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7/25/2017 Quiz Sheet

Course:FamilyMedicineClerkship Topic:Usmle
Question1

Selectthesinglebestanswertothenumberedquestion.

A50yearoldfemalewithatenyearhistoryoftypeIIdiabetespresentsforregularlyscheduledfollowup.Shehasnocomplaints,andjustvisitedherophthalmologistlast
week.Currentmedicationsincludeglyburide,metformin,andsimvastatin.Onphysicalexam,vitalsignsarevirtuallyunchangedfrompreviousvisits,withtemperature37.1C
(99F),HR80,BP140/83,RR15,andO2Sat98%onroomair.Neurologicalexaminationrevealsdiminishedsensationtolighttouchandpinprickinastockingdistribution
onthelowerextremitiesbilaterally.Remainderofphysicalexamisbenign.Laboratoryevaluationreveals:Na+136,K+3.9Cl104,HCO325,BUN15,Cr1.0,Glucose150
hemoglobinA1c:7.1%Urinalysis:negativeforketones,glucose,bilirubin,leukocyteesterase,orbloodmoderateproteinLipidprofile:Totalcholesterol146,HDL46,LDL
100.Atthistime,whichofthefollowingwouldbethemostappropriateintervention?

A. Increasesimvastatin
B. Increaseglyburide
C. Increasemetformin
D. Addhydrochlorothiazide
E. Addlisinopril

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Question2

Selectthesinglebestanswertothenumberedquestion.

A55yearoldfemalecomestotheemergencydepartmentcomplainingofaheadacheforthepastsixhours.Herheadachebeganabruptlyaftershefinishedeating
breakfast,andquicklyincreasedto8/10throbbingpainlocatedmainlyoverherrighttemple.Thepainhasbeenassociatedwithmildnauseabutnovomiting.Shedenies
chronicorrecurrentheadaches,butdidhaveoneheadachesimilartothisonetwoweeksago,whichresolvedaftertakingibuprofenandlyinginaquiet,darkroom.Shehas
smokedonepackofcigarettesdailyfor38years.Onphysicalexam,thepatienthastemperatureof37.0C(98.6F),pulseof99,andBP147/95.Neurologicalexaminationis
nonfocal,butmildphotophobiaandnuchalrigidityarenoted.Fundoscopicexaminationrevealsnopapilledema.Skinexamshowsnolesions.CTofthehead,obtained
withoutcontrast,revealsnoabnormalities.Whatisthemostappropriatenextstepinthemanagementofthispatient?

A. ObtainheadCTwithcontrast
B. Lumbarpuncture
C. Administeri.m.sumatriptan
D. Administeroralibuprofen
E. Administeri.v.ceftriaxone

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Question3

Selectthesinglebestanswertothenumberedquestion.

Afourweekoldmaleinfantisbroughtbyhismothertothephysicianfollowingoneweekofemesis.Thepatientsmotherstatesthatthepatienthasbeenvomitingnon
biliousmaterialimmediatelyaftereachfeeding,butthenbecomesfussyanddemandstobefedagain.Shedenieseverseeinganybloodintheemesis.Overthepasttwoor
threedays,theinfantsvomitinghasbecomeincreasinglysuddenandforceful.Thechildisirritable,withfewtears.Theoropharynxisdry,theinfantsfontanellesappear
sunken,andmoderateskintentingisnoted.Capillaryrefillisapproximately2seconds.Onabdominalexam,visibleperistalticwavesareobserved,anda1cmfirmmassis
palpatedintherightupperquadrant.Whatisthemostlikelylaboratoryfinding?

A. Na+130,K+2.9,Cl89,HCO335
B. Na+138,K+3.8,Cl100,HCO326
C. Na+150,K+4.0,Cl100,HCO324
D. Na+140,K+3.8,Cl100,HCO315
E. Na+130,K+5.8,Cl110,HCO320

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Question4

Selectthesinglebestanswertothenumberedquestion.

A30yearoldfemalepresentstoherphysicianwithabreastmass.Shefirstnotedasmalllumpinherleftbreastwhileshoweringaboutsixweeksago.Shehasnotedno
changeinthesizeofthemasssincethattime,andshedeniespainornippledischarge.Familyhistoryissignificantforapaternalgrandmotherwhohadbreastcanceratage
79.Physicalexaminationrevealsasoft,round,mobile1cmmassinthelowerouterquadrantoftheleftbreast.Noskinchangesarenoted.Whatisthemostappropriatenext
stepinthemanagementofthispatient?

A. Mammography
B. Referthepatientforradicalmastectomy
C. Beginlevonorgestrel/etinylestradiol
D. GenetictestingforBRCA1andBRCA2
E. Ultrasoundofbreastmass

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Question5

Selectthesinglebestanswertothenumberedquestion.

Anotherwisehealthy8yearoldgirlpresentswithtwoweeksofperianalpruritis.Shehastwoyoungerbrothers,oneofwhomhashadsimilarcomplaintsforthepastfew
days.Physicalexamrevealsperianalerythemawithmildexcoriations.Thescotchtapetestrevealsseveralbeanshapedwhiteeggs.Whatisthemostlikelydiagnosisin
thispatient?

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A. Trichuriasis
B. Enterobiasis
C. Childabuse
D. Fecalsoilage
E. Atopicdermatitis

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Question6

Selectthesinglebestanswertothenumberedquestion.

A66yearoldmalepresentstotheemergencydepartmentwithchestpain.Thepainbegantwohoursagoasthepatientwaswatchingtelevision.Thepainisdescribedas
"squeezing"andislocatedprimarilysubsternallywithradiationtothejaw.Pastmedicalhistoryincludesdiabetesmellitus,hypertension,hyperlipidemia,anda50pack/year
smokinghabit.Onphysicalexam,thepatientappearsanxiousanddiaphoretic.Thepatientisgivensupplementaloxygenbynasalcannula,andaspirin,morphine,and
nitroglycerinareadministered.EKGobtainedonpresentationtotheEDisshown.Ofthefollowing,whichisthemostappropriatestudytoobtainnext?


A. Aortogram
B. TroponinI
C. Stressecho
D. Exercisestresstest
E. CTangiogramofchest

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Question7

Selectthesinglebestanswertothenumberedquestion.

A73yearoldmalepresentstohisphysiciancomplainingofcoughandfatigue.Hiscoughbegan6monthsagoandhassteadilyworsened,andisnowassociatedwith
occasionalexpectorationofmucusstreakedwithbrightredblood.Patienthasalsonotedworseningdyspneaonexertionandaweightlossof15lbs.Thepatienthas
smokedapackandahalfofcigaretteseverydayforthepast60years.Pastmedicalhistoryissignificantforbipolardisordertreatedwithlithium.Physicalexamshows
unilaterallocalizedwheezingontheleftchestandclubbingofthedistalextremities.Capillaryrefillisbrisk.Noskintentingisobserved.ChestXrayisobtained,whichshows
alargemassatthelefthilum.Labsshow:Glucose130,Na+125,K+4.0,Cl91,HCO325,BUN15,Creatinine1.0Plasmaosmolality270(Normal:282295mOsm/kg)
Urineosmolality650mOsm/kg(Normal:501400mOsm/kg).Whichofthefollowingisthemostlikelymechanismforthispatient'shyponatremia?

A. Increasedoralintakeofhypotonicfluids
B. Decreasedoralintakeofsolutes
C. ImpairedsecretionofADHintheposteriorpituitary
D. Ectopicoverproductionofvasopressin
E. ResistancetoADHactiononthecorticalandmedullarycollectingtubules

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Question8

Selectthesinglebestanswertothenumberedquestion.

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A25yearoldstudentpresentswiththreedaysofvulvarpruritis.Shehashadatotalofsixlifetimepartners,andiscurrentlysexuallyactivewithonepartnerandstatesthat
theyoccasionallyusecondoms.Oneyearago,shewassuccessfullytreatedforaChlamydiainfection.Thepatientdeniesvaginalodororincreasedvaginaldischarge.
Physicalexamrevealsslightvulvarerythema,andspeculumexamshowsmoderateclumpywhitedischarge.VaginaldischargepHis4.0.Whifftestisnegative.Wetmount
results:KOHprepshowsoccasionalbuddingyeastandhyphae.Salineprepshows3WBCs,occasionalsquamouscells,andnobacteria.Whatisthenextbeststepinthe
managementofthispatient?

A. Clotrimazolevaginalcream
B. AzithromycinandrecommendthatherpartnerseeaphysicianforChlamydiascreeningandtreatment
C. Metronidazole
D. Ceftriaxone
E. Reassuranceandfollowupintwoweeks

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Question9

Selectthesinglebestanswertothenumberedquestion.

Asevenyearoldfemaleisbroughttothephysicianbyhermotherbecauseoffacialswellinganddark,colacoloredurine.Thesesymptomsbeganabruptlytwodaysago
andhavebeenassociatedwithanorexiaandmalaise.Therehavebeennoknownsickcontacts.Hermotherstatesthatthechildisuptodatewithherimmunizationsand
hasbeeningoodhealthexceptforarunnynoseandsorethroataroundtwoweeksago,whichresolvedafterafewdayswithouttreatment.Vitalsignsaretemperature37.2
C(98.9F),heartrate95,andbloodpressureof148/86.Thereisdiffuseedemaofthelowerextremities,face,andeyelids.Lungsandheartarecleartoauscultation.
Urinalysisshowsmoderatehematuriaandproteinuria,anddysmorphicRBCsandoccasionalRBCcastsarenotedonmicroscopicexamination.Basedonthesefindings,
whatisthemostlikelydiagnosis?

A. IgAnephropathy
B. Alportsyndrome
C. Thinbasementmembranenephropathy
D. Postinfectiousglomerulonephritis
E. HenochSchonleinpurpura

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Question10

Selectthesinglebestanswertothenumberedquestion.

A71yearoldmalecomestohisphysiciansofficecomplainingofmuscleweakness.Theweaknessbeganinsidiouslyseveralweeksago,andhasnowprogressedtothe
pointwherehehasdifficultywithnormalactivitiessuchasbrushinghishairorsittingunsupported.Pastmedicalhistoryissignificantforhyperlipidemia,chronicrenal
insufficiency,coronaryarterydisease,andcoronaryarterybypassandgrafting.Currentmedicationsincludeatorvastatin,fosinopril,metoprolol,aspirin,andspironolactone.
Physicalexaminationrevealsdiminisheddeeptendonreflexesanddecreasedmotorstrength.LaboratoryevaluationshowsNa+143,K+7.4,Cl101,HCO328,BUN30,
andcreatinine1.8.EKGisobtainedonpresentationandisseenhere.Whatisthemostappropriateinitialstepinthemanagementofthispatient?


A. Administeri.v.insulinandglucose
B. Administerp.o.sodiumpolystyrenesulfate
C. Administeri.v.sodiumbicarbonate
D. Administeri.v.calciumgluconate
E. Urgenthemodialysis

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Question11

Selectthesinglebestanswertothenumberedquestion.

A30yearoldfemalecomestoherphysician'sofficeforaroutinehealthexamination.Shehasbeeningoodhealthrecentlyandisuptodatewithhergynecological
examinations.Heronlymedicationisloratadineforseasonalallergiesandibuprofenforoccasionalheadaches.Physicalexaminationshowstemperature37.1C(98.8F),
pulse80,BP170/92,RR14,oxygensaturationof99%onroomair.A3/6midsystolicejectionmurmurispresent.Abdomenisnontenderwithasoftsystolicdiastolicbruit
thatlateralizestotheleftside.Thepatientisgrosslyintactneurologically,andfundoscopicexaminationshowssharpopticdiscmargins.LaboratoryevaluationshowsNa+
141,K+3.9,Cl106,HCO327,BUN18,Cr1.0,glucose98.Urinalysisshowstraceproteinuriaandnocasts.Whatisthemostlikelypathologicalmechanismcausingthis
patient'shypertension?

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A. Fibromusculardysplasia
B. Oversecretionofaldosterone
C. Exogenousadministrationofcorticosteroids
D. Atheroscleroticdisease
E. Catecholamineproducingtumor

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Question12

Selectthesinglebestanswertothenumberedquestion.

A23yearoldmalepresentswithsyncope.Hereportsthatwhilewalkingbrisklytohiscar,hefelthisheartracinginhischest,andshortlythereafterpassedout.Thepatient
deniesanypriorsyncopalepisodes,butdoesnoteoccasionalepisodesofpalpitationsthatoccuraftermoderateactivityorduringperiodsofincreasedstress.Thereisno
familyhistoryofneurologicaldisease,cardiacdisease,orsuddencardiacdeath.Onphysicalexamination,pulseis85andregular,BPis124/74,respiratoryrateis16,and
oxygensaturationis98%onroomair.Cardiacexaminationrevealspulsationatthefifthintercostalspaceattheleftparasternalareainthemidclavicularline.S1iswithin
normallimits,andS2isheardtosplitoninspiration.Theremainderofthephysicalexamisunremarkable.EKGtakenintheofficeshowsthefollowingtracinginleadII.
Whichofthefollowingwouldbethemostappropriatetreatmentforthispatient'sdisorder?


A. Radiofrequencyablationofpreexcitationpathway
B. UrgentDCcardioversion
C. Hearttransplant
D. Biventricularpacemakerplacement
E. Coronaryangioplasty

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Question13

Selectthesinglebestanswertothenumberedquestion.

A20yearoldhealthyfemalepresentstoherfamilyphysicianforroutineannualgynecologicalexam.Sheissexuallyactivewithhermonogamousmalepartnerandcurrently
usesthewithdrawalmethodforcontraception.Althoughthisisherfirstsexualpartner,shethinksherboyfriendhasprobablyhadintercoursewithotherwomenpriortotheir
relationship.HerLMPwas2daysago.SheagreestoroutinegonorrheaandChlamydiatesting.Onspeculumexamafterswabbingforthetest,somebleedingfromthe
cervicalmucosaisnoted.Bimanualexamisnormal.ThetestreturnspositiveforN.gonorrheae.Whatisthebestinitialstepinthemanagementofthispatient?

A. Reassuranceandencouragecondomuse
B. Startandoralcontraceptivepill(OCP)
C. Ceftriaxoneandazithromycin
D. Doxycycline
E. Ciprofloxacin

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Question14

Selectthesinglebestanswertothenumberedquestion.

A74yearoldmanpresentswithdoublevision.Hefirstnoticedthisseveralmonthsago,andalthoughhissymptomswaxandwane,henowexperiencesdailyepisodesof
seeingdouble,mostfrequentlyintheevenings.Healsoreportsincreasedgeneralizedfatigueandnotesthathesometimesgetssotiredatdinnerthathecanhardlychew
hisfood.Pastmedicalhistoryincludesosteoarthritis,hypertension,andabdominalaorticaneurysmrepair.Physicalexaminationrevealsacomfortable,ageappropriate
elderlygentlemanwithmilddysarthria.CardiacauscultationrevealsbothanS4anda2/6holosystolicmurmurheardbestattheleftuppersternalborderwithradiationtothe
carotids.Onneurologicexam,thepatienthas5/5strengthproximallyanddistally.Sensationisintactandreflexesare2+throughout.Ocularmovementsaresluggishbut
intactinalldirections.Thepatienthasmildbilateralptosis,whichisnotedtoincreasewithsustainedupwardgaze.Strokingthebottomofthefootresultsindownward
deflectionofthegreattoebilaterally.Whichofthefollowingisthemostappropriatenextstepindiagnosis?

A. Administeri.v.edrophonium
B. CTofchest
C. MRI/MRAofbrainandcerebralvessels
D. Temporalarterybiopsy
E. CSFexaminationforoligoclonalbands

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Question15

Selectthesinglebestanswertothenumberedquestion.

Onroutineexamination,afiveyearoldchildisnotedtohavealoudS1withafixedandwidelysplitS2thatdoesnotvarywithrespiration.Asoft,midsystolicejection
murmurisheardbestontheleftinthesecondintercostalspace.Remainderofphysicalexamisotherwiseunremarkable.Thereisnonailclubbing,hepatomegaly,orjugular
venousdistension.Thechildishealthyandactiveandhermotherhasnohealthconcerns.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

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A. Mitralvalveprolapse
B. Pulmonicregurgitation
C. TetralogyofFallot
D. Atrialseptaldefect
E. Ventricularseptaldefect

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Question16

Selectthesinglebestanswertothenumberedquestion.

