NBME Questions Part 1
Posted: Mon Apr 11, 2022 7:20 am
1.
Two clinical trials, Trial X and Trial Y, are conducted to assess the potential therapeutic efficacy of a new experimental antibiotic compared to the currently used antibiotic for treatment of urinary tract infections. The two studies are identical, except the statistical power is 0.8 in Study X, and 0.9 in Study Y. Which of the following is the most accurate conclusion regarding the likelihood of a type II error?
A. Greater in Trial X than in Trial Y
B. Greater in Trial Y than in Trial X
C. The same in Trial X and in Trial Y
D. Cannot be calculated from the data given
2.
A screening test is used to detect prostate cancer in a population of 100,000 men. The test has a sensitivity of 70% and a specificity of 90%. The test is then used to screen a second population in which the prevalence of prostate cancer is different. Which of the following is the most likely effect on the positive predictive value of this test?
A. Decreases as prevalence increases
B. Increases as prevalence decreases
C. Increases as prevalence increases
D. No change as prevalence changes
3. A retrospective study is conducted to assess the incidence and outcome of subarachnoid hemorrhage in a midwestern state. The annual incidence of this condition is 15 per 100,000 people, and the case fatality rate is 40%. Based on these data, which of the following represents the annual mortality rate for subarachnoid hemorrhage per 100,000 people in this state?
A. 0.4x15
B. 0.4 x 100,000
C. 0.6x15
D. 0.6 x 100,000
E. 0.4 x 0.6
4. A study is conducted to assess the effectiveness of vitamin C in preventing common colds in children. Patients are randomly assigned to receive either vitamin C or no intervention. Outcome events (common cold) are reported by the parents on a monthly basis for 1 year. Results show that those taking vitamin C have fewer colds compared with those who received no intervention (p<0.05). Which of the following raises the most concern about the validity of the conclusion that vitamin C supplements prevent the common cold?
A. Inadequate statistical power
B. Nonrandomization
C. Selection Bias
D. Variability in outcome assessment
5. A prospective study examined the relationship between the development of gastric cancer and exposure to a diet rich in selenium. The investigators estimated the relative risk of gastric cancer to be 0.3 in individuals with a high-selenium diet (95% confidence interval 0.1 - 0.8). Which of the following is the most appropriate interpretation of this findings?
A. Selenium causes gastric cancer
B. Selenium is associated with a lower risk of gastric cancer
C. Selenium is associated with a higher risk of gastric cancer
D. Selenium exposure is unrelated to gastric cancer
E. Selenium is positively correlated with gastric cancer
6. A study is conducted to evaluate the onset and course of cardiovascular disease in African American men and women in the USA. Census data from the year 2000 are used to select the study sample. A series of factors including family income and years of education is defined. Census tracts most representative of the national census data for the factors selected are used for sampling. Which of the following best describes this sampling technique?
A. Sequential
B. Self-Selection
C. Population-Based
D. Sample of Convenience
E. Blocked Randomization
7. An epidemiologist is investigating an outbreak of diarrhea among a total of 1000 consumers of vegetables. Of those consumers, 800 people ate tomatoes and 200 people ate lettuce. A total of 400 people became ill; 80 of these people ate tomatoes, and 40 people ate lettuce. Which of the following indicates the probability of diarrhea having developed in people who consumed lettuce?
A. 0.08
B. 0.1 C. 0.2 D. 0.4 E. 0.5
8. In order to determine risk factors for death from Coronary Artery Disease (CAD), persons aged 30 years and older are studied in a community. Every 2 years for a total of 10 years, blood pressure, serum cholesterol concentration, and smoking status are assessed along with deaths from CAD. Persons with increased blood pressure are compared with those who have normal pressure to determine which group has greater mortality from coronary artery disease. Which of the following best describes this type of study?
A. Randomized Clinical Trial
B. Case-Control Study
C. Cross-Sectional Study
D. Observational Cohort Study
E. Ecologic Study
9. A 76-year-old man comes to the physician for a follow-up examination. He has hypertension treated with a B-adrenergic antagonist. He lives on a farm in central California and says he has always distilled his own liquor. Before retiring 10 years ago, he worked in a hat factory and subsequently in a textile factory. He has smoked 2 packs of cigarettes daily for the past 55 years. He tells the physician that he has had several episodes of painful swelling of his right great toe. Physical
examination shows several lesions consistent with gouty tophi over the elbows bilaterally. Laboratory studies show:
Hemoglobin A1C 5.6
Serum Glucose Creatinine
Uric Acid
93 mg/dL 3.2 mg/dL 7.9 mg/dL
The most likely cause of this patient’s condition is which of the following?
A. Cigarette Smoking
B. Drinking home-distilled liquor
C. Farming in Central California
D. Working in a textile factory
E. Working in a hat factory
10. A previously healthy 18-year-old man is brought to the emergency department by his mother 45 minutes after she found him crouched in his closet, saying he had to hide from the intruders “from that other place.” There were no intruders in the house. He has no history of alcohol or drug use. He appears afraid of the physician and sits far away from her. During the interview, he says he has heard two male voices in his head for the past 2 weeks. Physical examination and laboratory studies show no abnormalities. Which of the following is the most likely diagnosis?
A. Schizophrenia
B. Delusional Disorder
C. Brief Psychotic Disorder
D. Schizoaffective Disorder
E. Bipolar Disorder
11. A 23-year-old man comes to the emergency department because of a 2- week history of back pain refractory to treatment with over-the-counter medications. He demands a prescription for an opioid drug because “they’re the only medications that decrease my pain.” He becomes upset when he is told that over-the-counter medications should relieve his symptoms. His temperature is 37.1°C (98.8°F), pulse is 70/min, respirations are 18/min, and blood pressure is 120/70 mmHg. Physical examination shows no abnormalities. Which of the following is the most appropriate actions by the physician?
A. Determine which drugs have been prescribed for the patient in the past
B. Obtain serum toxicology screening on the patient
C. Order an MRI of the spine
D. Prescribe only a 2-week course of a narcotic medication for the patient
E. Refer the patient to a drug addiction program
12. A 62-year-old man comes to the physician for a follow-up examination. Two weeks ago, he was discharged from the hospital after sustaining an acute myocardial infarction. He smokes 2 packs of cigarettes and drinks four 12-oz beers daily. His diet mostly consists of cured meats and fast food. He dos not exercise. The patient tells the physician, “I know that I need to make some changes in how I live so that my heart can be healthier. I just don’t have the willpower to quit smoking and drinking and all that stuff right now.” Which of the following best describes this patient’s stage of behavioral change?
A. Precontemplation B. Contemplation
C. Preparation
D. Action
E. Maintenance
13. A 67-year-old man comes to the physician because of a 2-month history of unexplained weight loss. He has a 50-year history of type 1 diabetes mellitus. He underwent gallstone removal 12 years ago. He has smoked 1 pack of cigarettes daily for 45 year. He is 188 cm (6 ft 2 in) tall and weighs 120 kg (265 lb.); BMI is 34 kg/m2. Physical examination shows no other abnormalities. Serum studies shows a calcium concentration of 11 mg/dL. An abdominal CT scan shows a pancreatic mass. A biopsy specimen of the mass shows pancreatic adenocarcinoma. Which of the following is the strongest predisposing risk factor for pancreatic cancer in this patient?
A. BMI of 34 kg/m2
B. Cigarette Smoking
C. History of gallstone disease
D. Type 1 Diabetes Mellitus
E. Hypercalcemia
14. A 20-year-old woman who works as a secretary comes to the physician because of an 8-year history of intermittent headaches. They begin with flashing lights in her right visual field, followed 20 minutes later by a unilateral throbbing headache accompanied by nausea and vomiting. They occur around the time of her menses. Which of the following is the most likely diagnosis?
