NBME Questions Part 2
Posted: Mon Apr 11, 2022 7:21 am
50. Three inexpensive tests are available to evaluate children with diarrhea for rotavirus. The sensitivity and specificity of each test are summarized in the table. If it is important to treat only those who actually have the disease because of the toxicity of the treatment, which of the following testing strategies is most appropriate?
A. Test 1 followed by test 3 if test 1 is positive
B. Test 3 followed by test 1 if test 3 is positive
C. Test 2 only
D. Test 2 followed by test 3 if test 2 is negative
E. Test 2 followed by test 3 if test 2 is positive
51. In immunocompromised patients, the case definition of a positive PPD skin test was changed from 10 mm of induration to 5 mm of induration. This change in case definition has which of the following effects on incidence and prevalence of a positive PPD skin test?
A. B. C. D. E.
Incidence Prevalence
↑ ↑
↑ ↓
NO CHANGE NO CHANGE ↓ ↑
↓ ↓
52. A 50-year-old man is brought to the physician by his wife because of personality changes for 2 years and cognitive decline for 3 months. His wife says, “He used to be such a kind and shy man, but now he screams at strangers for no apparent reason. The other day, he yelled at a woman at a convenience store for not ordering extra cheese in her sandwich. He said she needed the extra calcium.” She adds, “this has been going on for a while, but last month he almost invested all of our savings in a start-up company that was going to produce different kinds of hats strictly for dogs. He wasn’t like this before. He was a respected accountant. I stopped him, thank goodness, and it turned out to be a scam, anyway.” She adds, “I’m worried about his physical safety, too, because I’ve had to search for him five times within the past couple of months after he got lost wandering around our neighborhood. We’ve lived there for 20 years.” Neurologic examination shows a palmomental reflex and hyperreflexia throughout the upper and lower extremities. His mood appears normal except for occasional inappropriate cursing at the physician. His Mini-Mental State Examination score is 21/30. A CT scan of the head shows disproportionate atrophy of the frontal lobes bilaterally. Which of the following is the most likely diagnosis?
A. Dementia, Alzheimer type
B. Huntington Disease
C. Multi-infarct (vascular) Dementia
D. Parkinson Disease
E. Pick Disease
53. A 10-year-old girl is brought to the physician by her mother for a well-child examination. She has not yet had a menstrual period. She is at the 50th percentile for height and weight. Physical examination shows absence of breast bud development and no pubic or axillary hair. The mother asks how she will know when her daughter begins puberty. It is most appropriate for the physician to tell the mother that the first objective
sign of puberty will be which of the following?
A. Breast bud development
B. Development of axillary hair
C. Development of pubic hair
D. Onset of menses
E. Rapidly increasing height
54. A 30-year-old man who completed a successful course of treatment for Hodgkin disease 2 months ago calls his physician on an increasingly frequent basis. He takes his temperature several times daily and contacts the office whenever it is above 37.2°C (99°F). He also has episodes of tingling of his fingers that lasts several seconds. Although evaluation has shown no evidence of recurrence, he is increasingly fearful that Hodgkin disease may not be detected rapidly enough for successful treatment. Which of the following is the most likely diagnosis?
A. Adjustment disorder with anxiety
B. Dependent personality disorder
C. Generalized anxiety disorder
D. Obsessive-compulsive disorder
E. Somatic symptom disorder
55. A 41-year-old woman with systemic lupus erythematous is scheduled to undergo surgical placement of a peritoneal dialysis catheter. The surgeon asks the resident physician to get the consent form signed the evening before the procedure. The resident has never seen this procedure performed and has read little about it. He will not be assisting with the procedure. Which of the following actions by the resident physician is most appropriate?
A. ask a nurse to get a signature on the form
B. Ask the attending physician to obtain informed consent
C. Ask the patient to sign the form and tell her that the surgeon will answer questions the next morning
D. Obtain an informed consent by explaining what he believes is the major risk
E. Try to answer any of the patient’s questions concerning the procedure
56. A newborn is born with a lethal chromosome defect. He is unstable to suck sufficiently to maintain life. He has episodes of crying that occur every 2 1⁄2 hours and are relieved by tube feeding. Which of the following best describes the most appropriate clinical approach?
A. Feed by mouth only
B. Feed by whatever means necessary to maintain comfort
C. Give foods according to normal caloric requirement for age
D. Withhold feeding because of the severity of the diagnosis
57. Two days after admission to the hospital because of drug-induced thrombocytopenia, a 37-year-old woman develops a severe headache and becomes comatose. On admission, examination showed a few petechiae over the lower extremities, and her platelet count was 5000/mm3. A CT scan of the head shows an intracranial hemorrhage. A platelet transfusion is recommended, but the patient is a Jehovah’s Witness and had stated on admission that she did not want to receive transfusion of any blood products. Her husband is not a Jehovah’s Witness and wants her to have the transfusion. Which of the following is the most appropriate management regarding transfusion?
A. Do Not proceed with the transfusion
B. Obtain consent form from the hospital ethics committee
C. Obtain consent from the patient’s husband
D. Obtain consent from the patient’s minister
E. Proceed with the transfusion without consent
58. A 45-year-old man comes to the emergency department because of a tooth abscess. He has not seen a physician or a dentist in over 10 years. He lives alone, is unemployed, and receives income from an inheritance. When asked what he does with his time, he says that he reads “books on physics.” He has no friends, maintains minima contact with relatives, and says that he is “really quite comfortable.” Examination shows no symptoms of a thought disorder. Which of the following is the most likely diagnosis?
A. Antisocial personality disorder
B. Avoidant personality disorder
C. Borderline personality disorder
D. Dependent personality disorder
E. Narcissistic personality disorder
F. Obsessive-Compulsive personality disorder
G. Paranoid personality disorder
H. Schizoid personality disorder
59. A 17-year-old girl comes to the emergency department because of a swollen tender ankle. An x-ray of the ankle is strongly suggestive of osteosarcoma. She and her parents are told only that “further evaluation is needed.” Which of the following next steps is most appropriate?
A. Request that an oncologist discuss the findings with them immediately
B. Request the presence of the hospital chaplain, then discuss the findings
C. Speak with the parents alone about the findings
D. Speak with the patient alone about the findings
E. Speak with the patient and her parents about the findings
60. An 18-year-old boy has just been diagnosed with schizophrenia. His identical twin brother is unaffected, but he and his parents are concerned about his likelihood of developing the disorder. Which of the following best represents the brother’s risk for developing schizophrenia?
A. 10% B. 25% C. 50% D. 75% E. 100%
61. A 70-year-old woman is transferred to a rehabilitative service 2 days after operative repair of a fracture of the right femur. She weighs 65 kg (143 lb). Findings on physical and mental status examinations are unremarkable. Which of the following is the most important predictor of success in the rehabilitation of this patient?
A. Activity level before the fracture
B. Age
C. Postoperative hemoglobin concentration
D. Serum calcium concentration
E. Serum vitamin D concentration
62. A sedentary 50-year-old man with hypertension comes to the physician because of a 6-week history of depression, anxiety, difficulty sleeping, fatigue, decreased appetite, and poor memory and concentration. He had an anterior wall myocardial infarction 3 months ago. He has one glass of wine each evening. He is 165 cm (5 ft 5 in) tall and weighs 67 kg (148 lb); BMI is 25 kg/m2. His pulse is 104/min, respirations are 16/min, and blood pressure is 177/89 mmHg. His ECG is unchanged from his last appointment. Laboratory studies show a hemoglobin concentration of 13.8 g/dL and serum LDL-cholesterol concentration of 127 mg/dL; serum LDL- cholesterol concentration was 117 mg/dL at his last visit. Which of the following is most likely to decrease this patient’s risk for mortality over the next 2 years?
A. Abstinence from alcohol
B. Diet high in omega-3 fatty acids
C. Low-calorie diet
D. Antidepressant therapy
E. Anxiolytic treatment
63. A 37-year-old man who is HIV positive comes to the physician because of a 3-week history of severe pain in his legs and pain, numbness, and tingling in his feet. He is receiving antiretroviral therapy. On physical examination, the soles of the feet are tender to palpation. Sensation to pinprick is decreased over his calves and feet. Which of the following drugs is most appropriate for long-term relief of his pain?
A. Acetaminophen
B. Hydrocodone C. Methadone D. Naproxen
E. Nortriptyline
64. A 25-year-old woman is brought to the emergency department after collapsing in the intensive care unit where she works as a nurse. Coworkers report that she had appeared fine all morning, but shortly after lunch she became pale and diaphoretic and then collapsed. She has a history of several episodes of confusion and autonomic symptoms associated with hypoglycemia that occurred at various times of day without apparent precipitants. She is unresponsive. Her temperature is 37.1°C (98.8°F), pulse is 96/min, respirations are 18/min, and blood pressure is 100/60 mmHg. An initial fingerstick shows a blood glucose concentration less than 20 mg/dL. A bolus of 50% dextrose is administered. Laboratory studies now show:
Glucose
Plasma free insulin
32 mg/dL
70 μU/mL (N = 5-35)
C-peptide
Which of the followinpgroiisntshuelinmost likely<d1iapgmnoosli/sL?(N = 1.5-
A. Factitious disorder
B. Fructose intolerance
C. Glycogen storage disease
D. Insulinoma
E. Insulin autoimmune hypoglycemia
F. Non-B cell pancreatic tumor
G. Reactive hypoglycemia
13.4)
< 0.075 nmol/L (N = 0.3- 1.29
65. A 51-year-old man develops diaphoresis, tachycardia, and a blood pressure of 155/100 mmHg 24 hours after undergoing an abdominal operation. Two hours later, he has a generalized tonic-clonic seizure. Which of the following is most likely responsible for these adverse effects in this patient?
A. Acute renal failure
B. Alcohol withdrawal
C. Anaphylactic reaction
D. Narcotic pain medication
E. Sepsis from a gram-positive organism
66. A 2—year-old man is brought to the physician by his mother because of bizarre behavior for 6 months. Although he had always been a good student, he failed all his classes at college last term. He no longer showers or shaves, and his appearance has become disheveled and unkempt. He appears distracted at the beginning of the interview and then begins talking nonstop to unseen people in the corner of the examining room. His mother looks upset and says. “it seems as if he’s hearing voices all the time now. He’s really scaring our family.” Which of the following initial responses by the physician is most appropriate?