A62yearoldwomanwithCOPDpresentstoherphysiciancomplainingoftwodaysofincreasingdyspneaandcough.Sheusessupplementaloxygenathomeandhashad
toincreaseheroxygenflowtorelievehershortnessofbreath.Recently,hercoughhasbeenproductiveofcopiousamountsofthick,darkyellowsputum.Althoughshenever
checkedhertemperatureathome,shethinksshemighthavehadafeverlastnight.Pastmedicalhistoryincludeshypertensionandperipheralarterialdisease.Shehas
smoked12packsofcigarettesperdayforthelast45yearsandcontinuestosmoke.Currentmedicationsincludenebulizedalbuterol,tiotropium,inhaled
fluticasone/salmeterol,lisinopril,andpentoxyfylline.Physicalexaminationrevealsanuncomfortable,thinfemaleappearingolderthanherstatedage.Vitalsignsare:
temperature37.2C(99.0F),pulse80,bloodpressure136/70,respirations20/min,oxygensaturation88%on2LO2bynasalcannula.Thepatientisusingaccessory
musclestobreathe,andprolongedexpirationsandfaintexpiratorywheezesthroughoutthelungfields.Coarsecracklesareheardatthelungbases.ThepatientschestX
rayisshown.Whichofthefollowingisthemostappropriatetreatmentforthispatient?


A. Methylprednisolone
B. Prednisoneandamoxicillin
C. Guaifenasin
D. Trimethoprim/sulfamethoxazole
E. Aminophylline

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Question17

Selectthesinglebestanswertothenumberedquestion.

A64yearoldmalepresentsforroutinehealthevaluation.Hehasbeenfeelingwellandhasnocomplaints.Pastmedicalhistoryincludeshypertension,osteoarthritis,and
generalizedanxietydisorder.Medicationsincludehydrochlorothiazide,ibuprofen,atenolol,andparoxetine.Physicalexamshowstemperature37.9C(99.3F),pulse61,
bloodpressure131/70,andrespirations15/min.Laboratoryevaluationshows:Na+141K+3.9Cl103HCO325BUN18Creatinine1.2WBC9.7Hemoglobin10.1
Platelets179MCV73fL.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?

A. Addlisinopril
B. Measurereticulocytecount
C. TestB12andfolatelevels
D. Endoscopy
E. IndirectanddirectCoombs'tests

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Question18

Selectthesinglebestanswertothenumberedquestion.

A36yearoldAfricanAmericanmalecomestothecliniccomplainingoffatigueanddark,colacoloredurineforthepastfivedays.Hedeniesfever,nauseaorvomiting,
recenttravel,andi.v.druguse.Pastmedicalhistoryincludesulcerativecolitis.Medicationsincludesulfasalazineaswellastrimethoprim/sulfamethoxazolewhichthepatient
begantakingoneweekagoforapresumedStaphylococcalskininfection.Vitalsignsaretemperature36.8C(98.2F),pulse78,bloodpressure118/72,respirations14/min.
Physicalexaminationshowsscleralicterusandanontenderabdomenwithoutorganomegaly.Laboratoryevaluationshows:WBC8.6Hgb9.1Hct27.3Platelets212MCV
88fLNa+144K+4.8Cl101HCO326BUN14Creatinine1.0Glucose101LDH410U/LHaptoglobin8mg/dL.Whichofthefollowingisthemostappropriatenext
stepinmanagementofthispatient?

A. QuantitativeIgMforhepatitisAvirus

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B. Begindarbopoietininjections
C. Beginmethylprednisolone
D. Discontinuetrimethoprim/sulfamethoxazole
E. Immediatetransfusionofpackedredbloodcells

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Question19

Selectthesinglebestanswertothenumberedquestion.

A65yearoldfemalewithdiabetesisfoundonroutinescreeningtohaveatotalserumcholesterolconcentrationof198mg/dL,withaserumHDLcholesterolof58mg/dL
andserumLDLcholesterolof128mg/dL.Triglyceridesare78mg/dL,andlasthemoglobinA1cis6.5%.Thepatienthasnoknownhistoryofcoronaryarterydisease,does
notsmoke,andexercisesdaily.Currentmedicationsincluderosuvastatin,fosinopril,glyburide,andmetoprolol.Bloodpressureis129/78.Urinalysisshowsnoprotein.Which
ofthefollowingisthebestmanagementplanandtreatmentgoalforthispatient?

A. AddniacintoincreaseHDLto>80mg/dL
B. IncreaserosuvastatintotargetLDL<100mg/dL
C. Addgemfibroziltodecreasetriglyceridesto<70mg/dL
D. Discontinuefosinoprilandaddhydrochlorothiazidetodecreasebloodpressureto<120/80
E. BegininsulintherapytotargetHgbA1c<6.0%

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Question20

Selectthesinglebestanswertothenumberedquestion.

A5yearoldfemalepresentsforaprekindergartenphysicalandisfoundtohaveabloodpressureof146/85inbotharms.Pastmedicalhistoryisunremarkable,andthe
childhasbeenhealthyandasymptomatic.Physicalexaminationrevealsashort,stockyfemalewithabroad,shieldshapedchestandwidelyspacednipples.Thereare
diminishedfemoralpulsesbilaterally.Oncardiacauscultation,ashort2/6midsystolicmurmurisheardattheleftparavertebralinterscapulararea.Whichofthefollowingis
themostlikelyassociatedfindinginthispatient?

A. Increasedurinehomovanillicacid(HVA)andvanillylmandelicacid(VMA)
B. Tonsillarhypertrophy
C. Decreasedlevelsofthyroidstimulatinghormone(TSH)
D. Chestxrayshowingnotchingoftheribsbilaterally
E. Sensorineuralhearinglossandhematuria

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Question21

Selectthesinglebestanswertothenumberedquestion.

An84yearoldwomanhasexperiencedthreeweeksofdiffusemyalgias.Inadditiontoworseningfatigue,shehasstiffnessuponawakeninginhershoulders,hipgirdles,
neck,andtorso.Thestiffnessusuallyresolvesafterseveralhours.Shehasalsohadoccasionallowgradefeversanda6poundweightlosssincehersymptomsbegan.
Physicalexaminationshowsdecreasedactiverangeofmotionoftheshouldersandneck,butnomuscletenderness.Neurologicalexamshowsnormalsensationand
reflexes.Noabnormalfindingsarenotedonskinexamination.Whichofthefollowingisthemostlikelyassociatedfindinginthispatientsdisease?

A. Anticentromereantibodiespositiveat1:640
B. Absoluteneutrophilcountof950/mm3(Normal:>1800mm3)
C. Karyotypingshowingt(9,22)chromosomalrearrangement
D. Erythrocytesedimentationrate(ESR)of96mm/h(Normal:<20mm/h)
E. Xraysdemonstratingexpansionofthebonycortexinamosaicpattern

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Question22

Selectthesinglebestanswertothenumberedquestion.

An18yearoldfemalepresentstoherfamilyphysiciantodiscussoptionsforbirthcontrol.Menarchewasatage12.Hermensesoccuratregular28dayintervals,butshe
doeshavemoderateadominalcramping,bloating,andoccasionalnauseathatsometimespreventherfromgoingtoschool.Sheisinterestedinbecomingsexuallyactivebut
herboyfriend,whohashadothersexualpartnersinthepast,doesntliketousecondoms.Herfamilyhistoryissignificantforhermotherhavinghadovariancanceratage
40.Thepatientdoesnotsmokeandisotherwisehealthy.Whatwouldbethemostappropriateinitialstepinthemanagementofthispatient?

A. Recommendcondomusebecauseofthepatient'sfamilyhistoryofovariancancer
B. PrescribeanOCPafteraworkupofhercyclicalabdominalcramping
C. Startaprogestinonlypilltolimitthepatient'sintakeofestrogen
D. Prescribeacombinedoralcontraceptive
E. Recommendanintrauterinedevice(IUD)

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Question23

Selectthesinglebestanswertothenumberedquestion.

A55yearoldwomanhashadfourdaysofacoughproductiveofdarkyellowsputum.Shehasalsoexperiencedoccasionalshakingchillsandhassharpchestpainthatis
worstoninspiration.Shedeniesrecenttravelhistory,knownsickcontacts,orrecenthospitalization.Pastmedicalhistoryissignificantforosteoarthritisandhypertension.
Temperatureis38.0C(100.4F),pulse85,bloodpressure132/80,respirations22/min,oxygensaturation97%onroomair.Thepatientisalert,oriented,andinteractive.
HeartbeatisregularwithnormalS1andS2.ThereisnoJVD.Therearedecreasedbreathsoundsaswellasegophonyandpositivetactilefremitusattherightlungbase.

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Abdomenisobese,nondistended,andnontender.Therearenopetechiaeorrashesnotedonskinexam.Chestxrayisshown.Whichofthefollowingisthemost
appropriatetherapyforthispatient?


A. Enoxaparin
B. Vancomycinandmeropenem
C. Cefepimeandgentamicin
D. Azithromycin
E. Immediateneedlethoracostomy

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Question24

Selectthesinglebestanswertothenumberedquestion.

A15yearoldgirlisreferredfromherdentistaftershebledexcessivelyfollowingextractionofherwisdomteeth.Shealsoreportsprolongedmenseslasting810daysand
recurrentepistaxis.Hermotherexperiencedlengthypostpartumbleedingafterthedeliveryofallthreeofherchildren.Physicalexaminationrevealsscatteredpetechiae.
Laboratoryanalysisshows:WBC7.6Hemoglobin9.8Hematocrit29.1Platelets229PT12s(normal1115s)aPTT35s(normal2035s)Bleedingtime13min(normal2
7min).Whichofthefollowingisthemostappropriatetreatmentforthispatientsdisorder?

A. Plasmaphresis
B. Desmopressin
C. FactorVIIIconcentrate
D. Hydroxyurea
E. Splenectomy

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Question25

Selectthesinglebestanswertothenumberedquestion.

A27yearoldmalehashadasorethroatfortwoweeks.Thepainhasnowbecomesogreatthathehasgreatdifficultyswallowingandhasonlybeenabletoeatanddrink
smallamountsoverthepastfewdays.Hehashadoccasionalfevers,butdeniescoughorcoryza.Priortothis,thepatienthadbeenveryhealthyandhadnotbeentoa
physicianforfifteenyears.Vitalsignsonpresentationincludetemperature38.0C(100.4F),pulse90,bloodpressure118/75,andrespirations14/min.Onphysicalexam,no
tonsillarexudatesareseen,buttherearenumeroussoft,fluffywhiteplaquesinthepatientstongueandoropharynx.Thelesionsbleedslightlywhentheyarescraped.
Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?

A. Peripheralbloodsmearforatypicallymphocytes
B. RapidantigendetectiontestforGroupAbetahemolyticStreptococcus
C. AntibodyassayformeaslesvirusIgM(MVIgM)
D. Lateralneckradiographs
E. ELISAforHIV1antibodies

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Question26

Selectthesinglebestanswertothenumberedquestion.

A15yearoldotherwisehealthyfemalepresentstoherfamilyphysicianwithrightlowerquadrantabdominalpain.Althoughthepainwaxesandwanes,itreachesa7/10on
thepainscale,andibuprofenhasbeenineffective.Menarcheoccurredatage10andhermenseshavealwaysbeenregularat26daycycles.Thepatientisnotsexually
active.LMPwas2weeksago.Bimanualexamappreciatesnormalsizeovaries,butthepatientexperiencespainonpalpationoftherightadnexae.Anabdominalultrasound
revealsa5cmsmooth,thinwalled,unilocularcysticstructureontherightovary.UrinepregnancytestisnegativeandWBCisnormal.Whatisthemostlikelydiagnosis?

A. Polycysticovariansyndrome
B. Dermoidtumor
C. Endometriosis
D. Physiologicalovariancyst
E. Tuboovarianabscess

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Question27

Selectthesinglebestanswertothenumberedquestion.

Inordertoobtainajobataprison,a34yearoldmanundergoesarequiredchestxraytoscreenfortuberculosis.A14mmroundedopacityisnoted,surroundedbynormal
lungtissue.Therearesmallcalcificationswithintheopacity,butnoadenopathyoratelectasisisseenradiographically.Thepatienthasneversmokedandhasnoknown
exposurestotuberculosis.Thereisnofamilyhistoryoflungcancerorothermalignancy.Onphysicalexam,thepatienthastemperature37.0C(98.6F),pulse76,blood
pressure130/83,respirations14/min.Lungsarecleartoauscultationandpercussion.Nonailclubbingisseen.Whichofthefollowingisthemostappropriatenextstepinthe
managementofthispatient?

A. Repeatchestxrayin3months
B. Beginrifampin,isoniazid,pyrazinamide,andethambutol
C. Bronchoscopy
D. CTguidedneedlebiopsy
E. Thoracotomy

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Question28

Selectthesinglebestanswertothenumberedquestion.

A7yearoldgirlisbroughttoherphysicianbecauseherparentsareconcernedthatsheisshorterthanallofherclassmates.Thepatientspastmedicalhistoryisbenign,
andsheisotherwisehealthyandthrivingathomeandatschool.Hermotheris61in.(155cm)andherfatheris67in.(170cm)tall.Inreviewingheroldrecords,itappears
thathergrowthvelocityisnormal.Physicalexaminationshowsthechildtobeinthe3rdpercentileforherageforbothheightandweight.ThepatientisTannerstage1and
isotherwisedevelopmentallyappropriate.Theremainderofphysicalexamisnormal.Whatisthemostappropriatenextstepinthemanagementofthispatient?

A. Reassurance
B. Boneage
C. HIVtesting
D. SerumIGF1
E. Serumgrowthhormonelevel

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Question29

Selectthesinglebestanswertothenumberedquestion.

A26yearoldG2P1isat28weeksgestationofanuncomplicatedpregnancy.Thepatientdeniesdecreasedfetalmovement,dysuria,urinaryfrequencyorurgency,vaginal
bleedingordischarge,andnauseaandvomiting.Medicationsincludeaprenatalvitaminandfolateandironsupplements.Physicalexamshowsuterinefundalheight29cm
withfetalheartrateinthe150s.Laboratorytestingshows:Fastingserumglucose115mg/dLMaternalbloodtypeB+.Thepatient'surinalysisshowsthefollowing.Color:
yellowSpecificgravity:1.020(normal:1.0021.030)pH:5.2Glucose:negativeKetones:negativeProtein:1+RBC:negativeLeukocyteesterase:traceNitrite:2+
Urobilinogen:0.3EhrU/dL(normal:0.21.0EhrU/dL).Urineculturegrows25,000cfu/mLGramnegativerods.CervicalculturesforN.gonnorheaeandChlamydiaare
negative.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?

A. AdministerRhoGAM
B. Measurematernalserumalphafetoprotein(MSAFP)
C. Begininsulintherapy
D. Begincephalexin
E. Reassuranceandroutinefollowup

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Question30

Selectthesinglebestanswertothenumberedquestion.

A72yearoldmancomestohisphysicianbecausehehasbeenfeelingsadandthinksheneedshelp.Forthepastseveralweeks,hehasnoteddecreasedappetiteandan
8lbweightloss,andhehasseldomlefthishouse,eventoparticipateinhisweeklybowlingleague.Whileheisabletofallasleepnormally,heawakensafter34hoursand
isunabletofallasleepagain.HehasalsohadincreasingdifficultybalancinghischeckbookandwritinghisChristmascards,andbelievesthathejustcantstayfocused
enoughtocompletethesetasks.Sixmonthsago,hiswifeoffiftyyearsdied,andheoftenfeelsguiltythathedidnottreatheraskindlyasheshouldhave.Whenhethinks
abouthiswife,hethinksthathewouldratherbedeadthanwithouther,althoughhedenieshavingaplantoharmhimself.Pastmedicalhistoryincludescoronaryartery
diseaseandgout.Medicationsincludelisinopril,allopurinol,metoprolol,furosemide,andaspirin.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Adjustmentdisorder
B. Bereavement
C. Majordepressivedisorder
D. Dysthymicdisorder
E. Alzheimer'sdementia

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Question31

Selectthesinglebestanswertothenumberedquestion.

A2yearoldmalechildreturnstothephysicianwithcontinuedfeverandarash.Eightdaysago,hehadtheabruptonsetoffever,whichwaslateraccompaniedbyirritability
andanorexia.Feversto104F(40C)havecontinuedandhavenotdecreaseddespitehismothersrepeatedadministrationofacetaminophenandibuprofen.Physicalexam
revealsinflammationoftheconjunctivabilaterallywithoutpurulentdrainage.Thereisdiffusecervicallymphadenopathyandpeelingoftheskinaroundthefingernails.
Scatteredtargetlike,erythematous,macularlesionsarepresentonthetrunkandextremities.Therearenotonsillarexudates,butaphotoofthechildstongueisseenhere.
Whichofthefollowingisthemostlikelydiagnosisinthispatient?

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A. Drughypersensitivity
B. Scarletfever
C. Erythemainfectiosum
D. Kawasakidisease
E. RockyMountainspottedfever

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Question32

Selectthesinglebestanswertothenumberedquestion.