A. Migraine
B. Intracranial Mass
C. Tension-Type Headache
D. Cluster Headache
15. An 83-year-old man from Puerto Rico is admitted to the hospital because of abdominal pain and blood in his stool for 1 month. He has had an 11-kg (25-lb) weight loss during this period. The patient speaks little English and is accompanied by his children and extended family. The physician wishes to evaluate the patient for possible colon cancer, including ordering a colonoscopy. The patient’s family requests that he not be told any bad news and that they be allowed to make the decisions about his treatment. Which of the following is the most appropriate next step by the physician?
A. Have the family present when the diagnosis is shared with the patient, and allow them to participate in treatment planning
B. Inform the family that HIPAA requires that the patient receive this information and make his own decisions regarding his care
C. Respect the wishes of the family and do not share the diagnosis or treatment plan with the patient
D. Refer the matter to the hospital’s legal counsel to have a power of attorney appointed to a family member
E. Use a Spanish-speaking interpreter to determine how much the patient wishes to know about diagnosis and treatment
16. A 21-year-old woman comes to the physician because of a 2-week history of blood-tinged vomiting. She has a 2-year history of self-induced vomiting at least three times weekly after gorging on food. She is 160 cm (5 ft 3 in) tall and weighs 62 kg (137 lb.); BMI is 24 kg/m2. In addition to cognitive therapy, administration of which of the following drugs is the most appropriate treatment for this patient?
A. Haloperidol
B. Fluoxetine
C. Lorazepam
D. Medroxyprogesterone Acetate E. Sibutramine
17. A 70-year-old African American woman comes to the physician 1 day after the sudden onset of back pain. She has worked part time as a cashier for 30 years, and she has a low income. She has smoked one-half pack of cigarettes daily for 50 years and drinks three caffeinated beverages daily. Her vital signs are within normal limits. Physical examination shows tenderness to palpation over the spine in the low back. X-rays of the spine show a vertebral compression fracture of L3. Bone densitometry shows decreased bone mineral density. Which of the following is the greatest predisposing risk factor for this patient’s condition?
A. Ethnicity
B. Gender
C. Occupation
D. Smoking
E. Socioeconomic Status
18. A 60-year-old woman with a 2-year history of hypertension comes to the physician for a follow-up examination. Her hypertension has been poorly controlled during the past 6 months despite availability of appropriate pharmacotherapy. Which of the following statements by the physician is most appropriate to begin a discussion about this patient’s possible noncompliance with her medication regimen?
A. “I will arrange for a nurse to visit you every day to make sure that you are taking your medication properly.”
B. ”I’m sorry, but I must tell you that missing your medication could kill you.”
C. “It is hard to take pills every day for a condition that has no symptoms.”
D. “You clearly have not been taking your medications. You must be more responsible.”
E. “You realize that your high blood pressure could have been avoided.”
19. A 79-year-old woman is admitted to the hospital after sustaining a fracture of the right hip when she fell down the stairs in her two-story home. She worked as a librarian for 40 years until she retired 14 years ago. Her hobbies include reading, knitting, and gardening. She also volunteers at the local hospital, reading to patients. She occasionally visits a local health club to participate in a swimming pool-based exercise class. She is 155 cm (5 ft 1 in) tall and weighs 50 kg (110 lb.); BMI is 21 kg/m2. Which of the following recommendations by the physician is most likely to decrease this patient’s risk for additional fractures in the future?
A. Discontinue consumption of all alcoholic beverages
B. Go for long walk outside daily
C. Discontinue gardening
D. Lose weight
E. Increase participation in swimming pool-based exercise classes to at least three times weekly
20. A 35-year-old man is referred for psychiatric evaluation by a work- sponsored depression screening program. He has no history of serious illness, and his last routine examination was 12 years ago. He says that for the past 2 years he has felt down and has not fully enjoyed life. He is generally unmotivated and pessimistic about the future and has little energy for relationships or work. He wonders if he is just getting old. He has not had any changes in his appetite or sleep pattern, and his symptoms have not affected his ability to work. Although he has had occasional thoughts that life is not worth living, he has not had suicidal thinking or planning. Which of the following is the most likely diagnosis?
A. Adjustment disorder with depressed mood
B. Bipolar disorder
C. Avoidant personality disorder
D. Dysthymic disorder
E. Major depressive disorder
F. Schizoaffective disorder
21. A 19-year-old woman is brought to the physician by her mother because she has been increasingly withdrawn and isolated since graduating from high school 1 year ago. The mother reports that the patient stays in her bedroom much oft eh time and rarely sees friends. The patient says that she is not interested in her old friends or activities. She has been anxious and depressed about what she has learned by listening to radio broadcasts that only she can hear. She has been spending most of her time thinking about government scheme to control the “psychic pain” people feel. She does not drink alcohol or use illicit drugs. She appears disheveled and is malodorous. Vital signs are within normal limits. Physical examination show no abnormalities. On mental status examination, she is distracted. She has a sad mood and an anxious, sad, and blunted affect. She is oriented to person, place, and time. Which of the following is the most appropriate pharmacotherapy?
A. Buspirone
B. Donepezil
C. Lithium Carbonate D. Risperidone
E. Trazodone
22. A 54-year-old woman with terminal metastatic pancreatic cancer comes to the physician for a follow-up examination. She asks the physician to prescribe her a sufficient quantity of medication to allow her to commit suicide if the pain becomes unbearable. The physician refuses to do so, but he informs the patient that he will do everything he can to manage her pain. The physician’s decision in this situation is most consistent with which of the following ethical principles?
A. Autonomy
B. Beneficence
C. Dignity
D. Justice
E. Nonmaleficence
23. An 8-year-old girl is brought to the physician for a well-child examination. Her mother says that she has been well except for an occasional cold. Her immunizations are up to date. She is at the 50th percentile for her height and 60th percentile for weight. Physical examination shows breast bud development and a few pubic hairs. The mother asks whether her daughter’s development is normal. Which of the following is the most appropriate initial response by the physician?
A. “Your daughter’s breast development is somewhat less than might be expected for her age.”
B. “I think that your daughter is likely to begin menstruating in the next few months.”
C. “I would like to order laboratory studies to ensure that your daughter’s development is normal.”
D. ”I am concerned that your daughter may have precocious puberty.”
E. “Your daughter’s development is normal.”
24. A 27-year-old woman comes to the physician because she is concerned that she may have sleep apnea. Her husband recently told her that he has heard her snoring twice during the past year. The patient goes to bed at 10:30 pm and rises at 7 am. She feels rested in the morning and has no daytime sleepiness. She is 157 cm (5 ft 2 in) tall and weighs 58 kg (128 lb.); BMI is 23 kg/m2. Her pulse is 60/min, and blood pressure is 115/65 mmHg. Physical examination shows no abnormalities. Which of the following is the most appropriate initial action by the physician?
A. Reassurance
B. Recommend that the patient keep a sleep diary
C. Order an arterial blood gas analysis
D. Refer the patient for polysomnography
E. Initiate treatment with a continuous positive airway pressure device
25. A 18-year-old man is brought to the emergency department because of anxiety and confusion for 6 hours. He has not had visual or auditory hallucinations. He appears cachectic and older than his age. His temperature is 38.2°C (100.8°F), pulse is 130/min, respirations are 14/min, and blood pressure is 180/110 mmHg. Physical examinations shows diaphoresis, pupillary dilation, and muscle weakness. The patient undergoes gastric emptying followed by charcoal treatment. Toxicology screening will most likely be positive for which of the following substances?