A. “He must be schizophrenic. Does schizophrenia run in your husband’s family or yours?”
B. “He needs to take a shower. Have you tried sitting down with him and talking to him about taking better care of himself?”
C. “How frightening for you to see your son like this. Do you have any idea about what might be causing his behavior?”
D. “I am concerned he might be on drugs. Do you know anything about the friends he is hanging out with now?”
E. “Was he under any unusual stress at home or at school or did he have any problems with a girlfriend when all of this started?”
67. A 33-year-old man comes to the physician for a follow-up examination. He was diagnosed with epilepsy at the age of 10 years. His most recent seizure, which was generalized tonic-clonic, was 5 years ago. At that time, his medication was adjusted. He has no other history of major medical illness and has not had any collisions while driving his personal motor vehicle. Current medications include carbamazepine. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following best describes this patient’s status with respect to driving?
A. Determination of his driving status should be deferred until he has undergone an EEG while awake and asleep
B. He is medially qualified to drive
C. He is not medically qualified to drive until 10 years has passed since his last seizure
D. He is not medially qualified to drive while he takes carbamazepine
68. A 17-year-old boy is brought to the physician by his mother because she is concerned that his puberty is delayed. The mother states, “He is short. His father is 6 feet 5 inches tall. I don’t understand why he has not had his growth spurt.” When the mother leaves the room, the patient states, “I’m fine. I don’t know what’s the matter with her. She wants me to be tall like my dad.” The patient is 175 cm (5 ft 9 in) tall and weighs 70 kg (155 lb); BMI is 23 kg/m2. Sexual development is Tanner stage 4. In addition to reassuring the mother that her son is fine, which of the following is the most appropriate initial statement by the physician to the mother?
A. “Since your son is fine with his height, you should try to accept him as he is.”
B. “Tell me more about your concerns about your son’s height.”
C. ”We’ll do some blood tests just to be sure that all your son’s hormone levels are okay.”
D. “Your son is average for his height and weight.”
E. “Your son is not going to be any taller.”
69. A 27-year-old man comes to the physician for a psychiatric evaluation at the request of his new employer because his coworkers think he is “very odd.” He is employed as a computer repair specialist and lives alone. He refuses to socialize with anyone from work, and he has no friends that he sees regularly. He is extremely preoccupied with science fiction, the occult, and the afterlife, although he holds no particular religious beliefs. Which of the following personality disorders is the most likely explanation for his behavior?
A. Antisocial B. Borderline C. Narcissistic D. Paranoid
E. Schizotypal
70. A 58-year-old man comes to the physician to obtain a prescription for a benzodiazepine because he is experiencing an intolerable situation at work. He says that he needs to work until the age of 60 years before he can retire, but his younger boss is expecting too much of him. He feels anxious and thinks that he can complete his last 2 years of work if he decreases his anxiety. The physician prescribes a 1-month regimen of benzodiazepine therapy and schedules a follow-up appointment. Two weeks later, the patient’s wife calls and says, “My husband just got fired! I know it’s because he was talking too much of that drug you gave him. Didn’t you know he has a long history of alcoholism?” Which of the following is the most appropriate initial action by the physician?
A. Contact the patient to discuss the situation
B. Contact the risk management department of the medical practice’s insurance company regarding a potential claim
C. Discharge the patient from the medical practice for inappropriate use of medication
D. Inform the patient’s wife that her information cannot be accepted because of HIPAA
E. Refer the patient to a substance abuse program
71. A 50-year-old man is admitted to the hospital to undergo operative repair of an inguinal hernia. The surgeon has received written informed consent from the patient. After epidural anesthesia is administered, the patient decides that he does not want to have the operation. Which of the following is the most appropriate response by the surgeon?
A. “I understand that you may be afraid, but you are in good hands, and it will be over before you know it.”
B. “May we call your wife and ask her opinion about the operation?”
C. “Okay. We will cancel the operation for today.”
D. “Since you have already consented to the operation, I must make the decision that is best for your health and go ahead with the procedure.”
E. “Tell me about your concerns and why you want to cancel the operation.”
F. “You have a condition that is going to need operative intervention sooner or later.”
72. A 16-year-old girl calls the physician on a Friday night 2 hours after a condom broke during sexual intercourse with her boyfriend. She asks the physician to prescribe an emergency oral contraceptive. The physician on call is not the patient’s regular physician and does not dispense emergency contraception for moral reasons. After the physician respectfully informs the patient that he does not prescribe this contraceptive, it is most appropriate for the physician to state which of the following?
A. “I am obligated to discuss this with your parents.”
B. “I can have one of my colleagues call you back to further discuss your
concerns.”
C. “I recommend that you call the local women’s health clinic.”
D. “I will tell your regular physician to call you on Monday to talk with you about your situation.”
E. “I’m sorry, but you will have to research other ways to obtain the prescription yourself.”
73. A 55-year-old woman who is a physician is admitted tot the hospital because of a fractured femur sustained in a motor vehicle collision. Two days after admission, she develops tachycardia, restlessness, diaphoresis, and anxiety. She says that “vague shapes” are coming out of the walls. Which of the following is the most likely cause of this patient’s current condition?
A. Acute stress disorder
B. Alcohol withdrawal
C. Bipolar disorder
D. Histrionic personality disorder
E. Panic disorder
74. A 71-year-old man with prostate cancer is admitted to the hospital for a prostatic resection. On admission, his mental status is normal. Two days after the operation, he is confused and restless. He complains that he cannot sleep because little men are coming through his window at night. Which of the following is the most likely diagnosis?
A. Brief psychotic disorder
B. Delirium
C. Delusional disorder
D. Dementia
E. schizophrenia
75. A 12-year-old boy is brought to the physician by his mother for a presports physical examination. His mother is concerned because he is developing an enlarged left breast, and there is a family history of breast cancer. His left breast is slightly larger than the right breast, and the nipple is mildly tender. His penis appears slightly enlarged and his pubic hair is curling and beginning to darken at its base. Findings on physical examination are otherwise unremarkable. Which of the following is the most appropriate next step?
A. Explain that this finding indicates advanced physical development
B. Obtain more family history
C. Order serum alkaline phosphatase and estrogen studies
D. Reassure the mother that the physical findings are not uncommon for his age
E. Refer the patient to a specialist in adolescent medicine
76. A 48-year-old woman comes to the physician for a follow-up examination. She recently was diagnosed with systemic lupus erythematosus and is experiencing difficulty working as a schoolteacher because of increasingly severe pain and swelling of her ankles and knees. Current medications include daily prednisone, hydroxychloroquine, and oxycodone for pain. Which of the following is the most appropriate action by the physician to encourage healthy adaptation to illness in this patient?
A. Encourage the patient to participate in a support group for persons with her condition
B. Explain all abnormal physical examination findings in detail to the patient
C. Fill out the necessary paperwork for the patient to receive disability income
D. List all of the serious medical conditions she will develop if she does not follow her medication regimen
E. Provide the patient with written information on the pathophysiology of systemic lupus erythematosus
77. A 98-year-old woman is brought to the physician for a routine examination. She has type 2 diabetes mellitus and hypertension. Current medications include atenolol, hydrochlorothiazide, metformin, and glipizide. She has had no chest pain or shortness of breath. She lives with her 75-year-old daughter and 50-year-old grandson and says that she is feeling fine. She walks 2 miles daily. She does not drink alcohol or smoke cigarettes. She has had a 6.3-kg (14-lb) weight loss since her last visit 3 months ago. She is 157 cm (5 ft 2 in) tall and now weighs 37 kg (82 lb); BMI is 15 kg/m2. Physical examination shows multiple ecchymoses in various stages of healing on the upper extremities and torso. While assessing this patient’s condition, it is most appropriate for the physician to ask which of the following?
A. “Are you able to chew your food?”
B. “Are you noticing any change in your stools?”
C. “Are you safe at home?”
D. “Do you have enough green vegetables in your diet?”
E. “Do you think you are exercising too much?”
78. A 2-year-old girl is brought to the emergency department by ambulance 30 minutes after having a febrile seizure at day care. Physical examination shows nuchal rigidity, and bacterial meningitis is suspected. A lumbar puncture and immediate antibiotic therapy is planned, but the parents are not available to provide consent for the procedure and treatment. Which of the following is the most appropriate next step in management?
A. Administer the antibiotics, but postpone the lumbar puncture until a parent gives permission
B. Do not initiate any procedure or treatment until a legal guardian arrives
C. Obtain emergency consent via telephone consultation with hospital attorneys
D. Initiate the procedure and treatment without consent
E. Request that the day-care provider give consent in the parents’ absence
79. An 8-year-old boy is suspended from school because of persistent disruptive behavior. His teachers explain that he is in “constant motion” and never completes his assignments. He has been treated in the emergency department several times because of skateboarding injuries. If drug therapy is indicated, which of the following is most appropriate?
A. Alprazolam
B. Dexamethasone C. Fluoxetine
D. Methylphenidate E. Tranylcypromine
80. A 16-year-old boy comes to the physician for a health maintenance examination. He states that he frequently thinks about sex, daydreams about girls before going to sleep, and masturbates one to two times daily. He had had two heterosexual experiences culminating in orgasm. After counseling the patient about safe sex, which of the following is the most appropriate next step in management?
A. Advise social skills training
B. Inform the patient’s parents about his sexual activity
C. Measure serum testosterone concentration
D. Schedule next routine examination
E. Suggest that the patient decrease the frequency of masturbation
81. A 28-year-old man with ulcerative colitis comes to the physician for a follow-up examination. He underwent a partial colectomy 6 months ago, and his diarrhea and rectal bleeding have markedly improved since then. Current medications are mesalamine, and hydrocodone and acetaminophen. He lives with his parents and his academic progress has been slowed by multiple hospital admissions. He is now attending college part-time and has been working part-time as a pharmacy technician at a local drug store. He says, “I’ve been taking so much of my opiate prescription that I ran out and stole some more form my job. They caught me last week, but I haven’t told my parents yet.” Which of the following is the most appropriate initial action by the physician?