A54yearoldmanpresentswithacutekneepainwhichbeganlastnightwhilehewassleeping.Heisnowin9/10painandsaysthatheishardlyabletowalksecondaryto
hisinabilitytoflexhisleftknee.Pastmedicalhistoryincludeshypertension,nephrolithiasis,andtwosimilarepisodesofpainthathaveoccurredoverthepast16months,one
inhistoeandanotherinhisleftknee.Onphysicalexam,thepatientisvisiblyuncomfortableandisholdinghislegperfectlystill.Thereismarkederythemaandsofttissue
swellingsurroundingtheknee.Passiverangeofmotionisseverelydiminishedsecondarytothepatientspain.AnalysisofjointaspirateshowsaWBCof60,000and
abundantneedleshapedcrystalsthatshownegativebirefringenceunderapolarizingfilter.Treatmentisinitiatedwithcolchicine,prednisone,andindomethacin.Whatisthe
nextmostappropriatestepinthemanagementofthispatient?

A. 24hoururinecollectionforuricacid
B. Measurementofserumuricacid
C. Plainfilmxraysofknee
D. Begintherapywithallopurinol
E. Begintherapywithprobenecid

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Question33

Selectthesinglebestanswertothenumberedquestion.

A24yearoldmalecomestohisphysicianafternoticingmultiplebumpsonhishandsandlegs.Thereisaburningsensationinthelesions,buttheydonotitch.Eightdays
prior,thepatientwasfoundtohavecoldagglutininsandwasstartedonerythromycintotreatMycoplasmapneumoniae.Thepatientdeniesanyrecenttravelorsickcontacts,
butdoesworkwithimmigrantsathisjobasanimmigrationofficer.Physicalexaminationrevealsnumerousvesiculobullouslesionssymmetricallyonthepalmsofthehands
andontheextensorsurfacesofthearmsandlowerlegs.Aphotographofthispatientslesionsisseenhere.Whichofthefollowingisthemostlikelydiagnosisinthis
patient?


A. Erythemamultiforme
B. Smallpox
C. Fixeddrugeruption
D. StevensJohnsonsyndrome
E. RockyMountainspottedfever

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Question34

Selectthesinglebestanswertothenumberedquestion.

Amotherbringsher5yearoldsontothedoctorbecausehehasbeenscratchinganareaonhischestforthepastweek.Theitchingismuchworseatnight.Thepatienthas
nothadaknowncontactwithpoisonivy,hasnohistoryofatickbiteandhismothersaysthatnooneelsehasarashlikethis.Thechildhasbeenafebrileandhasnotbeen
actingsick.Thereisafamilyhistoryofeczemaandsothepatientsmotherusedsomeofherownsteroidcreamonhersonsrashforthepastthreedays,butthiswasnot
helpful.Physicalexamrevealsanareaofsmallerythematouspapulesthatareexcoriatedandtippedwithbloodcrustsonhisrightupperchestextendingunderhisrightarm.
Thereareseveralfaintthin,brownishlinesjustunderthesurfaceoftheskin.Severalofthewebspacesbetweenhisfingersalsoseemtohaveasimilarappearingrash,as
dothebottomofhisfeet.Whatisthemostlikelydiagnosisinthispatient?

A. Contactdermatitis
B. Atopicdermatitis
C. Scabies
D. Molluscumcontagiosum
E. Skinatrophyandtelangiectasiasfromthetopicalsteroids

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Question35

Selectthesinglebestanswertothenumberedquestion.

A36yearoldG1P0A0at18weeksgestationpresentsforroutineprenatalcare.Shehasnocomplaintsandhasfeltthebabymovingnormally.Heronlymedicationisa
prenatalvitamin.Familyhistoryissignificantformentalretardationinanephew.Physicalexaminationshowsafundalheightof17cmandafetalheartrateinthe160sby
Dopplerultrasonography.Laboratoryanalysisshowsalphafetoproteintobeelevatedto3.5multiplesofthemedian(MoM).UnconjugatedestriolandbetahCGarewithin
normallimits.Thiswomansfetusismostlikelytohavewhichofthefollowingconditions?

A. FragileXsyndrome
B. Cysticfibrosis
C. Anencephaly
D. Trisomy18
E. Trisomy21

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Question36

Selectthesinglebestanswertothenumberedquestion.

A3yearoldmaleisbroughttothephysicianbyhismotheraftershenotedmultiplebruisesonhisbody.Shedeniesanyrecenttrauma.Twoweeksago,thepatienthad
threedaysofcoughandlowgradefeverthatresolvedwithoutantibiotictherapy,butsincethattimehehasbeenwell.Pastmedicalhistoryisotherwiseunremarkable.The
patientisuptodateonallrequiredimmunizations.Onphysicalexam,thepatientisafebrileandplayinghappilyathismothersfeetintheexaminationroom.Thereareno
peritonsillarexudates.Tympanicmembranesareclear.Thereisnoabdominaltendernessororganomegaly.Examinationoftheskinshowsdiffuseandnumerouspetechiae
andpurpura.Laboratoryanalysisrevealsthefollowing:WBC7.5k/mcLhemoglobin12g/dLhematocrit36%platelets27k/mcLtotalbilirubin0.7mg/dLAST22U/LALT
18U/Lalkalinephosphatase120U/LLDH186U/LPT11s(normal1113s)PTT22s(normal2030s).Whichofthefollowingisthemostappropriateinitialtreatmentfor
thispatientsdisorder?

A. Prednisone
B. Ceftriaxone
C. Vincristine
D. Cyclophosphamide
E. Immediateplatelettransfusion

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Question37

Selectthesinglebestanswertothenumberedquestion.

A36yearoldconstructionworkerisbroughttotheemergencyroomafterahouseframecollapsedonhim.Hisupperthighsweretrappedunderaheavywoodenbeamfor
almosttwohourswhilehiscoworkersworkedtofreehim.Vitalsignsaretemperature37.2C(99.0F),pulse90,bloodpressure136/82,respirations16/min.Thepatientis
alertandoriented,butobviouslyinpain.Thereareoccasionalsuperficialabrasionsonthefaceandarms,butnolargelacerationsarenoted.Breathsoundsarepresentand
equalbilaterally.ThereisanormalS1andS2.Abdomenisnontender,nondistended,andatraumatic.Thepatientslegsshowbilateralecchymosesandtendernessatthe
upperthigh.Dorsalispedisandposteriortibialpulsesare2+,anddistallegsensationtolighttouchandpinprickisintact.LaboratoryanalysisshowsthefollowingNa+145
K+5.3Cl101bicarbonate22BUN17creatinine1.1glucose106.Dipstickurinalysisisunremarkableexceptfor4+blood.Microscopicurinalysisshows2WBCs/hpf,0
RBCs/hpf,3epithelialcells/hpf,andnocasts.Whatisthemostappropriatenextstepinthemanagementofthispatient?

A. Intubationandmechanicalventilation
B. Boluswith2Li.v.0.9%NaClsolution
C. Cystoscopy
D. Intravenouspyelogram
E. AbdominalandpelvicCT

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Question38

Selectthesinglebestanswertothenumberedquestion.

Asevenyearoldmaleisbroughtbyhismothertothephysicianbecauseofabaldpatchonhisheadwhichhasbeengettinglargerforthepastthreeweeks.Thechildhas
beenafebrileandfeelingwellthroughoutthistime.Thepatientsmotherhasseenhersonscratchthepatchonlyoccasionally,andtheboysaysthatitonlyitchesalittlebit.

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Pastmedicalhistoryincludesasthmatreatedwithalbuterol.Physicalexaminationrevealsmultiplenonerythematous,scaling,welldemarcatedpatchesonthescalp.A
microscopicexaminationofscrapingsfromoneofthelesionspreparedwithKOHshowsspores,butthereisnofluorescenceunderultravioletlight.Aphotographofthe
lesionisshown.Whichofthefollowingisthemostappropriatetreatmentforthispatient'scondition?


A. Clobetasolointment
B. Mupirocin
C. Griseofulvin
D. Permethrincream
E. Lindaneshampoo

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Question39

Selectthesinglebestanswertothenumberedquestion.

A37yearoldteacherhashadthreemonthsofnonproductivecough.Thecoughseemstobeworstatnightanduponawakeninginthemorning.Shedeniesfevers,
dyspnea,chestpain,wheezing,purulentnasaldischarge,orheartburn.PastmedicalhistoryincludesIBSandhypertension.Medicationsincludecandesartanandanoral
contraceptivepill.ShehasneversmokedortraveledoutsideoftheUnitedStates.Physicalexaminationrevealsanafebrile,wellnourished,healthyappearingfemale.The
oropharynxismoistandwithouterythemaorexudates.Nasalmucosaispinkandslightlyedematous.Breathsoundsarecleartoauscultationbilaterally.Firstandsecond
heartsoundsarewithinnormallimits,andnoadditionalheartsoundsormurmursarenoted.Thereisnoperipheraledema.Chestxrayshowsnormallungfields.Whichof
thefollowingisthemostappropriateinterventionatthistime?

A. Stopcandesartan
B. Beginantihistamineanddecongestant
C. Amoxicillin/clavulanate
D. Placetuberculinpurifiedproteinderivative(PPD)
E. ChestCT

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Question40

Selectthesinglebestanswertothenumberedquestion.

Followinga10hourcartrip,a73yearoldfemaledevelopsleftankleswellingandacuteshortnessofbreath.UltrasoundwithDopplerofherleftlegconfirmsthepresenceof
deepvenousthrombosis,andthepatientishospitalizedandstartedonaheparindripandoralwarfarin.Twodayslatersheisdischargedfromthehospitalwith
subcutaneousheparinandwarfarin.Shortlyuponarrivalhome,shedevelopspleuriticchestpainandshortnessofbreathandpresentstoherphysician.Physical
examinationrevealstachypneaandanoxygensaturationof89%onroomair.Laboratoryanalysisshowsheractivatedpartialthromboplastintimetobetherapeutically
increased,whileherprothrombintimeremainsbelowtheoptimaltherapeuticlevel.Aventilation/perfusionscanisobtained,whichshowsalargeperfusiondefectintheleft
lowerlobe.Whichofthefollowingisthemostappropriateinterventionatthistime?

A. Hospitaladmissionforobservation
B. Beginaspirin
C. Increaseheparin
D. Increasewarfarin
E. Placementofaninferiorvenacavafilter

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Question41

Selectthesinglebestanswertothenumberedquestion.

A56yearoldmalewithhypertensionandhistoryofdrugabuseandmedicationnoncompliancepresentstotheclinicforfollowup.Hehasbeenfeelingwellsincehislast
appointmentseveralmonthsago,butdoesadmittococaineuselastnightwhenheranintosomeoldfriends.Hedeniesanyotherdruguse.Medicationsinclude
hydrochlorothiazide,atenolol,andparoxetine.Vitalsignsaretemperature36.9C(98.4F),pulse85,bloodpressure202/122,andrespirations14/min.Physicalexamination
revealsacomfortable,pleasantmaleinnodistress.Thereisnopapilledemaorretinalhemorrhageonfundoscopicexam.Thepatientisalert,oriented,andneurologically
intact.Laboratoryevaluation,includingCBC,electrolytes,BUNandcreatinine,andurinalysisareallunremarkable.Whichofthefollowingisthemostappropriatenextstepin
themanagementofthispatient?

A. Obtainurinedrugscreen
B. HeadCTwithoutcontrast

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C. Administernaloxone
D. Administerorallabetalol
E. Administerintravenousnitroprusside

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Question42

Selectthesinglebestanswertothenumberedquestion.

A71yearoldmalewithahistoryofcoronaryarterydiseaseandcongestiveheartfailurepresentswithworseningdyspneaonexertion,orthopnea,andperipheraledema
overthepastweek.Twoyearsago,hehadacoronarystentplacedinhiscircumflexartery.Catheterizationatthattimeshowedanejectionfractionof25%,andsincethat
timethepatienthadbeenstablewithmedicaltherapy.Pastmedicalhistoryalsoincludesdiabetes,hypertension,andperipheralarterialdisease.Currentmedicationsinclude
clopidogrel,lisinopril,propranolol,bumetanide,spironolactone,glipizide,andmetformin.Physicalexaminationrevealsdiffusecracklesbilaterallyextendingfromthelung
basestotwothirdsofthewayupthelungfields.AnS3isheard,andthereis3+pittingedemaofthelowerextremitiesbilaterally.Chestxrayshowscardiomegalyand
pulmonaryedemainabatwingpattern.Thepatientisadmittedtothehospital,placedonafluidrestriction,andtreatedwithintravenousfurosemide.Followinganet
diuresisof3L,thepatientfeelsmuchbetter.Whichofthefollowingisthenextmostappropriatestepinthemanagementofthispatient?

A. Measurementofbrainnatriureticpeptide(BNP)
B. Echocardiography
C. Arterialbloodgas
D. Increasepropranolol
E. Endomyocardialbiopsy

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Question43

Selectthesinglebestanswertothenumberedquestion.

A5yearoldboypresentswithbedwetting.Hismotherstatesthatforthepasttwomonths,hehasbeenwettingthebedseveraltimesaweek.Thechildisembarrassed
aboutthisnewincontinence,andhashadnoproblemsinthedaytime.Thepatientsmotherinsiststhatthechildhasotherwisebeenhealthyshedeniesfeversand
increasedappetiteorfluidintake.Thepatientspastmedicalhistoryisremarkableonlyforahospitalizationatage1forbronchiolitis.Theboyliveswithhismother,father,
andayoungersisterwhowasadoptedfromRussiaseveralmonthsago.Everyoneathomehasbeenwell.Onphysicalexam,thepatientisatalkative,interactivemale.
Speech,motor,andphysicaldevelopmentareallnormal.Whatisthemostappropriateinitialstepinthemanagementofthispatient?

A. Urineculture
B. Voidingcystourethrogram
C. Recommendanenuresisalarm
D. Desmopressin
E. Urinalysis

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Question44

Selectthesinglebestanswertothenumberedquestion.

A22yearoldfirstyearlawstudentcomestothephysicianwithamenorrheaforthepastfourmonths.Thepatientadmitshavingbeenunderagreatdealofstressadjusting
totheacademicburdenoflawschool,butdidfinishherfirstsemesterwitha3.7GPA.Uponquestioning,sheacknowledgeseatinglargeamountsoffoodsuchasanentire
largepizzawhensheisfeelingstressed.Shefeelsguiltyaftersheeats,however,andforcesherselftovomititallup.Therestofthetime,sheeatsanormaldietofsalads
andgranola.Physicalexaminationrevealsanextremelythinfemale,withheightis69in.(175cm),weightis103lbs.(47kg).Thereisdiffusefinehairgrowthonthe
extremitiesandmilderosionoftheenameloftheanteriorteeth.Acallusispresentonthedorsalsurfaceoftheindexandmiddlefingersofthepatientsrighthand.TSHis
withinnormallimits.Aurinepregnancyscreenisnegative.Whichofthefollowingisthemostappropriatediagnosisinthispatient?

A. Anorexianervosa
B. Obsessivecompulsivedisorder
C. Borderlinepersonalitydisorder
D. Bulimianervosa
E. Hyperprolactinemia

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Question45

Selectthesinglebestanswertothenumberedquestion.

A18montholdfemaleisbroughttothephysicianbyhermother,whoisconcernedthatherchildisinpain.Thechildhashadspellsofintensesceamingandcryingforthe
pastfewhoursduringtheseepisodesthechilddoublesoverandcurlsupintoaball.Themotheralsoreportstwoepisodesofnonbilious,nonbloodyvomit.Themother
initiallythoughtthatthepatientmayhavecaughtavirusatdaycare,butshebecamemoreconcernedonehouragowhenherdaughterhadabowelmovementandthestool
seemedtobeslimywithapurplishcolor.Onphysicalexam,asausageshapedabdominalmassispalpatedintherightabdomen.Thereisnoabdominalrigidity,guarding,or
reboundtenderness.Anabdominalultrasoundrevealsabullseyeorcoiledspringappearinglesion.Thepatientismaden.p.o.,i.v.fluidsarestarted,andanasogastric
suctionisbegun.Whatisthenextbeststepinthemanagementofthispatient?

A. CTscan
B. Aircontrastenema
C. Surgery
D. Colonoscopy
E. Administeraglycerinsuppository

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Question46

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Selectthesinglebestanswertothenumberedquestion.

A29yearoldfemalemedicalstudentcomestoherphysicianwithgallstonesafterservingasamodelpatientforademonstrationofabdominalultrasoundtechniques.The
stoneswerelocatedwithinthegallbladder,andthepatientwassurprisedatthisfinding,becausesheneverhadexperiencedanypain.Physicalexaminationrevealsa
comfortable,afebrile,obesefemale.Murphyssignisnegative.Laboratoryexaminationshowsthefollowing:WBC7.0K/mm3albumin4.2g/dLAlkalinephosphatase72
U/LALT16IU/LAST19IU/Ltotalbilirubin0.3mg/dLconjugatedbilirubin0.1mg/dLlipase18U/L(normal:10140U/L).Whichofthefollowingisthemostappropriate
nextstepinthemanagementofthispatient?

