1. Stem: A 20-year-old nulliparous female presents for routine screening labs. Her past
medical history is significant for hypothyroidism and migraine headaches. She denies
vision disturbance, neck pain, a history of head trauma, or changes to her lifestyle. She
is taking sumatriptan for abortive migraine therapy, levothyroxine for hypothyroidism,
and combination oral contraceptives for family planning. Review of her past vitals are
significant for high blood pressure. Today she is asymptomatic, and her vitals
demonstrate a weight of 180 lbs., height of 64 inches, blood pressure of 162/90, pulse
at 90 bpm, and respirations of 16. Given this scenario, what is the most likely
explanation for her hypertension?
Answer choice:
A.
B.
C.
D.
E.
Essential hypertension
Malignant hypertension
Resistant hypertension
Secondary hypertension
Hypertensive urgency
Answer: The answer is D.
Explanation: Approximately 5% of patients with hypertension have hypertension secondary to
identifiable causes (D). It is most commonly noted among those less than 20 years or new-onset in those
over 50 years of age. It can be attributed to genetic causes, renal diseases, hyperaldosteronism, Cushing
syndrome, pheochromocytoma, coarctation of the aorta, pregnancy, thyroid or parathyroid disease, and
estrogen use. This patient is young, is taking oral contraceptives containing estrogen, and has a thyroid
disorder, making her more likely to have secondary hypertension. Though essential hypertension (A) is
the most common cause, it is usually seen in those ages 25–50 years. Malignant hypertension (B) and
hypertensive urgency (E) would require concomitant symptoms evidencing target organ damage and
she is not taking or failing 3 or more anti-hypertensive medications, which would be seen in resistant
hypertension (C).
References:
Sutters M. Systemic Hypertension. In: Papadakis M & McPhee S, eds. Current Medical Diagnosis &
Treatment 2017. San Francisco, CA: McGraw-Hill Education; 2017:441-443.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Hypertension, Secondary Hypertension
2. Stem: A 23-year-old Caucasian female presents to the clinic with fatigue and brittle
nails. She has a past history of menorrhagia. Laboratory studies indicate her hemoglobin
is below normal levels. Based on the most likely diagnosis, which of the following would
be the most appropriate medication to prescribe?
Answer Choice:
A.
B.
C.
D.
E.
Levofloxacin (Levaquin)
Oral iron
Indomethacin
Sumatriptan
Fluoxetine
Answer: The answer is B.
Explanation: Oral iron prescriptions are often given in the presence of iron deficiency, which often
presents as anemia. The primary symptoms of iron deficiency anemia are those of the anemia itself
(easy fatigability, tachycardia, palpitations, and dyspnea on exertion). Severe deficiency causes skin and
mucosal changes, including a smooth tongue, brittle nails, spooning of nails (koilonychia), and cheilosis.
Many iron-deficient patients develop pica, craving for specific foods (ice chips, etc.) often not rich in
iron. The most common cause of iron deficiency anemia in adults is chronic blood loss, most commonly
due to GI bleeding or heavy menstrual bleeding (B). Levofloxacin is a broad-spectrum antibiotic from the
drug class quinolones and is typically used for bacterial infections (A). Indomethacin is from the drug
class nonsteroidal anti-inflammatory drugs (NSAIDs) and is typically used for inflammatory conditions
(C). Sumatriptan is from the drug class triptans and is most often used for acute migraine headaches (D).
Fluoxetine is from the drug class selective serotonin reuptake inhibitors (SSRIs) and is indicated for a
variety of medical conditions. Some common uses include major depressive disorder and generalized
anxiety disorder (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Hematologic
Task Area: Pharmaceutical Therapeutics
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine, Pediatrics
Topic(s): Cytopenias, Anemia
3. Stem: A 40-year-old male presents to the clinic with a swollen and exquisitely tender
left great toe. Inspection reveals the overlying skin of the left great toe as tense, warm,
and dusky red. He admits to a past social history significant for excessive alcohol use.
Based on the most likely diagnosis, which of the following would be the most
appropriate medication to prescribe?
Answer Choice:
A.
B.
C.
D.
E.
Levofloxacin (Levaquin)
Oral iron
Indomethacin
Sumatriptan
Fluoxetine
Answer: The answer is C.
Explanation: This patient likely has gouty arthritis. Indomethacin is from the drug class nonsteroidal
anti-inflammatory drugs (NSAIDs) and is typically used for inflammatory conditions, such as Gout. Gout
is a metabolic disease with abnormal deposits of urate in tissues and characterized initially by a
recurring acute arthritis, usually monarticular, and later by chronic deforming arthritis. The MTP joint of
the great toe is the most susceptible joint (“podagra”), although others, especially those of the feet,
ankles, and knees, are commonly affected. The involved joints are swollen and exquisitely tender and
the overlying skin tense, warm, and dusky red. Common precipitants are alcohol excess (particularly
beer), changes in medications that affect urate metabolism, and, in the hospitalized patient, fasting
before medical procedures (C). Levofloxacin is a broad-spectrum antibiotic from the drug class
quinolones and is typically used for bacterial infections (A). Oral iron prescriptions are often given in the
presence of iron deficiency, which often presents as anemia. Iron is an essential component of the
hemoglobin structure (B). Sumatriptan is from the drug class triptans and is most often used for acute
migraine headaches (D). Fluoxetine is from the drug class selective serotonin reuptake inhibitors (SSRIs)
and is indicated for a variety of medical conditions. Some common uses include major depressive
disorder and generalized anxiety disorder (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Musculoskeletal
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Rheumatologic disorders, Gout
4. Stem: A female adult patient presents to the clinic with concerns of episodic, lateralized,
throbbing headaches with associated symptoms of nausea, vomiting, and pain with
light. Her headaches typically occur when she has a lack of sleep or consumes chocolate.
These headaches began early in her adult life, but she is now interested in taking
medication when the headaches occur. Based on the most likely diagnosis, which of the
following would be the most appropriate medication to prescribe for acute symptoms?
Answer Choice:
A.
B.
C.
D.
E.
Levofloxacin (Levaquin)
Oral iron
Topiramate
Sumatriptan
Fluoxetine
Answer: The answer is D.
Explanation: Typical migrainous headache is a lateralized throbbing headache that occurs episodically
following its onset in adolescence or early adult life. In many cases, the headaches do not conform to
this pattern. In this broader sense, migrainous headaches may be lateralized or generalized, may be dull
or throbbing, and are sometimes associated with anorexia, nausea, vomiting, photophobia,
phonophobia, osmophobia, cognitive impairment, and blurring of vision. Focal disturbances of
neurologic function (migraine aura) may precede or accompany the headaches. Visual disturbances
occur commonly and may consist of field defects (scotoma); of luminous visual hallucinations such as
stars, sparks, unformed light flashes (photopsia), geometric patterns, or zigzags of light; or of some
combination of field defects and luminous hallucinations (scintillating scotomas). Attacks may be
triggered by emotional or physical stress, lack or excess of sleep, missed meals, specific foods (e.g.,
chocolate), alcoholic beverages, bright lights, loud noise, menstruation, or use of oral contraceptives.
Sumatriptan is from the drug class triptans and is most often used for acute migraine headaches (D).
Levofloxacin is a broad-spectrum antibiotic from the drug class quinolones and is typically used for
bacterial infections (A). Oral iron prescriptions are often given in the presence of iron deficiency, which
often presents as anemia. Iron is an essential component of the hemoglobin structure (B). Topiramate is
a medication used for preventative purposes in relationship to migraine headaches but is not effective
for acute symptoms (C). Fluoxetine is from the drug class selective serotonin reuptake inhibitors (SSRIs)
and is indicated for a variety of medical conditions. Some common uses include major depressive
disorder and generalized anxiety disorder (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Neurologic System
Task Area: Pharmaceutical Therapeutics
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine
Topic(s): Headaches, Migraine
5. Stem: You are performing a routine physical on a 42-year-old female patient who
reports that she has a history of superficial spreading melanoma diagnosed 8 years ago.
It was excised with wide local excision. What is the most important component of
secondary prevention for this patient?
Answer choice:
a.
b.
c.
d.
e.
Annual history and physical exam
CT scan every 5 years
Lymph node biopsy
Regular CBC
Sun safe behavior
Answer: The answer is E.
Explanation: There are no clear recommendations for monitoring of asymptomatic patients. Although a
routine skin exam (A) is important, the most important primary prevention of other skin cancers is sun
safe behavior (E) (avoiding tanning beds, wearing sun protective clothing, using sun screen). CBC (D), CT
(B), and lymph node biopsy (C) would be used to stage more invasive melanomas.
References:
Swanson DL. Nevi and Melanoma. In: Soutor C, Hordinsky MK, eds. Clinical Dermatology. New York, NY:
McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2184&sectionid=165460425.
Accessed January 31, 2018.
Organ System: Dermatologic
Task Area: Health Maintenance
Core Rotation: Family Medicine
Topic(s): Neoplasms, Melanoma
6. Stem: An adult patient presents to the clinic with symptoms of loss of interest and
pleasure, withdrawal from activities, and feelings of guilt. She is also experiencing the
inability to concentrate, some cognitive dysfunction, chronic fatigue, and feelings of
worthlessness. She states this all began over a month ago when she lost her
employment. She is interested in starting a medication to help her with her symptoms.
Based on the most likely diagnosis, which of the following would be the most
appropriate medication to prescribe?
Answer Choice:
A.
B.
C.
D.
E.
Doxycycline
Oral iron
Indomethacin
Sumatriptan
Fluoxetine
Answer: The answer is E.
Explanation: A major depressive disorder consists of a syndrome of mood, physical, and cognitive
symptoms that occurs at any time of life. Complaints vary widely but most frequently include a loss of
interest and pleasure (anhedonia), withdrawal from activities, and feelings of guilt. Also included are the
inability to concentrate, some cognitive dysfunction, anxiety, chronic fatigue, feelings of worthlessness,
somatic complaints (unexplained somatic complaints frequently indicate depression), loss of sexual
drive, and thoughts of death. Unemployment has been associated with an increase in depression risk.
Diurnal variation with improvement as the day progresses is common. Vegetative signs that frequently
occur are insomnia, anorexia with weight loss, and constipation. Fluoxetine is from the drug class
selective serotonin reuptake inhibitors (SSRIs) and is indicated for a variety of medical conditions. Some
common uses include major depressive disorder and generalized anxiety disorder (E). Doxycycline is an
antibiotic from the drug class tetracyclines and is typically used for bacterial infections (A). Oral iron
prescriptions are often given in the presence of iron deficiency, which often presents as anemia. Iron is
an essential component of the hemoglobin structure (B). Indomethacin is from the drug class
nonsteroidal anti-inflammatory drugs (NSAIDs) and is typically used for inflammatory conditions (C).
Sumatriptan is from the drug class triptans and is most often used for acute migraine headaches (D).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Psychiatry/Behavioral
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Depressive disorders, Major depressive disorder
7. Stem: A confused patient presents to the emergency room with a blood pressure of
240/140. She is asymptomatic for dyspnea, chest pain, and vision or sensory
disturbance. A urinalysis demonstrates proteinuria and hematuria. What is the proper
blood pressure management goal?
Answer choice:
A.
B.
C.
D.
E.
130/80 in 24 hours
140/90 in 2 hours or less
160/100 in 24 hours
180/105 in 2 hours or less
130/80 in 2 hours or less
Answer: The answer is D.
Explanation: This is a depiction of hypertensive emergency, defined as having symptomatic elevations in
diastolic blood pressure, usually greater than 130 mm Hg. When it is associated with evidence of
multiple target organ damage, such as confusion (hypertensive encephalopathy) and/or hematuria
(hypertensive nephropathy), this demonstrates a more critical scenario (as seen in malignant
hypertension) warranting immediate intervention. The initial goal for reducing blood pressure in
hypertensive emergencies is to reduce pressure by no more than 25% within minutes to 2 hours (D). All
other options are too low and/or too slow (A, B, C, and E). If pressure is reduced by more than 25%,
there is increased risk of inducing cerebral, coronary, or renal ischemia.
References:
Sutters M. Systemic Hypertension. In: Papadakis M & McPhee S, eds. Current Medical Diagnosis &
Treatment 2017. San Francisco, CA: McGraw-Hill Education; 2017:468.
Organ System: Cardiovascular
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Hypertension
8. Stem: A 28-year-old female requests a second evaluation for frequent diarrhea and
abdominal pain over the last six months. She denies changes in her diet, fever, weight
loss, hematochezia, or recent foreign travel. She reports that a previous evaluation
“couldn’t find anything.” She describes her pain as intermittent cramps relieved by
defecation. She also notes bloating, periods of flatus, and constipation. Reportedly, her
stool occasionally contains mucus. The abdominal and rectal examination is normal. Her
stool was guaiac negative. This presentation is most consistent with which disorder?
Answer choice:
A.
B.
C.
D.
E.
Diverticulosis
Anorectal fistula
Crohn disease
Ulcerative colitis
Irritable bowel syndrome
Answer: The answer is E.
Explanation: Irritable bowel syndrome is characterized by intermittent abdominal pain and cramping
often relieved by defecation, alternating diarrhea and constipation, bloating, and increased gas (E).
There is no associated inflammation of the bowel. Diverticulosis is often clinically silent unless there is
associated inflammation, causing classically left lower quadrant abdominal pain (A). Anorectal fistulas
often cause discharge and may be a result of perianal abscess or associated with Crohn disease or
diverticulosis (B). Crohn disease and ulcerative colitis are diseases that cause inflammation and produce
rectal bleeding (C and D).
References:
Cunha JP. Irritable Bowel Syndrome.
https://www.medicinenet.com/irritable_bowel_syndrome_ibs/article.htm#irritable_bowel_syndrome_i
bs_definition_and_facts. Accessed September 22, 2017.
Ansari P. Anorectal Fistula. http://www.merckmanuals.com/professional/gastrointestinaldisorders/anorectal-disorders/anorectal-fistula. Accessed October 2016.
Organ System: Gastrointestinal/Nutritional
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Colorectal Disorders, Irritable Bowel Syndrome
9. Stem: You are evaluating a 4-year-old male who presents with right eye hyperemia
accompanied by thick, yellowish discharge, which is causing his eyelashes to be sticky
upon waking. Visual acuity is intact. His mother reports that he is in daycare and has not
had any respiratory symptoms. What is the best treatment?
Answer choice:
a. Azithromycin 1% ophthalmic solution, one drop in the affected eye twice daily for three
days
b. Cyclosporine 0.05% ophthalmic emulsion, one drop to the affected eye daily for seven
days
c. Levofloxacin ophthalmic solution 0.5%, one drop to the affected eye every two hours
while awake for two days
d. Polymyxin B/trimethoprim ophthalmic solution, one drop to the affected eye four times
daily for seven days
e. Trifluridine ophthalmic solution 1%, 1 drop to the affected eye every two hours while
awake for seven days
Answer: The answer is A.
Explanation: This child is exhibiting signs and symptoms consistent with bacterial conjunctivitis. Since he
is under age 6, he is at higher likelihood of developing bacterial conjunctivitis. Azithromycin (A) is
efficacious and the easiest to dose, being twice daily for only three days. Cyclosporine (B) is used for dry
eye, but not conjunctivitis. Levofloxacin (C), while potentially effective, has to be given every two hours
would be very difficult for a parent to administer. Polymyxin B/trimethoprim (D) is dosed four times
daily for seven days, likely requiring a note to have it administered at daycare once the child is no longer
considered contagious. Trifluridine (E) is an anti-viral, so not appropriate in this case.
References:
Chapter 16. Conjunctivitis. In: Usatine RP, Smith MA, Chumley HS, Mayeaux EJ, Jr. eds. The Color Atlas of
Family Medicine, 2e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=685&sectionid=45361051. Accessed
January 31, 2018.
Garcia-Ferrer FJ, Augsburger JJ, Corrêa ZM. Conjunctiva & Tears. In: Riordan-Eva P, Augsburger JJ. eds.
Vaughan & Asbury's General Ophthalmology, 19e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2186&sectionid=165516586. Accessed
January 31, 2018.
Organ System: EENT
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine; Pediatrics
Topic(s): Eye Disorders, Conjunctival disorders, Conjunctivitis
10. Stem: You are evaluating a 13-year-old boy for the chief complaint of headaches. Upon
further questioning, he admits that he has grown 6 inches in the past year. His parents
are average height and he is now 6’ 5” tall. He also is embarrassed to reveal that he has
noted galactorrhea for the past several months. Random serum IGF-1 is six times
normal. What is the imaging test of choice for this patient?
Answer choice:
a.
b.
c.
d.
e.
Chest x-ray
CT scan of the adrenal glands
MRI of the head
Plain films of the skull
Ultrasound of the thyroid gland
Answer: The answer is C.
Explanation: This patient has gigantism caused by a pituitary tumor. The tumor causes excess growth
hormone secretion, which is characterized by a sudden growth spurt, headaches, and galactorrhea. An
MRI of the head (C) will allow for diagnosis of the tumor, and it will help assess for appropriateness of
trans-sphenoidal resection of the tumor. A chest x-ray (A) would produce low yield of any significant
disease pattern for these symptoms, as would plain films of the skull (D), which would give information
to abnormal calcium growth and potential frontal bossing. CT scan of the adrenals (B) would not
produce adequate information for this clinical situation, and thus is not the best choice. Thyroid
disorders would not produce an abnormal growth pattern as described in this clinical case, so an
ultrasound of the thyroid (E) would be less helpful.
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical
Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=167996562. Accessed
January 31, 2018.
Organ System: Endocrine
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Pituitary Disorders, Acromegaly, Gigantism
11. Stem: A 28-year-old female presents to the Emergency Department with acute onset of
epigastric pain that radiates to the back, nausea, and vomiting. Vital signs include BP
98/60, pulse of 110 and regular, RR 24 and slightly labored, pulse oxygen level is 94% on
room air, and temperature is 33 °C. Amylase and lipase are both markedly elevated.
While awaiting the results of CT scan of the abdomen, what is the most important initial
clinical intervention?
Answer choice:
a.
b.
c.
d.
e.
Bowel rest
Enteral feeding
Intubation with mechanical ventilation
IV hydration
Supplemental oxygen
Answer: The answer is D.
Explanation: This patient exhibits SIRS criteria, which is most likely due to acute pancreatitis. Regardless
of the CT scan results, the most important initial intervention is aggressive IV hydration (D). Bowel rest
(A) is also part of treatment, as are enteral feedings (B), but they are not the most important initial
intervention. Supplemental oxygen administration (E) would be important if the patient was exhibiting
signs of hypoxia. Intubation (C) would be appropriate if the patient was showing signs of respiratory
failure. This patient is tachypneic, but there is nothing to indicate impending respiratory failure.
References:
Conwell DL, Banks PA. Acute Pancreatitis. In: Greenberger NJ, Blumberg RS, Burakoff R, eds. CURRENT
Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy, 3e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1621&sectionid=105184675. Accessed
January 31, 2018.
Organ System: Gastrointestinal/Nutritional
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine, Internal Medicine, Surgery
Topic(s): Pancreatic disorders, Acute Pancreatitis
12. Stem: A 22-year-old male presents to the clinic with new onset myalgias, headache, and
fatigue. He said this started soon after he returned from a camping trip. Further
examination revealed a rash with a “bulls-eye” appearance. Based on the most likely
diagnosis, which of the following would be the most appropriate medication to
prescribe for acute symptoms?
Answer Choice:
A.
B.
C.
D.
E.
Doxycycline
Oral iron
Topiramate
Sumatriptan
Fluoxetine
Answer: The answer is A.
Explanation: Lyme disease is the most common tick-borne disease in the United States and Europe and
is caused by genospecies of the spirochete B. burgdorferi. Stage 1 infection is characterized by erythema
migrans. About 1 week after the tick bite (range 3–30 days; median 7–10 days), a flat or slightly raised
red lesion appears at the site, which is commonly seen in areas of tight clothing such as the groin, thigh,
or axilla described as a lesion that progresses with central clearing (“bulls-eye” lesion). Most patients
with erythema migrans will have a concomitant viral-like illness (the “summer flu”) characterized by
myalgias, arthralgias, headache, and fatigue. Fever may or may not be present. The tetracycline drug
class is effective against the spirochete with doxycycline being the most commonly used (A). Oral iron
prescriptions are often given in the presence of iron deficiency, which often presents as anemia. Iron is
an essential component of the hemoglobin structure (B). Indomethacin is from the drug class
nonsteroidal anti-inflammatory drugs (NSAIDs) and is typically used for inflammatory conditions (C).
Sumatriptan is from the drug class triptans and is most often used for acute migraine headaches (D).
Fluoxetine is from the drug class selective serotonin reuptake inhibitors (SSRIs) and is indicated for a
variety of medical conditions. Some common uses include major depressive disorder and generalized
anxiety disorder (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Infectious Diseases
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal Medicine, Pediatrics
Topic(s): Lyme Disease
13. Stem: A 40-year-old female with an unremarkable medical history complains of
progressive sleep disturbance and changes in urination habits. The patient describes
urinary frequency night and day, and reports having intermittent bladder pain that is
relieved by urination. After ruling out infectious and neuroendocrine causes, she
requests symptomatic management. Which treatment option would be considered first
line medical therapy for her condition?
Answer choice:
A.
B.
C.
D.
E.
Amitriptyline
Hydrodistention
Sitz baths
Trimethoprim-sulfamethoxazole
Surgery
Answer: The answer is A.
Explanation: Amitriptyline is often used as a first line medical therapy in those with interstitial cystitis as
central and peripheral mechanisms may contribute to its activity (A). In this scenario, the patient’s sleep
disturbance may also benefit indirectly from the amitriptyline (off-label use for insomnia) as well.
Hydrodistention may be an option in some as it can provide useful diagnostic information and
symptomatic relief in approximately 20–30% of patients (B). Sitz baths won’t provide pre-voiding pain
(C). Trimethoprim-sulfamethoxazole has no indication for use as there is no evidence of infection (D).
Surgery is considered a last option (E).
References:
Meng MV, Walsh TJ, Chi TD. Urologic Disorders. In: Papadakis M & McPhee S, eds. Current Medical
Diagnosis & Treatment 2018. San Francisco, CA: McGraw-Hill Education; 2018:970.
Organ System: Genitourinary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Infectious Disorders, Cystitis
14. Stem: A 45-year-old female is brought to the ED via EMS after a syncopal episode. PMH
includes HTN treated with hydrochlorothiazide 50 mg daily. She reports she was
recently treated with clarithromycin for a respiratory illness. As you are evaluating her,
the cardiac monitor alarms and she becomes unconscious. You note polymorphic
ventricular tachycardia with a twisting-on-point appearance. You immediately
defibrillate the patient with success. What is the medication of choice for the
management of this condition?
Answer choice:
a.
b.
c.
d.
e.
Amiodarone
Lidocaine
Magnesium
Procainamide
Sotalol
Answer: The answer is C.
Explanation: This patient is a female on diuretic therapy and macrolide antibiotic treatment, which
places her at risk for acquired long QT syndrome and subsequent polymorphic ventricular tachycardia
(Torsades de Pointes). The management of patients presenting with a resuscitated VF arrest is aimed at
determining its cause and treating potential recurrence. Although the immediate treatment is
cardioversion or defibrillation, magnesium (C) is the medication of choice to suppress recurrent episodes
until the reversible causes have been addressed. Sotolol (E) has identified as a cause of long QT due to
blockage of potassium channels. Amiodarone (A), Lidocaine (B), and Procainamide (D) would potentially
treat the ventricular tachycardia, but not prevent further episodes, and are therefore not the treatment
of choice.
References:
Buckley II C, Garcia B. Cardiac Arrhythmias. In: Stone C, Humphries RL. eds. CURRENT Diagnosis &
Treatment: Emergency Medicine, 8e New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165064676. Accessed
January 31, 2018.
John RM, Stevenson WG. Ventricular Arrhythmias. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J,
Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=7974232. Accessed
January 31, 2018.
Organ System: Cardiovascular
Task Area: Pharmaceutical Therapeutics
Core Rotation: Emergency Medicine
Topic(s): Conduction Disorders/Dysrhythmias, Torsades de Pointes
15. Stem: A 60-year-old G5P5 woman has uterine procidentia. Which of the following
statements most accurately describes her condition?
Answer choice:
a.
b.
c.
d.
Decent of the cervix is seen halfway to the hymen
Decent of the cervix is seen at the level of the hymen
Herniation of intestines has occurred through the vaginal introitus
Herniation of three pelvic compartments through the vaginal introitus
e. Stage II pelvic organ prolapse
Answer: The answer is D
Explanation: Uterine procidentia is the most severe form of pelvic organ prolapse where there is
complete uterine prolapse and the cervix is beyond the vaginal outlet (introitus). It results from an
anterior, posterior, and apical compartment prolapse. Answer choices A, B, and E are incorrect because
the decent of the cervix remains in the vagina. Furthermore, A and B are descriptions of the old Pelvic
Organ Prolapse diagnostic system (terms Braden-Walker system) which lacks the precision compared to
the current standard “POP-Q” system. Answer choice C describes an enterocele.
References:
Hundley A F. Pelvic Support Defects, Urinary Incontinence, and Urinary Tract Infection. In: Link FW,
Carson SA, Flower WC, Snyder RR., eds. Step-Up to Obstetrics and Gynecology. Philadelphia, PA: Wolters
Kluwer Health; 2015: 243-255.
Rogers RG, Fashokun TB. Pelvic organ prolapse in women: Epidemiology, risk factors, clinical
manifestations, and management. In: UpToDate, Brubaker L, Eckler K (Eds.), UpToDate, Waltham, MA.
Available at http://www.uptodate.com (Accessed on December 1, 2017.)
Organ System: Reproductive
Task Area: Applying Basic Science Concepts
Core Rotation: Obstetrics-Gynecology
Topic(s): Uterine disorders, Prolapse
16. Stem: An otherwise healthy 28-year-old male presents with productive cough for four
weeks, shortness of breath, and muscle aches. He tells you the cough began about 6
weeks after visiting his family in Ohio, where he went spelunking as part of the family
trip. Chest radiograph shows perihilar infiltrates. Which of the following is the best
medication for this patient?
Answer choice:
A.
B.
C.
D.
E.
Ampicillin
Itraconazole
Levofloxacin
Meropenam
Doxycycline
Answer: The answer is B.
Explanation: Given the duration of symptoms, mild nature, exposure to a cave in Ohio, and perihilar
infiltrates, the most likely diagnosis is histoplasmosis. The best treatment for subacute infections is
itraconazole (B).
References:
Diagnosis and treatment of pulmonary histoplasmosis. UpToDate website.
https://www.uptodate.com/contents/diagnosis-and-treatment-of-pulmonary-histoplasmosis. Updated
September 15, 2016. Accessed October 17, 2017.
Organ System: Pulmonary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Internal Medicine, Family Medicine
Topic(s): Infectious Disorders, Fungal Pneumonia
17. Stem: A 17-year-old Hispanic male presents to primary care for a college entrance
physical. He reports no other concerns. His family history is positive for a mother with
diabetes. Vitals are: T – 98.7° F, orally; P – 88 bpm, regular; R – 15 bpm, unlabored; B/P
129/86 R arm, seated; Weight – 202 lbs; Height is 68 inches; BMI 30.7. His urinalysis
shows glucosuria and nonfasting glucose is 236. Point of care HgbA1c is 6.6%. Which of
the following is the most appropriate next step in management?
Answer choice:
A.
B.
C.
D.
E.
Order a fasting glucose
Referral to a nutritionist
Give metformin twice daily
Prescribe basal insulin nightly
Discharge home with clearance
Answer: The answer is B.
Explanation: As with adults, lifestyle modifications are the first line of treatment in pediatric patients
with type II diabetes, followed by oral and then injectable medications (B). Most patients are middle to
late adolescents, have a first or second degree relative with DM II, present without symptoms and, in
one third of cases, the diagnosis is made incidentally on routine urinalysis and labs where glucosuria and
a fasting plasma glucose or random plasma glucose measure greater than or equal to 126 or 200,
respectively. It can be confirmed by an HgbA1c greater than or equal to 6.5%.
References:
Reinehr T. Type 2 diabetes mellitus in children and adolescents. World J Diabetes. 2013; 4: 270-81.
Organ System: Endocrine
Task Area: Clinical Intervention
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Diabetes Mellitus, Type 2
18. Stem: A young child presents to the Emergency Department with dusky red and
purpuric macules distributed on the trunk and proximal upper extremities. He has been
treated with Trimethoprim-Sulfamethoxazole (TMP-SMX) for an infection. On physical
exam, a positive Nikolsky’s sign is exhibited. What is the next best step in treatment?
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SI, Glichrest BA, Paller AS, Leffell DJ, Wolff K: Fitzpatrick's Dermatology in General Medicine, 8th Edition,
www.accessmedicine.com. Figure 40-3>
Answer choice:
A.
B.
C.
D.
E.
Discontinue TMP-SMX and admit to Burn Unit
Discontinue TMP-SMX and start him on cephalexin
Continue current medications and refer to dermatology
Continue current medication and start him on a topical steroid
Continue current medication and start him on a topical antibiotic
Answer: The answer is A.
Explanation: This patient has early Stevens Johnson Syndrome (SJS). Sulfamethoxazole is a high-risk
medication for causing this type of reaction. SJS is a life-threatening reaction, usually to a drug. The
reaction can affect the skin and mucous membranes. The first step in treatment is to discontinue the
offending agent and admit the patient to a Burn Unit or ICU for advanced care (A).
References:
Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, & Wolff K. Fitzpatrick’s Dermatology in General
Medicine. 8th ed. New York, NY: McGraw-Hill; 2012.
Organ System: Dermatologic
Task Area: Pharmaceutical Therapeutics
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Desquamation, Stevens-Johnson Syndrome
19. Stem: Which of the following is diagnostic of nephrotic syndrome?
Answer choice:
A.
B.
C.
D.
E.
Hypolipidemia, proteinuria >10 g/24 h
Hyperlipidemia, proteinuria >1.5 g/24 h
Hyperlipidemia, proteinuria >2.5 g/24 h
Hyperlipidemia, proteinuria >10 g/24 h
Hyperlipidemia, proteinuria >3 g/24 h
Answer: The answer is E.
Explanation: Nephrotic syndrome is defined by proteinuria >3 g/24 h/1.73 m2, edema, hyperlipidemia,
lipiduria, and hypoalbuminemia (E). Nephrotic syndrome that is severe enough also predisposes the
patient to thrombosis due to loss of hemostasis control proteins including proteins C, S, and
antithrombin III. Infection is also a concern due to the loss of immunoglobulins. The patient may also
experience accelerated atherosclerosis due to hyperlipidemia.
References:
Watnick S, Woddell, T, Dirkx T. Kidney disease. In: McPhee SJ, Papadakis MA, eds. Current Medical
Diagnosis and Treatment. 57th ed. New York, NY: McGraw-Hill; 2018.
Organ System: Renal
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation: Internal Medicine, Family Medicine
Topic(s): Acute Disorders, Nephrotic Syndrome
20. Stem: A previously healthy, 15-year-old boy presents to the ED with a severe sore
throat, right side worse than left, with pain radiating to the R ear. He has associated
fevers, malaise, and odynophagia. He received routine childhood immunizations and has
no history of recent travel. On exam, he has mild trismus, a slightly muffled voice, fever
of 101.3 °F and tachycardia, though has no facial or neck edema. What is the most likely
diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Epiglottitis
Dental abscess
Infectious mononucleosis
Peritonsillar abscess
Streptococcal pharyngitis
Answer: The answer is D.
Explanation: Clinical signs and symptoms of a peritonsillar abscess (D) include severe sore throat,
(usually unilateral), fever, and muffled voice. Drooling and trismus are common as well, and pain
radiating to the ipsilateral ear is also suggestive of peritonsillar abscess. Streptococcal pharyngitis is a
major risk factor/concomitant illness; drooling and trismus are not seen with simple streptococcal
pharyngitis.
Epiglottitis (A) is unlikely, as this is generally caused by Haemophilus influenzae type B, and the patient
was vaccinated against this. Dental abscess (B) is unlikely, as his main symptoms are sore throat and ear
pain, with no mention of dental related pain, and he has no facial or neck edema. Infectious
mononucleosis (C) is in the differential, given his age, fevers, and sore throat. However, it is less likely
given the pain radiating to one ear and the trismus. Streptococcal pharyngitis (E) alone is within the
differential, but usually does not cause a muffled voice and trismus.
References:
Wald ER. Peritonsillar cellulitis and abscess. In www.uptodate.com. Updated February 28, 2017,
accessed September 29, 2017.
Organ System: EENT
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine
Topic(s): Oropharyngeal disorders, Infectious/inflammatory disorders, Peritonsillar Abscess
21. Stem: A 64-year-old woman who has not seen a clinician in 30 years presents for
evaluation, and is found to have congestive heart failure and a new diagnosis of Type 2
diabetes mellitus with a hemoglobin A1C of 9.5%. Part of her treatment regimen for
improved glucose control should include which of the following?
Answer choice:
a.
b.
c.
d.
e.
Desmopressin
Insulin
Glucagon
Rosiglitazone
Pioglitazone
Answer: The answer is B.
Explanation: Insulin (B) is recommended in patients presenting with an A1C relatively far from goal
(such as A1C >9%). Desmopressin (A) is not used in the treatment of diabetes mellitus, but in treatment
of diabetes insipidus, and glucagon (C) would raise the patient’s blood glucose level. Rosiglitazone (D)
and pioglitazone (E) would carry a high risk of exacerbating her CHF.
References:
McCulloch DK. Initial management of blood glucose in adults with type 2 diabetes mellitus. In
www.uptodate.com. Updated February 3, 2017, accessed October 17, 2017.
Organ System: Endocrine
Task Area: Pharmaceutical Therapeutics
Core Rotation: Internal Medicine
Topic(s): Diabetes mellitus, Type 2
22. Stem: A 28-year-old nurse who is generally healthy presents with 24 hours of fevers,
urinary frequency, R sided flank pain, and hematuria. Imaging studies are unremarkable.
She is diagnosed with pyelonephritis and started empirically on nitrofuantoin 100 mg PO
BID. Urine culture and sensitivity results are as outlined below. 48 hours later, she is
worsening and developing signs of sepsis. What is the most likely reason for her clinical
deterioration?
Urine culture:
Amoxicillin
Ciprofloxacin
Cephalexin
Doxycycline
Nitrofurantoin
Trimethoprim/sulfamethoxazole
>100,000 E. coli
resistant
resistant
resistant
sensitive
sensitive
sensitive
Answer choice:
a.
b.
c.
d.
e.
Antibiotic resistance
Improper drug selection
Misdiagnosis
Obstructive uropathy
Patient noncompliance
Answer: The answer is B.
Explanation: Nitrofuantoin does not penetrate the kidney adequately to treat pyelonephritis (B). This is
the leading concern in this case.
Misdiagnosis (C) is not an issue, as the patient does have pyelonephritis. Obstructive uropathy (D) has
been ruled out with imaging. Non-compliance (E) is unlikely, as the patient is a nurse. The organism is
sensitive to nitrofurantoin, therefore resistance (A) is not an issue. The clinical issue here is the intrinsic
lack of tissue penetration of the drug, not true resistance.
References:
Hooton TM, & Gupta K. Acute uncomplicated cystitis and pyelonephritis in women. In
www.uptodate.com. Updated November 21, 2016, accessed September 29, 2017.
Organ System: Genitourinary
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine
Topic(s): Infectious disorders, Pyelonephritis
23. Stem: You are working in the Emergency Room when a 28-year-old female patient
presents with shortness of breath. She is able to speak in two to three word sentences
and is sitting in a tripod position. PMH is significant for lupus and asthma. She selfadministered three doses of albuterol via nebulizer at home without relief. Other
medications include methotrexate and prednisone. Blood pressure is 90/50, HR is 104
and regular, RR is 24 and somewhat labored. Physical exam is noteworthy for distant
heart sounds, jugular venous distension, and normal breath sounds. EKG shows
electrical alternans and CXR is unremarkable. You decide to perform point of care
ultrasound for further evaluation. Given these findings, what is the most likely
ultrasound finding?
Answer choice:
a.
b.
c.
d.
e.
Dilated cardiomyopathy
Papillary muscle rupture
Pericardial tamponade
Takatsubo syndrome
Tension pneumothorax
Answer: The answer is C.
Explanation: This patient has lupus, which can redispose to development of pericardial effusion. This
type of effusion can develop slowly and insidiously. She has hypotension, JVD, and distant heart sounds
(Beck’s Triad), as well EKD findings of electrical alternans, which leads to the diagnosis of pericardial
tamponade (C). Dilated cardiomyopathy (A) does not produce electrical alternans on ECG, and a
papillary muscle rupture (B) would produce a noticeable murmur on exam, but not the ECG changes.
Takatsubo (D) is typically found as a finding on echocardiogram, and would also not produce ECG
changes such as electrical alternans. Tension pneumothorax (E) would produce abnormal and unequal
lung sounds, increased tympany, and a possible shift of tracheal deviation.
References:
Braunwald E. Pericardial Disease. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J, eds.
Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79743215. Accessed
January 31, 2018.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine
Topic(s): Traumatic, infectious, and inflammatory heart conditions, Pericardial Tamponade
24. Stem: A 23-year-old male patient is brought to the Emergency Department after a
motor vehicle collision. He was the restrained driver of a car that was involved in a
head-on crash with two other vehicles. He is complaining of left upper quadrant
abdominal pain and left shoulder pain. Vital signs include BP 104/68, pulse 104 and
regular, RR 16 and non-labored, and oxygen saturation of 96% on room air. He reports
that he has a history of von Willebrand’s disease, which was discovered after he had
significant bleeding after wisdom tooth extraction. Given this patient’s past medical
history and current presentation, which of the following would be the most appropriate
treatment for this patient?
Answer choice:
a.
b.
c.
d.
e.
Cryoprecipitate
Desmopressin
Factor VIII product
Factor IX product
Fresh frozen plasma
Answer: The answer is B.
Explanation: Desmopressin is used alone for minor bleeding in patients with von Willebrand’s disease.
In this case, there is significant concern for major bleeding from a splenic rupture because of the history
of major trauma, left upper quadrant pain, and left shoulder pain (Kehr’s sign). Desmopressin (B) would
be administered in conjunction with von Willebrand’s factor product. Factor VIII (C) is used for
hemophilia A. Factor IX (D) is used for hemophilia B. Fresh frozen plasma (E) is indicated for factor XI
deficiency. Cryoprecipitate (A) does not undergo viral inactivation and therefore should only be used in
life-threatening emergencies when appropriate factor VIII concentrates are not available.
References:
Nelson JG, Hemphill RR. Clotting Disorders. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD,
Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY:
McGraw-Hill. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109416673.
Accessed January 31, 2018.
Leavitt AD, Minichiello T. Disorders of Hemostasis, Thrombosis, & Antithrombotic Therapy. In: Papadakis
MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGrawHill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168013149.
Accessed January 31, 2018.
Organ System: Hematologic
Task Area: Pharmaceutical Therapeutics
Core Rotation: Emergency Medicine; Internal Medicine; Surgery
Topic(s): Coagulation Disorders, Clotting Factor Disorders
25. Stem: A 22-year-old male with diabetes mellitus type 1 with a history of alcohol abuse
presents to the emergency room with complaints of nausea and vomiting, and states he
has been out of insulin for the past two days. A finger stick glucometer reading shows
that his blood glucose is 432 mg/dL. A blood gas demonstrates a pH of 7.32, PCO2 36
mm Hg, and HCO3 20 mEq/L. Which of the following best describes the primary acid–
base disorder?
Answer choice:
A.
B.
C.
D.
E.
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
No disorder
Answer: The answer is A.
Explanation: The normal range for arterial blood pH is between 7.35 and 7.45. Acidosis is defined as an
arterial blood pH <7.35 and an alkalosis is defined as a pH >7.45. The normal range for PCO2 is 35 to 45
mEq/L. The normal range for serum bicarbonate is 23 to 28 45 mEq/L. This patient has a metabolic
acidosis based on the finding of a low pH (7.32) and a low HCO3 (20–45 mEq/L) (A). This patient’s CO2 is
36–45 mEq/L which is normal. The lungs will begin to compensate within minutes. CO2 is a volatile acid
produced in the tissues and must be removed by the lungs to maintain a normal pH. The respiratory rate
will increase in the setting of an acidosis to reduce the amount of CO2 via expiration and therefore
increase the pH. Contrariwise, in the setting of alkalosis, the respiratory rate will decrease and retain
CO2 to lower the pH. The kidneys attempt to compensate within hours to days by retaining increased
amounts of HCO3 to increase the pH in a setting of acidosis. Inversely, the kidneys will decrease amounts
of HCO3 through excretion to decrease the pH in a setting of alkalosis. There is no compensation noted
at this point.
References:
Acid-Base Balance. In: Levitzky MG, ed. Pulmonary Physiology. 9th ed. New York, NY: McGrawHill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2288&sectionid=178857393. Accesse
d January 22, 2018.
Organ System: Renal
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Fluid and Electrolyte Disorders, Acid/Base Disorders
26. Stem: A healthcare worker has just returned from a medical mission trip in Africa and
has begun developing the symptoms of fatigue, weight loss, fever, night sweats, and
productive cough. Which of the following is the most likely diagnosis?
Answer Choice:
A.
B.
C.
D.
E.
Infectious mononucleosis
Varicella zoster
Mumps
Pulmonary tuberculosis
Tetanus
Answer: The answer is D.
Explanation: The correct answer is pulmonary tuberculosis (D). Infectious mononucleosis is typically
caused by the Epstein-Barr virus. The protean manifestations of infectious mononucleosis reflect the
dissemination of the virus in the oral cavity and through peripheral blood lymphocytes and cell-free
plasma. Fever, sore throat, fatigue, malaise, anorexia, and myalgia typically occur in the early phase of
the illness. Physical findings include lymphadenopathy (discrete, nonsuppurative, and slightly painful,
especially along the posterior cervical chain), transient bilateral upper lid edema (Hoagland sign), and
splenomegaly (in up to 50% of patients and sometimes massive) (A). Varicella Zoster is typically caused
by varicella zoster virus (VZV), also known as human herpesvirus 3 (HHV-3), which is a member of the
Herpesviridae family. In varicella zoster, fever and malaise are mild in children and more marked in
adults. The pruritic rash begins prominently on the face, scalp, and trunk, and later involves the
extremities. Maculopapules change within a few hours to vesicles that become pustular and eventually
form crusts. New lesions may erupt for 1–5 days, so that different stages of the eruption are usually
present simultaneously (B). Mumps is typically caused by the paramyxovirus known as rubulavirus. In
mumps, parotid tenderness and overlying facial edema are the most common physical findings and
typically develop within 48 hours of the prodromal symptoms. Usually, one parotid gland enlarges
before the other, but unilateral parotitis occurs in 25% of patients. High fever, testicular swelling, and
tenderness (unilateral in 75% of cases) denote orchitis, which usually develops 7–10 days after the onset
of parotitis. The entire course of mumps rarely exceeds 2 weeks (C). Tuberculosis is typically caused by
the acid-fast bacilli Mycobacterium tuberculosis. The patient with pulmonary tuberculosis typically
presents with slowly progressive constitutional symptoms of malaise, anorexia, weight loss, fever, and
night sweats. Chronic cough is the most common pulmonary symptom. It may be dry at first but typically
becomes productive of purulent sputum as the disease progresses. Blood-streaked sputum is common,
but significant hemoptysis is rarely a presenting symptom. Tetanus is typically caused by the neurotoxin
tetanospasmin from the bacteria Clostridium tetani. The first symptom may be pain and tingling at the
site of inoculation, followed by spasticity of the muscles nearby. Stiffness of the jaw, neck stiffness,
dysphagia, and irritability are other early signs. Hyperreflexia develops later, with spasms of the jaw
muscles (trismus) or facial muscles and rigidity and spasm of the muscles of the abdomen, neck, and
back (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Infectious Diseases
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine
Topic(s): Tuberculosis
27. Stem: A 68-year-old female complains of a 2-week history of a dull constant headache
located on the L side in the temporal region. He also notes feeling more tired recently.
He denies injury. An erythrocyte sedimentation rate is elevated. What is the most
appropriate initial treatment for the patient to prevent blindness?
Answer choice:
A.
B.
C.
D.
E.
Prednisone 60 mg orally daily
Dorzolamide 1 drop L eye daily
Methotrexate once weekly
Botulism toxin injection of temporal artery
Timolol 1 drop L eye daily
Answer: The answer is A.
Explanation: Treatment of suspected giant cell (temporal) arteritis should be started immediately if
suspected initially with high dose prednisone. Prednisone can be started before a temporal artery biopsy
and will not interfere with biopsy results if the biopsy is completed within 2 weeks of initiation (A). The
other answer choices are indicated in the treatment of glaucoma and are not indicated in the treatment
of giant cell arteritis (B, C, D, and E). Methotrexate may be used in the treatment of giant cell arteritis
but is not first line. Botulism toxin injection of the temporal artery is not an indicated treatment for giant
cell arteritis (D).
References:
Langford CA, Fauci AS. The Vasculitis Syndromes. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo
DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.evms.idm.oclc.org/Content.aspx?bookid=2129&sectionid=19228
5458. Accessed September 07, 2018.
Organ System: Neurologic System
Task Area: Pharmaceutical Therapeutics
Core Rotation: Internal Medicine
Topic(s): Headaches, Secondary, Giant Cell (Temporal) Arteritis Treatment
28. Stem: Mr. Sandow is a 32-year-old male who complains of persistent anxiety, which has
worsened in the past few months. He describes several attacks of anxiety associated
with sobbing, shaking, palpitations, and a feeling like he is going to die. The patient
would like to be treated for his condition but is concerned about getting addicted to
medication since his best friend died of a drug overdose last year. Which of the
following treatments that are indicated for anxiety disorder would have the most
potential for abuse?
Answer choice:
A.
B.
C.
D.
E.
Alprazolam
Venlafaxine
Paroxetine
Buspirone
Methylphenidate
Answer: The answer is A.
Explanation: Benzodiazepines including alprazolam are indicated for generalized anxiety disorder and
panic disorder and have the potential for dependence and abuse (DEA Schedule IV). Venlafaxine, an
SNRI, and paroxetine, an SSRI, are also indicated for the patient’s condition and do not have the
potential for abuse (B and C). Buspirone has no abuse potential but is only indicated for generalized
anxiety disorder and may worsen panic disorder symptoms (D). Although methylphenidate has a high
risk for dependency and abuse (DEA Schedule II) it is not indicated for generalized anxiety or panic
disorder and may worsen anxiety (E).