A. Amphetamines B. Barbiturates
C. Benzodiazepines D. Marijuana
E. Opiates
26. A 70-year-old man comes to the physician because of difficulty sleeping since his wife died 8 months ago. He states that he sometimes wakes up an hour earlier than usual without being able to go back to sleep. He also often cries when he thinks about his wife. He tells the physician that he once briefly followed a woman down the street wo resembled her. The patient continues to enjoy visits with his grandchildren and remains an active member of his bowling team. He does not have any other depressive symptoms or suicidal ideation. Physical examination shows no abnormalities. Which of the following is the most appropriate initial action by the physician?
A. Obtain neurophysiological testing
B. Order a sleep study
C. Prescribe Diphenhydramine
D. Prescribe Antidepressant Therapy
E. Schedule regular appointments to monitor the patient
27. A 67-year-old woman comes to the physician for a health maintenance examination. Her brother and mother have a history of colon cancer. The physician recommends colonoscopy, but the patient says that she would prefer only for her stool to be tested for blood. The physician explains that testing the stool for occult blood is not appropriate in this case. The physician is most likely concerned about which of the following regarding this test?
A. Low Specificity
B. Low Sensitivity
C. Potential for a false positive result
D. Uncertain negative predictive value
E. Uncertain positive predictive value
28. To determine whether children of workers in a lead foundry sustain neurologic damage from exposure to dust on their parents’ clothing, a test for motor skills was given to 30 first-graders whose parents had worked at the foundry for 5 years or longer and to 30 controls. Which of the following groups of children would be the proper control group for this study?
A. First-graders living with guardians or relatives who worked at the foundry for 5 years or longer.
B. First-graders whose parents had never worked at the foundry
C. First-graders with motor impairment whose parents had never worked at the foundry
D. First-graders without motor impairment whose parents had worked at the foundry for 5 years or longer
E. Random sample of school children from the same community
29. A screening program is instituted for detection of vaginal Chlamydia Trachomatis infection among first-year women college students. At the initial screening, evidence of C. trachomatis infection is found in 500 of 2500 students. One year later, screening shows vaginal C. trachomatis infection in an additional 200 students. Which of the following is the annual incidence of C. trachomatis infection in this population of women students?
A. 8% B. 10% C. 16% D. 20% E. 28%
30. A case-control study is conducted to explore a possible association between exposure to an herbicide and the diagnosis of non-Hodgkin lymphoma. Controls are matched to cases by age, gender, and race. Exposure status is determined interviewing the subjects. On matched-pair analysis, the odds ratio is 3.2 (95% confidence interval: 1.4 - 5.4). Which of the following is most likely to affect the validity of this study?
A. Biased measurement of the condition
B. Biased measurement of the exposure
C. Confounding by age
D. Type I error
E. Type II error
31. A new antiplatelet agent is developed for the prevention of recurrence of stroke. In a large randomized clinical trial with equal numbers of men and women, the rates of stroke are lower in patients receiving the new agent than in patients receiving the standard treatment. Results are shown:
Recurrent Stroke Rates per 1000 Person-Years
Standard Treatment
New Antiplatelet Drug
Women
.12
.04
Men
.24
.08
Overall .18 .06
Based on the results, which of the following is the absolute risk reduction in women?
A. 8%
B. 12% C. 16% D. 33% E. 50% F. 62%
32. A study is conducted to assess 32 patients in a community of 1000 who have developed drug-resistant tuberculosis during a 1-year period. These patients are removed from the community for treatment. Assuming that the risk for infection and susceptibility to the disease is constant, which of the following best represents the number of individuals most likely to develop subsequent drug-resistant tuberculosis during the next year?
A. 27
B. 29 C. 31 D. 32 E. 33 F. 35
33. A study is designed to evaluate the relationship between ambient noise and hearing loss in an automobile manufacturing plant. Different locations in the manufacturing plant have strikingly different levels of ambient noise. Each employee is given a test for hearing acuity, and then the ambient noise level is measured at his or her workstation. Which of the following best describes this study design?
A. Cohort
B. Crossover
C. Case Series
D. Randomized Clinical Trial
E. Cross-Sectional
34. A premenopausal 49-year-old woman asks her physician about her risk for osteoporosis. Her mother had osteoporosis and disabling bone fractures after menopause. The patient works as a gardener for a landscape service and plays tennis 3 times a week. She does not smoke, drinks 1 glass of wine a week, and takes no medications. Her weight is 55 kg (122 lb.). Which of the following additional information is needed to evaluate her risk for osteoporosis?
A. Age at first sexual intercourse
B. Exposure to ionizing radiation
C. Exposure to organophosphate
D. Family history of rheumatic diseases
E. Dietary history
F. Socioeconomic history
35. A 19-year-old man is brought to the emergency department after being stabbed in the abdomen during a fight. He adamantly denies starting the fight and intends to “get even” at his first opportunity. He has been incarcerated for the past 3 years for committing an armed robbery but says that he was “set up.” Which of the following is the most likely diagnosis?
A. Antisocial personality disorder
B. Avoidant personality disorder
C. Bipolar disorder, manic
D. Borderline personality disorder
E. Conduct disorder
F. Dependent personality disorder
G. Narcissistic personality disorder
H. Paranoid personality disorder
I. Schizoid personality disorder
36. A 62-year-old woman comes to the physician for follow-up care of cramping abdominal pain and constipation for 3 months. Treatment with simethicone has provided some relief of symptoms. She also has had a 9-kg (20-lb) weight loss, increasing fatigability, and a need for more sleep. Endoscopy, colonoscopy, and a CT scan of the abdomen showed no abnormalities 1 month ago. She believes her difficulty sleeping is due to worries about her son who has been using drugs during the past few months. Over the past 3 weeks, she began to worry that she has cancer and will never get better. Vital signs are stable. Physical examination shows mild, diffuse abdominal tenderness. She is not anemic, and all other laboratory findings are within reference ranges. Which of the following initial actions by the physician is most appropriate?
A. Barium Enema
B. Repeat CT Scan
C. Repeat Colonoscopy
D. Increase in the amount of dietary fiber
E. Evaluation of the patient for Major Depressive Disorder
37. A 42-year-old man comes to the physician because of progressive weakness of his hands during the past 10 months. Physical examination shows atrophy of the hand muscles with fasciculations. There are also fasciculations of the tongue and trapezius muscles. Electromyography confirms the diagnosis of amyotrophic lateral sclerosis. Which of the following initial statements by the physician is most appropriate?
A. “You have amyotrophic lateral sclerosis, also called Lou Gehrig disease, which is a terminal illness. You will eventually need to go on a respirator. Have you thought about advance directives?”
B. “you have an incurable illness. I’m sorry to say there is nothing I can do for you. Are you religious?”
C. “You have Lou Gehrig disease. Have you ever heard anything about this disease before?”
D. “You have a mild case of amyotrophic lateral sclerosis, also called Lou Gehrig disease. We’ll check it every few months just to see if it is progressing.”
E. “You may have amyotrophic lateral sclerosis. We’ll check every few
months and if it progresses, then we’ll know for sure.”
38. A 75-year-old man with dementia, Alzheimer type, is brought to the hospital by his wife because of cough, difficulty breathing, and agitation that began after he ate breakfast 2 hours ago. He has been a resident of a skilled nursing care facility for 7 years. His wife visits the facility daily to feed him his midday meals. His two adult children visit him several times weekly. His wife mentions that the patient has been coughing during his meals for several weeks. He also has been taking longer to finish even smaller portions of food. Results of imaging studies are consistent with aspiration pneumonia with a developing compromised swallowing function. His medical records show no advance directives. In speaking with the patient’s family, it is most appropriate for the physician to address the issue of a feeding tube in which of the following manners?
