base. X-ray of the chest shows an infiltrate at the
right lung base. Predisposing factor for this patient's pneumonia?
- Decreased gag reflex

33. 44-yo F G4P4 with 9-month history of progressive loss of small amounts of urine while running;
she now has to wear an absorbent pad. Second-degree cystourethrocele. Dx?
- Stress incontinence

34. One day after uncomplicated spontaneous vaginal delivery, 23yo F G1P1 has onset of loss of
small amounts of urine. Received epidural anesthesia during L&D. Episiotomy without evidence of
hematoma. Voiding 50 to 75 mL of urine at a time. Postvoid residual volume is 300 mL. Dx?
- Overflow incontinence

35. 57yo F with breast cancer with increasing neck pain over the past 3 days. Fallen frequently
because of muscle weakness. VSS. Hyperreflexia of all extremities. Tenderness over the cervical
spine. Serum Ca is 11. X-rays show metastases to the cervical spine. Next step?
- Spinal cord decompression and cervical stabilization

36. 62yo F with 3-day history of progressive shortness of breath and cough productive of yellow
sputum. 7-year history of chronic obstructive pulmonary disease treated with albuterol and
ipratropium inhalers. Increased use of inhalers has not helped. T 37.2C, P 96, resp 28/min, BP 158/80.
Pulse oximetry on room air shows o2 saturation of 90%. Breath sounds decreased, diffuse wheezes
bilaterally. Labs show: WBC 9.5K (PMN 72%, Eosinophils 1%, lyphos 22%, monocytes 5%). CXR
normal. Treated with nebulized ipratropium and albuterol and intravenous methylprednisolone is
begun . 2 days later, feels well, but leukocyte count goes up to 18.5k. Cause?
- Glucocorticoid-induced demargination and storage pool release of segmented neutrophils

37. 52yo M with hiccups for 1 week. Smoked two packs daily for 30 years. No alcohol. T 37C, BP
150/95, P 70/min, resp 12/min. Sodium concentration is 120. X-ray of the chest shows right hilar
mass. Next step?
- Fluid restriction

38. 27yo F withANXIETY about attending her 10-year high school reunion. 2-year hx of profound
anxiety, palpitations, and sweating associated with an uneasiness around people; avoids family
gatherings. Acknowledges taht his fear is unreasonable. No drugs, but alcohol helps her. BP 130/90, p
88/min. WBC count is 9k. Dx?
- Social phobia

39. 21yo F with acne that developed 4 days ago while taking her medical college admission test.
Concerned about her appearance and plans to be in a wedding in 3 weeks. Similar episodes have
resolved completely without treatment. Predominance of comedones and pustules. No chronic
scarring. Initial step?
- Topical retinoic acid

40. Five weeks after delivery of a healthy full-term newborn, 22yo F G1P1 with depressed mood for 2
weeks. Mother is concerned that daughter is not able to take care of her infant. Lives alone with her
infant and has had thoughts of suicide and infanticide. Next step?
- Admission to the hospital treatment

41. 47yo M for a preemployment examination. Is a computer programmer, and he plays handball
once weekly. Maternal grandmother had type 2DIABETES , paternal uncle had heart disease. BP
126/80. SerumCHOLESTEROL concentration is 225. Next step?
- Serum lipid studies while fasting

42. 27yo F with 2-year history of intermittent diarrhea and severe cramping abdominal pain. Stools
are watery, occasionally foul-smelling, and nonbloody. Currently pain-free and no diarrhea for 2 days.
Also had intermittent constipation. No fever or weight loss. Returned from trip to Mexico 3 months
ago. Appendectomy at age 12 and c-section 4 years ago. Dx?
-IRRITABLE BOWEL syndrome

43. 67yo F with anorexia, fatigue, and weakness for 4 months and low back pain for 3 months
unresponsive to NSAIDS. Rx for HTN for 5 years. Calcium supplements for 5 years because her
mother had severe osteoporosis. Tenderness to palpation over the lumbar spine. X-ray of the lumbar
spine shows lytic changes. Bone scan shows increased uptake in the right hip consistent with
osteoporosis. Hb 8, Ca concentration 13. Blood smear shows rouleaux formation. Dx?
- Multiple myeloma

44. After uncomplicated laparoscopic cholecystectomy, 62yo M with no urine output since foley
catheter was removed 12 hours ago. Has been receiving intravenous 5% dextrose in water with
0.45% saline and morphine. Awake and alert and has a moderate amount of abdominal pain. Prop
serum studies showed: Na 137, K 4.2, BUN 18, Cr 1.2. One hour after receiving intravenous bolus of
0.9% saline, still no urine. Next step?
- Reinsertion of a Foley catheter

45. 13yo girl. Menses have occurred every other month since menarche 10 months ago. LMP 1 week
ago. Not sexually active. Development is Tanner stage 3. Next step?
- Discussion of pregnancy prevention

46. 42yo M with progressive swelling of the legs over the past 2 months. Stage IIA Hodgkin's disease
treated 1 year ago with radiation. T 37C, BP 102/80, P 110. Jugular venous distention increased with
inspiration. Lungs clear. Nondisplaced point of maximal impulse; heart sounds are distant. An early
diastolic sound is heard at the apex. Mild abdominal distention with shifting dullness. Liver edge
palpated 4 cm below right costal margin. 2+ peripheral edema up to knees. Mechanism of increased
central venous pressure?
- Constrictive pericarditis