A. Discuss treatment options and referral for detoxification program
B. Tell the patient that he needs to find a different physician since he broke the physician’s trust regarding his pain medications
C. Contact the Drug Enforcement Administration and report misuse of narcotics
D. Contact the patient’s parents and tell them about the left
E. Contact the police and report the patient
F. Prescribe methadone for the patient’s opiate addiction
82. A 29-year-old woman comes to the physician because of irregular menstrual periods since menarche at the age of 12 years. She is 160 cm (5 ft 3 in) tall and weighs 86 kg (190 lb); BMI is 34 kg/m2. She is evaluated, and the diagnosis of polycystic ovarian syndrome is made. After explaining the diagnosis, the physician discusses behavioral changes, including dietary modification and exercise as part of her treatment plan. Which of the following is most likely to result in patient adherence to this plan?
A. Ascertain the patient’s educational level and provide appropriate publications
B. Ask the patient to bring a family member or friend to the next appointment
C. Inform the patient of the health consequences of not treating her condition
D. Provide follow-up appointments to assess the patient’s progress in attaining her goals
E. Refer the patient to a support group
83. A 35-year-old woman comes to the physician because of a 6-month history of generalized pain and swelling of the breasts and pelvic discomfort. This is the patient’s fourth visit to the physician within the past 2 months for the same symptoms. Previous examinations and diagnostic studies have shown no abnormalities. During the history taking, the patient tells the physician that she has sexual fantasies about him. Which of the following is the most appropriate initial action by the physician?
A. Have a chaperone join them for the remainder of the examination
B. Interrupt the patient with a more neutral topic
C. Recommend that the patient seek psychiatric counseling
D. Stop the history taking and then refer the patient to another physician
E. Tell the patient that it is common for patients to fantasize about their physicians
84. A randomized clinical trial is conducted to compare wound healing and cosmetic differences between two surgical procedures for closing skin wounds following cesarean delivery. A total of 500 women undergoing cesarean delivery during a 6-month period are enrolled in the study. A research assistant is assigned to conduct outcome assessments of each participant at 2 weeks and 6 weeks following delivery. Both procedures require the expertise of surgical specialists who cannot be blinded to the procedure. Results show that Procedure A has lower rate of wound infection compared with Procedure B (relative risk of 0.66 with a 95% confidence interval of 0.30 – 1.45); the two procedures also have similar cosmetic results 6 weeks after delivery. Which of the following statements most accurately represents the comparison between Procedure A and Procedure B in a clinical care setting?
A. Neither procedure is superior
B. Procedure A is superior to Procedure B
C. Procedure B is superior to Procedure A
D. The two procedures should not be used in a clinical care setting
85. During a clinical study, an investigator tests a new drug for the treatment of breast cancer. A population of 10,000 patients with breast cancer is recruited and randomized into a treatment group and control group. Analysis of the data shows a p-value of 0.1 and no significant difference in the treatment outcomes between the experimental group and the control group. When repeating this study, which of the following is most likely to decrease the likelihood of making a beta error?
A. Add a second treatment group
B. Conduct the study for a shorter duration
C. Decrease the alpha level
D. Enroll participants with a different type of cancer
E. Increase the sample size
86. A physician prescribes a newly marketed drug to 45 patients. Over the next several weeks, she notes that the drug has good therapeutic efficacy, but it increased serum liver enzyme activities three times the normal value in 5 of the 45 patients. The physician is unable to find any official data linking the new drug with liver dysfunction. Which of the following is the most appropriate action by the physician?
A. Continue the drug in all patients but inform the drug company about the association
B. Discontinue the drug in all patients but study the results again to identify any other possible causes of the abnormal findings
C. Discontinue the new drug in affected patients and file MedWatch reports on the FDA’s Web site
D. Discontinue the new drug in all patients and take no further action
E. Do nothing, since the drug company most likely previously conducted all necessary research
87. A study is conducted to assess the effect of a new screening test on the mortality rate of prostate cancer. Prior to implementation of screening, the overall 5-year survival rate was 70%. After initiating the screening in the randomly selected study population, the 5-year survival rate increases to 85%. During this time, there were no changes in the treatment of prostate cancer. The apparent decrease in mortality could be due to which of the following types of bias?
A. Compliance B. Lead-time C. Recall
D. Selection
88. An investigator is conducting a randomized, double-blind, placebo-controlled clinical trial of a new medication for the treatment of mild insomnia in adults. A total of 2000 participants are enrolled in the study and randomized to one of two groups: 1000 participants receive the new medication (Group 1), and 1000 participants receive a placebo that appears identical to the medication (Group 2). Participants in both groups are instructed to take one pill 30 minutes before bedtime each day and to keep a sleep diary. After 1 month, each participant is interviewed, and the daily sleep diaries are reviewed. At follow-up, it is determined that 200 participants in Group 1 and 50 participants in Group 2 did not take the pill as directed. In accordance with intention-to-treat analysis, how should the data pertaining to all individuals wo did not adhere to the instructions be treated?
A. Analyze all nonadherent participants according to the group of the study to which each was randomized
B. Exclude all nonadherent participants from analysis
C. Exclude only nonadherent participants in Group 1 from analysis
D. Exclude only nonadherent participants in Group 2 from analysis
E. Perform separate analyses of the 250 nonadherent participants and the
89. An investigator is studying patients with West Nile virus infection. During a 5-year period, data are collected on 25 patients diagnosed with this condition as confirmed by testing at the Centers for Disease Control and Prevention. Demographic information on the patients is reported (age, gender, and ethnicity), as well as information about likely sources of infection. Which of the following best describes this study design?
A. Case series
B. Case-control study
C. Cohort study
D. Correlational study
E. Cross-sectional study
90. A 52-year-old man is brought to the physician by a social worker because his neighbors have reported that he has been confused and not taking care of himself. He has a 4-month history of diarrhea. Physical examination shows extreme muscle wasting, stomatitis, and a diffuse rash that is worse in sun-exposed areas. The patient is mildly disoriented and has poor long- term memory and paranoid ideation. Which of the following is the most likely diagnosis?
A. Beriberi
B. Pellagra
C. Scurvy
D. Wernicke syndrome
E. Whipple disease
91. A 50-year-old man who is a college professor has had an increasing cough for 6 months and hemoptysis for 1 week. He has smoked 1 pack of cigarettes per day for the past 32 years. He plays squash twice a week and swims 3 times a week. An x-ray of the chest shows a 3 x 4-cm hilar mass. Cytologic examination of sputum shows non-small cell carcinoma. The physician tells the patient he has lung cancer. The patient responds, “How can this be happening to me? I eat right and exercise.” Which of the following responses by the physician is most appropriate?
A. “Don’t worry. I will be there for you and make sure everything turns out the way you want.”
B. “Eating right and exercising will not help prevent cancer.”
C. “It must be difficult for you to accept this diagnosis when you feel healthy.”
D. “In fact, as you probably know, the major risk for lung cancer is smoking.”
E. “Regardless of your good habits, it’s time to realize that you have lung cancer.”
92. A 17-year-old boy comes to the physician because of an 8-kg (18-lb) weight gain during the past year. He has not had any major illness. He says that he does not eat excessively and has a moderate level of activity, including playing golf. His father and paternal uncles are all overweight. He is 178 cm (5 ft 10 in) tall and weighs 102 kg (224 lb); BMI is 32 kg/m2. When the physician finishes examining the patient, the patient asks, “Do you think that my weight gain is inherited from my father?” Which of the following is the most appropriate initial response by the physician?
A. “No, it’s because you’re eating wrong kinds of food.”
B. “No, let’s examine your environment more closely, as your paternal history is only incidental to your weight gain.”
C. “No, unfortunately it’s because you’re eating too much.”
D. “Yes, your paternal family history is the major contributing factor to your weight gain.”
E. “Yes, your weight gain can be caused by genes and environment combined.”
93. A 38-year-old man with a 3-year history of type 2 diabetes mellitus comes to the physician for a follow-up examination. In addition to taking an oral antihyperglycemic agent, he has tried controlling his condition with diet modifications and exercise. He is 188 cm (6 ft 2 in) tall and weighs 113 kg (250 lb); BMI is 32 kg/m2. Physical examination shows no other abnormalities. His hemoglobin A1C is 10%. The physician recommends
initiation of insulin injections to obtain better control over the patient’s blood glucose concentration. The patient responds, “I know that insulin would help control my blood sugar. But a lot of people in my family have diabetes, and insulin made them really sick at times.” This patient is most likely at which of the following stages of change regarding insulin administration?
A. Precontemplation B. Contemplation
C. Preparation
D. Action
E. Maintenance
94. A 27-year-old man comes to the physician for an examination before starting employment at a plastics factory. He has no history of major medical illness. He has never been sexually active. He has minimal contact with his parents and siblings and has no hobbies. When asked if he feels depressed, he says no. He shrugs in response to congratulations about his new job. Physical examination shows a flat affect. This patient most likely has which of the following types of personality disorders?
A. Antisocial
B. Avoidant
C. Borderline D. Schizoid
E. Schizotypal
95. A 47-year-old woman with psoriasis comes to the physician for follow-up care. At her last appointment she was given several topical creams, which must be used in a specified sequence twice daily. No improvement is apparent at this appointment. Which of the following is the most appropriate way for the physician to begin the discussion of this patient’s compliance with therapy?
A. “Did you use the creams twice daily?”
B. “How many tubes did you use in the last month?”
C. “How often did you skip treatments?”
D. “Most people find it difficult to sticks to a routine. How did you do?”
E. “Using something twice daily can be difficult. I assume you are like most patients who miss at least 10% of treatments.”
96. A 68-year-old man is asked to give informed consent for a herniorrhaphy. The surgeon gives the patient information about the risks and benefits of the procedure, says that the procedure resolves symptoms in more than 95% of patients, and tells the patient he has done more than 100 of these procedures. He tells the patient that he will need to pay for a portion of the cost of hospitalization. The patient says that he understands what he has been told, that he is willing to have the operation, and that his family will be available to discuss the procedure later in the day. In this patient, which combination of components fulfill the criteria for fully informed consent?
A. Family agreement, competence, cost
B. Family agreement, cost, reliability
C. Information, competence, voluntariness
D. Information, validity, cost
E. Validity, voluntariness, reliability
97. A girl is brought to the physician for a well-child examination. Her normal development includes using a pincer grasp, finder feeding, standing while holding onto a table, and playing peekaboo. Which of the following best represents this patient’s age (in months)?