References:
O’Donnell JM, Bies RR, Shelton RC. Drug Therapy of Depression and Anxiety Disorders. In: Brunton LL,
Hilal-Dandan R, Knollmann BC, eds. Goodman & Gilman's: The Pharmacological Basis of Therapeutics.
13th ed. New York, NY: McGraw-Hill; 2017.
http://accessmedicine.mhmedical.com.evms.idm.oclc.org/Content.aspx?bookid=2189&sectionid=16951
8711. Accessed September 07, 2018.
Satterfield JM, Feldman MD. Anxiety. In: Feldman MD, Christensen JF, Satterfield JM, eds. Behavioral
Medicine: A Guide for Clinical Practice. 4th ed. New York, NY: McGraw-Hill; 2014.
http://accessmedicine.mhmedical.com.evms.idm.oclc.org/content.aspx?bookid=1116&sectionid=62689
101. Accessed September 7, 2018.
Organ System: Psychiatry/Behavioral
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Anxiety Disorder Treatment
29. Stem: A 34-year-old female reports to the ER with complaints of feeling emotional, hot
flashes, and palpitations. She states her symptoms started about 2 weeks ago and have
been worsening. She is concerned that she might be entering early menopause as she
has not had a menstrual cycle in 2 months. On exam, you note a skinny female in no
acute distress. Her skin is warm and moist. Her HEENT demonstrates a normal eye exam
with clear conjunctiva and without periorbital edema. Examination of the neck reveals
an enlarged, non-tender thyroid bilaterally. The remainder of the HEENT exam is within
normal range. Her lungs are clear to auscultation bilaterally. Her cardiac exam
demonstrates tachycardia without murmurs, rubs, or gallops. Her abdominal exam
demonstrates positive bowel sounds without masses, distention, or tenderness to
palpation. Her neuro exam does not reveal focal deficits. She is also negative for
peripheral edema. Her vital signs are as follows: BP: 110/68, Temp: 99.8 °F, Pulse: 115
BPM, Pulse Ox: 99% on ambient air.
Her laboratory and diagnostic studies are as follows:
CBC – within normal limits
CMP – within normal limits
Urinalysis – within normal limits
Thyroid Stimulating Hormone – 0.1 mIU/L (Reference range 0.40–4.50 mIU/L)
Serum T4 – 2.7 ng/dL (Reference range 0.8–1.8 ng/dL)
Serum T3 – 245 ng/dL (Reference range 76–181 ng/dL)
What is the most likely cause of this patient’s symptoms?
Answer choice:
a.
b.
c.
d.
e.
Hypothyroidism
Hyperprolactenemia
Hyperparathyroidism
Thyroiditis
Hyperthyroidism
Answer: The answer is E.
Explanation: This patient is suffering from hyperthyroidism (E). This is made evident by her presenting
symptoms according to Table 229-4 in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,
8e. It is also evident by her physical exam and her labs. The absence of periorbital edema helps to focus
on hyperthyroidism over Grave’s disease. There is no evidence within the exam or the labs to suggest
that the patient is suffering from choices (A)–(D). Thyroiditis presents with a swollen and tender thyroid.
References:
Idrose A. Hyperthyroidism. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline
DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY:
McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109444027.
Accessed December 20, 2017.
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current
Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=167996562.
Accessed December 19, 2017.
Organ System: Endocrine
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Thyroid disorders, Hyperthyroidism
30. Stem: A 56-year-old male patient is brought to the ER with complaints of substernal
“crushing” chest pain that started when he was walking up the stairs at work. He admits
to having 2 similar episodes of pain in the last month; however, those episodes occurred
with heavier exertion while lifting multiple heavy boxes and each resolved as soon as he
rested. This time the pain did not resolve with rest. Upon examination, vitals show a BP
of 134/72 and pulse of 110. ECG shows no signs of acute ischemia. Troponin and CKMB
are both normal. You administer a dose of IV nitroglycerine, which does resolve his
chest pain. What is the most likely cause of this patient’s chest pain?
Answer choice:
a.
b.
c.
d.
e.
Unstable angina
Aortic dissection
Pulmonary embolism
ST segment elevation myocardial infarction
Non-ST segment elevation myocardial infarction
Answer: The answer is A.
Explanation: Unstable angina (A) is a clinical diagnosis based on history, physical exam findings, and
diagnostic testing that does not reveal a STEMI or NSTEMI. Unstable angina may precede or may be the
presenting diagnosis that leads to a new diagnosis of coronary artery disease. Characteristics include
left-sided or retrosternal chest pain, which may radiate to the jaw, neck, or left shoulder. Unstable
angina usually is associated with one of the following: 1) began within the past 2 months; 2) has
increasing frequency, intensity, or duration of existing angina symptoms; or 3) existing angina begins to
occur at rest, rather than with physical exertion or emotional stress.
Aortic dissection pain (B) is of abrupt onset, and is usually described as severe and tearing. It may
radiate from the anterior chest wall posteriorly to the interscapular region.
Pulmonary embolism pain (C) is usually of abrupt onset and pleuritic in nature. It has a duration of
several minutes to a few hours. There may be predisposing factors, such as deep venous thrombosis or
long periods of immobilization. Patients may also report cough or hemoptysis. On examination, the
patients are dyspneic and tachypneic with a tachycardia.
STEMI (D) and NSTEMI (E) will typically have diagnostic changes to the ST and T waves on ECG, either
initially or serially. Also, the troponin and cardiac markers will often be elevated. The chest pain typically
doesn’t respond to nitroglycerine as well with STEMI/NSTEMI.
References:
Rita K. Cydulka, Michael T. Fitch, Scott A. Joing, Vincent J. Wang, David M. Cline, O. John Ma. Tintinalli's
Emergency Medicine Manual 8th ed. New York, NY: McGraw-Hill.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal medicine, emergency medicine
Topic(s): Coronary Heart Disease, Angina pectoris-unstable
31. Stem: A 72-year-old man presents with 2 weeks of intermittent LLQ pain and cramping,
somewhat relieved with bowel movements. He has had a low grade fever, and a h/o
similar episode 1 year ago that resolved on its own. On exam he has mild LLQ
tenderness without guarding or rebound tenderness, a temperature of 99.5 °F, and labs
reveal a leukocytosis of 12.1 K/microL. What is the most appropriate therapy for this
patient?
Answer choice:
a.
b.
c.
d.
e.
Bulk forming laxatives
Gluten-free diet
Oral antibiotics targeting GI flora
Stool softeners and high fiber diet
Reassurance
Answer: The answer is C.
Explanation: The patient has acute uncomplicated diverticulitis, which requires antibiotic therapy
targeting GI flora (C). Based on his presentation he would not require inpatient care, and oral antibiotics
would be appropriate.
Bulk forming laxatives (A) would not have a role in acute diverticulitis, and may exacerbate the problem.
A gluten-free diet (B) is indicated in the management of celiac disease, but not specifically diverticulitis.
Stool softeners and a high fiber diet (D) are indicated in the management of constipation, and the high
fiber diet is recommended to help prevent recurrence of diverticulitis, but is not implemented during an
acute episode.
References:
Pemberton JH. Acute colonic diverticulitis: medical management. In www.uptodate.com. Updated July
18, 2017, accessed September 29, 2017.
Organ System: Gastrointestinal/Nutritional
Task Area: Clinical Intervention
Core Rotation: General Surgery
Topic(s): Colorectal disorders, Diverticulitis
32. Stem: A patient undergoes a Pelvic Organ Prolapse Quantification (POP-Q) exam and is
diagnosed with a stage IV cystocele. Due to her symptoms and failed conservative
therapies, you recommend which of the following procedures?
Answer choice:
a.
b.
c.
d.
Anterior colporrhaphy
Colpocleisis
Sacral colpopexy
Uterosacral ligament suspension
Answer: The answer is A
Explanation: A cystocele is an anterior compartment prolapse and would thus need an anterior repair
(colporrhaphy) with plication of the anterior endopelvic fascia. Colpocleisis is an obliterative surgery
rather than a reconstruction surgery; obliteration is not indicated. Uterosacral ligament suspension and
sacral colpopexy are for an apical compartment prolapse.
References:
Hundley A F. Pelvic Support Defects, Urinary Incontinence, and Urinary Tract Infection. In: Link FW,
Carson SA, Flower WC, Snyder RR., eds. Step-Up to Obstetrics and Gynecology. Philadelphia, PA: Wolters
Kluwer Health; 2015: 243-255.
Jelovsek JE. Pelvic organ prolapse in women: Choosing a primary surgical procedure. In: UpToDate,
Brubaker L, Eckler K (Eds.), UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed
on December 1, 2017.)
Organ System: Reproductive
Task Area: Clinical Intervention
Core Rotation: OB/GYN
Topic(s): Vaginal/vulvar disorders, Prolapse
33. Stem: A physician assistant recently joined the research team at the local teaching
hospital. The team is putting together a study that will randomize patients into a control
group and experimental group. They will then follow both groups over the next year.
Which one of the following would define this type of study?
Answer Choice:
A. Case series
B. Cohort study
C. Meta-analysis
D. Case controlled study
E. Randomized controlled study
Answer: The answer is E.
Explanation: Randomized controlled studies are designed to randomize participants into a control group
and an experimental group (E). The group can then be followed for a specific length of time to compare
outcomes. Case series report on a group of patients, but there is no control group (A). Cohort studies
can be either prospective or retrospective (B). The group shares a defining characteristic and is looked at
in intervals over time. Meta-analysis is a review of published studies using quantitative methods to
analyze all the data (C and D). Case controlled studies are retrospective analyses of two existing groups
and how they differ in outcomes.
Reference: Watkins E. Professional Practice for Physician Assistants. Kenmore, NY: RPSS Publishing;
2018.
Organ System: N/A
Task Area: Professional Practice
Core Rotations: N/A
Topic(s): Public Health, Medical Informatics
34. Stem: A 60-year-old male complains of a 2-day history of pain at the base of his left first
toe. He noted that it was painful just to touch the area lightly and that it appeared red
and swollen yesterday but has not worsened. He has had similar episodes involving the
same toe in the past, which he attributed to his shoes. He denies any known injury.
Monosodium urate crystals are present in aspiration of the joint. What is the most likely
diagnosis?
<CATCH: Insert Photo B>
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Stone JH: Current Diagnosis & Treatment: Rheumatology, 3rd Edition: www.accessmedicine.com
Copyright © The McGraw-Hill Companies, Inc. All rights reserved. Figure 42-2>
Answer choice:
A.
B.
C.
D.
E.
Acute gouty arthritis
Pseudogout
Rheumatoid arthritis
Septic arthritis
Degenerative joint disease
Answer: The answer is A.
Explanation: American College of Rheumatology criteria for the diagnosis of gout in this patient includes
multiple attacks of acute arthritis, maximum inflammation occurring within 1 day, joint erythema, first
metatarsophalangeal joint pain and swelling, unilateral attach involving the first metatarsophalangeal
joint, and monoarticular arthritis (A). Definitive diagnosis of gout is made by the presence of
monosodium urate crystals in the synovial fluid. Hyperuricemia may be noted but is not required for the
diagnosis of acute gout. The other choices would not have monosodium urate crystals present in the
joint aspirate (B, C, and E). Septic arthritis is always a consideration in an inflamed joint but is unlikely
based on the patient presentation (D).
References:
Burns C, Wortmann RL. Chapter 44. Gout. In: Imboden JB, Hellmann DB, Stone JH, eds. CURRENT
Diagnosis & Treatment: Rheumatology. 3rd edition. New York, NY: McGraw-Hill; 2013.
http://accessmedicine.mhmedical.com/content.aspx?bookid=506&sectionid=42584931. Accessed
September 01, 2018.
Organ System: Musculoskeletal
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine, Family Medicine
Topic(s): Rheumatologic disorders, Gout
35. Stem: The most common type of acute kidney injury is which of the following?
Answer choice:
A. Prerenal failure
B. Intrinsic renal failure
C. Postrenal failure
D. Drug induced
E. Diabetic associated
Answer: The answer is A.
Explanation: Prerenal failure is the most common cause of acute kidney injury (AKI); this is usually the
result of low intravascular volume, which results in decreased renal perfusion (A). This is often reversible
when treated appropriately. Obstructions of the urinary tract (e.g., benign prostatic hyperplasia), or post
renal failure, account for less than 5% of cases of AKI (C). Intrinsic renal failure occurs in the rest of the
cases (B). Drug-induced AKI is often intrinsic in etiology and renal failure associated with diabetes is
typically chronic and not acute (D and E).
References:
Watnick S, Woddell T, Dirkx T. Kidney disease. In: McPhee SJ, Papadakis MA, eds. Current Medical
Diagnosis and Treatment. 57th ed. New York, NY: McGraw-Hill; 2018.
Organ System: Renal
Task Area: Applying Basic Science Concepts
Core Rotation: Internal Medicine, Family Medicine, Emergency Medicine
Topic(s): Acute Kidney Injury, Acute Renal Failure
36. Stem: A 70-year-old Caucasian male presents with anorexia, early satiety, abdominal
pain, melena, and unintentional weight loss of at least 10 lbs over the past 6 months. His
past medical history is significant for tobacco use and GERD that has been previously
treated with antibiotics. Physical exam reveals multiple well-demarcated,
hyperpigmented, verrucous plaques with a “stuck-on” appearance across the patient’s
back. He reports that these have mostly appeared suddenly and are often pruritic. He is
also noted to have some velvety, hyperpigmented plaques on his posterior neck and
axilla. What is the most likely diagnosis?
http://accessmedicine.mhmedical.com/ViewLarge.aspx?figid=41159233&gbosContainerID=0&gbosid=0
Answer choice:
a.
b.
c.
d.
e.
Chronic liver disease
Colon cancer
Gastric adenocarcinoma
Inflammatory bowel disease
Pancreatitis
Answer: The answer is C.
Explanation: The correct answer is gastric adenocarcinoma (C), which commonly presents with
dyspeptic symptoms and weight loss in patients over 40 years of age. The patient’s physical exam
suggests Leser-Trélat sign, a paraneoplastic manifestation of intra-abdominal malignancy that is
characterized by the sudden appearance of diffuse seborrheic keratosis. The patient also presents with
acanthosis nigricans, which can be a sign of insulin resistance or internal malignancy. History of
Helicobacter Pylori infection is the most common risk factor.
Chronic liver disease (A) is incorrect. Skin manifestations of chronic liver disease and cirrhosis consist of
spider telangiectasias, palmar erythema, Dupuytren contractures, and caput medusa.
Colon cancer (B) is incorrect, as a Helicobacter Pylori infection is not a primary risk factor. The most
common presenting symptoms of colorectal cancer are dependent on tumor location, but may include
fatigue and weakness (due to anemia), change in bowels, and hematochezia.
Inflammatory bowel disease (D) is incorrect. Skin manifestations may include oral ulcers, erythema
nodosum, and pyoderma gangrenosum.
Pancreatitis (E) is incorrect. About 3% of patients with severe acute pancreatitis may develop
ecchymosis in the periumbilical region (Cullen’s sign) or along the flank (Grey Turner sign).
References:
Cornett PA, Dea TO. Cancer. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis
& Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168004201. Accessed
January 18, 2018.
Friedman LS. Liver, Biliary Tract, & Pancreas Disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds.
Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168015083. Accessed
January 18, 2018.
McQuaid KR. Gastrointestinal Disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical
Diagnosis & Treatment 2018. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168013478. Accessed
January 18, 2018.
Clinical features, diagnosis, and staging of gastric cancer. UpToDate.
https://www.uptodate.com/contents/clinical-features-diagnosis-and-staging-of-gastriccancer?search=Gastric%20Cancer&source=search_result&selectedTitle=1~150&usage_type=default&dis
play_rank=1. Updated November 14, 2017. Accessed January 18, 2018.
Clinical manifestations and diagnosis of acute pancreatitis. UpToDate.
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-acutepancreatitis?search=grey%20turner%20sign&source=search_result&selectedTitle=1~11&usage_type=de
fault&display_rank=1. Updated October 31, 2017. Accessed January 18, 2018.
Organ System: Gastrointestinal/Nutritional
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Neoplasms
37. Stem: A 30-year-old female with a history of chronic ear infections presents to the clinic
with persistent unilateral hearing loss in the right ear. She denies subjective fever,
headaches, otalgia, or URI symptoms. She is afebrile, and Weber and Rinne testing
suggest a conductive hearing loss. Otoscopic exam reveals a pearly mass behind an
intact tympanic membrane. There is no mastoid tenderness. Which of the following is
the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Cholesteatoma
Otitis media
Otitis externa
Squamous cell carcinoma
Vestibular Schwannoma
Answer: The answer is A.
Explanation: The correct answer is cholesteatoma (A), a keratinized mass in the middle ear that may
develop as a result Eustachian tube dysfunction (primary acquired) or tympanic membrane perforation
(secondary acquired).
Otitis media (B) is incorrect. The patient does not exhibit symptoms of acute infection, such as fever or
otalgia. Physical exam findings of otitis media include erythema, cloudiness, and bulging or hypomobility
of the tympanic membrane.
Otitis externa (C) is incorrect and presents with painful erythema and edema of the ear canal as well as
purulent discharge.
Squamous cell carcinoma (D) is an epithelial cell malignancy that typically occurs in areas subjected to
prolonged sun exposure, such as the outer auricle of the ear.
Vestibular schwannoma (acoustic neuroma), (E), is incorrect and presents with sensorineural, rather
than conductive, hearing loss. These tumors occur intracranially and arise from the internal auditory
canal. While unilateral hearing loss is a common presenting symptom, they are not associated with
chronic ear infections and are unlikely to be visualized on otoscopic exam.
References:
Lustig LR, Schindler JS. Ear, Nose, & Throat Disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds.
Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168008266. Accessed
January 17, 2018.
Chronic otitis media, cholesteatoma, and mastoiditis in adults. UpToDate.
https://www.uptodate.com/contents/chronic-otitis-media-cholesteatoma-and-mastoiditis-inadults?search=Cholesteatoma%20of%20Middle%20Ear&source=search_result&selectedTitle=1~150&us
age_type=default&display_rank=1. Updated April 27, 2017. Accessed January 17, 2018.
Organ System: EENT
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine
Topic(s): Ear Disorders, Middle ear, Cholesteatoma
38. Stem: A 19-year-old female with no past medical history presents to the clinic with
sudden onset of moderate pain in the intergluteal region while sitting. Physical exam
reveals a low-grade fever and a tender, fluctuant mass just lateral to the gluteal cleft.
There is no erythema, warmth, or induration of the surrounding skin. If a pilonidal sinus
is discovered, what is considered to be definitive management?
Answer choice:
a.
b.
c.
d.
e.
Cefazolin plus Metronidazole
Excision of the sinus and all tracts
Incision and drainage with primary closure
Incision and drainage with delayed closure
Trimethoprim-sulfamethoxazole
Answer: The answer is B.
Explanation: The correct answer is excision of the sinus and all tracts (B), as this is the most definitive
management for pilonidal disease. A primary would closure is associated with faster healing time, while
a delayed closure is associated with lower likelihood of recurrence.
Cefazolin plus Metronidazole (A) and Trimethopril-sulfamethoxazole (E) are both incorrect, because
there is no evidence of cellulitis to justify the use of antibiotics.
Incision and drainage, (C) and (D), is incorrect, as recurrence rates range from approximately 20 to 55
percent.
References:
Intergluteal pilonidal disease: Clinical manifestations and diagnosis. UpToDate.
https://www.uptodate.com/contents/intergluteal-pilonidal-disease-clinical-manifestations-anddiagnosis?search=Pilonidal%20Abscess&source=search_result&selectedTitle=1~23&usage_type=default
&display_rank=1. Updated April 5, 2017. Accessed December 29, 2017.
Management of intergluteal pilonidal disease. UpToDate.
https://www.uptodate.com/contents/management-of-intergluteal-pilonidaldisease?search=pilonidal%20cyst%20treatment&source=search_result&selectedTitle=1~23&usage_type
=default&display_rank=1. Updated June 21, 2016. Accessed December 29, 2017.
Organ System: Dermatologic
Task Area: Clinical Intervention
Core Rotation: Family Medicine
Topic(s): Other dermatologic disorders, Pilonidal Disease
39. Stem: A 50-year-old man presents to the Emergency Department by ambulance with
acute onset of severe dyspnea. He was recently discharged from the hospital after an
acute myocardial infarction and cardiac stent placement. His vitals are as follows: BP
110/50, RR 26, HR 112, Temp 99 °F, and pulse ox 91% on room air. Physical exam shows
an overweight male in acute distress with a new blowing holosystolic murmur and
bibasilar rales. Which of the following is the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Acute aortic insufficiency
Acute mitral regurgitation
Nosocomial pneumonia
Postmyocardial infarction syndrome
Pulmonary embolism
Answer: The answer is B.
Explanation: The correct answer is acute mitral regurgitation (B) as a result of papillary muscle or
chordae tendineae rupture secondary to myocardial infarction. Acute mitral regurgitation presents with
symptoms of pulmonary edema and a systolic murmur.
Acute aortic insufficiency (A) is incorrect. Aortic insufficiency may present with dyspnea, but is
associated with a high-pitched, blowing diastolic murmur heard best at the left sternal border.
Nosocomial pneumonia (C) is incorrect and typically presents with fever, cough, and evidence of
consolidation on pulmonary exam. There is no associated murmur.
Postmyocardial infarction syndrome (D), also known as Dressler’s syndrome, is incorrect. Dressler’s
syndrome is a type of pericarditis resulting from damage to cardiac tissue and typically presents with
fever, pleuritic chest pain, and pericardial effusion.
Pulmonary embolism (E) would be high on the differential for a patient presenting with acute dyspnea,
but does not typically present with a new heart murmur.
References:
Bashore TM, Granger CB, Jackson KP, Patel MR. Heart Disease. In: Papadakis MA, McPhee SJ, Rabow
MW, eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168190671. Accessed
January 02, 2018.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Valvular disorders, Mitral
40. Stem: A 58-year-old Caucasian male with a past social history of homelessness presents
to the free clinic to establish care and with concerns about worsening swelling in his
ankles and feet over the past several months. He admits to increasing fatigue, weakness,
anorexia, and decreasing urine output over that time. His blood pressure is 164/92 and
he has 2+ pitting edema at the lower extremities bilaterally. His exam is otherwise
normal. Which of the following is the most likely diagnosis?
Answer choice:
A.
B.
C.
D.
E.
Chronic kidney disease
Chronic liver failure
Congestive heart failure
Chronic depression
Chronic bronchitis
Answer: The answer is A.
Explanation: The symptoms the patient reports of edema, fatigue, weakness, anorexia, and decreasing
urine output over time along with the elevated blood pressure and pitting edema most closely correlate
with chronic kidney disease (A).
References:
Diagnostic approach to the patient with newly identified chronic kidney disease. UpToDate website.
https://www.uptodate.com/contents/diagnostic-approach-to-the-patient-with-newly-identifiedchronic-kidney-disease. Updated October 26, 2017. Accessed October 31, 2017.
Organ System: Renal
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Chronic Kidney Disease
41. Stem: A 30-year-old male presents to your office after being hit on the outstretched
hand with a thrown softball. There are no skin lesions, and an x-ray shows no bony
lesion. Your exam is consistent with a soft tissue mallet finger, neurovascular intact.
Which of the following conservative measures offers the most success in closed
treatment?
Answer choice:
A.
B.
C.
D.
Place a dorsal splint including the PIP and DIP joint
Put the patient in a pre-formed STAX splint, and allow him out daily for ROM
Place the patient in a STAX splint for six weeks and restrict DIP motion
Immediate referral for surgical repair
Answer: The answer is C.
Explanation: Closed treatment of a soft tissue or minimal bony mallet can be accomplished with a
preformed splint that hold the DIP joint in slight hyperextension and leaves the PIP joint free (C). Both
dorsal and volar splints have been used, but as the splint must be on for six weeks, material selection is
key. Surgical repair should be considered for large bone fragments, joint subluxion, or complex open
injuries.
References:
Botero SS, Diaz JJ, Benaida A, Collon S, Facca S, & Liverneaux P. Review of acute traumatic closed mallet
finger injuries in adults. Archives of Plastic Surgery. 2016 Mar;43(2):134-144.
https://doi.org/10.5999/aps2016.43.2.134.
Organ System: Musculoskeletal
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine, Family Medicine
Topic(s): Upper Extremity Disorders, Fractures/Dislocations
42. Stem: A 31-year-old male calls his PCP concerning worsening wheezing. He has taken 3
puffs of his short acting beta agonist (SABA) MDI every 20 minutes for the last 2 hours
without relief. His home peak flow meter is misplaced. His PCP directs him to start oral
prednisone at home, the patient has a supply of 20 mg tablets and takes one dose. His
girlfriend calls the PCP later in the day, reporting his wheezing has not improved. The
patient is then seen in the office where he appears tired and he speaks in short
sentences. His heart rate is 110 bpm, blood pressure 142/68, respirations 32 per
minute, temperature 99 F and pulse oximetry on room air 90%. HEENT exam reveals
rhinorrhea and lungs have diffuse coarse wheezing throughout. He is given a nebulizer
treatment of a SABA combined with ipratropium and another oral dose of prednisone
20 mg. He has not improved 30 minutes later.
Which selection is the best next intervention for this patient?
Answer choice:
a.
b.
c.
d.
e.
Initiate inhaled corticosteroid
Consider inpatient admission
Continue outpatient treatment with SABA MDI
Initiate empiric antibiotics
Obtain urgent pulmonary consultation
Answer: The answer is B
Explanation: This patient is having a moderate to severe exacerbation of his asthma and has borderline
hypoxia at rest that is not responding to appropriate initial treatment. Continued outpatient treatment
with SABA MDI will not definitively treat the underlying airway inflammation and obstruction. An
inhaled corticosteroid will benefit the patient but further systemic corticosteroids will provide more
immediate benefit. A chest radiograph will assist in determining the need for antibiotics but without
fever, it is unlikely that a bacterial lung infection is contributing to the exacerbation. The patient may
need pulmonary consultation if his condition does not improve but his exacerbation can be treated by
his PCP or hospitalist as an inpatient initially.
References:
Chesnutt AN, Chesnutt MS, Prendergast TJ. Pulmonary Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018 New York, NY: McGrawHill;http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168189660. Accessed
December 02, 2017.
Organ System: Pulmonary
Task Area: Clinical Intervention
Core Rotation: Internal Medicine
Topic(s): Other pulmonary disorders, Asthma
43. Stem: A 30-year-old male is in the office for evaluation of a non-tender, slow developing
mass in his left testicle. An ultrasound has been ordered. The radiology report notes
there is “dilation of the pampiniform plexus of the spermatic veins.” Which one of the
following is the most likely diagnosis based on this report?
Answer choice:
a.
b.
c.
d.
e.
Cryptorchidism
Hydrocele
Inguinal hernia
Spermatocele
Varicocele
Answer: The answer is E
Explanation: A varicocele (E) forms when the veins along the spermatic cord are engorged due to valve
incompetence, and is typically asymptomatic. Hydroceles (B) and inguinal hernias (C) are similar
mechanisms, which include a persistent, narrow processus vaginalis that acts like a one-way valve,
allowing for accumulation of fluid in the scrotum. Cryptorchidism is an undescended testicle that is not
consistent with ultrasound findings, and is also not consistent with a spermatocele, which can be
described as a soft, fluctuant mass that can be transilluminated.
References:
Bondesson JD. Urologic Conditions. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of
Emergency Medicine, 4e. New York, NY: McGraw-Hill.
Organ System: Genitourinary
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine
Topic(s): Testicular disorders, Varicocele
44. Stem: A 10-year-old female with Trisomy 21 has developed fatigue, headaches, and a
new onset limp. The mother denies any recent viral illness or travel. Immunizations are
up to date. A CBC is ordered and reveals a normochromic, normocytic anemia, white
blood count of 3,800 with > 20% lymphoblasts, and thrombocytopenia. A chest x-ray
reveals a mediastinal mass. Which of the following is the most likely diagnosis for this
patient?
Answer choice:
a.
b.
c.
d.
e.
Acute lymphocytic leukemia
Aplastic anemia
Chronic myelogenous leukemia
Idiopathic thrombocytopenia purpura
Multiple myeloma
Answer: The answer is A
Explanation: Acute leukemia is a malignancy of progenitor cells. ALL (A), specifically, impacts the
lymphoid chain. Lymphoblast cells can be seen on smear. When >20% of blasts are lymphoblasts, the
diagnosis of ALL is suggested. There is a pancytopenia seen with acute leukemia. Multiple myeloma (E) is
seen in the aging population (> 65 years old) and will present with bone pain and Bence Jones proteins
on UA. Both idiopathic thrombocytopenia purpura (D) and aplastic anemia (B) have a thrombocytopenia
associated with them, but the mediastinal mass present in the case is not consistent with either illness.
References:
Damon LE, Andreadis C. Blood Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current
Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
Organ System: Hematologic
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Pediatrics
Topic(s): Neoplasms, premalignancies, and malignancies, Lymphocytic Leukemia
45. Stem: Ellen Barns is a very demanding 45-year-old female who requests that she be
called personally by the physician with her lab results. She refuses to wait more than 10
minutes for her appointment without becoming upset and manipulative. Today she told
the front desk, “I have insurance so tell Dr. Yes that I am not waiting for her. She will
respect my time. I refuse to be treated like a person off the street.” In speaking with Dr.
Yes, she reveals her husband left her recently and states, “I hired the best lawyer in
town because I deserve to have everything. After all, I am a successful businesswoman.
There is a line of handsome rich men waiting to meet me anyway, his loss. You would
agree of course.” What is Ellen Barns’ most likely personality disorder?
Answer choice:
A.
B.
C.
D.
E.
Narcissistic
Histrionic
Paranoid
Borderline
Antisocial
Answer: The answer is A.
Explanation: This patient has characteristics that define narcissistic personality disorder including having
a grandiose sense of self-importance, believing she is special, being interpersonally exploitive and
arrogant, and having a sense of entitlement (A). Histrionic personality disorder would display excessive
sexuality or emotions designed to place them at the center of attention, evade responsibilities, and
control others (B). Those with paranoid personality disorder would have thoughts of distrust and
suspiciousness, which may include accusing her husband of cheating (C). Someone with borderline
personality disorder would show a pattern of mood instability and unstable but intense personal
relationships (D). The patient would likely exhibit self-destructive behaviors such as suicide threats with
her husband leaving. In antisocial personality disorder, the patient would have a history of conduct
disorder as a child and a pattern of disregard for and violation of the rights of others (E). She would
more likely have a criminal record and/or history of illegal drug use. She would likely react to her
husband leaving with hostility, which may result in assault or destroying her husband’s property.
References:
Young JQ. Personality Disorders. In: Feldman MD, Christensen JF, Satterfield JM, eds. Behavioral
Medicine: A Guide for Clinical Practice. 4th ed. New York, NY: McGraw-Hill; 2014.
http://accessmedicine.mhmedical.com.evms.idm.oclc.org/content.aspx?bookid=1116&sectionid=62689
362. Accessed September 7, 2018.
Janowsky D. Chapter 30. Personality Disorders. In: Ebert MH, Loosen PT, Nurcombe B, Leckman JF, eds.
CURRENT Diagnosis & Treatment: Psychiatry. 2nd ed. New York, NY: McGraw-Hill; 2008.
http://accessmedicine.mhmedical.com.evms.idm.oclc.org/content.aspx?bookid=336&sectionid=397179
02. Accessed September 7, 2018.
Organ System: Psychiatry/Behavioral
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Psychiatry
Topic(s): Personality Disorders
46. Stem: A 16-year-old male patient presents with fever, sore throat, and fatigue. Physical
findings include lymphadenopathy. The rapid streptococcal test is negative. The patient
states his girlfriend has the same symptoms. Which of the following should be discussed
as part of the patient education based on the most likely diagnosis for this patient?
Answer Choice:
A. The future risk of cervical cancer and appropriate screening required
B. The patient should refrain from any contact sports due to the possibility of
splenomegaly
C. The patient has a future risk of developing herpes zoster later as an adult
D. The patient should watch for symptoms of testicular inflammation
E. The patient will have future positive purified protein derivative skin tests
Answer: The answer is B.
Explanation: This patient is presenting with classic signs and symptoms of Epstein-Barr virus. Human
papillomavirus infections have been associated with an increased risk of cervical cancer with the
majority from types 16 and 18 and increased risk of genital warts with the majority from types 6 and 11
(A). Epstein-Barr virus infections have an increased risk of splenomegaly with potential rupture from
increased abdominal pressure or high-impact contact. Patients should be removed from contact sports
until the splenomegaly has resolved completely (B). Varicella zoster viral infections increase the risk of
having a herpes zoster (shingles) outbreak as an adult due to the inactive virus remaining present in the
host (C). Mumps is associated with the severe side effect of orchitis (testicular inflammation), which
could progress to infertility (D). The purified protein derivative (PPD) skin test is often used for annual
screening for tuberculosis. Patients with previous exposure to the bacteria Mycobacterium tuberculosis
will have a positive immune reaction to all future PPD skin tests without active or latent infection (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Infectious Diseases
Task Area: Health Maintenance
Core Rotation: Emergency Medicine, Family Medicine, Pediatrics
Topic(s): Epstein-Barr Virus Infections
47. Stem: A 6-month-old male patient presents to the pediatrician's office with his mother
and father for a routine well-child examination. On physical exam, there is no testicle
palpated in the right side of the scrotum. Which of the following answer choices
represents the best next step in the evaluation and management of this patient?
Answer Choice:
A. Attempt to palpate a retractile or undescended testis by sweeping one hand along the anterior
iliac spine with the other hand at the scrotum until the testis is pushed into a position where it
can be examined.
B. Order an ultrasound to look for the presence of the undescended testis in the inguinal canal or
abdominal cavity.
C. Obtain hormonal laboratory studies to evaluate for possible endocrine disorders.
D. Provide the parents with reassurance that this is normal up to one year of age and make a note
in the chart to re-evaluate at that time.
E. Refer the patient directly to Urology for further evaluation and treatment.
Answer: The answer is A.
Explanation: A complete history and physical exam should always be the first steps in the evaluation of
a potential problem. Often times, the testis is located within the inguinal canal and can be palpated by
manually bringing it into the scrotum (A). Ultrasonography may be obtained at some point during the
evaluation, but has limited capability sensitivity, and should not preclude a thorough physical
examination(B). While cryptorchidism can be associated with certain endocrine disorders, laboratory
evaluation should be performed after confirming the absence of a testis or presence of an undescended
testis (C). At 6 months, the vast majority of male infants should have palpable testis. As with ultrasound
and lab investigation, referral should be delayed until a thorough physical exam is complete (E).
References: Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds.
CURRENT Medical Diagnosis & Treatment 2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=2449
&sectionid=194577758. Accessed February 06, 2019.
Organ System: Genitourinary
Task Area: History Taking and Performing a Physical Exam
Core Rotation: Pediatrics
Topic(s): Cryptorchidism
48. Stem: A 65-year-old male patient presents to the Emergency Department for left-sided
facial hemiplegia and slurring of speech. The history and physical exam suggest that he
is likely suffering from an acute cerebrovascular accident. Which of the following answer
choices would be an absolute contraindication to the administration of tissue
plasminogen activator (TPA)?
Answer Choice:
A.
B.
C.
D.
E.
A cholecystectomy 7 days ago
Recent gastrointestinal bleeding
Seizure at onset of symptoms
Uncontrolled hypertension
Pregnancy
Answer: The answer is D.
Explanation: TPA is a thrombolytic agent used in the treatment of ischemic strokes. Strict guidelines
exist around its use, and in particular has absolute and relative contradictions. This information must be
obtained in order for TPA to remain a treatment option. Absolute contraindications include: intracranial
bleeding, subarachnoid hemorrhage, brain surgery, head trauma, or stroke in past 3 months,
uncontrolled hypertension, history of intracranial hemorrhage, known intracranial arteriovenous
malformation, neoplasm, aneurysm, active internal bleeding, endocarditis, known bleeding diathesis,
and abnormal blood glucose (D). Relative contraindications include: pregnancy minor/ rapidly improving
stroke symptoms, major surgery or serious trauma in the past 14 days, history of gastrointestinal or
urinary tract bleeding within 21 days, seizure at symptom onset, recent arterial puncture at a
noncompressible site, recent lumbar puncture, and post myocardial infarction pericarditis (A, B, C, and
E).
References: Bhat L, Humphries RL. Neurologic Emergencies. In: Stone C, Humphries RL, eds. CURRENT
Diagnosis & Treatment: Emergency Medicine. 8th ed. New York, NY: McGraw-Hill; 2017.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=2172
&sectionid=165065601. Accessed February 11, 2019.
Organ System: Neurologic
Task Area: History Taking & Performing Physical Examination, Clinical Intervention
Core Rotation: Emergency Medicine
Topic(s): Ischemic Stroke
49. Stem: A 34 year-old male and 33 year-old female present to the clinic with concerns of
infertility. They have engaged in unprotected and frequent intercourse for the past 3
months. Her past medical history is non-contributory but her sister and brother-in-law
are dealing with infertility. Her male partner has no history of testicular injury, surgeries,
or sexual dysfunction. Which of the following is the most appropriate recommendation
at this time?
Answer choice:
a.
b.
c.
d.
e.
Patient education on timed intercourse
Semen analysis
Hysterosalpingogram
Evaluation of Luteinizing Hormone
Pelvic ultrasound
Answer: The answer is A
Explanation: Patient education on timed intercourse (with or without ovulation predictor methods) is
the initial intervention recommended in women under the age of 35 years who have attempted
fertilization for <6 months. This patient is 33 and attempt has failed after 3 months. Furthermore, the
male partner does not have any risk factors warranting expedited evaluation. Although her sister is
dealing with infertility, you do not know the condition of the sister’s male partner. The American College
of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM)
recommend that women older than 35 years receive an expedited infertility evaluation (options include
those in other answer choices) and undergo treatment after 6 months of failed attempts to conceive or
earlier, if clinically indicated.
References:
Kuohung W., Hornstein MD. Overview of infertility. In: UpToDate, Barbieri RL, Eckler K. (Eds.), UpToDate,
Waltham, MA. Available at http://www.uptodate.com (Accessed on November 28, 2017.)
Organ System: Reproductive
Task Area: Clinical Intervention
Core Rotation: Obstetrics-Gynecology
Topic(s): Infertility
50. Stem: In an adult with low back pain who presents for evaluation, which of the following
is most consistently associated with a risk for malignancy in the United States?
Answer choice:
A.
B.
C.
D.
Unexplained weight loss
Reduced appetite
General malaise
History of cancer
Answer: The answer is D.
Explanation: While each of the choices has been posited as a possible red flag for cancer, the United
States literature consistently recommends a prior history as the most important finding (D).
References:
Verhagen AP, Downie A, Popal N, Maher C, & Koes BW. Red flags in current low back pain guidelines: a
review. European Spine Journal. 2016;25: 2788-2802. https://doi.org/10.1007/s00586-016-4684-0.
Organ System: Musculoskeletal
Task Area: Applying Basic Science Concepts
Core Rotation: Family Medicine, Internal Medicine, Surgery
Topic(s): Neoplasms, Benign
51. Stem: For 72 hours, a male patient has cough and fever. He has had several ill contacts
at work with similar symptoms. He has treated his fever with OTC ibuprofen. He has no
chest pain but does feel weak and fatigued. There is no vomiting or diarrhea. An oral
temperature is 101 F. HEENT exam reveals rhinorrhea. The neck is supple with nodes or
JVD. Heart is tachycardic without murmur. Lung exam reveals rales at the left lower
base. A PA chest radiograph is interpreted as having a left lower lobe infiltrate.
Which choice would lead to the hospitalization of the patient due to higher risk for
mortality?
Answer choice:
a.
b.
c.
d.
PMH of controlled hypertension
Age 55 years old
Age 65 years old and without PMH
Blood pressure of 102/64
e. Pulse oximetry on room air of 88%
Answer: The answer is E
Explanation: Hypoxia is an indication of respiratory distress and the patient should be considered for
inpatient care due to potential for increased mortality. Controlled hypertension and age less than 60
place the patient at low risk. A healthy patient older than 60 is also at low risk. Normotensive patients
are not at risk for pneumonia related mortality.
References:
Dabelić A. Respiratory Problems. In: South-Paul JE, Matheny SC, Lewis EL. eds.CURRENT Diagnosis &
Treatment: Family Medicine, 4e New York, NY: McGraw-Hill; .
http://accessmedicine.mhmedical.com/content.aspx?bookid=1415&sectionid=77057157. Accessed
December 02, 2017.
Organ System: Pulmonary
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine
Topic(s): Infectious Disorders, Bacterial Pneumonia
52. Stem: A 21-year-old male fast food worker without past medical history accidentally
spilled hot coffee on his uniform while serving a customer. He has a burn to his right
thigh that was initially treated at work with removal of the clothing and application of a
cold compress. His manager gave him oral ibuprofen out of the store first aid kit prior to
arrival. Other than a mild tachycardia, the only other physical abnormality is a deep red
thermal burn to the majority of the anterior right thigh with scattered small clear
blisters that is tender to palpation.
Which choice would be of lowest utility in the initial management of this burn injury?
Answer choice:
a.
b.
c.
d.
e.
Topical antibiotic ointment
Non-adherent dressing
Oral systemic antibiotics
Next day outpatient referral
Oral analgesics
Answer: The answer is C
Explanation: Starting oral systemic antibiotics prophylactically for this minor (approximately 10% body
surface area) 1st and 2nd degree burn is not indicated. A combination of topical antibiotic ointment with
a non-adherent dressing and oral analgesics for pain control is recommended initial treatment. The
patient should be seen the next day for re-evaluation of the burn.
References:
Drigalla D, Barth B. Burns & Smoke Inhalation. In: Stone C, Humphries RL. eds.CURRENT Diagnosis &
Treatment: Emergency Medicine, 8e New York, NY: McGraw-Hill;
http://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165069359. Accessed
November 26, 2017.
Organ System: Dermatologic
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine
Topic(s): Skin integrity, Burns
53. Stem: A 69-year-old female presents with 3 days of dyspnea and chest tightness. On
exam, she is afebrile, pulse is 110, blood pressure is 162/92, pulse oximetry is 90% on
room air. HEENT is unremarkable and neck supple without venous distention. Heart
tachycardic, regular and without murmur. Lungs have diffuse wheezing throughout lung
fields. Extremities are without cyanosis, clubbing or swelling. An EKG is performed
revealing a rapid sinus rhythm with a QRS complex > 0.12 seconds and an RSR pattern in
leads V1 and V2.
Based upon this episode, which chronic medical condition will this patient most likely have?
Answer choice:
a.
b.
c.
d.
e.
Pulmonary embolus
COPD
Aortic stenosis
Ischemic heart disease
Congestive heart failure
Answer: The answer is B
Explanation: COPD is most likely when the patient has flat neck veins, diffuse wheezing, a low pulse
oximetry measurement and a right bundle branch block found on electrocardiogram. Congestive heart
failure would present with jugular venous distension, rales on lung exam and ischemic changes to the
EKG. Clear lungs on auscultation and a left bundle branch block would likely be found with aortic
stenosis and ischemic heart disease. While pulmonary embolus may result in a right bundle branch block
on EKG, the lung exam will be without adventitious sounds and there may be asymmetrical leg swelling.
References:
Chapter 19. Basic ECG Reading. In: Gomella LG, Haist SA. eds. Clinician's Pocket Reference: The Scut
Monkey, 11e New York, NY: McGraw-Hill; 2007.
http://accessmedicine.mhmedical.com/content.aspx?bookid=365&sectionid=43074928. Accessed
November 21, 2017.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine
Topic(s): Conduction Disorders/dysrhythmias, Bundle branch block
54. Stem: A 3-year-old boy presents with his mother to the clinic, as she has noticed a
“crossed-eye.” He was born full-term with an uncomplicated delivery. Physical exam
reveals no gross deformities, pupils equal and reactive bilaterally, asymmetrical corneal
light reflexes, normal eyelids, white sclera, and normal visual acuity. Cover-uncover test
reveals esotropia of the right eye. What is the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Amblyopia
Anisocoria
Ectropion
Leukocoria
Strabismus
Answer: The answer is E.
Explanation: Strabismus (E) has a prevalence in childhood of 2–3%. Esotropia (crossed eyes) is a
deviation of the eyes toward the nose, and may involve one or both eyes. Exotropia (wall-eyed) results
in divergence of the eyes, and may involve one or both eyes. Physical exam findings of asymmetrical
corneal light reflexes and abnormal cover-uncover test are consistent with a diagnosis of strabismus.
Amblyopia (A) s a loss of visual acuity due to untreated strabismus, refractive errors, or visual
deprivation. This may occur in the nondominant eye of a child with strabismus.
Anisocoria (B) refers to a difference in size between the pupils. Anisocoria occurs with Horner syndrome,
third nerve palsy, Adie tonic pupil, iritis, and trauma.
Ectropion (C) refers to an inward turning of the lower eyelid and is usually noted in elderly patients due
to a degenerative process.
Leukocoria (white pupil), (D) is an uncommon condition that is associated with multiple serious disease
processes and requires prompt ophthalmologic consultation.
References:
Braverman R. Eye. In: Hay WW, Jr., Levin MJ, Deterding RR, Abzug MJ, eds. CURRENT Diagnosis &
Treatment Pediatrics 2016, 23e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1795&sectionid=125739533. Accessed
January 16, 2018.
Riordan-Eva P. Disorders of the Eyes & Lids. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current
Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=167995926. Accessed
January 16, 2018.
Organ System: EENT
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Pediatrics
Topic(s): Eye Disorders, Vision abnormalities, Strabismus
55. Stem: A 60-year-old man, admitted for a repeat total knee arthroplasty after sustaining
an infection, begins having multiple unformed stools and mild fever at POD #3. Which of
the following medications is indicated as first line treatment for his suspected
condition?
Answer choice:
A.
B.
C.
D.
Imodium
Vancomycin
Metronidazole
Keflex
Answer: The answer is B.
Explanation: Multiple unformed stools is very suggestive of infection with C. diff. Current IDSA
recommendations are to DC all antibiotics, start vancomycin, and avoid anti-diarrheal, especially opioid
ones (B). Metronidazole is the second-line drug (C).
References:
McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SC, ... Wilcox MH. Clinical practice
guidelines for clostridium difficile infections in adults and children: 2017 update by the infectious
disease society of America (IDSA) and society for healthcare epidemiology of america (SHEA). Clinical
Infectious Diseases. 2018 Mar19;66(7), e1-e48. https://doi.org/10.1093/cid/cix1085.