A. Reassurance
B. Endoscopicretrogradecholangiopancreatography(ERCP)
C. AbdominalCT
D. Ursodeoxycholicacid
E. Cholecystectomy

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Question47

Selectthesinglebestanswertothenumberedquestion.

A35yearoldmalewithahistoryofbipolardisorderpresentswithseveralweeksofdepression.Thoughhismoodisnoworsethanusual,hehasbeenfeelingextremely
fatigued.Hehasalsobeensleepingmorelatelyandreportsa9lbs.weightgainoverthisperiod.Hedeniesracingthoughts,hallucinations,orincreasesingoaldirected
activity.Currentmedicationsincludelithiumandomeprazole.Onphysicalexamination,thepatienthascoarsefacialfeaturesandslowedspeechandmovements.Thereare
areasofdiffusehairlossonthescalp,aswellasperiorbitalpuffinessandnonpittingedemaofthelegsbilaterally.Serumlithiumlevelis1.45mEq/L(normaltherapeutic
range:0.501.50mEq/L).Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient

A. Decreaselithiumdoseby50%
B. Orderthyroidstimulatinghormone(TSH)andfreeT4levels
C. Beginescitalopram
D. Beginrisperidone
E. Beginvalproicacid

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Question48

Selectthesinglebestanswertothenumberedquestion.

A38yearoldHIVpositivemalepresentsforregularlyscheduledfollowup.Hereceivedpneumococcalandinfluenzavaccinationslastyear,andhashadnoopportunistic
infectionsforseveralmonths.Currentmedicationsincludeefavirenzandnevirapine.Physicalexamisunchangedfromprevious.LaboratoryevaluationshowsCD4+
lymphocytecountof179/mm3.Tuberculinpurifiedproteinderivate(PPD)isplacedintradermally,andisread72hourslaterascausing4mmofinduration.Whichofthe
followingisthemostappropriatenextstepinthemanagementofthispatient?

A. Chestxray
B. Clarithromycin
C. Trimethoprimsulfamethoxazole
D. Fluconazole
E. Isoniazid,rifampin,andpyrizinamide

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Question49

Selectthesinglebestanswertothenumberedquestion.

An18yearoldG1at39weeksgestationpresentsinlabor.Herpregnancyhasbeencomplicatedbyexcessiveweightgainandgestationaldiabetesmellitus.Soonafter
presentation,thepatientrapidlydilatesandtheinfantsheaddescends.Theinfantsheadisdeliveredwithoutdifficulty,butbeforedeliveringthebody,theheadappearsto
retracttowardthepelvis.Initialattemptstodeliverthebodyareunsuccessful.Afetalscalpelectrodeisattached,whichshowsawavytracingwithheartratesbetween140
and150bpmwithmarkedbeattobeatvariability.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?

A. Caesareansection
B. Fundalpressure
C. Oxytocin
D. Suprapubicpressure
E. Fracturingthebaby'sclavicles

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Question50

Selectthesinglebestanswertothenumberedquestion.

Athreeweekoldinfantisbroughttotheclinicafterthepatientsadoptiveparentsnotedaredrashonherhandsandfeet.Thechildwasbornattermviavaginaldeliverytoa
28yearoldwomanwhoreceivednoprenatalcareandgaveherchildupforadoptionshortlyafterbirth.Onphysicalexamination,theinfantappearslethargicandhas
generalizedlymphadenopathy.Thereisprofuse,bloodtingedpurulentnasaldischarge,andthereisanerythematousmaculopapularrashonthedorsalandventralsurfaces
ofthehandsandfeet.Abdominalexaminationrevealshypoactivebowelsoundsandhepatosplenomegaly.Whichofthefollowingisthemostlikelyexplanationofthese
findings?

A. Congenitaltoxoplasmosis
B. Congenitalrubella
C. CongenitalCMVinfection
D. Congenitalsyphilis

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E. Herpesneonatorum

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Question51

Selectthesinglebestanswertothenumberedquestion.

A56yearoldmanreturnstotheofficebecausehiscalciumwasfoundtobeelevatedatapreviousvisit.Althoughtheremainderofhislabs,includingcompletebloodcount,
liverpanel,andchemistrieswereallwithinnormallimits,thepatientscalciumwas11.9mg/dL(normal:8.510.5mg/dL).Thepatientfeelswellandhasnocomplaints.
Currentmedicationsincludeverapamil,cetirizine,andatorvastatin.EKGshowsarightbundlebranchblock,stablefromprevious.Whichofthefollowingisthemost
appropriateinitialstepinthemanagementofthispatient?

A. Serumparathyroidhormonelevel
B. CTofchest/abdomen
C. Genetictestingformultipleendocrineneoplasia,type1
D. Discontinueverapamil
E. Intravenoussalineandfurosemide

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Question52

Selectthesinglebestanswertothenumberedquestion.

An83yearoldfemalewithdementiaisbroughttothephysicianbyhergranddaughterbecauseofachangeinherskincolor,whichhastakenonagoldenhueoverthepast
fewdays.Thepatientsgranddaughteralsoreportsthatshehasbeenunabletogetthepatienttoeatordrinkforthepast24hours,andthatalthoughthepatientsurine
outputhasdecreased,herurineappeareddarkbrownwhenshechangedherdiaperthismorning.Vitalsignsaretemperature39.1C(102.4F),pulse105,bloodpressure
77/45,respiratoryrate24,oxygensaturation96%onroomair.Onphysicalexamination,thepatientissomnolentbutarousabletopain.Theskinisjaundicedandthesclerae
areicteric.Lungsarecleartoauscultation.Abdominalexaminationrevealsdecreasedbowelsounds,withdiffusetendernesstopalpation.Thereisvoluntaryguardingofthe
rightupperquadrant.Whichofthefollowingisthemostappropriatenextstepinmanagementforthispatient?

A. AbdominalCT
B. Administer1Lbolusof0.9%NaCl
C. Begini.v.nafcillin
D. Urgentendoscopicretrogradepancreaticoduodenoscopy(ERCP)
E. Percutaneoustranshepaticdrainagetubeplacement

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Question53

Selectthesinglebestanswertothenumberedquestion.

A20yearoldpreviouslyhealthycollegefemalepresentswithtwoweeksofoccasionaldysuriaandincreasedvaginaldischarge.Shehasrecentlybecomesexuallyactive,
andsheandherasymptomaticpartneroccasionallyusecondomsastheironlymethodofbirthcontrol.Speculumexamrevealsafriablecervixwithamoderateamountof
purulentcervicaldischarge.ThepatienttestspositiveforChlamydiaandnegativeforgonorrhea.UAshowspyuriabutnoorganismisidentifiedongramstain.Urineculture
isnegative.Whatisthenextbeststepinmanagementforthispatient?

A. Ciprofloxacin
B. Ceftriaxoneanddoxycycline
C. Azithromycin
D. BenzathinepenicillinG
E. Reassurance

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Question54

Selectthesinglebestanswertothenumberedquestion.

A35yearoldmanpresentstohisphysicianwithneckpainthatbegansuddenlywhileatrestfourhoursago.Hispastmedicalhistoryissignificantforatenyearhistoryof
disorganizedschizophrenia,whichhasbeentreatedunsuccessfullywithanumberofmedicationsincludingolanzapine,risperidone,andhaloperidol,andhehasbeen
recentlyswitchedtothiothixene.Examinationshowsadisheveledmalewithaflataffect,holdinghisheadtwistedtotheright.Thereislimitedcervicalrangeofmotionand
pronouncedmusclecontractionofthesternocleidomastoidandparacervicalmuscles.Whichofthefollowingisthemostappropriatepharmacologicinterventionforthis
patientscondition?

A. Dantrolenei.v.
B. Increasep.o.thiothixene
C. Addclozapine
D. Oralibuprofen
E. Oraldiphenhydramine

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Question55

Selectthesinglebestanswertothenumberedquestion.

A37yearoldHIV+malepresentswithoneweekofheadacheandlowgradefever.Forthepasttwodays,hehashadnauseaandvomiting.Onphysicalexam,temperature
is38.1C(100.6F),pulse80,bloodpressure108/68,respirations15/min.Thepatientissomnolentbutarousable.Nuchalrigidityispresent.Withthepatientsupine,passive
kneeextensionelicitsneckpain.Lungsarecleartoauscultation.Therearenopetechiaeorcutaneoushemorrhagesseen.CTscanshowsnofocallesion,andlumbar
punctureisperformed.CSFanalysisshowsclear,lightyellowCSFwithanopeningpressureof290mmHg(normal:70180mmHg),25WBC(normal05)with96%
lymphocytes,15RBCs,aglucoseof38mg/dL(normal:4070mg/dL)andprotein50mg/dL(normal:1545mg/dL).Whichofthefollowingwouldbethemostappropriate
therapyforthispatient?

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A. Ceftriaxone
B. Acyclovir
C. Vancomycinandcefotaxime
D. Trimethoprimsulfamethoxazole
E. AmphotericinBandflucytosine

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Question56

Selectthesinglebestanswertothenumberedquestion.

A68yearoldwomanhashadworseningbackpainforthepastthreemonths.Herpainradiatestoherlegsbilaterally.Thepainisworstwhilewalkingorstandinguprightand
isassociatedwithweaknessandnumbnessofherlegswhilewalking.Sittingorlyingdownrelievesthepain,butthepatientalsofoundthatleaningforwardoverhergrocery
cartimprovedhersymptomswhileshoppingearlierthismorning.Shehasnothadfeverorbowelorbladderincontinence.Pastmedicalhistoryissignificantforhypertension
controlledwithlisinopril.Thepatientdoesnotsmoke.Physicalexaminationshowsnotendernessalongthelumbarspineandanegativestraightlegraisingtest.Thefeetare
warm,anddorsalispedispulsesare2+bilaterally.Nosaddleanesthesiaispresent,butthepatienthasweaknessoftheextensorhallucislongusbilaterally.Whichofthe
followingisthemostlikelypathologicalmechanismforthispatientssymptoms?

A. HerniationofthenucleuspulposusagainsttheL4nerveroots
B. Pyogenicabscessoftheepiduralspaceinthelumbarspine
C. Atheroscleroticocclusionofthepoplitealarteries
D. Malignanttumorinvasionofthelumbarspine
E. Narrowingofthelumbarspinalcanal

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Question57

Selectthesinglebestanswertothenumberedquestion.

A34yearoldfemalepresentstoherfamilyphysicianintearsbecauseshewantstohaveababy.Shehashadthreesecondtrimestermiscarriagesoverthepastfiveyears.
Sheandherhusband,whohastwochildrenfromapreviousmarriage,desperatelywanttoconceive,andtheirfailuretodosohasbeguntocausestressintheirmarriage.
Thepatientisotherwisehealthy,andthereisnohistoryofsexuallytransmittedinfectionsorhematologicorrheumatologicdiseases.Menarchebeganatage11andher
mensesareregularatintervalsof25days.Herpelvicexamrevealsaslightlyretroverteduterusandnormalsizeovaries.Whatisthemostlikelyetiologyofthispatients
recurrentpregnancylosses?

A. Maternalbalancedtranslocation
B. Cervicalincompetence
C. Paternalbalancedtranslocation
D. Retroverteduterus
E. Amnioticbandsyndrome

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Question58

Selectthesinglebestanswertothenumberedquestion.

Amotherbringsher8yearoldsontothefamilyphysicianbecauseofstrangebehaviorforthepastyearthatappearstobegettingworse.Forthepasttwelvemonths,the
patientsmotherhasnotedepisodesofrepetitiveblinkingorgrimacing.Theseepisodesappeartobebeyondhersonscontrol,andoftenoccuratinopportunetimes.The
patientisnowbeingteasedatschoolbyhisclassmatesforthesebehaviors.Duringthepatientinterview,thechildappearstobelisteningintentlytotheconversationwithhis
motherthereisaminuteorsoofrapid,repetitiveblinkingfollowedbyseveralgruntingnoisesfromthepatient.Whenasked,thechildisawareoftheblinkingandgrunting,
butcannotexplainwhyhewasdoingit.Thepatientdenieshallucinationsorbizarrethoughtsandstatesthathismoodisfine.Hedoeswellinschoolandhasaclosegroup
offriendsinhisneighborhoodwhoheenjoysplayingwith.Hisgrowthanddevelopmentarewithinnormallimits.Whatisthemostlikelydiagnosisinthispatient?

A. Autism
B. Rettsyndrome
C. Tourettesyndrome
D. Sydenhamchorea
E. Attentiondeficithyperactivitydisorder

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Question59

Selectthesinglebestanswertothenumberedquestion.

A51yearoldsupermarketcashierhashadworseningpainandtendernessofherleftleg.Hersymptomshavebeenworseningforthepasttwodays,eversinceshehadto
workthreeconsecutivedaysofdoubleshiftsduetoacoworkersabsence.Medicationsincludelisinoprilforhypertensionandhormonereplacementtherapyforhot
flashes.Physicalexaminationshowsanobesefemalewithtemperature38.1C(100.5F),pulse88,BP136/84,andrespirations14/min.Therearenumerousprominent
varicoseveinsonthelegsbilaterally.Theleftleghasa6inch(15cm)linearareaoferythemaandedemaonthemedialaspectofthekneeandcalf,withapalpable,nodular,
cordlikestructurelocatedjustunderneaththeskin.Dopplerultrasonographyisperformedonbothlegsandshowsasinglethrombusextendingfromthemiddletodistal
saphenousveinontheleft.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatientscondition?

A. Rest,elevation,nonsteroidalantiinflammatoryagents,andheat
B. Enoxaparin
C. Warfarin
D. SpiralCTofthechest
E. Placementofinferiorvenacavafilter

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Question60

Selectthesinglebestanswertothenumberedquestion.

Anotherwisehealthy26yearoldfemalepresentstoherfamilyphysicianwitharashonherneck.Shejustnoticedityesterday,butitispruriticandpainful.Thepatienthas
notbeenoutdoors,andcannotthinkofanythinginparticularthatcouldhavecausedtherash,otherthanperhapsusinganewhairsprayinpreparationforherbestfriends
weddingseveraldaysago.Onphysicalexam,thereisapapularandvesicularerythematousrashinathinlinearpatternthatencirclesherlowerneck.Theremainderofher
physicalexamisnormal.Whatisthemostappropriateinitialstepinthemanagementofthispatient?

A. Topicalsteroidcream
B. Oralprednisone
C. Reassurance
D. IgEtesting
E. Oralantibiotics

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Question61

Selectthesinglebestanswertothenumberedquestion.

A10yearoldgirlpresentswithseveralmonthsofdiarrheaandflatulence.Herparentsreportthatdespitethefactthatshehasbeeneatingwell,shehashadasmallweight
lossduringthisperiod.Shedeniesbloodinherstool,butdoesreportthatherstoolshavebeenquitefoulsmellingandgreasy.Physicalexaminationrevealsapale,thingirl
withblondehairandblueeyes.Bowelsoundsareslightlyhyperactive,andthereisnotendernesstopalpation.Lungssoundsarenormal.Thereisanerythematous,papulo
vesicularrashwithsignsofexcoriationbilaterallyatthekneesandelbows.Laboratoryevaluationshowsserumantitissuetransglutaminase(antiTTG)antibodiesare
elevated.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?

A. Loperamide
B. Dietaryavoidanceofwheat,barley,andoats
C. Chloridesweattest
D. Rectalbiopsy
E. Amoxicillin

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Question62

Selectthesinglebestanswertothenumberedquestion.

A53yearoldfemaleconsultsherphysicianduetoprogressiveitching,yellowingofherskin,andfatigue.Shedeniesanypasthistoryofjaundiceanddenieseverreceivinga
bloodtransfusionorabusingalcohol.HerpastmedicalhistoryincludeshypertensionandSjogrenssyndrome.Physicalexaminationshowsprominenthepatomegalyand
scatteredexcoriationsthroughouttheskin.Laboratoryevaluationshowsanelevatedbilirubin,moderatelyelevatedtransaminases,andmarkedlyelevatedalkaline
phosphatasewithanormalalbumin.Antimitochondrialantibodiesarepositiveat>1:256.Whichofthefollowingisthemostlikelydiagnosisforthispatient?

A. HepatitisC
B. Autoimmunehepatitis
C. Primarysclerosingcholangitis
D. Primarybiliarycirrhosis
E. Pancreaticcarcinoma

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Question63

Selectthesinglebestanswertothenumberedquestion.

A23yearoldstudenthastheacuteonsetofdizzinessandnauseaandvomiting.Hefeelsliketheroomisrotatingaroundhimtotheleft.Sixdaysago,hehadalowgrade
fever,myalgias,andasorethroat,whichresolvedyesterday.Hedeniesahistoryofsimilarepisodes,andhispastmedicalhistoryisentirelybenign.Physicalexamination
revealsmildhearinglossontheleftandhorizontalnystagmusthatresolveswhenthepatientlooksatafixedobject.Tympanicmembranesareclear.Thoughthepatientis
abletoambulate,heshowsmarkedgaitinstability.Thereisapositiveheadthrusttest.Thereisnodysarthria,motorweakness,sensoryloss,facialdroop,orlimbdysmetria
observed.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Labyrinthitis
B. Cerebellarinfarction
C. Benignparoxysmalpositionalvertigo
D. Multiplesclerosis
E. Suppurativeotitismedia

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Question64

Selectthesinglebestanswertothenumberedquestion.