A. 3 B. 9 C. 15 D. 21 E. 27
98. A 14-year-old boy is brought to the physician by his mother because of daily headaches for 2 months. The headaches are described as a bilateral aching in the temples. His mother states that he also “has not been himself” for the past few months. He seems more confused, often forgetting names, dates, and places, and he is clumsy with frequent falls. His school performance also has declined over the past quarter. Physical examination shows a broad-based, ataxic gait. He is alert and oriented to person, place, and time, but he is slow to answer questions. Chronic abuse of which of the following substances is the most likely cause of this patient’s condition?
A. Cocaine
B. Ethanol
C. Inhaled glue
D. Methamphetamines
E. PCP (phencyclidine)
99. A 43-year-old woman comes to the physician for a routine health maintenance examination. The physician is 30 minutes late for the appointment because of an emergency, and when he enters the examining room, the patient checks her watch. Which of the following initial statements by the physician is most appropriate?
A. “I apologize for being behind schedule, but this won’t take long.”
B. “I apologize for being late. Why don’t we reschedule for another
time?”
C. “I apologize for running behind. They made my schedule really tight today.”
D. “I’m sorry I got delayed. I hope I haven’t made you late somewhere else.”
E. ”I’m sorry I got tied up. The emergency room always seems to call me for their most difficult cases.”
100. A physician is sad because he has to inform a patient of recent test results that indicate progression of carcinoma to the terminal phase. When the patient sees the physician’s face, he begins to cry and says, “It’s bad news, isn’t it?” Which of the following responses by the physician is most appropriate?
A. “How have you been since the last time I saw you?”
B. “Let’s talk about the positive aspects first.”
C. “Look on the bright side of things.”
D. “Tell me how you are feeling.”
E. “There are other people who have it a lot worse than you.”
F. “Yes, it is.”
G. “You’ve had several years better off than many others with this disease.”
101. a 55-year-old woman comes to the physician because of a 6-week history of low energy, irritability, and crying spells. She has difficulty falling asleep and wakes up frequently at night. Her work as a bookkeeper has been affected because she cannot focus. She has not been attending church or her bridge club. She has been taking lorazepam for 15 years for generalized anxiety disorder. She has had postmenopausal symptoms for 1 year successfully treated with estrogen replacement therapy. Her temperature is 37°C (98.6 °F), pulse is 82/min, and blood pressure is 120/76 mmHg. Physical examination and laboratory studies show no abnormalities. Mental status examination shows a constricted affect. She describes her mood as “testy.” Her speech is slightly slowed. There is no evidence of psychosis. She says she wishes that she “wouldn’t wake up some days” but does not have any intent or plan to harm herself. Which of the following is the most likely cause of this patient’s symptoms?
A. Estrogen toxicity
B. Generalized anxiety disorder
C. Lorazepam toxicity
D. Major depressive disorder
102. A previously healthy 35-year-old man has become increasingly depressed, impulsive, and difficult over the past year. He grimaces intermittently and has rigid, jerking, purposeless movements of the fingers. Which of the following historical factors is most relevant in establishing a diagnosis?
A. Dietary deficiency
B. Exposure to environmental toxins
C. Family history of similar illness
D. Pet with an unexplained illness
E. Tick bite
F. Travel to a foreign country
103. a 15-year-old girl comes to the physician’s office for a health maintenance examination. Her mother was recently diagnosed with squamous cell carcinoma of the face, and her maternal grandfather died of metastatic melanoma. During the visit, the physician advises her about methods of photoprotection, including daily use of a sunscreen. In a patient of this age, which of the following factors is most likely to predict compliance with photoprotection?
A. Ability to tan
B. Advice of the physician to wear sunscreen
C. Concern about premature aging of skin
D. Desire to prevent sunburn
E. Family history of skin cancer
F. Use of sunscreen by her peers
104. a 35-year-old man who uses crack cocaine daily comes to the emergency department because of a 2-hour history of substernal chest pain. He last used cocaine 6 hours ago. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 14/min, and blood pressure is 160/100 mmHg. Which of the following is the most appropriate next step in patient care?
A. Admit the patient to the hospital for cocaine detoxification
B. Admit the patient to the hospital for possible myocardial ischemia
C. Educate the patient about the risks of cocaine use and send the patient home
D. Transfer the patient to a psychiatric facility
105. A 26-year-old woman comes to the physician 5 weeks after the birth of her first child. She worries constantly that the infant is ill and wakes him 10 to 14 times every night to make sure he is well. She has had no crying spells or problems with appetite. She is worried that she will infect the infant with her germs and washes her own hands 30 times per day. For 2 months prior to the delivery, she worried about people breaking into her house and checked the lock on the front door three to four times every night. She is not breast-feeding. Which of the following is the most appropriate pharmacotherapy?
A. Alprazolam
B. Haloperidol
C. Lithium carbonate
D. Methylphenidate
E. Phenelzine
F. Sertraline
106. A 65-year-old woman is being treated in the hospital for widely metastatic breast cancer unresponsive to chemotherapy. She has never married and has no children or siblings. Throughout her illness, another woman she had introduced as “my close friend,” has been with her during hospitalizations and office visits. The patient is moved to an inpatient hospice after she decides she wants no further curative therapy. She and her friend appear very distressed when they read a sign outside the hospice unit that states only family members are permitted to stay after visiting hours. Her friend says, “We can’t bear to be apart. It would be cruel to separate us now.” Which of the following responses by the physician is most appropriate?
A. “Don’t worry. I’ll call you right away if something happens to your friend. Just leave your number with the nurses.”
B. “I’m sorry, but only family is allowed to stay with patients in the hospital. You will have to leave after your 15 minutes are up.”
C. “The two of you seem to have a very important relationship. Of course you may stay together.”
D. “Visiting hours are posted outside. You are welcome during any of those times. I’m sorry, but an exception cannot be made in your case.”
E. “Well, I guess we could bend the rules this time, but if anyone asks, you’re her sister. Does that sound OK?”
107. A 63-year-old woman is brought to the emergency department because of a 2-day history of fever, abdominal tenderness, and painful urination. She appears agitated. Her temperature is 38.8°C (101.8°F). Laboratory studies show a leukocyte count of 14,000/mm3. she is admitted to the hospital. Two hours later, the nurses note that she has torn up four breakfast menus because she found them to be too confusing. She is highly educated, and her husband says that she does not behave this way at home. Which of the following is the most likely cause of this patient’s current mental status?
A. Amnesia
B. Delirium
C. Dementia
D. Mild cognitive impairment
E. Occult cerebral infarction
108. A randomized controlled study of 2000 patients with insomnia is conducted to evaluate the efficacy of a new medication to treat this condition. Ten subjects from both the control and treatment groups do not complete the study and are not included in the analysis. Study subjects in the treatment group are able to fall asleep an average of 5 minutes faster than study subjects in the control group. The difference is statistically significant (p=0.001). Subjects in neither group report an improvement in quality of life. The investigators conclude that the new medication is efficacious in treating insomnia. These findings are most likely an example of which of the following types of error?
A. Exclusion of subjects who did not have an expected response to the medication
B. Failure to distinguish between statistical significance and clinical significance
C. Failure to find a clinically significant result due to the attrition of subjects
D. Failure to reject a null hypothesis when it is not true
E. Rejecting a null hypothesis when it is true
109. In an epidemiologic study of workers in the aniline dye industry, 500 workers with bladder cancer and 200 workers without bladder cancer are selected. The investigators ask both groups past exposure to aniline dye.
Results are shown in the table:
Yes No
Bladder Cancer
Yes No
Exposur e to Aniline Dyes
250 250 500
50 300 150 400 200 700
Which of the following is the odds ratio for the exposure variable?
A. 0.33 B. 0.5 C. 1
D. 1.5 E. 2
F. 3
110. A study is designed to evaluate the efficacy of coenzyme Q10 in improving cardiac output in patients with congestive heart failure (CHF). Sixty patients with CHF are recruited for the study. Each subject is assigned by coin toss to one of two groups (standard care or standard care plus coenzyme Q10). Which of the following best describes this study design?
A. Case-control
B. Case series
C. Crossover
D. Cross-sectional
E. Historical cohort
F. Randomized clinical trial
111. An 80-year-old woman is being evaluated for suspected temporal arteritis (TA). Her erythrocyte sedimentation rate (ESR) is 100 mm/h. Treatment of TA involves the use of glucocorticoids, which could have serious adverse effects. The pretest probability for TA is 50% in this patient. In the evaluation of TA, ESR testing in this patient, which of the following is the most appropriate next step in management?
A. Additional testing to confirm the diagnosis of TA
B. Corticosteroid therapy, since the diagnosis of TA has been established with 99% certainty
C. Elimination of TA from further diagnostic consideration
D. Repeat ESR; if again positive, corticosteroid therapy
E. Repeat ESR; if normal, additional testing to confirm the diagnosis of TA
112. An investigator wishes to conduct a study of the development of breast cancer in women. Seven hundred healthy women will be observed for 10 years. Complete family histories will be obtained from each volunteer. The goal of the study is to determine if the number of family members who previously received diagnosis of breast cancer correlates with the incidence of the future development of breast cancer in this population. Which of the following designs is most appropriate for this study?
A. Case series
B. Cohort
C. Crossover
D. Cross-sectional
E. Randomized controlled
113. A study is conducted to assess the effectiveness of injections of lidocaine into “trigger points” of pain symptoms in patients with fibromyalgia. Fifty patients are randomly assigned to biweekly trigger-point injections with 0.9% saline only or 0.9% saline plus lidocaine. The graph shows daily self-reported pain scores in relation to the injections. Which of the following is the most likely explanation for these findings?
A. Placebo effect
B. Regression to the mean
C. Selection bias
D. Type II error
E. Uncontrolled confounding
114. An examination is scaled so that the scores are approximately normally distributed with a mean of 500 and a standard deviation of 100. Which of the following is the percentage of examinees with scores between 400 and 600?
A. 16%
B. 50%
C. 67%
D. 90%
E. 95%
115. Ten healthy human subjects are given a new drug and monitored for drug effect and toxicity. Blood samples are periodically taken and analyzed to define the human pharmacokinetics of the drug for the first time. Which of the following best describes this trial?
A. Preclinical testing
B. Phase 1
C. Phase 2
D. Phase 3
E. Phase 4
116. In a survey of 100 households (average three residents per household), 45 individuals with asthma are detected. Which of the following is the best estimate of the prevalence of asthma?