Organ System: Infectious Diseases
Task Area: Pharmaceutical Therapeutics
Core Rotation: Surgery, Internal Medicine
Topic(s): Bacterial Diseases
56. Stem: A 25-year-old female patient presents to the Urgent Care complaining of passing
out at home two hours ago. She notes that this event occurred earlier in the day, shortly
after returning home from a walk around the neighborhood with her dog. Which of the
following answer choices, if present in her history and physical examination, would
suggest a benign prognosis for this patient?
Answer Choice:
A.
B.
C.
D.
E.
A prodromal sensation prior to losing consciousness
Chest pains associated with the episode
Loss of consciousness while climbing steps
Total loss of consciousness lasting 5 minutes
Persistent focal neurologic defect
Answer: The answer is A.
Explanation: Neurally mediated syncope is the most common cause of syncope evaluated in the clinic. It
is common in young patients between the ages of 10 and 30 and is typically accompanied by a prodrome
representing activation of the autonomic nervous system. Features of the prodrome can include
palpitations, pallor, diaphoresis, lightheadedness, or dizziness (A). A single, neurally mediated, syncopal
event generally has an excellent prognosis. Chest pain and exertional syncope can suggest cardiac origin
(B and C). Syncope by definition is transient and brief, so persistent symptoms or extended loss of
consciousness are unlikely to be benign in nature and necessitate further evaluation (D and E).
References: Freeman R. Syncope. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J,
eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=2129
&sectionid=192011273. Accessed February 11, 2019.
Organ System: Neurologic
Task Area: History Taking & Performing Physical Examination
Core Rotation: Emergency Medicine
Topic(s): Syncope
57. Stem: A 15-year-old male presents with a sudden onset of target-shaped lesions on the
extensor surfaces of the arms and palms of the hands. They are asymptomatic. What is
the most common cause of these lesions?
<CATCH: Insert photo C>
<CATCH: Insert credit line underneath the photo: Reproduced with permission from Goldsmith LA, Katz
SI, Glichrest BA, Paller AS, Leffell DJ, Wolff K: Fitzpatrick's Dermatology in General Medicine, 8th Edition,
www.accessmedicine.com. Figure 39-3>
Answer choice:
A.
B.
C.
D.
E.
Aspirin use
Herpes simplex virus
Epstein-Barr virus
Tetracycline antibiotic
Varicella zoster virus
Answer: The answer is B.
Explanation: Erythema multiforme is a cutaneous reaction to antigenic stimuli. There are many things
that can cause this reaction, including infections and drugs. By far, the most common cause is the herpes
simplex virus (B). Other common causes include mycoplasma, sulfonamides, and penicillin.
References:
Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, & Wolff K. Fitzpatrick’s Dermatology in General
Medicine. 8th ed. New York, NY: McGraw-Hill.
Organ System: Dermatologic
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Family Medicine
Topic(s): Desquamation, Erythema Multiforme
58. Stem: A 36-year-old female with a history of panic disorder presents to the clinic with a
respiratory rate of 30 breaths per minute and complaints of tingling around her mouth
and her hands. A blood gas demonstrates a pH of 7.49, PCO2 31 mEq/L, and HCO3 23
mEq/L. Which of the following best describes the primary acid–base disorder?
Answer choice:
A.
B.
C.
D.
E.
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
No disorder
Answer: The answer is D.
Explanation: The normal range for arterial blood pH is between 7.35 and 7.45. Acidosis is defined as an
arterial blood pH <7.35 and an alkalosis is defined as a pH >7.45. The normal range for PCO2 is 35 to 45
24 mEq/L. The normal range for serum bicarbonate is 23 to 28 24 mEq/L. This patient has a metabolic
alkalosis based on the finding of a high pH (7.49) and a normal HCO3 (24 mEq/L). This patient’s CO2 is 30
mm Hg, which is low secondary to her rapid breathing. CO2 is a volatile acid produced in the tissues and
must be either removed or retained by the lungs to maintain a normal pH. The respiratory rate will
increase in the setting of an acidosis to reduce the amount of CO2 via expiration and therefore increase
the pH. Inversely, in the setting of alkalosis, the respiratory rate will decrease and retain CO2 to lower
the pH. However, in this setting, the patient is breathing rapidly, decreasing the retention of CO2. The
kidneys attempt to compensate within hours to days by retaining increased amounts of HCO3 to
increase the pH in a setting of acidosis. Inversely, the kidneys will decrease amounts of HCO3 through
excretion to decrease the pH in a setting of alkalosis (D). There is no compensation noted at this point.
References:
Acid-Base Balance. In: Levitzky MG, eds. Pulmonary Physiology. 9th ed. New York, NY: McGrawHill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2288&sectionid=178857393. Accesse
d January 22, 2018.
Organ System: Renal
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation: Internal Medicine, Emergency Medicine
Topic(s): Fluid and Electrolyte Disorders, Acid/Base Disorders
59. Stem: A 4-month-old female infant presents with her mother for a routine well-baby
check. She has been feeding well, and her mother has no concerns. Physical exam
reveals a well-appearing, well-nourished infant in no acute distress. Cardiac exam
reveals a loud, high-pitched holosystolic murmur at the left lower sternal border. The
remainder of a complete physical examination is unremarkable. What is the most likely
diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Aortic regurgitation
Atrial septal defect
Coarctation of the aorta
Patent ductus arteriosus
Ventricular septal defect
Answer: The answer is E.
Explanation: Ventricular septal defect (VSD), (E), is a defect in the ventricular septum between the left
and right ventricles, and is often asymptomatic. The murmur associated with VSD is described as a loud,
high-pitched holosystolic murmur at the left lower sternal border and may decrease with Valsalva or
handgrip.
Aortic regurgitation (A) is incorrect. The murmur of aortic regurgitation is characterized as a blowing,
decrescendo diastolic murmur heard best at the third and fourth intercostal space at the left sternal
border.
Atrial septal defect (B) is incorrect. A systolic ejection murmur can be heard as a result of increased flow
through the pulmonary valve.
Coarctation of the aorta (C) is incorrect. The cardinal physical finding is decreased or absent femoral
pulses. Coarctation is usually diagnosed by a pulse and blood pressure (> 15 mm Hg) discrepancy
between the arms and legs on physical examination. A systolic ejection murmur is often heard at the
aortic area and the lower left sternal border, along with an apical ejection click if there is an associated
bicuspid aortic valve.
Patent ductus arteriosis (D) is incorrect. A continuous machine-like murmur is best heard at the left
sternal border, at the first or second intercostal space.
References:
Jone P, Darst JR, Collins KK, Miyamoto SD. Cardiovascular Diseases. In: Hay WW, Jr., Levin MJ, Deterding
RR, Abzug MJ, eds. CURRENT Diagnosis & Treatment Pediatrics 2016, 23e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1795&sectionid=125741666. Accessed
December 29, 2017.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Pediatrics
Topic(s): Congenital Heart Disease, Ventricular Septal Defect
60. Stem: A 22-year-old Asian male presents with diarrhea, flatulence, and crampy
abdominal pain that occurs after ingestion of dairy products. He denies fevers, weight
loss, steatorrhea, constipation, melena, hematochezia, tenesmus, or skin rashes. His
past medical history is unremarkable, and his family history is significant for lactose
intolerance. Which of the following diagnostic test is most likely to confirm lactose
intolerance in this patient?
Answer choice:
a.
b.
c.
d.
e.
Hydrogen breath test
IgA tissue transglutaminase antibody
Sweat chloride test
Urea breath test
Colonoscopy
Answer: The answer is A.
Explanation: The correct answer is hydrogen breath test (A). Resolution of symptoms with a 2-week
lactose-free diet is suggestive of lactase deficiency, which can be confirmed with a hydrogen breath test
if necessary. About 90% of Asian Americans are lactose intolerant, compared with less than 25% of
Caucasians.
IgA tissue transglutaminase antibody (B) is 98% sensitive and 98% specific for the diagnosis of celiac
diease. Celiac disease commonly presents with weight loss, chronic diarrhea, abdominal distention, and
growth retardation. More atypical symptoms include the rash of dermatitis herpetiformis, iron
deficiency anemia, and osteoporosis. A gluten-free diet would be prescribed to treat this condition.
A sweat chloride test (C) is used to make a diagnosis of cystic fibrosis. Gastrointestinal manifestations of
cystic fibrosis may include steatorrhea, diarrhea, abdominal pain, and failure to thrive.
A urea breath test (D) is used to test for Helicobacter Pylori infection as a cause for gastritis. Common
symptoms of gastritis include epigastric pain, early satiety, anorexia, nausea or vomiting, hematemesis,
and melena.
Colonoscopy (E) is not an appropriate test to confirm lactose intolerance. A colonoscopy may be useful
to rule out malignancy or inflammatory bowel disease in patients with weight loss, tenesmus, or bloody
stools.
References:
McQuaid KR. Gastrointestinal Disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical
Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168013478. Accessed
January 18, 2018.
Organ System: Gastrointestinal/Nutritional
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Family Medicine
Topic(s): Food allergies, food sensitivities, Lactose Intolerance
61. Stem: In a premature infant with known hyaline membrane disease, which one of the
following is needed to support the infant’s breathing?
Answer choice:
a.
b.
c.
d.
e.
Aerosolized albuterol
Antibiotic therapy
Corticosteroid injections
Surfactant therapy
Thalidomide
Answer: The answer is D
Explanation: Hyaline membrane disease occurs due to the deficit of surfactant. It is essential to replace
the surfactant (D) to support the pulmonary system. Corticosteroids (C) can be given to the mother prior
to delivery to help mature the lungs, but are not indicated for the delivered baby. Antibiotics (B) and
albuterol (A) are not indicated. Thalidomide (E) helps cough in a patient with idiopathic pulmonary
fibrosis.
References:
Smith D, Grover TR. The Newborn Infant. In: Hay WW, Jr., Levin MJ, Deterding RR, Abzug
MJ. eds. CURRENT Diagnosis & Treatment Pediatrics, 23e. New York, NY: McGraw-Hill.
Organ System: Pulmonary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Pediatrics
Topic(s): Other Pulmonary Disease, Hyaline Membrane Disease
62. Stem: A 20-year-old male presents to his family practice provider complaining of
anterior neck pain that began eight hours ago. The pain also radiates to the ears. Vital
signs are stable except for a temperature of 101.5 ᵒF. Physical exam finds erythema of
the skin overlying the thyroid and an extremely tender thyroid with marked fluctuance
on palpation. What is the best treatment plan for this patient’s suspected diagnosis?
Answer choice:
a.
b.
c.
d.
e.
NSAIDS and propranolol
Levothyroxine and warm compresses
Antibiotics and surgical drainage
Methimazole and thyroidectomy
Neck CT and fine needle aspiration biopsy
Answer: The answer is C
Explanation: Patients with infectious (suppurative) thyroiditis usually are febrile and have severe pain,
tenderness, redness, and fluctuation in the region of the thyroid gland. The treatment for infectious
(suppurative) thyroiditis with fluctuance is intravenous antibiotics and surgical drainage. NSAID’s along
with propranolol (A) would not effectively treat patients infection, and similar treatments in choices B
and C would also not be effective for the same rationale. CT needle biopsy in an acute setting would not
drain the growing infection (E).
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGraw-
Hill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=167996562.
Organ System: Endocrine
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine
Topic(s): Thyroid disorders, Thyroiditis
63. Stem: A 30-year-old male presents to the clinic after noticing enlargement of his right
testis. He denies fevers, tenderness, dysuria, or urethral discharge. He is in a
monogamous relationship and denies concerns about sexually transmitted infections.
Past medical history is significant for a right-sided cryptorchidism that self-resolved. A
physical exam reveals a discrete, firm, nontender mass of the right testis that does not
transillumnate or decrease in size when the patient is supine. Which of the following is
the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Epididymitis
Hydrocele
Testicular torsion
Testicular tumor
Varicocele
Answer: The answer is D.
Explanation: Testicular cancers (D) are the most common neoplasm in men ages 20–35. The most
common symptom is painless enlargement of the testis, and a discrete mass is often noted on exam.
Testicular cancer is slightly more common on the right, and a history of cryptorchidism is considered to
be a significant risk factor.
Epididymitis (A) presents with fever, irritative voiding symptoms, and painful enlargement of the
epididymis. Sexually transmitted forms usually occur in men under 40 years of age, and non-sexually
transmitted forms usually occur in older men and are associated with UTI or prostatitis.
A hydrocele (B) is a collection of fluid between the two layers of the tunica vaginalis. A hydrocele may
develop in the presence of a testicular tumor, but will transilluminate on exam.
Testicular torsion (C) is an emergent condition that presents with acute onset of pain and swelling of the
testis, along with nausea. Examination may reveal tenderness and a high-riding testis.
A varicocele (E) is engorgement of the internal spermatic veins above the testis. These almost always
occur on the left side and significantly decrease in size when the patient is placed in a supine position. A
varicocele is described on exam as a “bag of worms.”
References:
Cornett PA, Dea TO. Cancer. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis
& Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168004201. Accessed
January 18, 2018.
Meng MV, Walsh TJ, Chi TD. Urologic Disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current
Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168019217. Accessed
January 18, 2018.
Organ System: Genitourinary
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine
Topic(s): Neoplasms, Testicular Cancer
64. Stem: A 50-year-old man presents to the Emergency Department from a rehabilitation
center, where he is recovering from a recent hospitalization for a pulmonary embolism.
He is on low-molecular-weight heparin, and his platelets have decreased from
250,000/microL to 100,000/microL. He denies abnormal bleeding or bruising. What is
the most appropriate management?
Answer choice:
a.
b.
c.
d.
e.
Continue current management and monitor platelet count
Order PF4-heparin antibody ELISA and await results
Platelet transfusion
Stop low-molecular-weight heparin and start a thrombin inhibitor
Switch to unfractionated heparin
Answer: The answer is D.
Explanation: This patient is experiencing heparin-induced-thrombocytopenia (HIT), and the correct
answer is to stop low-molecular-weight heparin and start a thrombin inhibitor (D). In cases of suspected
HIT, treatment should not be delayed while awaiting lab results. All forms of heparin, including
unfractionated heparin, should be immediately discontinued ((A), (B), and (E)), and an alternative
anticoagulant should be initiated. A platelet transfusion (C) should be avoided in most cases, unless
acute bleeding is present.
References:
Leavitt AD, Minichiello T. Disorders of Hemostasis, Thrombosis, & Antithrombotic Therapy. In: Papadakis
MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGrawHill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168013149.
Accessed January 23, 2018.
Organ System: Hematologic
Task Area: Pharmaceutical Therapeutics
Core Rotation: Emergency Medicine
Topic(s): Coagulation Disorders, Thrombocytopenia
65. Stem: A 66-year-old male smoker is diagnosed with pulmonary hypertension secondary
to severe COPD. Which one of the following physiologic changes occurs as a result of
this condition?
Answer choice:
a.
b.
c.
d.
e.
Left artrial dilation
Left ventricular wall thickening
Pulmonary artery pressure decreases
Right ventricular afterload increases
Serum angiotensin converting enzyme levels increase
Answer: The answer is D
Explanation: The most common mechanism that leads to cor pulmonale is pulmonary hypertension that
alters the right ventricle structure. Pulmonary artery pressures increase (C) and right ventricle afterload
increases (D). Cor pulmonalae develops due to pulmonary vasculature changes; therefore, left atrial and
ventricle changes are not typically seen (A), (B). ACE levels rise in sarcoidosis, whereas BNP levels rise in
cor pulmonalae (E).
References:
Mann DL, Chakinala M. Heart Failure: Pathophysiology and Diagnosis. In: Kasper D, Fauci A, Hauser S,
Longo D, Jameson J, and Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY:
McGraw-Hill.
Organ System: Pulmonary
Task Area: Applying Basic Science Concepts
Core Rotation: Internal Medicine
Topic(s): Pulmonary Circulation, Cor Pulmonale
66. Stem: During a routine well-woman exam, a 32-year old woman states that she has mild
left-lower quadrant pain. Her menstrual cycles are regular occurring every 28 days. She
is on day 10 of her current cycle. Pelvic exam is significant for a palpable mobile left
adnexal mass. Pregnancy test is negative. Ultrasound reveals a 3 cm unilocular fluidfilled cyst with a thin wall and no septations. Which of the following is the most
appropriate next step?
Answer choice:
a.
b.
c.
d.
e.
Surgical management due to risk of rupture
Enhanced imaging with MRI
Repeat Ultrasound in 6 weeks
Measure serum human chorionic gonadotropin (hCG) levels
Administer clomiphene citrate
Answer: The answer is C
Explanation: The description is classic for a functional follicular ovarian cyst (pre-menopausal, 3 cm,
unilateral, causes tenderness, unilocular, thin-walled and without septations). Follicular cysts are
typically self-limited and thus, ultrasound should be repeated at 6 weeks to determine if resolved.
Surgical management is needed for hemorrhagic corpus luteum cysts with unstable patient. Imaging nor
hCG is indicated for this patient and clomiphene citrate is not appropriate for treatment of cysts.
References:
Muto MG. Approach to the patient with an adnexal mass. In: UpToDate, Sharp HT, Goff B, Falk SJ. (Eds.),
UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed on December 1, 2017.)
Zerden, M. Ovarian and adnexal disease In: Link FW, Carson SA, Flower WC, Snyder RR., eds. Step-Up to
Obstetrics and Gynecology. Philadelphia, PA: Wolters Kluwer Health; 2015: 357-366.
Organ System: Reproductive
Task Area: Clinical Intervention
Core Rotation: Obstetrics-Gynecology
Topic(s): Ovarian disorders, Cysts
67. Stem: A dexamethasone suppression test is used to diagnose which of the following
conditions?
Answer choice:
a. Addison disease
b.
c.
d.
e.
Cushing syndrome
Acromegaly
Sheehan syndrome
Graves disease
Answer: The answer is B
Explanation: Cushing syndrome refers to the manifestations of excessive corticosteroids. In the
dexamethasone suppression test, dexamethasone 1 mg is given in the evening, and a serum cortisol
level is collected in the morning. In patients without hypercortisolism, endogenous cortisol production
is suppressed by the administration of exogenous dexamethasone. In patients with Cushing syndrome,
the serum cortisol level remains elevated despite the administration of dexamethasone. Addison’s
disease is a disorder of low corticosteroids, and Acromegaly (C) develops from a pituitary adenoma
typically, as well as Sheehan syndrome (D), which is also related to the pituitary gland.
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGrawHill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=167996562.
Organ System: Endocrine
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Adrenal disorders, Cushing syndrome
68. Stem: In metabolic alkalosis the lungs attempt to compensate by which of the
following?
Answer choice:
A.
B.
C.
D.
E.
Decreasing blood flow to the alveoli
Increasing blood flow to the alveoli
Increasing the respiratory rate
Decreasing the respiratory rate
Increasing blood flow to the kidneys
Answer: The answer is D.
Explanation: Primary acid-base disturbances have a compensatory response; however, this response will
not completely restore the pH to normal. The lungs begin to compensate within minutes to change the
pH. Carbon dioxide (CO2) is a volatile acid produced in the body and must be removed by the lungs to
maintain a normal pH. The respiratory rate will increase in the setting of an acidosis to reduce the
amount of CO2 via expiration and therefore increase the pH (C). Inversely, in the setting of alkalosis, the
respiratory rate will decrease and retain the CO2 (D).
References:
Acid-Base Balance. In: Levitzky MG, ed. Pulmonary Physiology. 9th ed. New York, NY: McGrawHill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2288&sectionid=178857393. Accesse
d January 22, 2018.
Organ System: Renal
Task Area: Applying Basic Science Concepts
Core Rotation: Internal Medicine, Emergency Medicine
Topic(s): Fluid and Electrolyte Disorders, Acid/Base Disorders
69. Stem: An 8-year-old girl presents with her mother to primary care for evaluation of
allergic rhinitis recalcitrant to daily cetirizine. Her main symptoms include a persistent
dry cough, daily fatigue at recess and new-onset coughing spells several hours after
falling asleep at night two nights weekly. There is no fever. Which of the following is the
most appropriate next step in management?
Answer choice:
A.
B.
C.
D.
E.
Referral to an allergist
Pulmonary function testing
Check oxygen saturation
Discharge home
Nebulizer administration
Answer: The answer is C.
Explanation: The most immediately available resource in a primary care office for a patient with a
suspected asthma diagnosis by history alone is an oxygen saturation check (C). If low, a nebulizer would
be the next most likely step (E). Definitive diagnosis requires spirometry once the patient is known to be
stable. Referral to an allergist may be helpful at a later date (A). Discharge home with no further care is
contraindicated (D).
References:
Papadakis MA, McPhee SJ. Current Medical Diagnosis and Treatment 2016. 55th ed. New York, NY:
McGraw-Hill; 2016.
Organ System: Pulmonary
Task Area: Clinical Intervention
Core Rotation: Pediatrics, Family Medicine
Topic(s): Other Pulmonary Diseases, Asthma
70. Stem: In a patient with metatarsalgia, which of the following statements would be
helpful in leading to a diagnosis of Morton’s neuroma?
Answer choice:
A.
B.
C.
D.
Predominantly male disorder of the forefoot
Occurs in the second interdigital space
Has a greater than 70% success rate with conservative treatment
Pain often radiates to the toes on either side of the interdigital space
Answer: The answer is D.
Explanation: Interdigital neuromas occur predominantly in females at a ratio of 4:1. They most
commonly occur in the third interdigital space, and conservative treatment is useful in 30%, primarily
used to delay surgery. Radiation to the digits on either side of the neuroma is common (D).
References:
Di Caprio F, Meringolo R, Eddine MS, & Ponziani L. Morton’s interdigital neuroma of the foot: A
literature review. Foot Ankle Surg. 2018 Apr;24(2):92-98. https://doi.org/10.1016j.fas2017.01.007.
Organ System: Musculoskeletal
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Family Medicine
Topic(s): Lower Extremity Disorders
71. Stem: A 24-year-old woman underwent a transfusion of 2 units of packed red blood
cells after suffering a splenic laceration. Approximately 30 minutes into the transfusion,
there is evidence of an acute hemolytic transfusion reaction and the transfusion is
stopped. What did the patient most likely report to the provider at the onset of this
transfusion reaction?
Answer Choice:
A.
B.
C.
D.
Flank pain
Diarrhea
Tinnitus
Urticaria
E. Circumoral numbness
Answer: The answer is A.
Explanation: An acute hemolytic reaction is the result of ABO isoagglutinins lysing donor erythrocytes,
which leads to release of hemoglobin from the cells. Extracellular hemoglobin has direct toxic effects on
the renal tubular cells. Intravascular hemolysis leads to cell death and decreased oxygen-oxygen carrying
capacity of erythrocytes, resulting in hypoxia. Both large volume cell death and hypoxia induce
inflammation, which can manifest as pain (A). Diarrhea is most commonly associated with graft-versushost disease, which is the result of donor lymphocytes attacking an immunodeficient host (B). Tinnitus is
not commonly associated with acute hemolytic transfusion reactions. Urticaria reactions are usually
related to plasma proteins in transfused components and may not present until after the transfusion is
complete (D). Circumoral numbness is most commonly associated with hyperventilation, which may
occur if a patient is experiencing difficulty breathing (E). In the setting of a transfusion, this is most likely
to occur with bronchospasm that occurs during an anaphylactic reaction. This type of reaction is most
likely to occur after a few milliliters of blood product has been transfused, making it less likely after 30
minutes of transfusion.
References:
Bunn H, Kaufman R. Blood Transfusion. In: Aster JC, Bunn H, eds. Pathophysiology of Blood Disorders. 2nd
ed. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1900&sectionid=137395856. Accessed
December 07, 2018.
Chajewski OS, Squires JE. Postoperative Blood Transfusion. In: McKean SC, Ross JJ, Dressler DD, Scheurer
DB, eds. Principles and Practice of Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1872&sectionid=138891186. Accessed
December 07, 2018.
Dzieczkowski JS, Tiberghien P, Anderson KC. Transfusion Biology and Therapy. In: Jameson J, Fauci AS,
Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New
York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192280223. Accessed
December 07, 2018.
Organ System: Hematologic
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Surgery, Internal Medicine, Emergency Medicine
Topic(s): Transfusion Reaction
72. Stem: Which of the following lab value combinations is consistent with a patient who
has hypercortisolism due to an adrenal tumor?
Answer choice:
a. Elevated ACTH levels, elevated cortisol levels
b.
c.
d.
e.
Elevated ACTH levels, cortisol levels within normal limits
Decreased ACTH levels, elevated cortisol levels
ACTH levels within normal limits, decreased cortisol levels
Decreased ACTH levels, decreased cortisol levels
Answer: The answer is C
Explanation: Once hypercortisolism is confirmed, a plasma or serum ACTH is obtained. A decreased level
of ACTH indicates a probable adrenal tumor, whereas higher levels are produced by pituitary or ectopic
ACTH-secreting tumors.
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGrawHill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=167996562.
Organ System: Endocrine
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Neoplasms, Neoplastic syndrome
73. Stem: A 69-year-old woman with a history of mitral valve stenosis and end-stage chronic
kidney disease (GFR < 15 ml/min) was admitted to the hospital for evaluation and
management of two hours of palpitations and shortness of breath. ECG provided the
diagnosis of new onset atrial fibrillation. Cardiac enzymes were negative for myocardial
infarction. She was started on a beta-blocker, which provided rate control. What is the
most appropriate therapeutic agent to initiate to protect against stroke?
Answer Choice:
A.
B.
C.
D.
E.
Dabigatran
Warfarin
Idarucizumab
Aspirin
Rivaroxaban
Answer: The answer is B.
Explanation: Warfarin is the first-line treatment to prevent complications such as stroke in patients with
mitral stenosis and atrial fibrillation. Newer, more convenient medications like the anti-Xa inhibitors,
dabigatran and rivaroxaban, have not been demonstrated to decrease the risk of thromboembolism in
patients with mitral valve stenosis (A and E). In addition, these agents should be avoided in this patient
because of her severely decreased renal function. Idarucizmab is a reversal dabigatran and would not
prevent an ischemic stroke (C). Antiplatelet medications like aspirin have not been demonstrated to be
effective at decreasing the risk of stroke when used alone in patients with atrial fibrillation (D).
References:
Michaud GF, Stevenson WG. Atrial Fibrillation. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill; 2018.
http://usj-ezproxy.usj.edu:2195/content.aspx?bookid=2129&sectionid=192028757. Accessed February
28, 2019.
Organ System: Neurologic
Task Area: Health Maintenance
Core Rotation: Internal Medicine, Primary Care
Topic(s): Stroke
74. Stem: A 54-year-old female with a past medical history of chronic kidney disease,
diabetes mellitus type 2, osteoarthritis, and tobacco use presents for her annual
physical exam. She is accompanied by her three adult daughters. She has been doing
well since her last visit. The only change to her health is that she has started
experiencing occasional leakage of urine. When asked what triggers the leakage, she
says it occurs when she coughs or laughs hard. The amount of leakage varies from just a
spot to full wetness of the underwear. Physical examination reveals blood pressure
130/88 mmHg, pulse 86/minute, respirations 14/minute, pulse oximetry 98%,
temperature 37oC (98.6oF), body mass index 22 kg/m2. There is no evidence of pelvic
organ prolapse. The patient asks you why she is having the leakage. Which of the
following is her greatest risk factor?
Answer choice:
A. Age
B. Childbirth history
C. Diabetes mellitus
D. Cigarette smoking
E. Body mass index
Answer: The answer is A.
Explanation: This patient is presenting with signs and symptoms of urinary incontinence. Many studies
have assessed the natural history and progression of urinary incontinence. Increased age is regarded as
a highly significant risk factor (A). Childbirth history may play a role in development of urinary
incontinence, but it is unclear from the vignette if the patient’s deliveries were vaginal or Cesarean (the
prevalence of urinary incontinence is greater with a history of vaginal versus Cesarean deliveries) (B).
Diabetes mellitus is associated with only a modest increase is incontinence risk (C). An association
between urinary incontinence and cigarette smoking has not been well demonstrated in the literature
(D). Obesity (BMI ≥ 30 kg/m2) has been shown to be strongly associated with urinary incontinence (E).
However, the patient in this vignette has a normal BMI.
References:
Danforth K, Townsend M, Lifford K, et al. Risk factors for urinary incontinence among middle-aged
women. Am J Obstet Gynecol. 2006;194(2):339–345.
Milsom I, Gyhagen M. The prevalence of urinary incontinence. Climacteric.
2018;DOI:10.1080/13697137.2018.1543263.
Organ System: Genitourinary
Task Area: Health Maintenance
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Bladder Disorders, Incontinence
75. Stem: A 30-year-old male presents to your family medicine office for a routine physical
exam. His pulse is 70 and regular, and his blood pressure is 118/76. Physical examination
is unremarkable with normal vital signs. He is concerned because he recently found out
that his cousin has been diagnosed with hereditary hemochromatosis. The patient and
his wife are thinking about starting a family. What is the most appropriate intervention
to recommend to this patient?
Answer Choice:
A.
B.
C.
D.
E.
C282Y homozygote testing
Hepatic function panel, serum
Iron, serum
Lactate dehydrogenase, serum (LDH)
Transferrin saturation and serum ferritin, serum
Answer: The answer is E.
Explanation: The patient has a family history of hemochromatosis; however, it is not in a first degree
relative, so automatic genetic testing is not indicated (A). A serum iron level alone is not enough to
establish the diagnosis (C). A hepatic function panel might show abnormalities in later stages of the
disease, but is not an appropriate screening test for an asymptomatic patient (B). Serum LDH can
indicate liver damage but is non-specific (D). Combined measurement of the percent transferrin
saturation and serum ferritin provides a simple means to exclude patients from further analysis. If either
is elevated in the absence of a known inflammatory condition, further genetic testing for hereditary
hemochromatosis is indicated. We generally apply a combination threshold of transferrin saturation
>45% with a ferritin >200 μg/L for women and >250 μg/L for men.
References: Chang MS, Smith B, Grace ND. Hereditary Hemochromatosis. In: Greenberger NJ, Blumberg
RS, Burakoff R, eds. CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy. 3rd
ed. New York, NY: McGraw-Hill; 2015.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1621&sectionid=105186694. Accessed
February 13, 2019.
Organ System: Hematologic
Task Area: Health Maintenance
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Hemochromatosis
76. Stem: A 32-year-old male with a diagnosis of diabetes mellitus type 1 and chronic kidney
disease (stage 2) presents to the emergency room with complaints of weakness, nausea,
and vomiting. His arterial blood gas demonstrates a pH of 7.32, PCO2 36 mm Hg, and
HCO3 18 mEq/L. Which of the following best describes the primary acid–base disorder?
Answer choice:
A.
B.
C.
D.
E.
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
No disorder
Answer: The answer is A.
Explanation: The normal range for arterial blood pH is between 7.35 and 7.45. Acidosis is defined as an
arterial blood pH <7.35 and an alkalosis is defined as a pH >7.45. The normal range for PCO2 is 35 to 45
mm Hg. The normal range for serum bicarbonate is 23 to 28 mEq/L. This patient has a metabolic acidosis
based on the finding of a low pH (7.32) and a low HCO3 (18 mEq/L) (A). This patient’s CO2 is 36 mEq/L,
which is normal. The lungs will begin to compensate within minutes. CO2 is a volatile acid produced in
the tissues and must be removed by the lungs to maintain a normal pH. The respiratory rate will
increase in the setting of an acidosis to reduce the amount of CO2 via expiration and therefore increase
the pH. Contrariwise, in the setting of alkalosis, the respiratory rate will decrease and retain CO2 to
lower the pH. The kidneys attempt to compensate within hours to days by retaining increased amounts
of HCO3 to increase the pH in a setting of acidosis. Inversely, the kidneys will decrease amounts of HCO3
through excretion to decrease the pH in a setting of alkalosis. There is no compensation noted at this
point.
References:
Acid-Base Balance. In: Levitzky MG, eds. Pulmonary Physiology. 9th ed. New York, NY: McGrawHill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2288&sectionid=178857393. Accesse
d January 22, 2018.
Organ System: Renal
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Fluid and Electrolyte Disorders, Acid/Base Disorders
77. Stem: You are evaluating a 36-year-old male patient in the office. He is complaining of
rectal bleeding, tenesmus, and intermittent mucous production. He reports that he had
a similar issue about 10 years ago and was on enema therapy at that time. He lost his
health insurance and has not taken medication in several years. Colonoscopy shows
inflammation from the rectum to the mid-transverse colon. What is the most important
health maintenance recommendation for this patient?
Answer choice:
a.
b.
c.
d.
e.
Cholesterol screening
Folic acid supplementation
Influenza vaccination
Surveillance colonoscopy
Smoking cessation
Answer: The answer is D.
Explanation: Patients with Crohn’s disease and ulcerative colitis that extends proximal to the rectum are
at greater risk of developing colorectal cancer. This patient had an initial episode 10 years ago and is
now having an exacerbation. He should be advised to have surveillance colonoscopy (D) every 1–2 years.
Folic acid supplementation (B) may reduce the risk of colorectal cancer, but it has not been proven in
large-scale studies. Influenza vaccination (C) is of great priority in patients with autoimmune diseases,
but colorectal cancer prevention is more important. Smoking cessation (E) could actually contribute to
exacerbation of ulcerative colitis. Cholesterol screening (A), while important, would not change the
overall management of the patients symptoms, and thus not the best choice for this question.
References:
McQuaid KR. Gastrointestinal Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical
Diagnosis & Treatment 2018 New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168013478. Accessed
January 31, 2018.
Organ System: Gastrointestinal/Nutritional
Task Area: Health Maintenance
Core Rotation: Internal Medicine
Topic(s): Colorectal disorders, Inflammatory Bowel Disease
78. Stem: You are seeing a 66-year-old male smoker for routine follow up of hypertension.
He mentions that his older brother just underwent surgery for an abdominal aortic
aneurysm (AAA). What is the most appropriate screening test for this patient?
Answer choice:
a.
b.
c.
d.
e.
Abdominal x-ray
CT scan
Contrast aortography
MRI
Ultrasound
Answer: The answer is E.
Explanation: Smokers as well as first degree family members of patients who have had AAA are at
greater risk of AAA themselves. Therefore, abdominal ultrasound (E) is recommended as a screening
tool. Not all aneurysm are calcified, so abdominal x-ray (A) may miss up to 25% of aneurysms. CT scan
(B) exposes the patient to radiation, MRI (D) is costly, and contrast aortography (C) carries risk of
bleeding, anaphylaxis, and atheroembolism, making the risk outweigh the benefit.
References:
Creager MA, Loscalzo J. Diseases of the Aorta. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J,
Loscalzo J, eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79744168. Accessed
January 31, 2018.
Organ System: Cardiovascular
Task Area: Health Maintenance
Core Rotation: Internal Medicine
Topic(s): Vascular Disease, Aortic Aneurysm
79. Stem: You are called to see a 22-year-old female patient who recently underwent
laparoscopy and lysis of adhesions from previous bowel surgery related to her Crohn’s
disease. She has had persistent nausea, vomiting, and bloating since the surgery.
Abdominal flat plate showed multiple air-fluid levels in the small bowel. An initial
attempt at NG tube placement was unsuccessful, so endoscopic-assisted NG tube
placement was attempted. The patient vomited during the procedure and is now found
to have oxygen saturation of 82% on high flow oxygen via nasal cannula. Her BP is
110/82, pulse is 120 and regular, RR is 30 and labored, and temperature is 37.5 °C.
Physical examination reveals increased work of breathing, diffuse crackles across the
lung fields, and accessory muscle use. What is the most important clinical intervention
for this patient?
Answer choice:
a.
b.
c.
d.
e.
Broad spectrum antibiotic coverage
Enteral nutrition
Intravenous diuresis
Intravenous fluid administration
Intubation with mechanical ventilation
Answer: The answer is E.
Explanation: This patient is suffering from ARDS, as evidenced by severe hypoxemia despite aggressive
supplemental oxygen administration. Respiratory failure alone requires ventilatory support. She is also
exhibiting signs of impending respiratory failure with tachypnea and labored breathing. ARDS requires
intubation and mechanical ventilation with a high initial FIO2 to relieve hypoxemia, and application of
PEEP to increase functional residual capacity (FRC).
References:
Kershaw CD, Martin GS. Acute Respiratory Distress Syndrome. In: McKean SC, Ross JJ, Dressler DD,
Scheurer DB, eds. Principles and Practice of Hospital Medicine, 2e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1872&sectionid=146980583. Accessed
January 31, 2018.
Matuschak GM, Lechner AJ. Acute Lung Injury and the Acute Respiratory Distress Syndrome:
Pathophysiology and Treatment. In: Lechner AJ, Matuschak GM, Brink DS, eds. Respiratory: An
Integrated Approach to Disease. New York, NY: McGraw-Hill; 2012.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1623&sectionid=105765027. Accessed
January 31, 2018.
Organ System: Pulmonary
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine; Internal Medicine
Topic(s): Other Pulmonary Disorders, Acute Respiratory Distress Syndrome
80. Stem: A 17-year-old male is brought in with a complaint of acute onset left scrotal pain
and swelling for the past 12 hours, accompanied by nausea. He denies trauma to the
area. He recalls similar episodes in the past, where he had intense scrotal pain that
spontaneously resolved after a few minutes, so he never sought treatment for it.
Physical examination reveals a massively swollen scrotum. You are unable to palpate the
scrotum due to pain. You attempt to elicit a cremasteric reflex, which is negative. There
is mild improvement in pain when you elevate the affected scrotum. Among the
following, what is the most appropriate next step in this patient’s management?
Answer choice:
a.
b.
c.
d.
e.
Observation with pain control
Doppler ultrasound
Radionuclide imaging
Manual detorsion
Immediate surgical exploration
Answer: The answer is E.
Explanation: Testicular torsion refers to twisting of the spermatic cord and its contents. It is a medical
emergency. Prompt recognition and treatment are critical to testicular salvage. Torsion must therefore
be excluded in all patients who present with an acute scrotum. It is a clinical diagnosis, with most
patient presenting with severe unilateral scrotal pain and swelling, nausea, and vomiting. Physical exam
may reveal a high-riding testicle with an absent cremasteric reflex. If history and physical examination
indicate torsion, immediate surgical intervention (E) is indicated and should not be delayed to attempt
manual detorsion or to perform imaging. Delay in treatment can lead to decreased fertility or to
orchiectomy. Imaging studies such as Doppler ultrasound (B), radionuclide imaging (C) would delay
treatment of a serious condition. Observation with pain control (A) is unacceptable.
References:
Sharp V, Kieran K, Arlen A. Testicular Torsion: Diagnosis, Evaluation, and Management. Am Fam
Physician. 2013;88(12):835-840.
Organ System: Genitourinary
Task Area: Clinical Intervention
Core Rotation: Surgery
Topic(s): Testicular disorders, Testicular Torsion
81. Stem: A 21-year-old woman presents for evaluation of a right breast lump present in the
inferior lateral aspect, mobile, and approximately 1 cm in size. There are no associated
skin changes or nipple discharge, and she has no family history of breast cancer.
Ultrasound shows a solid mass without suspicious features. What is the best course of
treatment for this patient at this time?
Answer choice:
a.
b.
c.
d.
e.
Cryoablation
Excisional biopsy
Follow up ultrasound in 3–6 months
MRI of the breast
Reassurance
Answer: The answer is C.
Explanation: The most likely diagnosis is a fibroadenoma of the breast. The patient is low-risk for breast
cancer given her age and lack of family history, along with a lack of suspicious features of the mass. Core
needle biopsy or follow-up ultrasound (C) would be appropriate at this point. Biopsy proven
fibroadenomas (B) do not require excision if they are clinically and radiographically stable and
asymptomatic. Simple reassurance without further follow up (E) would not be indicated, as it is
important to ensure stability of the mass. Cryoablation (A) can be an alternative to surgical excision, if
the lesion is proven to be a fibroadenoma by core needle biopsy. MRI of the breast (D) is indicated in
evaluation of an equivocal mammogram or ultrasound result, especially in a patient who is not a surgical
candidate.
References:
Sabel MS. Overview of Benign Breast Disease. In www.uptodate.com. Updated July 5, 2017. Accessed
December 25, 2017 and December 27, 2017.
Organ System: Reproductive
Task Area: Clinical Intervention
Core Rotation: Obstetrics-Gynecology
Topic(s): Breast disorders, Fibroadenoma
82. Stem: A 66-year-old female with a long history of COPD and severe pulmonary
hypertension presents for her 6-month evaluation. She is complaining of the typical,
chronic shortness of breath and fatigue, and has no other complaints. She has been
adherent to her medications and therapy and has been as active as she can be
considering her disease. On physical examination, her blood pressure is 168/89, pulse
82, respirations 20, and has a resting oxygen saturation rate of 91% on room air. Jugular
venous pulsation is noted, especially when the patient takes a deep breath. Her breath
sounds are present but decreased throughout and without wheeze. She has a regular
rate and rhythm on cardiac exam, and a 3/6 holosystolic murmur that is best
appreciated at the 5th intercostal space, L sternal border. There is also chronic 1-2+
edema to the lower extremities. Based on this clinical scenario, what is the most likely
etiology for this patient’s murmur detected on physical exam?
Answer choice:
A.
B.
C.
D.
E.
Mitral regurgitation
Aortic regurgitation
Tricuspid stenosis
Tricuspid regurgitation
Mitral stenosis
Answer: The answer is D.
Explanation: This patient with severe pulmonary hypertension can develop tricuspid regurgitation as her
pulmonary disease, which places stress on the valve leaflets by exerting increased pressure and
backflow (D). The clinical manifestations related to this cause regurgitated flow, thus causing JVP to
increase. It will especially increase and be more prominent during inspiration by increasing the
intrathoracic pressures. The best clinical landmark to appreciate a murmur of this nature would be at
the 5th intercostal space, L sternal border. The other choices are also landmarks during the cardiac
exam. However, these other valvular diseases would have other landmarks to detect that specific
disease (A, B, C, and E).
References:
Tricuspid Regurgitation. In: Papadakis MA, McPhee SJ, eds. Quick Medical Diagnosis & Treatment 2017.
New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2033&sectionid=152419133. Accessed
April 24, 2018.
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with
valvular heart disease: a report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63:e57.
Organ System: Cardiovascular
Task Area: History Taking and Performing Physical Exams
Core Rotation: Family Medicine, Internal Medicine, Surgery
Topic(s): Valvular Disorders, Tricuspid Valve
83. Stem: A 45-year-old female with chronic kidney disease comes to the office for routine
follow-up. Three months ago, therapy with a statin (3-hydroxy-3-methylglutaryl
coenzyme A reductase inhibitor) was initiated, and since that time, the patient says she
has been having muscle pain. Physical examination shows tenderness to palpation over
the quadriceps muscles. Results of laboratory studies include elevated serum creatine
kinase level. Urinalysis shows presence of myoglobin. Which of the following is the most
likely diagnosis?
Answer choice:
A. Pyelonephritis
B.
C.
D.
E.
Rhabdomyolysis
Acute cystitis
Diabetic ketoacidosis
Compartment syndrome
Answer: The answer is B.
Explanation: Myoglobin present in the urine is a result of rhabdomyolysis. Rhabdomyolysis is a clinical
syndrome defined by muscle necrosis with subsequent release of intracellular contents into the
extracellular space (B). Myoglobin is filtered through the glomerulus. Thus, distal convoluted tubule
(DCT) damage and obstruction can occur and result in acute kidney injury (AKI). Rhabdomyolysis
symptoms include muscle pain and dark urine. Labs reveal an elevated serum creatinine kinase (CK
20,000–50,000 IU/L) and a false positive finding of heme on the urine dipstick. However, microscopy will
demonstrate none to very few red blood cells present in the urine. The most common causes of
rhabdomyolysis include crush injuries, overexertion, and alcohol. Medications may also result in muscle
necrosis and include statins, selective serotonin reuptake inhibitors, and psychotics. Treatment is
focused on discontinuing the offending agent, fluid repletion, and protection of kidney function.
References:
Hellman DB, Imboden JB. Rheumatologic & immunologic disorders. In: McPhee SJ, Papadakis MA, eds.
Current Medical Diagnosis and Treatment. 57th ed. New York, NY: McGraw-Hill; 2018.
Organ System: Renal
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Chronic Kidney Disease
84. Stem: An 18-year-old high school football player presents to your practice with a nondominant shoulder injury from a football practice. He wants to know when he can start
playing again. Your x-ray evaluation is consistent with a type II AC separation, and your
return to sports advice is which of the following?
Answer choice:
A.
B.
C.
D.
He can return to sports when his pain has resolved
Return to sports in two to four weeks
Return to sports in six to twelve weeks
Return to sports when he can throw overhead
Answer: The answer is B.
Explanation: Type II injuries can return to some sports in two to four weeks, as with all AC joint injuries,
throwing and overhead athletes can take longer, by up to four weeks (B). Type I can return in 3 days to
two weeks, and Type III in six to twelve weeks (C). An orthopedic surgeon should see levels of injury
Type III and above, especially if neurovascular symptoms are present. (UpToDate 2018)
Organ System: Musculoskeletal
Task Area: Health Maintenance
Core Rotation: Family Medicine
Topic(s): Upper Extremity Disorders, Fractures/Dislocations
85. Stem: A 28-year-old pregnant female presents to the primary care office complaining of
bilateral wrist pain. She is in her third trimester and has been experiencing pain in her
wrist recently, especially at night. She denies ever having symptoms like this before. On
further questioning, she reports numbness in her thumb, index, middle, and half of the
fourth finger. You suspect the patient’s symptoms are pregnancy related. What would
be the best preventative measure/patient education to discuss with your patient at this
time?
Answer Choice:
A.
B.
C.
D.
E.
Seek Rheumatology consultation immediately for possible steroid injection
Seek orthopedic consultation immediately for possible surgery
Avoid activities that provoke symptoms and wear wrist splints at night
Look up different wrist exercises the patient can do at home three times a day
If her symptoms get worse, there is no need for follow up
Answer: The answer is C.
Explanation: This patient is presenting with signs/symptoms concerning for carpal tunnel syndrome
(CTS). CTS is caused by compression of the median nerve in the carpal tunnel. Typically, symptoms
include numbness and tingling mainly in the thumb and radial fingers. Symptoms are typically worse at
night. In pregnancy, symptoms can appear rapid and are likely due to fluid retention. Avoiding activities
that provoke symptoms and wearing wrist splints at night is first-line therapy for CTS, especially in
pregnancy (C). Rheumatology consultation is not indicated in CTS. Orthopedic consultation for surgical
release is a treatment for CTS and should be discussed with patients but is not first-line (A and B). Wrist
exercises could provoke and worsen symptoms of CTS (D). If symptoms progress, patients should seek
consult immediately to avoid permanent complications (E).