A. Encourage the family to come to a consensus based on their perception of the patient’s wishes
B. Explain that a feeding tube is difficult to monitor and may not prevent aspiration
C. Follow only the wishes of the wife
D. Help the adult children encourage the wife to start a gradual withdrawal from the patient
E. Recommend a tube, because feeding will be more efficient and prevent starvation
39. A 12-year-old girl is referred to the emergency department by her physician because she has been unable to walk for 5 days. Her parents appear very anxious, but she seems unconcerned about her symptoms. Her temperature is 37.0°C (98.6°F), pulse is 70/min, and blood pressure is 115/70 mmHg. Deep tendon reflexes in the lower extremities are equal bilaterally. Sensation to pain and to light touch is variable. Which of the following is the most likely diagnosis?
A. Brief Psychotic Disorder
B. Conversion Disorder
C. Depersonalization/Derealization Disorder
D. Illness Anxiety Disorder (Hypochondriasis)
E. Post-Traumatic Disorder
40. A 13-year-old girl is brought to the physician by her mother for a routine well-child examination. Neither the child nor the mother has any particular health concerns. The patient is doing well is school and participates in soccer and lacrosse in a local recreation league. The physician wants to ask the patient about sexuality and sexual activity. Which of the following actions by the physician is most appropriate?
A. Ask the mother to leave the room before asking the patient any questions
B. Ask the patient to leave the room and then ask the mother about her daughter
C. Ask the questions with both the mother and the patient present
D. Give the patient a questionnaire that she can fill out at home
E. Tell the patient that some sensitive questions are next and that only she can ask her mother to leave the room
41. A sedentary 50-year-old woman comes to the physician because of decreased energy for several months. She states that she has not seen a physician in years because she does not trust doctors. She says, “But, I just turned 50, so I thought I’d get myself checked out.” she has smoked one-half pack of cigarettes daily for 33 years. She is 163 cm (5 ft 4 in) tall and weighs 86 kg (189-lb); BMI is 33 kg/m2. Her blood pressure is 148/92 mmHg. Breath sounds are decreased and mildly tubular on auscultation. Cardiac examination shows a laterally displaced point of maximal impulse. There is trace pedal edema. Serum studies show a fasting glucose concentration of 122 mg/dL, total cholesterol concentration of 238 mg/dL, and HDL-cholesterol concentration of 31 mg/dL. An ECG suggests left ventricular hypertrophy. It is most appropriate for the physician to primarily focus on which of the following for the first several visits?
A. Control of her hypertension
B. Establishing a therapeutic alliance with the patient
C. Evaluation and treatment of chronic obstructive pulmonary disease
D. Recommendation of smoking cessation
E. Treatment of her hyperlipidemia
42. A 36-year-old woman comes to the emergency department because she thinks she had a heart attack when she was grocery shopping this morning. She had the sudden onset of palpitations, shortness of breath, dizziness, numbness and tingling of her hands and feet, and shaking. The symptoms lasted about 30 minutes and resolved spontaneously. She has a history of two similar episodes in the past month; one occurred while she was at home and the other while she was at work. She is otherwise healthy. Physical examination, ECG, and laboratory studies show no abnormalities. Which of the following is the most likely diagnosis?
A. Acute stress disorder
B. Generalized anxiety disorder
C. Panic disorder
D. Social phobia
E. Specific phobia
43. A previously healthy 16-year-old girl is brought to the physician by her 18- year-old sister because of a 2-day history of a thick, yellow vaginal discharge and burning with urination. She does not want her parents to know that she is sexually active. Her temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 110/70 mmHg. Examination shows a mucopurulent discharge at the cervical os and friability of the cervix. The uterus is small, firm, and nontender. There are no adnexal masses or external vaginal lesions. A Gram stain of the discharge shows gram- negative diplococci in pairs and greater than 30 leukocytes/hpf. Urinalysis is within normal limits. Testing for Neisseria gonorrhoeae and Chlamydia trachomatis is ordered. Which of the following is the most appropriate course of action?
A. Do not prescribe antibiotics until testing results are available
B. Obtain written consent from a parent before prescribing antibiotics
C. Obtain written consent from her sister before prescribing antibiotics
D. Prescribe antibiotics and notify her parents
E. Prescribe antibiotics without notifying her parents
44. A 20-year-old man is brought to the emergency department 30 minutes after being involved in a motorcycle collision. Physical examination shows severe contusions on the chest and abdomen. He has an unsteady gait and slurred speech. The patient is admitted to the hospital for observation for possible damage to the spleen. By the third night, he becomes restless and begins having generalized tonic-clonic seizures. The diagnosis of substance withdrawal is made. Which of the following best describes the patient’s substance withdrawal and the immediate treatment required?
A. B. C. D. E.
Withdrawal
Buspirone Cocaine Ethanol Heroin △9-THC
Medication
Lorazepam Haloperidol Diazepam Naloxone Phenytoin
45. In a study to assess whether neck irradiation is a risk factor for thyroid cancer, the researchers identify a group of patients with thyroid cancer and a similar group of patients without thyroid cancer. History of prior neck irradiation is obtained from each group based on strict criteria for exposure. This type of study is best described as which of the following?
A. Case-Control
B. Case Series
C. Cohort
D. Cross-Sectional
E. Randomized Clinical Trial
46. A case-control study examining the relationship of a risk factor and disease generated the following data:
Risk Factor
Present Absent
Disease
Present Absent
50 30 80 50 70 120
100 100 200
Which of the following is the estimated odds ratio of the presence of the risk factor and development of disease?
A. (50x30)/(50x70)=0.4
B. (50x50)/(30x70)=1.2
C. (50x70)/(50x30)=2.3
D. (50x50x30x70)/(1003)=5.25
E. Cannot be determined
47. Serum cholesterol concentrations are measured as part of a community study. The mean and standard deviation are given for women by age group:
Age (Years)
45-49 50-54 55-59 60-62
Cholesterol (mg/dL)
229 47 246 50 255 48 244 36
Assuming serum cholesterol concentrations follow a normal (gaussian) distribution, which of the following is the probability that a woman between the ages of 50 and 54 years has a serum cholesterol concentration greater than 296 mg/dL?
A. 1% B. 2.5% C. 5% D. 16%
E. 95%
48. In a case control study, 100 men who have bladder cancer were compared with 100 controls. Cases and controls were asked about their alcohol consumption. The investigators calculated an odds ratio of 3.0; the 95% confidence interval was 1.8 to 6.6 for the association of bladder cancer and alcohol consumption. Which of the following is the most appropriate interpretation of this result?
A. At least 5% of the bladder cancers can be attributed to the consumption of alcohol
B. At least 5% of consumers of alcohol will develop cancer of the bladder
C. The likelihood is 95% that the true value for the odds ratio is between 1.8 and 6.6
D. There is at least a 5% increased risk for bladder cancer among consumers of alcohol
E. Men who drink alcohol are 5 times more likely to develop bladder cancer than those who do not drink alcohol
F. There is a 95% chance that the true odds ratio is 3.0
49. To determine whether angiotensin-converting enzyme (ACE) inhibitors are superior to calcium channel blockers in preventing renal disease progression in patients with newly diagnosed type 1 diabetes mellitus, which of the following is the major advantage of a randomized controlled trial versus a prospective cohort study?