A. 15%
B. 20% C. 30% D. 40% E. 45%
A. Test 1 followed by test 3 if test 1 is positive
B. Test 3 followed by test 1 if test 3 is positive
C. Test 2 only
D. Test 2 followed by test 3 if test 2 is negative
E. Test 2 followed by test 3 if test 2 is positive
51. In immunocompromised patients, the case definition of a positive PPD skin test was changed from 10 mm of induration to 5 mm of induration. This change in case definition has which of the following effects on incidence and prevalence of a positive PPD skin test?
A. B. C. D. E.
Incidence Prevalence
↑ ↑
↑ ↓
NO CHANGE NO CHANGE ↓ ↑
↓ ↓
52. A 50-year-old man is brought to the physician by his wife because of personality changes for 2 years and cognitive decline for 3 months. His wife says, “He used to be such a kind and shy man, but now he screams at strangers for no apparent reason. The other day, he yelled at a woman at a convenience store for not ordering extra cheese in her sandwich. He said she needed the extra calcium.” She adds, “this has been going on for a while, but last month he almost invested all of our savings in a start-up company that was going to produce different kinds of hats strictly for dogs. He wasn’t like this before. He was a respected accountant. I stopped him, thank goodness, and it turned out to be a scam, anyway.” She adds, “I’m worried about his physical safety, too, because I’ve had to search for him five times within the past couple of months after he got lost wandering around our neighborhood. We’ve lived there for 20 years.” Neurologic examination shows a palmomental reflex and hyperreflexia throughout the upper and lower extremities. His mood appears normal except for occasional inappropriate cursing at the physician. His Mini-Mental State Examination score is 21/30. A CT scan of the head shows disproportionate atrophy of the frontal lobes bilaterally. Which of the following is the most likely diagnosis?
A. Dementia, Alzheimer type
B. Huntington Disease
C. Multi-infarct (vascular) Dementia
D. Parkinson Disease
E. Pick Disease
53. A 10-year-old girl is brought to the physician by her mother for a well-child examination. She has not yet had a menstrual period. She is at the 50th percentile for height and weight. Physical examination shows absence of breast bud development and no pubic or axillary hair. The mother asks how she will know when her daughter begins puberty. It is most appropriate for the physician to tell the mother that the first objective
sign of puberty will be which of the following?
A. Breast bud development
B. Development of axillary hair
C. Development of pubic hair
D. Onset of menses
E. Rapidly increasing height
54. A 30-year-old man who completed a successful course of treatment for Hodgkin disease 2 months ago calls his physician on an increasingly frequent basis. He takes his temperature several times daily and contacts the office whenever it is above 37.2°C (99°F). He also has episodes of tingling of his fingers that lasts several seconds. Although evaluation has shown no evidence of recurrence, he is increasingly fearful that Hodgkin disease may not be detected rapidly enough for successful treatment. Which of the following is the most likely diagnosis?
A. Adjustment disorder with anxiety
B. Dependent personality disorder
C. Generalized anxiety disorder
D. Obsessive-compulsive disorder
E. Somatic symptom disorder
55. A 41-year-old woman with systemic lupus erythematous is scheduled to undergo surgical placement of a peritoneal dialysis catheter. The surgeon asks the resident physician to get the consent form signed the evening before the procedure. The resident has never seen this procedure performed and has read little about it. He will not be assisting with the procedure. Which of the following actions by the resident physician is most appropriate?
A. ask a nurse to get a signature on the form
B. Ask the attending physician to obtain informed consent
C. Ask the patient to sign the form and tell her that the surgeon will answer questions the next morning
D. Obtain an informed consent by explaining what he believes is the major risk
E. Try to answer any of the patient’s questions concerning the procedure
56. A newborn is born with a lethal chromosome defect. He is unstable to suck sufficiently to maintain life. He has episodes of crying that occur every 2 1⁄2 hours and are relieved by tube feeding. Which of the following best describes the most appropriate clinical approach?
A. Feed by mouth only
B. Feed by whatever means necessary to maintain comfort
C. Give foods according to normal caloric requirement for age
D. Withhold feeding because of the severity of the diagnosis
57. Two days after admission to the hospital because of drug-induced thrombocytopenia, a 37-year-old woman develops a severe headache and becomes comatose. On admission, examination showed a few petechiae over the lower extremities, and her platelet count was 5000/mm3. A CT scan of the head shows an intracranial hemorrhage. A platelet transfusion is recommended, but the patient is a Jehovah’s Witness and had stated on admission that she did not want to receive transfusion of any blood products. Her husband is not a Jehovah’s Witness and wants her to have the transfusion. Which of the following is the most appropriate management regarding transfusion?
A. Do Not proceed with the transfusion
B. Obtain consent form from the hospital ethics committee
C. Obtain consent from the patient’s husband
D. Obtain consent from the patient’s minister
E. Proceed with the transfusion without consent
58. A 45-year-old man comes to the emergency department because of a tooth abscess. He has not seen a physician or a dentist in over 10 years. He lives alone, is unemployed, and receives income from an inheritance. When asked what he does with his time, he says that he reads “books on physics.” He has no friends, maintains minima contact with relatives, and says that he is “really quite comfortable.” Examination shows no symptoms of a thought disorder. Which of the following is the most likely diagnosis?
A. Antisocial personality disorder
B. Avoidant personality disorder
C. Borderline personality disorder
D. Dependent personality disorder
E. Narcissistic personality disorder
F. Obsessive-Compulsive personality disorder
G. Paranoid personality disorder
H. Schizoid personality disorder
59. A 17-year-old girl comes to the emergency department because of a swollen tender ankle. An x-ray of the ankle is strongly suggestive of osteosarcoma. She and her parents are told only that “further evaluation is needed.” Which of the following next steps is most appropriate?
A. Request that an oncologist discuss the findings with them immediately
B. Request the presence of the hospital chaplain, then discuss the findings
C. Speak with the parents alone about the findings
D. Speak with the patient alone about the findings
E. Speak with the patient and her parents about the findings
60. An 18-year-old boy has just been diagnosed with schizophrenia. His identical twin brother is unaffected, but he and his parents are concerned about his likelihood of developing the disorder. Which of the following best represents the brother’s risk for developing schizophrenia?
A. 10% B. 25% C. 50% D. 75% E. 100%
61. A 70-year-old woman is transferred to a rehabilitative service 2 days after operative repair of a fracture of the right femur. She weighs 65 kg (143 lb). Findings on physical and mental status examinations are unremarkable. Which of the following is the most important predictor of success in the rehabilitation of this patient?
A. Activity level before the fracture
B. Age
C. Postoperative hemoglobin concentration
D. Serum calcium concentration
E. Serum vitamin D concentration
62. A sedentary 50-year-old man with hypertension comes to the physician because of a 6-week history of depression, anxiety, difficulty sleeping, fatigue, decreased appetite, and poor memory and concentration. He had an anterior wall myocardial infarction 3 months ago. He has one glass of wine each evening. He is 165 cm (5 ft 5 in) tall and weighs 67 kg (148 lb); BMI is 25 kg/m2. His pulse is 104/min, respirations are 16/min, and blood pressure is 177/89 mmHg. His ECG is unchanged from his last appointment. Laboratory studies show a hemoglobin concentration of 13.8 g/dL and serum LDL-cholesterol concentration of 127 mg/dL; serum LDL- cholesterol concentration was 117 mg/dL at his last visit. Which of the following is most likely to decrease this patient’s risk for mortality over the next 2 years?
A. Abstinence from alcohol
B. Diet high in omega-3 fatty acids
C. Low-calorie diet
D. Antidepressant therapy
E. Anxiolytic treatment
63. A 37-year-old man who is HIV positive comes to the physician because of a 3-week history of severe pain in his legs and pain, numbness, and tingling in his feet. He is receiving antiretroviral therapy. On physical examination, the soles of the feet are tender to palpation. Sensation to pinprick is decreased over his calves and feet. Which of the following drugs is most appropriate for long-term relief of his pain?
A. Acetaminophen
B. Hydrocodone C. Methadone D. Naproxen
E. Nortriptyline
64. A 25-year-old woman is brought to the emergency department after collapsing in the intensive care unit where she works as a nurse. Coworkers report that she had appeared fine all morning, but shortly after lunch she became pale and diaphoretic and then collapsed. She has a history of several episodes of confusion and autonomic symptoms associated with hypoglycemia that occurred at various times of day without apparent precipitants. She is unresponsive. Her temperature is 37.1°C (98.8°F), pulse is 96/min, respirations are 18/min, and blood pressure is 100/60 mmHg. An initial fingerstick shows a blood glucose concentration less than 20 mg/dL. A bolus of 50% dextrose is administered. Laboratory studies now show:
Glucose
Plasma free insulin
32 mg/dL
70 μU/mL (N = 5-35)
C-peptide
Which of the followinpgroiisntshuelinmost likely<d1iapgmnoosli/sL?(N = 1.5-
A. Factitious disorder
B. Fructose intolerance
C. Glycogen storage disease
D. Insulinoma
E. Insulin autoimmune hypoglycemia
F. Non-B cell pancreatic tumor
G. Reactive hypoglycemia
13.4)
< 0.075 nmol/L (N = 0.3- 1.29
65. A 51-year-old man develops diaphoresis, tachycardia, and a blood pressure of 155/100 mmHg 24 hours after undergoing an abdominal operation. Two hours later, he has a generalized tonic-clonic seizure. Which of the following is most likely responsible for these adverse effects in this patient?
A. Acute renal failure
B. Alcohol withdrawal
C. Anaphylactic reaction
D. Narcotic pain medication
E. Sepsis from a gram-positive organism
66. A 2—year-old man is brought to the physician by his mother because of bizarre behavior for 6 months. Although he had always been a good student, he failed all his classes at college last term. He no longer showers or shaves, and his appearance has become disheveled and unkempt. He appears distracted at the beginning of the interview and then begins talking nonstop to unseen people in the corner of the examining room. His mother looks upset and says. “it seems as if he’s hearing voices all the time now. He’s really scaring our family.” Which of the following initial responses by the physician is most appropriate?
A. “He must be schizophrenic. Does schizophrenia run in your husband’s family or yours?”
B. “He needs to take a shower. Have you tried sitting down with him and talking to him about taking better care of himself?”
