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Rutgers (formerly UMDNJ) PANCE/PANRE Review Course with Exam Master Practice
Questions $ 449.00

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PANCE/PANRE Review: Reproductive
System, Gastrointestinal System/Nutrition,
Genitourinary System

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Congratulations, you have passed this exam.Your Exam Score:81
Exam Average Score: 82


* 1. An 18-year-old female presents with progressively worsening abdominal pain x 4 hrs.
Pain began in the epigastrium and has now localized to the RLQ. Physical exam reveals positive
psoas sign and Rovsing's sign. She is currently menstruating. Which of the following is the best
initial test?
A. Both abdominal ultrasonography and CT scanning are useful in diagnosing appendicitis as
well as excluding other diseases with similar presenting symptoms. However, CT scanning is
more accurate.
B. Standard abdominal radiography is frequently normal in acute appendicitis.
C. Amylase and lipase would be indicated if pancreatitis was suspected.
D. Urinalysis is usually normal in acute appendicitis.
Answer: A
* This question is required.
A. abdominal CT

B. abdominal plain film

C. amylase and lipase

D. urinalysis

* 2. A 10-month old baby has multiple episodes of inconsolable screaming with vomiting
and diarrhea. Physical exam reveals T 102F, tender and distended abdomen and a palpable
sausage-shaped mass. What is the most likely diagnosis?
A. Primary bacterial peritonitis accounts for less than 2% of pediatric peritonitis cases.
B. Intussusception is the most frequent cause of intestinal obstruction in the first two years of
life. Typically a thriving infant 3-12 months old develops paroxysms of abdominal pain with
screaming and drawing up of the knees. Vomiting and diarrhea occur soon afterward. Abdomen
is tender and distended, on palpation a sausage-shaped mass may be found, usually in the upper
mid abdomen.
C. Pyloric stenosis is characterized by painless projectile vomiting and an olive shaped
epigastric mass.
D. Volvulus accounts for 10% of neonatal intestinal obstruction. Most infants present with
recurrent bile stained vomitus in the first 3 weeks of life.
Answer: B
* This question is required.
A. bacterial peritonitis

B. intussusception

C. pyloric stenosis

D. volvulus

* 3. A 57-year-old female presents with fever and abdominal pain localized to the LLQ. She
has a history of fluctuating constipation and loose stools. Which of the following is the
diagnostic test of choice?
A. Empiric treatment of diverticulitis is generally started without diagnostic imaging; imaging is
required if patients do not respond after 2-4 days. Abdominal CT is the test of choice in
suspected diverticulitis, and may demonstrate bowel wall thickening, abscess formation, and
B. Although abdominal radiographs may indicate displaced colon, extraluminal gas or colonic
mucosal abnormalities, they are more helpful in excluding other causes of LLQ pain.
C. Urinalysis may demonstrate protein and WBCs but this is nonspecific.
D. Lower endoscopic examination is contraindicated in suspected diverticulitis due to the
potential to cause perforation.
Answer: A
* This question is required.
A. abdominal CT scan

B. abdominal plain film

C. urinalysis

D. colonoscopy

* 4. A 75-year-old presents with progressive constipation, fatigue and weight loss. Labs
reveal iron deficiency anemia. Which of the following is the most likely pathology?
A. Adenocarcinomas constitute almost all colorectal cancer cases.
B. See A. Carcinoid tumors make up 1/3 of small intestine neoplasms and usually arise in the
ileum. Only 8% of carcinoid tumors affect the colon.
C. A minority of small intestine sarcomas are caused by smooth muscle tumors
D. Squamous cell carcinoma is typical in cervical cancer and skin cancer.
Answer: A
* This question is required.
A. adenocarcinoma

B. carcinoid

C. leiomyosarcoma

D. squamous cell carcinoma

* 5. A patient presents with rectal bleeding. Exam reveals a prolapsed internal hemorrhoid
that can be manually reduced. This is an example of what stage of hemorrhoid?
A. A stage I hemorrhoid is defined as bleeding with no prolapse. Dietary modifications or
rubberband ligation are recommended interventions.
B. A stage II hemorrhoid is defined as prolapse with spontaneous reduction. Bleeding and
seepage occur. They are managed with rubberband ligation or coagulation, as well as dietary
C. A stage III hemorrhoid is prolapse requiring digital reduction with bleeding and seepage.
They are managed by surgical hemorrhoidectomy or rubberband ligation, as well as dietary
D. A stage IV hemorrhoid is prolapsed and cannot be reduced or may be strangulated. This
needs surgical hemorrhoidectomy.
Answer: C
* This question is required.
A. stage I

B. stage II

C. stage III

D. stage IV

* 6. A 47-year-old female presents with nausea and dull RUQ pain x 3 hours, now radiating
to the right shoulder. The pain began shortly after a large meal. She took antacids with no relief.
Physical exam reveals BP 130/85; P89; T100.1F; Ht 5'5"; Wt 195; RUQ tenderness and (+)
Murphy's sign. What is the recommended initial diagnostic study?
A. CT scan is a more expensive test and exposes the patient to unnecessary radiation.
B. Although HIDA scan is 95% sensitive, its specificity varies markedly and can be as poor as
50% in critically ill or jaundiced patients.
C. Only 15% of gallstones are radiopaque and, therefore, visible on plain film.
D. RUQ ultrasonography non-invasively diagnoses gallstones in 95% of patients with
cholecystitis. Ultrasonography can also exclude common bile duct obstruction and may
occasionally show bile duct stones. It is the least expensive and least invasive diagnostic tool.
Answer: D
* This question is required.
A. abdominal CT scan

B. HIDA scan

C. plain film of abdomen

D. ultrasound of abdomen

* 7. An 8-month old infant presents with vomiting followed by voluminous watery diarrhea
for the past 3 days. The child has had a low grade fever for the past 2 days. Mother denies any
significant past medical history or use of medications. What is the most likely infectious agent
A. Clostridium difficile occurs as a result of antibiotic therapy. Fever, tenesmus, and abdominal
pain with diarrhea (sometimes with gross blood) are typical symptoms.
B. Cytomegalovirus rarely causes diarrhea in immunocompetent children.
C. Norwalk virus chiefly causes sporadic outbreaks of vomiting but also some diarrhea in older
children and adults.
D. Rotavirus is the most common cause of acute gastroenteritis in developed countries. It mainly
affects infants between 3-15 months, with peak incidence in the winter months. Vomiting is the
first symptom in 80-90% of patients, followed by low grade fever and voluminous watery
diarrhea. Diarrhea usually last 4-8 days.
Answer: D
* This question is required.
A. Clostridium difficile

B. cytomegalovirus

C. Norwalk virus

D. rotavirus

* 8. A 75-year-old presents with constant LLQ pain and high fever for the past 3 hours. He
admits to constipation x 2 days prior. Labs reveal leukocytosis and CT scan shows bowel wall
thickening and multiple large diverticula. What is the initial recommended therapy?
A. See B for explanation.
B. Patients with severe diverticulitis should be admitted. IV antibiotic therapy should cover
anaerobic and gram negative bacteria. Monotherapy can be with a 2nd-generation
cephalosporin (i.e. cefoxitin), piperacillin-tazobactam, or ticarcillin clavulanate. Single-agent
treatment appears to be as effective as combination therapy (i.e. metronidazole or clindamycin
plus an aminoglycoside or 3rd-generation cephalosporin).
C. See B for explanation.
D. See B for explanation.
Answer: B
* This question is required.
A. emergent surgical intervention