References:
Papadakis MA, McPhee SJ, Bernstein J. Tunnel Syndrome. In: Papadakis MA, McPhee SJ, Bernstein
J, eds. Quick Medical Diagnosis & Treatment 2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.ezproxy.lynchburg.edu/content.aspx?bookid=2566&sectionid=2
06880095.
Organ System: Neurology
Task Area: Health Maintenance
Core Rotation: Obstetrics-Gynecology
Specific Topic(s): Carpel Tunnel Syndrome
86. Stem: A 21-year-old female presents to your clinic for further evaluation with her
mother. Her mother states that ever since she was a young child, the patient hasn’t had
many friends and has preferred to stay at home instead of socializing. The patient
insisted her mother home school her as well. Her mother feels the patient’s symptoms
developed after she was accidentally lost in a store for several hours at the age of six.
Upon further questioning, the patient expressed her fear and anxiety about going out in
public and prefers to just stay at home where “nothing can happen to her.” Based on
the given information, what best describes this patient’s symptoms?
Answer Choice:
A.
B.
C.
D.
E.
Agoraphobia
Social phobia
Animal phobia
Situational phobia
Panic disorder
Answer: The answer is A.
Explanation: Agoraphobia is an excessive fear of being in a situation where one perceives an unsafe
environment and no means to escape (A). Agoraphobia can be the result of a childhood event, as in this
case of being lost in a store. Social phobia is an anxiety response of being observed by others because of
fear that they will act in an embarrassing or humiliating manner (B). Animal phobia is a fear of animals,
most commonly dogs, snakes, and insects (C). Situational phobia is a fear of a specific situation, most
commonly driving, flying, and enclosed spaces (D). Panic disorder requires a patient to have recurrent
and unpredictable panic attacks, which are distinct episodes of intense fear and discomfort associated
with a variety of physical symptoms (E).
References:
Shelton RC. Anxiety Disorders. In: Ebert MH, Leckman JF, Petrakis IL, eds. CURRENT Diagnosis &
Treatment: Psychiatry. 3rd ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2509&sectionid=20080477
Organ System: Psychiatry/Behavioral
Task Area: Formulating Most Likely Diagnosis
Core Rotation:
Topic(s): Phobias, Agoraphobia
87. Stem: A 70-year-old woman with a recent diagnosis of depression now presents with
BLE paresthesias and restless leg syndrome. Labs reveal a macrocytic anemia. Which of
the following factors in her past medical history likely led to her current problem?
Answer choice:
a.
b.
c.
d.
e.
High dose folate supplementation
Lack of sun exposure
Low carbohydrate/high protein diet
S/p bariatric surgery 1 year ago
S/p R hemicolectomy 3 years prior for colon cancer
Answer: The answer is D.
Explanation: The most likely diagnosis is vitamin B12 deficiency based on her symptoms and labs.
Bariatric surgery (D) is a known risk factor for B12 deficiency due to malabsorption.
Folate deficiency is often seen in conjunction with B12 deficiency. High dose folate supplementation (A)
would not lower B12 levels. Lack of sun exposure (B) is associated with vitamin D deficiency, but not B12
deficiency. A high protein diet (C) would provide adequate dietary intake of vitamin B12, therefore
making this unlikely. Colon resection (E) would not affect nutrient absorption.
References:
Schrier SL. Clinical manifestations and diagnosis of vitamin B12 and folate deficiency. In
www.uptodate.com. Updated July 28, 2017, accessed September 19, 2017.
Organ System: Hematologic
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Internal Medicine
Topic(s): Anemias, Vitamin B12 Deficiency
88. Stem: A 54-year-old man with a history of hypertension, controlled with enalapril,
presents to the Emergency Department with a 3-hour history of agitation, headache,
and tremors. On further questioning it is revealed that the patient used cocaine 5 hours
prior to the visit, as he is under a lot of stress at work. Vitals include: T 99.6, p100, R 20,
BP 198/106. Which physical exam component should be performed as part of his
evaluation?
Answer choice:
a.
b.
c.
d.
e.
1 finger localization
Digital rectal exam
Drop test
Funduscopic exam
Pneumatic otoscopy
Answer: The answer is D.
Explanation: The patient should be evaluated for hypertensive emergency, to determine if there is endorgan damage related to symptomatic uncontrolled hypertension. Given that a headache is present, he
requires funduscopic exam (D) to evaluate for flame hemorrhages or papilledema, which can indicate
hypertensive retinopathy or (rarely) hypertensive encephalopathy. CT or MRI of the brain may also be
warranted. The other physical exam components or special tests listed ((A), (B), (C), and (E)) would not
screen for end-organ damage related to uncontrolled hypertension.
References:
Elliott WJ, Varon J. Evaluation and Treatment of Hypertensive Emergencies in Adults. In
www.uptodate.com. Updated December 18, 2017, accessed December 26, 2017.
Organ System: Cardiovascular
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Emergency Medicine
Topic(s): Hypertension, Hypertensive Emergency
89. Stem: A 72-year-old male with PMH of HTN and hyperlipidemia presents with a
nosebleed for 3 hours. He is currently on a baby aspirin a day but no anticoagulants. The
nosebleed was spontaneous and not associated with trauma. Vital signs are pulse 58,
blood pressure 134/72, respirations 12, oral temperature 98.7 F. On exam, the patient is
alert with blood dribbling from his right nare. On rhinoscopy, an area of bleeding is
noted at the anterior septum in the right nare. The remainder of the EENT exam is
significant for a small amount of blood in the oropharynx.
What is the initial approach to provide hemostasis?
Answer choice:
a.
b.
c.
d.
e.
Chemical cauterization
Direct nasal pressure
Thrombogenic foam
Topical vasoconstrictors
Anterior epistaxis balloon
Answer: The answer is B
Explanation: The patient likely has an anterior nosebleed. Direct nasal pressure should provide
hemostasis through direct tamponade. Topical vasoconstrictors can be added to this method but should
not be relied upon alone. Chemical cauterization, thrombogenic foam or an anterior epistaxis balloon
can be used if direct nasal pressure fails.
References:
McGinnis HD. Nose and Sinuses. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM.
eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill;
2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109387197.
Accessed November 27, 2017.
Organ System: EENT
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine
Topic(s): Nose/Sinus Disorders, Epistaxis
90. Stem: A 29-year-old female is unable to become pregnant after attempting for 6
months. One year prior, she had a spontaneous miscarriage 2 weeks into her first
trimester for which she was seen in the ED and obtained no follow up. She notes an
increased feeling of anxiety and tiredness over the last 2 years. At work, her pulse has
been racing and she will become periodically short of breath during her work as a chef.
She has becoming increasingly intolerant near the oven and stoves due to heat and is
concerned she is having hot flashes and early menopause due to irregular menstruation.
On exam, she is anxious appearing and restless. Her heart rate is 114 at rest and regular.
Her skin is warm and moist, there is white sclera noted above and below the iris
bilaterally on exam. Her thyroid gland is enlarged without nodules or tenderness on
palpation. A serum TSH measures < 0.1 mIU/L (range 0.4-4.0 mIU/L). An EKG reveals a
sinus tachycardia.
Which of the following medications is initially indicated to treat this condition?
Answer choice:
a.
b.
c.
d.
e.
Digoxin
Radioactive iodine
Methimazole
Propylthiouracil
Lithium carbonate
Answer: The answer is D
Explanation: Initial treatment for the patient with hyperthyroidism attempting pregnancy should be
Propylthiouracil rather than Methimazole due to increased risk of fetal abnormalities from the latter
drug when administered during the first trimester. Radioactive iodine and lithium carbonate will be
contraindicated during or when desiring pregnancy. Digoxin would be indicated to control rapid atrial
fibrillation in the hyperthyroid patient, propranolol may be used to control tachycardia otherwise.
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGraw-Hill; .
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=167996562. Accessed
November 28, 2017
Organ System: Endocrine System
Task Area: Pharmaceutical Therapeutics
Core Rotation: Internal Medicine
Topic(s): Thyroid disorders, Hyperthyroidism
91. Stem: One ova is fertilized by one sperm with subsequent division after fertilization. A
chorion is shared but each fetus has a separate amniotic sac. Which of the following
appropriately defines the zygosity, chorionicity, and amnionicity of the multiple
pregnancy?
Answer choice:
a.
b.
c.
d.
Dizygotic twins: diamniotic, dichorionic
Dizygotic twins: monochorionic-diamniotic
Monozygotic twins: dichorionic-diamniotic
Monozygotic twins: monochorionic-diamniotic
Answer: The answer is D
Explanation: Monozytotic (identical twins) occur when 1 ova is fertilized by 1 sperm and then separate.
A shared chorion (1 placenta) is monochorionic and 2 amniotic sacs are diamniotic. The other choices
are variations of zygosity, chorionicity, and amnionicity. Dizygotic twins result from the fertilization of 2
separate ova during a single ovulatory cycle.
References:
Mandy GT. Neonatal complications, outcome, and management of multiple births. In: UpToDate,
Weisman LE, Kim MS. (Eds.), UpToDate, Waltham, MA. Available at http://www.uptodate.com
(Accessed on December 22, 2017.)
Organ System: Reproductive
Task Area: Applying Basic Science Concepts
Core Rotation: Obstetrics-Gynecology
Topic(s): Complicated Pregnancy, Multiple Gestation
92. Stem: A 6-week-old male, born at term without complications, is brought to the clinic by
his parents due to vomiting after breastfeeding for one week. The mother has
attempted smaller frequent feedings but the vomiting continues. There has been no
blood in the vomitus and the patient has been hungry. He has been extremely fussy
when unlatched from feeding. The parents have noted a decrease in volume of stool
over the last week and there has been no blood. No fever on rectal temperature at
home, no skin rash and no ill contacts. There is a plan for daycare after maternity leave
is complete. No illnesses since birth. Immunizations are up to date. There are no chronic
medications. Family medical history is significant for asthma in the father, well
controlled with steroid inhaler daily. Upon examination, the patient is feeding hungrily
at the mother’s breast with deep latching. Vital signs are within infant parameters and
rectal temperature is 99F. Weight is down 1kg from newborn visit after delivery. HEENT
are unremarkable, lungs are clear to auscultation, heart is tachycardic without murmur.
Abdomen is slightly distended with visible peristalsis and hyperactive bowel sounds.
Testes are descended and the patient is circumcised. The skin is warm and dry without
lesion. Labs done prior to visit reveal a decreased K+ and an elevated hemoglobin.
Which of the following is the most likely etiology for the patient’s symptoms?
Answer choice:
a.
b.
c.
d.
e.
Spontaneous relaxation of the lower esophageal sphincter
Foreign body in esophageal lumen
Gastric cardia herniating through diaphragmatic hiatus
Pyloric muscular hypertrophy
Localized erosion of gastric mucosa
Answer: The answer is D
Explanation: Vomiting after feeding, weight loss, dehydration and electrolyte abnormalities on lab work
should prompt concern for pyloric stenosis. It is unlikely that GERD will cause these findings. The
patient’s lack of mobility should prevent the ingestion of a foreign body. A hiatal hernia may cause
regurgitation but not overt vomiting. The patient is not at risk for gastric ulcer.
References:
Hoffenberg EJ, Furuta GT, Kobak G, Liu E, Soden J, Kramer RE, Brumbaugh D. Gastrointestinal Tract. In:
Hay WW, Jr., Levin MJ, Deterding RR, Abzug MJ. eds.CURRENT Diagnosis & Treatment Pediatrics, 23e
New York, NY: McGraw-Hill;
http://accessmedicine.mhmedical.com/content.aspx?bookid=1795&sectionid=125742582. Accessed
November 28, 2017.
Organ System: Gastrointestinal/Nutritional
Task Area: Applying Basic Science Concepts
Core Rotation: Pediatrics
Topic(s): Gastric disorders, Pyloric stenosis
93. Stem: A 40-year-old male complains of testicular pain and swelling for 72 hours. He
denies trauma. He is sexually active with his spouse, there is no condom use but
intermittent anal intercourse. He has radiation of the pain into the low pelvis. There is
no fever and no nausea, vomiting or diarrhea. There is dysuria at the end of the urine
stream without gross hematuria. He has self-treated with OTC ibuprofen without relief.
On exam, patient is afebrile and uncomfortable appearing. His abdomen is soft,
nontender and has active bowel sounds in all quadrants. The penis is uncircumcised and
the foreskin is retractable. The left testicle appears to be slightly swollen but without
redness or abnormal lie. Maximal tenderness is found palpating the posterior of the
affected testicle. Cremasteric reflex is intact bilaterally. A urinalysis is pending.
Which of the following is the best initial management for this patient’s problem?
Answer choice:
a.
b.
c.
d.
e.
Ultrasound of the scrotum
Manual detorsion of the affected testicle
Prostatic massage and culture of secretions
Surgical consultation for incision and debridement
Manual reduction of retracted foreskin
Answer: The answer is A
Explanation: An ultrasound of the scrotum should be done to differentiate epididymitis from testicular
torsion. If there is lack of blood flow to the affected testicle then manual detorsion may be indicated.
Prostatic massage is not done due to concerns for causing bacteremia. Surgical consultation would be
indicated for concern of necrotizing infection of the scrotum. The patient does not have an apparent
paraphimosis causing his complaint.
References:
Belcher C, Dawson M. Infectious Disease Emergencies. In: Stone C, Humphries RL. eds. CURRENT
Diagnosis & Treatment: Emergency Medicine, 8e New York, NY: McGraw-Hill;
http://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165067897. Accessed
December 01, 2017.
Organ System: Genitourinary
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Emergency Medicine
Topic(s): Infectious disorders, Epididymitis
94. Stem: In a 30-year-old female presenting with a suspected third interspace Morton’s
neuroma, which treatment modality in primary care is associated with the best
outcome?
Answer choice:
A.
B.
C.
D.
Immediate referral for surgical evaluation
Plantar orthosis with metatarsal pad
Steroid infiltration of the neuroma site
Ultrasound guided injection
Answer: The answer is C.
Explanation: Plantar orthoses have short term to limited effect (B). Immediate referral is not a
treatment modality (A). Steroid infiltration has 30% effectiveness, with some studies showing up to 50%
partial relief (C). Those who get relief can be pain free for up to two years. The injections can be
carefully repeated. Ultrasound guidance did not increase the effectiveness rate (D).
References:
Pires RS, Pereira AA, Abreu-e-Silva GM, Labronici PJ, Figueriredo LB, Godoy-Santos AL, & Kfuri M. Ottawa
ankle rules and subjective surgeon perception to evaluate radiograph necessity following foot and ankle
sprain. Annals of Medical and Health Sciences Research. 2014;4(3),432-435.
https://doi.org/http://dx.doi.org/10.4103/2141-9248.133473.
Organ System: Musculoskeletal
Task Area: Clinical Intervention
Core Rotation: Family Medicine
Topic(s): Lower Extremity Disorders
95. Stem: A patient presents with a chief complaint of a rash described in the location of the
left leg, for a duration of 2 days, and with a timing following exposure to poison ivy
while outdoor camping. Which of the following would be the most appropriate
evaluation and management level for this history based solely on this information?
Answer Choice:
A.
B.
C.
D.
E.
Problem-focused
Expanded problem-focused
Detailed
Comprehensive
High complexity
Answer: The answer is A.
Explanation: A problem-focused level is the correct answer. When determining the level of evaluation
and management (E/M) for history, the following components are considered: chief complaint (CC),
history of present illness (HPI), review of systems (ROS), and past, family, and social history (PFSH). The
CC is required for all levels. The HPI includes eight elements: location, quality, severity, duration, timing,
context, modifying factors, and associated signs/symptoms. The ROS includes fourteen systems:
constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal,
genitourinary, musculoskeletal, integumentary (which includes the breast), neurologic, psychiatric,
endocrine, hematologic/lymphatic, and allergic/immunologic. Medical necessity, as deemed by the
treating provider in light of the patient’s current or previous conditions, determines the number of
systems required for review. For PFSH, the past history includes documentation of previous illnesses,
hospitalizations, surgeries, medications, allergies, and immunizations. The family history provides
information regarding potential hereditary illnesses. The social history may list details of the patient’s
substance use (tobacco/alcohol/illicit drugs), sexual history, employment status, level of education,
marital status, or living arrangements. Problem-focused levels include HPI: brief (≤3), ROS: none, and
PFSH: none (A). Expanded problem-focused levels include HPI: brief (≤3), ROS: problem pertinent (1),
and PFSH: none (B). Detailed levels include HPI: extended (≥4), ROS: extended (2-9), and PFSH: pertinent
(1) (C). Comprehensive levels include HPI: extended (≥4), ROS: complete (≥10), and PFSH: complete (2 or
3) (D). High complexity is only associated with medical decision-making levels (E).
References: Pohlig C, Manaker S. Professional Coding and Billing Guidelines for Clinical
Documentation. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, eds. Principles and Practice of
Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1872&sectionid=137531571. Accessed
February 12, 2019.
Organ System:
Task Area: Professional Practice
Core Rotation: Family Medicine, Internal Medicine, Pediatrics
Topic(s): Medical Informatics, Papulosquamous Disorders, Contact Dermatitis
96. Stem: A 51-year-old male has had a severe sore throat for 24 hours. He has significant
pain with swallowing and has developed mild hoarseness. He has felt feverish. There is
no nasal congestion, cough or ear problems. When he lays down, he feels his throat is
closing and he cannot breathe. There is no nausea or vomiting. He has had no ill
contacts. On exam, he is sitting upright which helps with the pain and dyspnea. EENT is
significant for a slightly injected oropharynx without tonsillar hypertrophy or exudates.
The neck is supple and without lymphadenopathy. On auscultation, there is a high
pitched musical sound during inspiration. Heart is regular and without murmur. The skin
is clear and without rash. A rapid throat swab is negative. Which of the following is the
most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Acute laryngitis
Peritonsillar abscess
Acute epiglottitis
Streptococcal pharyngitis
Croup syndrome
Answer: The answer is C
Explanation: With stridor and dyspnea with position changes, the patient likely has acute epiglottitis.
There would be tonsillar hypertrophy unilaterally and trismus with drooling if peritonsillar abscess was
present. Acute laryngitis should have concurrent URI symptoms. Streptococcal pharyngitis and croup are
more common in the pediatric population and the patient’s history and physical exam are not consistent
with either condition.
References:
Rubin MA, Ford LC, Gonzales R. Sore Throat, Earache, and Upper Respiratory Symptoms. In: Kasper D,
Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds.Harrison's Principles of Internal Medicine, 19e New
York, NY: McGraw-Hill; 2014.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79725618. Accessed
December 01, 2017.
Organ System: Pulmonary
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Infectious Disorders, Acute Epiglottitis
97. Stem: A 25-year-old G1P0 African American female and her partner present to the clinic
for their first prenatal visit. The couple is excited about this pregnancy since she had
been diagnosed with polycystic ovarian syndrome a few years prior. Based on her
reported LMP, she is approximately 12 weeks gestation. Her Blood Pressure is 124/82
mmHg, Heart Rate of 74 bpm, and Respiratory Rate of 14. She is afebrile and calculated
BMI is 30 kg/m2. Which of the following is recommended at this time?
Answer choice:
a.
b.
c.
d.
Await the results of the 50-g 1-hour glucose tolerance test at 24 weeks gestation
Obtain a fasting plasma glucose via finger-stick at this visit
Perform an A1C measurement at this visit
Order a 75-g 2-hour glucose tolerance test when she reaches 13 weeks gestation
Answer: The answer is C
Explanation: Option C is the best option since this is the recommended evaluation for overt diabetes in
an at-risk woman early in pregnancy. This patient has multiple risk-factors for developing gestational
diabetes (age, race, PCOS). However, she is also at risk for overt diabetes (BMI, history of PCOS, Race)
and needs evaluation at the first prenatal visit. Awaiting until 13 or 24 weeks gestation delay the
diagnosis. Patients not at risk for overt diabetes are screened for gestational diabetes between 24-28
weeks gestation. A fasting plasma glucose via finger-stick at this visit is not the most reliable since her
last food or liquid intake is unknown.
References:
Coustan DR. Diabetes mellitus in pregnancy: Screening and diagnosis. In: UpToDate, Nathan DM, Green
MF, Barss VA. (Eds.), UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed on
December 22, 2017.)
Organ System: Reproductive
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Obstetrics-Gynecology
Topic(s): Complicated Pregnancy, Gestational trophoblastic disease
98. Stem: A 22-year-old patient was recently diagnosed with dermatitis herpetiformis. This
skin condition is associated with which one of the following enteropathies?
Answer choice:
a.
b.
c.
d.
e.
Celiac disease
Crohn’s disease
Eosinophillic enteropathy
HIV-associated enteropathy
Ulcerative colitis
Answer: The answer is A
Explanation: Dermatitis herpetiformis is associated with gluten-sensitivity enteropathy, but in many it
will be in a subclinical form. The typical symptoms of celiac (A) include: weight loss, diarrhea, abdominal
distention, and growth retardation. Atypical symptoms include: dermatitis herpetiformis, iron deficiency
anemia, and osteoporosis. Dermatitis herpetiforms is a cutaneous variant of celiac. Though it occurs in
only 10% of those with celiac, almost all patients who present with this rash have evidence of celiac on
intestinal biopsy.
References:
McQuaid KR. Gastrointestinal Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical
Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
Organ System: Gastrointestinal/Nutritional
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine
Topic(s): Small Intestine disorders, Celiac Disease
99. Stem: A 59-year-old black male presents with a complaint of shortness of breath and
bilateral foot swelling. He has a past medical history of primary amyloidosis. He denies
tobacco use, drinks a 12 oz beer nightly on the weekends, and denies illicit drug use. On
physical exam, the patient is noted to have a prominent S₃ and S₄, and pulmonary rales
on auscultation. Further examination reveals the patient to be positive for jugular
venous distention. His AP chest x-ray demonstrates pulmonary edema at the bases, R>L,
but no cardiac abnormality. His EKG demonstrates nonspecific ST-T–wave abnormalities
and a square root sign. The echocardiogram demonstrates early diastolic filling, and left
ventrical thickening. Which of the following findings aid in differentiating this patient’s
condition from constrictive pericarditis?
Answer choice:
a.
b.
c.
d.
e.
The presence of amyloid plaques on cardiac MRI
A decrease in left ventricular pressure with inspiration during cardiac catheterization
Pericardial thickening on cardiac CT
A normal heart size on chest x-ray
The presence of Kussmaul sign on physical exam
Answer: The answer is A.
Explanation: This patient has restrictive cardiomyopathy, as demonstrated by his history of amyloidosis,
which is one of the most common causes. Amyloid plaques are not present in constrictive
cardiomyopathy (A). (B), (C), (D), and (E) are all present in constrictive pericarditis. (D) and (E) can both
be present.
References:
Niemann JT. Cardiomyopathies and Pericardial Disease. In: Tintinalli JE, Stapczynski J, Ma O,
Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide, 8e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109428893.
Accessed December 04, 2017.
Bashore TM, Granger CB, Jackson KP, Patel MR. Heart Disease. In: Papadakis MA, McPhee SJ,
Rabow MW. eds. Current Medical Diagnosis & Treatment 2017. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1843&sectionid=135705950.
Accessed December 04, 2017.
Sorajja, P, Hoit, B. (2017). Differentiating constrictive pericarditis and restrictive
cardiomyopathy. UpToDate, https://www.uptodate.com/contents/differentiating-constrictivepericarditis-and-restrictivecardiomyopathy?source=search_result&search=restrictive%20cardiomyopathy&selectedTitle=2
~82.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine, Emergency Medicine
Topic(s): Cardiomyopathy, Restrictive
100.
Stem: Which of the following statements most accurately describes a complete
hydatidiform mole?
Answer choice:
a.
b.
c.
d.
Typically contains fetal/embryonic tissue
Carries a lower risk of developing gestational trophoblastic neoplasia than a partial mole
Consists of only paternal DNA
Are typically triploid (69,XXX)
Answer: The answer is C
Explanation: Complete moles develop from the fertilization of an “empty egg” (absent or inactivated
maternal chromosomes) and only contain paternal DNA resulting in diploid karyotype (commonly
46,XX). Complete moles carry a higher risk (15-20%) of developing neoplasia.
Answers A, B, and D describe a partial hydatidiform moles occur when an ovum containing 1 set of
haploid maternal chromosomes are fertilized by 2 sperm, which results in triploidy (most common
69,XXX). Partial moles contain fetal/embryonic tissue and have a lower risk (1-5%) of developing
neoplasia.
References:
Baergen RN. Gestational trophoblastic disease: Pathology. In: UpToDate, Goff B, Dizon DS, Falk SJ (Eds.),
UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed on December 29, 2017.)
Organ System: Reproductive
Task Area: Applying Basic Science Concepts
Core Rotation: Obstetrics-Gynecology
Topic(s): Complicated Pregnancy, Gestational Trophoblastic Disease
101.
Stem: A 69-year-old white female presents with a complaint of decreased
vision. The patient states that she noticed a problem almost two years ago and it has
been progressively worsening. She says she can’t see things directly in front of her
unless she turns her head slightly to look out the corner of her eye. Her past medical
history is negative. She states she is generally healthy and for that reason did not feel
the need to seek immediate medical attention. Her visual acuity is as follows: OD: 20/30,
OS: 20/40, OU: 20/30.
The medical assistant noted that the patient seemed to cock her head to one side or the
other to read the letters on the chart during the visual acuity exam. Her peripheral vision
was noted to be intact; however, a bilateral central field vision deficit was noted on visual
field testing. The slit lamp reveals the following:
<CATCH: Insert Photo D>
<CATCH: Insert credit line underneath the photo: Reproduced with permission from Maxine A.
Papadakis, Stephen J. McPhee, Michael W. Rabow. Current Medical Diagnosis & Treatment 2019.
Copyright © McGraw-Hill Education. All rights reserved. E-Figure 7-41 B.>
What is the cause of this patient’s decreased vision?
Answer choice:
a.
b.
c.
d.
e.
Acute angle closure glaucoma
Age related macular degeneration
Uveitis
Catarct
Retinal detachment
Answer: The answer is B.
Explanation: This patient has age related macular degeneration (B), as demonstrated by her history and
the presence of drusen on slit lamp exam. The presentation of acute angle closure glaucoma (A) is that
of rapid onset and severe pain with profound visual loss. This patient had slow progressive visual loss.
Uveitis (C) presents as pain, redness, and photophobia of the eye. A cataract (E), though slowly
progressive, is not localized to central vision loss, but is rather a gross visual loss. On exam a cataract will
opacify verses forming drusen.
References:
Riordan-Eva P. Disorders of the Eyes & Lids. In: Papadakis MA, McPhee SJ, Rabow MW. eds.
Current Medical Diagnosis & Treatment 2017. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1843&sectionid=135699961.
Accessed December 13, 2017.
Organ System: EENT
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine
Topic(s): Eye Disorders, Retinal disorders, Macular degeneration
102.
Stem: A 30-year-old female presents with a complaint of abdominal bloating,
and increased burping and passing gas. She states that two days ago she had an episode
of abdominal pain following eating a chicken burrito. She states that the episode lasted
two hours and that she consumed TUMS® to aid in the feeling of indigestion. Her past
medical history is consistent for hypertension controlled with Lisinopril 10 mg PO daily.
Her past surgical history is consistent for two Cesarean sections. She denies tobacco or
drug use and states she drinks alcoholic beverages socially. On physical exam, you note
a moderately obese female in no acute distress. HEENT is atraumatic, normocephalic,
and absent of any abnormalities. Lungs are clear to auscultation bilaterally. Cardiac
exam reveals regular rate and rhythm on auscultation. Abdominal exam reveals no
obvious distention, normoactive bowel sounds, and minimal right upper quadrant
tenderness. The patient is noted to have a positive Murphy’s sign on exam. The
remainder of her exam is within normal range. Her labs are within normal range and her
ultrasound demonstrates a functional gallbladder with multiple small floating stones,
with the largest measuring 2 cm.
After discussing the test results with the patient in detail you discuss the treatment plan,
which consists of referral to a general surgeon for elective cholecystectomy. The patient
states she does not wish to have surgery and refuses referral. What is the next best
management for this patient at this time?
Answer choice:
a. Lithotripsy
b. Nonsteroidal anti-inflammatory medications as needed
c. Laparoscopic cholecystectomy
d. Bariatric surgery
e. Ursodeoxycholic acid
Answer: The answer is E.
Explanation: The patient is a candidate for treatment with ursodeoxycholic acid (E). The criteria for
ursodeoxycholic acid are refusal of cholecystectomy, a functioning gallbladder, and small floating stones
on US. She is not a candidate for lithotripsy (A), as her stones are too large. NSAIDs (B) may assist in
management of her pain, but will not resolve her condition. The patient has refused surgery, making the
option of a lap chole (C) not the best management option. Though bariatric surgery (D) can be an option
to treat her moderate obesity, it will not treat the cholelithiasis and can in fact worsen the condition.
References:
Friedman LS. Liver, Biliary Tract, & Pancreas Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168015083.
Accessed December 20, 2017.
Besinger B, Stehman CR. Pancreatitis and Cholecystitis. In: Tintinalli JE, Stapczynski J, Ma O,
Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide, 8e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109430493.
Accessed December 20, 2017.
Organ System: Gastrointestinal/Nutritional
Task Area: Clinical Intervention
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Biliary disorders, Cholelithiasis
103.
Stem: A 48-year-old Caucasian female with a history of diabetes presents to
your clinic for a routine check-up. She is new to the area and wants to establish care
with a new provider. She reports a blood pressure of 190/100 mm Hg, measured at a
recent work-sponsored health fair. She was urged to follow up with her primary
provider. Today her blood pressure is 185/102 mm Hg. Her HgbA1C is 9%, BMI is
30kg/m2, and her urine reveals microalbuminuria. The patient believes her father also
takes blood pressure medication. Which of the following drug classes would be the most
appropriate initial choice for treatment of her hypertension?
Answer choice:
a. Amlodipine
b. Clonidine
c. Diltiazem
d. Ramipril
e. Hydrochlorothiazide
Answer: The answer is D.
Explanation: The patient above, based on the information provided, will more than likely be diagnosed
with primary essential hypertension. Essential hypertension is typically diagnosed after 3 separate
occasions of blood pressure readings of ≥ 160 systolic/ ≥ 100 diastolic.
Every patient has risk factors that make him/her susceptible to getting hypertension, even with lifestyle
modifications. This patient has both modifiable as well as non-modifiable risk factors that are most likely
contributing to her diagnosis. She is a female between the ages of 25–50 years; in addition, her history
of diabetes, obesity, and family history of hypertension are also pertinent factors. Other well known risk
factors for developing essential hypertension include lack of physical activity, smoking, high cholesterol
levels, and sleep apnea.
Successful treatment of hypertension in any patient must be viewed and explained as a comprehensive
approach that should include multifactorial lifestyle modifications and pharmaceutical therapy.
Although most diabetics require combinations of three to five antihypertensive medications,
monotherapy is usually attempted first. Single agent drugs used to treat hypertension in diabetic
patients that are also effective in providing beneficial effects for diabetic nephropathy are the ACE
inhibitors or ARBs (D). Most U.S. and international guidelines recommend a goal of less than 130–140
mm Hg systolic blood pressure for diabetics.
References:
Primary Essential Hypertension. In: Maxine A. Papadakis, et al. eds. Current Medical Diagnosis &
Treatment 2018. New York, NY: McGraw-Hill.
Organ System: Cardiovascular
Task Area: Pharmaceutical Therapeutics
Core Rotation: Internal medicine, Family medicine
Topic(s): Hypertension, Essential hypertension
104.
Stem: A 28-year-old roofer presents to your office with right elbow pain. This
pain has a gradual onset, and worsens when he’s carrying his tool bag. He denies
specific trauma and has no known medical problems. His exam shows no gross swelling,
and no skin lesions. You suspect tennis elbow to be the cause of his symptoms. What
examination or combination of examinations would make your diagnosis clear?
Answer choice:
A. Elbow plain films
B. Palpation of the medial epicondyle
C. Palpation of the lateral epicondyle
D. Palpation of the lateral epicondyle with resisted wrist dorsiflexion
Answer: The answer is D.
Explanation: Plain elbow films would be useful if trauma is suspected, but this patient’s presentation is
more insidious (A). Direct palpation of either epicondyle would be a significant clue; with the addition of
the wrist resisted dorsiflexion is almost pathognomonic (B, C, and D).
References:
Brown DE, & Neumann RD. Orthopedic secrets. 3rd ed. Philadelphia, PA: Hanley & Belfus; 2004.
Organ System: Musculoskeletal
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Family Medicine
Topic(s): Upper Extremity Disorders, Soft Tissue Injuries
105.
Stem: In patients with known stage 5 chronic kidney disease, which of the
following is an absolute indication to initiate dialysis?
Answer choice:
A.
B.
C.
D.
E.
Diabetic with a GFR of 15 ml/min
Non diabetic with a GFR of 15 ml/min
Hyperkalemia
Hypocalcemia
Anemia
Answer: The answer is A.
Explanation: (D) Indicators for initiation are those that constitute uremic symptoms. Typical uremic
symptoms include but are not limited to: pruritus, fatigue, anorexia and weight loss, nausea, and
emesis. Patients nearing the need for dialysis may have abnormalities in their potassium, calcium, and
phosphorus levels as well as anemia and metabolic acidosis but they may be able to be managed
medically. Absolute indicators for dialysis are those that are life threatening. The recommendation to
begin dialysis for those individuals with the diagnosis of diabetes is a GFR of 15ml/min (A). Non-diabetics
should begin dialysis with a GFR of 10 ml/min.
References:
Daugirdas J, Blake P, Ing T. Handbook of Dialysis. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2007.
Organ System: Renal
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Chronic Kidney Disease
106.
Stem: A patient presents to the clinic with a chief complaint of a sore throat,
described as a sharp stabbing quality with a moderate pain severity and associated
symptoms of congestion and fever. He denies a cough on review of systems. Which of
the following would be the most appropriate evaluation and management level for this
history based solely on this information?
Answer Choice:
A.
B.
C.
D.
E.
Problem-focused
Expanded problem-focused
Detailed
Comprehensive
High complexity
Answer: The answer is B.
Explanation: When determining the level of evaluation and management (E/M) for history, the
following components are considered: chief complaint (CC), history of present illness (HPI), review of
systems (ROS), and past, family, and social history (PFSH). The CC is required for all levels. The HPI
includes eight elements: location, quality, severity, duration, timing, context, modifying factors, and
associated signs/symptoms. The ROS includes fourteen systems: constitutional, eyes,
ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal,
integumentary (which includes the breast), neurologic, psychiatric, endocrine, hematologic/lymphatic,
and allergic/immunologic. Medical necessity, as deemed by the treating provider in light of the patient’s
current or previous conditions, determines the number of systems required for review. For PFSH, the
past history includes documentation of previous illnesses, hospitalizations, surgeries, medications,
allergies, and immunizations. The family history provides information regarding potential hereditary
illnesses. The social history may list details of the patient’s substance use (tobacco/alcohol/illicit drugs),
sexual history, employment status, level of education, marital status, or living arrangements. Problemfocused levels include HPI: brief (≤3), ROS: none, and PFSH: none (A). Expanded problem-focused levels
include HPI: brief (≤3), ROS: problem pertinent (1), and PFSH: none (B). Detailed levels include HPI:
extended (≥4), ROS: extended (2-9), and PFSH: pertinent (1) (C). Comprehensive levels include HPI:
extended (≥4), ROS: complete (≥10), and PFSH: complete (2 or 3) (D). High complexity is only associated
with medical decision-making levels (E).
References: Pohlig C, Manaker S. Professional Coding and Billing Guidelines for Clinical
Documentation. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, eds. Principles and Practice of
Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1872&sectionid=137531571. Accessed
February 12, 2019.
Organ System:
Task Area: Professional Practice
Core Rotation: Family Medicine, Internal Medicine, Pediatrics
Topic(s): Medical Informatics, Oropharyngeal disorders, Pharyngitis
107.
Stem: Mr. Sandow is a 32-year-old male who complains of persistent anxiety,
which has worsened in the past few months. He describes several attacks of anxiety
associated with sobbing, shaking, palpitations, and a feeling like he is going to die. The
patient would like to be treated for his condition but is concerned about getting
addicted to medication since his best friend died of a drug overdose last year. You
decide to prescribe Sertraline 25 mg daily for 1 week, then increasing to 50 mg daily.
The patient returns to you after 1 month and has discontinued the medication after the
second week. In asking about potential reasons for discontinuing the medication the
patient will most likely reveal what common adverse reaction?
Answer choice:
A.
B.
C.
D.
E.
Sexual dysfunction
Gynecomastia
Chest pain
Cough
Urinary frequency
Answer: The answer is A.
Explanation: Sexual dysfunction is a common side effect of selective serotonin reuptake inhibitors
(SSRIs), which may result in discontinuing the treatment (A). Gynecomastia is a potential side effect of
treatment with tricyclic antidepressants but would likely not be noticeable with a 2-week treatment (B).
The other answer choices are not common adverse reactions of SSRIs and if present should provoke
further investigation (C, D, and E).
References:
https://online.epocrates.com/drugs/1443/Zoloft
https://online.epocrates.com/drugs/1310/Tofranil
Eisendrath SJ, Cole SA, Christensen JF, Gutnick D, Cole M, Feldman MD. Depression. In: Feldman MD,
Christensen JF, Satterfield JM, eds. Behavioral Medicine: A Guide for Clinical Practice. 4th ed. New York,
NY: McGraw-Hill; 2014.
Organ System: Psychiatry/Behavioral
Task Area: Pharmaceutical Therapeutics
Core Rotation: Psychiatry, Family Medicine, Internal Medicine
Topic(s): Anxiety Disorder Treatment, Side Effects
108.
Stem: A 16-year-old patient presents to the clinic with fever for the past 2 days.
Physical examination reveals parotid tenderness and overlying facial edema that
recently began to develop. Patient states he has never received any vaccinations. Which
of the following is the most likely diagnosis?
Answer Choice:
A.
B.
C.
D.
E.
Infectious mononucleosis
Varicella zoster
Mumps
Pulmonary tuberculosis
Tetanus
Answer: The answer is C.
Explanation: The correct answer is mumps (C). Infectious mononucleosis is typically caused by the
Epstein-Barr virus. The protean manifestations of infectious mononucleosis reflect the dissemination of
the virus in the oral cavity and through peripheral blood lymphocytes and cell-free plasma. Fever, sore
throat, fatigue, malaise, anorexia, and myalgia typically occur in the early phase of the illness. Physical
findings include lymphadenopathy (discrete, non-suppurative, and slightly painful, especially along the
posterior cervical chain), transient bilateral upper lid edema (Hoagland sign), and splenomegaly (in up to
50% of patients and sometimes massive) (A). Varicella zoster is typically caused by varicella zoster virus
(VZV), also known as human herpesvirus 3 (HHV-3), which is a member of the Herpesviridae family. In
varicella zoster, fever and malaise are mild in children and more marked in adults. The pruritic rash
begins prominently on the face, scalp, and trunk, and later involves the extremities. Maculopapules
change within a few hours to vesicles that become pustular and eventually form crusts. New lesions may
erupt for 1–5 days, so that different stages of the eruption are usually present simultaneously (B).
Mumps is typically caused by the paramyxovirus known as rubulavirus. In mumps, parotid tenderness
and overlying facial edema are the most common physical findings and typically develop within 48 hours
of the prodromal symptoms. Usually, one parotid gland enlarges before the other, but unilateral
parotitis occurs in 25% of patients. High fever, testicular swelling, and tenderness (unilateral in 75% of
cases) denote orchitis, which usually develops 7–10 days after the onset of parotitis. The entire course
of mumps rarely exceeds 2 weeks. Tuberculosis is typically caused by the acid-fast bacilli Mycobacterium
tuberculosis. The patient with pulmonary tuberculosis typically presents with slowly progressive
constitutional symptoms of malaise, anorexia, weight loss, fever, and night sweats. Chronic cough is the
most common pulmonary symptom. It may be dry at first but typically becomes productive of purulent
sputum as the disease progresses. Blood-streaked sputum is common, but significant hemoptysis is
rarely a presenting symptom (D). Tetanus is typically caused by the neurotoxin tetanospasmin from the
bacteria Clostridium tetani. The first symptom may be pain and tingling at the site of inoculation,
followed by spasticity of the muscles nearby. Stiffness of the jaw, neck stiffness, dysphagia, and
irritability are other early signs. Hyperreflexia develops later, with spasms of the jaw muscles (trismus)
or facial muscles and rigidity and spasm of the muscles of the abdomen, neck, and back (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Infectious Diseases
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine, Family Medicine, Pediatrics
Topic(s): Mumps
109.
Stem: An 18-year-old male presents with a hard lesion and swelling of his upper
right eyelid. He was evaluated in the ER 1 week ago and diagnosed with an internal
hordeolum. The provider instructed him to use warm compresses and apply a topical
antibiotic ointment daily. He complied with these instructions for the first 48 hours,
then stopped as it was feeling better. Today, his right upper eyelid is moderately swollen
and elevated with a firm underlying mass. Right conjunctiva is mildly erythematous
adjacent to the lesion. The patient does not complain of tenderness, but does report
itching. There’s no fever, drainage, or involvement of left eye. Which of the following is
the most appropriate treatment plan?
Answer choice:
a.
b.
c.
d.
e.
Topical Trimethoprim with Polymyxin B
Oral Clindamycin
Dexamethasone ophthalmic solution
Ketorolac ophthalmic solution
Ophthalmologist referral for incision and curettage
Answer: The answer is E.
Explanation: A hordeolum is an infection of one or more glands of the lid. When the meibomian glands
are involved, it is called an internal hordeolum. An external hordeolum (stye) is an infection of a gland of
Zeis or Moll.
Pain, redness, and swelling are the principal symptoms. The intensity of the pain is a function of the
amount of lid swelling. An internal hordeolum may point to the skin or to the conjunctival surface. An
external hordeolum always points to the skin.
Most hordeola are caused by staphylococcal infections, usually Staphylococcus aureus. Culture is seldom
required. Treatment consists of warm compresses several times a day for 10–15 minutes. If the process
does not begin to resolve within 48 hours, incision and drainage of the purulent material is indicated (E).
Antibiotic ointment is routinely applied to the site. Systemic antibiotics are indicated if cellulitis
develops.
References:
Vagefi, M. Reza. Lids & Lacrimal Apparatus. Paul Riordan-Eva, and James J. Augsburger, eds. Vaughan &
Asbury's General Ophthalmology, 19e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com.library1.unmc.edu:2048/content.aspx?bookid=2186&sectionid=
165516400.
Organ System: EENT
Task Area: Clinical Intervention
Core Rotation: Family medicine, internal medicine, emergency medicine
Topic(s): Eye Disorders, lid disorders, Hordeolum
110.
Stem: A mother brings in her 4-year-old child with complaints of a rash on his
face that is worsening in appearance. She reports that it started a couple of days ago as
superficial blisters on his chin that ruptured easily. Now, he is developing more lesions
with honey-colored crusts over the surface. The underlying skin of the region is
reddened. What is the most appropriate treatment for this condition?
Answer choice:
a.
b.
c.
d.
e.
Triamcinolone cream
Benzoyl peroxide gel
Mupirocin cream
Selenium sulfide shampoo
Adapalene gel
Answer: The answer is C.
Explanation: Impetigo is a contagious infection of the skin, most often caused by staphylococci or
streptococci. The lesions of this rash consist of macules, vesicles, bullae, pustules, and honey-colored
crusts that, when removed, leave denuded red areas. The superficial blisters that present with this
condition are typically filled with purulent material and rupture easily. The face and other exposed parts
are most often involved. Children are especially susceptible to these infections in settings such as
daycare facilities, schools, locker rooms, etc., where they share items and hygiene isn’t always
supervised.
Soaks and scrubbing can be beneficial, especially in unroofing the crusts. Topical agents, such as
bacitracin, mupirocin (C), and retapamulin are first-line treatment options for infections limited to
smaller areas. In widespread cases, systemic antibiotics are indicated. Cephalosporins or doxycycline are
reasonable and effective choices, depending on the patient’s age and allergy status.
References:
Impetigo. In: Maxine A. Papadakis, et al., eds. Current Medical Diagnosis & Treatment 2018. New York,
NY: McGraw-Hill, pp. 128–129.
Organ System: Dermatologic
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family medicine, internal medicine
Topic(s): Infectious diseases, bacterial, Impetigo
111.
Stem: An otherwise healthy 44-year-old male presents to the ED describing
paroxysmal anterior chest pain since yesterday. He states the pain radiates to his back.
He denies cough, shortness of breath, diaphoresis, or nausea but admits he had a
“cough and cold” 2 weeks ago that resolved without complications. He does note that
the pain seems to worsen when he is lying down. Examination reveals blood pressure
120/80 mm Hg, pulse 90 bpm, temperature 100.8 °F (38.2 °C), lungs clear to
auscultation bilaterally with no adventitious breath sounds, and regular heart rate and
rhythm without murmur but with audible rub. An ECG is ordered. Which of the
following is the most likely finding to support your primary diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Q waves in leads II, III, and aVF
Diffuse ST segment elevation
Flattening of T waves in V1, V2, and V3
Shortened PR interval
ST depression in leads I and aVL
Answer: The answer is B.
Explanation: In this patient, a viral syndrome preceded the onset of acute pericarditis. Viruses,
especially coxsackieviruses and echoviruses, are the most common cause of acute pericarditis. Males
under the age of 50 are usually the most commonly affected. The presentation of acute pericarditis
depends on its cause, but is most often associated with chest pain which is usually pleuritic or postural.
The pain often will radiate to the neck, shoulders, back or epigastrium. Patient is often febrile and a
pericardial friction rub is characteristic of this condition, with or without evidence of pericardial fluid or
constriction. Diagnosis is usually clinical in viral pericarditis, but cardiac enzymes may be slightly
elevated. Echocardiogram is usually normal. The ECG will reveal diffuse ST elevation (B), followed by a
return to baseline, then T-wave inversion ((A), (C), (D), and (E)).
References:
Acute Inflammatory Pericarditis. In: Maxine A. Papadakis, et al. eds. Current Medical Diagnosis &
Treatment 2018. New York, NY: McGraw-Hill, pp. 432–434.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal medicine, emergency medicine
Topic(s): Traumatic, infectious, and inflammatory heart conditions, Acute Pericarditis
112.