C. “How frightening for you to see your son like this. Do you have any idea about what might be causing his behavior?”
D. “I am concerned he might be on drugs. Do you know anything about the friends he is hanging out with now?”
E. “Was he under any unusual stress at home or at school or did he have any problems with a girlfriend when all of this started?”
67. A 33-year-old man comes to the physician for a follow-up examination. He was diagnosed with epilepsy at the age of 10 years. His most recent seizure, which was generalized tonic-clonic, was 5 years ago. At that time, his medication was adjusted. He has no other history of major medical illness and has not had any collisions while driving his personal motor vehicle. Current medications include carbamazepine. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following best describes this patient’s status with respect to driving?
A. Determination of his driving status should be deferred until he has undergone an EEG while awake and asleep
B. He is medially qualified to drive
C. He is not medically qualified to drive until 10 years has passed since his last seizure
D. He is not medially qualified to drive while he takes carbamazepine
68. A 17-year-old boy is brought to the physician by his mother because she is concerned that his puberty is delayed. The mother states, “He is short. His father is 6 feet 5 inches tall. I don’t understand why he has not had his growth spurt.” When the mother leaves the room, the patient states, “I’m fine. I don’t know what’s the matter with her. She wants me to be tall like my dad.” The patient is 175 cm (5 ft 9 in) tall and weighs 70 kg (155 lb); BMI is 23 kg/m2. Sexual development is Tanner stage 4. In addition to reassuring the mother that her son is fine, which of the following is the most appropriate initial statement by the physician to the mother?
A. “Since your son is fine with his height, you should try to accept him as he is.”
B. “Tell me more about your concerns about your son’s height.”
C. ”We’ll do some blood tests just to be sure that all your son’s hormone levels are okay.”
D. “Your son is average for his height and weight.”
E. “Your son is not going to be any taller.”
69. A 27-year-old man comes to the physician for a psychiatric evaluation at the request of his new employer because his coworkers think he is “very odd.” He is employed as a computer repair specialist and lives alone. He refuses to socialize with anyone from work, and he has no friends that he sees regularly. He is extremely preoccupied with science fiction, the occult, and the afterlife, although he holds no particular religious beliefs. Which of the following personality disorders is the most likely explanation for his behavior?
A. Antisocial B. Borderline C. Narcissistic D. Paranoid
E. Schizotypal
70. A 58-year-old man comes to the physician to obtain a prescription for a benzodiazepine because he is experiencing an intolerable situation at work. He says that he needs to work until the age of 60 years before he can retire, but his younger boss is expecting too much of him. He feels anxious and thinks that he can complete his last 2 years of work if he decreases his anxiety. The physician prescribes a 1-month regimen of benzodiazepine therapy and schedules a follow-up appointment. Two weeks later, the patient’s wife calls and says, “My husband just got fired! I know it’s because he was talking too much of that drug you gave him. Didn’t you know he has a long history of alcoholism?” Which of the following is the most appropriate initial action by the physician?
A. Contact the patient to discuss the situation
B. Contact the risk management department of the medical practice’s insurance company regarding a potential claim
C. Discharge the patient from the medical practice for inappropriate use of medication
D. Inform the patient’s wife that her information cannot be accepted because of HIPAA
E. Refer the patient to a substance abuse program
71. A 50-year-old man is admitted to the hospital to undergo operative repair of an inguinal hernia. The surgeon has received written informed consent from the patient. After epidural anesthesia is administered, the patient decides that he does not want to have the operation. Which of the following is the most appropriate response by the surgeon?
A. “I understand that you may be afraid, but you are in good hands, and it will be over before you know it.”
B. “May we call your wife and ask her opinion about the operation?”
C. “Okay. We will cancel the operation for today.”
D. “Since you have already consented to the operation, I must make the decision that is best for your health and go ahead with the procedure.”
E. “Tell me about your concerns and why you want to cancel the operation.”
F. “You have a condition that is going to need operative intervention sooner or later.”
72. A 16-year-old girl calls the physician on a Friday night 2 hours after a condom broke during sexual intercourse with her boyfriend. She asks the physician to prescribe an emergency oral contraceptive. The physician on call is not the patient’s regular physician and does not dispense emergency contraception for moral reasons. After the physician respectfully informs the patient that he does not prescribe this contraceptive, it is most appropriate for the physician to state which of the following?
A. “I am obligated to discuss this with your parents.”
B. “I can have one of my colleagues call you back to further discuss your
concerns.”
C. “I recommend that you call the local women’s health clinic.”
D. “I will tell your regular physician to call you on Monday to talk with you about your situation.”
E. “I’m sorry, but you will have to research other ways to obtain the prescription yourself.”
73. A 55-year-old woman who is a physician is admitted tot the hospital because of a fractured femur sustained in a motor vehicle collision. Two days after admission, she develops tachycardia, restlessness, diaphoresis, and anxiety. She says that “vague shapes” are coming out of the walls. Which of the following is the most likely cause of this patient’s current condition?
A. Acute stress disorder
B. Alcohol withdrawal
C. Bipolar disorder
D. Histrionic personality disorder
E. Panic disorder
74. A 71-year-old man with prostate cancer is admitted to the hospital for a prostatic resection. On admission, his mental status is normal. Two days after the operation, he is confused and restless. He complains that he cannot sleep because little men are coming through his window at night. Which of the following is the most likely diagnosis?
A. Brief psychotic disorder
B. Delirium
C. Delusional disorder
D. Dementia
E. schizophrenia
75. A 12-year-old boy is brought to the physician by his mother for a presports physical examination. His mother is concerned because he is developing an enlarged left breast, and there is a family history of breast cancer. His left breast is slightly larger than the right breast, and the nipple is mildly tender. His penis appears slightly enlarged and his pubic hair is curling and beginning to darken at its base. Findings on physical examination are otherwise unremarkable. Which of the following is the most appropriate next step?
A. Explain that this finding indicates advanced physical development
B. Obtain more family history
C. Order serum alkaline phosphatase and estrogen studies
D. Reassure the mother that the physical findings are not uncommon for his age
E. Refer the patient to a specialist in adolescent medicine
76. A 48-year-old woman comes to the physician for a follow-up examination. She recently was diagnosed with systemic lupus erythematosus and is experiencing difficulty working as a schoolteacher because of increasingly severe pain and swelling of her ankles and knees. Current medications include daily prednisone, hydroxychloroquine, and oxycodone for pain. Which of the following is the most appropriate action by the physician to encourage healthy adaptation to illness in this patient?
A. Encourage the patient to participate in a support group for persons with her condition
B. Explain all abnormal physical examination findings in detail to the patient
C. Fill out the necessary paperwork for the patient to receive disability income
D. List all of the serious medical conditions she will develop if she does not follow her medication regimen
E. Provide the patient with written information on the pathophysiology of systemic lupus erythematosus
77. A 98-year-old woman is brought to the physician for a routine examination. She has type 2 diabetes mellitus and hypertension. Current medications include atenolol, hydrochlorothiazide, metformin, and glipizide. She has had no chest pain or shortness of breath. She lives with her 75-year-old daughter and 50-year-old grandson and says that she is feeling fine. She walks 2 miles daily. She does not drink alcohol or smoke cigarettes. She has had a 6.3-kg (14-lb) weight loss since her last visit 3 months ago. She is 157 cm (5 ft 2 in) tall and now weighs 37 kg (82 lb); BMI is 15 kg/m2. Physical examination shows multiple ecchymoses in various stages of healing on the upper extremities and torso. While assessing this patient’s condition, it is most appropriate for the physician to ask which of the following?
A. “Are you able to chew your food?”
B. “Are you noticing any change in your stools?”
C. “Are you safe at home?”
D. “Do you have enough green vegetables in your diet?”
E. “Do you think you are exercising too much?”
78. A 2-year-old girl is brought to the emergency department by ambulance 30 minutes after having a febrile seizure at day care. Physical examination shows nuchal rigidity, and bacterial meningitis is suspected. A lumbar puncture and immediate antibiotic therapy is planned, but the parents are not available to provide consent for the procedure and treatment. Which of the following is the most appropriate next step in management?
A. Administer the antibiotics, but postpone the lumbar puncture until a parent gives permission
B. Do not initiate any procedure or treatment until a legal guardian arrives
C. Obtain emergency consent via telephone consultation with hospital attorneys
D. Initiate the procedure and treatment without consent
E. Request that the day-care provider give consent in the parents’ absence
79. An 8-year-old boy is suspended from school because of persistent disruptive behavior. His teachers explain that he is in “constant motion” and never completes his assignments. He has been treated in the emergency department several times because of skateboarding injuries. If drug therapy is indicated, which of the following is most appropriate?
A. Alprazolam
B. Dexamethasone C. Fluoxetine
D. Methylphenidate E. Tranylcypromine
80. A 16-year-old boy comes to the physician for a health maintenance examination. He states that he frequently thinks about sex, daydreams about girls before going to sleep, and masturbates one to two times daily. He had had two heterosexual experiences culminating in orgasm. After counseling the patient about safe sex, which of the following is the most appropriate next step in management?
A. Advise social skills training
B. Inform the patient’s parents about his sexual activity
C. Measure serum testosterone concentration
D. Schedule next routine examination
E. Suggest that the patient decrease the frequency of masturbation
81. A 28-year-old man with ulcerative colitis comes to the physician for a follow-up examination. He underwent a partial colectomy 6 months ago, and his diarrhea and rectal bleeding have markedly improved since then. Current medications are mesalamine, and hydrocodone and acetaminophen. He lives with his parents and his academic progress has been slowed by multiple hospital admissions. He is now attending college part-time and has been working part-time as a pharmacy technician at a local drug store. He says, “I’ve been taking so much of my opiate prescription that I ran out and stole some more form my job. They caught me last week, but I haven’t told my parents yet.” Which of the following is the most appropriate initial action by the physician?