An18montholdmalepresentsforawellchildexamination.Whileobservingthechildplayinginhismotherslap,itappearsthatthechildhasawanderingrighteye.The
patientsmotherdeniesanyfamilyhistoryofvisualdisordersorcancer,andsaysthatthechildhasappearedcompletelyhealthylately.Onphysicalexamination,thereisno
tendernesstomildpressureoneithereye.Scleraarenoninjected.Awhitepupillaryreflexispresentontheright.Withthechildvisuallyfixedonatoy,eachofhiseyesare
separatelycoveredandthenuncovered.Thereisnoeyemovementwhenthepatientsrighteyeiscoveredandrapidlyuncovered,butthepatientsrighteyerefixatesonthe
toywhenthelefteyeiscoveredandthenuncovered.Whatisthemostappropriatenextstepinthemanagementofthispatient?

A. MRIofhead

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B. Occlusionoflefteyewithpatch

C. Occlusionofrighteyewithpatch
D. Atropineeyedrops
E. Reassurance

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Question65

Selectthesinglebestanswertothenumberedquestion.

Anotherwisehealthy15yearoldmalecomestohisphysicianwiththecomplaintoffacialacne.Hehastriedmultipleoverthecounteracnewasheswithoutimprovement,
andheandhismotherarehopefulthatamedicationwillhelp.Thepatientsdietisacceptablebutdoesincludelargeamountsoffastfood.Heisunderamoderateamountof
stressjugglingschoolandhiscompetitivetravelingsoccerteam,butbothheandhismomfeelthatheishandlingthiswell.Onphysicalexam,thepatientsfacehas
scatteredopenandclosedcomedonesandafewsmallpapules.Noscarringisnoted,andhisbackandupperarmsarenotaffected.Whatisthemostappropriateinitialstep
inthemanagementofthispatient?

A. Isotretinoin
B. Topicalretinoid
C. Oralerythromycin
D. Reassurance
E. Avoidanceofgreasyfoods

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Question66

Selectthesinglebestanswertothenumberedquestion.

A19yearoldfemalecomestoherphysicianbecauseofvisualblurringforthepastweek.Forthepastfewmonths,shehasalsohasexperienceddailyheadaches,which
areworstinthemorninguponawakeningandimprovethroughoutthedayoraftertakingibuprofen.Herpastmedicalhistoryisunremarkable,andheronlymedicationisa
combinationoralcontraceptivepill.Physicalexaminationshowsheight62inches(157cm),weight206lbs.(93kg),temperature37.2C(99.0F),pulse72,bloodpressure
118/76.Fundoscopicexaminationshowsbilateralpapilledema.Neurologicalexaminationshowsnofocaldeficits.CTshowsnormalventriclesandnoevidenceformass
lesion,butincreasedvolumeanddistensionoftheperiopticsubarachnoidspace.LumbarpunctureshowsanelevatedopeningpressureandclearCSFwithnormalcell
counts,protein,andglucose.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Asepticmeningitis
B. Craniopharyngioma
C. DandyWalkermalformation
D. Subduralhemorrhage
E. Pseudotumorcerebri

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Question67

Selectthesinglebestanswertothenumberedquestion.

A17yearoldbasketballplayercomestothephysicanaftertwistinghiskneeinagameoneweekago.Afterjumpingtocatchapass,hetwistedonhisflexedrightknee
andfeltasharppain.Hedeniesanyjointdislocationorpoppingsoundsorsensations,butwasscarcelyabletobearweightaftertheinjuryandhadtobehelpedoffthe
court.Thefollowingmorning,hiskneewasswollen,andalthoughhispainhasimproved,hehashadseveralepisodeswherehiskneelocksintoanextendedposition.On
physicalexamination,thereisamoderateeffusionoftherightkneeandtendernesstopalpationalongthemedialjointline.Extendingthefullyflexedkneewhileapplyinga
moderatevarusstresscausesanaudibleclickandreproducesthepatientspain.Withthekneeflexedtoninetydegrees,thereisnomovementofthetibiaonthefemur
whenthelowerlegispulledanteriorly.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. OsgoodSchlatterdisease
B. Tornanteriorcruciateligament
C. Iliotibialbandsyndrome
D. Slippedcapitalfemoralepiphysis
E. Meniscalinjury

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Question68

Selectthesinglebestanswertothenumberedquestion.

A31yearoldfemalepresentswithseveralweeksofprogressivefatigue,weakness,andweightloss.Shehasalsohadoccasionalnauseaanddiarrhea.Pastmedicalhistory
includesjuvenilediabetesandhypothyroidism.Onphysicalexamination,thepatienthasareasofbronzedhyperpigmentationonherface,neck,andthedorsumofher
hands.Theremainderofphysicalexamiswithinnormallimits.Laboratoryexaminationissignificantforasodiumof130mEq/Landaglucoseof65mg/dL.Whichofthe
followingisthemostappropriatenextstepinthediagnosisofthispatient?

A. Thyroidultrasound
B. MeasurementofinsulinlikegrowthfactorI(IGF1)
C. Measurementof21hydroxylaseactivity
D. Cosyntropinstimulationtest
E. Dexamethasonesuppressiontest

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Question69

Selectthesinglebestanswertothenumberedquestion.

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AsixmontholdfemaleisbroughttotheclinicinDecemberwithwheezingandrespiratorydifficultyforthepastseveralhours.Shedidhavealowgradefevertwodaysago
accompaniedbyrhinorrhea,buthasotherwisebeenwellsincebirth.Vitalsignsaretemperature38.6C(101.5F),pulse160,bloodpressure87/59,respirations60/min.
Nasalflaringandintercostalretractionsarenoted.Auscultationofthelungsrevealsfaintinspiratorycracklesatthelungbasesanddiffuseexpiratorywheezing.Achestxray
showsanormalcardiacsilhouette,hyperexpandedlungs,andperibronchialthickening.Whichofthefollowingtestswouldbemostlikelytoconfirmthediagnosisinthis
patient?

A. Rigidbronchoscopy
B. Echocardiogram
C. Methacholinechallengetest
D. Rapidantigentestforrespiratorysyncytialvirus
E. Sweatchloridetest

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Question70

Selectthesinglebestanswertothenumberedquestion.

A72yearoldfemalewithabdominalpainandunstablevitalsignsisfoundonangiographytohavearupturedabdominalaorticaneurysm.Pastmedicalhistoryincludes
hypertension,diabetes,andchronicrenalinsufficiencywithbaselinecreatinineof1.2mg/dL.Thepatientisrushedtosurgeryandheraortaissuccessfullyrepairedinan
eighthouroperationwherethepatientreceivesfiveunitsofpackedredbloodcellsandseverallitersofintravenousfluid.Onthedayfollowingtheoperation,laboratory
analysisrevealsplasmacreatinineof2.1mg/dLandBUNof46mg/dL.Thefractionalexcretionofsodium(FeNa)iscalculatedtobe0.53%,andmicroscopicurinalysis
showsoccasionalhyalinecasts,butnoRBCs,WBCs,orcellularorgranularcasts.Whichofthefollowingisthemostlikelyexplanationforthispatientsabnormallaboratory
values?

A. Cytotoxiceffectsofiodinatedcontrastmaterial
B. Reducedbloodflowtothekidneys
C. Ischemicnecrosisofrenaltubulecells
D. Obstructionofthedistalurinaryoutflowsystem
E. Interstitialinflammationcausedbydrughypersensitivity

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Question71

Selectthesinglebestanswertothenumberedquestion.

A38yearoldwomanhashadfourweeksofwatery,nonbloodydiarrheaandcrampingabdominalpain.Shedeniesahistoryofsimilarsymptoms,sickcontacts,drinking
unpurifiedwater,andrecenttravel.Therehavebeennochangestoherdiet,andshedoesnotdrinkmilkoreatdairyproducts.Currentmedicationsincludeesomeprazole
andibuprofen.Shecompletedacourseofamoxicillin/clavulanateforasinusinfectiontwomonthsago.Onphysicalexamination,sheisafebrile.Bowelsoundsareslightly
hyperactive,andthereismildlowerabdominaltendernesstopalpation.Whichofthefollowingtestswillmostlikelyleadtothediagnosisinthispatient?

A. Sudanstainforfecalfat
B. Microscopicexaminationofthestoolforovaandparasites
C. Dxylosetest
D. Bariumuppergastrointestinalseries
E. ELISAforC.difficileassociatedtoxinsAandB

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Question72

Selectthesinglebestanswertothenumberedquestion.

Afouryearoldmalepresentswithapainfulrighthand.Oneweekago,hewasbittenbyhispetkittenonthehand.Hismotheralsoreportsanoccasionallowgradefever.On
physicalexam,thereareseveralerythematous,painfulcutaneouspapulesandpustulespresentnearthenearlyhealedbitesite,aswellastenderunilateralaxillary
lymphadenopathyontheright.Whichofthefollowingistheorganismmostlikelytobethecauseofthispatientsinfection?

A. MethicillinsensitiveStaphylococcusaureus
B. Yersiniapestis
C. Francisellatularensis
D. Bartonellahenselae
E. Pasteurellamultocida

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Question73

Selectthesinglebestanswertothenumberedquestion.

Athreeyearoldmalecomestothephysicianbecauseofdelayedspeechdevelopment.Thepatientsmotherisalsoconcernedbecausehersonmakespooreyecontact
andoftenrepetitivelybitesorflapshishands.Familyhistoryissignificantforamaternalunclewithmildmentalretardation.Onphysicalexam,thepatienthasalongface
withalargejawandlargeevertedears.Furthertestingrevealsnormalhearingandvision,andanIQof55.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. TaySachsdisease
B. FragileXsyndrome
C. Downsyndrome
D. PraderWillisyndrome
E. Rettsyndrome

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Question74

Selectthesinglebestanswertothenumberedquestion.

A72yearoldfemalepresentsafterpassingoutwhilewalkingbacktoherhousefromthemailbox.Otherthananabrasiononherelbow,shedeniesanytraumafromthe
fallandrecoveredquicklyfollowingtheincident.Therewasnobowelorbladderincontinenceorprodromebeforetheattack.Onreviewofsystems,thepatientadmitsto
occasionalexertionalchestpainsthatarerelievedbytakingherhusbandsnitroglycerin.Physicalexaminationshowsvitalsignsofheartrate75andregular,bloodpressure
138/78,andrespirations13/min.Thereisasmallabrasionandassociatedecchymosisonthepatientsleftelbow,butnoothersignsoftrauma.Oncardiacauscultation,
thereisaharsh,III/VIsystoliccrescendodecrescendomurmurheardbestatthebaseoftheheartandbilaterallyattheclavicles.Lungfieldsareclear,andthereisno
peripheraledema.Neurologicalexaminationshowsnofocalabnormality.EKGshowsnormalsinusrhythmwithleftventricularhypertrophyandnormalPRandQTintervals.
Whichofthefollowingisthemostappropriatestepinthemanagementofthispatientssyncope?

A. Urinedrugscreen
B. HeadCT
C. Tilttabletesting
D. Referraltoacardiologistforpacemakerplacement
E. Referraltoacardiacsurgeonforvalvereplacement

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Question75

Selectthesinglebestanswertothenumberedquestion.

A31yearoldmalewitha9yearhistoryofulcerativecolitispresentswithsevereabdominalpainforthepastfewhours.Hehadbeenstablewithsulfasalazinetreatment,but
oneweekagowasstartedonhighdoseprednisoneandloperamideforaflare.Vitalsignsaretemperature38.6C(101.6F),pulse120,bloodpressure118/75,and
respirations20/min.Theabdomenisdistended,withmarkedlydecreasedbowelsounds.Thoughthelowerabdomenistender,thereisnoreboundtendernessorrigidity.
Laboratoryanalysisisnotableforawhitebloodcountof12,000(normal:4,50011,000)andahematocritof34.5%(normal:3949%).Theremainderofthepatientslabs,
includingLFTs,lipase,andlacticacid,arenormal.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Clostridiumdifficilecolitis
B. Sigmoidvolvulus
C. Acutepancreatitis
D. Ischemiccolitis
E. Toxicmegacolon

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Question76

Selectthesinglebestanswertothenumberedquestion.

A57yearoldmalepresentswiththreeweeksoffatigue.Hedeniesdepressedmood,palpitations,changesinbowelhabits,syncope,ornewmedications.Onphysical
examination,thepatientstemperatureis36.7C(98.6F),pulse100,andbloodpressure126/82.Peripheralpulsesare2+,butarenotedtobeirregularlyirregular.Breath
soundsareequalbilaterally,andthereisnoperipheraledema.InitialtroponinIisnotelevated.Thepatientisstartedonintravenousdiltiazem,andanEKGisobtained.The
patientsEKGisseenhere.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?


A. Heparinandwarfarin
B. Cardiaccatheterization
C. Cardiacdefibrillatorimplantation
D. Ibutilide
E. Electricalconversion

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Question77

Selectthesinglebestanswertothenumberedquestion.

A25yearoldmalewithahistoryofintravenousdrugabusepresentswithfever,chills,andshortnessofbreathfortwodays.Helastusedheroinfivedaysago.Vitalsigns
includetemperature38.8C(102F),pulse90,bloodpressure116/78,respirations18/min.ThereisagradeII/VIsystolicmurmurheardbestatthelowerrightsternalborder.
Faintcracklesareheardthroughoutthelungfields.Therearenosplinterhemorrhages,peripheralpetechiae,orerythematouspatchesonthepalmsorsoles.No

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abnormalitiesareseenonfundoscopicexam.Neurologicalexamisnormal.Achestxrayshowsnoevidenceofpneumonia.Threesetsofbloodculturesaredrawn,andthe
patientisstartedonempiricantibiotictherapywithvancomycinandcefepime.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?

A. Naloxone
B. Buprenorphine
C. Ciprofloxacin
D. Transthoracicechocardiogram
E. Ddimer

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Question78

Selectthesinglebestanswertothenumberedquestion.

An18yearoldcollegestudentpresentswiththesuddenonsetoffever,headache,myalgias,andnauseaandvomitingtwelvehoursago.Healsocomplainsofneckstiffness
andphotophobia.Vitalsignsincludetemperature39.7C(103.5F),pulse120,bloodpressure95/60,andrespirations20/min.Onphysicalexamination,heissomnolentbut
arousable.Thereispronouncednuchalrigidity.Withthehipsflexed,attemptstostraightenthekneeresultinspasmofthehamstrings.Small,12mmpetechiallesionsare
presentonthetrunk,legs,andsoftpalate.Therapywithintravenousfluidandsupplementaloxygenisbegun,andlumbarpunctureisperformed.Whichofthefollowingisthe
mostlikelyfindingonCSFanalysisinthispatient?

A. IncreasedWBCwithneutrophilicpredominance,increasedprotein,decreasedglucose
B. IncreasedproteinwitholigoclonalbandsofIgG
C. XanthrochromiaandincreasedRBCs
D. IncreasedWBCwithlymphocyticpredominance,increasedprotein,normalglucose
E. IncreasedWBCwithlymphocyticpredominance,numerousRBCs,elevatedprotein,normalglucose

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Question79

Selectthesinglebestanswertothenumberedquestion.

A53yearoldfemalewithtypeIIdiabetespresentsisbroughttothephysicianbyherhusbandbecauseoflethargy,fatigue,anddecreasedresponsiveness.Shehadbeen
feelingwelluntiltwodaysago,whenshedevelopedmyalgiasandupperrespiratorycongestion.Medicationsincludeglipizide,metformin,lisinopril,andatorvastatin.On
physicalexamination,thepatientissomnolentbutarousable.Vitalsignsincludetemperature36.7C(98.6F),pulse130,bloodpressure102/64,respirations15/min.There
isnonuchalrigidity.Thereispoorskinturgorandthepatientsmucousmembranesaredry.Laboratoryevaluationshowsthefollowing:Na+124,K+4.0,Cl92,HCO324,
BUN70,creatinine2.1,glucose965,totalprotein6.1g/dL,albumin4.5g/dL,AST12U/L,ALT17U/L,Alk.Phosphatase110U/L,totalbilirubin0.7mg/dL.Whichofthe
followingisthemostlikelydiagnosisinthispatient?

A. Syndromeofinappropriateantidiuretichormonesecretion(SIADH)
B. Diabeticketoacidosis
C. Bacterialmeningitis
D. Nonketotichyperosmolarcoma
E. Acutesinusitis

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Question80

Selectthesinglebestanswertothenumberedquestion.