B. hospitalization, IV ceftriaxone and IV metronidazole

C. hospitalization, increased fluids and clear liquid diet

D. outpatient therapy, oral ciprofloxacin and metronidazole

* 9. A 28-year-old male presents with progressively worsening abdominal pain x 4 hours.
Pain began in the epigastric area and has now progressed to the RLQ. Physical exam reveals
rebound tenderness and tenderness at McBurney's point. What is the most likely diagnosis?
A. Appendicitis is characterized by abdominal pain starting in the epigastric area then localizing
to RLQ. Pain steadily increases and anorexia is frequent. Vomiting is not prominent. Rebound
tenderness and McBurney's point tenderness on physical exam are common findings.
B. Acute cholecystitis or cholelithiasis presents with RUQ pain with radiation to the right
shoulder, often worsened after fatty meals. Patients typically complain of bloating and nausea
without vomiting. Fever is usually present.
C. Diverticulitis typically affects patients 50 years and older. Pain is usually subacute and
constant, located in the LLQ. Fever is almost always present. Constipation or diarrhea may
D. Pancreatitis presents with constant epigastric pain radiating to the back with nausea and
vomiting. Abdominal findings may vary with severity of the attack.
Answer: A
* This question is required.
A. appendicitis

B. cholecystitis

C. diverticulitis

D. pancreatitis

* 10. A 40-year-old male presents to the emergency department complaining of constant
epigastric and back pain with episodes of nausea and vomiting x 8 hours. He admits to having
recently "fallen off the wagon" and binge drinking over the past two weeks. Physical exam
reveals epigastric tenderness, guarding, and abdominal distention. What is the most likely
A. Acute cholecystitis presents with RUQ pain that radiates to the right shoulder, with
unexplained fever. Pain typically worsens after large, fatty meals. Murphy's sign is common.
B. The majority of cases of acute pancreatitis are linked to biliary tract disease (i.e. passed
gallstone) or excessive alcohol intake. The symptoms are abdominal pain, nausea and vomiting.
Pain is usually constant, located in the epigastrium with radiation to the back. Abdominal
findings vary with severity of the attack.
C. Appendicitis is characterized by abdominal pain starting in the epigastrium and later
localizing to RLQ. Pain steadily increases and anorexia is frequent. Vomiting is not prominent.
Rebound tenderness and McBurney's point tenderness are common findings.
D. Diverticulitis most often affects patients middle-aged and older. Pain is usually subacute and
constant, typically located in the LLQ. Fever is typically present. Constipation or diarrhea may
* This question is required.
A. cholecystitis

B. pancreatitis

C. appendicitis

D. diverticulitis

* 11. A 48-year-old wheelchair-bound female presents with a complaint of abdominal
distention and lack of appetite, with two episodes of nausea and vomiting x 1 day. She states she
has not had a bowel movement in four days. Digital examination reveals firm stool in the rectal
vault. What is the initial management?
A. Colonoscopy is not usually recommended to treat fecal impaction, but should be considered in
patients with alarm symptoms or who are older than age 50. Increased dietary fiber intake is
recommended to help with bowel regularity, but will not help acutely.
B. Initial treatment should be relief of the impaction, either by digital disimpaction or with an
enema (saline, mineral oil, or diatrizoate) and long term care focused on maintaining soft stools
and regular bowel movements.
C. GoLytely is traditionally used for colonic lavage prior to colonoscopy and, although an
increase in fluid intake may help, this patient should be given a more aggressive management
D. The fecal impaction needs to be addressed by either digital disimpaction or enema before
long term management can be prescribed. Lactulose, although successful for the treatment of
chronic constipation, does produce side effects such as cramping, bloating, and flatulence.
Answer: B
* This question is required.
A. colonoscopy now and increased dietary fiber intake

B. digital disimpaction now and milk of magnesia daily

C. prescribe GoLytely and increase daily fluid intake

D. start patient on daily lactulose

* 12. A 20-year-old male brought to the emergency room complains of worsening, colicky,
RLQ pain for the past four hours. He states that it began as diffuse middle abdominal pain which
then shifted to his RLQ. If positive, which of the following findings will help to confirm the
suspected diagnosis?
A. A positive Grey Turner's sign is seen in acute hemorrhagic pancreatitis. It is a characteristic
discoloration along the flanks, resulting from the tracking of blood from the pancreatic area of
the retroperitoneum.
B. A positive McMurray's test is indicative of a meniscal tear in the knee.
C. A positive Murphy's sign is indicative of acute cholecystitis; it is done when a patient
complains of RUQ pain and tenderness.
D. A positive psoas sign suggests irritation of the psoas muscle by an inflamed peritoneum.
Answer: D
* This question is required.
A. Grey Turner's sign

B. McMurray's test

C. Murphy's sign

D. psoas sign

* 13. A 28-year-old male with no significant past medical or family history presents
complaining of intermittent dyspepsia not related to food intake x 3 weeks. The pain has
occasionally awakened him from sleep. He denies weight loss, dysphagia, vomiting or
hematemesis. Urea breath test is negative for H. pylori. Which of the following is the best
A. Antibiotics are an important component of the multimodal approach to H. pylori disease.
B. Bismuth has antibiotic properties when used with other antibiotics to treat H. pylori infection.
C. See D.
D. PPIs are the initial empiric treatment for functional dyspepsia or GERD. They are more
effective than H2-receptor antagonists.
Answer: D
* This question is required.
A. antibiotics

B. bismuth

C. cimetidine

D. proton pump inhibitors

* 14. A 46-year-old male with HIV-disease presents with worsening odynophagia x 3
weeks. Endoscopy reveals diffuse, linear yellow-white plaques adherent to the esophageal
mucosa. What is the most likely cause of his symptoms?
A. Candida albicans is a common pathogen in immunocompromised patients and gives the
described classic endoscopic appearance.
B. Barrett esophagus appears as orange epithelium arising upward from the stomach.
C. Esophageal carcinoma (either squamous or adenocarcinoma) have characteristic tumor-like
findings on endoscopy, confirmed with biopsy.
D. CMV esophagitis will show several large shallow superficial ulcers on endoscopy.
Answer: A
* This question is required.
A. candida albicans esophagitis

B. Barrett esophagus

C. esophageal carcinoma

D. cytomegalovirus esophagitis

* 15. A 39-year-old male with no significant past medical history presents complaining of a
small amount of bright red blood per rectum for the past 4 days, noted in the toilet bowl after
defecation. What diagnostic test would be most useful initially in identifying the source of
A. In otherwise healthy patients under age 45, anoscopy is indicated to look for evidence of
anorectal disease. This patient likely has hemorrhoids.
B. Barium enema may be useful to look for large bowel lesions, usually found in older patients.
C. Colonoscopy is the preferred initial study in patients with acute large-volume bleeding
requiring hospitalization.
D. CBC is nonspecific although it may provide evidence of anemia or infection.
Answer: A
* This question is required.
A. anoscopy

B. barium enema

C. colonoscopy

D. complete blood count

* 16. A healthy, 46-year-old female returns from a cruise two days early due to a "sick ship"
outbreak of nausea, vomiting and diarrhea experienced by many travelers. She appears mildly
dehydrated and has experienced 4-5 loose, non-bloody diarrheal episodes for the past 2 days.
Which of the following will improve her condition most?
A. Bismuth subsalicylate (Pepto-Bismol) reduces symptoms in patients with diarrhea by virtue of
its anti-inflammatory and antibacterial properties. Frequent feedings of tea, "flat" carbonated
beverages, and soft, easily digested foods are recommended.
B. Empiric antibiotics are not indicated for mild to moderate diarrheal symptoms.
C. High fiber foods and milk products should be avoided.
D. Dehydration will worsen and may even become serious if the patient is NPO for 1-2 days.
Answer: A
* This question is required.
A. bismuth subsalicylate (Pepto-Bismol) and increased oral fluids