A. Discuss treatment options and referral for detoxification program
B. Tell the patient that he needs to find a different physician since he broke the physician’s trust regarding his pain medications
C. Contact the Drug Enforcement Administration and report misuse of narcotics
D. Contact the patient’s parents and tell them about the left
E. Contact the police and report the patient
F. Prescribe methadone for the patient’s opiate addiction
82. A 29-year-old woman comes to the physician because of irregular menstrual periods since menarche at the age of 12 years. She is 160 cm (5 ft 3 in) tall and weighs 86 kg (190 lb); BMI is 34 kg/m2. She is evaluated, and the diagnosis of polycystic ovarian syndrome is made. After explaining the diagnosis, the physician discusses behavioral changes, including dietary modification and exercise as part of her treatment plan. Which of the following is most likely to result in patient adherence to this plan?
A. Ascertain the patient’s educational level and provide appropriate publications
B. Ask the patient to bring a family member or friend to the next appointment
C. Inform the patient of the health consequences of not treating her condition
D. Provide follow-up appointments to assess the patient’s progress in attaining her goals
E. Refer the patient to a support group
83. A 35-year-old woman comes to the physician because of a 6-month history of generalized pain and swelling of the breasts and pelvic discomfort. This is the patient’s fourth visit to the physician within the past 2 months for the same symptoms. Previous examinations and diagnostic studies have shown no abnormalities. During the history taking, the patient tells the physician that she has sexual fantasies about him. Which of the following is the most appropriate initial action by the physician?
A. Have a chaperone join them for the remainder of the examination
B. Interrupt the patient with a more neutral topic
C. Recommend that the patient seek psychiatric counseling
D. Stop the history taking and then refer the patient to another physician
E. Tell the patient that it is common for patients to fantasize about their physicians
84. A randomized clinical trial is conducted to compare wound healing and cosmetic differences between two surgical procedures for closing skin wounds following cesarean delivery. A total of 500 women undergoing cesarean delivery during a 6-month period are enrolled in the study. A research assistant is assigned to conduct outcome assessments of each participant at 2 weeks and 6 weeks following delivery. Both procedures require the expertise of surgical specialists who cannot be blinded to the procedure. Results show that Procedure A has lower rate of wound infection compared with Procedure B (relative risk of 0.66 with a 95% confidence interval of 0.30 – 1.45); the two procedures also have similar cosmetic results 6 weeks after delivery. Which of the following statements most accurately represents the comparison between Procedure A and Procedure B in a clinical care setting?
A. Neither procedure is superior
B. Procedure A is superior to Procedure B
C. Procedure B is superior to Procedure A
D. The two procedures should not be used in a clinical care setting
85. During a clinical study, an investigator tests a new drug for the treatment of breast cancer. A population of 10,000 patients with breast cancer is recruited and randomized into a treatment group and control group. Analysis of the data shows a p-value of 0.1 and no significant difference in the treatment outcomes between the experimental group and the control group. When repeating this study, which of the following is most likely to decrease the likelihood of making a beta error?
A. Add a second treatment group
B. Conduct the study for a shorter duration
C. Decrease the alpha level
D. Enroll participants with a different type of cancer
E. Increase the sample size
86. A physician prescribes a newly marketed drug to 45 patients. Over the next several weeks, she notes that the drug has good therapeutic efficacy, but it increased serum liver enzyme activities three times the normal value in 5 of the 45 patients. The physician is unable to find any official data linking the new drug with liver dysfunction. Which of the following is the most appropriate action by the physician?
A. Continue the drug in all patients but inform the drug company about the association
B. Discontinue the drug in all patients but study the results again to identify any other possible causes of the abnormal findings
C. Discontinue the new drug in affected patients and file MedWatch reports on the FDA’s Web site
D. Discontinue the new drug in all patients and take no further action
E. Do nothing, since the drug company most likely previously conducted all necessary research
87. A study is conducted to assess the effect of a new screening test on the mortality rate of prostate cancer. Prior to implementation of screening, the overall 5-year survival rate was 70%. After initiating the screening in the randomly selected study population, the 5-year survival rate increases to 85%. During this time, there were no changes in the treatment of prostate cancer. The apparent decrease in mortality could be due to which of the following types of bias?
A. Compliance B. Lead-time C. Recall
D. Selection
88. An investigator is conducting a randomized, double-blind, placebo-controlled clinical trial of a new medication for the treatment of mild insomnia in adults. A total of 2000 participants are enrolled in the study and randomized to one of two groups: 1000 participants receive the new medication (Group 1), and 1000 participants receive a placebo that appears identical to the medication (Group 2). Participants in both groups are instructed to take one pill 30 minutes before bedtime each day and to keep a sleep diary. After 1 month, each participant is interviewed, and the daily sleep diaries are reviewed. At follow-up, it is determined that 200 participants in Group 1 and 50 participants in Group 2 did not take the pill as directed. In accordance with intention-to-treat analysis, how should the data pertaining to all individuals wo did not adhere to the instructions be treated?
A. Analyze all nonadherent participants according to the group of the study to which each was randomized
B. Exclude all nonadherent participants from analysis
C. Exclude only nonadherent participants in Group 1 from analysis
D. Exclude only nonadherent participants in Group 2 from analysis
E. Perform separate analyses of the 250 nonadherent participants and the
89. An investigator is studying patients with West Nile virus infection. During a 5-year period, data are collected on 25 patients diagnosed with this condition as confirmed by testing at the Centers for Disease Control and Prevention. Demographic information on the patients is reported (age, gender, and ethnicity), as well as information about likely sources of infection. Which of the following best describes this study design?
A. Case series
B. Case-control study
C. Cohort study
D. Correlational study
E. Cross-sectional study
90. A 52-year-old man is brought to the physician by a social worker because his neighbors have reported that he has been confused and not taking care of himself. He has a 4-month history of diarrhea. Physical examination shows extreme muscle wasting, stomatitis, and a diffuse rash that is worse in sun-exposed areas. The patient is mildly disoriented and has poor long- term memory and paranoid ideation. Which of the following is the most likely diagnosis?
A. Beriberi
B. Pellagra
C. Scurvy
D. Wernicke syndrome
E. Whipple disease
91. A 50-year-old man who is a college professor has had an increasing cough for 6 months and hemoptysis for 1 week. He has smoked 1 pack of cigarettes per day for the past 32 years. He plays squash twice a week and swims 3 times a week. An x-ray of the chest shows a 3 x 4-cm hilar mass. Cytologic examination of sputum shows non-small cell carcinoma. The physician tells the patient he has lung cancer. The patient responds, “How can this be happening to me? I eat right and exercise.” Which of the following responses by the physician is most appropriate?
A. “Don’t worry. I will be there for you and make sure everything turns out the way you want.”
B. “Eating right and exercising will not help prevent cancer.”
C. “It must be difficult for you to accept this diagnosis when you feel healthy.”
D. “In fact, as you probably know, the major risk for lung cancer is smoking.”
E. “Regardless of your good habits, it’s time to realize that you have lung cancer.”
92. A 17-year-old boy comes to the physician because of an 8-kg (18-lb) weight gain during the past year. He has not had any major illness. He says that he does not eat excessively and has a moderate level of activity, including playing golf. His father and paternal uncles are all overweight. He is 178 cm (5 ft 10 in) tall and weighs 102 kg (224 lb); BMI is 32 kg/m2. When the physician finishes examining the patient, the patient asks, “Do you think that my weight gain is inherited from my father?” Which of the following is the most appropriate initial response by the physician?
A. “No, it’s because you’re eating wrong kinds of food.”
B. “No, let’s examine your environment more closely, as your paternal history is only incidental to your weight gain.”
C. “No, unfortunately it’s because you’re eating too much.”
D. “Yes, your paternal family history is the major contributing factor to your weight gain.”
E. “Yes, your weight gain can be caused by genes and environment combined.”
93. A 38-year-old man with a 3-year history of type 2 diabetes mellitus comes to the physician for a follow-up examination. In addition to taking an oral antihyperglycemic agent, he has tried controlling his condition with diet modifications and exercise. He is 188 cm (6 ft 2 in) tall and weighs 113 kg (250 lb); BMI is 32 kg/m2. Physical examination shows no other abnormalities. His hemoglobin A1C is 10%. The physician recommends
initiation of insulin injections to obtain better control over the patient’s blood glucose concentration. The patient responds, “I know that insulin would help control my blood sugar. But a lot of people in my family have diabetes, and insulin made them really sick at times.” This patient is most likely at which of the following stages of change regarding insulin administration?
A. Precontemplation B. Contemplation
C. Preparation
D. Action
E. Maintenance
94. A 27-year-old man comes to the physician for an examination before starting employment at a plastics factory. He has no history of major medical illness. He has never been sexually active. He has minimal contact with his parents and siblings and has no hobbies. When asked if he feels depressed, he says no. He shrugs in response to congratulations about his new job. Physical examination shows a flat affect. This patient most likely has which of the following types of personality disorders?
A. Antisocial
B. Avoidant
C. Borderline D. Schizoid
E. Schizotypal
95. A 47-year-old woman with psoriasis comes to the physician for follow-up care. At her last appointment she was given several topical creams, which must be used in a specified sequence twice daily. No improvement is apparent at this appointment. Which of the following is the most appropriate way for the physician to begin the discussion of this patient’s compliance with therapy?
A. “Did you use the creams twice daily?”
B. “How many tubes did you use in the last month?”
C. “How often did you skip treatments?”
D. “Most people find it difficult to sticks to a routine. How did you do?”
E. “Using something twice daily can be difficult. I assume you are like most patients who miss at least 10% of treatments.”
96. A 68-year-old man is asked to give informed consent for a herniorrhaphy. The surgeon gives the patient information about the risks and benefits of the procedure, says that the procedure resolves symptoms in more than 95% of patients, and tells the patient he has done more than 100 of these procedures. He tells the patient that he will need to pay for a portion of the cost of hospitalization. The patient says that he understands what he has been told, that he is willing to have the operation, and that his family will be available to discuss the procedure later in the day. In this patient, which combination of components fulfill the criteria for fully informed consent?
A. Family agreement, competence, cost
B. Family agreement, cost, reliability
C. Information, competence, voluntariness
D. Information, validity, cost
E. Validity, voluntariness, reliability
97. A girl is brought to the physician for a well-child examination. Her normal development includes using a pincer grasp, finder feeding, standing while holding onto a table, and playing peekaboo. Which of the following best represents this patient’s age (in months)?