A52yearoldfemalecomesinforayearlyphysical.Shehasbeenfeelingcompletelywell,anddenieschestpain,shortnessofbreath,weightloss,decreasedexercise
tolerance,orchangeinstoolfrequencyorcaliber.Pastmedicalhistoryissignificantforhypertensioncontrolledwithhydrochlorothiazide.Althoughshehasahistoryof
severalabnormalPapsmearsthirtyyearsago,hertestshavebeennormalsincethen,withherlastnormalPapoccurringtwoyearsago.Shehadanormalmammogram
earlierthisyear.Shehassmokedonehalfapackofcigarettesdailyforthirtyfiveyears,anddrinks12glassesofwinenightly.Hermotherdiedatage63fromovarian
cancer,andherfatherdiedatage70fromlungcancer.Hersiblingsarealiveandwell.EKGshowssinusrhythmwithanormalaxisandintervals.Ofthefollowing,whichis
themostappropriatescreeningtesttoofferthispatient?

A. Papsmear
B. CA125
C. Chestxray
D. Exercisestresstest
E. Colonoscopy

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Question81

Selectthesinglebestanswertothenumberedquestion.

A19yearoldmalepresentstotheemergencyroomatmidnightwithwheezingandshortnessofbreath.Althoughhistoryisdifficulttoobtainsecondarytothepatient's
tachypnea,heisabletostatethathissymptomsstartedonehouragoandhavebeenprogressivelyworsening.Pastmedicalhistoryissignificantforseasonalallergiesand
asthma.Currentmedicationsincludeinhaledalbuterolandbudesonide.Onphysicalexam,thepatientappearsanxiousandissittingupright.Vitalsignsonpresentationare
pulse120,respirations42/minute,BP118/68,andO2Sat93%onroomair.Nasalflaringisnoted.Theskinappearspale.Nomurmurs,rubs,orgallopsareappreciatedon
cardiacauscultation.Bilateral,symmetricalwheezingispresent.ABGobtainedonpresentationshowspH7.51,pO270mmHg,andpCO229mmHg.SupplementalO2by
nasalcannulaisstarted,andthepatientistreatedwithnebulizedalbuterolandi.v.methylprednisolone.Thirtyminutesaftertreatment,thepatientisreassessed.No
wheezingisnoted,andbreathsoundsareequalbilaterally.Vitalsarepulse121,respiratoryrate35/minute,BPis120/71,whichdropsto108/65oninspiration.RepeatABG
isobtained,showingpH7.40,pCO241mmHg,pO272mmHg.Whatisthemostappropriatenextstepinmanagement?

A. Obtainchestxray
B. Begini.v.albuterol

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C. Begini.v.theophylline

D. Administerinhaledsalmeterol
E. Intubationandmechanicalventilation

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Question82

Selectthesinglebestanswertothenumberedquestion.

A45yearoldwomanpresentstoherfamilyphysiciancomplainingthatthebigtoeonherrightfootisyellowandsomewhatpainfulattimes.Shenoticedthediscolorationof
hernaillastweekwhensheremovedhernailpolish,andhasbeenavoidingwearinghernormalsummersandalsbecauseshefeelsembarrassed.Sheisotherwisehealthy
andhasnohistoryofdiabetesorperipheralvasculardisease.Physicalexamrevealsathickened,yellowfirsttoenailontherightfoottheothernailsappearhealthy.
Peripheralpulsesarestrongandequal.Therearenorashesorlesionsonthesurroundingskin.Whatisthemostappropriateinitialstepinmanagementofthispatient?

A. Griseofulvin
B. KOHexaminationofnailscapings
C. Reassurance
D. Nailremoval
E. Nailbiopsyandculture

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Question83

Selectthesinglebestanswertothenumberedquestion.

A13montholdfemalepresentstoherdoctortwoweeksafterbeingsuccessfullytreatedforanuncomplicatedfebrileUTI.Sincethattime,avoidingcystourethrogram
(VCUG)showedgradeIrefluxbilaterally,andarenalultrasoundshowednormalkidneys.Thepatientspastmedicalhistoryisotherwiseunremarkable.Onphysicalexam,
thepatientisafebrile.Urinalysisisnegativeforleukocyteesteraseandnitriteandmicroscopicexaminationshowsonlyoccasionalhyalinecastsandsquamousepithelial
cells.Whatisthemostappropriatenextstepinthemanagementofthispatient?

A. Cultureurinemonthly
B. Repeatrenalultrasoundinonemonth
C. Beginantibioticprophylaxis
D. RepeatVCUGinthreemonths
E. Reassurance

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Question84

Selectthesinglebestanswertothenumberedquestion.

A65yearoldmalecomestothephysicianbecauseoffatigueandincreasingabdominalgirth.Overthepastsixmonths,hehasalsoexperiencedanunintentionalweight
lossof15lbs.,whichhebelievesisduetothefactthathefeelsfullafteronlyafewbitesofhismeals.Thepatienthasnopastmedicalhistory,asthishisfirstvisittoa
physiciansincebeingdischargedfromthearmy40yearsago.Thepatientdeniessmokingbutdoesdrink13beerseveryevening.Onphysicalexamination,thepatient
appearsemaciatedwithavisiblydistendedandprotuberantabdomen.Noicterusisnoted.Neckveinsarenondistendedandlungsarecleartoauscultation.ThereisanS4
presentoncardiacauscultation.Abdominalexaminationshowsshiftingdullnesstopercussionandapositivefluidwave.Thereisafirm,red,nontendernoduleatthe
umbilicus.Examinationoftheskinshowsnospiderangiomataorpalmarerythema.Thereis1+edemaattheanklesbilaterally.Labaratoryresultsincludealbuminof3.6
g/dL,AST39U/L,andALT29U/L.Paracentesisisperformed,yieldingclear,strawcoloredfluid,withanalbuminconcentrationof2.7g/dL,650leukocytes(85%
lymphocytes,15%PMNs).NoorganismsareseenonGramstain.Whichofthefollowingisthemostlikelycauseofthispatientsascites?

A. Spontaneousbacterialperitonitis
B. Alcoholiccirrhosis
C. BuddChiarisyndrome
D. Congestiveheartfailure
E. Peritonealmetastaticdisease

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Question85

Selectthesinglebestanswertothenumberedquestion.

A19yearoldcollegefemalepresentstostudenthealthbecausesheisnolongermenstruating.Shehasmissedherlast5mensesandstatesthatthe3priormenseswere
verylightandunpredictable.Menarcheoccurredatage10andhermenseshadbeenoccurringatregularat24dayintervalsuntilthisrecentchange.Sheissexuallyactive
usingonlycondomsforbirthcontrol.Shetakesnomedications.Thepatientdeniesbreasttenderness,abdominalfullness,andnausea,thoughshehasnoticeda10pound
weightgainoverthepastfewmonths.Shefeelsthatshemighthavealittlelessenergythanusual.Physicalexamiswithinnormallimits.BMIis21.Aqualitativeserumbeta
hCGisnegativeforpregnancy.Whatisthemostappropriatenextstepinthemanagementofthispatient?

A. Urinepregnancytest
B. QuantitativeserumbetahCG
C. Folliclestimulatinghormone(FSH)
D. Serumthyroidstimulatinghormone(TSH)andprolactin
E. Serumandrogenlevels

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Question86

Selectthesinglebestanswertothenumberedquestion.

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A53yearoldfemalepresentscomplainingofdepression,insomnia,andincreasingfatigue.Shealsodescribesoccasionalepisodeswhereherfaceandneckbecomered
andflushed.Thesefrequentlyoccuratnightandwakeherfromsleep.Herlastmenstrualperiodwasfivemonthsago.Hermenseshadbeenirregularforoneyear,but
beforethen,hermenstrualhistorywasnormal.Physicalexamisremarkableforanatrophicvaginalmucosawithdecreasedsecretions.Whichofthefollowingdiagnostic
testsismostlikelytoconfirmthecauseofthispatientsamenorrhea?

A. UrinebetahCG
B. Folliclestimulatinghormone(FSH)
C. Thyroidstimulatinghormone(TSH)
D. Karyotyping
E. Prolactin

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Question87

Selectthesinglebestanswertothenumberedquestion.

A10yearoldmalepresentswithaoneweekhistoryofalimpthatseemstobegettingworse.Thepatientdescribeshipandupperlegpainthatisworstwhenhestandswith
hisfullweightonhisleftfoot.Thepainstartedlastweek,butyesterdayitsuddenlyworsenedafterhejumpedoffofamovingswingyesterday.Onphysicalexamination,the
patientmoderatelyobeseandatTannerstage2ofsexualdevelopment.Hewalkswithapronouncedlimp,andrefusestobearweightontheleftfoot.Thereismarked
limitationofbothactiveandpassiverangeofmotionatthehip.Examinationofotherjointsiswithinnormallimits.Whichofthefollowingisthemostlikelydiagnosisinthis
patient?

A. LeggCalvePerthesdisease
B. Slippedcapitalfemoralepiphysis
C. Transientsynovitis
D. OsgoodSchlatterdisease
E. Growingpains

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Question88

Selectthesinglebestanswertothenumberedquestion.

A38yearoldwomanhassuddenonsetofnauseaandvomitingandsevere,colickyflankpainthatradiatestotheperineum.Onphysicalexamination,thepatientshifts
positionfrequentlyandseemsunabletositstill.Urinalysisshowstraceprotein,3+blood,pH=7.2.Microscopicanalysisshowsmanyredcellsandafewwhitecells,butno
castsorbacteria.Laboratoryanalysisshows:Na+141K+3.0,Cl119,HCO312,BUN17,Creatinine1.0,glucose111,calcium9.8,magnesium1.6,phosphate3.0.Which
ofthefollowingisthemostlikelyetiologyofthispatientselectrolyteabnormalities?

A. Increasedproductionofendogenouslacticacid
B. DecreasednetsecretionofH+atthedistalrenaltubule
C. Deficiencyofaldosterone
D. Excessivereleaseofparathyroidhormone(PTH)
E. Physiologicalstressresponsetopain

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Question89

Selectthesinglebestanswertothenumberedquestion.

A46yearoldhomelessmanisbroughttothehospitalafterpassersbywitnessedhimhavingconvulsionsonthestreet.Onphysicalexamination,thepatientisdisheveled,
unshaven,andhasafaintodorofalcoholonhisbreath.Heissemicomatose,andarousesonlytopain.Vitalsignsaretemperature38.3C(101F),pulse115,blood
pressure166/96,respirations15/min,andoxygensaturation98%onroomair.Thereisa4cmsimplelacerationonhislefttemple.Therearenoothervisibleinjuries,andthe
remainderofthephysicalexaminationisnormal.Laboratoryevaluationshowsthefollowing:Hematocrit38%meancorpuscularvolume109fLsodium133mEq/Lglucose
62mg/dLmagnesium1.0mEq/Lalbumin3.0g/dLALT60IU/LAST123IU/LPT19s.Thepatientisplacedinmechanicalrestraintsandi.v.fluidwithglucose,thiamine,
folate,andmagnesiumisbegun.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?

A. Intravenousdiazepam
B. Oralphenobarbital
C. MRIofheadandneck
D. Lumbarpuncture
E. Intravenoussomatostatin

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Question90

Selectthesinglebestanswertothenumberedquestion.

A41yearoldfemalepresentswithmenstrualirregularitiesforthepastseveralmonths.Shealsocomplainsofincreasedhairgrowthonherface,andnotesthatatarecent
healthscreeningfair,shewastoldthatshehadprediabetes.Heronlymedicationisparoxetine.Onphysicalexamination,thepatientsbloodpressureis160/94,and
numerouspurplestriaearenotedonthepatientsabdomen.Thereisincreasedsubcutaneousfatdepositionintheskinofthecheeksandintheposteriorcervicalregion.A
24hoururinecollectionforcortisolismarkedlyelevated.Followingtheadministrationofhighdosedexamethasone,thepatientscortisolleveldecreasesby90%.Whichof
thefollowingisthemostlikelycauseofthesefindingsinthispatient?

A. McCuneAlbrightsyndrome
B. Pituitaryadenoma
C. Adrenaladenomaorcarcinoma
D. EctopicproductionofACTHbyalungtumor
E. Surreptitioususeofexogenousglucocorticoids

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Question91

Selectthesinglebestanswertothenumberedquestion.

A25yearoldgraduatestudentcomplainsofalumpunderhisclavicleforthepasttwoweeks.Hefirstnoticedthelumpafterbeinghitintheshoulderduringarugbymatch.
Hehasotherwisebeenwell,anddeniesanyothersymptomsincludingfever,nightsweats,weightloss,orrecentinfectionsorillnesses.Onphysicalexamination,thepatient
iscomfortableandafebrile.Thereisa4cm,rubbery,nontendersupraclavicularlymphnodeontheleft,aswellasnumerous12cmenlargedcervicalandaxillarynodes.
Theclavicleisnontender,andthereisfullrangeofmotionatbothshoulders.Thereisnoevidenceofadrainingabscessorresolvingcellulitis.Laboratoryevaluationshows
thefollowing.WBC8.0k/mcL(Normal:4.511.0k/mcL)Differential:66%neutrophils,30%lymphocytes,3%monocytes,1%eosinophilsHemoglobin14.3g/dL(Normal:
13.517.5g/dL)Hematocrit43%(Normal:3949%)Platelets212k/mcL(Normal:150450k/mcL)Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Acutemyelogenousleukemia
B. Infectiousmononucleosis
C. Hodgkin'slymphoma
D. Trauma
E. Felty'ssyndrome

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Question92

Selectthesinglebestanswertothenumberedquestion.

A31yearoldfemalepresentstoherphysicianinJanuarywithseveraldaysoffever,malaise,andacoughproductiveofyellowgreensputum.Shehadbeenfeelingwell
untilfourdaysagowhenshedevelopedasorethroatandrhinorrheathiswassoonfollowedbyfever,malaise,andmyalgias.Twodaysagoshebeganexperiencinga
hackingcoughthathasbeenoccasionallyproductiveofpurulentsputum.Vitalsignsincludetemperature37.2C(99.0F),pulse80,bloodpressure118/78,respirations
14/min,oxygensaturation98%onroomair.Nocracklesorrhonchiareappreciatedonauscultationofthelungs.Whichofthefollowingisthemostappropriateinitialstepin
themanagementofthispatient?

A. Azithromycin
B. Ceftriaxoneandlevofloxacin
C. Salmeterol
D. Amantadine
E. Pseudophedrineandacetaminophen

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Question93

Selectthesinglebestanswertothenumberedquestion.

A38yearoldfemalepresentswithweaknessandtinglinginherhandsandlowerextremities.Shewasfeelingwelluntilyesterdaywhenshenotedapinsandneedles
sensationinherfingersandtoes.Shenotedweaknessinherhandsandlegstoday,andhaddifficultyholdingapenorwalkingwithoutdragginghertoesonthegroundwhile
atworktoday.Herpastmedicalhistoryincludesgastroesophagealrefluxandanovernighthospitalizationthreeweeksagofordehydrationfollowinganepisodeof
gastroenteritis.Physicalexaminationshowspoorinspiratoryeffortanddiminishedbreathsoundsbilaterally.Deeptendonreflexescannotbeelicitedattheankle,knee,wrist,
orelbow,andthepatienthas3+musclestrengthdistallyand4+musclestrengthproximally.Thereisaflexorplantarresponse.Cerebellartestingandcranialnervetesting
shownogrossdeficit.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Caudaequinasyndrome
B. Multiplesclerosis
C. Amyotrophiclateralsclerosis
D. Myastheniagravis
E. Acuteinflammatorydemyelinatingpolyneuropathy

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Question94

Selectthesinglebestanswertothenumberedquestion.

A10yearoldmalewithasthmareturnstohisphysicianforfollowup.Twomonthsago,histeachernotedhimwheezingafterplayingontheplayground,andpulmonary
functiontestingconfirmedadiagnosisofasthma.Sincethattime,hehasbeenusingarescueinhalerapproximatelyonetimeaweekatschooltorelievewheezingandchest
tightnessthatseemtooccurfollowingstrenuousactivity.Hehasalsobeenusinghisrescueinhalerapproximatelyonetimeaweekathomeatnightwhenheawakenswith
chesttightnessordifficultybreathing.Currentmedicationsincludealbuterolandatomoxetine.Onphysicalexam,thepatientiscomfortableandafebrile.Thepatientslungs
arecleartoauscultation,andnowheezingorprolongedexpirationisnoted.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?

A. Repeatspirometry
B. Cetirizine
C. Inhaledsalmeterol
D. Inhaledfluticasone
E. Oralprednisone

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Question95

Selectthesinglebestanswertothenumberedquestion.