Block 3 part 1

1. 42yo M with 2-week history of increasingly severe headaches and 2-day hx of nausea, vomiting,
neck stiffness, and unsteadiness. Has type 2DIABETES treated with glyburide. T 38.1, Bilateral
papilledema. Neuro exam shows mild meningismum and diffusely brisk deep tendon reflexes. Broad-
based gait. Recall 2/3 jobjects after 5 minutes. CT head normal. Cerebrospinal fluid analysis shows a
glucose of 18, protein 108, leukocyte 59 ( 1% PMN, 99% lymphocytes); cryptococcal antigen assay is
positive. Appropriate pharmacotherapy?
- Amphotericin B
2. 50yo F with progressive dyspnea over the past 2 weeks and constant, sharp chest pain for 4 days.
Pain localized to center of chest and worse while supine. Underwent right, modified radical
mastectomy and adjuvant chemo. Hx of hypothyroidism Rx with thyroid replacementTHERAPY .
Smoked one pack of cigarettes daily for 30 years. Dyspneic and diaphoretic. T 37.2, BP 90/70 with
pulsus paradoxus of 20 mm Hg. Pulse is 110/min. Jugular venous distention to angle of mandible.
Liver is 14 cm with 4 cm of shifting abdominal dullness. ABG on room air shows: pH 7.5, PcO2 30,
PO2 70. CXR shows enlarged cardiac silhouette with a globular configurtion. ECG shows sinus tach
with nonspecific ST-seg changes. Next step?
- Echocardiography

3. 26yo F in ED with marked confusion for 2 hours; flu-like illness for 3 days. Over the past 6 weeks,
Increased fatigue, weakness, and nausea. Recently started thyroid hormone replacement therapy for
autoimmune thyroiditis; 1 week ago, her serum thyroid-stimulating hormone concentration was 3
uUmL. T 38C, BP 80/40, P 140/min. Appears confused and lethargic, with cool, mottled skin.
Generalized hyperpigmentation, especially involving the palmar creases. Lungs clear. Labs show: Hb
10, WBC 9k (segmented PMNs 55%, eosinophils 20%, lymphocytes 25%); serum Na 124, Cl 92, K 6.4
HCO3 16. CXR and u/a normal. ECG shows sinus tachycardia with peaked T waves. Which to confirm
cause?
- ACTH stimulation test

4. 7yo F says that she feels well. Son reports 1 month ago, she got lost while driving. 2 weeks ago
forgot to turn off stove. Wearing bilateral hearing aids since audiometry 2 years ago showed bilateral
high-frequency hearing loss. visual acuity 20/25 in both eyes. Neuro exam shows mild fine tremors of
the hands when the arms are outstretched; not present at rest. Muscle strength is 5/5. DTR
decreased at ankles. Gait normal. Sensation to vibration is mildly decreased over the toes. Which
warrants further evaluation?
- Memory loss

5. 32yo F with vaginal discharge for 2 weeks. Sexually active with one female partner for 5 years.
Last pap 6 years ago. No drugs or alcohol. Exam shows grayish vaginal discharge with a pH greater
than 4.5 Wet mountWILL show which?
- Clue cells

6. 67yo M has had shortness of breath on exertion for 3 months, he has had an 11.3-kgWEIGHT
LOSS . Smoked two packs daily for 25 years. Decreased breath sounds on the left. CXR shows a
large left-sided pleural effusion. Next step?
- Thoracentesis

7. 67yo M with 6-month history of double vision, slurred speech, and difficulty swallowing liquids.
Shortness of breath with exertion. Has pernicious anemia treated with monthly vitamin B12 injections
and autoimmune thyroid disease treated with thyroid replacement therapy. Bilateral ptosis and
disconjugate gaze. Bilateral facial weakness and hypernasal speech. Tongue is weak, and the gag
reflex is reduced. DTR 2+, Babinski's sign is absent. CT chest shown. Dx?
- Thymoma

8. 32yo F for a rooutine health maintenance examination. Mother and sister have hx of low back pain
and disc herniation. Patient is a postal worker, 86 kg and 165 cm tall. BP 130/78, P 74/min. ROM of
spine is normal and without pain. No scoliosis or excessive kyphosis of the back. Most effective
strategy to decrease patient's risk for developing low back pain?
- Weight-loss program

9. 19yo M 45 minutes after sustaining a single, large stab wound to the right upper quadrant of
abdomen. Obtunded. BP 60/palpable, P 148/min. Breath sounds are equal bilaterally. 4-cm laceration
midclavicular line. Abdomen distended. Next step?
- Laparotomy
10. 2yo boy with fever and cough for 2 days. Streptococcus pneumoniae meningitis at age of 1 year,
bacteremia at 18 months, pnuemonia at 22 months. Two maternal uncles died before age of 2 from
"infection." T 39.8. Hb 10, WBC 36k (PMN 70%, Bands 20%, lymphocytes 8%, monocytes 2%),
Platelets 240k; IgA <5, IgG 30, IgM <5. CXR shows an infiltrate in the left upper lobe. Next step?
- Intravenous immunoglobulin infusion