B. empiric antibiotic treatment with ciprofloxacin

C. high fiber foods and milk products to "coat the stomach"

D. watchful waiting and nothing by mouth for 1-2 days

* 17. An elderly nursing home patient is diagnosed with osteomalacia. Appropriate
pharmacologic treatment is received and her nutritional status has improved. Which lifestyle
recommendation below is most important at this time?
A. Adequate nutrition is important for overall health; however, a balanced diet, high in vitamins
and minerals, is most beneficial.
B. While exercise is important, this description is not a prudent aspect of physical activity for the
elderly residing in a nursing home.
C. There is no extensive documentation of the effects of stress on osteomalacia.
D. Sun exposure for at least 15 minutes twice weekly is essential to maintain proper vitamin D
Answer: D
* This question is required.
A. eating and drinking adequate volumes of high calorie foods

B. physical activity of at least 1 hour of strength training daily

C. reducing stress levels by engaging in relaxation therapy

D. sun exposure for 15 minutes twice weekly

* 18. A 56-year-old male with a history of alcohol abuse presents with dyspnea. Further
questioning reveals chronic anorexia, muscle cramps, paresthesias and irritability. Physical exam
reveals tachycardia, cardiomegaly and peripheral edema. What is the most important step in the
management of this patient?
A. The tachycardia is associated with high output heart failure associated with the "wet" beriberi
found in this patient. Beta blockers will not resolve his tachycardia.
B. The high output heart failure secondary to beriberi may be treated with diuretics, but his
underlying disorder is the thiamine deficiency.
C. IM calcium is reserved for documented severe hypocalcemia which manifests as tetany and
arrhythmias but not cramps.
D. Chronic alcohol abuse is the most common cause of thiamine deficiency. Chronic thiamine
deficiency leads to beriberi which can be wet (cardiovascular) or dry (neurologic). Fifty to 100
mg/d of thiamine is administered IV for the first few days, followed by daily oral doses of 5-10
Answer: D
* This question is required.
A. administer beta blocker to resolve tachycardia

B. determine exact height and weight before administering diuretics

C. reduce muscle cramps with IM calcium injections

D. treat thiamine deficiency with large parenteral doses of thiamine

* 19. A 42-year-old healthy female presents complaining of bloating, abdominal cramping
and flatulence. Further questioning correlates symptoms with ingestion of dairy products. Which
of the following tests will provide the most useful information?
A. An allergic skin panel is used to diagnose allergic responses, not enzyme deficiencies.
B. A barium swallow study is used to differentiate between mechanical lesions and motility
disorders of the esophagus.
C. The hydrogen breath test is the most widely available test for the diagnosis of lactase
deficiency. A rise in breath hydrogen of >20 ppm within 90 minutes results in a positive test. A
trial with lactose-free diet resulting in reduced symptoms is also diagnostic.
D. An upper endoscopy is the study of choice for evaluating persistent heartburn, dysphagia, and
structural abnormalities of the upper GI system.
Answer: C
* This question is required.
A. allergic skin panel

B. barium swallow study

C. hydrogen breath test

D. upper endoscopy

* 20. A 51-year-old male with history of alcohol abuse presents with retching, vomiting,
and 3 episodes of hematemesis over the past 3 hours. Endoscopy reveals a 2 cm linear mucosal
defect at the gastroesophageal junction. What is the most likely diagnosis?
A. Barrett esophagus is most often due to chronic acid reflux. It is characterized by endoscopic
findings of normal squamous epithelium of the esophagus being replaced with metaplastic
columnar epithelium.
B. Candida esophagitis causes severe odynophagia. Endoscopy will reveal yellow linear streaks.
C. Esophageal varices appear as dilated submucosal veins, often associated with cirrhosis and
underlying portal hypertension.
D. This is the classic presentation and endoscopic finding of a Mallory-Weiss tear.
Answer: D
* This question is required.
A. Barrett esophagus

B. Candida esophagitis

C. esophageal varices

D. Mallory-Weiss tear

* 21. A 40-year-old female presents complaining of RUQ abdominal pain and 3 episodes of
vomiting over the past 3 hours. Which of the following physical exam findings, if positive,
would be most helpful to make an accurate diagnosis?
A. A positive fluid wave test aids in the diagnosis of ascites.
B. McMurray's sign indicates a meniscal tear in the knee.
C. Murphy sign, or inhibition of inspiration by pain on palpation of the RUQ, is often positive in
cases of acute cholecystitis.
D. Rovsing's sign indicates peritoneal irritation such as in appendicitis.
Answer: C
* This question is required.
A. fluid wave test

B. McMurray's sign

C. Murphy sign

D. Rovsing's sign

* 22. A 49-year-old male with history of alcohol abuse presents for his initial visit
complaining of vague, right upper quadrant abdominal pain, weakness, fatigue and a 25 pound
weight loss over the past year. Initial labs reveal elevated AST and alkaline phosphatase and a
low serum albumin. Which of the following physical findings will most likely be found in this
A. There are no significant associated optic disc findings in cirrhosis.
B. Unless the patient has other underlying cardiac abnormalities, the pulse and BP readings are
usually normal in cirrhosis.
C. See B.
D. Jaundice is often mild at first, and increases in severity as cirrhosis progresses.
Answer: D
* This question is required.
A. atrophy of optic discs

B. hypertension

C. irregular pulse

D. jaundice

* 23. A 52-year-old female with no significant past medical history presents with nausea,
vomiting and severe epigastric pain radiating to her back. Her serum amylase and lipase are both
elevated. What is the most likely diagnosis?
A. The pain in cholecystitis is more often in the RUQ and radiates to the right shoulder.
B. These are classic finding of pancreatitis.
C. PUD does not usually cause elevation in the amylase and lipase values.
D. A UTI usually presents with lower abdominal/pelvic pain, and is not associated with
elevations of lipase or amylase.
Answer: B
* This question is required.
A. cholecystitis

B. pancreatitis

C. peptic ulcer disease

D. urinary tract infection

* 24. A 17-year-old previously healthy male presents with RLQ pain, nausea, anorexia and
fever of 101F x 4 hours. What is the most likely cause of his condition?
A. Cholelithiasis is uncommon in a 17-year-old male; it would usually cause RUQ pain.
B. Pancreatitis is also uncommon in this patient; it typically cause epigastric pain which
radiates into the back.
C. This is a classic description of appendicitis; obstruction is the main cause.
D. A UTI is very uncommon in an otherwise healthy adolescent male. Pyelonephritis causes
flank pain.
Answer: C
* This question is required.
A. blockage of the common bile duct by a cholesterol stone

B. pancreatic irritation and inflammation secondary to alcohol consumption

C. obstruction of the appendix by a fecalith

D. urinary tract infection ascending to the renal parenchyma

* 25. A 27-year-old female first presented 2 months ago complaining of nonbloody,
intermittent diarrhea, low-grade fever, malaise, continued mild weight loss, and crampy,
continuous lower abdominal pain. Labs have been unremarkable, except for an elevated
sedimentation rate. Low residue diet has had little effect on symptoms. Sigmoidoscopy reveals
erythema, edema, and friable rectal mucosa. What medication should be prescribed at this time?
A. 5-ASA agents, like mesalamine, are frequently used as first-line therapy in patients with mild-
moderate Crohn's disease or ulcerative colitis disease.
B. Anti-TNF agents are reserved for moderate-severe inflammatory bowel disease who do not
respond to 5-ASA agents.
C. Cyclosporine is also reserved for ulcerative colitis patients who do not respond to first line
D. While antibiotics are often prescribed and may reduce inflammation through alteration of gut
flora, the common choices are oral metronidazole, ciprofloxacin, or rifaximin.
Answer: A
* This question is required.
A. mesalamine