A24yearoldstudentseekstreatmentfornasalcongestion,sneezing,andarunnynose.Hissymptomsoccurdailyforfourtosixweekseveryyearinthespringandfall,and
areworsewhenheisoutdoorsordoingyardwork.Recently,hehasbeentakingoverthecounterpseudophedrineandchlorpheniramine,butthesehavenotsignificantly
improvedhissymptoms.Thepatientsfamilyhistoryincludesamotherwithasthmaandabrotherwitheczema.Onphysicalexam,theconjunctivaeareinjected,andthe

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patientspalpebraeareswollen.Thenasalturbinatesareboggyandedematous,andarebluishgrayincolor.Thereisnolymphadenopathyorthyromegaly.Whichofthe
followingisthemostappropriatestepinthemanagementofthispatient?

A. Diphenhydramine
B. Fexofenadine
C. Nasalbeclomethasone
D. Guaifenasin
E. MeasureserumIgElevels

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Question96

Selectthesinglebestanswertothenumberedquestion.

Attheinsistenceofhiswife,a71yearoldfarmerpresentstohaveabumponhisshoulderevaluated.Thebumphasbeenthereforseveralyears,andthoughitisnot
painful,itdoesitchfromtimetotime.Thepatientdoesreportmanyyearsofsunexposurewhileworkingonhisfarm.Physicalexaminationrevealsacomfortable,fair
skinnedgentleman.Onthepatientsleftshoulder,thereisasmooth,3cmby4cmpapularlesionwithnumerousdilatedbloodvesselsthroughout.Aphotoofthislesionis
seenhere.Whichofthefollowingisthemostappropriatetherapyforthispatient?


A. Podophillinresin
B. Shavebiopsy
C. Localexcision
D. Topicaltacrolimus
E. Excision,lymphnodebiopsy,andradiation

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Question97

Selectthesinglebestanswertothenumberedquestion.

A10yearoldboyreturnstothephysicianforanonhealingrashonhisarms,legs,andface.Twoweeksago,heinitiallydevelopedasmall,intenselypruriticareaof
erythemaonhisarmthatprogressedintosmallfluidfilledblisters.Hewasinitiallytreatedwithprednisoneforcontactdermatitis,butaftertherashcontinuedtospread,he
wasgivenaprescriptionforcephalexin.Despitefinishingthecourseofcephalexin,therashhascontinuedtospreadtohislegs,neck,andface.Thepatientsimmunizations
areuptodate,andhehasneverbeenhospitalizedandtakesnochronicmedications.Onphysicalexamination,thechildiscomfortableandpleasant,withvitalsigns
includingtemperature36.8C(98.2F),pulseof90/min,bloodpressure100/68,andoxygensaturationof99%onroomair.Therearenumerouslinearareasoferythemaand
excoriationarenotedonthepatientsarms,legs,neck,andface.Thelesionsappeartobeinvariousstagesofevolution:somearevesicular,whilesomearecoveredwitha
goldenyellowcrust.GramstainofoneofthelesionsshowsnumerousGrampositivecocciinclumps.Whichofthefollowingisthemostappropriatetreatmentforthispatient
atthistime?

A. Trimethoprimsulfamethoxazole
B. Acyclovir
C. Dicloxacillin
D. Vancomycin
E. Varicellazosterimmuneglobulin(ZVIG)

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Question98

Selectthesinglebestanswertothenumberedquestion.

A43yearoldteacherreturnstoherphysicianafterroutinelabevaluationrevealedelevatedlivertransaminaseswithanALTof158U/LandanASTof108U/L.Thepatient
hasbeeninhernormalstateofhealth,andhasnocomplaints.Pastmedicalhistoryissignificantfordiabetesmellitusandhypertension,andcurrentmedicationsinclude
metforminandenalapril.Thepatientdeniesforeigntravel,bloodtransfusions,oruseofoverthecounterorherbalmedications.SheisaJehovahsWitnessanddoesnot
smokeorusealcohol.Physicalexaminationshowsacomfortable,obesefemale.Thereisnoorganomegaly,rightupperquadrantorabdominaltenderness,jaundice,scleral
icterus,asterixis,orspiderangiomata.Laboratoryevaluationshowsthefollowing:HepatitisAIgM:negativeHepatitisAIgG:positiveHepatitisBsurfaceantigen(HBsAg):
negativeHepatitisBsurfaceantibody(HBsAb):positiveHepatitisBcoreantibody(HBcAb):negativeHepatitisCPCR:negative.Whichofthefollowingisthemostlikely
explanationforthispatientselevatedliverenzymes?

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A. HepatitisAinfection
B. HepatitisBinfection
C. Adverseeffectofmetformin
D. Fattyinfiltrationoftheliver
E. Alcoholabuse

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Question99

Selectthesinglebestanswertothenumberedquestion.

A25yearoldgraduatestudentreturnstoherphysicianwithcomplaintsofabdominalpainanddiarrhea,whichhavebeenpersistentnearlyayear.Shecontinuesto
experiencenearlydailyepisodesofpostprandialabdominalpainandvisibleabdominaldistension,whicharerelievedbythepassageofstool.Duringtheseepisodes,her
stoolsarelooseandgassy,andwhileshedenieseverpassingbloodinherstool,shehasperiodicallynoticedlargequantitiesofmucus.Workuptothispointhasbeen
unrevealing,andhasincludedthyroidfunctiontests,colonoscopy,celiacsprueantibodies,andfecaloccultbloodtesting.Shedeniesfevers,weightloss,nauseaand
vomiting,andrefluxsymptoms.Thepatientspastmedicalhistoryissignificantonlyfordepression,whichiswellcontrolledwithsertraline.Onphysicalexamination,the
patientappearshealthy.Shehasnormoactivebowelsoundsandanontenderabdomen.Hemoccultisnegative.Whichofthefollowingisthemostappropriatenextstepin
themanagementofthispatient?

A. Reassurance,education,anddietarymodification
B. Bariumenema
C. Cultureofthestoolforovaandparasites
D. Mesalamine
E. Exploratorylaparotomy

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Question100

Selectthesinglebestanswertothenumberedquestion.

A24yearoldfemalereturnstoherphysicianafteraroutinePapsmearshowedatypicalsquamouscellsofundeterminedsignificance.Shehasnopasthistoryofabnormal
Papsmearsorsexuallytransmittedinfections,andothertestingfromherlastvisit(includingbetahCGandtestingforgonorrheaandchlamydia)wasnegative.Shehasa
lifetimetotaloffoursexualpartners,andiscurrentlysexuallyactivewithonepartner,usingonlyanoralcontraceptivepillforbirthcontrol.Menarchewasatage11,and
menseshavebeenunremarkable.PCRrevealsthepresenceofhumanpapillomavirusDNA,type18.Whichofthefollowingisthemostappropriatenextstepinthe
managementofthispatient?

A. Rapidplasmareagin(RPR)testing
B. Beginimiquimod
C. Endometrialbiopsy
D. Colposcopy
E. Reassuranceandroutinefollowup

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Question101

Selectthesinglebestanswertothenumberedquestion.

Anotherwisehealthy2yearoldmalereturnsforfollowupofbilateraleareffusions.Severalmonthsago,thepatientcompletedacourseofamoxicillinforbilateralacuteotitis
media,butlaterfollowuprevealedpersistenteffusions.Athislastvisit,audiometryrevealedonlyslighthearinglossbilaterally(<20db).Today,hismotherstatesthatshe
doesfeelthathedoesntseemtohearaswellashissiblings,thoughhehasbeenafebrileandhasnoothersymptoms.Physicalexamrevealsnonerythematous,immobile
tympanicmembraneswithpersistenteffusionsbilaterally.Repeataudiometryrevealsabilateralhearingdeficitof42decibels.Whatisthemostappropriatenextstepinthe
managementofthispatient?

A. Chlorpheniramineandpseudophedrine
B. Prednisolone
C. Referralfortympanostomytubeplacement
D. Cefdinir
E. Followupinthreemonths

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Question102

Selectthesinglebestanswertothenumberedquestion.

A24yearoldwomanwithahistoryofrecurrentheadachesreturnsforfollowup.Forthepastyearandahalf,shehasexperiencedsevereheadachesaccompaniedby
nauseaandvomitingseveraltimesperweek.Herpainispulsatingandthrobbing,andtypicallyaffectsthelefttemporalregionofherhead.Theheadacheslastatleast
severalhours,buthavelastedaslongasthreedaysandhaverequiredhertomissseveraldaysofwork.Pastmedicalhistoryissignificantformajordepressionand
dysmenorrhea.Hermotherhasahistoryofsimilarheadaches.Severalweeksago,shewasseenandgivenaprescriptionfororalsumatriptan.Today,shestatesthatshe
continuestohaveseveralheadacheseachweek,justasshedidpreviously,buttakingsumatriptanandlyinginadarkroomhelpsrelievethemwithinafewhours.Her
neurologicalexaminationisnormal.Thereisnopapilledema.Whichofthefollowingisthemostappropriatestepinthemanagementofthispatient?

A. Inhalationof100%oxygen
B. HeadCTwithandwithoutcontrast
C. Lumbarpuncture
D. Amitriptyline
E. Intranasaldihydroergotamine

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Question103

Selectthesinglebestanswertothenumberedquestion.

A16yearoldfemalepresentswithabdominalpainandfever.Thepainbegan12hoursago,andwasinitiallyfocusedintheumbilicalarea,buthassinceshiftedtotheright
lowerquadrant.Shehasalsoexperiencednauseaandhadoneepisodeofvomiting.Sheissexuallyactivewithonepartner,andherlastmenstrualperiodwasthreeweeks
ago.Shehasnoteatenanythingsinceyesterdayanddoesnotfeelhungry.Vitalsignsincludetemperature38.1C(100.5F),pulse96/min,bloodpressure112/70.The
patientislyingverystillontheexaminationtablewithherhipsflexed.Herabdominalexaminationshowsvoluntaryguardingandtendernesstopalpationgreatestintheright
lowerquadrant,approximatelymidwaybetweentheumbilicusandtheanterioriliacspine.Laboratoryanalysisshowsawhitebloodcountof14,000.Whichofthefollowingis
themostappropriatenextstepinthemanagementofthispatient?

A. Diagnosticperitoneallavage
B. Doxycycline
C. Boluswith3Li.v.normalsaline(0.9%NaCl)
D. CTofabdomen
E. UrinebetahCG

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Question104

Selectthesinglebestanswertothenumberedquestion.

A44yearoldfemalepresentswithepigastricabdominalpain,nausea,andvomiting.Hersymptomsbeganaftereatingfriedchickenandicecreamatacarnivaltwonights
ago,andhaveprogressivelyworsened.Physicalexaminationshowsanobese,afebrilefemale,withpulse110andbloodpressure96/60.Thereismild,diffusetendernessto
palpationthroughouttheabdomenandworstattheepigastrium.Bowelsoundsareabsent,andthereisnoreboundtendernessorguarding.Laboratoryevaluationshowsthe
following:WBC12,000/mm3Hct49%AST18ALT25Lipase320Totalbilirubin2.0.Rightupperquadrantultrasoundrevealsnumerousgallstones,butnogallbladderwall
thickeningorpericholecysticfluidcollection.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Acutepancreatitis
B. Biliarycolic
C. Cholecystitis
D. Choledocholithiasis
E. Ovariantorsion

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Question105

Selectthesinglebestanswertothenumberedquestion.

A58yearoldmalewithahistoryofdiabetesmellitusandcoronaryarterydiseasepresentswithfailuretoachieveorsustainanerection.Thisproblemhasbeenpersistent
forthepastyear,andhasbeencausingagreatdealofstressinhismarriage.Whenquestionedregardingnocturnalerections,hestatesthathecannotrecallthelasttime
thatheawakenedwithanerection.Previously,thishadbeenatypicaloccurrence.Currentmedicationsincludeatorvastatin,glyburide,metformin,isosorbidedinitrate,and
metoprolol.Physicalexaminationrevealsnormalexternalgenitalia.Thereisdiminishedsensationtopinprickinthedistallowerextremitiesbilaterally.Whichofthefollowing
isthemostappropriateinitialstepinthemanagementofthispatient?

A. Sertraline
B. Yohimbine
C. Alprostadil
D. Tadalafil
E. Reassurance

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Question106

Selectthesinglebestanswertothenumberedquestion.

A23yearoldwomanpresentswithatwoweekhistoryofbloodydischargefromherrightbreast.Familyhistoryissignificantfora58yearoldauntwhowasrecently
diagnosedwithbreastcancer.Onphysicalexamination,therightbreastisslightlytendertopalpationintheareaofthenipple.Therearenomasses,andtheskinshowsno
dimpling,retractions,orinflammatorychanges.Thereisnoaxillaryadenopathy.UrinebetahCGisnegative.Whichofthefollowingisthemostlikelydiagnosisinthis
patient?

A. Intraductalpapilloma
B. Infiltratingductalcarcinoma
C. Acutemastitis
D. Paget'sdiseaseofthebreast
E. Fibroadenoma

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Question107

Selectthesinglebestanswertothenumberedquestion.

A73yearoldmaleisbroughttothephysicianbyhiswife,whoisconcernedaboutarapidfunctionaldeclineoverthepastseveralmonths.Herhusbandusedtomanagethe
familysfinances,buthehasbecomeincreasinglyforgetful,andnowisunabletoperformthistaskoreventorememberthelastfewwordsofaconversation.Overthistime,
hehasalsodevelopeddifficultywalking,andrecentlyhasbecomeincontinentofurine.Minimentalstateexaminationshowsimpairedshorttermmemory.Thyroidfunction
testsandserumB12levelsarenormal.WhichofthefollowingisthemostlikelyfindingonCTimagingofthehead?

A. Grossatrophyofthecaudatenucleus

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B. Biconvex,extraaxialareaofhemorrhagethatdoesnotcrosssuturelines
C. Multipleringenhancinglesionsthroughoutthebrain
D. Corticalatrophyandventricularenlargement
E. Ventricularenlargementwithoutcerebralatrophy

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Question108

Selectthesinglebestanswertothenumberedquestion.

A14yearoldboywithahistoryofinsulindependentdiabetesmellitusisbroughttotheclinicbyhismother,whoisconcernedaboutworseninglethargyoverthepastfew
days.Currentmedicationsincludeglargineandlisproinsulin,andthepatientdoeshisowninjectionsandbloodglucosemonitoring.Reviewofsymptomsispositivefor
polyuria,polydipsia,andgeneralizedweakness.Vitalsignsincludetemperature36.9C(98.4F),pulse120,bloodpressure94/52,andrespiratoryrate24/min.Onphysical
examination,afruityodorisnotedonthepatientsbreath.Thepatientsskinandmucousmembranesaredry,andthereisdecreasedskinturgor.Whichofthefollowingsets
ofvalueswouldbemostlikelyfoundonthispatientsarterialbloodgas(ABG)?

A. pH=7.11,pCO2=73,PaO2=54,HCO3=28
B. pH=7.20,pCO2=20,PaO2=98,HCO3=13
C. pH=7.34,pCO2=60,PaO2=60,HCO3=31
D. pH=7.48,pCO2=45,PaO2=98,HCO3=30
E. pH=7.56,pCO2=20,PaO2=95,HCO3=24

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Question109

Selectthesinglebestanswertothenumberedquestion.

A23yearoldG2P2presentsonpostpartumday10withfeverandatenderleftbreast.Hersymptomsbegantwodaysago,andhavebeenaccompaniedbymyalgias,chills,
andmalaise.Shehasbeenbreastfeedinghernewdaughter,andreportsthatthishasbeengoingwell,andthatherchildhasappearedhealthysincebirth.Vitalsignsinclude
temperature38.4C(101.1F),pulse90,andbloodpressure112/68.Onphysicalexamination,thepatientsleftbreastiserythematousandengorged,andverytenderto
palpation.Nomassesorareasoffluctuanceareappreciated.Therightbreastisunremarkable.Whichofthefollowingisthemostappropriateinitialstepinthemanagement
ofthispatient?

A. Incisionanddrainage
B. Mammography
C. Tetracycline
D. Dicloxacillin
E. Cephalexinandtemporarycessationofbreastfeeding

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Question110

Selectthesinglebestanswertothenumberedquestion.

A6yearoldboyfromGhanapresentswithchestandabdominalpainforthepastday.Hispainbegansuddenlywhileatrestlastnight,isa9/10inintensityandunrelieved
byibuprofen,andislocalizedmainlytohisepigastriumandleftupperquadrant,back,andchest.Pastmedicalhistoryisunremarkable,andimmunizationsareuptodate.
Onphysicalexamination,thepatientisafebrileandnormotensivebuttachycardic.Lungsarecleartoauscultation,andthereismoderatetendernesstopalpationintheleft
upperquadrant.Laboratoryevaluationshowsawhitebloodcountof11,000andahematocritof31%.Chestxrayshowsnoatelectasisorinfiltrate,andabdominalxray
showsnofreeairandmoderateenlargementofthespenicsilhouette.Thepatientisgiveni.v.fluids,ceftriaxone,andmorphine.Whichofthefollowingisthemost
appropriatenextstepinthemanagementofthispatient?