11. 47yo M threatening to harm a radio announcer he believed was broadcasting his thoughts. Over
the past 20 years, has been hospitalized for similar things. past symptoms improved with neuroleptic
therapy; after discharge, he discontinued the medication and his symptoms worsened. Pharm?
- Haloperidol decanoate

12. 16yo girl with episodes of palpitations over the past 6 months. When she runs or plays
basketball. VSS. Weighs 55 kg and 180 cm tall. Arm span is 188 cm. Upper segment to lower
segment ratio is 0.85. Legs appear long and are hyperextensible. 4/6 early diastolic murmur is heard
along the upper and middle left sternal border with radiation to the apex. Peripheral pulses are
bounding. Cause?
- Aoritic incompetence

13. 38yo F G2P1 at 38 weeks' gestation has had no fetal movement for 36 hours. Fetal heart tones
are heard by doppler. Next step?
- Nonstress test

14. 42yo F with persistently increasedBLOOD PRESSURES . Blood pressure has ranged between
150-170/105-115. Occasional headaches. In addition, she has had increased urine output over the
past 6 weeks that she attributes to a diet high in sodium. Fundoscopic examination shows mild
arteriovenous nicking. PMI is not displaced. Serum Na 144, Cl 90 K 2.9, HCO3 32, BUN 20, Cr 1.2.
Underlying cause?
- Autonomous production of aldosterone

15. 32yo F who is HIV positive has a CD4+ T-lymphocyte count of 800 (normal=500). Her health
maintenance regimen should include immunization against which pathogen?
- Influenza virus

16. Newborn is in severe respiratory distress following delivery. Born at 35 weeks' to a 35yo F
G2P1A1 who did not receive prenatal care. Pallor with perioral cyanosis, anisarca,
hepatosplenomegaly, and scattered petechiae. Cord blood Hb is 4, and reticulocyte count is 18%.
Direct antiglobulin (Coombs') test is positive. Which set of blood groups?
- Mother: O, Rh-negative; Newborn O, Rh-positive

17. 67yo M with 3-month history of right leg pain after walking two blocks. Smoked two packed daily
for 50 years. BMI is 28. Right lower extremity shows shiny skin and decreasedHAIR GROWTH .
Peripheral pulses are shown. Right ankle brachial index is o.6 (N>1), and the left is 0.9. In addition to
smoking cessation, next step?
- Daily exercise program

18. 32yo M with alcoholism in ED unable to stand and has had "funny eye movements"; increasingly
confused over the past 5 days. BP 180/60, P 110/min. Sixth cranial nerve palsy, horizontal diplopia,
strabismus, and an asymmetric horizontal-gaze evoked nystagmus. Broad-based, uncertain gait.
Cause is deficiency of which?
- Vitamin B1 (thiamine)

19. 6mo girl born with alumbosacral myelomeningocele which was successfully repaired at 2 days of
age. Anterior fontanelle is 6 x 8 cm and bulging and the posterior fontanelle is 3 x 4 cm and bulging.
severe motor and sensory deficits. Increasing head circumference. Cause of increased intracranial
pressure?
- NOT B, Decreased absorption of cerebrospinal fluid
- No idea what the answer is (maybe obstruction of cerebrospinal fluid flow?)
20. 18yo M prior to participation in school sports. Dull ache in the scrotum since being hit in that area
during a basketball game 2 months ago. 2-cm, hard, nontender mass in the right testicle. Does not
transilluminate or change in size when placed in supine position. Cause?
- Germinal cell tumor

21. 42yo F with right-sided abdominal cramps and nausea. Eyes are yellow. Underwent laparoscopic
cholecystectomy for acute cholecystitis; intraoperative cholangiography was not performed at that
time. Serum studies show: Total bilirubin 8, Direct bili 5, alkaline phosphatase 650, AST 20, ALT 18.
Abdominal ultrasonography shows dilation of the intrahepatic biliary ducts. Next step?
- Endoscopic retrograde cholangiopancreatography

22. 72yo M with hypertension had increasingly severe back pain over the past 2 months. Had a
myocardial infarction 4 years ago. Marked tenderness over T11, T12, L1, and L2. X-ray of lumbosacral
spine shows osteoblastic lesions. Dx?
- Metastatic prostate carcinoma

23. 67yo M with lethargy, confusion, muscle cramps, and decreased appetite for 7 days. T 37C, BP
120/70, P 98. Breath sounds diminished at right lung base. Serum Na 114, K 4.3, Cr 1, Thyroid-
stimulating hormone 4.1. CXR shows 2-cm nodule in the right lower lobe and mediastinal
adenopathy. Biopsy will show?
- Small cell carcinoma
Block 3 part 2

24. CountyHEALTH officer investigates outbreak of illness among persons ttending a church
picnic. Onset of nausea and vomiting 3 to 4 hours after the picnic. Investigation implicates egg salad
as the vehicle of transmission. Cause?
- Staphylococcus aureus