A. Better control for confounding variables
B. Less likely to show regression to the mean
C. Lower risk for a Type I error
D. Lower risk for a Type II error
E. Requirement of fewer patients to achieve statistical significance
Two clinical trials, Trial X and Trial Y, are conducted to assess the potential therapeutic efficacy of a new experimental antibiotic compared to the currently used antibiotic for treatment of urinary tract infections. The two studies are identical, except the statistical power is 0.8 in Study X, and 0.9 in Study Y. Which of the following is the most accurate conclusion regarding the likelihood of a type II error?
A. Greater in Trial X than in Trial Y
B. Greater in Trial Y than in Trial X
C. The same in Trial X and in Trial Y
D. Cannot be calculated from the data given
2.
A screening test is used to detect prostate cancer in a population of 100,000 men. The test has a sensitivity of 70% and a specificity of 90%. The test is then used to screen a second population in which the prevalence of prostate cancer is different. Which of the following is the most likely effect on the positive predictive value of this test?
A. Decreases as prevalence increases
B. Increases as prevalence decreases
C. Increases as prevalence increases
D. No change as prevalence changes
3. A retrospective study is conducted to assess the incidence and outcome of subarachnoid hemorrhage in a midwestern state. The annual incidence of this condition is 15 per 100,000 people, and the case fatality rate is 40%. Based on these data, which of the following represents the annual mortality rate for subarachnoid hemorrhage per 100,000 people in this state?
A. 0.4x15
B. 0.4 x 100,000
C. 0.6x15
D. 0.6 x 100,000
E. 0.4 x 0.6
4. A study is conducted to assess the effectiveness of vitamin C in preventing common colds in children. Patients are randomly assigned to receive either vitamin C or no intervention. Outcome events (common cold) are reported by the parents on a monthly basis for 1 year. Results show that those taking vitamin C have fewer colds compared with those who received no intervention (p<0.05). Which of the following raises the most concern about the validity of the conclusion that vitamin C supplements prevent the common cold?
A. Inadequate statistical power
B. Nonrandomization
C. Selection Bias
D. Variability in outcome assessment
5. A prospective study examined the relationship between the development of gastric cancer and exposure to a diet rich in selenium. The investigators estimated the relative risk of gastric cancer to be 0.3 in individuals with a high-selenium diet (95% confidence interval 0.1 - 0.8). Which of the following is the most appropriate interpretation of this findings?
A. Selenium causes gastric cancer
B. Selenium is associated with a lower risk of gastric cancer
C. Selenium is associated with a higher risk of gastric cancer
D. Selenium exposure is unrelated to gastric cancer
E. Selenium is positively correlated with gastric cancer
6. A study is conducted to evaluate the onset and course of cardiovascular disease in African American men and women in the USA. Census data from the year 2000 are used to select the study sample. A series of factors including family income and years of education is defined. Census tracts most representative of the national census data for the factors selected are used for sampling. Which of the following best describes this sampling technique?
A. Sequential
B. Self-Selection
C. Population-Based
D. Sample of Convenience
E. Blocked Randomization
7. An epidemiologist is investigating an outbreak of diarrhea among a total of 1000 consumers of vegetables. Of those consumers, 800 people ate tomatoes and 200 people ate lettuce. A total of 400 people became ill; 80 of these people ate tomatoes, and 40 people ate lettuce. Which of the following indicates the probability of diarrhea having developed in people who consumed lettuce?
A. 0.08
B. 0.1 C. 0.2 D. 0.4 E. 0.5
8. In order to determine risk factors for death from Coronary Artery Disease (CAD), persons aged 30 years and older are studied in a community. Every 2 years for a total of 10 years, blood pressure, serum cholesterol concentration, and smoking status are assessed along with deaths from CAD. Persons with increased blood pressure are compared with those who have normal pressure to determine which group has greater mortality from coronary artery disease. Which of the following best describes this type of study?
A. Randomized Clinical Trial
B. Case-Control Study
C. Cross-Sectional Study
D. Observational Cohort Study
E. Ecologic Study
9. A 76-year-old man comes to the physician for a follow-up examination. He has hypertension treated with a B-adrenergic antagonist. He lives on a farm in central California and says he has always distilled his own liquor. Before retiring 10 years ago, he worked in a hat factory and subsequently in a textile factory. He has smoked 2 packs of cigarettes daily for the past 55 years. He tells the physician that he has had several episodes of painful swelling of his right great toe. Physical
examination shows several lesions consistent with gouty tophi over the elbows bilaterally. Laboratory studies show:
Hemoglobin A1C 5.6
Serum Glucose Creatinine
Uric Acid
93 mg/dL 3.2 mg/dL 7.9 mg/dL
The most likely cause of this patient’s condition is which of the following?
A. Cigarette Smoking
B. Drinking home-distilled liquor
C. Farming in Central California
D. Working in a textile factory
E. Working in a hat factory
10. A previously healthy 18-year-old man is brought to the emergency department by his mother 45 minutes after she found him crouched in his closet, saying he had to hide from the intruders “from that other place.” There were no intruders in the house. He has no history of alcohol or drug use. He appears afraid of the physician and sits far away from her. During the interview, he says he has heard two male voices in his head for the past 2 weeks. Physical examination and laboratory studies show no abnormalities. Which of the following is the most likely diagnosis?
A. Schizophrenia
B. Delusional Disorder
C. Brief Psychotic Disorder
D. Schizoaffective Disorder
E. Bipolar Disorder
11. A 23-year-old man comes to the emergency department because of a 2- week history of back pain refractory to treatment with over-the-counter medications. He demands a prescription for an opioid drug because “they’re the only medications that decrease my pain.” He becomes upset when he is told that over-the-counter medications should relieve his symptoms. His temperature is 37.1°C (98.8°F), pulse is 70/min, respirations are 18/min, and blood pressure is 120/70 mmHg. Physical examination shows no abnormalities. Which of the following is the most appropriate actions by the physician?
A. Determine which drugs have been prescribed for the patient in the past
B. Obtain serum toxicology screening on the patient
C. Order an MRI of the spine
D. Prescribe only a 2-week course of a narcotic medication for the patient
E. Refer the patient to a drug addiction program
12. A 62-year-old man comes to the physician for a follow-up examination. Two weeks ago, he was discharged from the hospital after sustaining an acute myocardial infarction. He smokes 2 packs of cigarettes and drinks four 12-oz beers daily. His diet mostly consists of cured meats and fast food. He dos not exercise. The patient tells the physician, “I know that I need to make some changes in how I live so that my heart can be healthier. I just don’t have the willpower to quit smoking and drinking and all that stuff right now.” Which of the following best describes this patient’s stage of behavioral change?
A. Precontemplation B. Contemplation
C. Preparation
D. Action
E. Maintenance
13. A 67-year-old man comes to the physician because of a 2-month history of unexplained weight loss. He has a 50-year history of type 1 diabetes mellitus. He underwent gallstone removal 12 years ago. He has smoked 1 pack of cigarettes daily for 45 year. He is 188 cm (6 ft 2 in) tall and weighs 120 kg (265 lb.); BMI is 34 kg/m2. Physical examination shows no other abnormalities. Serum studies shows a calcium concentration of 11 mg/dL. An abdominal CT scan shows a pancreatic mass. A biopsy specimen of the mass shows pancreatic adenocarcinoma. Which of the following is the strongest predisposing risk factor for pancreatic cancer in this patient?
A. BMI of 34 kg/m2
B. Cigarette Smoking
C. History of gallstone disease
D. Type 1 Diabetes Mellitus
E. Hypercalcemia
14. A 20-year-old woman who works as a secretary comes to the physician because of an 8-year history of intermittent headaches. They begin with flashing lights in her right visual field, followed 20 minutes later by a unilateral throbbing headache accompanied by nausea and vomiting. They occur around the time of her menses. Which of the following is the most likely diagnosis?