B. anti-TNF therapy

C. cyclosporine

D. vancomycin

* 26. A 24-year-old male describes several months history of mild fever, LLQ crampy pain
relieved with defecation, fecal urgency, tenesmus, and mucous in the stool; all symptoms have
been present intermittently. What additional historical finding would support the most likely
A. Bloody diarrhea is the hallmark of ulcerative colitis.
B. Disease severity of ulcerative colitis may be lower in active smokers.
C. Flatulence and oily stool are not associated with ulcerative colitis. They are common in
infectious diarrhea, such as Giardia.
D. Only in cases of severe disease does significant weight loss become a cause for concern.
Answer: A
* This question is required.
A. bloody diarrhea

B. current tobacco smoker > 2 ppd

C. progressively increasing flatulence and oily stool

D. weight loss of at least 10 pounds

* 27. A 67-year-old female with a history of atherosclerosis presents to the emergency
department due to confusion. Her daughter reports a history of severe postprandial abdominal
pain that has been occurring over the past several days. Exam reveals tachycardia and
hypotension. Which of the following physical exam findings will most likely be found in this
A. See D.
B. See D.
C. See D.
D. The key finding with acute mesenteric ischemia is severe, steady epigastric and periumbilical
pain with minimal or no findings on physical exam of the abdomen. This is due to the fact that
the visceral peritoneum is severely ischemic or infarcted and the parietal peritoneum is not
Answer: D
* This question is required.
A. diffuse abdominal tympany to percussion

B. hyperactive bowel sounds

C. rectal bleeding

D. normal abdominal physical exam findings

* 28. A 52-year-old female with a history of worsening ulcerative colitis x 9 years is
hospitalized with signs of toxicity. After 3 days of appropriate medical treatment, an abdominal
plain film shows colonic dilation of 8 cm. Which of the following is of most concern for this
A. The diagnosis of toxic megacolon associated with ulcerative colitis is characterized by colonic
dilations > 6 cm. In patients who worsen or fail to improve within 48-72 hours, surgery should
be performed to prevent perforation.
B. Colonic ischemia is associated with mesenteric arterial infarct or occlusion.
C. Patients with ulcerative colitis are at increased risk of colorectal cancer; however, this
patient has developed toxic megacolon which may result in perforation, a more serious concern.
D. Polyp formation is associated with diverticular bleeding and is not a life threatening concern.
Answer: A
* This question is required.
A. bowel perforation

B. colonic ischemia

C. malignant transformation

D. polyp formation

* 29. A 57-year-old obese female with a history of Crohn's colitis x 30 years presents with
fatigue, weakness, and a positive fecal occult blood test. An annular constricting lesion is found
on colonoscopy. Which of the following is the most likely finding?
A. Adenocarcinoma of the colon is the cause of most colorectal cancers. Patients with Crohn's
colitis are at increased risk. An annular constricting lesion is a classic colonoscopy finding of
adenocarcinoma of the colon.
B. Intestinal lymphoma is more likely to be found in the distal small intestine. It is seen in
patients with immunosuppression such as HIV/AIDS or Crohn's disease.
C. Paraneoplastic syndrome is a constellation of symptoms considered to be due to the remote
effects of a cancer.
D. Squamous cell carcinomas are common in skin, anus, and esophagus, not colorectal
Answer: A
* This question is required.
A. adenocarcinoma of the colon

B. intestinal lymphoma

C. paraneoplastic syndrome

D. squamous cell carcinoma

* 30. A 48-year-old homeless male with a history of alcohol abuse presents to the
emergency department with a painful hemarthrosis of the right knee. He does not recall a history
of trauma. Exam reveals bleeding gums, petechiae, purpura, and splinter hemorrhages. Blood
tests reveal anemia and elevated BUN/creatinine. Which of the following will best treat this
A. While dietary improvement is advised, over the long haul he needs immediate intervention.
B. Vitamin C deficiency is not treated with fresh frozen plasma.
C. Liver transplant is reserved for those individuals with liver failure which is not correctable
with routine treatment.
D. Malnutrition and alcohol abuse are two strong risk factors for vitamin C deficiency.
Atraumatic hemarthrosis in this setting is highly suggestive of scurvy. Vitamin C (ascorbic acid)
deficiency is best treated with 300-1000 mg of ascorbic acid per day.
Answer: D
* This question is required.
A. dietary administration of fresh fruits and vegetables

B. fresh frozen plasma transfusion

C. liver transplant

D. vitamin C administration

* 31. A patient complains of erectile dysfunction. Nocturnal erections are recorded during
nocturnal tumescence testing. What would be the most appropriate initial therapy?
A. Penile implantation is an invasive procedure and not the best initial choice.
B. Vasoactive prostaglandin injections into the penis is a treatment generally used for organic
dysfunction, not dysfunction that is psychogenic in origin.
C. Nocturnal erections indicate psychogenic impotence; the patient would likely benefit from
behaviorally oriented sex therapy.
D. Testosterone injections are most appropriate for patients with documented androgen
Answer: C
* This question is required.
A. implanted prosthetic device

B. penile prostaglandin injections

C. behavioral therapy

D. testosterone injections

* 32. A 74-year-old female complains of an intense urge to urinate followed by a small
amount of leakage that she is unable to hold back. What is the most likely cause of her
A. Very common in the geriatric population, urge incontinence (detrusor overactivity) refers to
involuntary bladder contractions that cause urine leakage.
B. Overflow incontinence is the least common cause of incontinence. Patients complain of
frequency, urgency, and leakage. An elevated postvoid residual amount differentiates this from
detrusor over activity.
C. Stress incontinence (detrusor underactivity) is urine leakage in response to a stress maneuver,
such as lifting, laughing, coughing, or sneezing.
D. Urethral obstruction is a rare cause of incontinence in older women, however not uncommon
in men. Patients present with dribbling after voiding.
Answer: A
* This question is required.
A. detrusor overactivity

B. detrusor underactivity

C. urethral incompetence

D. urethral obstruction

* 33. A 72-year-old male smoker presents complaining of a 2 week history of hematuria.
Further questioning reveals mild irritative symptoms. What would be the best first step in the
work-up of this patient?
A. Abdominal CT scan or ultrasonography may be used to detect filling defects or masses but are
not the most appropriate first test.
B. Cystoscopy with biopsy would be best to confirm the presence of bladder cancer.
C. See A for explanation.
D. Urine cytology will confirm the presence of hematuria as well as detect exfoliated cells from
normal and abnormal urothelium. This is the first step in the workup of suspected bladder
Answer: D
* This question is required.
A. abdominal CT scan

B. cystoscopy

C. renal ultrasonography

D. urine cytology

* 34. A hospitalized patient is noted to be somewhat edematous, especially in the periorbital
and scrotal regions. He also has elevated blood pressure. Urinalysis reveals microscopic
hematuria, mild-moderate proteinuria, and red cell casts. What is the most likely diagnosis?
A. Patients with glomerulonephritis are often hypertensive and edematous with the urine findings
as above plus red and white blood cells. RBC casts are the hallmark of glomerulonephritis.
B. Interstitial nephritis is manifested by hematuria and sometimes proteinuria; white cells and
white cell casts are present but not red cell casts.
C. Nephrotic syndrome causes peripheral edema, large proteinuria (>3.5g/day), and
hypoalbuminemia. Red cell casts are not generally present.
D. Hematuria, hypertension, and proteinuria are common in polycystic kidney disease, however,
red cell casts and edema are not.
Answer: A
* This question is required.
A. glomerulonephritis