25. 64yo F has moderately severe postoperative pain 1 day after a total abdominal hysterectomy and
bilateral salpingo-oophorectomy. Most appropriate analgesic?
- Patient-controlled intravenous morphine

26. 67yo M with congestive heart failure admitted because of progressive shortness of breath. X-ray
of the chest shows cardiomegaly, cephalization of blood vessels, and a right-sided pleural effusion.
Which pleural fluid findings is most likely?
- Protein 2.5; Glucose 90; Leukocyte count 2000; Segmented neutrophils (%) 60; Monocytes (%) 40

27. 17yo boy in ED because of bizarre behaviour for 6 hours. Was out with friends, he has been
confused and has "trashed" his room. BP 165/95. Hypervigilant, has little spontaenous speech, and is
disoriented. Abruptly becomes assaultive two times and needs to be restrained. Substance taken?
- PCP

28. Three days after treatment of a hip fracture, 62yo F becomes acutelySHORT OF BREATH and
coughts up a small amount of blood-tingd sputum. BP 110/70, P 110/min, ABG on 40% oxygen by
face mask shows: pH 7.4, PCO2 32, PO2 70. Ventillation-perfusion lung scans show multiple
segmental areas of mismatch on the right. Next step?
- Heparin therapy

29. 18yo M because of 3-year hx of fatigue and migrating joint pain. Brought large folder containing
information about previousMEDICAL consultations, laboratory tests, and x-rays. He is preoccupied
with his symptoms. When asked about his mood, he states that the future appears bleak, and that he
is too tired to think about it. Next step?
- Ask about suicidal feelings

30. 52yo M smoked one pack of cigarettes daily for 20 years and does not drink. Sedentary lifestyle
and requests advice about beginning a regular exercise program. Father died of a myocardial
infarction at 62 years. BMI is 25. P 80, BP 140/90. In addition to serum cholesterol concentration,
most appropriate next step before starting exercise program?
- Exercise stress test

31. 37yo F G2P1 at 12 weeks' gestation for first prenatalVISIT . Has hypertension treated with a
beta-adrenergic blocking agent. First pregnancy was complicated by premature rupture of
membranes at 26 weeks', followed rapidly by a preterm vaginal delivery. Carrier of the sickle cell
trait. Hx of appendectom at 1ge 14 yearsNo smoke, alcohol, or drugs. BP 130/82. Greatest
riskFACTOR for preterm delivery?
- Previous preterm delivery

32. 62yo M with abdominal pain for 48 hours. T 38.6, BP 130/80, P 110/min. Diffuse left lower
quadrant tenderness with no peritoneal signs. Rectal exam normal, stool for occult blood is negative.
WBC 14.7k, Next step?
- Ct scan of the abdomen

33. 57yo M 6 hours after onset of weakness of his right face, arm, and leg. Three days ago, he had an
episode of sudden visual loss in his left eye that he describes as "a shade coming down." Resolved
within 10 minutes. Has hypertension and T2DM, both poorly controlled. Expressive aphasia and right
lower facial droop. Moderate weakness on the right, worse i n the upper extremity. DTR 3+ in the
right and 2+ in the left. Babisnki's sign present on the right. Most appropriate test to establish
cause?
- Carotid ultrasonography

34. 27yo F with 2-day history of weakness of her arms and legs and numbness of her hands and feet
and 4-hour hx of mild shortness of breath. Sensation of "electrical shocks" extending from the
buttocks to the feet. Today, she tripped and fell several times and was unable to button clothes or
hold utensils. Three weeks ago, had mild upper gastrointestinal illness that resolved. Mild facial
weakness; cranial nerves are otherwise intact. Babinski's sign is absent bilaterally. Sensation to
vibration is slightly decreased at the fingers and toes. Most appropriate test to establish cause?
- Electromyography and nerve conduction studies

35. 32yo M receiving intesnive chemo for Hodgkin's disease has a T of 39C, respirations 40/min.
Widespread crackles are heard in all lung fields. X-ray of the chest chest shows a diffuse alveolar and
interstitial pattern. Causal organism?
- Pneumocystis jiroveci (formerly P. carini)

36. 40yo M 1 hour after a high-speed MVC. Awake and alert but has severe pain over the sternum.
SBP is 80, p 80, resp 10/min. ECG shows multifocal premature ventricular contractions but no T-
segment changes. His Po2 is 100. After 1 L of lactated Ringer's solution, his Po2 decreases to 60
while breathing 4 L/min of oxygen by nasal cannula. Pulmonary capillary wedge pressure has
increased from 14 to 24 (N=1-10). Explanation for poor response to fluid?
- Myocardial contusion

37. 3yo boy is brought for a follow-up examination. Just completed a 10-day course of amoxicillin that
has not resolves his right ear pain. Appears irritable. T 38.9, downward and lateral displacement of
the right auricle with tenderness to palpation of the posterior auricular area; his neck is supple. Next
step?
- CT scan of the head