A. Migraine
B. Intracranial Mass
C. Tension-Type Headache
D. Cluster Headache
15. An 83-year-old man from Puerto Rico is admitted to the hospital because of abdominal pain and blood in his stool for 1 month. He has had an 11-kg (25-lb) weight loss during this period. The patient speaks little English and is accompanied by his children and extended family. The physician wishes to evaluate the patient for possible colon cancer, including ordering a colonoscopy. The patient’s family requests that he not be told any bad news and that they be allowed to make the decisions about his treatment. Which of the following is the most appropriate next step by the physician?
A. Have the family present when the diagnosis is shared with the patient, and allow them to participate in treatment planning
B. Inform the family that HIPAA requires that the patient receive this information and make his own decisions regarding his care
C. Respect the wishes of the family and do not share the diagnosis or treatment plan with the patient
D. Refer the matter to the hospital’s legal counsel to have a power of attorney appointed to a family member
E. Use a Spanish-speaking interpreter to determine how much the patient wishes to know about diagnosis and treatment
16. A 21-year-old woman comes to the physician because of a 2-week history of blood-tinged vomiting. She has a 2-year history of self-induced vomiting at least three times weekly after gorging on food. She is 160 cm (5 ft 3 in) tall and weighs 62 kg (137 lb.); BMI is 24 kg/m2. In addition to cognitive therapy, administration of which of the following drugs is the most appropriate treatment for this patient?
A. Haloperidol
B. Fluoxetine
C. Lorazepam
D. Medroxyprogesterone Acetate E. Sibutramine
17. A 70-year-old African American woman comes to the physician 1 day after the sudden onset of back pain. She has worked part time as a cashier for 30 years, and she has a low income. She has smoked one-half pack of cigarettes daily for 50 years and drinks three caffeinated beverages daily. Her vital signs are within normal limits. Physical examination shows tenderness to palpation over the spine in the low back. X-rays of the spine show a vertebral compression fracture of L3. Bone densitometry shows decreased bone mineral density. Which of the following is the greatest predisposing risk factor for this patient’s condition?
A. Ethnicity
B. Gender
C. Occupation
D. Smoking
E. Socioeconomic Status
18. A 60-year-old woman with a 2-year history of hypertension comes to the physician for a follow-up examination. Her hypertension has been poorly controlled during the past 6 months despite availability of appropriate pharmacotherapy. Which of the following statements by the physician is most appropriate to begin a discussion about this patient’s possible noncompliance with her medication regimen?
A. “I will arrange for a nurse to visit you every day to make sure that you are taking your medication properly.”
B. ”I’m sorry, but I must tell you that missing your medication could kill you.”
C. “It is hard to take pills every day for a condition that has no symptoms.”
D. “You clearly have not been taking your medications. You must be more responsible.”
E. “You realize that your high blood pressure could have been avoided.”
19. A 79-year-old woman is admitted to the hospital after sustaining a fracture of the right hip when she fell down the stairs in her two-story home. She worked as a librarian for 40 years until she retired 14 years ago. Her hobbies include reading, knitting, and gardening. She also volunteers at the local hospital, reading to patients. She occasionally visits a local health club to participate in a swimming pool-based exercise class. She is 155 cm (5 ft 1 in) tall and weighs 50 kg (110 lb.); BMI is 21 kg/m2. Which of the following recommendations by the physician is most likely to decrease this patient’s risk for additional fractures in the future?
A. Discontinue consumption of all alcoholic beverages
B. Go for long walk outside daily
C. Discontinue gardening
D. Lose weight
E. Increase participation in swimming pool-based exercise classes to at least three times weekly
20. A 35-year-old man is referred for psychiatric evaluation by a work- sponsored depression screening program. He has no history of serious illness, and his last routine examination was 12 years ago. He says that for the past 2 years he has felt down and has not fully enjoyed life. He is generally unmotivated and pessimistic about the future and has little energy for relationships or work. He wonders if he is just getting old. He has not had any changes in his appetite or sleep pattern, and his symptoms have not affected his ability to work. Although he has had occasional thoughts that life is not worth living, he has not had suicidal thinking or planning. Which of the following is the most likely diagnosis?
A. Adjustment disorder with depressed mood
B. Bipolar disorder
C. Avoidant personality disorder
D. Dysthymic disorder
E. Major depressive disorder
F. Schizoaffective disorder
21. A 19-year-old woman is brought to the physician by her mother because she has been increasingly withdrawn and isolated since graduating from high school 1 year ago. The mother reports that the patient stays in her bedroom much oft eh time and rarely sees friends. The patient says that she is not interested in her old friends or activities. She has been anxious and depressed about what she has learned by listening to radio broadcasts that only she can hear. She has been spending most of her time thinking about government scheme to control the “psychic pain” people feel. She does not drink alcohol or use illicit drugs. She appears disheveled and is malodorous. Vital signs are within normal limits. Physical examination show no abnormalities. On mental status examination, she is distracted. She has a sad mood and an anxious, sad, and blunted affect. She is oriented to person, place, and time. Which of the following is the most appropriate pharmacotherapy?
A. Buspirone
B. Donepezil
C. Lithium Carbonate D. Risperidone
E. Trazodone
22. A 54-year-old woman with terminal metastatic pancreatic cancer comes to the physician for a follow-up examination. She asks the physician to prescribe her a sufficient quantity of medication to allow her to commit suicide if the pain becomes unbearable. The physician refuses to do so, but he informs the patient that he will do everything he can to manage her pain. The physician’s decision in this situation is most consistent with which of the following ethical principles?
A. Autonomy
B. Beneficence
C. Dignity
D. Justice
E. Nonmaleficence
23. An 8-year-old girl is brought to the physician for a well-child examination. Her mother says that she has been well except for an occasional cold. Her immunizations are up to date. She is at the 50th percentile for her height and 60th percentile for weight. Physical examination shows breast bud development and a few pubic hairs. The mother asks whether her daughter’s development is normal. Which of the following is the most appropriate initial response by the physician?
A. “Your daughter’s breast development is somewhat less than might be expected for her age.”
B. “I think that your daughter is likely to begin menstruating in the next few months.”
C. “I would like to order laboratory studies to ensure that your daughter’s development is normal.”
D. ”I am concerned that your daughter may have precocious puberty.”
E. “Your daughter’s development is normal.”
24. A 27-year-old woman comes to the physician because she is concerned that she may have sleep apnea. Her husband recently told her that he has heard her snoring twice during the past year. The patient goes to bed at 10:30 pm and rises at 7 am. She feels rested in the morning and has no daytime sleepiness. She is 157 cm (5 ft 2 in) tall and weighs 58 kg (128 lb.); BMI is 23 kg/m2. Her pulse is 60/min, and blood pressure is 115/65 mmHg. Physical examination shows no abnormalities. Which of the following is the most appropriate initial action by the physician?
A. Reassurance
B. Recommend that the patient keep a sleep diary
C. Order an arterial blood gas analysis
D. Refer the patient for polysomnography
E. Initiate treatment with a continuous positive airway pressure device
25. A 18-year-old man is brought to the emergency department because of anxiety and confusion for 6 hours. He has not had visual or auditory hallucinations. He appears cachectic and older than his age. His temperature is 38.2°C (100.8°F), pulse is 130/min, respirations are 14/min, and blood pressure is 180/110 mmHg. Physical examinations shows diaphoresis, pupillary dilation, and muscle weakness. The patient undergoes gastric emptying followed by charcoal treatment. Toxicology screening will most likely be positive for which of the following substances?