A. 3 B. 9 C. 15 D. 21 E. 27
98. A 14-year-old boy is brought to the physician by his mother because of daily headaches for 2 months. The headaches are described as a bilateral aching in the temples. His mother states that he also “has not been himself” for the past few months. He seems more confused, often forgetting names, dates, and places, and he is clumsy with frequent falls. His school performance also has declined over the past quarter. Physical examination shows a broad-based, ataxic gait. He is alert and oriented to person, place, and time, but he is slow to answer questions. Chronic abuse of which of the following substances is the most likely cause of this patient’s condition?
A. Cocaine
B. Ethanol
C. Inhaled glue
D. Methamphetamines
E. PCP (phencyclidine)
99. A 43-year-old woman comes to the physician for a routine health maintenance examination. The physician is 30 minutes late for the appointment because of an emergency, and when he enters the examining room, the patient checks her watch. Which of the following initial statements by the physician is most appropriate?
A. “I apologize for being behind schedule, but this won’t take long.”
B. “I apologize for being late. Why don’t we reschedule for another
time?”
C. “I apologize for running behind. They made my schedule really tight today.”
D. “I’m sorry I got delayed. I hope I haven’t made you late somewhere else.”
E. ”I’m sorry I got tied up. The emergency room always seems to call me for their most difficult cases.”
100. A physician is sad because he has to inform a patient of recent test results that indicate progression of carcinoma to the terminal phase. When the patient sees the physician’s face, he begins to cry and says, “It’s bad news, isn’t it?” Which of the following responses by the physician is most appropriate?
A. “How have you been since the last time I saw you?”
B. “Let’s talk about the positive aspects first.”
C. “Look on the bright side of things.”
D. “Tell me how you are feeling.”
E. “There are other people who have it a lot worse than you.”
F. “Yes, it is.”
G. “You’ve had several years better off than many others with this disease.”
101. a 55-year-old woman comes to the physician because of a 6-week history of low energy, irritability, and crying spells. She has difficulty falling asleep and wakes up frequently at night. Her work as a bookkeeper has been affected because she cannot focus. She has not been attending church or her bridge club. She has been taking lorazepam for 15 years for generalized anxiety disorder. She has had postmenopausal symptoms for 1 year successfully treated with estrogen replacement therapy. Her temperature is 37°C (98.6 °F), pulse is 82/min, and blood pressure is 120/76 mmHg. Physical examination and laboratory studies show no abnormalities. Mental status examination shows a constricted affect. She describes her mood as “testy.” Her speech is slightly slowed. There is no evidence of psychosis. She says she wishes that she “wouldn’t wake up some days” but does not have any intent or plan to harm herself. Which of the following is the most likely cause of this patient’s symptoms?
A. Estrogen toxicity
B. Generalized anxiety disorder
C. Lorazepam toxicity
D. Major depressive disorder
102. A previously healthy 35-year-old man has become increasingly depressed, impulsive, and difficult over the past year. He grimaces intermittently and has rigid, jerking, purposeless movements of the fingers. Which of the following historical factors is most relevant in establishing a diagnosis?
A. Dietary deficiency
B. Exposure to environmental toxins
C. Family history of similar illness
D. Pet with an unexplained illness
E. Tick bite
F. Travel to a foreign country
103. a 15-year-old girl comes to the physician’s office for a health maintenance examination. Her mother was recently diagnosed with squamous cell carcinoma of the face, and her maternal grandfather died of metastatic melanoma. During the visit, the physician advises her about methods of photoprotection, including daily use of a sunscreen. In a patient of this age, which of the following factors is most likely to predict compliance with photoprotection?
A. Ability to tan
B. Advice of the physician to wear sunscreen
C. Concern about premature aging of skin
D. Desire to prevent sunburn
E. Family history of skin cancer
F. Use of sunscreen by her peers
104. a 35-year-old man who uses crack cocaine daily comes to the emergency department because of a 2-hour history of substernal chest pain. He last used cocaine 6 hours ago. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 14/min, and blood pressure is 160/100 mmHg. Which of the following is the most appropriate next step in patient care?
A. Admit the patient to the hospital for cocaine detoxification
B. Admit the patient to the hospital for possible myocardial ischemia
C. Educate the patient about the risks of cocaine use and send the patient home
D. Transfer the patient to a psychiatric facility
105. A 26-year-old woman comes to the physician 5 weeks after the birth of her first child. She worries constantly that the infant is ill and wakes him 10 to 14 times every night to make sure he is well. She has had no crying spells or problems with appetite. She is worried that she will infect the infant with her germs and washes her own hands 30 times per day. For 2 months prior to the delivery, she worried about people breaking into her house and checked the lock on the front door three to four times every night. She is not breast-feeding. Which of the following is the most appropriate pharmacotherapy?
A. Alprazolam
B. Haloperidol
C. Lithium carbonate
D. Methylphenidate
E. Phenelzine
F. Sertraline
106. A 65-year-old woman is being treated in the hospital for widely metastatic breast cancer unresponsive to chemotherapy. She has never married and has no children or siblings. Throughout her illness, another woman she had introduced as “my close friend,” has been with her during hospitalizations and office visits. The patient is moved to an inpatient hospice after she decides she wants no further curative therapy. She and her friend appear very distressed when they read a sign outside the hospice unit that states only family members are permitted to stay after visiting hours. Her friend says, “We can’t bear to be apart. It would be cruel to separate us now.” Which of the following responses by the physician is most appropriate?
A. “Don’t worry. I’ll call you right away if something happens to your friend. Just leave your number with the nurses.”
B. “I’m sorry, but only family is allowed to stay with patients in the hospital. You will have to leave after your 15 minutes are up.”
C. “The two of you seem to have a very important relationship. Of course you may stay together.”
D. “Visiting hours are posted outside. You are welcome during any of those times. I’m sorry, but an exception cannot be made in your case.”
E. “Well, I guess we could bend the rules this time, but if anyone asks, you’re her sister. Does that sound OK?”
107. A 63-year-old woman is brought to the emergency department because of a 2-day history of fever, abdominal tenderness, and painful urination. She appears agitated. Her temperature is 38.8°C (101.8°F). Laboratory studies show a leukocyte count of 14,000/mm3. she is admitted to the hospital. Two hours later, the nurses note that she has torn up four breakfast menus because she found them to be too confusing. She is highly educated, and her husband says that she does not behave this way at home. Which of the following is the most likely cause of this patient’s current mental status?
A. Amnesia
B. Delirium
C. Dementia
D. Mild cognitive impairment
E. Occult cerebral infarction
108. A randomized controlled study of 2000 patients with insomnia is conducted to evaluate the efficacy of a new medication to treat this condition. Ten subjects from both the control and treatment groups do not complete the study and are not included in the analysis. Study subjects in the treatment group are able to fall asleep an average of 5 minutes faster than study subjects in the control group. The difference is statistically significant (p=0.001). Subjects in neither group report an improvement in quality of life. The investigators conclude that the new medication is efficacious in treating insomnia. These findings are most likely an example of which of the following types of error?
A. Exclusion of subjects who did not have an expected response to the medication
B. Failure to distinguish between statistical significance and clinical significance
C. Failure to find a clinically significant result due to the attrition of subjects
D. Failure to reject a null hypothesis when it is not true
E. Rejecting a null hypothesis when it is true
109. In an epidemiologic study of workers in the aniline dye industry, 500 workers with bladder cancer and 200 workers without bladder cancer are selected. The investigators ask both groups past exposure to aniline dye.
Results are shown in the table:
Yes No
Bladder Cancer
Yes No
Exposur e to Aniline Dyes
250 250 500
50 300 150 400 200 700
Which of the following is the odds ratio for the exposure variable?
A. 0.33 B. 0.5 C. 1
D. 1.5 E. 2
F. 3
110. A study is designed to evaluate the efficacy of coenzyme Q10 in improving cardiac output in patients with congestive heart failure (CHF). Sixty patients with CHF are recruited for the study. Each subject is assigned by coin toss to one of two groups (standard care or standard care plus coenzyme Q10). Which of the following best describes this study design?
A. Case-control
B. Case series
C. Crossover
D. Cross-sectional
E. Historical cohort
F. Randomized clinical trial
111. An 80-year-old woman is being evaluated for suspected temporal arteritis (TA). Her erythrocyte sedimentation rate (ESR) is 100 mm/h. Treatment of TA involves the use of glucocorticoids, which could have serious adverse effects. The pretest probability for TA is 50% in this patient. In the evaluation of TA, ESR testing in this patient, which of the following is the most appropriate next step in management?
A. Additional testing to confirm the diagnosis of TA
B. Corticosteroid therapy, since the diagnosis of TA has been established with 99% certainty
C. Elimination of TA from further diagnostic consideration
D. Repeat ESR; if again positive, corticosteroid therapy
E. Repeat ESR; if normal, additional testing to confirm the diagnosis of TA
112. An investigator wishes to conduct a study of the development of breast cancer in women. Seven hundred healthy women will be observed for 10 years. Complete family histories will be obtained from each volunteer. The goal of the study is to determine if the number of family members who previously received diagnosis of breast cancer correlates with the incidence of the future development of breast cancer in this population. Which of the following designs is most appropriate for this study?
A. Case series
B. Cohort
C. Crossover
D. Cross-sectional
E. Randomized controlled
113. A study is conducted to assess the effectiveness of injections of lidocaine into “trigger points” of pain symptoms in patients with fibromyalgia. Fifty patients are randomly assigned to biweekly trigger-point injections with 0.9% saline only or 0.9% saline plus lidocaine. The graph shows daily self-reported pain scores in relation to the injections. Which of the following is the most likely explanation for these findings?
A. Placebo effect
B. Regression to the mean
C. Selection bias
D. Type II error
E. Uncontrolled confounding
114. An examination is scaled so that the scores are approximately normally distributed with a mean of 500 and a standard deviation of 100. Which of the following is the percentage of examinees with scores between 400 and 600?
A. 16%
B. 50%
C. 67%
D. 90%
E. 95%
115. Ten healthy human subjects are given a new drug and monitored for drug effect and toxicity. Blood samples are periodically taken and analyzed to define the human pharmacokinetics of the drug for the first time. Which of the following best describes this trial?
A. Preclinical testing
B. Phase 1
C. Phase 2
D. Phase 3
E. Phase 4
116. In a survey of 100 households (average three residents per household), 45 individuals with asthma are detected. Which of the following is the best estimate of the prevalence of asthma?
A. 15%
B. 20% C. 30% D. 40% E. 45%