38. 47yo M with fever and chills for 1 day. 20-year history of alcoholism and cirrhosis of the liver. One
month ago, he underwent evacuation of a subdural hematoma, post-op course complicated by
generalized tonic-clonic seizures; he has been receiving carbamazepine since.CONTINUES to
drink. T 38.9, BP 120/80. scleral icterus, ascites, and splenomegaly. Labs: HCT 39%, MCV 102,
Leukocyte count 1200 (PMN 6%, eosinophils 1%, basophils 1%, lymphos 80%, monocytes 12%).
Platelets 210k. Cause of decreased leukocyte count?
- Carbamazepine therapy

39. 42yo carpenter with 6-month history of pain and numbness in his dominant hand that awakens
him at night Numbness in his long and index fingers afterDRIVING for extended periods of time.
Minimal atrophy of the thenar muscles. Normal sensation to light touch on the little finger and palm
of the right hand. Sensation to light touch decreased at the tip of the thumb, index finger, and long
finger. Site of nerve injury?
- Median nerve at the wrist

40. 37yo M with 2-month history of pain in the forearm and little finger of his dominant hand; he has
been working as a receptionist for 6 months. Numbness in his little finger and weakness of his grip.
Decreased sensation to light touch at the tip of the little finger. Paresthesias are elicited with
compression of the cubital tunnel.
- Ulnar nerve at the elbow

41. The genetic disease institute at a universityHOSPITAL developed a rapid screening test for a
serious but treatable inherited metabolic disorder. Test has a sensitivity of 95% and a specificity of
96%. The institute proposes to use this screening test on the general population where the
prevalence of disease is 0.1%. Most likely result of this screening program?
- Positive predictive value decreases

42. Two days after admission to the hospital for treatment of severe lower lobe pneumonia, 72yo M
has increasingly worse renal function. On admission, BP 80/40, BUN 14, Cr 0.7; received 4L IV fluids.
Receiving ceftriaxone and azithromycin therapy since admission. Has HTN, TYPE 2DM, and
osteoarthritis. T 37.8, P 92/min, BP 126/80. Jugular venous pressure is 4 cm H2O. Egophony in left
posterior lung. BUN 32, Cr 1.9; Urinary fractional excretion of sodium is 3%. His urine output is 300
mL/24 h. His postvoid residual volume is 70 mL. U/A shows muddy brown casts. Renal u/s normal.
Cause?
- Acute tubular necrosis

43. 52yo F with 3-month history of intermittent bloody discharge from the right breast. 3-year history
of major depressive disorder treated with fluoxetine. No masses are noted on palpation.
Serosanguineous fluid can be expressed from the nipple of the right breast by pressing on the left
side of areola. Dx?
- Intraductal papilloma

44. 28yo M in ED by police because of severe pain in right lower quadrant of abdomen for 36 hours.
Incarcerated in the county jail, and his court hearing is scheduled in 12 hours. CBC, liver tests, and
erythrocyte sedimentation rate are normal. Dx?
- Malingering

45. 62yo F with bloating and cramping abdominal pain and intermittent diarrhea over the past 5
years. Sx increased over the past month since starting aNEW DIET with yogurt and cottage
cheese as low-fat sources of calcium and protein. VSS. No masses or organomegaly. Bowel sounds
are increased. Stool for occult blood is negative. Explanation for diarrhea?
- Malabsorption

46. 16yo high school wrestler with a rash on his forearms and the back of his legs for 1 week. Allergic
to pollen and dust. Patches of erythema with mild lichenification over the antecubital and popliteal
fossae. Clusters of painful umbilicated vesicles at sites of active skin inflammation. Dx?
- Eczema herpeticum

Block 4 part 1

1.32yo M with intermittent diarrhea for 6 months. 5.4-kgWEIGHT LOSS during this period. VSS.
Serum studies show a calcium concentration of 7.8, and phosphorus concentration of 2.2. Stool
specimen shows fat globules. Explanation of hypocalcemia?
- Vitamin D deficiency

2. 67yo F intubated for 1 week after left lobectomy for lung cancer. Has chronic obstructive
pulmonary disease. Her preoperative functional vital capacity was 40% of predicted. BP 130/75, P
72/min. Ventilator settings are a synchronized intermittent mandatory ventilation of 8/min, FiO2 of
40%, and positive-end expiratory pressure of 5. ABG shows Ph 7.42, Pco2 47, Po2 90, O2 sat 96%.
Next step?
- Wean from the ventilator

3. Four days after resection of an obstructing sigmoid colon cancer and colostomy, 47yo M has T
39.3. Central venous catheter was inserted into left subclagian. P 94/min, BP 128/70. Colostomy
shows no abnormalities. Blood cultures grow staphylococcus aureus. Source of bacteria?
- Central venous catheter

4. 13yo boy prior to participation in sports. No hx of serious illness, no meds. Patient is at 95th
percentile for height and above the 95th percentile for weight and BMI. BP 130/83. In addition to
recommending participation in sports, which is most appropriate pharmacothearpy?
- No pharmacotherapy is indicated

5. 80yo F has had bleeding gums for 3 weeks.DIET of only tea and toast for 2 years. VSS. Gums
are hypertrophied and exude blood with pressure. Ecchymoses of the inner thighs and small
hemorrhages around the hair follicles. Supplementation with which vitamin would have prevented?
-C