B. interstitial nephritis

C. nephrotic syndrome

D. polycystic kidney disease

* 35. A 26-year-old female undergoes abdominal ultrasound which reveals multiple cysts in
both kidneys. Which of the following is least likely to be found in this patient's presentation?
A. Hematuria is common in polycystic kidney disease due to rupture of cysts into the renal pelvis,
a renal stone, or urinary tract infection.
B. Fifty percent of patients with polycystic kidney disease will have hypertension at time of
diagnosis; most patients will develop it during the course of the disease.
C. Patients have large kidneys that may be palpable on abdominal exam.
D. Polyuria is not typical in polycystic kidney disease.
Answer: D
* This question is required.
A. hematuria

B. hypertension

C. palpable kidneys

D. polyuria

* 36. A patient has a pH of 7.32, a PaCO
of 49, and an HCO
of 28. What is the acid base
A. Metabolic acidosis with complete compensation would show a normal pH but an abnormal
and HCO
B. The low pH indicates acidosis, not alkalosis.
C. The low pH and elevated PaCO
indicates respiratory acidosis with partial compensation
evidenced by the elevated HCO
D. See B for explanation.
Answer: C
* This question is required.
A. metabolic acidosis with complete compensation

B. metabolic alkalosis with no compensation

C. respiratory acidosis with partial compensation

D. respiratory alkalosis with no compensation

* 37. A 69-year-old male with a history of hypertension has a serum potassium level of 5.9
mEq/L. He is experiencing mild muscle weakness and diarrhea and his ECG shows peaked T-
waves. His medications include lisinopril and spironolactone. Which of the following is the best
initial treatment?
A. Insulin, bicarbonate and beta agonists would be appropriate if cardiac toxicity or muscular
paralysis were present or if serum potassium was severe (>6.5 mEq/L).
B. See A for explanation.
C. Kayexalate is an ion exchange resin that binds K+ and would be the best initial treatment.
D. Although these medications may be the cause of his hyperkalemia, decreasing the dose may
not be fast enough to lower the K+ level; in light of his symptoms, pharmacologic treatment is
Answer: C
* This question is required.
A. administer intravenous insulin plus glucose

B. administer intravenous sodium bicarbonate

C. administer oral sodium polystyrene sulfonate (Kayexalate)

D. decrease dosage of lisinopril and spironolactone

* 38. A 65-year-old male presents complaining of urinary hesitancy and post-void dripping
which have developed over the past few months. Further questioning reveals decreased force and
caliber of stream; he denies dysuria, hematuria or nocturia. What is the most likely finding on
physical exam?
A. A hard prostate is associated with malignancy.
B. Indurations, especially with a shrunken prostate, indicate advanced malignancy.
C. This patient describes symptoms of benign prostatic hyperplasia. It is most often associated
with a smooth, firm, elastic enlargement of the prostate.
D. A soft, spongy prostate, often tender, indicates prostatitis. Patients present with fever, dysuria
and perineal tenderness.
Answer: C
* This question is required.
A. hard, rough, symmetrically enlarged prostate

B. indurated, irregular, shrunken prostate

C. smooth, firm, elastic enlargement of the prostate

D. soft, spongy, fluid-like enlargement of the prostate

* 39. A 48-year-old male has a history of stable angina treated with daily transdermal
nitroglycerin. He has recently been diagnosed with erectile dysfunction secondary to systemic
vascular disease. Which of the following would be the best treatment option for this patient?
A. Organic erectile dysfunction does not respond to behavioral therapy.
B. Hormonal replacement therapy is limited to erectile dysfunction secondary to hypogonadism.
C. Patients taking nitrates should not take phosphodiesterase 5 (PDE-5) inhibitors, such as
sildenafil (Viagra), due to their vasoactive properties.
D. Vacuum constriction devices are suitable for patients with vascular disorders.
Answer: D
* This question is required.
A. behaviorally oriented sexual therapy

B. hormone replacement

C. phosphodiesterase 5 (PDE-5) inhibitor

D. vacuum constriction device

* 40. A 47-year-old male presents with right flank pain and nausea x 5 hours. He has
vomited once. He is unable to find a position of comfort. Urinalysis reveals hematuria and low
urine pH. What diagnostic test would be most diagnostic?
A. Most stones, regardless of location or type, will be found if both abdominal plain film and
ultrasonography are completed. However, this approach takes more time.
B. Helical or spiral CT is the initial imaging modality of choice. All calculi except those
associated with indinavir (protease inhibitor) will be seen.
C. Cystoscopy will miss any stone outside of the bladder. Culture and sensitivity will not
diagnose stones.
D. Ultrasonography of the abdomen is helpful to visualize stones suspected of being located at
the ureterovesicular junction. CT scan will better visualize the entire urinary tract.
Answer: B
* This question is required.
A. abdominal plain film and renal ultrasound

B. helical CT of the abdomen and pelvis

C. cystoscopy with urine culture and sensitivity

D. ultrasonography of the abdomen

* 41. A 41-year-old otherwise healthy female presents complaining of fever, chills, nausea,
vomiting and right flank pain x 6 hours. Which of the following physical exam findings would
most likely be present in this patient?
A. CVA tenderness is usually pronounced in acute pyelonephritis.
B. A positive fluid wave test is found in patients with ascites.
C. Murphy sign is associated with acute cholecystitis/lithiasis.
D. A positive obturator sign indicates peritoneal inflammation such as in appendicitis.
Answer: A
* This question is required.
A. costovertebral angle tenderness

B. fluid wave

C. Murphy sign

D. obturator sign

* 42. A 42-year-old healthy male presents complaining of fever, suprapubic pain, and
dysuria x 2 days. Abdominal exam confirms lower abdominal pain, no rebound. Rectal exam
reveals a warm and extremely tender, edematous prostate. Which of the following studies will
best reveal the underlying cause?
A. Wet mount is useful to diagnose bacterial vaginosis.
B. CT will help differentiate diverticulitis.
C. Cystoscopy is not indicated in suspected cases of acute bacterial prostatitis.
D. The urine culture will demonstrate the causative pathogen. E. coli and Pseudomonas spp are
the most common pathogens in acute bacterial prostatitis.
Answer: D
* This question is required.
A. wet mount

B. abdominopelvic CT

C. cystoscopy

D. urine culture

* 43. A 12-year-old male presents with acute onset of severe right scrotal pain x 2 hours.
Physical exam reveals severe tenderness and a high-riding right testicle. Urinalysis is normal.
What is the most likely diagnosis?
A. Prostatitis is unusual in a young male and more commonly causes perineal pain.
B. Acute epididymitis may present with scrotal pain but the urinalysis is usually positive for
white blood cells, bacteria, and blood.
C. Testicular torsion usually occurs in prepubertal males with an acute onset of pain,
tenderness, and a high riding testis. Cremasteric reflex will be absent.
D. A urinary stone is uncommon in boys, and does not present with scrotal or testicular pain.
Stones are associated with flank pain.
Answer: C
* This question is required.
A. acute bacterial prostatitis

B. acute epididymitis

C. testicular torsion

D. urinary stone

* 44. A 26-year-old male presents for an initial history and physical examination. He has a
strong family history of renal cell carcinoma in several first degree relatives. Which of the
following is the most significant risk factor he should be counseled to avoid?
A. Environmental risk factors, such as alcohol, diet, and industrial dyes, are not associated with
an increased risk of renal cell carcinoma.
B. The only risk factor with evidence linking to renal cell carcinoma is smoking.
C. See A.
D. See A.
Answer: B
* This question is required.
A. alcohol ingestion in moderate quantities