Stem: A 17-year-old male with a history of asthma presents with 1 day of fever
to 102° F (oral), chills, rhinorrhea, sore throat, fatigue, dry cough, malaise, and aches. He
also endorses intermittent nausea but denies other gastrointestinal complaints or rash.
On exam, the pharynx is erythematous with no exudates, the chest is clear, and the
abdomen shows no organomegaly. He is allergic to cefdinir. Which of the following is
the most effective treatment?
Answer choice:
A.
B.
C.
D.
E.
Oseltamivir 75 mg by mouth twice daily for 5 days
Prednisone 20 mg three tabs by mouth daily for 5 days
Zanamivir 10 mg 2 inhalations twice daily for 5 days
Penicillin 500 mg by mouth twice daily for 10 days
Azithromycin 500 mg by mouth daily for 3 days
Answer: The answer is A.
Explanation: The patient most likely has influenza given the fever, clear chest, and lack of exudates and
organomegaly. He is within 2 days of symptom onset, so antivirals are indicated. Zanamivir is
contraindicated in patients with asthma, so oseltamivir is the most appropriate choice (A).
References:
Papadakis MA, McPhee SJ. Current Medical Diagnosis and Treatment 2016. 55th ed. New York, NY:
McGraw-Hill; 2016.
Organ System: Pulmonary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Emergency Medicine, Family Medicine
Topic(s): Infectious Disorders, Influenza
113.
Stem: A 47-year-old female with a history of kidney stones, gastric ulcers, and
depression presents to primary care for evaluation of fatigue and to establish care. She
reports that the fatigue started a few months prior to the other conditions, which have
all evolved over the last year and for which she sees specialists. She was in good health
prior to one year ago. Which of the following sets of objective findings is most
consistent with a diagnosis of primary hyperparathyroidism?
Answer choice:
A.
B.
C.
D.
E.
Elevated calcium, constipation
Elevated vitamin D, Chvostek sign
Suppressed vitamin D, elevated creatinine
Low calcium/creatinine ratio, hypocalciuria
Monoclonal antibodies, normal vitamin D
Answer: The answer is A.
Explanation: Constipation completes the stereotypical set of symptoms of clinical hyperparathyroidism
along with the conditions present in the patient’s history and the diagnosis is confirmed by elevated
calcium (A). These values are elevated since overproduction of parathyroid hormone causes increased
absorption of calcium from the gastrointestinal tract. Elevated vitamin D and Chvostek sign occur in
hypoparathyroidism (B). Suppressed vitamin D and elevated creatinine might occur in secondary
hyperparathyroidism from chronic kidney disease (C). Low calcium/creatinine ratio and hypocalciuria
occur in hypocalciuric hypercalcemia(D). Monoclonal antibodies on electrophoresis in conjunction with a
normal vitamin D occur in multiple myeloma, which is on the differential for hypercalcemia (E).
References:
Michels TC, Kelly KM. Parathyroid disorder. Am Fam Physician. 2013; 88: 249-57.
Organ System: Endocrine
Task Area: Applying Basic Science Concepts
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Parathyroid Disorders, Hyperparathyroidism
114.
Stem: A 45-year-old male patient presents to the family practice clinic for two
days of mild abdominal pain, nausea, and constipation. On physical exam, he is without
fever, but does have some left lower quadrant tenderness with deep palpation. His
examination is otherwise within normal limits. Based on these findings, which of the
following is the next step in the diagnosis and treatment of this patient?
Answer choice:
A.
B.
C.
D.
E.
Recommend clear liquids until symptoms resolve
Prescribe a 10-day course of oral antibiotics
Refer the patient to the Emergency Department
Obtain an IV contrast CT scan of the abdomen and pelvis
Obtain a complete blood count
Answer: The answer is A.
Explanation: The symptoms and exam are suggestive of mild diverticulitis. Although many clinicians
prescribe antibiotics, this is not necessary for resolution (B). Clear liquids until symptoms resolve is
sufficient (A). A CT scan is unnecessary given the lack of severity as is any additional lab work (C, D, and
E).
References:
McQuaid KR. Gastrointestinal Disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical
Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168013478. Accessed
January 06, 2018.
Organ System: Gastrointestinal/Nutritional
Task Area: Clinical Intervention
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Colorectal Disorders, Diverticulitis
115.
Stem: A 24-year-old African American male presents to the Emergency
Department with concerns of bilateral knee and shin pain for 2 days after attending a
family reunion picnic for the afternoon in the July heat. He also reports chest tenderness
with a new cough starting in the last day. Which of the following is the next best choice
in management?
Answer choice:
A.
B.
C.
D.
E.
Referral to hematology
Order a chest radiograph
Prescribe acetaminophen
Give azithromycin
Discharge home
Answer: The answer is B.
Explanation: The patient in the vignette is most likely experiencing a sickle cell vaso-occlusive crisis
complicated by acute chest syndrome. Management includes admission, ordering a CBC, CMP, UA, chest
x-ray, sending blood and urine cultures and giving IV fluids, IV anti-inflammatories or narcotics, and
considering antibiotics pending culture and chest x-ray results (B).
References:
Yale SH, Nagib N, Guthrie T. Approach to the vaso-occlusive crisis in adults with sickle cell disease. Am
Fam Physician. 2000;61:1349-56.
Organ System: Hematologic
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Hemoglobinopathies, Sickle Cell Disease
116.
Stem: A 16-year-old male patient presents with fever, sore throat, and fatigue.
Physical findings include lymphadenopathy. The rapid streptococcal test is negative. The
patient states his girlfriend has the same symptoms. Which of the following is the most
likely causative organism?
Answer Choice:
A.
B.
C.
D.
E.
Epstein-Barr virus
Human herpesvirus 3
Paramyxovirus
Acid-fast bacilli
Clostridium tetani
Answer: The answer is A.
Explanation: The correct answer is Epstein-Barr virus (A). Infectious mononucleosis is typically caused by
the Epstein-Barr virus. The protean manifestations of infectious mononucleosis reflect the dissemination
of the virus in the oral cavity and through peripheral blood lymphocytes and cell-free plasma. Fever,
sore throat, fatigue, malaise, anorexia, and myalgia typically occur in the early phase of the illness.
Physical findings include lymphadenopathy (discrete, nonsuppurative, and slightly painful, especially
along the posterior cervical chain), transient bilateral upper lid edema (Hoagland sign), and
splenomegaly (in up to 50% of patients and sometimes massive). Varicella zoster is typically caused by
varicella zoster virus (VZV), also known as human herpesvirus 3 (HHV-3), which is a member of the
Herpesviridae family. In varicella zoster, fever and malaise are mild in children and more marked in
adults. The pruritic rash begins prominently on the face, scalp, and trunk, and later involves the
extremities. Maculopapules change within a few hours to vesicles that become pustular and eventually
form crusts. New lesions may erupt for 1–5 days, so that different stages of the eruption are usually
present simultaneously (B). Mumps is typically caused by the paramyxovirus known as rubulavirus. In
mumps, parotid tenderness and overlying facial edema are the most common physical findings and
typically develop within 48 hours of the prodromal symptoms. Usually, one parotid gland enlarges
before the other, but unilateral parotitis occurs in 25% of patients. High fever, testicular swelling, and
tenderness (unilateral in 75% of cases) denote orchitis, which usually develops 7–10 days after the onset
of parotitis. The entire course of mumps rarely exceeds 2 weeks (C). Tuberculosis is typically caused by
the acid-fast bacilli Mycobacterium tuberculosis. The patient with pulmonary tuberculosis typically
presents with slowly progressive constitutional symptoms of malaise, anorexia, weight loss, fever, and
night sweats. Chronic cough is the most common pulmonary symptom. It may be dry at first but typically
becomes productive of purulent sputum as the disease progresses. Blood-streaked sputum is common,
but significant hemoptysis is rarely a presenting symptom (D). Tetanus is typically caused by the
neurotoxin tetanospasmin from the bacteria Clostridium tetani. The first symptom may be pain and
tingling at the site of inoculation, followed by spasticity of the muscles nearby. Stiffness of the jaw, neck
stiffness, dysphagia, and irritability are other early signs. Hyperreflexia develops later, with spasms of
the jaw muscles (trismus) or facial muscles and rigidity and spasm of the muscles of the abdomen, neck,
and back (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Infectious Diseases
Task Area: Applying Basic Science Concepts
Core Rotation: Emergency Medicine, Family Medicine, Pediatrics
Topic(s): Epstein-Barr Virus Infections
117.
Stem: A 51-year-old female patient with a history of HTN, obesity, and
prediabetes returns for a follow-up visit with you to monitor her lipid levels. She was
evaluated 6 months ago at her annual physical with fasting labs and found to have a
total cholesterol of 310 mg/dL (<200 desirable), LDL cholesterol 195 mg/dL (<130
desirable), and HDL cholesterol 30 mg/dL (>40 desirable). She is not currently taking any
medications for cholesterol lowering. She was educated on dietary and physical activity
modification to her lifestyle, which she has been trying to implement daily. Today, her
fasting lipid results are as follows:
Total cholesterol = 388 mg/dL; LDL cholesterol = 192 mg/dL; HDL = 31 mg/dL
What is the most appropriate pharmacologic therapy to initialize for this patient?
Answer choice:
a.
b.
c.
d.
e.
Low intensity statin
Moderate intensity statin
High intensity statin
Moderate intensity statin plus gemfibrozil
High intensity statin plus niacin
Answer: The answer is C.
Explanation: Treatment decisions for hypercholesterolemia are based on the presence of clinical CAD or
diabetes, patient age, LDL cholesterol greater than 190 mg/dL, and the estimated 10-year risk of
developing cardiovascular disease. The 2013 ACA/AHA guidelines define four groups of patients who
benefit from statin medications, along with the recommended level of treatment intensity:
1) Presence of clinical atherosclerotic cardiovascular disease—high intensity statin OR moderate
intensity if over age 75
2) Primary elevation of LDL > 190 mg/dL—high intensity statin
3) Age 40–75 with diabetes and LDL ≥ 70 mg/dL—moderate intensity statin OR high intensity statin if 10year CVD risk is 7.5% or higher
4) Age 40–75 without clinical atherosclerotic cardiovascular disease or diabetes, with LDL 70–189 mg/dL
and estimated 10-year CVD risk of 7.5% or higher—moderate to high intensity statin.
References:
Lipid Disorders—Screening and Treatment of High Blood Cholesterol. In: Maxine A. Papadakis, et al.,
eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill, pp. 1271–1277.
Organ System: Cardiovascular
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family medicine, internal medicine
Topic(s): Lipid Disorders, Hypercholesterolemia
118.
Stem: A 38-year-old female presents to your office with recurrent heartburn
and reports a “constant sour taste” in her mouth for the last 2 months. She has tried
over-the-counter medications including TUMS on occasion and ranitidine 75mg twice
daily for the last 4 weeks with minimal relief. She has a normal diet, denies alcohol use
or smoking. She has not had any fevers, nausea, vomiting or changes in her bowel
habits. Your presumptive diagnosis is gastroesophageal reflux (GERD). Which of the
following diagnostic studies is considered the gold standard for confirmation of your
diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Esophageal manometry
24-hour esophageal pH probe
Upper endoscopy with biopsies
Barium swallow study
Abdominal ultrasound
Answer: The answer is B.
Explanation: Although esophageal pH monitoring (B) is considered unnecessary in most patients for
diagnosis of GERD, it is considered the current gold standard for documenting abnormal esophageal acid
exposure.
Esophageal manometry (A) may be utilized in evaluating heartburn or chest pain symptoms, but is not
considered the gold standard. It will reveal information on the integrity of the lower esophageal
sphincter and esophageal muscle, assessing swallowing difficulties.
A barium swallow study (esophagography), (D), should not be performed to diagnose GERD, but can be
utilized in patients with severe dysphagia and to identify esophageal strictures.
Abdominal ultrasound (E) will not reveal information regarding the acidity of the environment of the
esophagus. It is more beneficial for assessment of structural abnormalities of the abdomen.
References:
Gastroesophageal Reflux Disease. In: Maxine A. Papadakis, et al., eds. Current Medical Diagnosis &
Treatment 2018. New York, NY: McGraw-Hill, pp. 615–618.
Organ System: Gastrointestinal/Nutritional
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation: Family medicine, internal medicine
Topic(s): Esophageal disorders, Gastroesophageal reflux disease
119.
Stem: An adult patient presents to the clinic with symptoms of loss of interest
and pleasure, withdrawal from activities, and feelings of guilt. She is also experiencing
the inability to concentrate, some cognitive dysfunction, increased alcohol use, chronic
fatigue, and feelings of worthlessness. She states this all began over a month ago when
she lost her employment. Upon further questioning, she reveals that she has had
thoughts of hurting herself three hours or more each day and is at the point where she
plans to use the gun in the house to “end the pain.” Which of the following would be
the best intervention for this patient at this visit?
Answer Choice:
A.
B.
C.
D.
E.
Reassure the patient that things will get better with time
Convince the patient to be admitted to the hospital
Inform local law enforcement that she has a gun in the house
Schedule her for outpatient counseling services
Start her on venlafaxine to treat her depression
Answer: The answer is B.
Explanation: A major depressive disorder consists of a syndrome of mood, physical, and cognitive
symptoms that occurs at any time of life. Complaints vary widely but most frequently include a loss of
interest and pleasure (anhedonia), withdrawal from activities, and feelings of guilt. Also included are the
inability to concentrate, some cognitive dysfunction, anxiety, chronic fatigue, feelings of worthlessness,
somatic complaints (unexplained somatic complaints frequently indicate depression), loss of sexual
drive, and thoughts of death. Unemployment has been associated with an increase in depression risk.
The most important complication is suicide. The immediate goal of psychiatric evaluation is to assess the
current suicidal risk and the need for hospitalization versus outpatient management. Perhaps the one
most useful question is to ask the person how many hours per day he or she thinks about suicide. If it is
more than 1 hour, the individual is at high risk. Further assessing the risk by inquiring about intent,
plans, means, and suicide-inhibiting factors (e.g., strong ties to children or the church) is essential.
Alcohol, hopelessness, delusional thoughts, and complete or nearly complete loss of interest in life or
ability to experience pleasure are all positively correlated with suicide attempts (B). Reassuring the
patient is not appropriate based on the severity of the presentation (A). Law enforcement would not
need to be involved if the patient agreed to be admitted, which is the best option for this patient (C).
Due to the severity of the case, inpatient services would be more appropriate than outpatient services
(D). Venlafaxine is from the drug class serotonin norepinephrine reuptake inhibitors (SNRIs) and is
indicated for a variety of medical conditions. Some common uses include major depressive disorder and
generalized anxiety disorder. There is an increased risk of suicide attempts on these medications. This
would not be as appropriate as admitting the patient due to the severity of the case (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Psychiatry/Behavioral
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine
Topic(s): Suicidal/Homicidal Behaviors
120.
Stem: A 35-year-old male patient presents to the Urgent Care for a two-day
history of burning urination and penile discharge. On physical examination, scant cloudy
discharge is present at the penile meatus. The patient admits to having had sexual
intercourse with a new partner approximately one week ago. Based on this information,
which of the following answer choices represents the best course of management?
Answer Choice:
A. Obtain a urethral swab for laboratory testing and treat prophylactically with both ceftriaxone
and azithromycin.
B. Obtain a urethral swab for laboratory testing and treat with ceftriaxone and azithromycin upon
receipt of lab results.
C. Obtain a urethral swab for laboratory testing and treat prophylactically with ceftriaxone only.
D. Obtain a urethral swab for laboratory testing and treat prophylactically with azithromycin only.
E. Disregard urethral swab and treat prophylactically with both azithromycin and ceftriaxone.
Answer: The answer is A.
Explanation: Neisseria gonorrhoeae and Chlamydia trachomatis are the most common causes of acute
urethritis, with N. gonorrhoeae being the single most likely culprit. In most cases of urethral
discharge/urethritis, immediate laboratory confirmation of the causative pathogen is not available,
making prophylactic administration of antibiotics the mainstay of therapy (B). Current recommendations
for treatment of gonorrhea include coverage with both ceftriaxone and azithromycin, which is also
effective against chlamydia and other forms of nongonococcal urethritis (C and D). Laboratory
confirmation of pathogen is important to rule out other causes of urethritis like herpes simplex II and to
aid in the management of sexual partners (E). As a result of these factors, both lab testing and
prophylactic dual antibiotic therapy is recommended (A).
References: Zenilman JM. Chapter 3. Urethral Discharge. In: Klausner JD, Hook EW, III, eds. CURRENT
Diagnosis & Treatment of Sexually Transmitted Diseases. New York, NY: McGraw-Hill; 2007.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=369&
sectionid=39914779. Accessed February 08, 2019.
Organ System: Genitourinary
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine
Topic(s): Urethritis
121.
Stem: A 68-year-old male patient presents to the family practice clinic for 8
weeks of ongoing lower back pain. Subsequent plain film radiographs of the lumbar
spine reveal multiple lytic lesions diffusely spread throughout the lumbar vertebrae.
Which of the following answer choices represents the most likely diagnosis based on
this information alone?
Answer Choice:
A. Acute myeloid leukemia
B.
C.
D.
E.
Osteosarcoma
Tuberculosis
Ankylosing spondylitis
Multiple myeloma
Answer: The answer is E.
Explanation: Multiple lytic lesions is the classic appearance of multiple myeloma on plain film
radiograph. Multiple myeloma also has a strong predilection for the lumbar spine (E). Osteosarcoma is
uncommon in the elderly population, as a greater predilection for the femur, and generally appears as a
large lucency on radiography (B). Although tuberculosis can present in the lumbar spine as Pott’s
disease, it is uncommon in the United States and appears as ___ on radiographs (C). The classic
appearance of ankylosing spondylitis on radiographs is bambooing of the spine (D). Acute myeloid
leukemia is rare in the elderly population, and is unlikely to present in the vertebral skeleton (A).
References:
Organ System: Hematologic
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine
Topic(s): Multiple Myeloma
122.
Stem: A 40-year-old female patient presents to the family practice office
complaining of bilateral wrist pain. The pain is worse at the end of the day and is
accompanied by numbness and tingling in her palms, both of which are more prominent
at night. She reports that she is an electrical engineer and uses her hands heavily at
work, especially on the computer. The remainder of her history and physical
examination are consistent with a diagnosis of carpal tunnel syndrome (CTS). Which of
the following answer choices represents the best approach to patient education
regarding her diagnosis?
Answer choice:
A. CTS involves irritation of the median nerve. He should avoid prolonged wrist extension at work.
He may also benefit from wearing cock-up wrist splints at work and at night.
B. CTS involves irritation of the median nerve. He should be referred to Orthopedics to discuss
carpal tunnel release surgery.
C. CTS involves irritation of the radial nerve. He should avoid prolonged wrist extension. He may
benefit from wearing thumb spica splints at work and at night.
D. CTS involves irritation of the median nerve. He should avoid prolonged wrist extension. He may
benefit from forced flexion splints at work and at night.
E. CTS involves irritation of the median nerve. He should limit all wrist flexion and extension for the
next month.
Answer: The answer is A.
Explanation: CTS is a common disorder seen in individuals who use their hands at work. Repetitive,
forceful wrist movements, gripping, or exposure to repeated vibration causes increased pressure on the
median nerve as it runs under the transverse carpal ligament. Conservative management, which involves
wrist splinting and decrease of provocative activities, is generally recommended for three months (E). If
symptoms continue, referral to Orthopedics may be warranted for a discussion of glucocorticoid
injections or surgical release of the transverse ligament (B). Splinting should be done in a neutral
position with cock-up wrist splints to limit extension and flexion at night and during activities that
exacerbate symptoms (A, C, and D).
References: Shuping L, Hill III J. Work-Attributed Musculoskeletal Conditions. In: Mitra R, ed. Principles
of Rehabilitation Medicine. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=2550
&sectionid=206768529. Accessed February 13, 2019.
Organ System: Neurologic System, Musculoskeletal
Task Area: Health Maintenance
Core Rotation: Emergency Medicine
Topic(s): Carpal Tunnel Syndrome
123.
Stem: A 49-year-old man presents to the urgent care clinic for evaluation of
back pain that radiates down the posterior aspect of the right leg to the lateral aspect of
his right foot. The leg pain is accompanied by numbness and tingling. His symptoms
started 2 weeks ago when he was moving boxes in the basement. Physical exam
demonstrates decreased ankle jerk on the right lower extremity and 4/5 strength with
right plantar flexion. Left lower extremity exam is unremarkable. What other physical
exam finding supports the most likely diagnosis?
Answer Choice:
A.
B.
C.
D.
E.
Decreased rectal tone
Positive McMurray test on right lower extremity
Positive Apley grind test on the right lower extremity
Positive straight leg test on the right lower extremity
Vesicular rash along the T10 dermatome
Answer: The answer is D.
Explanation: This patient is presenting with a history of moving boxes, which often involves bending and
twisting motions that increase the risk of a disc herniation. The pain radiating down the lower extremity
is consistent with the S1 dermatome and the accompanying numbness and tingling suggest nerve root
irritation. When examining a patient for a lumbosacral radiculopathy, passive elevation of the affected
leg while the patient is in a supine position reproduces or increases the radiating leg pain. This test is
known as the straight leg raise test (D). Decreased rectal tone is present when there is compression of
the spinal cord, conus, or cauda equina (A). In addition to bowel and bladder incontinence, patients with
this type of disc herniation also have saddle anesthesia, not unilateral lower extremity symptoms. The
McMurray and Apley grind tests are used to evaluate the knee joint for a meniscal injury and are
therefore not correct (B and C). A vesicular rash in a dermatomal distribution is consistent with a herpes
zoster infection (E). While a Herpes zoster infection may also cause numbness and tingling in a
dermatomal distribution, the T10 distribution is inconsistent with the patient history and physical exam
findings.
References:
LeBlond RF, Brown DD, Suneja M, Szot JF. The Spine, Pelvis, and Extremities. In: LeBlond RF, Brown DD,
Suneja M, Szot JF, eds. DeGowin’s Diagnostic Examination. 10th ed. New York, NY: McGraw-Hill; 2014.
http://usj-ezproxy.usj.edu:2195/content.aspx?bookid=1192&sectionid=68669600. Accessed December
08, 2018.
McMahon PJ, Kaplan LD, Popkin CA. Chapter 3. Sports Medicine. In: Skinner HB, McMahon PJ, eds.
CURRENT Diagnosis & Treatment in Orthopedics. 5th ed. New York, NY: McGraw-Hill; 2014. http://usjezproxy.usj.edu:2195/content.aspx?bookid=675&sectionid=45451709. Accessed December 08, 2018.
Organ System: Musculoskeletal
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Primary Care, Internal Medicine, Emergency Medicine
Topic(s): Herniated Nucleus Pulposus
124.
Stem: A 20-year-old, otherwise healthy woman presents to the emergency
room via ambulance after falling from a third story balcony. Upon arrival, she is
unresponsive with a GCS of 5. What legal premise allows the provider to intubate her
without her permission?
Answer Choice:
A.
B.
C.
D.
E.
Implied consent
Informed consent
Assumed consent
Written consent
Verbal consent
Answer: The answer is A.
Explanation: Medical emergencies allow providers to operate under the theory of implied consent
because the need for treatment outweighs the need to obtain informed consent (A). Both written
consent and verbal consent are forms of informed consent and require the patient to be awake and
competent to understand the risks and benefits of a procedure, as well as the other basic components
required by law (A, B, D, and E). Assumed consent is not a theory recognized by law; therefore, it is not a
correct answer (C).
References:
Eckerline CA, Shopp JD. Legal Aspects of Emergency Care. In: Stone C, Humphries RL, eds. CURRENT
Diagnosis & Treatment: Emergency Medicine. 8th ed. New York, NY: McGraw-Hill; 2017. http://usjezproxy.usj.edu:2195/content.aspx?bookid=2172&sectionid=165057252. Accessed February 28, 2019.
Organ System: N/A
Task Area: Professional Practice
Core Rotation: Emergency Medicine
Topic(s): Legal/Medical Ethics
125.
Stem: A 73-year-old male with a history of HTN, dyslipidemia, COPD, and a
recent diagnosis of HFpEF (Heart Failure with preserved Ejection Fraction) with an EF of
60% was brought to the Emergency Department with a new cerebrovascular accident
(CVA). During the admission, it was noted that the patient was found to have a new
onset of atrial fibrillation, with rates in the 120–130 range. The patient had been feeling
reasonably well prior to this event, but had been complaining of dyspnea for the last
several months. The patient had been taking all of his medications, which included
metoprolol, atorvastatin, salmeterol inhaler, and a daily aspirin. On physical
examination, the patient was found to have mild crackles throughout all lung fields, and
an irregularly irregular rhythm with a 2/6 systolic murmur, which was appreciated at the
apex, and slightly louder in the left lateral decubitus position. Given this clinical
scenario, what is the most likely etiology for this patient’s clinical exam murmur?
Answer choice:
A.
B.
C.
D.
E.
Aortic stenosis
Pulmonic stenosis
Tricuspid stenosis
Mitral stenosis
High flow filling pressures
Answer: The answer is D.
Explanation: This patient presented with symptoms of a new CVA, most likely brought on by a
thromboembolic state, caused by the presence of mitral stenosis. In this clinical scenario, the patient
developed HFpEF, which can cause higher filling pressures to be present. Over time, mitral stenosis will
develop, and this leads to 47% of the population with mitral stenosis to develop atrial fibrillation (D).
The thrombus formation is secondary to the stenosis, and thus can also create an environment for CVA.
References:
Chandrashekhar Y, Westaby S, Narula J. Mitral stenosis. Lancet. 2009;374:1271.
Diker E, Aydogdu S, Ozdemir M, et al. Prevalence and predictors of atrial fibrillation in rheumatic
valvular heart disease. Am J Cardiol. 1996;77:96.
Organ System: Cardiovascular
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Emergency Medicine, Internal Medicine, Surgery
Topic(s): Valvular Disorders, Mitral Stenosis
126.
Stem: A 13-year-old male presents to your clinic with a two-week history of a
painful, enlarging mass in his right mid-shaft tibia. He is active in sports, but denies
known trauma. His mother states that in the beginning, they managed the pain with
Tylenol and Motrin, but that no longer seems to help. Your initial treatment plan is to
get a plain radiograph. What condition are you suspecting that meets these symptoms?
Answer choice:
A.
B.
C.
D.
Osteoid osteoma
Osteosarcoma
Ewing’s sarcoma
Myosarcoma
Answer: The answer is C.
Explanation: Osteoid osteoma is a benign cortical lesion, not associated with mass formation (A). It can
be painful but is typically an incidental finding under age 40. Osteosarcoma has a similar presentation to
Ewing’s but is found in the bone metaphysis predominantly (B and C). Myosarcoma is a malignant tumor
of muscles, usually found in large muscle mass, like the thigh (D).
References:
The European Sarcoma Network Working Group [ESMO], 2014.
Organ System: Musculoskeletal
Task Area: Health Maintenance
Core Rotation: Family Medicine, Emergency Medicine, Pediatrics
Topic(s): Neoplasms, Malignant
127.
Stem: A 67-year-old male with history of hypertension comes in to your office
for his annual wellness visit. The nurse reviews his immunizations and notes that he has
received Pneumovax-23 and Zostavax immunizations at age 65. He had a Tdap shot 4
years ago before his granddaughter was born. He received the seasonal influenza
vaccine at Walgreens last week. Which of the following immunizations are indicated at
this time?
Answer choice:
A. Pneumococcal 13-valent conjugate vaccine (Prevnar-13)
B. Zoster vaccine live (Zostavax)
C. Tdap
D. Meningococcal conjugate vaccine (MenACWY)
E. HPV-9 valent vaccine (Gardasil)
Answer: The answer is A.
Explanation: Adults age 65 or older should receive two pneumococcal vaccinations, which includes both
Pneumovax-23 and Prevnar-13 (A). The patient is up to date on both Zostavax and Tdap vaccines (B and
C). Meningococcal conjugate vaccine (MenACWY) and HPV-9 valent vaccine (Gardasil) are not indicated
(D and E).
References:
Chesnutt AN, Chesnutt MS, Prendergast NT, Prendergast TJ. Pulmonary Disorders. In: Papadakis MA,
McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment 2019. New York, NY: McGrawHill; 2018. http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194434470.
Accessed September 01, 2018.
https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-easy-read.pdf
Organ System: Infectious Diseases
Task Area: Health Maintenance
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Adult Immunizations
128.
Stem: A 22-year-old woman presents to your primary care clinic with complaints
of intermittent cramping and lower abdominal pain for the last 6 months. The pain
usually begins later in the day, is followed by a feeling of fecal urgency, and improves
after she has a loose stool. She has a normal appetite and denies any weight loss or
blood in her stools. The patient was recently promoted at work and reports increased
stress with her new position. Otherwise, her past medical history and family history are
unremarkable. Which of the following is the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Cholecystitis
Gastroenteritis
Diverticulitis
Irritable bowel syndrome
Ulcerative colitis
Answer: The answer is D.
Explanation: Irritable bowel syndrome (D) is a chronic condition diagnosed by presence of symptoms for
at least 3 months and absence of organic disease. Lower adominal pain, which is intermittent and
crampy in nature and typically associated with a change in stool frequency or form and/or relieved by
defacation, are common presentations. Diarrhea, constipation, or a combination of both can be
described by patients. Other complaints may include abdominal distension, bloating, and gas. Stress and
anxiety are common psychosocial factors. A physical exam is usually unremarkable, as are laboratory
findings.
Cholecystitis (A) would present with RUQ pain, association to eating/meals, N/V, and possibly fever and
signs of systemic illness. Gastroenteritis (B) would not likely be presenting for 6 months. Diverticulitis (C)
would tend to present with LLQ pain and possibly N/V and mild fever, and stool occult blood is common.
Ulcerative colitis (E) should present with bloody diarrhea and mucus in stools. The abdominal pain tends
to be LLQ cramping if present, and relieved by defacation. Patient will generally have weight loss as well.
References:
Irritable Bowel Syndrome. In: Maxine A. Papadakis, et al., eds. Current Medical Diagnosis & Treatment
2018. New York, NY: McGraw-Hill, pp. 653–657.
Organ System: Gastrointestinal
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family medicine, internal medicine
Topic(s): Colorectal disorders, Irritable Bowel Syndrome
129.
Stem: A 14-year-old male patient with type 1 diabetes presents to the ED with
nausea and vomiting. His mother states that he has become increasingly lethargic. She
checked his blood sugar this morning at home and found it to be 300 mg/dL. Despite
giving him a bolus correction, he remained above 300 mg/dL all morning. Vitals taken in
the ED are: blood pressure 80/60, pulse 120, respiratory rate of 20, and temperature 37
°C. On exam, he is able to answer questions, his lips are dry, cardiac: tachycardia with
normal rhythm and no murmur audible, lungs: tachypnea with clear auscultation,
abdomen is soft with generalized tenderness on palpation, no hepatosplenomegaly or
rebound tenderness. The ER providers believe this is diabetic ketoacidosis. Which of the
following laboratory results support the diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Blood sugar >126 mg/dL, pCO2 is elevated, and bicarbonate > 15 mEq/L
Blood sugar > 200 mg/dL, blood pH < 7.3, and bicarb > 15 mEq/L
Hyperkalemia, blood pH < 7.3, and ketonemia
Hypokalemia, hypernatremia, blood glucose > 180 mg/dL
pCO2 is low, blood pH > 7.5, and ketonuria
Answer: The answer is C
Explanation: Essential to making the diagnosis is a blood sugar > 250mg/dL, acidosis (pH < 7.3),
bicarbonate < 15 mEq/L, and positive serum ketones (C). Other laboratory studies that support the
diagnosis include: hyperkalemia, slight hyponatremia, hyperphosphatemia, elevated BUN and
creatinine. pCO2 levels are low due to hyperventilation.
References:
Masharani U. Diabetes Mellitus & Hypoglycemia. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current
Medical Diagnosis & Treatment 2018 New York, NY: McGraw-Hill;
. http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=167998145. Accessed
May 08, 2018.
Organ System: Endocrine
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Emergency Medicine
Topic(s): Diabetes mellitus, Type 1
130.
Stem: A 26-year-old female presents to the office for evaluation of ongoing
nasal congestion. She describes similar symptoms occurring last May and September.
On review of systems, she is also positive for itchy, watery eyes and occasional sneezing.
She denies fever, chills, or pharyngitis. Which of the following physical exam findings
would be expected when evaluating this patient?
Answer choice:
a.
b.
c.
d.
Atrophic changes of the turbinates
Edematous and erythematous tonsils
Pale or violaceous turbinates
Soft grayish appearing lesions on the buccal mucosa
e. Unilateral purulent discharge from the nares
Answer: The answer is C
Explanation: The violaceous color change (C) is secondary to venous engorgement. Viral rhinitis will give
have a more erythematous appearance of the turbinates (D). Atrophy (A) can occur with system disease
such as syphilis or lupus. Unilateral purulent discharge (E) should alert the examiner to a possible foreign
body in the nares. Red, swollen tonsils (B) would be more consistent with a diagnosis of viral or bacterial
pharyngitis.
References:
Lustig LR, Schindler JS. Ear, Nose, & Throat Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
Organ System: EENT
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine
Topic(s): Nose/Sinus Disorders, Allergic Rhinitis
131.
Stem: A 72-year-old patient presents to the urgent care clinic for evaluation of
pain and redness on her face. She states that the skin redness developed last night along
with the pain. She denies pruritis. She has not taken her temperature at home. There is
no recent use of any new detergents, soaps, or lotions. She is on aspirin, 81 mg a day.
She has no known allergies. On exam, temperature is 37.2 °C. Skin exam reveals a welldefined indurated area on the right cheek that extends to the nasolabial fold. No bullae
is noted. Which of the following treatment regimens is recommended?
Answer choice:
a.
b.
c.
d.
e.
Acyclovir
Fluocinonide
Ketoconazole
Penicillin
Vancomycin
Answer: The answer is D
Explanation: This clinical presentation is consistent with erysipelas, with a well demarcated, red, and
painful skin area. It is commonly seen on the face and extremities. The organism causing this illness is
Streptococcus pyogenes, which will respond to penicillin (D). Acyclovir (A) is an antiviral. Fluocinonide
(B) is a topical steroid. Ketoconazole (C) is a topical antifungal. Vancomycin (E) is not needed in the case
of a strep infection.
References:
Stevens DL. Infections of the Skin, Muscles, and Soft Tissues. In: Kasper D, Fauci A, Hauser S, Longo D,
Jameson J, and Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGrawHill.
Organ System: Dermatologic
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine
Topic(s): Infectious diseases, Bacterial, Erysipelas
132.
Stem: A 17-year-old female presents for evaluation after striking her head
against a goal post during her varsity soccer game. She denies loss of consciousness, but
her mother reports that she was “dazed” for one to two minutes after the injury. What
other symptom would support the decision to discharge the patient home with parental
supervision?
Answer Choice:
A.
B.
C.
D.
E.
Multiple episodes of vomiting
Persistent anterograde amnesia
Unilateral throbbing headache
Hemiplegia
Nuchal rigidity
Answer: The answer is C.
Explanation: Migrainous or frontal headaches are common following a mild TBI. Intractable vomiting
suggests a more severe traumatic brain injury that would warrant imaging the patient with a noncontrast head CT scan (A). Although a brief period of amnesia can accompany a mild concussion, the
patient typically returns to a normal level of consciousness and cognitive function within minutes of the
event. If anterograde amnesia is present and persistent, a CT scan of the head is usually warranted to
evaluate for more severe injury (B). Hemiplegia is most commonly associated with injuries to the
corticospinal tracts, making this less likely in the setting of a mild concussion (D). Nuchal rigidity is most
commonly encountered in the setting of a subarachnoid hemorrhage or some infection of the meninges
(E).
References:
Manley GT, Hauser SL, McCrea M. Concussion and Other Traumatic Brain Injuries. In: Jameson J, Fauci
AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th
ed. New York, NY: McGraw-Hill; 2018.
http://usj-ezproxy.usj.edu:2195/content.aspx?bookid=2129&sectionid=192533001.Accessed February
20, 2019.
Naik P, Mollman M. Headache. In: Stone C, Humphries RL, eds. CURRENT Diagnosis & Treatment:
Emergency Medicine. 8th ed. New York, NY: McGraw-Hill; 2017. http://usjezproxy.usj.edu:2195/content.aspx?bookid=2172&sectionid=165060254. Accessed February 27, 2019.
Organ System: Neurologic
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Primary Care, Internal Medicine, Emergency Medicine
Topic(s): Concussion
133.
Stem: A patient presents to the clinic with family members who are concerned
with an abnormal behavioral pattern. After a complete, detailed examination, you
diagnose the patient with borderline personality disorder. Which of the following clinical
findings would be most likely present in this patient?
Answer Choice:
A.
B.
C.
D.
E.
Unstable and intense interpersonal relationships
Poor dentition
Repetitive actions such as washing the hands many times
Excessive demands for attention
Fear of rejection
Answer: The answer is A.
Explanation: Patients with borderline personality disorder may exhibit clinical findings of impulsiveness;
have unstable and intense interpersonal relationships; are suffused with anger, fear, and guilt; lack selfcontrol and self-fulfillment; have identity problems and affective instability; may be suicidal; and may
display aggressive behavior, feelings of emptiness, and occasional psychotic decompensation (A).
Bulimia nervosa is the episodic uncontrolled ingestion of large quantities of food followed by recurrent
inappropriate compensatory behavior to prevent weight gain such as self-induced vomiting, diuretic or
cathartic use, or strict dieting or vigorous exercise. Vomiting can result in poor dentition, pharyngitis,
esophagitis, aspiration, and electrolyte abnormalities (B). Obsessive-compulsive disorder (OCD),
classified as an anxiety disorder in the DSM-IV, now is part of a separate category of obsessivecompulsive disorder and related disorders in DSM-5. In OCD, the irrational idea or impulse repeatedly
and unwantedly intrudes into awareness. Obsessions (recurring distressing thoughts, such as fear of
exposure to germs) and compulsions (repetitive actions such as washing the hands many times or
cognitions such as counting rituals) are usually recognized by the individual as unwanted or
unwarranted and are resisted, but anxiety often is alleviated only by ritualistic performance of the
compulsion or by deliberate contemplation of the intruding idea or emotion (C). Patients with a
narcissistic personality disorder may exhibit clinical findings of exhibitionism, grandiosity, preoccupation
with power, lacking interest in others, and excessive demands for attention (D). Patients with an
avoidant personality disorder may exhibit clinical findings of fear of rejection, hyperreaction to rejection
and failure, poor social endeavors, and low self-esteem (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Psychiatry/Behavioral
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine, Pediatrics
Topic(s): Personality Disorders, Borderline
134.
Stem: Which of the following examples of malignant bone tumors is primarily
known as non-metastasizing?
Answer choice:
A.
B.
C.
D.
Chondrosarcoma
Osteosarcoma
Ewing’s sarcoma
Osteoblastoma
Answer: The answer is A.
Explanation: Osteosarcoma and Ewing’s are highly malignant and often have mets on presentation (B
and C). Osteoblastoma is a benign tumor (D).
References:
The European Sarcoma Network Working Group [ESMO], 2014; Gaspar et al., 2015.
Organ System: Musculoskeletal Medicine
Task Area: Health Maintenance
Core Rotation: Family Medicine
Topic(s): Neoplasms, Malignant
135.
Stem: A 33-year-old man was brought to the emergency room in
cardiopulmonary arrest after overdosing on heroin. Despite ongoing resuscitation
efforts for nearly an hour, there was no return of spontaneous pulses. The provider now
has to tell the patient’s wife that he is deceased. What is the most appropriate method
of delivering the bad news?
Answer Choice:
A.
B.
C.
D.
E.
Ask-tell-ask
Tell-ask-review
Smile-nod-answer
Inquire-inform-imply
Reassure-explain-educate
Answer: The answer is A.
Explanation: The best way to deliver bad news or a new diagnosis to a patient and/or his family member
is to begin by asking what the patient or family member knows and understands about the situation or
diagnosis. After identifying the initial understanding the patient or family member has, provide clear and
concise information using plain English. Finish the interview by providing the family member or patient
with a time to ask questions of their own or ask them to express their emotions regarding the
information (A). Tell-ask-review does not allow the provider to understand where the patient or family
member is aware of before informing them of the diagnosis or bad news (B). Smile-nod-answer assumes
the patient or family member has enough basic knowledge to ask relevant questions (C). It is also
inappropriate to smile during the delivery of bad news or diagnoses with poor prognoses. Inquireinform-imply is not correct because nothing should be implied in this situation (D). Information must be
provided in a very clear manner and an understanding must be expressed by the patient or family
member. Reassure-explain-educate is not the most appropriate answer because patients or family
members you are speaking with may not know anything, making reassurance seem inappropriate at the
beginning of the discussion (E).
References:
Lustbader D, Hajizadeh N. Intensive Talk: Delivering Bad News and Setting Goals of Care. In: Oropello JM,
Pastores SM, Kvetan V, eds. Critical Care. New York, NY: McGraw-Hill; 2016. http://usjezproxy.usj.edu:2195/content.aspx?bookid=1944&sectionid=143521818. Accessed February 28, 2019.
Organ System:
Task Area: Professional Practice
Core Rotation: Emergency Medicine, Internal Medicine, Surgery, Primary Care
Topic(s): Patient Care and Communication
136.
Stem: A 70-year-old farmer is at his primary care office for his annual exam. He
has noted some left eye irritation on and off over the past few months. He denies any
blurred or impaired vision at this time. He has had no history of eye trauma. He does
wear corrective lenses for reading. On physical exam, his left eye is noted to have a
triangular thickening of the bulbar conjunctiva that extends to the outer surface of the
cornea. There is normal papillary reaction to light and accommodation. Which one of
the following is the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Blepharitis
Conjunctivitis
Pinguecula
Pterygium
Xanthelasma
Answer: The answer is D
Explanation: A pinguecula (C) is a conjunctival nodule that arises temporally or nasally. They are
common and have little significance. The pterygium (D) is similar to the pinguecula, but it crosses the
limbus to the surface of the cornea. Both are found in workers exposed to outdoor conditions (farmers
and fisherman). Blepharitis (A) is an inflamed eyelid. Conjunctivitis (B) is inflammation of the
conjunctiva. Xanthelasma (E) is fat deposited under the skin of the eyelids.
References:
Horton JC. Disorders of the Eye. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds.
Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill.
Organ System: EENT
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine
Topic(s): Eye Disorders, Corneal disorders, Pterygium
137.
Stem: A 60-year-old male is in the office today with a chief complaint of “I’m still
having trouble with my heartburn.” The patient states that for the past 2–3 weeks he
has had mild stomach discomfort and a gnawing sensation in the upper abdomen. He
says it feels like hunger pains. If he eats or takes an antacid, he has some relief. He says
the only medications he is currently taking are hydrochlorothiazide for his hypertension
and ibuprofen for his arthritis. He is otherwise healthy. Review of systems reveals mild
nausea and slight decrease in appetite over the past 2 weeks. No vomiting or diarrhea.
His vitals are all within normal range and his physical exam is unremarkable today.
Which one of the following is the diagnostic procedure of choice for this patient?
Answer choice:
a. Abdominal ultrasound
b.
c.
d.
e.
Colonoscopy
Upper endoscopy
Upper GI barium swallow
Upright and decubitus abdomen plain film
Answer: The answer is C
Explanation: Endoscopy (C) provides the most sensitive and specific approach to examination of the
upper GI tract. It allows for direct visualization and biopsy to rule out malignancy or H. pylori infection.
Small lesions can be missed on x-ray (A), (B), and (E). Barium studies (D) are still occasionally used first
line. Sensitivity of single-contrast barium meals is 80%; double contrast can reach 90%. Sensitivity is
decreased with small ulcers. It can be difficult to distinguish benign ulcers versus malignant on
radiographs.
References:
McQuaid KR. Gastrointestinal Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical
Diagnosis & Treatment 2018 New York, NY: McGraw-Hill;
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168013478. Accessed
May 08, 2018.
Organ System: Gastrointestinal/Nutritional
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Gastric disorders, Peptic Ulcer Disease
138.
Stem: A 14-year-old type 1 diabetic patient is in the office today for a one week
follow-up. The patient and her mother state that she has been experiencing blood
sugars in the morning (6am) ranging from 220–300 mg/dL despite healthy dietary
habits. The patient had been instructed at her last visit to check and record blood sugars
at bedtime and again at 2am. The patient brought in her logbook today. At bedtime
(10pm), her blood sugars range from 110–150 mg/dL. At 2am, her blood sugar checks
range from 120–140mg/dL. Which one of the following is the most likely cause of the
morning hyperglycemia?
Answer choice:
a.
b.
c.
d.
e.
Her evening bedtime snack
She is developing diabetic ketoacidosis
She is experiencing the dawn phenomenon
This is likely due to a recent illness
This is the somogyi effect
Answer: The answer is C
Explanation: She is experiencing the dawn phenomenon (C). The somogyi effect (E) is a prebreakfast
hyperglycemia that occurs due to nocturnal hypoglycemia—the hypoglycemia causes a surge of counterregulatory hormones, resulting in the hyperglycemia. The dawn phenomenon is a more common cause
of prebreakfast hyperglycemia and occurs due to waning evening or bedtime insulin. There is reduced
tissue sensitivity between 5am and 8am due to a spike in the normal release of growth hormone hours
before. The early morning (2am) blood sugar check can distinguish between the two. Her bedtime snack
should not impact her morning glucose in the morning, and she does not appear to be in the condition
of developing ketoacidosis, as her glucose has not remained higher. (Masharani, 2011)
Organ System: Endocrine
Task Area: Applying Basic Science Concepts
Core Rotation: Internal Medicine
Topic(s): Diabetes mellitus, Type 1
139.
Stem: A patient presents to the clinic with family members who are concerned
with an abnormal behavioral pattern. After a complete, detailed examination, you
diagnose the patient with narcissistic personality disorder. Which of the following
clinical findings would be most likely present in this patient?
Answer Choice:
A.
B.
C.
D.
E.
Unstable and intense interpersonal relationships
Poor dentition
Repetitive actions such as washing the hands many times
Excessive demands for attention
Fears rejection
Answer: The answer is D.
Explanation: Patients with borderline personality disorder may exhibit clinical findings of impulsiveness;
have unstable and intense interpersonal relationships; are suffused with anger, fear, and guilt; lacks selfcontrol and self-fulfillment; have identity problems and affective instability; may be suicidal; and may
display aggressive behavior, feelings of emptiness, and occasional psychotic decompensation (A).