6. 57yo F 2 days after sudden onset of severe low back pain; the pain does not radiate to the lower
extremities. Pain began when she was lifting her grandson. No weakness or sensory loss, no urinary
incontinence. 10-year hx of rheumatoid arthritis treated with prednisone. T 37C, BP 139/60, P 64/min.
Exquisite tenderness to percussion over the lumbar spine. Bilateral straight-leg raising to 80 degrees
does not increase the pain. Bbinski's sign is absent bilaterally. Dx?
- Osteoporotic compression fracture

7. 32yo plumber with 3-week history of constant, dull, low back pain that does not radiate to the
extreities. Pain began after he unloaded heavy equipment from his van. It increases with activity and
is temporarily relieved by bed rest and ibuprofen. TTP over lumbar paraspinalREGION bilaterally.
Bilateral straight-leg raising to 80 degrees does not increase the pain. Dx?
- Muscle strain

8. 22yo primigravid woman at 16 weeks' gestation with progressive shortness of breath over the past
48 hours. T 37C, bp 120/70, P 100/min. Scattered wheezes are heard. Pelvic exam shows uterus that
exends to the umbilicus. Fetal heart tones are absent. HCT 32%, WBC 11k, serum beta-hcG 300k.
Pulse oximetry on room air shows o2 sat of 92%. CXR shows multiple round densities throughout all
lung fields. Dx?
- Choriocarcinoma

9. 21yo F with adnexal mass on pelvic exam. Uses oral contraceptives. Photo shown. Dx?
- Benign cystic teratoma

10. Study to compare effectiveness of lorazepam and midazolam in providing sedation for children
who require mechanical ventilation. 100 kids ramondly selected. Paralytic agents are administered to
26 of the 50 children in the lorazepam group and to 2 of the 50 children in the midazolam group to
allow more synchronized mechanical ventilation. Results show sedation score of 1 for 92% of the
lorazepam group and 12% of the midazolam group. Which features of this study raises concern of
validity?
- Confounding variables

11. 30yo F 4 months after starting treatment with lithium carbonate; during this period she has had a
3.2-kg weight gain. Med prescribed for manic symptoms.CONTINUES to take the lithium
carbonate (300 mg three times daily). T 37C, bp 120/80, p 70/min. Next step is measurement of
which?
- Serum thyroid-stimulating hormone concentration

12. 87yo F with 4-month history of vulvar itching. Excoriated areas from scratching and a white, thin
vulva. Labia minora are absent, and small fissures at the introitus. Dx?
- Lichen sclerosus

13. 28mo boy has hx of cyanosis since birth with episodes of syncope. Cyanosis and clubbing. Lungs
are clear. Right ventricular heave, a systolic click, a single S2, and a grade 3/6 systolic murmur. Dx?
- Tetralogy of Fallot

14. 17yo boy sustains a head injury and loses conciousness after diving into a freshwater lake from a
platform. Submerged for 3 minutes. Initially cyanotic but then begins to cough and breath
spontaneously after a 5-minute resuscitation. Over the next 36 hours, which complications is most
likely?
- Acute respiratory distress syndrome

15. 4-week-old newborn with increasing difficulty feeding, poor weight gain, and excessive
perspiration since birth. Respirations are 80/min and labored. A grade 2/6 holosystolic murmur is
heard over the lower left sternal border. Lungs are clear. Chest x-ray shows cardiomegaly with
increased pulmonary vascular markings. ECG shows right ventricular hypertrophy. Explanation for
absence of murmur on initial exam?
- High pulmonary vascular resistance

16. Over the past 3 months, 30yo F with intermittent episodes of headaches, palpitations, sweating,
and irritability. BP 150/100, while supine and 149/100 standing, P 90/min supine and 110/min
standing. No abnormalities except for pallor. Location of lesion?
-ADRENAL gland

17. One month after uneventful renal transplant for glomerulonephritis, 38yo F with increased serum
urea nitrogen and creatinine concentrations; Had been receiving hemodialysis for 3 years. Current
meds include cyclosporine and prednisone. Over the past 48 hours, urine output has remained
stable. Both renal biopsy and a radionuclide scan confirm acute rejection. Most effective treatment?
- Increased dosage of corticosteroids

18. 72yo M with 2-month history of urination twice nightly, frequency, and urgency. 15-year hx of
T2DM. BP 135/86. Mild enlargement of the prostate with no palpable nodules. His postvoid residual
volume is 10 mL. Urea nitrogen concentration of 45 mg/dL and creatinine concentration of 3.8 mg/dL.
Urine dipstick shows 3_ prtein. Whihch would have prevented progression of renal disease?
- Oral enalapril therapy

19. 72yo M with chronic abdominal pain and headaches for 4 months. More forgetful over the past 6
months. Hx of gout. Smoked one pack daily for 50 years and drinks 10 oz of homemade whiskey
daily. No meds. BP 160/98, p 74/min. Mild short-term memory loss and decreased sensation to
pinprick in the distal extremities. Has an ataxic gait. Gouty tophi on dorsal aspect of the left elbox.
Labs show: HCT 33%, MCV 70, BUN 17, Glucose 90, Cr 2, Uric acid 14. Next step?
- Measurement of blood lead concentration