B. cigarette smoking

C. dietary intake of nitrates and preservatives

D. exposure to industrial dyes

* 45. A previously healthy 35-year-old male is seriously injured in a motor vehicle accident,
sustaining lacerations resulting in massive hemorrhage. He is diagnosed with acute kidney
failure and admitted to the ICU. Which of the following is the most likely cause of his renal
A. BUN and creatinine will be elevated as a result of the renal failure, not the cause.
B. Obstructed renal flow from the kidneys (postrenal azotemia) is the least common cause of
acute kidney injury; this is not a likely cause in this scenario.
C. Prerenal azotemia is the most common cause of acute kidney injury and is due to renal
hypoperfusion. It commonly occurs in cases of volume depletion, such as that seen in massive
D. Volume overload due to excess administration of IV fluids may cause congestive heart failure
but is not commonly a cause of renal failure.
Answer: C
* This question is required.
A. failure to excrete adequate amounts of urea nitrogen

B. obstructed renal flow from the kidneys

C. renal hypoperfusion

D. volume overload secondary to iatrogenic fluids

* 46. A 74-year-old male in the ICU with multi-system organ failure and congestive heart
failure becomes lethargic, disoriented, and complains of a severe headache. Serum sodium level
is 106 mEq/L (normal range 135-145 mEq/L). Which of the following is the best immediate
treatment for this patient?
A. Diuretic therapy in hypervolemic hyponatremia should be administered but very cautiously. It
is not the immediate therapy needed to correct his symptomatic, very low sodium.
B. The patient's sodium deficit should be accurately calculated and a 3% saline infusion should
be initiated at 0.5 mL/kg body weight/hour. Although a potentially hazardous treatment in light
of the hypervolemia, this patient's condition is critical.
C. The headache is not a life-threatening condition and can be addressed later.
D. If the hyponatremia was mild to moderate, free water intake should be reduced, but not
withheld, to less than 1-1.5 L/d.
Answer: B
* This question is required.
A. diuretic therapy (furosemide) to avoid edema

B. hypertonic (3%) saline via intravenous route

C. treat headache with appropriate analgesia

D. withhold all fluids until sodium level rises

* 47. A 44-year-old male presents with muscular weakness, fatigue and muscle cramps. He
has been suffering from infectious diarrhea for the past 4 days. He is weak, BP is 104/66, pulse is
regular with a rate of 60. His ECG shows decreased amplitude, flattening of the T waves and
prominent U waves. What treatment should be initiated once serum electrolytes have been
A. Decreased calcium is not common with diarrhea, and does not show the ECG changes
B. Hypokalemia is common after diarrhea, often presents with the above findings, and may show
ECG findings classically as described above. Oral supplementation is preferred.
C. Hypophosphatemia can be found in rickets, as a side effect of medications, or associated with
genetic causes. It presents with rhabdomyolysis, paresthesias, and encephalopathy. ECG
findings are not seen.
D. Hypernatremia would be treated with sodium restriction. The patient would present with
thirst, dehydration, and irritability. No specific ECG changes are associated.
Answer: B
* This question is required.
A. calcium replacement

B. oral potassium supplementation

C. phosphate replacement intravenously

D. sodium restriction and high flow oxygen

* 48. A 34-year-old male with a history of panic attacks presents with anxiety, light-
headedness, and perioral paresthesias. His respiratory rate is 28 breaths per minute, but
unlabored. Which of the following should be done immediately for this patient?
A. Breathing into a paper bag should be discouraged in cases of hyperventilation syndrome from
anxiety. It does not correct the PCO
and may decrease the PCO
B. Invasive administration of bicarbonate is not indicated and could be harmful.
C. Reassurance may be sufficient for the anxious patient, but sedation may be necessary if the
process persists.
D. Supplemental oxygen by any route is not indicated as the PCO
is usually elevated or normal
in these patients.
Answer: C
* This question is required.
A. breathe into a paper bag

B. IV bicarbonate administration

C. reassurance and use of sedative if needed

D. supplementation with oxygen via high flow rebreather mask

* 49. A 25-year-old female presents complaining of malodorous, nonirritating vaginal
discharge for three days. Exam reveals gray-white secretions with a pH of 5.2 and a "fishy" odor.
What microscopic finding would most likely be found on a wet mount of vaginal secretions?
A. Clue cells are stippled or granulated epithelial cells indicative of bacterial vaginosis. The
appearance is caused by adherence of the Gardnerella vaginalis organisms to the edges of the
vaginal epithelial cells.
B. Hyphae indicate candidiasis. Candida most commonly causes vulvar pruritus, and thick, curd-
like vaginal discharge. Exam reveals vulvar erythema and a pH between 4.0-5.0.
C. Motile protozoa indicate Trichomonas. Symptoms include profuse, frothy, greenish, foul-
smelling vaginal discharge, sometimes associated vulvar pruritus. Trichomoniasis symptoms
most commonly are most severe just after menstruation. The vaginal pH usually exceeds 5.0.
D. Multinucleated giant cells are seen with the herpesvirus. Herpesvirus usually presents as
painful vesicles that progress to superficial ulcerations.
Answer: A
* This question is required.
A. clue cells

B. hyphae

C. motile protozoa

D. multinucleated giant cells

* 50. Three days status-post Cesarean section, a woman presents with chills, increased
uterine pain, and foul smelling lochia. Temperature is 38.0 C. On exam the uterus is soft and
tender with cervical motion tenderness. Clindamycin is started. Which of the following should be
added to the drug regimen?
A. Ampicillin is the third drug started, after clindamycin and gentamicin, when there has been no
response to the 2-drug regimen.
B. Ceftriaxone may be used to treat endometritis but is not considered first line treatment.
C. The patient has endometritis, the most common cause of postpartum fever. Risk factors
include Cesarean section, prolonged rupture of membranes and prolonged labor. Clindamycin,
an aminoglycoside, is the recommended first line treatment regimen for endometritis.
D. Metronidazole is added when there is evidence of sepsis.
Answer: C
* This question is required.
A. ampicillin

B. ceftriaxone

C. gentamicin

D. metronidazole

* 51. Which of the following women has the highest chance of developing ovarian cancer?
A. Ovarian cancer occurs at all ages but is more common postmenopausally. In addition, oral
contraceptives decrease the risk of epithelial ovarian cancer by 50% for users of 5 years or
B. Pregnancy is associated with a risk reduction of 13-19% per pregnancy.
C. Nulliparous postmenopausal women are at the highest risk of ovarian cancer. Ovulation
disrupts the germinal epithelium and activates cellular repair mechanisms. Repeated ovulation
may enable mutations to occur, which can contribute to tumor progression.
D. The woman is postmenopausal but had two pregnancies which lowers her risk. Hormone
replacement therapy (HRT) with unopposed estrogen can increase the risk of endometrial cancer
but has not been found to increase the risk of ovarian cancer.
Answer: C
* This question is required.
A. 30-year-old gravida 0 on oral contraceptive pills