Bulimia nervosa is the episodic uncontrolled ingestion of large quantities of food followed by recurrent
inappropriate compensatory behavior to prevent weight gain such as self-induced vomiting, diuretic or
cathartic use, or strict dieting or vigorous exercise. Vomiting can result in poor dentition, pharyngitis,
esophagitis, aspiration, and electrolyte abnormalities (B). Obsessive-compulsive disorder (OCD),
classified as an anxiety disorder in the DSM-IV, now is part of a separate category of obsessivecompulsive disorder and related disorders in DSM-5. In OCD, the irrational idea or impulse repeatedly
and unwantedly intrudes into awareness. Obsessions (recurring distressing thoughts, such as fear of
exposure to germs) and compulsions (repetitive actions such as washing the hands many times or
cognitions such as counting rituals) are usually recognized by the individual as unwanted or
unwarranted and are resisted, but anxiety often is alleviated only by ritualistic performance of the
compulsion or by deliberate contemplation of the intruding idea or emotion (C). Patients with a
narcissistic personality disorder may exhibit clinical findings of exhibitionism, grandiosity, preoccupation
with power, lacking interest in others, and excessive demands for attention (D). Patients with an
avoidant personality disorder may exhibit clinical findings of fear of rejection, hyperreaction to rejection
and failure, poor social endeavors, and low self-esteem (E).
References: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis & Treatment
2019 New York, NY: McGraw-Hill;
. http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Psychiatry/Behavioral
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine, Pediatrics
Topic(s): Personality Disorders, Narcissistic
140.
Stem: A 58-year-old Caucasian male presents to primary care for follow up after
discharge from the hospital for new onset systolic heart failure. His PMH is positive only
for chronic kidney disease with a recent GFR of 29 and Cr of 2.6. His vital signs are stable
and exam does not reveal edema. He is not currently on any medications for heart
failure and has no known drug allergies. Which of the following medications is most
appropriate to add to his regimen in order to improve mortality?
Answer choice:
A.
B.
C.
D.
E.
Lisinopril
Carvedilol
Isosorbide dinitrate
Hydrochlorothiazide
Spironolactone
Answer: The answer is B.
Explanation: Carvedilol is known to reduce mortality in heart failure and is a mainstay of treatment for
stable patients without allergies or severe reversible airway disease (B). Isosorbide dinitrate does not
reduce mortality as well as beta blockers and studies show it is more effective for African American
patients (C). Lisinopril and spironolactone are contraindicated given the patient’s creatinine and history
of chronic kidney disease (A and D). While useful in heart failure, hydrochlorothiazide is reserved for
patients with signs of fluid overload, which are not present in this patient (E).
References:
Chavey WE, Bleske BE, Van Harrison R, Hogikyan RV, Kesterson SK, Nicklas JM. Pharmacologic
management of heart failure caused by systolic dysfunction. Am Fam Physician. 2008;77:957-64.
Organ System: Cardiovascular
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Heart Failure
141.
Stem: Mr. Jones is a 61-year-old male with a history of congestive heart failure
who presents to the emergency room for the chief complaint of shortness of breath.
Two hours later, Mrs. Smith, a 70-year-old female with a history of congestive heart
failure, presents to the emergency room with the chief complaint of shortness of
breath, too. The same healthcare provider who took care of Mr. Jones also takes care of
Mrs. Smith. The healthcare provider initiates and follows the congestive heart failure
protocol workup and admission guidelines for both patients. Utilization of evidencebased practice guidelines to ensure a provider acts consistently in cases that are similar
in ethically relevant ways is an example of what fundamental ethical guideline for
approaching ethical decision-making?
Answer Choice:
A.
B.
C.
D.
E.
Informed consent
Justice
Nonmaleficence
Beneficence
Autonomy
Answer: The answer is B.
Explanation: Informed consent refers to the process by which a patient understands and agrees to the
evaluation and treatment proposed by the healthcare provider (A). Justice refers to the ethical concept
of treating everyone in a fair manner and thus is the best answer choice (B). Evidence-based practice
guidelines have helped hospital systems improve justice amongst patients as well as decrease infection
and readmission rates. Nonmaleficence is the duty of health care providers to do no harm (C).
Beneficence is the obligation of health care providers to help people in need (D). Autonomy is the right
of a patient to choose and follow his or her own plan of life, and control his or her own destiny (E).
References:
Bernet W. Forensic Psychiatry. In: Ebert MH, Leckman JF, Petrakis IL, eds. CURRENT Diagnosis &
Treatment: Psychiatry. 3rd ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.ezproxy.lynchburg.edu/content.aspx?bookid=2509&sectionid=2
00981455.
Bodenheimer T, Grumbach K. Medical Ethics and Rationing of Health Care. In: Bodenheimer T,
Grumbach K, eds. Understanding Health Policy: A Clinical Approach. 7th ed. New York, NY: McGraw-Hill;
2016.http://accessmedicine.mhmedical.com.ezproxy.lynchburg.edu/content.aspx?bookid=1790&sectio
nid=121192090.
Organ System:
Task Area: Professional Practice
Core Rotation: Family Medicine, Emergency Medicine, Internal Medicine, Surgery
Topic(s): Legal/Medical Ethics
142.
Stem: A 62-year-old male presents to your internal medicine office with his
daughter, who is a nurse. She is concerned because she has noted that he has increasing
difficulty getting up out of his chair. This has been worsening over the past six months.
He has had several recent episodes of choking on his food while eating and she noticed
last week that his eyelids “seemed droopy.” His past medical history is significant for
HTN and hyperlipidemia, and he is on Lisinopril 10 mg daily and simvastatin 20 mg daily.
On physical exam, his pulse is 84 and regular, and his blood pressure is 118/84. His skin
exam is unremarkable. HEENT exam shows bilateral ptosis. His lungs are clear. Cardiac
exam reveals a regular rate and rhythm without murmur/rub/gallop. Abdominal exam
is soft without tenderness noted. There is no organomegaly noted. He has 2+ pulses
throughout and reflexes are 2+/4+ bilaterally. Bilateral weakness on shoulder abduction
is noted. What is the most likely diagnosis?
Answer Choice:
A.
B.
C.
D.
E.
Botulism
Graves’ disease
Lambert-Eaton syndrome
Mitochondrial myopathy
Myasthenia gravis
Answer: The answer is E.
Explanation: The patient fits the demographic of myasthenia gravis, with presentation in the 50s or 60s
in males (E). This can be distinguished from Lambert-Eaton syndrome because those patients have
depressed or absent reflexes and experience autonomic changes such as dry mouth and impotence
(C). This patient’s symptoms progressed over several months. Botulism would progress more quickly
(A). Although Graves’ disease can manifest with muscle weakness, the remainder of the clinical picture
does not fit (B). Most of the mitochondrial myopathies have onset at or before puberty (D).
References: Amato AA. Myasthenia Gravis and Other Diseases of the Neuromuscular
Junction. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of
Internal Medicine. 20th ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192533554. Accessed
February 14, 2019.
Rao AK, Maslanka S. Botulism. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo
J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192021677. Accessed
February 14, 2019.
Organ System: Neurologic
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Myasthenia Gravis
143.
Stem: Most urinary tract infections (UTIs) are caused by which of the following?
Answer choice:
A.
B.
C.
D.
E.
Gram-positive bacteria
Escherichia coli
Staphylococcus aureus
Pseudomonas aeruginosa
Candida albicans
Answer: The answer is B.
Explanation: Approximately 95% of cases of UTI are caused by Escherichia coli (B). This bacteria is
commonly found in feces. The remaining gram-negative urinary pathogens are usually other
enterobacteria, typically Klebsiella or Proteus mirabilis, and occasionally Pseudomonas aeruginosa.
References:
Meng MV, Walsh TJ, Chi TD. Urologic Disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current
Medical Diagnosis & Treatment 2018. New York, NY: McGrawHill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168019217. Accesse
d January 28, 2018.
Organ System: Genitourinary System
Task Area: Applying Basic Science Concepts
Core Rotation: Family Medicine, Emergency Medicine, Internal Medicine
Topic(s): Infectious Disorders, Cystitis
144.
Stem: In a patient with known idiopathic pulmonary fibrosis, which one of the
following has been shown to improve the patient’s cough?
Answer choice:
a.
b.
c.
d.
e.
Azathioprine alone
Azathioprine plus a steroid
N-acetylcystine
Steroid monotherapy
Thalidomide
Answer: The answer is E
Explanation: Thalidomide (E) has anti-inflammatory, immunomodulatory, and antiangiogenic effects.
Small studies have shown reduction of cough and improved quality of life. Steroids (D), N-acetylcystine
(C), and immunotherapy (azathioprine), (A) and (B), lack evidence of efficacy.
References:
Tighe RM, Meltzer EB, Noble PW. Idiopathic Pulmonary Fibrosis. In: Grippi MA, Elias JA, Fishman JA,
Kotloff RM, Pack AI, Senior RM, Siegel MD. eds. Fishman's Pulmonary Diseases and Disorders, Fifth
Edition. New York, NY: McGraw-Hill.
Organ System: Pulmonary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Internal Medicine
Topic(s): Restrictive Pulmonary Disease, Idiopathic Pulmonary Fibrosis
145.
Stem: A patient presents to the clinic with vulvar itching and pain for “months.”
On exam, the vulva appears moist with raised, erythematous demarcated plaques. A
few of the plaques are ulcerated. When acetic acid is applied, the lesions are more
distinct with white epithelium. Which of the following is most appropriate?
Answer choice:
a.
b.
c.
d.
e.
Topical triamcinolone
Laser ablation therapy
Colposcopy with biopsy
Culture for PCR analysis
Methotrexate
Answer choice: The answer is C
Explanation: The lesion described is highly suspicious for vulvar intraepithelial neoplasia (VIN) and
requires biopsy above all other choices. Colposcopy aids in the visualization of lesion(s) for adequate
biopsy.
References:
Grace M. Benign vulvar disease. In: Link FW, Carson SA, Flower WC, Snyder RR., eds. Step-Up to
Obstetrics and Gynecology. Philadelphia, PA: Wolters Kluwer Health; 2015: 342-347.
Holschneider CH. Vulvar intraepithelial neoplasia. In: UpToDate, Goff B, Garcia RL, Falk SJ. (Eds.),
UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed on December 1, 2017.)
Organ System: Reproductive
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Obstetrics-Gynecology
Topic(s): Neoplasms of the breast and reproductive tract
146.
Stem: A 22-year-old female reports to the clinic complaining of an intense
ringing in her right ear and dizziness that started when she woke up this morning. The
patient states both symptoms started this morning when she woke up. Her past medical
history is consistent with treatment of an otitis media infection of the right ear over six
weeks ago. She takes no medications, and she denies tobacco use, EtOH use, and drug
use. Her vital signs are as follows: BP: 110/68, Temp: 98.8 °F, Pulse: 75 BPM, Pulse Ox:
98% on ambient air.
Her HEENT reveals TMs that are without erythema, edema, or exudate, and have a cone of
light at the 12 o’clock position. There is minimal scarring to the right TM at the 6 o’clock
position, consistent with having had myringotomy tubes placed when she was 4 years old.
The remainder of her workup is with in normal range. Which of the following tests and
results would support a diagnosis of benign positional peripheral vertigo in this patient?
Answer choice:
a.
b.
c.
d.
e.
A deviation of the eyes in the same direction of a head thrust in a Halmagyi head thrust
The absence of down beating nystagmus on a Dix-Hallpike maneuver test
The absence of nystagmus on a Pagnini-McClure test
A worsening of the patient’s vertigo with the Epley maneuver
The presence of a positive ocular tilt reaction
Answer: The answer is B.
Explanation: This patient is suffering from BPPV. The preferred tests for assessing this condition are the
Epley maneuver, and the Dix-Hallpike maneuver (B). A confirmatory test for the Dix-Hallpike maneuver
is the presence of rotary nystagmus that lasts no longer than 30 seconds, which is a positive test for
BPPV. The absence of down beating nystagmus indicates that it is not central vertigo. Answers (A), (C),
(D), and (E) are all indicators of central vertigo or a lesion causing ventral vertigo.
References:
Goldman B. Vertigo. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.
Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109436887.
Accessed December 19, 2017.
Lustig LR, Schindler JS. Ear, Nose, & Throat Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168008266.
Accessed December 19, 2017.
Organ System: EENT
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation: Family Medicine
Topic(s): Ear Disorders, Inner ear, Vertigo
147.
Stem: A 69-year-old male patient with a history of diet-controlled diabetes and
hypertension (treated with lisinopril) presents to the Emergency Department (ED) with
right-sided paralysis and aphasia. The patient’s wife states he was in his normal state of
health when she left to go to the grocery store 3.5 hours ago. When she returned home
from the grocery store, she went into the living room to ask him a question and he was
unable to answer her. She immediately called emergency medical services, who
evaluated him, including his BG (which was 108 mg/dl). He was transported to the ED.
On physical exam, his temperature is 36.8°C (98.2°F), his pulse is 88 and irregular, his
respiratory rate is 14 and non-labored, and his blood pressure is 174/94. His skin exam is
unremarkable. He follows commands and is able to raise his left hand and squeeze your
hand to answer questions. Right sided facial droop is noted and decreased sensation
and decreased deep tendon reflexes are noted on the right. His lungs are clear. Cardiac
exam reveals an irregular rate and rhythm without murmur/rub/gallop. Abdominal
exam is soft without tenderness noted. There is no organomegaly noted. He has 2+
pulses throughout and reflexes are 2+/4+ bilaterally. What is the most likely diagnosis?
Answer Choice:
A.
B.
C.
D.
E.
Complicated migraine
Ischemic CVA
Hemorrhagic CVA
Hypoglycemia
Subdural hematoma
Answer: The answer is B.
Explanation: Although complicated migraines can present with neurologic symptoms, this does not fit
this patient’s clinical picture (A). He has what appears to be a new onset arrhythmia (potentially atrial
fibrillation), which is a risk factor for ischemic CVA, making this a more likely diagnosis than hemorrhagic
CVA (B). He is diabetic but is not on medication that would predispose him to hypoglycemia, plus his
blood glucose is normal (D). Hemorrhagic stroke is a possibility, but statistically much less likely (C).
Subdural hematoma would be much more likely if the patient had sustained a traumatic head injury (E).
References: Zeiger Roni F, McGraw-Hill's Diagnosaurus 4.0:
http://accessmedicine.mhmedical.com/diagnosaurus.aspx
Smith WS, Johnston S, Hemphill, III J. Ischemic Stroke. In: Jameson J, Fauci AS, Kasper DL, Hauser SL,
Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill;
2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192532037. Accessed
February 15, 2019.
Stroke. In: Simon RP, Aminoff MJ, Greenberg DA, eds. Clinical Neurology. 10th ed. New York, NY:
McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2274&sectionid=176235249. Accessed
February 15, 2019.
Organ System: Neurologic
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine
Topic(s): Stroke
148.
Stem: A 25-year-old female presents to the office for a 2-day history of purulent
vaginal discharge and mild lower abdominal discomfort. She reports her partner advised
her that he was recently treated for gonorrhea. Vaginal exam reveals purulent cervical
discharge. The bimanual exam is unremarkable. She has no known drug allergies. What
is the most appropriate first line treatment for this patient?
Answer choice:
A.
B.
C.
D.
E.
Ceftriaxone 250 mg IM x 1 and azithromycin 1g po x 1
Ciprofloxacin 500 mg po bid x 3d
Azithromycin 500 mg x 1d then 250 mg x 4d and ciprofloxacin 500 mg x 1
Cefixime 400 mg x 1
Doxycycline 100 mg po x 3d
Answer: The answer is A.
Explanation: Dual therapy covering gonorrhea and chlamydia is recommended by the Center for Disease
Control and Prevention. A combination of ceftriaxone and azithromycin is the recommended regimen in
the United States for uncomplicated gonococcal infections of the urethra, cervix, or rectum (A). A
combination of azithromycin and ciprofloxacin is no longer recommended due to fluoroquinolone
resistance in the United States (C).
References:
Swygard H, Sena AC, Leone P, Cohen MS. Chapter 16. Gonorrhea. In: Klausner JD, Hook EW, III, eds.
CURRENT Diagnosis & Treatment of Sexually Transmitted Diseases. New York, NY: McGraw-Hill; 2007.
https://www.cdc.gov/std/tg2015/gonorrhea.htm
Boslett BA, Schwartz BS. Bacterial & Chlamydial Infections. In: Papadakis MA, McPhee SJ, Rabow MW,
eds. CURRENT Medical Diagnosis & Treatment 2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194855632. Accessed
September 01, 2018.
Organ System: Infectious Diseases
Task Area: Pharmaceutical Therapeutics
Core Rotation: Obstetrics-Gynecology, Family Medicine
Topic(s): STIs, Gonorrhea
149.
Stem: A 10-year-old male patient presents to the pediatric office with his
mother for fever and sore throat over the last two days. His mother says that this
morning she noticed the onset of “swollen cheeks.” On examination, he has a
temperature of 101 degrees Fahrenheit and swollen, tender parotid glands bilaterally.
Based on the given information, which of the following answer choices represents a
potential complication of his most likely diagnosis?
Answer Choice:
A.
B.
C.
D.
E.
Orchitis
Vision loss
Encephalitis
Osteonecrosis of the jaw
Bowl infarction
Answer: The answer is A.
Explanation: Complications from mumps are rare; however, orchitis is the most common complication,
occurring in roughly 3–10% of male adolescents and adults diagnosed with mumps. Encephalitis is
technically a complication, but is exceedingly rare, and much less common than orchitis (C). The other
answer choices are simply not complications of mumps virus (B, D, and E).
References: Shandera WX, Dandachi D. Viral & Rickettsial Infections. In: Papadakis MA, McPhee SJ,
Rabow MW, eds. CURRENT Medical Diagnosis & Treatment 2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=2449
&sectionid=194854416. Accessed February 06, 2019.
Organ System: Genitourinary
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Pediatrics
Topic(s): Orchitis
150.
Stem: A healthcare worker has just returned from a medical mission trip in
Africa and has begun developing the symptoms of fatigue, weight loss, fever, night
sweats, and productive cough. Which of the following is the most likely causative
organism?
Answer Choice:
A.
B.
C.
D.
E.
Epstein-Barr virus
Human herpesvirus 3
Paramyxovirus
Acid-fast bacilli
Clostridium tetani
Answer: The answer is D.
Explanation: The correct answer is acid-fast bacilli (D). Infectious mononucleosis is typically caused by
the Epstein-Barr virus. The protean manifestations of infectious mononucleosis reflect the dissemination
of the virus in the oral cavity and through peripheral blood lymphocytes and cell-free plasma. Fever,
sore throat, fatigue, malaise, anorexia, and myalgia typically occur in the early phase of the illness.
Physical findings include lymphadenopathy (discrete, nonsuppurative, and slightly painful, especially
along the posterior cervical chain), transient bilateral upper lid edema (Hoagland sign), and
splenomegaly (in up to 50% of patients and sometimes massive) (A). Varicella zoster is typically caused
by varicella zoster virus (VZV), also known as human herpesvirus 3 (HHV-3), which is a member of the
Herpesviridae family. In varicella zoster, fever and malaise are mild in children and more marked in
adults. The pruritic rash begins prominently on the face, scalp, and trunk, and later involves the
extremities. Maculopapules change within a few hours to vesicles that become pustular and eventually
form crusts. New lesions may erupt for 1–5 days, so that different stages of the eruption are usually
present simultaneously (B). Mumps is typically caused by the paramyxovirus known as rubulavirus. In
mumps, parotid tenderness and overlying facial edema are the most common physical findings and
typically develop within 48 hours of the prodromal symptoms. Usually, one parotid gland enlarges
before the other, but unilateral parotitis occurs in 25% of patients. High fever, testicular swelling, and
tenderness (unilateral in 75% of cases) denote orchitis, which usually develops 7–10 days after the onset
of parotitis. The entire course of mumps rarely exceeds 2 weeks (C). Tuberculosis is typically caused by
the acid-fast bacilli Mycobacterium tuberculosis. The patient with pulmonary tuberculosis typically
presents with slowly progressive constitutional symptoms of malaise, anorexia, weight loss, fever, and
night sweats. Chronic cough is the most common pulmonary symptom. It may be dry at first but typically
becomes productive of purulent sputum as the disease progresses. Blood-streaked sputum is common,
but significant hemoptysis is rarely a presenting symptom. Tetanus is typically caused by the neurotoxin
tetanospasmin from the bacteria Clostridium tetani. The first symptom may be pain and tingling at the
site of inoculation, followed by spasticity of the muscles nearby. Stiffness of the jaw, neck stiffness,
dysphagia, and irritability are other early signs. Hyperreflexia develops later, with spasms of the jaw
muscles (trismus) or facial muscles and rigidity and spasm of the muscles of the abdomen, neck, and
back (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Infectious Diseases
Task Area: Applying Basic Science Concepts
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine
Topic(s): Tuberculosis
151.
Stem: A patient presents to the clinic with family members who are concerned
with an abnormal behavioral pattern. After a complete, detailed examination, you
diagnose the patient with avoidant personality disorder. Which of the following clinical
findings would be most likely present in this patient?
Answer Choice:
A.
B.
C.
D.
E.
Unstable and intense interpersonal relationships
Poor dentition
Repetitive actions such as washing the hands many times
Excessive demands for attention
Fear of rejection
Answer: The answer is E.
Explanation: Patients with borderline personality disorder may exhibit clinical findings of impulsiveness;
have unstable and intense interpersonal relationships; are suffused with anger, fear, and guilt; lacks selfcontrol and self-fulfillment; have identity problems and affective instability; may be suicidal; and may
display aggressive behavior, feelings of emptiness, and occasional psychotic decompensation (A).
Bulimia nervosa is the episodic uncontrolled ingestion of large quantities of food followed by recurrent
inappropriate compensatory behavior to prevent weight gain such as self-induced vomiting, diuretic or
cathartic use, or strict dieting or vigorous exercise. Vomiting can result in poor dentition, pharyngitis,
esophagitis, aspiration, and electrolyte abnormalities (B). Obsessive-compulsive disorder (OCD),
classified as an anxiety disorder in the DSM-IV, now is part of a separate category of obsessivecompulsive disorder and related disorders in DSM-5. In OCD, the irrational idea or impulse repeatedly
and unwantedly intrudes into awareness. Obsessions (recurring distressing thoughts, such as fear of
exposure to germs) and compulsions (repetitive actions such as washing the hands many times or
cognitions such as counting rituals) are usually recognized by the individual as unwanted or
unwarranted and are resisted, but anxiety often is alleviated only by ritualistic performance of the
compulsion or by deliberate contemplation of the intruding idea or emotion (C). Patients with a
narcissistic personality disorder may exhibit clinical findings of exhibitionism, grandiosity, preoccupation
with power, lacking interest in others, and excessive demands for attention (D). Patients with an
avoidant personality disorder may exhibit clinical findings of fear of rejection, hyperreaction to rejection
and failure, poor social endeavors, and low self-esteem (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Psychiatry/Behavioral
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine, Pediatrics
Topic(s): Personality Disorders – Avoidant
152.
Stem: A college-age student presents to your office with an acute knee injury.
The patient was tackled playing ultimate Frisbee and twisted his knee. It began to swell
immediately. You correctly asses this as a hemarthrosis, due to its acute onset. What
injury is most commonly associated with this finding?
Answer choice:
A.
B.
C.
D.
Acute on chronic meniscal tear
Patella subluxation
Anterior cruciate ligament tear
Lateral collateral ligament strain
Answer: The answer is C.
Explanation: Of the choices presented, anterior cruciate ligament tear is the only one commonly
associated with bleeding in the joint (C). Meniscal tears can be associated with bleeding if they are acute
and peripheral (A). Lateral collateral can be associated with effusion, but less common to bleed without
associated pathology (D). Patella dislocations cause capsular injury and can lead to bleeding; subluxation
rarely does (B).
References:
Brown DE, & Neumann RD. Orthopedic secrets. 3rd ed. Philadelphia, PA: Hanley & Belfus; 2004.
Organ System: Musculoskeletal Medicine
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Family Medicine, Emergency Medicine, Surgery
Topic(s): Lower Extremity Disorders, Soft-tissue Injuries
153.
Stem: A 41-year-old male reports to the ED with severe unrelenting abdominal
pain. The patient states that the pain started yesterday as a dull ache and has
progressed to a sharp, stabbing pain that he can feel in his back. He states that he has
not been able to eat or drink in the last 12 hours, as he keeps vomiting. His past medical
history is negative for disease and medications. His past social history is positive for
heroin use, regular alcohol consumption, and tobacco use. His vital signs are as follows:
BP: 160/78, Temp: 100.8 °F, Pulse: 129 BPM, Pulse Ox: 97% on ambient air.
On physical exam, you note a well-nourished and well-developed male in acute distress. The
patient is pacing the around the gurney, refusing to lay down as he states the pain is too
intense. His abdominal exam reveals minimal distention, hypoactive bowels sounds,
moderate tenderness to palpation, bilateral upper quadrants, and guarding. His cardiac
exam reveals tachycardia without murmurs, gallops, or rubs on auscultation. The remainder
of his physical exam is within normal range. Which of the following criteria is the least
necessary for a diagnosis of pancreatitis?
Answer choice:
a.
b.
c.
d.
e.
Clinical presentation consistent with acute pancreatitis
Serum lipase value elevated above the upper limit of normal
Serum alanine aminotransferase value elevated above the upper limit of normal
Imaging findings consistent for acute pancreatitis on CT
Imaging findings characteristic of acute pancreatitis on US
Answer: The answer is C.
Explanation: The patient’s clinical presentation and history of EtOH and drug use is consistent with that
of acute pancreatitis. The presence of (A), (B), (D), and (E) can aid in the diagnosis of pancreatitis when
two of the criteria are met. A serum alanine aminotransferase value elevated above the upper limit of
normal (C) is consistent with the presence and diagnosis of gallstone pancreatitis.
References:
Besinger B, Stehman CR. Pancreatitis and Cholecystitis. In: Tintinalli JE, Stapczynski J, Ma O,
Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide, 8e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109430493.
Accessed December 20, 2017.
Friedman LS. Liver, Biliary Tract, & Pancreas Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168015083.
Accessed December 20, 2017.
Organ System: Gastrointestinal/Nutritional
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Pancreatic disorders, Acute Pancreatitis
154.
Stem: A mother brings in her 20-month-old male child for abdominal pain that
started today. The mother states that while playing the patient will suddenly drop to his
knees and holds on to his stomach. She states he remains in this position for a few
minutes and then returns to playing. While gathering a history from the mother you
note the patient to pull his knees up into his abdomen and start crying. Once the
episode is over you examine the patient to find a noncontributory exam. As you are
walking out the mother stops you and asks if his funny looking poop has anything to do
with his pain. She states it looked like dark jelly in the toilet. What diagnostic finding
would you expect to be present based on this patient’s presentation and mother’s
stated history?
Answer choice:
a.
b.
c.
d.
e.
An olive shaped mass on plain film
A target sign on ultrasound
A crescent sign on ultrasound
A sausage shaped mass on ultrasound
A hand in glove sign on plain film
Answer: The answer is B.
Explanation: This patient has a classic presentation of intussusception. The diagnostic modality of choice
is an ultrasound, which will demonstrate a target sign (B). An olive shaped mass (A) will not be evident
on a plain film, is associated with pyloric stenosis, and is palpable. A crescent sign (C) may be present on
plain film when evaluating intussusception. A sausage shaped mass (D) is palpable in intussusception
and not seen on ultrasound. A hand in glove sign (E) is not present in intussusception.
References:
Fleischman RJ. Acute Abdominal Pain in Infants and Children. In: Tintinalli JE, Stapczynski J, Ma
O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive
Study Guide, 8e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109434572.
Accessed December 20, 2017.
Organ System: Gastrointestinal
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation: Pediatrics, Internal Medicine
Topic(s): Small intestine disorders, Intussusception
155.
Stem: A 37-year-old Hispanic male presents for a follow up of his diabetes and
coronary heart disease risk management. He is 6’ 2", weighs 185 pounds, has a waist
circumference of 38", and a blood pressure of 132/84 mm Hg. He has had type 2
diabetes for 5 years. He takes 1000 mg of metformin and 40 mg of atorvastatin once
daily. His mother had coronary artery bypass graft surgery with complications at age 53.
Fasting lipid results today: total cholesterol 207 mg/dL; HDL cholesterol 30 mg/dL; LDL
cholesterol 107 mg/dL; and triglycerides 350 mg/dL.
In addition to reinforcement of the lifestyle changes that he has implemented and good
control of diabetes, which of the following might now be considered to address his elevated
triglyceride levels?
Answer choice:
a.
b.
c.
d.
e.
Continue the atorvastatin daily and add a dose of a fenofibrate daily
Change the atorvastatin 40 mg daily to lovastatin 40 mg daily
Continue the atorvastatin daily and add a cholesterol absorption inhibitor (ezetimibe)
Discontinue the atorvastatin and initiate a bile acid sequestrant (colestipol)
Continue the atorvastatin daily and add a bile acid sequestrant (colestipol)
Answer: The answer is A.
Explanation: Normal TG levels are less than 150 mg/dL; levels ranging from 150 to 199 mg/dL are
classified as borderline high; levels from 200 to 499 mg/dL are high, and levels 500 mg/dL or greater are
considered very high. Although the benefit of targeting TG directly remains uncertain, several studies
suggest there may be some advantage to such treatment. Two major studies, the Helsinki Heart Study
(HHS) and Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, found that fibrates
were highly effective at lowering TG. Moreover, both studies showed that a reduction in TG was
associated with a trend toward fewer ASCVD events and a significant reduction in nonfatal MI. In the 18year HHS follow-up, TG reduction with fibrates significantly lowered the ASCVD mortality rate (A).
Treatment with fibrates has been found to be cost-effective as both monotherapy and combination
therapy for lowering TG and raising HDL-C, but not in reducing cardiovascular events, except in
individuals with TG concentrations greater than 200 mg/dL and HDL-C concentrations less than 40
mg/dL. Changing the atorvastatin to lovastatin 40 mg (B) will actually be providing the patient with a
statin of lower efficacy.
Cholesterol absorption inhibitors and bile acid sequestrants ((C), (D), and (E)) are not considered
effective in decreasing triglyceride levels. Fenofibrates, niacin and omega-3 acid ethyl esters are primary
choices in managing elevated triglycerides and low HDL levels.
References:
American Association of Clinical Endocrinologists and American College of Endocrinology
2017 Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease, ENDOCRINE
PRACTICE Vol 23 (Suppl 2) April 2017.
Organ System: Cardiovascular
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family medicine, internal medicine
Topic(s): Lipid Disorders, Hypertriglyceridemia
156.
Stem: A previously healthy 3-year-old girl is brought to the Emergency Room by
her mother, who is concerned about her breathing. She exhibits a mild stridor that mom
reports began 20 minutes ago after she was eating cut-up pieces of a hotdog for lunch.
The stridor occurred suddenly, accompanied by a sudden and frequent cough. The girl
becomes quite anxious at times and then calms down. On exam, she is afebrile with
audible stridor heard without a stethoscope. There is no wheezing on auscultation and
no dullness to percussion across the lung fields. What is the most appropriate next step
of care?
Answer choice:
a.
b.
c.
d.
e.
Bronchoscopy
Chest CT scan
Nebulized albuterol
Hydration and observation
Chest x-ray
Answer: The answer is A.
Explanation: Aspiration of foreign bodies peaks in incidence between 1–3 years of age. The most
common objects aspirated are food and toys. Although most patients are asymptomatic, primary
presentation would include cough, which is classically sudden in onset, gagging, choking, stridor, or
cyanosis. Signs depend on the location of the aspirated object and the degree of obstruction. Stridor and
hoarseness predominate with a laryngotracheal obstruction, and wheezing and decreased breath
sounds usually indicate bronchial obstruction. Plain chest x-ray may be helpful to confirm the diagnosis
of foreign body aspiration, but in >50% of tracheal FB cases and 25% of bronchial FB cases they can be
normal. Thus, if clinical suspicion is high, diagnostic study of choice is bronchoscopy (A).
References:
Rita K. Cydulka, Michael T. Fitch, Scott A. Joing, Vincent J. Wang, David M. Cline, O. John Ma. Tintinalli's
Emergency Medicine Manual 8th ed. New York, NY: McGraw-Hill, pp. 375-377.
Organ System: Pulmonary
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Other Pulmonary Disorders, Foreign body aspiration
157.
Stem: You are on a medical mission to a third world country, and you notice a
significant increase in the number of patients presenting with productive cough,
malaise, and hemorrhagic fever. You speak to other healthcare providers, who report
similar findings. Concerned for a potential contagious disease outbreak, you decide to
investigate further. Which of the following should be undertaken as the initial step to
determine if an outbreak has occurred?
Answer choice:
A. Draft a written report to communicate findings to healthcare professionals
B. Determine if the number of cases exceeds what the local health authorities normally see in a
comparable time period
C. Develop an effective treatment plan
D. Implement control and prevention measures
E. Initiate surveillance
Answer: The answer is B.
Explanation: An outbreak or an epidemic occurs when more cases of disease occur than expected in a
given area or among a specific group of people over a specific period of time. Making this determination
is the first step in determining if an outbreak has occurred (B). Drafting a written report to communicate
findings to healthcare professionals would occur only after investigations and data gathering are
complete, not at the beginning of the process (A). The goal of such a report is to summarize the
investigation, its findings, and its outcomes, and to communicate the information in an effective
manner. Development of an effective treatment plan would occur after the outbreak has been
established, which would include implementation of control and prevention measures and surveillance
to monitor for efficacy once control and prevention measures have been implemented (C, D, and E).
References: Public Health Workforce 3.0: Recent Progress and What’s on the Horizon to Achieve the
21st-Century Workforce. Centers for Disease Control and Prevention.
https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson6/section2.html#step2.
Organ System:
Task Area: Professional Practice
Core Rotation: Family Medicine, Internal Medicine, Emergency Medicine
Topic(s): Professional Development, Using Epidemiologic Techniques to Evaluate the Spread of Disease
158.
Stem: A 47-year-old male presents to his primary care provider complaining of
twice weekly episodes of hypertension with headache, sweating, palpitations, and
anxiety over the last four months. During the episodes, his blood pressure has ranged
from 180/104 to 220/116. He denies any other past medical history and is not taking
any medications. Vital signs in clinic: BP: 166/98, HR: 112. His physical exam is
unremarkable other than appearing anxious. Lab taken during the appointment are as
follows:
Plasma free metanephrines
42 nmol/L (<0.50 nmol/L)
TSH
2.6 mU/mL (0.35-5 mU/mL)
Aldosterone
12 (7-20 ng/dL)
Renin:
2.9 ng/mL/h (0.6–4.3 ng/mL/h)
24 hr urine metanephrines
Markedly elevated
CT scan abdomen
7 mm left adrenal tumor
Which of the following medications should initially be started in this patient?
Answer choice:
A.
B.
C.
D.
E.
Beta blocker
Alpha blocker
ACE inhibitor
Aldosterone antagonist
Loop diuretic
Answer: The answer is B
Explanation: Symptoms of pheochromocytoma typically include hypertension, headache, sweating,
palpitations, anxiety with a sense of impending doom, and tremor. Elevated urinary metanephrines
effectively confirms most pheochromocytomas that were detected by elevated plasma metanephrines.
Patients must receive adequate treatment for hypertension using alpha-blockers or calcium channel
blockers, either alone or in combination. Blood pressure must be controlled before beta-blockers are
added for control of tachyarrhythmias.
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGrawHill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=167996562.
Organ System: Endocrine
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Neoplasms, Neoplastic syndrome
159.
Stem: A 42-year-old female presents to the emergency department with
complaints of severe, sudden onset, right upper quadrant pain for the past four hours.
The pain began after she ate a large, fatty meal. She also reports nausea and vomiting,
and states that her pain slightly improves after she vomits. Based on this patient’s
reported history, which of the following would you most likely find on physical exam?
Answer choice:
a.
b.
c.
d.
e.
Positive Murphy sign
Positive Romberg sign
Positive anterior drawer sign
Positive iliopsoas sign
Positive Kernig sign
Answer: The answer is A
Explanation: The acute attack of cholecystitis is often precipitated by a large or fatty meal and is
characterized by the sudden appearance of steady pain localized to the epigastrium or right
hypochondrium, which may gradually subside over a period of 12–18 hours. Vomiting occurs in about
75% of patients and in half of instances affords variable relief. Right upper quadrant abdominal
tenderness (often with a Murphy sign, or inhibition of inspiration by pain on palpation of the right upper
quadrant) is almost always present and is usually associated with muscle guarding and rebound
tenderness.
References:
Friedman LS. Liver, Biliary Tract, & Pancreas Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018 New York, NY: McGrawHill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=168015083.
Organ System: Gastrointestinal/Nutritional
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Emergency Medicine
Topic(s): Biliary disorders, Acute/chronic cholecystitis
160.
Stem: A 9-year-old presents to the clinic with fever, malaise, and a pruritic rash
that began prominently on the face, scalp, and trunk, and later moved to the
extremities. Physical examination demonstrates a variety of lesions, including
maculopapules, vesicles, and pustulars. His mother states the patient has never received
any vaccinations. Which of the following should be discussed as part of the patient
education based on the most likely diagnosis for this patient?
Answer Choice:
A.
B.
C.
D.
E.
The future risk of cervical cancer and appropriate screening required
The patient should refrain from any contact sports due to the possibility of splenomegaly
The patient has a future risk of developing herpes zoster later as an adult
The patient should watch for symptoms of testicular inflammation
The patient will have future positive purified protein derivative skin tests
Answer: The answer is C.
Explanation: This patient is presenting with classic signs and symptoms of varicella zoster virus. Human
papillomavirus infections have been associated with an increased risk of cervical cancer with the
majority from types 16 and 18 and increased risk of genital warts with the majority from types 6 and 11
(A). Epstein-Barr virus infections have an increased risk of splenomegaly with potential rupture from
increased abdominal pressure or high-impact contact. Patients should be removed from contact sports
until the splenomegaly has resolved completely (B). Varicella zoster viral infections increase the risk of
having a herpes zoster (shingles) outbreak as an adult due to the inactive virus remaining present in the
host (C). Mumps is associated with the severe side effect of orchitis (testicular inflammation), which
could progress to infertility (D). The purified protein derivative (PPD) skin test is often used for annual
screening for tuberculosis. Patients with previous exposure to the bacteria Mycobacterium tuberculosis
will have a positive immune reaction to all future PPD skin tests without active or latent infection (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill;
2018.http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Access
ed February 12, 2019.
Organ System: Infectious Diseases
Task Area: Health Maintenance
Core Rotation: Emergency Medicine, Family Medicine, Pediatrics
Topic(s): Varicella-Zoster Virus Infections
161.
Stem: A 56-year-old male presents to the clinic with acute onset suprapubic
pain, fever, and irritation while urinating. Examination reveals a warm, exquisitely
tender prostate on rectal exam. Which of the following would be the most appropriate
outpatient medication to prescribe for the most likely diagnosis?
Answer Choice:
A.
B.
C.
D.
E.
Levofloxacin (Levaquin)
Oral iron
Indomethacin
Sumatriptan
Fluoxetine
Answer: The answer is A.
Explanation: Acute bacterial prostatitis is usually caused by gram-negative rods, especially E. coli and
Pseudomonas species and less commonly by gram-positive organisms (e.g., enterococci). Perineal,
sacral, or suprapubic pain, fever, and irritative voiding complaints are common. Varying degrees of
obstructive symptoms may occur as the acutely inflamed prostate swells, which may lead to urinary
retention. High fevers and a warm and often exquisitely tender prostate are detected on examination.
Care should be taken to perform a gentle rectal examination, since vigorous manipulations may result in
septicemia. Prostatic massage is contraindicated. Levofloxacin is a broad-spectrum antibiotic from the
drug class quinolones and is typically used for outpatient acute prostatitis infection treatment. (A). Oral
iron prescriptions are often given in the presence of iron deficiency, which often presents as anemia.
Iron is an essential component of the hemoglobin structure (B). Indomethacin is from the drug class
nonsteroidal anti-inflammatory drugs (NSAIDs) and is typically used for inflammatory conditions (C).
Sumatriptan is from the drug class Triptans and is most often used for acute migraine headaches (D).
Fluoxetine is from the drug class selective serotonin reuptake inhibitors (SSRIs) and is indicated for a
variety of medical conditions. Some common uses include major depressive disorder and generalized
anxiety disorder (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Genitourinary System
Task Area: Pharmaceutical Therapeutics
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine
Topic(s): Prostatitis
162.
Stem: A 54-year-old male comes into clinic with fatigue and LUQ abdominal
pain. On physical exam he has splenomegaly. Serologic testing shows a WBC count of
65,000 (normal 4,000–11,000), hemoglobin of 13.0 (normal 13.5–17.5), and a platelet
count of 550,000 (normal 150,000–400,000). Peripheral blood was tested and showed a
positive Philadelphia chromosome (9;22) translocation. Based on these clinical findings
and labs, what would be the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Acute myeloid leukemia
Acute lymphocytic leukemia
Chronic lymphocytic leukemia
Chronic myeloid leukemia
Hodgkin’s lymphoma
Answer: The answer is D.
Explanation: Chronic myeloid leukemia (D) is a disorder of middle age (median 55 years). Patients will
typically complain of fatigue, night sweats, low grade fevers, abdominal tenderness, or fullness,
especially in LUQ. On physical exam, the spleen is enlarged (often markedly). Lab findings that are
characteristic are markedly elevated WBC (median 150,000/mcL), Hgb/Hct normal to mildly decreased,
platelet count normal to markedly elevated, and hallmark Philadelphia chromosome—a reciprocal
translocation between the long arms of chromosomes 9 and 22- detected by PCR test in peripheral
blood smear or bone marrow.
References:
“Chronic Myeloid Leukemia.” In: Maxine A. Papadakis, et al., eds. Current Medical Diagnosis &
Treatment 2018. New York, NY: McGraw-Hill, pp. 531–533.
Organ System: Hematologic
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal medicine, Family medicine
Topic(s): Neoplasms, Premalignancies, and Malignancies, Acute/chronic myelogenous leukemia
163.
Stem: A 40 year old female had a thyroidectomy for papillary thyroid cancer.
The patient complains of perioral numbness and muscle cramping. The nurse notes that
she has a positive Trousseau sign when blood pressure cuff is placed. What is the most
likely cause of this patient’s tetany?
Answer choice:
a.
b.
c.
d.
e.
Hypoglycemia
Hyperglycemia
Hypocalcemia
Hyponatremia
Hypokalemia
Answer: The answer is C
Explanation: Acquired hypoparathyroidism is most commonly caused by an anterior neck surgery such
as thyroidectomy. The given symptoms of perioral numbness, muscle cramping, and Trousseau sign are
associated with the hypocalcemia found in hypoparathyroidism. Trousseau’s sign is not seen in disorders
related to glucose, sodium or potassium disorders (A,B,D,E).
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid=167
996562.
Organ System: Endocrine
Task Area: Applying Basic Science Concepts
Core Rotation: Internal Medicine
Topic(s): Parathyroid disorders, Hypoparathyroidism
164.
Stem: A rectocele is associated with prolapse of which pelvic compartment?
Answer choice:
a.
b.
c.
d.
Anterior
Apical
Cervical
Posterior
Answer: The answer is D
Explanation: To characterize types of prolapse, the pelvic anatomy is composed of 3 pelvic
compartments. A posterior compartment prolapse is associated with rectoceles and enteroceles.
Anterior compartment prolapse is associated with urethroceles and cystoceles. Apical compartment
prolapse (answer choice B) is associated with vaginal vault prolapse and procidentia. “Cervical” is NOT
one of the 3 pelvic compartments.
References:
Rogers RG, Fashokun TB. Pelvic organ prolapse in women: Epidemiology, risk factors, clinical
manifestations, and management. In: UpToDate, Brubaker L, Eckler K (Eds.), UpToDate, Waltham, MA.
Available at http://www.uptodate.com (Accessed on December 1, 2017.)
Organ System: Reproductive
Task Area: Applying Basic Science Concepts
Core Rotation: Obstetrics-Gynecology
Topic(s): Vaginal/Vulvar disorders, Rectocele
165.
Stem: A 12-year-old child is brought to your clinic after getting her index finger
of her left hand caught in a car door. You note she is intact neurovascular to the distal
tip as best you can determine but has a nail bed laceration with active bleeding. Which
of the following statements represents acceptable standard of care for this injury?
Answer choice:
A. Gauze dressing and splint, return to the clinic if bleeding does not resolve
B. Alumifoam splint and routine follow up with a hand surgeon
C. Nail must be removed and the nailbed repaired with an absorbable small gauge suture
(6-0)
D. Xeroform dressing and three days of antibiotics
Answer: The answer is C.
Explanation: Nail bed injures are considered open fractures until proven otherwise. Nail bed anatomy
must be restored to allow for normal growth of the nail with healing. Any active bleeding needs to be
explored and addressed (C).
References:
Brown DE, & Neumann RD. Orthopedic secrets. 3rd ed. Philadelphia, PA: Hanley & Belfus; 2004.
Organ System: Musculoskeletal
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine, Surgery
Topic(s): Upper Extremity Disorders, Soft-tissue Injuries
166.
Stem: An 86-year-old female presents to your clinic with a family member. The
patient admits to having not seen a care provider in several years, and over the last
several months has noticed increasing dyspnea and decreased ability to do her normal
activities around the house. She also reports that she occasionally gets dizzy, especially
in the morning. On physical exam, her pulse is 86 and regular, and her blood pressure is
168/94. Her HEENT is unremarkable, and her lungs are clear. She has a regular rate and
rhythm with a 3/6 systolic murmur that also has a reduced S2 heart sound best
appreciated at the base of the heart. There is no peripheral edema noted, and she has
2+ pulses throughout. Based on this clinical scenario, what is the most likely etiology of
these clinical findings?
Answer choice:
A.
B.
C.
D.
E.
Aortic stenosis
Aortic regurgitation
Pulmonary stenosis
Mitral stenosis
Tricuspid regurgitation
Answer: The answer is A.
Explanation: This patient is presenting with typical and classic symptoms and physical exam findings
consistent with aortic stenosis (A). The history of increasing dyspnea and dizziness, along with the
physical exam findings and location of the murmur locate this pathology to the aortic valve as the most
likely culprit. Pulmonary and mitral stenosis typically have findings that are located more at the upper
and lower L sternal borders (2nd and 5th intercostal regions respectively) and usually do not soften the
second heart sound (C and D).
References:
Lindman BR, Clavel MA, Mathieu P, et al. Calcific aortic stenosis. Nat Rev Dis Primers. 2016;2:16006.