20. 5yo girl with T 40C, tachypnea, and a nonproductive cough for 12 days. Four days ago was
treated with antibiotic for suspected pneumococcal pneumonia. Diminished breath sounds over the
right lower lung fields and dullness to percussion at the right costphrenic angle. Dx?
- Empyema

21. 57yo M with intermittent urainry incontinence over the past 6 months. Loss of small amounts of
urine when he coughs or sneezes. No pain or blood with urination. 15-year hx of T2DM with
peripheral neuropathy, retinopathy, and gastroparesis. Nroaml-sized prostate. Neuro exam shows
decreased sensation in a stocking-glove distribution. Achilles tendon reflexes absent bilaterally. U/A
shows 2+ protein with no leukocytes or erythrocytes. Postvoid residual volume is 500mL. Mechanism
of incontinence?
- Overflow incontinence from acontractile bladder

22. 15yo boy 30 minutes after a 2-minute episode of loss of consciousness after completing a 400-
meter race. Feels fine except forSHORTNESS OF BREATH . BP 110/70, P 70/min. Lungs are clear.
2/6 systolic murmur is heard at the left sternal border with minimal radiation to the neck, the murmur
becomes louder when he stands. Dx?
- Hypertrophic obstructive cardiomyopathy

23. 62yo F 1 hour after a 1-minute episode of loss of consciousness; symptoms began when she
stood up after she passed a dark, watery stool. Has had diarrhea and dark stools for 2 days.
Receiving warfarin therapy for DVT for 2 weeks. BP 82/60, P 150/min. Unable to stand. 2/6 systolic
murmur is heard at the second right intercostal space with no radiation. Dx?
- Orthostatic hypotension

Block 4 part 2

24. 24yo F. Menses occur at regular 28-day intervals and last 5 to 6 days. LMP 3 weeks ago. No meds,
Bimanual exam shows a c-cm, mildly tender left adnexa. A pregnancy test is negative. Next step?
- Repeat examination in 2 weeks

25. 42yo M with 2-month history of staring spells that last 1 to 2 minutes each. Smacks his lips and
picks at his shirt collar. Four years ago, he was comatose for 2 weeks after sustaining a head injury in
a motorcycle collision; required 6 mo of rehab. Intermittent episodes of smelling burnt rubber that
occur approximately every 2 weeks. Hears an intense hissing sound during these episodes. Dx?
- Complex partial seizures

26. 16yo boy with neurofibromatosis with 1-year history of headaches during which his parents say
he appears pale. Six months ago, operative treatment for optic nerve glioma. BP 164/105, P 102/min.
Thyroid glands are not enlarged. No murmurs. Cause of highBLOOD PRESSURE ?
- Catecholamine-producing tumor

27. 42yo M with 3-month hx of progressiveSHORTNESS OF BREATH with exertion that began
after upper respiratory tract infection. Father and paternal grandfather had "lung and liver problems."
Smoked one pack daily for 25 years. Pulse oximetry on room air shows o2 sat of 89%, Expiratory
wheezes are heard bilaterally. Alk phos 100, AST 60, ALT 76. Dx?
- Emphysema

28. 23yo F G1P1 requesting postcoital contraceptive advice. One day ago, patient's condom broke
during sexual intercourse. LMP 2 weeks ago. Pregnancy test is negative. Recommendation?
- Oral levonorgestrel now and again in 12 hours

29. 70yo M with urinary hesitancy and frequency for 9 months. T 37.5. Circumcised penis with no
urethral discharge. Testicular examination normal. Enlarged rubbery prostate that is nontender to
palpation. U/A shows leukocytes and no erythrocytes. Gram stain of urine shows gram-negative rods.
Cause?
- Outflow obstruction of the bladder

30. 62yo F with 2-day history of fatigue and a 1-hour hx of headache and confusion. No fever,
nausea, or vomiting. 6-year hx of HTN treated with hydrochlorothiazide and lisinopril. BP 250/135.
Funduscopic exam shows bilateral papilledema. Lungs clear. S4 and no murmurs. ECG shows left
ventricular hypertrophy with a strain pattern. Initial pharmacotherapy?
- Nitroprusside
31. 20yo AA man with sickle cell disease with 1-week hx of shortness of breath on exertion, fatigue,
and generalized weakness. No fever, chills,NIGHT SWEATS , or cough. Labs show HCT 20%, MCV
110, WBC 2.3k, reticulocyte count 1.8%. Mechanism for these findings?
- Increased demand for folic acid

32. 47yo F with 36-hour hx of nausea, vomiting, and abdominal pain that radiates to her back. Had
intermittent episodes of cramping abdominal pain 1 to 2 hours after meals; pain lasts several hours.
Family Hx of CAD and hypertension. Moderate epigastric and right upper quadrant tenderness with
no guarding or rebound; bowel sounds are decreased. Labs show: HCT 45%, wbc 9k, total bilirubin
1.5, alk phosphatase 120, AST 78,AMYLASE 365, lipase 1223, triglycerides 300. Dx?
- Gallstone pancreatitis