B. 40-year-old gravida 4, para 4

C. 55-year-old gravida 0

D. 60-year-old gravida 2, para 2 on hormone replacement therapy

* 52. A 28-year-old female presents for evaluation of infertility x 1 year. Her menstrual
cycle is every 28 days with moderate flow. History reveals an elective abortion 12 years ago and
Chlamydia 5 years ago (successfully treated). Transvaginal ultrasonography is normal as is her
partner's sperm analysis. Which of the following tests would be best to do at this time?
A. Because of the history and a normal transvaginal ultrasound, an abdominal ultrasound is
unlikely to reveal any addition information.
B. Computed tomography (CT) is expensive and is not first line for diagnosis in suspected pelvic
factor infertility.
C. A history of regular menses and prior pregnancy followed by chlamydia suggests a pelvic
factor as the cause of infertility. Salpingitis, endometriosis, leiomyomas, DES exposure, and
previous abdominal surgery can all cause scar tissue, which increases the risk of developing
occlusion of the fallopian tubes. Hysterosalpingography is the diagnostic study of choice.
Radiographic dye is instilled into the uterine cavity and then radiographs are taken to check
uterine contour, patency of the tubes, and the ability of dye to freely spill into the pelvis.
D. A laparoscopy is often done after the hysterosalpingography. Laparoscopy can help detect
endometriosis, also a risk factor for infertility.
Answer: C
* This question is required.
A. abdominal ultrasonography

B. computed tomography

C. hysterosalpingography

D. laparoscopy

* 53. A woman presents at 6-weeks gestation and reports that she has a history of cervical
incompetence. A history of which of the following will most likely be found on further
A. Second trimester spontaneous abortions are usually maternal in origin with cervical
incompetence or uterine anomalies most often the reason. Cervical incompetence can be
congenital (as in DES exposure) or acquired (as in cervical conization for cervical cancer).
B. First trimester spontaneous abortions are usually fetal in origin and have nothing to do with
the status of the cervix.
C. A history of multiple elective abortions is more likely to result in cervical stenosis, not
cervical incompetence.
D. Cryotherapy for cervical dysplasia consists of freezing the ectocervix with liquid nitrogen. It
can be used for CIN 1, 2, 3. Cold-knife conization is another form of treatment for CIN 1, 2, 3 in
which a portion of the cervix is removed. Conization does increase the risk of cervical
incompetence but cryotherapy does not.
Answer: A
* This question is required.
A. second trimester spontaneous abortion

B. first trimester spontaneous abortion

C. first trimester elective abortion

D. cryotherapy for cervical dysplasia

* 54. A woman at 27 weeks gestation is being treated with magnesium sulfate for preterm
labor. Serum magnesium level is 11 mEq. Which of the following physical exam findings is
consistent with this serum magnesium level?
A. Cardiac depression is rare until serum levels are above 25 mEq.
B. Therapeutic serum levels of magnesium are 4-8 mEq. Loss of deep tendon reflexes is the first
sign of abnormally high magnesium levels. This usually occurs when the MgSO4 levels are
between 10-12 mEq. Calcium gluconate can be given if magnesium toxicity occurs.
C. Paralysis occurs above 15 mEq.
D. Respiratory depression occurs above 15 mEq.
Answer: B
* This question is required.
A. cardiac depression

B. loss of deep tendon reflexes

C. paralysis

D. respiratory depression

* 55. A 30-year-old woman presents to the emergency department complaining of severe
left adnexal tenderness. She a 10-pack year history of smoking; otherwise her medical history is
insignificant. Quantitative serum beta-hCG level is 3500 mIU/mL. Transvaginal ultrasonography
reveals a 2 cm left adnexal mass. Vital signs are stable. What is the best management for this
A. Laparoscopy is the second best choice. If the ectopic was greater 3.5 cm, or the patient had
unstable vital signs, a history of peptic ulcer disease, renal disease, or blood dyscrasias, or if she
was deemed unreliable, laparoscopy would be the treatment of choice. However, since the
patient has no significant medical history, the ectopic is small and the vitals are stable, she is a
good candidate for medical treatment. B. Laparotomy is only indicated over laparoscopy (see
above) if the patient is in shock or has known significant abdominal adhesions which would
make laparoscopy unsafe. C. The patient's diagnosis is early ectopic pregnancy. Methotrexate is
a folic acid antagonist which has been shown to destroy small, unruptured ectopic pregnancies.
Current studies show that up to 80% of early ectopic pregnancies can be treated successfully
with methotrexate. Methotrexate is indicated if the beta-hCG level is less than 5,000 mIU/mL
and smaller than 3.5 cm (see A for more details). D. Suspected ectopic pregnancy is an obstetric
* This question is required.
A. laparoscopy

B. laparotomy

C. methotrexate

D. send home with instructions to follow-up with obstetrician

* 56. A 26-year-old presents at 38 weeks gestation for a non-stress test (NST) to evaluate
fetal well-being. The test shows a fetal heart rate of 130 beats per minute with three accelerations
up to 135 beats per minute, lasting approximately 10 seconds each. What is the next step in
A. Biophysical profile (BPP) adds sonographic findings to the NST result. It examines five
parameters of fetal wellbeing (each worth 2 points) including NST reactivity, fetal tone,
breathing movements, gross body movements and amniotic fluid volume. Scores of under 8
warrant further evaluation of fetal wellbeing. BPP is indicated if vibroacoustic stimulation has
no effect on the fetal heart rate. B. Oxytocin stress test consists of infusing oxytocin and watching
for late decelerations with contractions. A positive test is worrisome. Because this test causes
contractions, it is not the first step in the management. C. This patient's NST is non-reactive so
further intervention is indicated before the woman can be sent home. D. Vibroacoustic
stimulation (VAS) is a vibrating auditory source that is placed on the woman's abdomen. A short
burst of sound is delivered to the fetus to "wake" it up. If the non-reactive NST is due to a sleep
cycle, the fetal heart rate will increase and severa
* This question is required.
A. biophysical profile

B. oxytocin stress test

C. send home--the test is normal

D. vibroacoustic stimulation

* 57. A 35-year-old G
presents with a history of infertility x 2 years. She complains of
moderate to severe dysmenorrhea and dyspareunia which occurs during the last 2 weeks of her
menstrual cycle. Menses is every 30 days lasting 4-5 days. Which of the following is the most
likely diagnosis?
A. Pain due to adhesions is not cyclical in nature.
B. Endometriosis most commonly occurs during the reproductive years with infertility,
dysmenorrhea and dyspareunia as the main presenting complaints.
C. Fibroids most commonly cause menstrual abnormalities such as menorrhagia (prolonged
menstrual cycles) or metrorrhagia (intermittent bleeding between cycles).
D. Polycystic ovarian syndrome commonly has anovulation as the presenting symptom. Obesity
is common in patients with polycystic ovary syndrome (PCOS).
Answer: B
* This question is required.
A. adhesions

B. endometriosis

C. fibroids

D. polycystic ovary syndrome

* 58. A 19-year-old female with no prenatal care presents complaining of a moderate
amount of painless bright red vaginal bleeding. By LMP she is approximately 34 weeks
pregnant. The bleeding was sudden in onset after sexual intercourse. She denies contractions.
What is the most likely diagnosis?
A. Placental abruption is the most common cause of painful third trimester bleeding and the
most common obstetrical cause of DIC. Risk factors include HTN, trauma, and cocaine use.
B. Placenta previa is the most common cause of painless third trimester bleeding. Risk factors
include multiple gestation, multiparity, advanced maternal age and scarred endometrium. The
patient should be admitted and closely monitored until delivery can be safely planned.
C. Uterine rupture is most commonly seen in a laboring patient with a history of a prior classical
cesarean section. Symptoms include painful heavy bleeding and a contracted uterus.
D. Vasa previa is a rare condition caused by the rupture of the fetal vessels that cross the
membranes covering the cervix. Diagnosis is seldom made until rupture of membranes occur.
Answer: B
* This question is required.
A. placental abruption