A. Amphetamines B. Barbiturates
C. Benzodiazepines D. Marijuana
E. Opiates
26. A 70-year-old man comes to the physician because of difficulty sleeping since his wife died 8 months ago. He states that he sometimes wakes up an hour earlier than usual without being able to go back to sleep. He also often cries when he thinks about his wife. He tells the physician that he once briefly followed a woman down the street wo resembled her. The patient continues to enjoy visits with his grandchildren and remains an active member of his bowling team. He does not have any other depressive symptoms or suicidal ideation. Physical examination shows no abnormalities. Which of the following is the most appropriate initial action by the physician?
A. Obtain neurophysiological testing
B. Order a sleep study
C. Prescribe Diphenhydramine
D. Prescribe Antidepressant Therapy
E. Schedule regular appointments to monitor the patient
27. A 67-year-old woman comes to the physician for a health maintenance examination. Her brother and mother have a history of colon cancer. The physician recommends colonoscopy, but the patient says that she would prefer only for her stool to be tested for blood. The physician explains that testing the stool for occult blood is not appropriate in this case. The physician is most likely concerned about which of the following regarding this test?
A. Low Specificity
B. Low Sensitivity
C. Potential for a false positive result
D. Uncertain negative predictive value
E. Uncertain positive predictive value
28. To determine whether children of workers in a lead foundry sustain neurologic damage from exposure to dust on their parents’ clothing, a test for motor skills was given to 30 first-graders whose parents had worked at the foundry for 5 years or longer and to 30 controls. Which of the following groups of children would be the proper control group for this study?
A. First-graders living with guardians or relatives who worked at the foundry for 5 years or longer.
B. First-graders whose parents had never worked at the foundry
C. First-graders with motor impairment whose parents had never worked at the foundry
D. First-graders without motor impairment whose parents had worked at the foundry for 5 years or longer
E. Random sample of school children from the same community
29. A screening program is instituted for detection of vaginal Chlamydia Trachomatis infection among first-year women college students. At the initial screening, evidence of C. trachomatis infection is found in 500 of 2500 students. One year later, screening shows vaginal C. trachomatis infection in an additional 200 students. Which of the following is the annual incidence of C. trachomatis infection in this population of women students?
A. 8% B. 10% C. 16% D. 20% E. 28%
30. A case-control study is conducted to explore a possible association between exposure to an herbicide and the diagnosis of non-Hodgkin lymphoma. Controls are matched to cases by age, gender, and race. Exposure status is determined interviewing the subjects. On matched-pair analysis, the odds ratio is 3.2 (95% confidence interval: 1.4 - 5.4). Which of the following is most likely to affect the validity of this study?
A. Biased measurement of the condition
B. Biased measurement of the exposure
C. Confounding by age
D. Type I error
E. Type II error
31. A new antiplatelet agent is developed for the prevention of recurrence of stroke. In a large randomized clinical trial with equal numbers of men and women, the rates of stroke are lower in patients receiving the new agent than in patients receiving the standard treatment. Results are shown:
Recurrent Stroke Rates per 1000 Person-Years
Standard Treatment
New Antiplatelet Drug
Women
.12
.04
Men
.24
.08
Overall .18 .06
Based on the results, which of the following is the absolute risk reduction in women?
A. 8%
B. 12% C. 16% D. 33% E. 50% F. 62%
32. A study is conducted to assess 32 patients in a community of 1000 who have developed drug-resistant tuberculosis during a 1-year period. These patients are removed from the community for treatment. Assuming that the risk for infection and susceptibility to the disease is constant, which of the following best represents the number of individuals most likely to develop subsequent drug-resistant tuberculosis during the next year?
A. 27
B. 29 C. 31 D. 32 E. 33 F. 35
33. A study is designed to evaluate the relationship between ambient noise and hearing loss in an automobile manufacturing plant. Different locations in the manufacturing plant have strikingly different levels of ambient noise. Each employee is given a test for hearing acuity, and then the ambient noise level is measured at his or her workstation. Which of the following best describes this study design?
A. Cohort
B. Crossover
C. Case Series
D. Randomized Clinical Trial
E. Cross-Sectional
34. A premenopausal 49-year-old woman asks her physician about her risk for osteoporosis. Her mother had osteoporosis and disabling bone fractures after menopause. The patient works as a gardener for a landscape service and plays tennis 3 times a week. She does not smoke, drinks 1 glass of wine a week, and takes no medications. Her weight is 55 kg (122 lb.). Which of the following additional information is needed to evaluate her risk for osteoporosis?
A. Age at first sexual intercourse
B. Exposure to ionizing radiation
C. Exposure to organophosphate
D. Family history of rheumatic diseases
E. Dietary history
F. Socioeconomic history
35. A 19-year-old man is brought to the emergency department after being stabbed in the abdomen during a fight. He adamantly denies starting the fight and intends to “get even” at his first opportunity. He has been incarcerated for the past 3 years for committing an armed robbery but says that he was “set up.” Which of the following is the most likely diagnosis?
A. Antisocial personality disorder
B. Avoidant personality disorder
C. Bipolar disorder, manic
D. Borderline personality disorder
E. Conduct disorder
F. Dependent personality disorder
G. Narcissistic personality disorder
H. Paranoid personality disorder
I. Schizoid personality disorder
36. A 62-year-old woman comes to the physician for follow-up care of cramping abdominal pain and constipation for 3 months. Treatment with simethicone has provided some relief of symptoms. She also has had a 9-kg (20-lb) weight loss, increasing fatigability, and a need for more sleep. Endoscopy, colonoscopy, and a CT scan of the abdomen showed no abnormalities 1 month ago. She believes her difficulty sleeping is due to worries about her son who has been using drugs during the past few months. Over the past 3 weeks, she began to worry that she has cancer and will never get better. Vital signs are stable. Physical examination shows mild, diffuse abdominal tenderness. She is not anemic, and all other laboratory findings are within reference ranges. Which of the following initial actions by the physician is most appropriate?
A. Barium Enema
B. Repeat CT Scan
C. Repeat Colonoscopy
D. Increase in the amount of dietary fiber
E. Evaluation of the patient for Major Depressive Disorder
37. A 42-year-old man comes to the physician because of progressive weakness of his hands during the past 10 months. Physical examination shows atrophy of the hand muscles with fasciculations. There are also fasciculations of the tongue and trapezius muscles. Electromyography confirms the diagnosis of amyotrophic lateral sclerosis. Which of the following initial statements by the physician is most appropriate?
A. “You have amyotrophic lateral sclerosis, also called Lou Gehrig disease, which is a terminal illness. You will eventually need to go on a respirator. Have you thought about advance directives?”
B. “you have an incurable illness. I’m sorry to say there is nothing I can do for you. Are you religious?”
C. “You have Lou Gehrig disease. Have you ever heard anything about this disease before?”
D. “You have a mild case of amyotrophic lateral sclerosis, also called Lou Gehrig disease. We’ll check it every few months just to see if it is progressing.”
E. “You may have amyotrophic lateral sclerosis. We’ll check every few
months and if it progresses, then we’ll know for sure.”
38. A 75-year-old man with dementia, Alzheimer type, is brought to the hospital by his wife because of cough, difficulty breathing, and agitation that began after he ate breakfast 2 hours ago. He has been a resident of a skilled nursing care facility for 7 years. His wife visits the facility daily to feed him his midday meals. His two adult children visit him several times weekly. His wife mentions that the patient has been coughing during his meals for several weeks. He also has been taking longer to finish even smaller portions of food. Results of imaging studies are consistent with aspiration pneumonia with a developing compromised swallowing function. His medical records show no advance directives. In speaking with the patient’s family, it is most appropriate for the physician to address the issue of a feeding tube in which of the following manners?