33. 3mo girl with 3-day history of grunting and increasing difficulty breathing. T 36.7, respirations are
76/min. Grunting, nasal flaring, and marked intercostal retractions. Bronchial breath sounds and
occasional bilateral crackles are heard. Serum Ca 5.6, Phosphorus 11, alkaline phosphatase 250.
Capillary blood gass on 100% o2: pH 7.36, PCo2 38, Po2 46. X-ray of the chest shows bilateral,
diffuse interstitial infiltrates and absence of the thymic shadow. Bronchoalveolar lavage is positive for
pneumocystis jiroveci (formerly P. carinii). Mechanism?
- Dysmorphogenesis of the third and fourth pharyngeal pouches

34. 32yo F with bright redrectal bleeding and severe stabbing pain with each bowel movement of the
past 2 weeks. Blood-streaked stools, and blood on the toilet paper. Has had mild constipation. Small
anal fissure at the posterior midline. Next step?
- Anesthetic ointment and stool softeners

35. 37yo primigravid woman at 9 weeks' gestation with progressive nausea and vomiting. Sx began
at 6 weeks' but have worsened. T 36.9, P 105/min, BP 110/60. Serum electrolyte concentrations are
wnl. U/A shows 3+KETONES . In addition to intravenous hydration, most appropriate initial step?
- Antiemetic therapy

36. 67yo F with severe chest pain 4 hours after undergoing outpatient endoscopy and dilatation of an
esophageal stricture. Three hours later, vomited small amount of blood and had severe pain. Pale. T
38C, bp 140/85, P 125/min. Crepitus in the neck and moderate epigastric tenderness. Lungs are
clear. Cause?
- Esophageal perforation

37. 57yo M skin has appeared yellow for 3 weeks. Jaundice and scleral icterus. Total serum bilirubin is
8 with direct component of 6.2. CT abdomen shows large lesion in the head of the pancreas. Patient
says he does not want to hear the report and wife agrees. Course of action?
- Withold the results as the patient wishes

38. 45yo F with shortness of breath, chest pain, dizziness, and mild numbness and tingling around
the lips for 2 hours. Feels like she is going to die. Had imilar episodes during vacation. Pulse is
120/min. Glucose is 120. ECG shows sinus tachycardia. Sublingual nitroglycerin therapy does not
relieve her symptoms. Next step?
- Lorazepam

39. 67yo M with 3-day histor of fever and headache. Five years ago, he underwent placement of a
mechanical aortic valve for treatment of sequelae of rheumatic fever. T 40 C, BP 110/65, P 110/min.
3/6, systolic ejection murmur is heard. Neuro examination shows mild left hemiparesis. Babinski's
sign is present on the left. Greatest risk for which complications?
- Brain abscess

40. 47yo F with 15-year history of poorly controlled T2DM. Requires 100 U of insulin daily. Multiple
attempts atWEIGHT LOSS have been unsuccessful. BMI 75. BP 150/95. Cr is 0.8. Next step?
- Gastric bypass
41. 67yo F drinks 1 ounce of alcohol daily. BP 138/62, P 76/min. Lungs are clear Labs show Hb 12.8,
Serum: Ca 11.9, Cr 0.8, Phosphorus 2.8, total protein 6.5 (albumin 4.2), ionized calcium 5.8 (N=4.5-
5.1). Next step?
- Measurement of serum parathyroid hormone concentration

42. 44yo F 2 days after being discharged from theHOSPITAL for abdominal pain; exploratory
laparoscopy normal. Admitted numerous times for variety of symptoms; all work-ups had been
negative. T 39.2, Reddened, indurated laparoscopic wound. Admitted and given antibiotics. On the
second hospital day, a nurse witnesses the patient rubbing saliva into her laparosopy site. Dx?
- Factitious disorder

43. 52yo F with large pimple on her right hand for 2 weeks that has failed to heal. Resides in
southwestern USA where she owns a nursery and gardenSHOP . Painless red papule with several
nontender subcutaneous nodular lesions above it. Dx?
- Sporotrichosis

44. 6yo boy with progressive visual loss over the past year. Deterioration of his hearing, speech,
writing, and intellectual performance. Maternal uncle had similar symptoms. Visual acuity is 20/200
bilaterally. Funduscopic examination shows optic atrophy. Weakness and spasticity of all extremities.
DRT are exremely hyperactive. Babinski's sign is present bilaterally. MRI shows marked symmetric
white matter disease involving all lobes. Diagnostic studies will show?
- An excess of very long chain fatty acids

45. 57yo M with 1day history of severe pain and swelling of his right knee that worsens with
movement. T 37.2. Warmth, erythema, and diffuse tenderness with a moderate effusion. Aspiration
of the knee joint yields cloudy fluid, fluid analysis shows a wbc count of 9k. Negatively birefringent,
needle-shaped crystals. Initial pharmacotherapy?
- Indomethacin

46. 18yo M 1 week after he had a BP 140/110 during routine precollege examination. Upper
extremities appear to be more muscular than the lower extremities. Radial pulses are normal;
femoral, posterior tibial , and dorsalis pedis pulses are decreased. 2/6 systolic murmur heard over the
precordium, anterior chest, and back. ECG shows left ventricular hypertrophy. Next step?
- Operative treatment?