A. ELISAforHIV1antibodies
B. Hemoglobinelectrophoresis
C. CTofchest
D. Vancomycin
E. Hydroxyurea

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Question111

Selectthesinglebestanswertothenumberedquestion.

A9yearoldAfricanAmericanfemaleisbroughttothephysicianbyhermother,whoisconcernedaboutalumpinthepatientsleftbreast.Shenotedthislumptwoweeks
ago,andisconcernedbecausethepatientsgrandmotherwasrecentlydiagnosedwithbreastcancer.Thechildisotherwisewell,andhasnotyethadonsetofmenses.On
physicalexamination,theleftbreastandareolaareenlargedandareTannerstage3.Thereisasmalltendermassbeneaththeareolaontheleft.Therightbreastisflatand
prepubertal.Thereisnoaxillaryadenopathy.Theexternalgenitaliaaregrosslynormal,andarecoveredwithfinevelushair.Whichofthefollowingisthemostappropriate
nextstepinthemanagementofthispatient?

A. Reassuranceandanticipatoryguidance
B. Transdermalethinylestradiol
C. Measurementofserumluteinizinghormone(LH)level
D. Mammography
E. Openbiopsyofbreast

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Question112

Selectthesinglebestanswertothenumberedquestion.

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A4yearoldHispanicchildisbroughttohispediatricianafterhedevelopedswellingofhiseyesandanklesoverthepastweek.Temperatureis37.4C(99.3F),pulseis
120/min,bloodpressure104/61,andrespirations28/min.Inadditiontoperiorbitalswellingand2+edemaoftheankles,hehasaprotuberantabdomenwithapositivefluid
wave.LaboratoryevaluationshowsBUN7mg/dL,creatinine0.4mg/dL,albumin1.4g/dL,andcholesterol498mg/dL.Urinalysisshowsnobloodand4+protein.Whichof
thefollowingisthemostlikelyassociatedfindinginthispatientsdisorder?

A. "Applegreen"birefringenceunderpolarizedlightwithCongoredstain
B. Fusionofepithelialfootprocessesonelectronmicroscopy
C. LowcomplementC3andincreasedantistreptolysinOtiter
D. Presenceofcytoplasmicantineutrophilantibody(ANCA)staining
E. GranulardepositsofIgGandC3inthebasementmembrane

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Question113

Selectthesinglebestanswertothenumberedquestion.

A57yearoldfemalewithhypertensionpresentsforscheduledfollowup.Onphysicalexamination,thepatientsbloodpressureis128/80,butanewmassispalpatedonthe
patientsleftthyroidlobe.Themassisfirm,smooth,andnontender,andmeasures2cmby1cm.Thereisnocervicallymphadenopathyorlidlag,andthepatienthasno
historyofheadorneckradiationorthyroiddisease.LaboratoryevaluationshowsTSHof1.9mU/Landcalciumof9.9mg/dL.Whichofthefollowingisthemostappropriate
nextstepinthemanagementofthispatient?

A. Reassurance
B. Radionuclidethyroidscan
C. Fineneedleaspiration
D. Beginpropylthiouracil
E. Totalthyroidectomy

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Question114

Selectthesinglebestanswertothenumberedquestion.

A13yearold,121lb(55kg)malepresentswithnauseaandperiumbilicalabdominalpainandisdiagnosedwithappendicitis.Followinganuncomplicatedlaparoscopic
appendectomy,thepatientiscomfortableandstable,withvitalsignsinthenormalrange.Thepatientisnotyeteating.Laboratoryanalysisshowselectrolyteswithinnormal
limitsandcreatinineatpreoperativebaseline.Whichofthefollowingisthemostappropriatemaintenancefluidandinfusionrateforthispatient?

A. Normalsaline(0.9%NaCl)+20mEqKClat70mL/h
B. Ringerslactateat70mL/h
C. Normalsaline(0.9%NaCl)at95mL/h
D. 5%dextroseandnormalsaline(0.225%NaCl)+20mEqKClat95mL/h
E. 5%dextroseandnormalsaline(0.225%NaCl)+20mEqKClat120ml/h

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Question115

Selectthesinglebestanswertothenumberedquestion.

A27yearoldG2P2A0atsixweekspostpartumpresentswithdepressedmood,dryskin,andproblemsbreastfeeding.Thoughshewasinitiallyabletobreastfeedwithout
difficulty,shehasbeenunabletoproduceadequatelactationtofeedherdaughter,andlatelyhermilkhascompletelydriedup.Hermostrecentpregnancywasuneventful,
butdeliveryofherhealthyfemaleinfantwascomplicatedbysevereuterineatonyrequiringmultiplebloodtransfusionsandtreatmentwithprostaglandins.Onphysical
examination,thepatienthasabloodpressureof90/64.Skintentingandfinewrinklesarenotedaroundtheeyesandmouth.Therearediminisheddeeptendonreflexeswith
aprolongedrelaxationphase.Laboratoryevaluationisnotableforahemoglobinof10.5g/dL,thyroidstimulatinghormoneof0.1U/mL,andprolactinof2ng/mL(normal020
ng/mL).Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Sheehansyndrome
B. Grave'sdisease
C. Uterinerupture
D. Hashimotothyroiditis
E. Pituitaryprolactinoma

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Question116

Selectthesinglebestanswertothenumberedquestion.

A12montholdmaleisbroughttothephysicianforawellchildcheckup.Hehasbeenhealthy,andhismothersonlyparticularconcernisthathehasgrownincreasingly
uneasyaroundanyadultsotherthanher.Thechildeatsthreemealsaday,andisabletofeedhimselfsmallfingerfoods.Hecanpulltostandandcantemporarilystand
unsupported,buthehastoholdontofurnitureoradultsinordertowalk.Hismotherreportsthatherespondsbyturninghisheadwhenhisnameiscalled,andthatheisable
toshakehisheadno.Hebabblesfrequently,buthasnotyetsaidMamaorothersimplewords.Whichofthefollowingmostaccuratelyrepresentsthischilds
development?

A. Motornormalsocialnormallanguagenormal
B. Motordelayedsocialnormallanguagenormal
C. Motornormalsocialdelayedlanguagenormal
D. Motornormalsocialnormallanguagedelayed
E. Motordelayedsocialdelayedlanguagedelayed

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Question117

Selectthesinglebestanswertothenumberedquestion.

A45yearoldmalepresentswithintermittentchestpainforthepastmonth.Hedescribesburning,retrosternalpainthatusuallyoccursaftereatingorwhilelyingdownor
bendingover.Healsonotesthathehasbeenhoarselately,especiallyuponawakeninginthemorning.Pastmedicalhistoryincludesafatherandgrandfatherwhodiedof
coronaryarterydiseaseintheir60s.Intheoffice,thepatientiscomfortable,andphysicalexaminationisentirelyunremarkable.Whichofthefollowingisthemostappropriate
initialstepinthemanagementofthispatient?

A. Metoclopramide
B. Ranitidine
C. Lansoprazole
D. Lifestylemodificationandsmokingcessation
E. Upperendoscopy

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Question118

Selectthesinglebestanswertothenumberedquestion.

A27yearoldG0presentswithheavymenstrualperiodsandpainduringmenses.Hersymptomsbegantwoandahalfyearsagowhenshediscontinuedheroral
contraceptivemedicationsothatshecouldattempttobecomepregnant.Hersymptomsseemtobegettingworse,andherpainisnowonlyminimallycontrolledwithover
thecountermedications.Currentmedicationsincludeescitalopramandasneededibuprofenandnaproxen.Pelvicexaminationrevealsanontender,fixed,retroverted
uterus.Speculumexaminationshowssmallbluishspotsintheposteriorfornix,butnocervicaldrainageordischarge.Thereismoderateuterosacralnodularityon
rectovaginalexamination.Thepatientshematocritis30%,andherurinebetahCGisnegative.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Endometrialcarcinoma
B. Pelvicinflammatorydisease
C. Endometritis
D. Premenstrualdysphoricdisorder
E. Endometriosis

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Question119

Selectthesinglebestanswertothenumberedquestion.

A33yearoldfemalewithathreeyearhistoryofrecurrentgastricandduodenalulcersdespitemedicalmanagementisfoundonsubsequentevaluationtohaveafasting
gastrinlevelof989pg/mL(normal:<100pg/mL).AbdominalCTscanrevealsa2cmmassintheheadofthepancreas,andsurgicalexplorationisplanned.Following
successfulresectionofthismass,thepatientsfastinggastrinlevelisfoundtobe1020pg/mL.Pathologicalanalysisoftheresectedspecimenshowsittobeaglucagonoma.
Whichofthefollowingisthemostlikelyadditionalassociatedfindinginthispatient?

A. Squamouscellcarcinomaofthelung
B. Hyperplasiaoftheparathyroidglands
C. Pheochromocytoma
D. Pancreaticadenocarcinoma
E. Breastcarcinoma

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Question120

Selectthesinglebestanswertothenumberedquestion.

A17yearoldfemalepresentsforfollowupofheranemia.Threemonthsago,routinelabworkshowedahematocritof31%,andthepatientwasstartedonoraliron
supplements.Intheofficetoday,thepatientfeelswellanddeniesrecentillnessesormedications,menorrhagia,hematemesis,hematocheziaormelena,andtrauma.
Physicalexaminationshowsacomfortablefemaleinnoacutedistress.Thereismoderatepalloroftheconjunctivaebilaterally,andthespleenispalpable1cmbelowtheleft
costalmargin.Thereisnospooningofthenails,andpositionandvibratorysensationareintactonneurologicalexam.Thestoolisnegativeforoccultblood.Further
laboratoryanalysisshowsthefollowing:WBC7.1k/mL,Hgb10g/dL,Hct30%,Platelets220k/mLMCV85fL,MHC31pg,MCHC39%LDH150U/L,Totalbilirubin1.2
mg/dL,Reticulocytes4%.AdirectCoombstestisnegative.Thepatientsperipheralbloodsmearisseenhere.Whichofthefollowingtestsismostlikelytoconfirmthe
diagnosisinthispatient?

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A. Bonemarrowbiopsy
B. Osmoticfragilitytest
C. Hemoglobinelectrophoresis
D. Quantitativeglucose6phosphagedehydrogenaseenzymeactivity
E. Thickandthinbloodsmears

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Question121

Selectthesinglebestanswertothenumberedquestion.

A66yearoldmalepresentswiththeabruptonsetofpainintheleftlowerabdomen,whichhasbeenprogressivelyworseningoverthepasttwodays.Thepainisnow
constant,andhehasalsoexperiencedfeversandmilddiarrhea.Hedeniesdysuria,nausea,andhematochezia.Onphysicalexam,thepatientisalertandinmilddistress.
Vitalsignsincludetemperature38.1C(100.6F),pulse90,andbloodpressure131/84.Thepatientsbowelsoundsaredecreased,andtheabdomenistendertopalpation
withvoluntaryguardingintheleftlowerquadrant.Thereisnocostovertebralangletenderness.Stoolisnegativeforoccultblood.LaboratoryanalysisshowsaWBCof14.5
k/mm3.Thepatientsabdominalxray,takenwiththepatientsittingupright,isshownhere.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthis
patient?

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A. Bowelrest,metronidazole,andciprofloxacin
B. Microscopicexaminationofthestoolforovaandparasites
C. Bariumenema
D. Urgentcolonoscopy
E. Emergentlaparotomy

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Question122

Selectthesinglebestanswertothenumberedquestion.

A63yearoldwomanwithahistoryofbreastcancerpresentsforfollowup.Fiveyearsago,thepatientwasdiagnosedwithlymphnodepositiveinvasiveductalcarcinomaof
therightbreast,forwhichsheunderwentlumpectomyandbreastradiationfollowedbychemotherapy.Thepatienthasbeenfeelingverywellrecently,andthoughshedoes
notesomerecentirregularmenstrualspottingandbleeding,shedenieschestpain,shortnessofbreath,andboneorjointpains.ThepatientisaG0,andmenopause
occurredatage53.Currentmedicationsincludehydrochlorothiazideandtamoxifen.Physicalexaminationrevealsapleasant,obeseCaucasianfemaleinnodistress.Heart
rateisregular,withnormalS1andS2.Lungfieldsarecleartoauscultationbilaterally.Pelvicexamshowsananteverteduterinefundus.Adnexaearenonenlargedand
nontender.Thereisasmallamountofbrownishbloodinthevaginalvault.Nomassesorlymphadenopathyarefoundonbreastexamination.Bilateralmammographyshows
nochangefromprevious.Whichofthefollowingisthemostappropriatenextstepinthemanagementofthispatient?

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A. MeasurementofserumCEAandCA153
B. Endometrialbiopsy
C. CTofchestandabdomen
D. Technetium99bonescan
E. Reassuranceandroutinefollowup

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Question123

Selectthesinglebestanswertothenumberedquestion.

A73yearoldmanwithapastmedicalhistoryofhypertension,coronaryarterydisease,andosteoarthritispresentsformedicalevaluationandpreoperativeclearancebefore
undergoingalefthiparthroplasty.Heiseagertoproceedwiththeoperation,andstatesthathehasbeenfeelingwellanddenieschestpain,dypnea,orsyncope.Twoyears
ago,thepatienthadanonSTelevationmyocardialinfarctionandunderwenttwovesselangioplastyandstentplacement,andthepatienttoleratedgeneralanesthesia
withoutcomplicationtenyearsagowhenhehadsuccessfulbilateralinguinalherniarepairs.Currentmedicationsincludeatorvastatin,clopidogrel,metoprolol,aspirin,and
enalapril.Onphysicalexam,vitalsignsincludepulse64,bloodpressure126/72,respirations12/min,andoxygensaturation98%onroomair.Lungfieldsareclearto
auscultation.Thereisaharsh,II/VImidsystolicejectionmurmurheardbestoverthesecondrightintercostalspacewithradiationtotherightneck.Thereisnoperipheral
edema.EKGshowsnormalsinusrhythmandleftventricularhypertrophy.Whichofthefollowingisthemostappropriatedecisionregardingthispatientsscheduledsurgery?

A. Advisethepatienttoproceedwithhissurgeryasplanned
B. Discontinuemetoprolol
C. Obtainpreoperativeechocardiogram
D. Obtainpreoperativecoronaryangiography
E. Advisethepatienttocanceltheprocedure

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Question124

Selectthesinglebestanswertothenumberedquestion.

Overthepastseveralweeks,a37yearoldnursewithahistoryofdepressionandgeneralizedanxietydisorderhasexperiencedneardailyepisodesofsweating,anxiety,
palpations,andtremor.Thepatientdeniesanyassociationwithidentifiablestressors,andstatesthatthesymptomscanoccuratanytimeofday,butmostfrequentlyaffect
heratwork.Duringhermostrecentepisode,shelostconsciousnessandhadtoberevivedbyhercoworkers.Intheoffice,thepatientisinitiallypleasantandalert,but
quicklygrowsirritable,tremulous,andafterafewminutes,somnolent.Followingadministrationofsupplementaloxygenbynasalcannulaanda1Lbolusof0.45%NaClwith
5%dextrose,thepatientfeelsmuchbetter.Labstakenatthetimeofhersymptomsincludethefollowing:Na+137mEq/L,K+3.9mEq/L,Cl99mEq/L,HCO324mEq/L,
BUN11mg/dL,Creatinine0.7mg/dL,Glucose36mg/dL,TSH1.1mcU/mL,FreeT48mcg/dL,T3160ng/dL,Insulin96mcU/mL(normal:<100mcU/mL),Cpeptide0.03
ng/mL(normal:0.701.89ng/mL),Parathyroidhormone,Nterminal318pg/mL.Toxicologyisnegativeforcocaine,amphetamines,opiates,benzodiazepines,andcannabis.
Serumassayforsulfonylureasisnegative.Whichofthefollowingisthemostlikelydiagnosisinthispatient?

A. Thyrotoxicosis
B. Insulinoma
C. Multipleendocrineneoplasia,type1
D. Panicdisorder
E. Factitiousdisorder

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Question125

Selectthesinglebestanswertothenumberedquestion.

A63yearoldmalepresentswithfeverandurinaryfrequencyforthepasttwodays.Healsonotesurinaryurgencyandfeelingsofincompletevoiding.Onphysicalexam,the
patienthasatemperatureof37.9C(100.3F),pulse90,andbloodpressure121/76.Bowelsoundsarenormoactive,andthereisnoabdominalorcostovertebralangle
tenderness.Ondigitalrectalexam,theprostateisslightlyenlarged,nodular,boggy,andtendertopalpation.Stoolisnegativeforoccultblood.Thepatientsurinalysisshows
cloudyurinethatisnegativeforketones,glucose,protein,andblood,andpositiveforleukocyteesteraseondipstickanalysis.Whichofthefollowingisthemostappropriate
treatmentforthispatient?

A. Moxifloxacin
B. Tamsulosin
C. Trimethoprim/sulfamethoxazole
D. Anidulafungin
E. Finasteride

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