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with
valvular heart disease: a report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:e57.
Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA. 1997;277:564.
Organ System: Cardiovascular
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Family Medicine, Internal Medicine, Surgery
Topic(s): Valvular Disorders, Aortic
167.
Stem: A 6-month-old infant is brought to the emergency room for evaluation
due to a 2-day history of feeding difficulties and constipation. The infant is picked up
and you notice the findings in the attached picture. What additional information in the
patient’s history would most likely confirm your suspected diagnosis?
<CATCH: Insert Photo E>
<CATCH: Insert credit line underneath the photo: Reproduced with permission from KJ Knoop, LB Stack,
AB Storrow, RJ Thurman. The Atlas of Emergency Medicine, 4th Edition,
www.accessemergencymedicine.com. Copyright © MrcGraw-Hill Education. All rights reserved. Figure
17-55>
Answer choice:
A.
B.
C.
D.
E.
Ingestion of honey
Peanut allergy
Contact with pet cat
Cough
Nasal congestion
Answer: The answer is A.
Explanation: Infantile botulism is commonly associated with ingestion of raw honey (A). The patient’s
classic presentation of poor feedings, constipation, and floppiness is consistent with the diagnosis of
infantile botulism. The other choices are not associated with infantile botulism (B, D, and E). Botulism is
not spread between an infected pet to humans (C). Pet cats are typically associated with toxoplasmosis
infections from contact with an infected cat’s litter.
References: Botulism
Williams SR, Sztajnkrycer MD, Thurman R. Toxicological Conditions. In: Knoop KJ, Stack LB, Storrow AB,
Thurman R, eds. The Atlas of Emergency Medicine. 4th ed. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1763&sectionid=125437231. Accessed
September 01, 2018.
http://www.cfsph.iastate.edu/FastFacts/pdfs/botulism_F.pdf
Organ System: Infectious Diseases, Neurologic System
Task Area: History Taking and Performing Physical Examination
Core Rotation: Emergency Medicine, Pediatrics
Topic(s): Botulism, Infantile
168.
Stem: Your supervising physician is a specialist in colorectal surgery at a
teaching hospital. You inform her that you would like to learn how to perform one of
the procedures she uses to treat hemorrhoid patients in the outpatient clinic. In order
for you to be able to perform the procedure, permission to do so must be documented
in which of the following?
Answer choice:
A. State law governing the physician/PA relationship
B. Third party payor agreements with the institution
C. Your employment contract
D. Your medical malpractice insurance agreement
E. Your credentialing/privileging agreement
Answer: The answer is E.
Explanation: The services which most healthcare providers, including PAs, are permitted to
provide/perform are determined in the credentialing/privileging process (E). Hospital credentialing is the
process of obtaining, verifying, and assessing the qualifications of a licensed health care practitioner, as
required by the Joint Commission and the National Committee for Quality Assurance (NCQA). Privileging
is the authorization that a hospital or similar institution’s governing body (e.g., Board of Trustees) grants
a practitioner to provide specific services based on factors such as license, training, experience, etc.
State laws govern the extent of the physician/PA relationship and mandate (in most, but not all states)
that PAs must practice with a collaborating physician; most states now allow the details of each PA’s
scope of practice to be decided at the practice level (A). A third-party payor is an entity that pays
medical claims on behalf of the insured. Examples of third-party payors include government agencies,
insurance companies, health maintenance organizations (HMOs), and employers. Third party payors do
not dictate specific procedures a provider can perform (B). An employment contract includes items such
as your job description, salary and benefits, contract term and cause for termination, and a collaborative
practice agreement (C). In a healthcare setting, however, an employment contract generally does not
specify procedures a provider can perform. A medical malpractice insurance agreement defines the
terms of protection from liability associated with wrongful practices resulting in bodily injury, medical
expenses, and property damage, as well as the cost of defending lawsuits related to such claims; it does
not involve specifying services or procedures a provider may perform (D).
References: Medical Professional Liability. The Center for Insurance Policy and Research.
https://www.naic.org/cipr_topics/topic_med_mal.htm.
Organ System:
Task Area: Professional Practice
Core Rotation: All
Topic(s): Physician/PA Relationship, Professional and Clinical Limitations, Scope of Practice
169.
Stem: An otherwise healthy 5-month-old boy is brought to urgent care from
daycare by his parents for 1 day of low-grade fever, tachypnea, wheezing, and periods
of apnea by history. His oxygen saturation is stable. You correctly diagnose croup. Which
of the following is the next most appropriate step in care?
Answer choice:
A.
B.
C.
D.
E.
Humidification of inspired air and monitoring
Inhaled bronchodilator and corticosteroids
Antibiotics and non-steroidal anti-inflammatories
Pneumococcal vaccination and discharge home
Intubation and ventilatory support
Answer: The answer is A.
Explanation: Croup or laryngotracheitis is most commonly caused by human parainfluenza virus, so
antibiotics are not indicated (C). Though inhaled bronchodilators and corticosteroids may help if the
patient has coexistent asthma, their use for croup alone is not supported by the literature (B). Though
the patient is currently stable and does not require intubation, discharge home for a tachypneic, actively
wheezing patient is contraindicated (D and E). The most appropriate care is supportive and watchful
with hydration, humidification of inspired air, and monitoring for improvement (A).
References:
Papadakis MA, McPhee SJ. Current Medical Diagnosis and Treatment 2016. 55th ed. New York, NY:
McGraw-Hill; 2016.
Organ System: Pulmonary
Task Area: Clinical Intervention
Core Rotation: Pediatrics, Emergency Medicine
Topic(s): Infectious Disorders, Croup
170.
Stem: An 83-year-old man presents to the primary care office for routine followup. Past medical history includes HTN, diabetes, and CAD. He has shown mild signs over
time of memory impairment, and this seems to have worsened over the past few
months. He has had multiple hospitalizations for urosepsis over the past year and this
has led to significant deconditioning. He has had to move in with his daughter and sonin-law as well as their two children. On physical exam, his pulse is 89 and regular, and
his blood pressure is 128/84. His skin exam shows multiple areas of ecchymosis in
various stages of healing on his arms. HEENT exam is unremarkable. His lungs are clear.
Cardiac exam reveals a regular rate and rhythm without murmur/rub/gallop.
Abdominal exam is soft without tenderness noted. There is no organomegaly noted. He
has 2+ pulses throughout and reflexes are 2+/4+ bilaterally. Upon questioning, he states
that his daughter sometimes “handles him roughly” when she is assisting him. What is
the most significant risk factor for elder abuse?
Answer Choice:
A.
B.
C.
D.
E.
Coronary artery disease
Diabetes
Hypertension
Memory impairment
Urosepsis
Answer: The answer is D.
Explanation: Risk factors for elder abuse include situations in which caregivers react under high levels of
stress or frustration. Elders with increased medical needs such as debility, dementia, or cognitive
impairment are at increased risk (D). Though the other conditions require time and attention, they are
not specific risk factors for abuse (A, B, C, and E).
“With the exception of dementia, which is a documented risk factor for financial exploitation, specific
diseases have not been identified as conferring a greater risk of abuse. In general, however, functional
impairment and poor physical health have consistently been shown to be associated with a greater risk
of abuse among older persons, irrespective of the cause of such limitations.”
References: Lachs MS, Pillemer KA. Elder Abuse. New England Journal of Medicine. 2015;373(20):19471956. doi:10.1056/NEJMra1404688
Carmen T, Lachs, MS. Detecting, Assessing, & Responding to Elder Mistreatment. In: Williams BA, Chang
A, Ahalt C, Chen H, Conant R, Landefeld C, Ritchie C, Yukawa M, eds. Current Diagnosis & Treatment:
Geriatrics. 2nd ed. New York, NY: McGraw-Hill; 2014.
http://accessmedicine.mhmedical.com/content.aspx?bookid=953&sectionid=53375697. Accessed
February 15, 2019.
Organ System: Psychiatry/Behavioral
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine
Topic(s): Elder Abuse
171.
Stem: A 13-year-old male is brought to the Emergency Department after
sustaining a head injury with resultant loss of consciousness while playing in a football
game. His mother states that he ran into another player and “went down.” She thinks he
was unconscious for at least a minute. The patient can’t recall anything from
immediately before or immediately after the hit. He is feeling better and his head CT
was read as negative. Which of the following is the most accurate patient education
information to provide to the player and his parents?
Answer Choice:
A. He may return to play immediately.
B.
C.
D.
E.
He must remain awake for the next 8 hours.
He should be on bed rest.
Use of electronic devices should be minimized.
There is no need for follow up.
Answer: The answer is D.
Explanation: Concussion has been recognized as a reversible traumatic brain injury and the effects can
be variable, but long-term effects of multiple concussions have been linked to cognitive dysfunction.
Therefore, specific protocols regarding treatment and return to play have been developed. Those
treatments do include physical rest, but not bed rest (C). Athletes should not return to play until
reevaluated by a medical professional (A and E). Many people believe that patients with concussion
should not got to sleep, but there is no evidence to support this practice (B). Evidence does show that
cognitive rest is beneficial; therefore, use of electronic devices such as TV, computer, tablet, and phone
should be minimized (D).
References: Martin JE. Head Injuries. In: Stone C, Humphries RL, eds. CURRENT Diagnosis & Treatment:
Emergency Medicine. 8th ed. New York, NY: McGraw-Hill; 2017.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165060773. Accessed
February 14, 2019.
Organ System: Neurologic
Task Area: Health Maintenance
Core Rotation: Emergency Medicine, Family Medicine, Pediatrics
Topic(s): Concussion
172.
Stem: A G2P1 has been followed with serial ultrasounds for placenta previa. Her
last sentinel bleed was at 32 weeks gestation when the placenta was 1 cm away from
the os. At that time, she received prophylactic betamethasone for fetal lung maturity.
Bleeding resolved. Today at 36 weeks gestation, she presents for her routine ultrasound
and the placenta is just barely over the os. Which of the following is recommended at
this time?
Answer choice:
a.
b.
c.
d.
e.
Repeat serial ultrasound at 38 weeks
Schedule patient for cesarean delivery
Proceed with induction of labor
Administer tocolytics and fluids
Perform a McDonald cerclage
Answer: The answer is B
Explanation: With uncomplicated placenta previa (non-bleeding), the mode and timing of delivery is
dictated by placental location in relation to the internal cervival os; most recommend elective cesarean
delivery between 36 and 37 weeks gestation if < 2cm from the os. This patient has a partial previa since
the placenta is over the os, which is certainly < 2cm. Repeating the ultrasound at 38 weeks is too late;
induction of labor places the patient at increased risk of abruption and bleeding. Tocolytics, fluids, and
cerclage are indicated in other pregnancy complications.
References:
Lockwood CJ, Russo-Stieglitz K. Placenta previa: Management. In: UpToDate, Berghella V, Barss VA.
(Eds.), UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed on December 22,
2017.)
Organ System: Reproductive
Task Area: Clinical Intervention
Core Rotation: Obstetrics-Gynecology
Topic(s): Complicated Pregnancy, Placenta Previa
173.
Stem: A 72-year-old female complains of fatigue and associated neck and
shoulder discomfort for several months. She has had recent onset of left sided headache
described as dull and constant. Migraine headache is in the past medical history but this
current headache is different. Oral acetaminophen has not provided relief. On exam,
she is afebrile and her remaining vital signs are within normal parameters. She has
tenderness on palpation of the left scalp, otherwise there are no other HEENT findings.
The neck is supple and without bruit. Skin, lungs and heart exam have no focal findings.
A complete blood count and basic metabolic panel reveal a hemoglobin of 10.2 gm/dL
(normal range 12-15 gm/dL).
Which diagnostic test will distinguish giant cell arteritis from polymyalgia rheumatica as the
etiology for this patient’s symptoms?
Answer choice:
a.
b.
c.
d.
e.
Erythrocyte sedimentation rate
C-reactive protein
Magnetic resonance angiography
Temporal artery biopsy
Color duplex ultrasonography
Answer: The answer is D
Explanation: Temporal artery biopsy is the gold standard to diagnose giant cell arteritis. The diagnosis of
polymyalgia rheumatica is largely a clinical diagnosis. The ESR and CRP will both be elevated for each
condition. MRA and ultrasonography are not common imaging modalities used to diagnose either
disease.
References:
Hellmann DB. Chapter 30. Giant Cell Arteritis & Polymyalgia Rheumatica. In: Imboden JB, Hellmann DB,
Stone JH. eds. CURRENT Diagnosis & Treatment: Rheumatology, 3e New York, NY: McGraw-Hill; 2013.
http://accessmedicine.mhmedical.com/content.aspx?bookid=506&sectionid=42584916. Accessed
November 21, 2017.
Organ System: Cardiovascular
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Family Medicine
Topic(s): Vascular Disease, Giant cell arteritis
174.
Stem: A 45-year-old white female has a facial rash for several months. She
complains of redness and flushing to the central face with associated greasiness of the
skin. There have been mostly solid pimples scattered throughout the flushing. The
patient notes that applying makeup will worsen the condition. OTC facial cleansers have
not helped. On exam, she is afebrile without vital sign abnormalities. Examination of her
central face is consistent with her description. There are no pustules or open
comedomes. The remainder of the physical exam is focal for dandruff of the scalp.
Which is the best anticipatory guidance to provide the patient?
Answer choice:
a.
b.
c.
d.
e.
Topical antibiotics will be the initial treatment choice
Topical corticosteroids are used for maintenance treatment
Resolution of the condition will occur with antibiotic treatment
Sun exposure is key to decreasing outbreaks
Regular alcohol use will improve the condition
Answer: The answer is A
Explanation: Rosacea is initially treated with topical antibiotics such as metronidazole or clindamycin.
Topical steroids, sun exposure without sunscreen protection and alcohol use will exacerbate the
condition. Antibiotic treatment may control the condition but the prognosis is a persistent process that
will require regular care.
References:
Shinkai K, Fox LP. Dermatologic Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current
Medical Diagnosis & Treatment 2018 New York, NY: McGraw-Hill; .
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168006971. Accessed
November 21, 2017.
Organ System: Dermatologic
Task Area: Health Maintenance
Core Rotation: Family Medicine
Topic(s): Acneiform Eruptions, Rosacea
175.
Stem: A 23-year-old male complains of left eye pain after being elbowed by his
opponent during a Jiu-Jitsu match the preceding day. He is afebrile, pulse is 61, blood
pressure 152/62, respirations 10 and room air pulse oximetry 99% on room air. HEENT
exam reveals a layer of blood involving approximately ⅓ of the anterior chamber of the
left eye. There is surrounding ecchymosis without crepitus or deformity on palpation.
Extraocular movements are intact in all directions. There are no further physical exam
abnormalities.
Which additional clinical finding is commonly associated with the patient’s condition?
Answer choice:
a.
b.
c.
d.
e.
Globe rupture
Subconjunctival hemorrhage
Elevated intraocular pressure
Peaked pupil
Unchanged visual acuity
Answer: The answer is C
Explanation: Hyphema will be commonly associated with elevated intraocular pressure which should
monitored daily during ongoing management. Globe rupture, subconjunctival hemorrhage and peaked
pupil can be a result of eye trauma but not necessarily associated with hyphema. Decreased visual
acuity is a usual complaint linked to hyphema.
References:
Chapter 24. Eye Trauma—Hyphema. In: Usatine RP, Smith MA, Chumley HS, Mayeaux EJ, Jr.. eds. The
Color Atlas of Family Medicine, 2e New York, NY: McGraw-Hill; 2013.
http://accessmedicine.mhmedical.com/content.aspx?bookid=685&sectionid=45361059. Accessed
November 26, 2017.
Organ System: EENT
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine
Topic(s): Eye Disorders, Traumatic disorders, Hyphema
176.
Stem: A 48-year-old male alcoholic presents with a large wound on his calf that
has been present up to six weeks. He has no insurance, so had used alcohol to clean the
wound, and an anesthetic. He does not remember how he got it, but it has a fetid odor
and serosanguinous drainage. What is your best serology test to monitor treatment in
this patient?
Answer choice:
A.
B.
C.
D.
CBC with differential
Blood cultures
Estimated sedimentation rate
C-reactive protein
Answer: The answer is D.
Explanation: C-reactive protein rises with the acuity of the infectious or inflammatory process, and
declines with the onset of effective treatment (D). ESR rises slowly and persists so is not useful in
monitoring treatment (C). CBC and blood cultures will likewise take longer to show change, and are
useful in the initial selection of treatment (A and B).
References:
Brown DE, & Neumann RD. Orthopedic secrets. 3rd ed. Philadelphia, PA: Hanley & Belfus; 2004.
Organ System: Musculoskeletal Medicine
Task Area: Health Maintenance
Core Rotation: Emergency Medicine
Topic(s): Infectious Diseases
177.
Stem: A 64-year-old female presents to your internal medicine office to follow
up to a recent ED visit for the complaint of right hand weakness. She notes that she
went to pick up a pen to write something down and was unable to pick it up or to grip it.
These symptoms persisted for 45 minutes and resolved while she was on the way to ED.
The patient’s past medical history is significant for hypertension and diabetes. She has a
35-pack-year smoking history and currently smokes 5 cigarettes a day. Her medications
include lisinopril and metformin. Her most recent hemoglobin A1C from last month is
6.9. Her evaluation in ED (including a head CT) was unrevealing and she was advised to
follow up with her PCP. Vital signs include height of 65 inches, weight of 150 pounds,
blood pressure of 118/78, pulse 84 and regular, and respiratory rate 12 and nonlabored. Skin exam is unremarkable. Her HEENT exam is unremarkable with the
exception of a carotid bruit auscultated on the left. Her lungs are clear. Cardiac exam
reveals a regular rate and rhythm without murmur/rub/gallop. Abdominal exam is soft
and no tenderness is noted. There is no peripheral edema noted, and she has 2+ pulses
throughout. What is the most important patient education to provide for this patient?
Answer Choice:
A.
B.
C.
D.
E.
Diabetes education
Low salt diet
Regular exercise
Smoking cessation
Weight loss
Answer: The answer is D.
Explanation: Risk factors for atherosclerosis and thus TIA/CVA include hypertension, diabetes,
hyperlipidemia, cigarette smoking, and family history. However, this patient’s blood pressure is well
controlled, making low salt diet minimally helpful (B). Regular exercise and weight loss may be beneficial
but would not have as great an effect as smoking cessation (C, D, and E). Her diabetes is under good
control with a hemoglobin A1C less than 7.0, so diabetes education would be less beneficial (A).
References:
Henderson GV. Transient Ischemic Attack and Stroke. In: McKean SC, Ross JJ, Dressler DD, Scheurer
DB, eds. Principles and Practice of Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1872&sectionid=146986657. Accessed
February 15, 2019.
Organ System: Neurologic
Task Area: Health Maintenance
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine
Topic(s): Transient Ischemic Attack
178.
Stem: A 23-year-old female patient presents to your family medicine practice
with the chief complaint of “anxiety.” She reports that she feels worried all the time
because she thinks that her boyfriend is cheating on her. She also is fearful that her
coworkers are conspiring against her. She has insisted on paying the utilities for her
apartment because she thought that her roommates were cheating her and making her
pay more than her fair share. Her physical exam is unremarkable. You are concerned
that this may be more than an anxiety disorder. Which personality disorder are her
symptoms most consistent with?
Answer Choice:
A.
B.
C.
D.
E.
Avoidant personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Paranoid personality disorder
Answer: The answer is E.
Explanation: Patients with avoidant personality disorder fear rejection, hyperreact to rejection and
failure, and have poor social endeavors and low self-esteem (A). Patients with borderline personality
disorder are impulsive, have unstable and intense interpersonal relationships, and have significant
amounts of anger, fear, and guilt (B). They have identity problems and are frequently unstable. Patients
with histrionic personality disorder are dependent, immature, and emotionally labile (C). Patients with
narcissistic personality disorder tend to be grandiose and exhibitionists, and make excessive demands
for attention (D). Patients with paranoid personality disorder are defensive, oversensitive, suspicious,
and often hyper-alert (E).
References: Personality Disorders. In: Papadakis MA, McPhee SJ, Bernstein J, eds. Quick Medical
Diagnosis & Treatment 2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2566&sectionid=206892018. Accessed
February 15, 2019.
Organ System: Psychiatry/Behavioral
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine, Obstetrics-Gynecology,
Pediatrics
Topic(s): Personality Disorders
179.
Stem: A 22-year-old female is brought to student health by her friend
complaining of a 2-day history of worsening HA, fever, nausea, vomiting, and stiff neck.
What is the most appropriate initial treatment plan?
Answer choice:
A.
B.
C.
D.
E.
EMS transport to ER
Rocephin 1 gram IM
Augmentin 850 mg po bid x 10 days
Neurology referral
CT head with contrast
Answer: The answer is A.
Explanation: This patient exhibits the classic triad of meningitis including HA, nuchal rigidity, and fever.
This patient should be transported to the emergency room immediately for further evaluation, which
may include lumbar puncture and blood cultures (A). The other choices are not appropriate due to the
need for urgent further evaluation and potential empirical intravenous antibiotics (B, C, D, and E).
References:
Acute Meningitis and Encephalitis. In: Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson J, Loscalzo J,
eds. Harrison's Manual of Medicine. 19th ed. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1820&sectionid=127560270. Accessed
September 01, 2018.
Organ System: Infectious Diseases
Task Area: History Taking and Performing Physical Examination
Core Rotation: Family Medicine, Emergency Medicine
Topic(s): Meningitis, Acute
180.
Stem: You encounter the surgeon on call while rounding in the hospital. You
notice that his balance seems to be unsteady and when you ride the elevator with him,
a strong smell of alcohol permeates the air. He asks you to first assist with an emergent
appendectomy. What is the most appropriate and immediate way to manage this
situation?
Answer Choice:
A.
B.
C.
D.
E.
Call the state office of professional misconduct
Confront the physician in the locker room
Contact the chief of the medical staff
Refuse to go into the operating room
Speak with the scrub nurse in the operating room
Answer: The answer is C.
Explanation: The situation may require a report to the state office of professional misconduct; however,
this is not a solution to the immediate problem (A). Confronting the physician in the locker room could
place you at risk for your personal safety, so it is not a good choice (B). Contacting the chief of the
medical staff is an appropriate choice because you need assistance in dealing with this situation and
obtaining this assistance from a peer and supervisor is more appropriate (C). Refusing to go into the
operating room is not the best way to advocate for patient safety (D). Speaking with the scrub nurse
may be necessary, but it spreads gossip about the issue without helping determine a solution (E).
References: Lo B, Grady C. Ethical Issues in Clinical Medicine. In: Jameson J, Fauci AS, Kasper DL, Hauser
SL, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGrawHill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192279783. Accessed
February 13, 2019.
Organ System:
Task Area: Professional Practice
Core Rotation: Surgery
Topic(s): Risk Management, Ensuring Patient Safety and Avoiding Medical Errors
181.
Stem: Erythema migrans is the most common clinical manifestation of Lyme
disease, and occurs one to two weeks after a tick bite. What is the proportion of
patients who will display this classic rash?
Answer choice:
A.
B.
C.
D.
50–60%
70–80%
90%
40–70%
Answer: The answer is B.
Explanation: Recognition of the rash in patients presenting for care is the best first step in diagnosis and
treatment. Lesions 5 cm or larger have a better early diagnosis indicator than antibody serology, which
is positive in less than 40%.
References:
Sanchez, Vannier, Wormser, & Hu, 2016.
Organ System: Infectious Diseases
Task Area: Health Maintenance
Core Rotation:
Topic(s): Spirochetal Diseases—Lyme disease
182.
Stem: A 43-year-old female without past medical history complains of a
constellation of symptoms worsening during the last year. She is tired and feels blue
most days. She has gained 24 lbs during this time. Constipation has become a problem
as has swelling in her bilateral lower legs. On exam, blood pressure is 101/58, pulse 58,
respirations 10 and there is no fever. She appears pale and downcast. Her hair and skin
are dry. EENT is unremarkable, neck is supple though the thyroid is enlarged. Heart is
bradycardic and without murmur, lungs are clear to auscultation. There is truncal
obesity and a non-tender abdomen without hepatosplenomegaly. Bilateral lower
extremities have generalized edema to the knees. Serum labs reveal a normal
hemoglobin and basic metabolic profile. An EKG is sinus bradycardia. A serum TSH is 24
mIU/L (range 0.4-4.0 mIU/L).
Which of the following is the most likely diagnosis?
Answer choice:
a. Hyperparathyroidism
b. Addison disease
c. Hyperthyroidism
d. Hyperaldosteronism
e. Hypothyroidism
Answer: The answer is E
Explanation: The patient has cardinal symptoms and findings of hypothyroidism and the elevated serum
TSH is confirmatory. Hypercalcemia and anemia would be consistent with hyperparathyroidism.
Hyperpigmentation is associated with Addison disease. The TSH level in hyperthyroidism is significantly
low while tachycardia is common. Hypertension and hypokalemia is associated with
hyperaldosteronism.
References:
Allweiss P, Hueston WJ, Carek PJ. Endocrine Disorders. In: South-Paul JE, Matheny SC, Lewis EL. eds.
CURRENT Diagnosis & Treatment: Family Medicine, 4e New York, NY: McGraw-Hill;
http://accessmedicine.mhmedical.com/content.aspx?bookid=1415&sectionid=77058601. Accessed
November 28, 2017.
Organ System: Endocrine System
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine
Topic(s): Thyroid disorders, Hypothyroidism
183.
Stem: A 55-year-old female notes swelling in her left neck for the last 3 months.
She has no prior history of this and has not self-treated. Her PMH is significant for
hypertension treated with low dose diuretic and a remote history of tobacco use. On
exam, she appears well and is afebrile. HEENT is unremarkable. Neck is supple and she
has an isolated enlarged lymph node in the left anterior cervical chain without overlying
redness. The remainder of her physical exam is without focality.
Which initial finding below will differentiate between Hodgkin and non-Hodgkin lymphoma?
Answer choice:
a.
b.
c.
d.
e.
Presence of painless lymphadenopathy
Presence of “B” symptoms
Lymph node biopsy results
Bone marrow biopsy results
Whole body PET scan findings
Answer: The answer is C
Explanation: Lymph node biopsy will determine the classification of this potential lymphoma. “B”
symptoms can occur with both as can painless lymphadenopathy. Bone marrow studies and PET
scanning will be utilized for lymphoma staging.
References:
Damon LE, Andreadis C. Blood Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current
Medical Diagnosis & Treatment 2018 New York, NY: McGraw-Hill;
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168012363. Accessed
December 01, 2017.
Organ System: Hematologic System
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Neoplasms, premalignancies, and malignancies, Lymphoma
184.
Stem: A 26-year-old male without significant PMH has been involved in a
moderate speed motor vehicle collision. He was unseatbelted and his right anterolateral
chest impacted the steering wheel. He complains of chest pain at the area of impact and
moderate dyspnea mostly due to pain. He is alert and interactive with the ED trauma
team. A portable chest radiograph reveals loss of lung markings to the periphery at the
right apices, approximately 15% of lung volume, likely causing his symptoms. A pigtail
catheter is placed for treatment. The remainder of his evaluation is nonfocal for injury.
Which criteria indicates the patient is not stable for outpatient treatment for his condition?
Answer choice:
a.
b.
c.
d.
e.
Respiratory rate of 20 per minute
Pulse of 90 beats per minute
White blood cell count of 15,000 cells/mcL
Blunting of right costophrenic angle on chest radiograph
Inpatient treatment is required for this condition
Answer: The answer is D
Explanation: Blunting on the chest radiograph indicates a hemothorax, a contraindication for outpatient
treatment of the patient’s small pneumothorax. The respiratory rate and pulse are within criteria
parameters. While the WBC count may increase due to stress response in trauma, this is not a criteria to
be met. After observation in the ED, small pneumothoraces can be discharged to outpatient treatment if
criteria indicating stability is met.
References:
Nicks BA, Manthey D. Pneumothorax. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline
DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill;
2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109429615.
Accessed December 06, 2017.
Organ System: Pulmonary System
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine
Topic(s): Pleural Diseases, Pneumothorax
185.
Stem: The parents of a 2-month-old bring their daughter to the pediatrician’s
office for evaluation. The mother is concerned because over the past few days, the baby
has been fussy during nursing and she noticed a blue hue around the mouth. The
mother states the baby was born at 39 weeks and that the prenatal course was without
any complications. On physical exam today, there is a harsh systolic ejection murmur
audible at the left upper sternal border with a single second heart sound. Lungs are
clear without wheezes, rales, or rhonchi. There is no peripheral edema noted in the legs.
Which of the following is the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Atrial septal defect
Coarctation of the aorta
Patent ductus arteriosus
Tetralogy of Fallot
Ventricular septal defect
Answer: The answer is D
Explanation: This is a cyanotic congenital heart defect that results in an overriding aorta, right
ventricular hypertrophy, pulmonary stenosis, and ventricular septal defect. Typically, Tetralogy (D) will
present in the neonatal period with mild to moderate cyanosis without respiratory distress. The patient
does not typically present in heart failure. The murmur of tetralogy consists of a harsh systolic murmur
and a single second heart sound. Cyanosis can occur with pulmonic and subpulmonic stenosis as well as
VSD. Coarctation (B) would show blood pressure discrepancies and reduced or absent pulses. PDA (C)
has a machinery quality murmur and the second heart sound is usually normal. ASD (A) has an early
ejection systolic murmur with a wide split of the second heart sound. VSD (E) is typically a pansystolic
murmur.
References:
Harikrishnan, KN and Vettukattil, JJ. Congenital Heart Diseases. In: Elmoselhi A. ed. Cardiology: An
Integrated Approach. New York, NY: McGraw-Hill.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Pediatrics
Topic(s): Congenital Heart Disease, Tetralogy of Fallot
186.
Stem: A 22-year-old patient with known HIV is in the clinic today. He is
concerned about new skin lesions that have been developing over the past several
weeks. He also admits to increased fatigue and weight loss of about 5–6 lbs over the
past month. He hasn't come in sooner because he lost his insurance a few months ago
and has been burdened with financial problems ever since. He is not taking any
medications at this time. On physical exam of the skin there are multiple irregularly
shaped red plaques on the chest, as well as 3 purple nodules. Which of the following is
the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Hansen's disease
Histoplasmosis
Kaposi's sarcoma
Seborrheic keratosis
Syphilis
Answer: The answer is C
Explanation: Plaques and papules of Kaposi's sarcoma (C) can be found on cutaneous or mucosal
surfaces as well as in the GI and pulmonary tracts. This is a rare, malignant skin lesion that was seen in
elderly men with chronic conditions, but now continues to be a problem for homosexual men with HIV.
Kaposi's sarcoma is an AIDS-defining illness. Hansen's disease (or leprosy) (A) presents with hyper- or
hypopigmented macules and loss of sensation at the site of lesions. Though cutaneous histoplasmosis
(B) can be found in immunocompromised patients, the presentation is a non-healing ulcer. Seborrheic
keratosis (D) has a wart-like appearance with colors ranging from white to black. Primary syphilis lesions
(E) present as a painless chancre, where secondary syphilis rash can be a rough, red-brown rash on the
palms and soles of the feet.
References:
Shinkai, Kanade, and Fox, LP. Dermatologic Disorders. In: Papadakis, MA et al. eds. Current Medical
Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
Organ System: Dermatologic
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Neoplasms, Kaposi Sarcoma
187.
Stem: A 22-year-old female is brought to student health by her friend
complaining of a 2-day history of worsening HA, fever, nausea, vomiting, and stiff neck.
Which exam finding in combination with these symptoms is most consistent with a
diagnosis of acute bacterial meningitis?
Answer choice:
A.
B.
C.
D.
E.
Petechial rash
Diffuse abdominal tenderness
Expiratory wheezing
Scleral icterus
Clear nasal drainage
Answer: The answer is A.
Explanation: Acute meningococcal infections due to meningococcus may present with petechial lesions
on the trunk, extremities, and may also involve the head, palms and soles, and mucous membranes (A).
This is due to injury to small blood vessels. The other choices suggest other etiologies and are not
consistent with the diagnosis of acute bacterial meningitis (B, C, and D). Clear nasal drainage is nonspecific and may be associated with upper respiratory infections that may suggest a viral etiology (E).
References:
Acute Meningitis and Encephalitis. In: Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson J, Loscalzo J,
eds. Harrison's Manual of Medicine. 19th ed. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1820&sectionid=127560270. Accessed
September 01, 2018.
Cohen MS, Rutala WA, Weber DJ. Chapter 180. Gram-Negative Coccal and Bacillary Infections. In:
Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, eds. Fitzpatrick's Dermatology in
General Medicine. 8th ed. New York, NY: McGraw-Hill; 2012.
http://accessmedicine.mhmedical.com/content.aspx?bookid=392&sectionid=41138907. Accessed
September 01, 2018.
Organ System: Infectious Diseases
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine, Emergency Medicine
Topic(s): Meningitis, Acute
188.
Stem: A 51-year-old male is brought into the ED via ambulance for a complaint
of sudden dizziness with nausea and vomiting. The patient states he has vomited 6
times in the last two hours and the vomiting occurs every time he moves. He states 20
minutes after arrival that his symptoms seem to have improved and the dizziness has
subsided. He states that he feels as if he is not hearing well from his left ear. He further
states he had a similar occurrence of the same symptoms lasting about 30 minutes last
night, however not as bad as the symptoms he had today. He currently takes no
medications, drinks alcoholic beverages socially, and he denies tobacco use and drug
use. On PE you note a diaphoretic male in no acute distress. The remainder of his
physical exam is within normal range. His vital signs are as follows: BP: 140/68, Temp:
98.8 °F, Pulse: 105 BPM, Pulse Ox: 98% on ambient air.
His ECG demonstrates a normal sinus rhythm and rate, without ST–T wave changes or
ischemia. His HEENT reveals TMs that are without erythema, edema, or exudate, and have a
cone of light at the 12 o’clock position. The remainder of his workup is within normal range.
What is the most likely cause of this patient’s symptoms?
Answer choice:
a.
b.
c.
d.
e.
Labyrinthitis
Ototoxicity
Cerbellopontine angle tumor
Meniere’s disease
Post-traumatic vertigo
Answer: The answer is D.
Explanation: The patient is suffering from Meniere’s disease (D). He has had a waxing and waning of
symptoms, which do not persist for long after onset. His symptoms also occurred suddenly and can de
differentiated from labyrinthitis (A) by the presence of nausea and vomiting; from ototoxicity (B) by the
lack of medications in his PMH; from cerbellopontine angle tumors (C) by the sudden onset; and from
post traumatic vertigo (E) by the lack of presence of trauma in his PMH.
References:
Goldman B. Vertigo. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.
Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill;
2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109436887.
Accessed December 19, 2017.
Lustig LR, Schindler JS. Ear, Nose, & Throat Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2017. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1843&sectionid=135700660.
Accessed December 13, 2017.
Organ System: EENT
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine
Topic(s): Ear Disorders, Other abnormalities of the ear, Meniere Disease
189.
Stem: An adult patient presents with complaints of recurring distressing
thoughts, such as fear of exposure to germs. He has experienced this since childhood,
but it is now beginning to interfere with his daily activities and employment. Which of
the following additional findings would be most likely present in this patient?
Answer Choice:
A.
B.
C.
D.
E.
Physiologic hyperarousal, including startle reactions
Poor dentition
Repetitive actions such as washing the hands many times
Excessive demands for attention
Fear of rejection
Answer: The answer is C.
Explanation: Patients with PTSD can experience physiologic hyperarousal, including startle reactions,
illusions, overgeneralized associations, sleep problems, nightmares, dreams about the precipitating
event, impulsivity, difficulties in concentration, and hyper-alertness. The symptoms may be precipitated
or exacerbated by events that are a reminder of the original traumatic event (A). Bulimia nervosa is the
episodic uncontrolled ingestion of large quantities of food followed by recurrent inappropriate
compensatory behavior to prevent weight gain such as self-induced vomiting, diuretic or cathartic use,
or strict dieting or vigorous exercise. Vomiting can result in poor dentition, pharyngitis, esophagitis,
aspiration, and electrolyte abnormalities (B). Obsessive-compulsive disorder (OCD), classified as an
anxiety disorder in the DSM-IV, now is part of a separate category of obsessive-compulsive disorder and
related disorders in DSM-5. In OCD, the irrational idea or impulse repeatedly and unwantedly intrudes
into awareness. Obsessions (recurring distressing thoughts, such as fear of exposure to germs) and
compulsions (repetitive actions such as washing the hands many times or cognitions such as counting
rituals) are usually recognized by the individual as unwanted or unwarranted and are resisted, but
anxiety often is alleviated only by ritualistic performance of the compulsion or by deliberate
contemplation of the intruding idea or emotion (C). Patients with a narcissistic personality disorder may
exhibit clinical findings of exhibitionism, grandiosity, preoccupation with power, lacking interest in
others, and excessive demands for attention (D). Patients with an avoidant personality disorder may
exhibit clinical findings of fear of rejection, hyperreaction to rejection and failure, poor social endeavors,
and low self-esteem (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Psychiatry/Behavioral
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine, Pediatrics
Topic(s): Obsessive-Compulsive and Related Disorders
190.
Stem: A 16-year-old patient presents to the clinic with fever for the past 2 days.
Physical examination reveals parotid tenderness and overlying facial edema that
recently began to develop. The patient states he has never received any vaccinations.
Which of the following should be discussed as part of the patient education based on
the most likely diagnosis for this patient?
Answer Choice:
A.
B.
C.
D.
E.
The future risk of cervical cancer and appropriate screening required
The patient should refrain from any contact sports due to the possibility of splenomegaly
The patient has a future risk of developing herpes zoster later as an adult
The patient should watch for symptoms of testicular inflammation
The patient will have future positive purified protein derivative skin tests
Answer: The answer is D.
Explanation: This patient is presenting with classic signs and symptoms of mumps. Human
papillomavirus infections have been associated with an increased risk of cervical cancer with the
majority from types 16 and 18 and increased risk of genital warts with the majority from types 6 and 11
(A). Epstein-Barr virus infections have an increased risk of splenomegaly with potential rupture from
increased abdominal pressure or high-impact contact. Patients should be removed from contact sports
until the splenomegaly has resolved completely (B). Varicella zoster viral infections increase the risk of
having a herpes zoster (shingles) outbreak as an adult due to the inactive virus remaining present in the
host (C). Mumps is associated with the severe side effect of orchitis (testicular inflammation), which
could progress to infertility (D). The purified protein derivative (PPD) skin test is often used for annual
screening for tuberculosis. Patients with previous exposure to the bacteria Mycobacterium tuberculosis
will have a positive immune reaction to all future PPD skin tests without active or latent infection (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Infectious Diseases
Task Area: Health Maintenance
Core Rotation: Emergency Medicine, Family Medicine, Pediatrics
Topic(s): Mumps
191.
Stem: While on a five-week rotation in the Emergency Department, a PA
student performs a history and physical examination on a patient with a suspected sinus
infection. Which of the following actions, if performed by the attending physician, might
be considered ethical violations in the evaluation and management of the patient?
Answer Choice:
A. Carefully reviewing the student documentation for correctness and applying appropriate cosignature once completed
B. Repeating the physical exam on the patient
C. Advising the student to re-interview the patient after a discussion of missing components of the
patient history
D. Allowing the student to discharge the patient prior to discussing the case with the attending
physician
E. Allowing the student to practice writing the patient prescriptions
Answer: The answer is D.
Explanation: The student-preceptor relationship is critical to appropriate medical education and the
advancement of good medical practice. In this case, all of the answer choices besides D are part of the
normal working relationship between students and attending providers (A, B, C, and E). Students should
be given opportunities to practice history taking, physical examination, documentation, and prescription
writing. It is unethical and potentially dangerous to allow a student of limited clinical experience to
evaluate and discharge a patient without oversight (D).
References: Levinson W, Ginsburg S, Hafferty FW, Lucey CR. Educating for Professionalism. In: Levinson
W, Ginsburg S, Hafferty FW, Lucey CR, eds. Understanding Medical Professionalism. New York, NY:
McGraw-Hill; 2014.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=1058
&sectionid=59867650. Accessed February 07, 2019.
Organ System:
Task Area: Professional Practice
Core Rotation:
Topic(s): Legal/Medical Ethics
192.
Stem: A 41-year-old male was recently diagnosed with diabetes, hypertension,
and hyperlipidemia. He has noticed his glove, hat, and shoe sizes have increased over
the last three years. Notable findings on his physical exams include coarse facial
features of the jaw and forehead, macroglossia, malocclusion of the teeth, large feet
with thickened pads, and enlarged hands with doughy, moist handshake. His labs were
drawn yesterday and are below:
TSH
4.1 mU/mL (0.35-5 mU/mL)
FT4
1.1 mg/dL (0.8-1.8 mg/dL)
Cortisol:
12 (8-20 mg/dL)
Glucose:
143 mg/dL
PRL:
8 mg/L (<15 mg/L)
IGF-I:
Elevated
What diagnostic test should be ordered to confirm his diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Oral glucose tolerance test
Dexamethasone suppression test
DXA scan to evaluate bone structure
Five day blood pressure screening
Contrast CT of sella turcica
Answer: The answer is A
Explanation: Excessive GH causes acromegaly if it occurs after closure of epiphyses. The hands and feet
enlarge, causing patients to enlarge their rings and increase shoe size. Facial features coarsen. and hat
size increases. The mandible becomes more prominent, causing prognathism and malocclusion. For
screening purposes, a random serum IGF-1 can be obtained. If the IGF-1 is elevated, then and oral
glucose challenge is initiated with glucose syrup administered orally. Serum growth hormone is
measured 60 minutes afterward; acromegaly is excluded if the serum growth hormone is less than 1
ng/mL.
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGraw-
Hill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=167996562.
Organ System: Endocrine
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Primary Care
Topic(s): Pituitary disorders, Acromegaly
193.
Stem: An otherwise healthy 35-year-old male comes to clinic with a 3-weekhistory of a lump on his left upper eyelid. He reports that when symptoms initially
appeared, the eyelid was tender, red, and swollen, then progressed to a painless
nodule. He denies any constitutional symptoms. He also denies trauma to the eye
region. On physical examination, you see a pea-sized nodule at the medial margin of the
left upper eyelid. There is no surrounding erythema, no discharge, and no tenderness to
palpation. Visual acuity tests are within normal limits. What is the appropriate
treatment for this condition?
Answer choice:
a.
b.
c.
d.
e.
Cryotherapy
Incision and curettage
Topical corticosteroids
Topical antibiotics
Warm compresses
Answer: The answer is E.
Explanation: A chalazion is a slow-growing lump that forms due to blockage and swelling of an oil gland
in the eyelid. It is typically not due to an infection. Either the upper or lower eyelid can be affected. The
initial presentation is usually eyelid swelling and erythema, followed a few days later by a painless, firm,
pea-sized nodule. Many chalazia resolve spontaneously within a month. Treatment with warm
compresses (E) applied to the eyelid for 10–15 minutes at a time, 4 to 6 times a day for several days, is
recommended to promote drainage. There is no indication for antibiotics (D), as the condition is not due
to infection. Patients with refractory or recurrent lesions can be referred to an ophthalmologist for
consideration of more invasive treatment, such as incision and curettage or steroid treatment.
References:
Carlisle RT, Digiovanni J. Differential Diagnosis of the Swollen Red Eyelid. Am Fam Physician.
2015;92(2):106–12.
Simon B, Huang L, Nakra T, et al. Intralesional triamcinolone acetonide injection for primary and
recurrent chalazia: is it really effective? Ophthalmology.2005;112(5):913-17.
Organ System: EENT
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine
Topic(s): Eye Disorders, Lid disorders, Chalazion
194.
is:
Stem: The treatment of choice for patients with symptomatic acute cholecystitis
Answer choice:
a.
b.
c.
d.
e.
Broad spectrum oral antibiotics
IV fluid rehydration
Open cholecystectomy
Laparoscopic cholecystectomy
Close observation
Answer: The answer is D
Explanation: Because of the high risk of recurrent attacks, cholecystectomy—generally
laparoscopically—should be performed within 24 hours of admission to the hospital for acute
cholecystitis. Compared with delayed surgery, surgery within 24 hours is associated with a shorter
length of stay, lower costs, and greater patient satisfaction.
References:
Friedman LS. Liver, Biliary Tract, & Pancreas Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018 New York, NY: McGrawHill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=168015083.
Organ System: Gastrointestinal/Nutritional
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine
Topic(s): Biliary disorders, Acute/chronic cholecystitis
195.
Stem: Which of the following medications is least likely to lead to a hemolytic
episode in a person with G6PD deficiency?
Answer choice:
a.
b.
c.
d.
e.
Nitrofurantoin
Primaquine
Sulfonamides
Acetaminophen
Thiazide diuretics
Answer: The answer is D.
Explanation: Glucose-6-phosphate dehydrogenase (G6PD) is a protein that helps red blood cells work
properly. G6PD deficiency occurs when a person does not make enough G6PD, which can lead to
destruction of red blood cells (called hemolysis). Red blood cell destruction can be caused by several
triggers, including antimalarial drugs, aspirin, nitrofurantoin, nonsteroidal anti-inflammatory drugs
(NSAIDs), quinidine, quinine, and sulfa drugs. Other common triggers are mothballs and fava beans.
Acetaminophen (D) has a very low risk of triggering hemolysis in a G6PD patient.
References:
Glader B. Hereditary hemolytic anemias due to red blood cell enzyme disorders. In: Greer JP, Arber D,
Glader B, et al, eds. Wintrobe's Clinical Hematology, 13th edition. Wolters Kluwer/Lippincott Williams &
Wilkins, Philadelphia 2014.
Organ System: Hematologic
Task Area: Applying Basic Science Concepts
Core Rotation: Family Medicine
Topic(s): Anemias, G6PD Deficiency
196.
Stem: In a patient who is symptomatic for Lyme disease for more than four
weeks on presentation, what serology test(s) are recommended?
Answer choice:
A.
B.
C.
D.
Enzyme immunoassay (EIA) followed by Western blot testing
Western blot test alone
Enzyme immunoassay (EIA) followed by IgM and IgG western blot
No specific testing is recommended after four weeks of symptoms
Answer: The answer is B.
Explanation: EIA and Western blot testing are recommended initial testing, EIA plus IgM and IgG for less
than four weeks, and Western blot alone for more than four weeks (A, B, and C). Not testing is not
currently recommended (D).
References:
Sanchez et al., 2016, p. 1769.
Organ System: Infectious Diseases
Task Area: Health Maintenance
Core Rotation:
Topic(s): Spirochetal Diseases, Lyme Disease
197.