A. Encourage the family to come to a consensus based on their perception of the patient’s wishes
B. Explain that a feeding tube is difficult to monitor and may not prevent aspiration
C. Follow only the wishes of the wife
D. Help the adult children encourage the wife to start a gradual withdrawal from the patient
E. Recommend a tube, because feeding will be more efficient and prevent starvation
39. A 12-year-old girl is referred to the emergency department by her physician because she has been unable to walk for 5 days. Her parents appear very anxious, but she seems unconcerned about her symptoms. Her temperature is 37.0°C (98.6°F), pulse is 70/min, and blood pressure is 115/70 mmHg. Deep tendon reflexes in the lower extremities are equal bilaterally. Sensation to pain and to light touch is variable. Which of the following is the most likely diagnosis?
A. Brief Psychotic Disorder
B. Conversion Disorder
C. Depersonalization/Derealization Disorder
D. Illness Anxiety Disorder (Hypochondriasis)
E. Post-Traumatic Disorder
40. A 13-year-old girl is brought to the physician by her mother for a routine well-child examination. Neither the child nor the mother has any particular health concerns. The patient is doing well is school and participates in soccer and lacrosse in a local recreation league. The physician wants to ask the patient about sexuality and sexual activity. Which of the following actions by the physician is most appropriate?
A. Ask the mother to leave the room before asking the patient any questions
B. Ask the patient to leave the room and then ask the mother about her daughter
C. Ask the questions with both the mother and the patient present
D. Give the patient a questionnaire that she can fill out at home
E. Tell the patient that some sensitive questions are next and that only she can ask her mother to leave the room
41. A sedentary 50-year-old woman comes to the physician because of decreased energy for several months. She states that she has not seen a physician in years because she does not trust doctors. She says, “But, I just turned 50, so I thought I’d get myself checked out.” she has smoked one-half pack of cigarettes daily for 33 years. She is 163 cm (5 ft 4 in) tall and weighs 86 kg (189-lb); BMI is 33 kg/m2. Her blood pressure is 148/92 mmHg. Breath sounds are decreased and mildly tubular on auscultation. Cardiac examination shows a laterally displaced point of maximal impulse. There is trace pedal edema. Serum studies show a fasting glucose concentration of 122 mg/dL, total cholesterol concentration of 238 mg/dL, and HDL-cholesterol concentration of 31 mg/dL. An ECG suggests left ventricular hypertrophy. It is most appropriate for the physician to primarily focus on which of the following for the first several visits?
A. Control of her hypertension
B. Establishing a therapeutic alliance with the patient
C. Evaluation and treatment of chronic obstructive pulmonary disease
D. Recommendation of smoking cessation
E. Treatment of her hyperlipidemia
42. A 36-year-old woman comes to the emergency department because she thinks she had a heart attack when she was grocery shopping this morning. She had the sudden onset of palpitations, shortness of breath, dizziness, numbness and tingling of her hands and feet, and shaking. The symptoms lasted about 30 minutes and resolved spontaneously. She has a history of two similar episodes in the past month; one occurred while she was at home and the other while she was at work. She is otherwise healthy. Physical examination, ECG, and laboratory studies show no abnormalities. Which of the following is the most likely diagnosis?
A. Acute stress disorder
B. Generalized anxiety disorder
C. Panic disorder
D. Social phobia
E. Specific phobia
43. A previously healthy 16-year-old girl is brought to the physician by her 18- year-old sister because of a 2-day history of a thick, yellow vaginal discharge and burning with urination. She does not want her parents to know that she is sexually active. Her temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 110/70 mmHg. Examination shows a mucopurulent discharge at the cervical os and friability of the cervix. The uterus is small, firm, and nontender. There are no adnexal masses or external vaginal lesions. A Gram stain of the discharge shows gram- negative diplococci in pairs and greater than 30 leukocytes/hpf. Urinalysis is within normal limits. Testing for Neisseria gonorrhoeae and Chlamydia trachomatis is ordered. Which of the following is the most appropriate course of action?
A. Do not prescribe antibiotics until testing results are available
B. Obtain written consent from a parent before prescribing antibiotics
C. Obtain written consent from her sister before prescribing antibiotics
D. Prescribe antibiotics and notify her parents
E. Prescribe antibiotics without notifying her parents
44. A 20-year-old man is brought to the emergency department 30 minutes after being involved in a motorcycle collision. Physical examination shows severe contusions on the chest and abdomen. He has an unsteady gait and slurred speech. The patient is admitted to the hospital for observation for possible damage to the spleen. By the third night, he becomes restless and begins having generalized tonic-clonic seizures. The diagnosis of substance withdrawal is made. Which of the following best describes the patient’s substance withdrawal and the immediate treatment required?
A. B. C. D. E.
Withdrawal
Buspirone Cocaine Ethanol Heroin △9-THC
Medication
Lorazepam Haloperidol Diazepam Naloxone Phenytoin
45. In a study to assess whether neck irradiation is a risk factor for thyroid cancer, the researchers identify a group of patients with thyroid cancer and a similar group of patients without thyroid cancer. History of prior neck irradiation is obtained from each group based on strict criteria for exposure. This type of study is best described as which of the following?
A. Case-Control
B. Case Series
C. Cohort
D. Cross-Sectional
E. Randomized Clinical Trial
46. A case-control study examining the relationship of a risk factor and disease generated the following data:
Risk Factor
Present Absent
Disease
Present Absent
50 30 80 50 70 120
100 100 200
Which of the following is the estimated odds ratio of the presence of the risk factor and development of disease?
A. (50x30)/(50x70)=0.4
B. (50x50)/(30x70)=1.2
C. (50x70)/(50x30)=2.3
D. (50x50x30x70)/(1003)=5.25
E. Cannot be determined
47. Serum cholesterol concentrations are measured as part of a community study. The mean and standard deviation are given for women by age group:
Age (Years)
45-49 50-54 55-59 60-62
Cholesterol (mg/dL)
229 47 246 50 255 48 244 36
Assuming serum cholesterol concentrations follow a normal (gaussian) distribution, which of the following is the probability that a woman between the ages of 50 and 54 years has a serum cholesterol concentration greater than 296 mg/dL?
A. 1% B. 2.5% C. 5% D. 16%
E. 95%
48. In a case control study, 100 men who have bladder cancer were compared with 100 controls. Cases and controls were asked about their alcohol consumption. The investigators calculated an odds ratio of 3.0; the 95% confidence interval was 1.8 to 6.6 for the association of bladder cancer and alcohol consumption. Which of the following is the most appropriate interpretation of this result?
A. At least 5% of the bladder cancers can be attributed to the consumption of alcohol
B. At least 5% of consumers of alcohol will develop cancer of the bladder
C. The likelihood is 95% that the true value for the odds ratio is between 1.8 and 6.6
D. There is at least a 5% increased risk for bladder cancer among consumers of alcohol
E. Men who drink alcohol are 5 times more likely to develop bladder cancer than those who do not drink alcohol
F. There is a 95% chance that the true odds ratio is 3.0
49. To determine whether angiotensin-converting enzyme (ACE) inhibitors are superior to calcium channel blockers in preventing renal disease progression in patients with newly diagnosed type 1 diabetes mellitus, which of the following is the major advantage of a randomized controlled trial versus a prospective cohort study?
A. Better control for confounding variables
B. Less likely to show regression to the mean
C. Lower risk for a Type I error
D. Lower risk for a Type II error
E. Requirement of fewer patients to achieve statistical significance