B. placenta previa

C. uterine rupture

D. vasa previa

* 59. A woman presents to the clinic after having a positive pregnancy test at home.
According to her last menstrual period, she is 10 weeks pregnant. She denies vaginal bleeding or
any pregnancy symptoms. On speculum exam, the cervix is closed. Sonography reveals a fetus in
the uterus but no fetal heart rate. What is the most likely diagnosis?
A. Complete abortion is defined as bleeding, cervical dilation, and passage of all products of
conception. The uterus will be empty on ultrasound.
B. Incomplete abortion is defined as heavy vaginal bleeding and cervical dilation with passage
of some, but not all, of the products of conception.
C. Inevitable abortion is defined as heavy vaginal bleeding and cervical dilation without passage
of products of conception.
D. Missed abortion is a nonviable pregnancy without bleeding or cervical dilation. In early
pregnancy, patients often report an abrupt ending of prior pregnancy symptoms. When it occurs
later in the pregnancy, findings can include absence of uterine growth and lack of fetal
movement. Early in the pregnancy, it is often found on routine ultrasonography.
Answer: D
* This question is required.
A. complete abortion

B. incomplete abortion

C. inevitable abortion

D. missed abortion

* 60. An 18-year-old pregnant female presents complaining of vaginal bleeding and
hyperemesis. She is 11 weeks gestation by her last menstrual period. Qualitative b-HCG is
positive. Ultrasonography shows grape-like vesicles in the uterine cavity. What is the most likely
A. Chorioadenoma destruens is an invasive mole that invades the myometrium or adjacent
structures. It is not common.
B. Choriocarcinoma is a pure epithelial tumor which is less common than other forms of
gestational trophoblastic disease.
C. Hydatidiform mole is a benign gestational trophoblastic disease which occurs in two forms:
complete and incomplete. Grape-like vesicles without a fetus present is the cardinal sign for
D. Placental-site trophoblastic tumor is a malignant gestational trophoblastic disease which can
metastasize to the lungs, pelvis (better prognosis), brain or liver (worse prognosis).
Answer: C
* This question is required.
A. chorioadenoma destruens

B. choriocarcinoma

C. hydatidiform mole

D. placental-site trophoblastic tumor

* 61. A 30-year-old female presents for a routine gynecologic exam. Her family history is
significant for breast and colorectal cancer and she is concerned regarding her personal risk of
cancer. Which of the following factors present in her history has the strongest evidence of
decreasing her risk of ovarian cancer?
A. A large pooled study of over 5,000 women with cancer and over 7,000 in the control group
found no increased risk with the use of fertility drugs.
B. Pregnancy is associated with a 13-19% decreased risk of ovarian cancer per pregnancy.
C. The use of OCPs is protective in terms of ovarian cancer. For women taking oral
contraceptives for 5 years or longer, the risk of epithelial ovarian cancer decreases by half.
D. There are a number of studies indicating an association of diet with ovarian cancer. Eating
more saturated animal fats seems to contribute to an increased risk.
Answer: C
* This question is required.
A. infertility treatment

B. one full term pregnancy

C. oral contraceptive use

D. typical American diet

* 62. A 52-year-old female presents for an annual GYN visit. She complains of hot flashes,
night sweats, and dyspareunia. Over the last several years, her menses have become irregular and
much more infrequent. Which of the following will most likely be found on physical exam?
A. The majority of postmenopausal women will have some degree of atrophy of the vaginal
epithelium. This may lead to symptomatic atrophic vaginitis.
B. Menopause is associated with a reduction in breast size.
C. With menopause, in addition to vaginal changes, there are atrophic changes of the cervix
(usually shrinks), and atrophy of the uterus (affecting both the myometrium and endometrium).
D. With menopause, there is also less cervical mucus, which can lead to vaginal dryness and
Answer: A
* This question is required.
A. atrophic vaginitis

B. breast swelling

C. uterine enlargement

D. vaginal discharge

* 63. A 22-year-old otherwise healthy female presents complaining of a lump in her right
breast. Physical exam reveals a round, firm, mobile, discrete nontender mass 1 cm in diameter.
There are no visible skin abnormalities. What is the most likely diagnosis?
A. A breast abscess would present with a palpable mass and signs of infection such as erythema
and tenderness.
B. Early breast carcinoma typically presents with a firm or hard lump which is nontender and
has poorly defined margins. Other findings such as skin or nipple retraction may present later.
C. Fat necrosis is a rare breast condition which presents with a mass, often with skin or nipple
retraction. Carcinoma must be ruled out because of the clinically identical appearance.
D. Fibroadenoma is a common, benign tumor, which most commonly occurs in young women.
The classic presentation is as described. Lesions are typically 1-5 cm in diameter.
Answer: D
* This question is required.
A. breast abscess

B. carcinoma

C. fat necrosis

D. fibroadenoma

* 64. A 20-year-old female presents with vaginal discharge and lower abdominal/pelvic
pain. She is sexually active with multiple partners, and admits to only occasional condom use.
She appears uncomfortable, but is in no acute distress. Vital signs are normal and pelvic exam
reveals purulent vaginal discharge and cervical motion tenderness. What is the recommended
A. Inpatient treatment is indicated for febrile patients, patients with significant abdominal
findings (i.e., rebound, guarding), or those who appear toxic.
B. See A.
C. Outpatient therapy is appropriate in this case of PID. Alternatives include: ceftriaxone (one
IM dose) plus doxycycline OR metronidazole or cefoxitin (single IM dose) plus doxycycline with
or without metronidazole.
D. A concern with GC resistance to quinolones makes this choice inappropriate.
Answer: C
* This question is required.
A. IV clindamycin plus gentamicin

B. IV doxycycline plus cefoxitin

C. IM ceftriaxone plus PO doxycycline

D. PO levofloxacin plus metronidazole

* 65. A 28-year-old overweight African-American G
female with a significant family
history of diabetes presents for routine prenatal care. A 3-hour 100-g oral glucose tolerance test
(OGTT) result in the following (mg/dL): fasting 82 (normal); 1 hour 190 (elevated); 2 hour 173
(elevated). Which of the following correctly describes her future risk of developing diabetes?
A. See C.
B. Women with GDM have a higher risk of developing diabetes. It almost always is type 2.
C. This patient meets the diagnostic criteria for GDM, and thus has a 50-60% risk of developing
diabetes within 10-15 years.
D. See C.
Answer: C
* This question is required.
A. It is unlikely as gestational diabetes does not predispose to diabetes in the future.

B. She is more likely to develop type 1 diabetes within 20 years.

C. She has gestational diabetes and has about a 50% risk of DM within 10-15 years.

D. The patient will almost certainly develop frank DM within 5 years.

* 66. A primiparous female presents to the emergency room with concerns about heavy
blood loss that began 2 weeks after vaginal delivery. She states she is using about ten pads per
day with visible clots. She is currently stable; blood pressure 102/70. Which of the following is
indicated for this patient?
A. The patient is stable and does not require blood transfusion at this time.
B. Labetalol is not indicated and may have detrimental effects with a hypovolemic patient.
C. Norepinephrine would be indicated if blood pressure was low or falling or the patient was
D. In delayed postpartum hemorrhage (2 weeks or more after delivery), oxytocin, 15-methyl
PGF-2 alpha, or ergot alkaloids (i.e. methylergonovine maleate) should be given for at least 2
days (48 hrs) in addition to broad-spectrum antibiotics.
Answer: D
* This question is required.
A. blood transfusion

B. labetalol

C. norepinephrine

D. oxytocin