Stem: A 64-year-old U.S.–Mexico border patrol agent from Arizona comes to
clinic with a report of fever, cough, chest pain, headache, muscle aches, and joint pain
for the past 2 weeks. He reports mild anorexia, but no weight loss. He also denies
cutaneous symptoms. Posteroanterior and lateral chest radiographs are performed, and
reveal right lower lobe infiltrates and ipsilateral hilar adenopathy. Of the following,
which is the most appropriate treatment for the patient?
Answer choice:
a.
b.
c.
d.
e.
Fluconazole
Doxycycline
Amphotericin B
Amoxicillin
Supportive care
Answer: The answer is E.
Explanation: This patient presents from the southwestern U.S., where Coccidioides species is endemic,
and coccidioidomycosis infections are common. Most infections are caused by inhalation of spores.
Common presentation ranges from self-limited acute pneumonia (valley fever) to disseminated disease,
especially in immunosuppressed patients. Most immunocompetent patients with primary coccidioidal
infection do not require antifungal therapy. However, treatment should be administered to those with
severe disease (eg., loss of > 10% body weight, night sweats > 3 weeks, bilateral lung infiltrates, and
symptoms persisting > 2 months), and those at much higher risk for dissemination because of major
immunosuppression or pregnancy. The current patient falls into none of those categories, and thus can
be treated with supportive care (E). There is no role for antibiotics in the treatment of fungal infections.
References:
Galgiani JN, Ampel NM, Blair JE, Catanzaro A, et al. 2016 Infectious Diseases Society of America (IDSA)
Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis. 2016 Sep;63(6):e11246.
Saubolle MA, McKellar PP, Sussland D. Epidemiologic, clinical, and diagnostic aspects of
coccidioidomycosis. J Clin Microbiol. 2007;45(1):26-30.
Organ System: Pulmonary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine
Topic(s): Infectious Disorders, Fungal Pneumonia
198.
Stem: You have a 20-year-old college athlete who presents with a sports related
knee injury. Your exam is suspicious for an anterior cruciate ligament rupture. What
epidemiologic factors might influence your differential?
Answer choice:
A.
B.
C.
D.
ACL injuries are most common in males regardless of activity
Women’s ice hockey players have a high incidence of ACL ruptures
Women have a higher incident rate across all sports on a per incident exposure
Female gymnasts have a low incidence of ACL ruptures
Answer: The answer is C.
Explanation: Males have a higher injury rate in American football from contact injuries (A). Women’s ice
hockey and men’s baseball have a low incidence (B). Female gymnasts are at significantly higher risk
than their male counterparts (D). The incidents in sports of all kinds has a higher incidence rate in
females, but is balanced out statistically by the number of male incidents in contact football (C).
References:
UpToDate, July 2018.
Organ System: Musculoskeletal
Task Area: Health Maintenance
Core Rotation: Family Medicine, Emergency Medicine
Topic(s): Lower Extremity Disorders, Soft-tissue Injuries
199.
Stem: A 19-year-old woman is struck in the head by a falling tree branch during
a hike through the forest. She is knocked unconscious but wakes up after a few minutes.
She complains of a severe headache, nausea, and vomiting. Physical exam is significant
only for a hematoma over the right temporal region. A head CT was performed; please
see attached image. What is the most likely etiology of her symptoms?
<CATCH: Insert Photo F>
<CATCH: Insert credit line underneath the photo: Reproduced with permission from John M. Oropello,
Stephen M. Pastores, Vladimir Kvetan: Critical Care, www.accessmedicine.com. Copyright © McGraw-Hill
Education. All rights reserved. Figure 50-1>
Answer Choice:
A.
B.
C.
D.
E.
Ruptured ACom aneurysm
Ventral thalamic infarct
Neuritic plaque development
Mass within the right external auditory canal
Tearing of the middle meningeal artery
Answer: The answer is E.
Explanation: Tearing of the middle meningeal artery is the most common etiology of an epidural
hematoma (E). Blunt force trauma to the head is often the source of vessel damage, and the
presentation of an epidural hematoma is often initial loss of consciousness followed by returned
alertness, accompanied by nausea and vomiting. A ruptured aneurysm of the right anterior
communicating artery would result in a subarachnoid hemorrhage, which is not consistent with the
intracerebral hemorrhage seen in the attached image (A). The most common symptom related to a
subarachnoid hemorrhage is a sudden, severe headache, which is not consistent with the history of the
present illness. An infarct of the ventral thalamus results in a pure sensory stroke, described as
unilateral numbness and tingling on the same side as the injury (B). Neuritic plaque development is
predominant in Alzheimer’s disease (C). On a CT scan, Alzheimer’s disease most commonly appears as
generalized brain atrophy or atrophy centralized in the area of the hippocampus, making this answer
unlikely. The image presented does not include the external auditory canal, making the diagnosis of a
mass unlikely (D). A mass in the external auditory canal would present with the insidious onset of
unilateral hearing loss, vertigo, and tinnitus, which is not this patient’s chief complaint.
References:
Manley GT, Hauser SL, McCrea M. Concussion and Other Traumatic Brain Injuries. In: Jameson J, Fauci
AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th
ed. New York, NY: McGraw-Hill; 2018. http://usjezproxy.usj.edu:2195/content.aspx?bookid=2129&sectionid=192533001.Accessed February 27, 2019.
Dhawan V, Ullman JS. Traumatic Brain and Spinal Cord Injury. In: Oropello JM, Pastores SM, Kvetan
V, eds. Critical Care. New York, NY: McGraw-Hill; 2016. http://usjezproxy.usj.edu:2195/content.aspx?bookid=1944&sectionid=143519430. Accessed February 28, 2019.
Ropper AH, Samuels MA, Klein JP. Chapter 34. Cerebrovascular Diseases. In: Ropper AH, Samuels MA,
Klein JP, eds. Adams & Victor's Principles of Neurology. 10th ed. New York, NY: McGraw-Hill;
2014. http://usj-ezproxy.usj.edu:2195/content.aspx?bookid=690&sectionid=50910885.Accessed
February 28, 2019.
Seeley WW, Miller BL. Alzheimer’s Disease. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill;
2018. http://usj-ezproxy.usj.edu:2195/content.aspx?bookid=2129&sectionid=192532255. Accessed
February 28, 2019.
Walker MF, Daroff RB. Dizziness and Vertigo. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill;
2018.http://usj-ezproxy.usj.edu:2195/content.aspx?bookid=2129&sectionid=192011330. Accessed
February 28, 2019.
Organ System: Neurologic
Task Area: Applying Basic Science Concepts
Core Rotation: Emergency Medicine
Topic(s): Intracranial Hemorrhage
200.
Stem: A patient presents following active military duty with symptoms of
flashbacks, nightmares, avoidance, and negative thoughts and feelings. Which of the
following additional findings would be most likely present in this patient?
Answer Choice:
A.
B.
C.
D.
E.
Physiologic hyperarousal, including startle reactions
Poor dentition
Repetitive actions such as washing the hands many times
Excessive demands for attention
Fear of rejection
Answer: The answer is A.
Explanation: Patients with PTSD can experience physiologic hyperarousal, including startle reactions,
illusions, overgeneralized associations, sleep problems, nightmares, dreams about the precipitating
event, impulsivity, difficulties in concentration, and hyper-alertness. The symptoms may be precipitated
or exacerbated by events that are a reminder of the original traumatic event (A). Bulimia nervosa is the
episodic uncontrolled ingestion of large quantities of food followed by recurrent inappropriate
compensatory behavior to prevent weight gain such as self-induced vomiting, diuretic or cathartic use,
or strict dieting or vigorous exercise. Vomiting can result in poor dentition, pharyngitis, esophagitis,
aspiration, and electrolyte abnormalities (B). Obsessive-compulsive disorder (OCD), classified as an
anxiety disorder in the DSM-IV, now is part of a separate category of obsessive-compulsive disorder and
related disorders in DSM-5. In OCD, the irrational idea or impulse repeatedly and unwantedly intrudes
into awareness. Obsessions (recurring distressing thoughts, such as fears of exposure to germs) and
compulsions (repetitive actions such as washing the hands many times or cognitions such as counting
rituals) are usually recognized by the individual as unwanted or unwarranted and are resisted, but
anxiety often is alleviated only by ritualistic performance of the compulsion or by deliberate
contemplation of the intruding idea or emotion (C). Patients with a narcissistic personality disorder may
exhibit clinical findings of exhibitionism, grandiosity, preoccupation with power, lack of interest in
others, and excessive demands for attention (D). Patients with an avoidant personality disorder may
exhibit clinical findings of fear of rejection, hyperreaction to rejection and failure, poor social endeavors,
and low self-esteem (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Psychiatry/Behavioral
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine
Topic(s): Trauma- and Stressor-Related Disorders, Post-Traumatic Stress Disorder
201.
Stem: A 60-year-old male complains of a 2-day history of pain at the base of his
left first toe. He noted that it was painful just to touch the area lightly and that it
appeared red and swollen yesterday but has not worsened. He has had similar episodes
involving the same toe in the past, which he attributed to his shoes. He denies any
known injury. Monosodium urate crystals are present in aspiration of the joint. What is
the most appropriate initial treatment regimen for this patient?
<CATCH: Insert Photo B>
<CATCH: Insert credit line under Photo B: Reproduced with permission from Imboden JB, Hellmann DB,
Stone JH: Current Diagnosis & Treatment: Rheumatology, 3rd Edition: www.accessmedicine.com
Copyright © The McGraw-Hill Companies, Inc. All rights reserved. Figure 42-2>
Answer choice:
A.
B.
C.
D.
E.
Indomethacin
Allopurinol
Probenecid
Febuxostat
Acetaminophen
Answer: The answer is A.
Explanation: NSAIDs such as indomethacin are indicated for the treatment of acute gout by decreasing
pain and inflammation (A). Colchicine is also an option for acute gout. Either option works best if started
within 48 hours of initial symptoms. Allopurinol, probenecid, and febuxostat are used to treat
hyperuricemia, prevent acute gout flares, and treat chronic gout. These agents should be initiated after
the acute flare (B, C, and D). Acetaminophen is unlikely to provide significant benefit for the patient’s
pain or inflammation (E).
References:
Burns C, Wortmann RL. Chapter 44. Gout. In: Imboden JB, Hellmann DB, Stone JH. eds. CURRENT
Diagnosis & Treatment: Rheumatology. 3rd ed. New York, NY: McGraw-Hill;
2013.http://accessmedicine.mhmedical.com/content.aspx?bookid=506&sectionid=42584931. Accessed
March 07, 2019.
Organ System: Musculoskeletal
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Gout, Acute
202.
Stem: In HIV-positive patients with CD4 counts less than 200 cells per µL, what is
the most common fungal infection?
Answer choice:
a.
b.
c.
d.
e.
Cryptococcal meningitis
Cryptococcal pneumonitis
Aspergillus pneumonia
Pneumocystis jiroveci pneumonia
Coccidioidomycosis
Answer: The answer is D.
Explanation: The majority of fungal infections in immunocompromised patients are related to either
Candida bloodstream infections or invasive Aspergillus tissue infections. There are, however, various
particular fungi with predilection for infecting specific subsets of immune-compromised patients, such
as HIV-infected people. Specifically, in HIV-infected patients with blood CD4 counts less than 200 cells
per µl, the chief fungal infection is Pneumocystis jiroveci pneumonia (D). Cryptococcal meningitis and
pneumonitis are also observed, but with much less frequency than Pneumocystitis jiroveci pneumonia.
Endemic mycoses, which include histoplasmosis, coccidioidomycosis, blastomycosis, and less commonly,
opportunistic aspergillosis, also remain concerns in this population of patients.
References:
Gilroy SA and Bennett NJ. Pneumocystis pneumonia. Semin Respir Crit Care Med. 2011 Dec;32(6):77582.
Limper A. The Changing Spectrum of Fungal Infections In Pulmonary and Critical Care Practice: Clinical
Approach To Diagnosis. Proc Am Thorac Soc. 2010 May;7(3):163-8.
Organ System: Pulmonary
Task Area: Applying Basic Science Concepts
Core Rotation: Internal Medicine
Topic(s): Infectious Disorders, HIV-related Pneumonia
203.
Stem: A 4-week-old infant is brought to the office by his mother and has been
feeding poorly since his prior visit. He has failed to gain weight and becomes breathless
and diaphoretic after feeding or crying. Vitals are as follows: Pulse 140 and regular;
respirations 40; blood pressure: R arm 100/65, L arm 98/65, R leg 80/45, L leg 78/45;
pulse ox 96%. Cardiac exam reveals 4+ carotid pulses bilaterally and absent femoral
pulses bilaterally. A loud systolic ejection murmur is heart best at the lower left sternal
border. ECG reveals normal sinus rhythm with right ventricular hypertrophy.
Answer choice:
a.
b.
c.
d.
e.
Atrial septal defect
Coarctation of the aorta
Pulmonary stenosis
Tetralogy of Fallot
Ventricular septal defect
Answer: The answer is B.
Explanation: Coarctation of the aorta (B) is a narrowing in the aortic arch that usually occurs in the
proximal descending aorta, near the takeoff of the left subclavian artery near the ductus arteriosus.
Coarctation accounts for about 6% of all congenital heart disease, and three times as many males as
females are affected. The incidence of associated bicuspid aortic valve with coarctation is 80%–85%. The
cardinal physical finding is decreased or absent femoral pulses. Coarctation is usually diagnosed by a
pulse and blood pressure (> 15 mm Hg) discrepancy between the arms and legs on physical examination.
Approximately 40% of children with coarctation will present as young infants. Coarctation is the leading
cause of heart failure in the first month of life. A systolic ejection murmur is often heard at the aortic
area and the lower left sternal border, along with an apical ejection click if there is an associated
bicuspid aortic valve. ECGs in older children may be normal or may show LVH. ECG usually shows RVH in
infants with severe coarctation because the RV serves as the systemic ventricle during fetal life.
Atrial septal defect (A), pulmonary stenosis (C), Tetralogy of Fallot (D), and ventricular septal defect (E)
are all incorrect. While these may result in failure to thrive in infancy, none of these disorders are
associated with the physical exam findings of absent femoral pulses and blood pressure discrepancy
between the arms and legs. Additionally, Tetralogy of Fallot would present in infants with severe
cyanosis.
References:
Jone P, Darst JR, Collins KK, Miyamoto SD. Cardiovascular Diseases. In: Hay WW, Jr., Levin MJ, Deterding
RR, Abzug MJ, eds. CURRENT Diagnosis & Treatment Pediatrics 2016, 23e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1795&sectionid=125741666. Accessed
December 29, 2017.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Pediatric Medicine
Topic(s): Congenital Heart Disease, Coarctation of Aorta
204.
Stem: A 4-year-old girl is brought to the Emergency Department for evaluation
of an acute rash. Her parents report a recent upper respiratory infection in an otherwise
healthy child. She denies abdominal pain, nausea, vomiting, and joint pain. On physical
exam, she is well-appearing and afebrile. There are multiple petechial and ecchymoses,
no epistaxis or gingival bleeding, no palpable purpura, and no hepatosplenomegaly or
lymphadenopathy. Labs reveal a platelet count of 20,000/microL and an otherwise
normal complete blood count and peripheral smear. PT, PTT, and bleeding time are all
within normal range. Which of the following is the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Acute lymphocytic leukemia
Disseminated intravascular coagulation
Henoch-Schönlein purpura
Idiopathic thrombocytopenic purpura
Thrombotic thrombocytopenic purpura
Answer: The answer is D.
Explanation: Idiopathic thrombocytopenic purpura (ITP), (D), is an acquired autoimmune disorder that
results in an isolated thrombocytopenia with no apparent underlying cause. It often occurs in children
age 2–5 years, frequently following an acute viral illness, and is typically self-limited. The platelet count
is markedly reduced to <50,000/microL (often <10,000/microL).
Acute lymphocytic leukemia (A) presents clinically with intermittent fevers, weight loss, petechiae or
bruising, bone pain, hepatomegaly and/or splenomegaly, and lymphadenopathy. While some patients
may present initially with a single cytopenia, most patients have a decrease in at least two blood cell
lines.
Disseminated intravascular coagulation (DIC), (B), often accompanies severe infection or critical illness.
Signs of DIC include shock, diffuse bleeding, and thrombosis. PT and PTT are prolonged, while platelet
count and fibrinogen may be decreased.
Henoch-Schönlein purpura (C) is the most common type of small vessel vasculitis in children. It often
occurs in the spring or fall, following an acute upper respiratory infection. The most common sign is
palpable purpura. Polyarthralgias and abdominal pain are common. The platelet count is normal or
elevated, and coagulation studies are normal.
Thrombotic thrombocytopenic purpura (TTP), (E), presents with thrombocytopenia, hemolytic anemia,
CNS abnormalities, fever, and renal dysfunction.
References:
Ambruso DR, Nuss R, Wang M. Hematologic Disorders. In: Hay WW, Jr., Levin MJ, Deterding RR, Abzug
MJ, eds. CURRENT Diagnosis & Treatment Pediatrics 2016, 23e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1795&sectionid=125745760. Accessed
January 23, 2018.
Leavitt AD, Minichiello T. Disorders of Hemostasis, Thrombosis, & Antithrombotic Therapy. In: Papadakis
MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGrawHill. http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168013149.
Accessed January 23, 2018.
Organ System: Hematologic
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Pediatrics
Topic(s): Coagulation Disorders, Idiopathic Thrombocytopenic Purpura
205.
Stem: You are called to the Emergency Room to evaluate a 30-year-old male
brought in by his girlfriend. She reports that he has had the “stomach flu” for the last 2
days and has been vomiting everything he tries to eat or drink. He has been growing
increasingly sleepy and weak. Initial workup includes the following results:
Na 148 (normal 136-144), potassium 5.0 (normal 3.5-5.0), chloride 100 (normal 100-111),
bicarbonate 14 (normal 20-29), BUN 28 (normal 7-20), glucose 68 (normal 64-100),
measured osmolality 293 (normal 275-295). Ethanol is negative.
Which intravenous fluid would be the appropriate choice for initial management of this
patient?
Answer choice:
a. Sodium bicarbonate
b.
c.
d.
e.
Colloid fluid
Isotonic crystalloid fluid
Hypotonic crystalloid fluid
Hypertonic crystalloid fluid
Answer: The answer is C.
Explanation: Hypovolemia results from decreased intravascular volume secondary to loss of blood or
fluids and electrolytes. The most common causes are trauma, bleeding, and dehydration. Hypovolemia
presents with signs of oliguria, altered mental status, cool extremities, tachycardia, and loss of moisture
to mucous membranes. In this patient, dehydration secondary to vomiting is the cause of his
hypovolemia. Management would be to rapid replacement with boluses of isotonic crystalloid (0.9%
normal saline or lactated Ringer solution) in 1-liter increments (C) to normalize electrolyte imbalance.
References:
Hypovolemic Shock. In: Maxine A. Papadakis, et al., eds. Current Medical Diagnosis & Treatment 2018.
New York, NY: McGraw-Hill, pp. 501–505.
Organ System: Genitourinary
Task Area: Clinical Intervention
Core Rotation: Emergency medicine, internal medicine
Topic(s): Fluid and Electrolyte Disorders, Hypovolemia
206.
Stem: A female patient presents with acute onset of fever, cough and myalgias.
She has been taking OTC acetaminophen with some relief, resting and pushing fluids.
There has been no dyspnea nor vomiting or diarrhea. On exam, she appears ill and is
actively coughing. HEENT is significant for rhinorrhea and injection of the oropharynx.
Neck is supple, lungs have coarse rhonchi heard at the apices and the cardiac exam
reveals tachycardia without murmur. The skin is moist and warm without rash. A rapid
influenza antigen test is positive.
Which choice below would place this patient at high risk for flu related complications?
Answer choice:
a.
b.
c.
d.
e.
Age > 50 years old
Recent Hemoglobin A1c of 8.2%
Missed influenza vaccination for current season
Currently attempting to get pregnant
Ejection fraction (LVEF) of 65% on recent echocardiogram
Answer: The answer is B
Explanation: A Hemoglobin A1c of 8.2% indicates poorly controlled diabetes, a high risk population.
Patients 65 or older are more at risk for flu related complications as compared to a younger population.
Unvaccinated status does not necessarily place the patient at risk. Pregnant patients are at risk but
those attempting to become pregnant are not. An ejection fraction below 50% would indicate heart
failure or cardiomyopathy placing the patient in a high risk status.
References:
Dabelić A. Respiratory Problems. In: South-Paul JE, Matheny SC, Lewis EL. eds.CURRENT Diagnosis &
Treatment: Family Medicine, 4e New York, NY: McGrawHill;http://accessmedicine.mhmedical.com/content.aspx?bookid=1415&sectionid=77057157. Accessed
December 01, 2017.
Organ System: Pulmonary System
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine
Topic(s): Infectious Disorders, Influenza
207.
Stem: A surgical consult is requested by the emergency department for a male
patient with less than 48 hours of low abdominal pain. The patient has been triaged and
examined by the ED clinician. Normal saline intravenous has been started and the
patient was given morphine 2 mg intravenous for pain. Diagnostic studies are pending
and a decision will be needed if patient should undergo imaging or exploratory
laparoscopy.
Which finding will provide the greatest contribution to the patient’s risk for appendicitis?
Answer choice:
a.
b.
c.
d.
e.
Acute vomiting
Right lower quadrant abdominal pain
White blood cell count > 15,000 cells/mcL
Temperature > 101F
Elevated erythrocyte sedimentation rate
Answer: The answer is C
Explanation: Using the appendicitis inflammatory response score, the elevated white blood count will
contribute the most towards the overall score. Presence of vomiting, location of pain and fever will
contribute individually but not to the extent of leukocytosis. The C-reactive protein is a component of
the score but ESR is not.
References:
Liang MK, Andersson RE, Jaffe BM, Berger DH. The Appendix. In: Brunicardi F, Andersen DK, Billiar TR,
Dunn DL, Hunter JG, Matthews JB, Pollock RE. eds.Schwartz's Principles of Surgery, 10e New York, NY:
McGraw-Hill; 2015.
http://accessmedicine.mhmedical.com/content.aspx?bookid=980&sectionid=59610872. Accessed
November 30, 2017
Organ System: GastrointestinalNutritional
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Surgery
Topic(s): Small Intestine disorders, Appendicitis
208.
Stem: A 53-year-old male is in the endoscopy suite for a colonoscopy. He is
noted on intake to have tachycardia. On examination, blood pressure is 143/88, pulse is
134 and irregular. There is no jugular venous distention and cardiac auscultation is
without murmur. His lungs have equal and clear breath sounds bilaterally. The abdomen
is soft and non-tender. The extremities are without cyanosis, clubbing or edema. An EKG
is being performed.
On review of the EKG, which finding will differentiate atrial fibrillation from atrial flutter?
Answer choice:
a.
b.
c.
d.
e.
Tachycardia
Prolonged PR interval
Shortened PR interval
Irregular QRS response
Widened QRS morphology
Answer: The answer is D
Explanation: Atrial fibrillation will have an irregular QRS response while atrial flutter is usually regular.
Both may present with a rapid, slow or normal rate. The PR interval is immeasurable and the QRS is
usually narrow for both arrhythmias.
References:
Bashore TM, Granger CB, Jackson KP, Patel MR. Heart Disease. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018 New York, NY: McGraw-Hill;
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168190671. Accessed
November 21, 2017.
Organ System: Cardiovascular
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Conduction Disorders/dysrhythmias, Atrial Fibrillation/Flutter
209.
Stem: A 42-year-old female comes to your office as a new patient. She
complains of painful swelling and stiffness in the morning for several hours in both of
her hands intermittently over the past year. Furthermore, she notes feeling more tired
recently. Based on the history and physical exam findings what is your most likely
diagnosis?
<CATCH: Insert Photo G>
<CATCH: Insert credit line underneath the photo: Reproduced with permission from JE South-Paul, SC
Matheny, EL Lewis: CURRENT Diagnosis & Treatmnent: Family Medicine, 4th ed, www.
Accessmedicine.com. Copright © McGraw-Hill Education. All rights reserved. Figure 24-4>
Answer choice:
A.
B.
C.
D.
E.
Rheumatoid arthritis
Degenerative joint disease
Septic arthritis
Gout
Polymyalgia rheumatica
Answer: The answer is A.
Explanation: The history of morning stiffness greater than 1 hour, symmetrical arthritis, and arthritis of
hand joints (proximal interphalangeal second and third in this case) meets the American College of
Rheumatology diagnostic criteria for rheumatoid arthritis (A). She also presents with fatigue, which is a
common presenting symptom. Degenerative joint disease is unlikely due to the patient’s age, swelling,
absence of injury, and stiffness that is worse in the morning (B). Septic joints can occur in patients with
rheumatoid arthritis but there is no indication of erythema or sudden worsening of a single joint pain or
swelling (C). Gout is typically monoarticular with abrupt onset and severe pain (A). Polymyalgia
rheumatica typically presents in the elderly and involves pain and stiffness at the hip and shoulder girdle
(E).
References:
Johnson BE. Arthritis: Osteoarthritis, Gout, & Rheumatoid Arthritis. In: South-Paul JE, Matheny SC, Lewis
EL, eds. CURRENT Diagnosis & Treatment: Family Medicine. 4th ed. New York, NY: McGraw-Hill; 2015.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1415&sectionid=77056695. Accessed
September 04, 2018.
Organ System: Musculoskeletal System
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Rheumatoid Arthritis
210.
Stem: A 68-year-old female complains of a 2-week history of a dull constant
headache located on the L side in the temporal region. He also notes feeling more tired
recently. He denies injury. What past medical history would most likely support a
diagnosis of giant cell arteritis (temporal arteritis)?
Answer choice:
A.
B.
C.
D.
E.
Polymyalgia rheumatica
Coronary artery disease
Rheumatoid arthritis
Trigeminal neuralgia
Migraine
Answer: The answer is A.
Explanation: Polymyalgia rheumatica is strongly associated with giant cell arteritis (A). 10–20% of
patients who have a previous history of isolated polymyalgia rheumatica develop giant cell arteritis.
Symptoms of polymyalgia rheumatica may develop in as much as 50% of patients who present with
giant cell arteritis, which includes stiffness and aches in the shoulders, hips, and thighs. The other
choices are not associated with increased risk of giant cell arteritis (B, C, D and E).
References:
Goadsby PJ. Headache. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds.
Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.evms.idm.oclc.org/content.aspx?bookid=2129&sectionid=19201
1003. Accessed September 06, 2018.
Langford CA, Fauci AS. The Vasculitis Syndromes. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo
DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.evms.idm.oclc.org/Content.aspx?bookid=2129&sectionid=19228
5458. Accessed September 06, 2018.
Organ System: Neurologic System
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Headache, Secondary Causes, Giant Cell Arteritis
211.
Stem: A healthcare worker has just returned from a medical mission trip in
Africa and has begun developing the symptoms of fatigue, weight loss, fever, night
sweats, and productive cough. Following successful treatment, which of the following
should be discussed as part of the patient education based on the most likely diagnosis
for this patient?
Answer Choice:
A.
B.
C.
D.
E.
The future risk of cervical cancer and appropriate screening required
The patient should refrain from any contact sports due to the possibility of splenomegaly
The patient has a future risk of developing herpes zoster later as an adult
The patient should watch for symptoms of testicular inflammation
The patient will have future positive purified protein derivative skin tests
Answer: The answer is E.
Explanation: This patient is presenting with classic signs and symptoms of tuberculosis. Human
papillomavirus infections have been associated with an increased risk of cervical cancer with the
majority from types 16 and 18 and increased risk of genital warts with the majority from types 6 and 11
(A). Epstein-Barr virus infections have an increased risk of splenomegaly with potential rupture from
increased abdominal pressure or high-impact contact. Patients should be removed from contact sports
until the splenomegaly has resolved completely (B). Varicella zoster viral infections increase the risk of
having a herpes zoster (shingles) outbreak as an adult due to the inactive virus remaining present in the
host (C). Mumps is associated with the severe side effect of orchitis (testicular inflammation), which
could progress to infertility (D). The purified protein derivative (PPD) skin test is often used for annual
screening for tuberculosis. Patients with previous exposure to the bacteria Mycobacterium tuberculosis
will have a positive immune reaction to all future PPD skin tests without active or latent infection (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Infectious Diseases
Task Area: Health Maintenance
Core Rotation: Emergency Medicine, Family Medicine, Internal Medicine
Topic(s): Tuberculosis
212.
Stem: A newborn presents to the office one month following delivery for
routine evaluation. She has been feeding well and gaining weight appropriately. You
notice a continuous machine-like murmur at the left sternal border, second intercostal
space. The child is not cyanotic and is in no acute distress with normal vital signs. The
remainder of a complete physical exam are within normal limits. What is the most likely
diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Atrial septal defect
Patent ductus arteriosis
Tetralogy of Fallot
Transposition of the great arteries
Ventricular septal defect
Answer: The answer is B.
Explanation: The ductus arteriosis (B) allows shunting of blood from the pulmonary artery to the aorta
in utero, and normally closes immediately after birth. Patent ductus arteriosis (PDA) accounts for 10% of
all congenital heart disease, is twice as common in females than in males, and is more frequently found
in preterm infants weighing less than 1,500 g. Clinical symptoms are usually minimal in childhood. A
continuous machine-like murmur is best heard at the left sternal border, at the first or second
intercostal space. ECG is likely to show left ventricular hypertrophy in cases of a large shunt.
Atrial septal defect (A) is a form of congenital heart disease that is characterized by a defect in the
interatrial septum, resulting in shunting of blood from the left to the right atrium. Many patients with
ASD are asymptomatic at birth. A systolic ejection murmur can be heard as a result of increased flow
through the pulmonary valve. Chronic volume overload of the right heart chambers, along with delayed
closure of the pulmonary valve, results in a fixed split S2. Right bundle branch block is found in most
patients with ASD.
Tetralogy of Fallot (C) and transposition of the great arteries (D) are incorrect. Both present with severe
cyanosis in infants. The murmur associated with Tetralogy of Fallot is a harsh systolic ejection murmur at
the left upper sternal border.
Ventricular septal defect (E) is incorrect. Ventricular septal defect (VSD) is a defect in the ventricular
septum between the left and right ventricles. The murmur associated with VSD is described as a loud,
high-pitched holosystolic murmur at the left lower sternal border and may decrease with Valsalva or
handgrip. In addition, the S2 heart sound is physiologically split.
References:
Jone P, Darst JR, Collins KK, Miyamoto SD. Cardiovascular Diseases. In: Hay WW, Jr., Levin MJ, Deterding
RR, Abzug MJ, eds. CURRENT Diagnosis & Treatment Pediatrics 2016, 23e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1795&sectionid=125741666. Accessed
December 29, 2017.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Pediatric Medicine
Topic(s): Congenital Heart Disease, Patent Ductus Arteriosus
213.
Stem: A 25-year-old female patient presents to the emergency department via
ambulance after being involved in a motor vehicle collision. After the initial trauma
survey and a subsequent CT of her abdomen and pelvis, she is revealed to have an open
anteroposterior compression fracture type II of the pelvic ring. Which of the following
answer choices represents a potential complication associated with this type of pelvic
injury?
Answer Choice:
A.
B.
C.
D.
E.
Diaphragmatic rupture
Laceration of the vaginal wall
Urethral laceration
Splenic contusion
Lumbar vertebral fracture
Answer: The answer is C.
Explanation: Pelvic fractures can be devastating injuries that result in multiple soft tissue complications.
Clues to the specific type of injury can often be appreciated by the type of fracture. Anteroposterior
“open book” fractures present with the highest incidence of associated urethral injures (C). Visceral
contusion and diaphragmatic rupture are potential complications of pelvic ring fractures, but are less
common and associated with lateral compression and vertical shear fractures respectively (D and A).
Vertebral injuries can occur with a number of pelvic fractures but are not associated specifically with
anteroposterior fractures (E). Vaginal injuries are not common with pelvic fractures (B).
References: Barton MA, Derstine H, Barclay-Buchanan CJ. Pelvis Injuries. In: Tintinalli JE, Stapczynski J,
Ma O, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide. 8th ed. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=1658
&sectionid=109387862. Accessed February 06, 2019.
Organ System: Genitourinary
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine
Topic(s): Pelvic Fractures
214.
Stem: In a 17-year-old high school athlete with an injury sustained on the field
playing football, which of the following test is most helpful in diagnosing an acute
anterior cruciate rupture?
Answer choice:
A.
B.
C.
D.
Pivot shift
Lachman
Anterior drawer
Dial test
Answer: The answer is B.
Explanation: The anterior drawer test has a sensitivity of 92% and a specificity of 91% but is NOT
accurate in acute injury (C). It may be a false positive in the setting of a PCL injury. A positive pivot shift
is highly specific in an ACL rupture, but difficult to do in a patient not cooperative and relaxed, as in an
acute setting (A). The dial test is used to asses PCL injury and injury to the posterior lateral corner of the
knee (D).
References:
UpToDate, July 2018.
Organ System: Musculoskeletal
Task Area: Health Maintenance
Core Rotation: Family Medicine, Emergency Medicine
Topic(s): Lower Extremity Disorders, Soft-tissue Injuries
215.
Stem: An 18-year-old female with a history of allergic rhinitis and asthma
presents to the Emergency Department with 3 hours of shortness of breath following
outdoor soccer practice that afternoon. She is short of breath with walking and regular
activity despite taking 2 puffs of her albuterol inhaler at symptom onset and again 4
hours later. She can speak in full sentences. Peak flow is 65% of her best. Which of the
following is the next best step in therapy?
Answer choice:
A.
B.
C.
D.
E.
Administer nebulized albuterol and discharge home
Administer albuterol with spacer and prescribe oral steroids
Administer nebulized ipratropium and order a chest x-ray
Administer oxygen via nasal cannula and order a VQ scan
Administer ipratropium with spacer and prescribe azithromycin
Answer: The answer is B.
Explanation: Given current symptoms and peak flow, albuterol via spacer and a short course of oral
steroids is the most appropriate treatment (B). Albuterol delivered by spacer is as effective as albuterol
delivered by nebulizer (A). Chest x-ray, VQ scan, and azithromycin are not indicated given the patient’s
current symptoms (C, D, and E).
References:
Management of acute exacerbations of asthma in adults. UpToDate website.
https://www.uptodate.com/contents/management-of-acute-exacerbations-of-asthma-in-adults.
Updated July 13, 2017. Accessed November 10, 2017.
Organ System: Pulmonary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Emergency Medicine
Topic(s): Other Pulmonary Disorders, Asthma
216.
Stem: A 64-year-old male presents to the Emergency Department for worsening
abdominal pain and constipation. He has not had a bowel movement in two days and
notes that he has not had any flatus either. He vomited once today, and described it as
foul smelling. On examination, he has absent bowel sounds diffusely and his abdomen is
distended. Which of the following imaging studies would be most appropriate in the
evaluation of this patient given the above information?
Answer choice:
A.
B.
C.
D.
E.
Acute abdominal series including flat and upright abdominal films
CT scan of the abdomen and pelvis with IV contrast
Abdominal ultrasound with focus on the right upper quadrant
Abdominal MRI
Barium enema
Answer: The answer is B.
Explanation: Given that the patient likely has an abdominal obstruction, a CT scan with IV contrast is the
most appropriate choice (B). Obstructions can be seen on plain radiographs of the abdomen, but plain
films lack the ability to give information about etiology and the health of surrounding tissue (A).
Ultrasonography may be utilized to see an obstruction, but like an x-ray, cannot give information
regarding etiology and complications (C). The same can be said for a barium study (E). Magnetic
resonance imaging takes time and requires the patient to remain still during the procedure (D). It is not
a good choice, therefore, for an acutely ill patient.
References:
McAninch S, Smithson III CC. Gastrointestinal Emergencies. In: Stone C, Humphries RL, eds. CURRENT
Diagnosis & Treatment: Emergency Medicine. 8th ed. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165065027. Accessed
January 10, 2018.
Organ System: Gastrointestinal/Nutritional
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation:
Topic(s):
217.
Stem: A 30-year-old woman has recently undergone a work-up for recurrent
episodes of chest pain that typically awaken her in the early morning. She admits to
occasional cocaine use, and is negative for other cardiac risk factors. She was diagnosed
with Prinzmetal (variant) angina after negative coronary angiography. Which of the
following medications is indicated for prevention of her symptoms?
Answer choice:
a.
b.
c.
d.
e.
Adenosine
Aspirin
Nifedipine
Propranolol
Warfarin
Answer: The answer is C.
Explanation: Nifedipine (C) and other long-acting calcium channel blockers are effective prophylactically
for the prevention of coronary vasospasm and Prinzmetal (variant) angina.
Adenosine (A) is incorrect. Adenosine is an antiarrhythmic medication most commonly used to treat
supraventricular tachycardia (SVT). Aspirin (B) is incorrect. Although aspirin is beneficial in the
prevention and treatment of cardiovascular disease, it is not effective in the prevention of coronary
vasospasm. Propranolol (D) is incorrect. Beta-blockers are contraindicated in the treatment of
Prinzmetal angina, and may actually worsen coronary vasospasm. Warfarin (E) in incorrect. Warfarin is
an anticoagulant with no role in the prevention of coronary vasospasm and Prinzmetal angina.
References:
Bashore TM, Granger CB, Jackson KP, Patel MR. Heart Disease. In: Papadakis MA, McPhee SJ, Rabow
MW, eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168190671. Accessed
January 02, 2018.
Organ System: Cardiovascular
Task Area: Pharmaceutical Therapeutics
Core Rotation: Internal Medicine
Topic(s): Coronary Artery Disease, Angina Pectoris, Prinzmetal Variant
218.
Stem: Which of the following is a common complication of advanced chronic
kidney disease?
Answer choice:
A.
B.
C.
D.
E.
Hypophosphatemia
Metabolic alkalosis
Hypokalemia
Hypoparathyroidism
Anemia
Answer: The answer is E.
Explanation: Advanced Chronic Kidney Disease (CKD), stage 3 (GFR < 60ml/min) can cause anemia,
metabolic acidosis, and hyperkalemia as well as renal hyperparathyroidism and hyperphosphatemia (E).
It is a normochromic, normocytic and is a result of decreased production of erythropoietin by the
kidneys.
References:
Watnick S, Woddell T, Dirkx T. Kidney disease. In: McPhee SJ, Papadakis MA, eds. Current Medical
Diagnosis and Treatment. 57th ed. New York, NY: McGraw-Hill; 2018.
Organ System: Renal
Task Area: Applying Basic Science Concepts
Core Rotation: Internal Medicine, Family Medicine
Topic(s): Chronic Kidney Disease
219.
Stem: A patient is evaluated for vaginal bleeding and pelvic pain. Her baseline
hCG was 2000 IU/L and transvaginal ultrasound was inconclusive. Which of the following
hCG levels and corresponding time points are most suggestive of an ectopic pregnancy?
Answer choice:
a.
b.
c.
d.
e.
2000 IU/L (Hour 0)
3500 IU/L (Hour 0)
3500 IU/L (Hour 48)
2000 IU/L (Hour 0) and 4500 IU/L (Hour 72)
3500 IU/L (Hour 0) and 5000 IU/L (Hour 72)
Answer: The answer is D
Explanation: Typically, a normal intra-uterine pregnancy will have a doubling of hCG within 48-72 hours.
Although answer E represents a rise, it is not a normal rise, which is suggestive of an EP. The normal
doubling, suggestive of an intra-uterine pregnancy, is represented by the 2000 value at Hour 0 and 4500
value at hour 72. Single hCG values (choices a, b, c) without a gestational age or TVUS are not helpful in
the diagnosis of EP.
References:
References: Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. In: UpToDate, Barbieri
RL, Sharp HT, Levine D, Falk SJ (Eds.), UpToDate, Waltham, MA. Available at http://www.uptodate.com
(Accessed on December 22, 2017.)
Organ System: Reproductive
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Obstetrics-Gynecology
Topic(s): Complicated Pregnancy, Ectopic Pregnancy
220.
Stem: A 55-year-old man with a history of morbid obesity, diabetes, and chronic
lower extremity swelling presents with a sudden onset of fever and chills, followed by
development of redness, pain, and swelling to his right shin and calf. His symptoms have
been present for about 2 days without any improvement. He denies trauma to the leg,
other than trimming his toenails 2 days prior to the onset. On exam, he has mild to
moderate tenderness on palpation, with erythema of the right shin and calf, without
fluctuance or crepitus. What is the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Allergic contact dermatitis
Cellulitis
Necrotizing fasciitis
Septic bursitis
Venous stasis dermatitis
Answer: The answer is B.
Explanation: Cellulitis (B) is characterized by acute onset of pain, erythema, and swelling at the site. It is
often associated with fevers, and develops after some type of break in the skin (acute or chronic),
allowing bacteria to penetrate the skin. Common risk factors include diabetes, obesity, lower extremity
edema, tinea pedis, and trauma to the site.
Allergic contact dermatitis (A) is characterized by focal rash and itching, and fever and pain are unlikely.
Necrotizing fasciitis (C) a deep space soft tissue infection, with some similar findings compared with
straightforward cellulitis, but is also characterized by pain out of proportion to physical findings, and
rapid deterioration including signs of systemic toxicity. Septic bursitis (D) is unlikely in this patient as he
does not have joint pain. Venous stasis (E) dermatitis is chronic and often bilateral, presenting with
erythema and scaling of the legs.
References:
Spelman D, Baddour, LM. Cellulitis and Skin Abscess: Clinical Manifestations and Diagnosis. In
www.uptodate.com. Updated September 6, 2017, Accessed December 25, 2017
Stevens DL, and Baddour LM. Necrotizing Soft Tissue Infections. In www.uptodate.com. Updated
October 4, 2017. Accessed December 25, 2017.
Organ System: Dermatologic
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Infectious diseases, Bacterial, Cellulitis
221.
Stem: A 76-year-old man presents to the clinic with 3 months of cough, night
sweats, and fatigue and a 15 lb. weight loss. He has noted intermittent sputum
production including blood-tinged sputum over the last month. He is a non-smoker who
immigrated to the United States from Laos 50 years ago. Vital signs show T99.2, R20, BP
132/74, O2 sat 94% room air. Once you confirm the most likely diagnosis, what is the
most appropriate therapy for this patient?
Answer choice:
a.
b.
c.
d.
e.
Amoxicillin/clavulanate x 10 days
Cisplatin + docetaxel x 4–6 months
Isoniazid, rifampin, ethambutol, and pyrazinamide x 6–9 months
Prednisone + ipratropium x 6 weeks
Voriconazole x 4–6 moths
Answer: The answer is C.
Explanation: The most likely diagnosis for this patient is active pulmonary tuberculosis. After the
diagnosis is made by history, CXR, and sputum AFB culture, 4 drug therapy (C) is started pending final
sensitivities. There are a few options for drug combinations and dosing intervals, and drug resistance is a
problem in certain parts of the world. Other therapies listed here ((A), (B), (D), and (E)) cover treatment
for bacterial pneumonia, lung cancer, COPD exacerbation, and fungal pulmonary infections but are not
active therapies against tuberculosis.
References:
Treatment for TB Disease. In www.cdc.gov. Updated August 11, 2016. Accessed December 25, 2017.
Organ System: Pulmonary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Internal Medicine
Topic(s): Infectious Disorders, Tuberculosis
222.
Stem: A 10-year-old boy presents to the ED with 24 hours of fevers, headaches,
and painful L eye swelling. His mother is suspicious he may have sinusitis, as he has had
this in the past. On exam the child appears fatigued, but non-toxic, without any focal
neurologic deficits or mental status change. What entity is a “do not miss” in the
emergency evaluation of this patient?
Answer choice:
a.
b.
c.
d.
e.
Acute mastoiditis
Bacterial meningitis
Orbital cellulitis
Preseptal cellulitis
Ramsay-Hunt syndrome
Answer: The answer is C.
Explanation: Orbital cellulitis (C) is most common in children, and the vast majority of cases stem from
an acute sinusitis. Advanced cases including those with subperiosteal abscess can pose a threat to the
patient’s vision, and extension into the CNS carries risk of mortality, making orbital cellulitis a true
emergency.
Preseptal cellulitis (D) would be in the differential diagnosis, but does not carry the risk to vision and life
that orbital cellulitis does, and therefore is not considered the “do not miss” in this case. Bacterial
meningitis (B) in children is usually characterized by fever and symptoms of meningeal irritation, which
this patient does not have. It is an emergency but this patient does not meet criteria for meningitis.
Mastoiditis (A) is characterized by pastauricular swelling, erythema, tenderness, and protrusion of the
auricle, along with ear pain. Ramsay-Hunt syndrome (E) is a complication of herpes zoster infection,
characterized by facial paralysis, ear pain, and vesicles involving the auricle and auditory canal, and
therefore is unlikely in this patient.
References:
Gappy C, Archer SM, Barza M. Orbital cellulitis. In www.uptodate.com. Updated January 4, 2016,
accessed September 29, 2017.
Wald ER. Acute Mastoiditis in Children: Clinical Features and Diagnosis. In www.uptodate.com. Updated
January 3, 2017. Accessed December 25, 2017.
Kaplan SL. Bacterial Meningitis in Children Older than One Month: Clinical Features and Diagnosis. In
www.uptodate.com. Updated August 30, 2017. Accessed December 25, 2017.
Albrecht MA. Clinical Manifestations of Varicella-Zoster Virus Infection: Herpes Zoster. In
www.uptodate.com. Updated August 2, 2016. Accessed December 25, 2017.
Organ System: EENT
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine
Topic(s): Eye Disorders, Orbital disorders, Orbital Cellulitis
223.
Stem: A G2P1 is 30 weeks gestational age and presents to Labor and Delivery
Triage with concern of “her water breaking because of fluid leakage.” During the
speculum exam, you perform a nitrazine test and the result matches a pH of 4.0. Which
of the following is the most likely source?
Answer choice:
a.
b.
c.
d.
e.
Amniotic fluid
Bacterial vaginosis
Blood contamination
Vaginal discharge
Seminal fluid
Answer: The answer is D
Explanation: Normal (physiologic) vaginal discharge is acidic at a pH of 3.8-4.2. Amniotic fluid is alkaline
(>7.0). Semen and blood can cause false positives (alkaline). Bacterial vaginosis is a pH of > 4.5 .
References:
Duff P. Preterm premature (prelabor) rupture of membranes. In: UpToDate, Lockwood CJ, Barss VA
(Eds.), UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed on December 22,
2017.)
Organ System: Reproductive
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Obstetrics-Gynecology
Topic(s): Complicated Pregnancy, Premature rupture of membranes
224.
Stem: After a recent upper respiratory infection, a 40-year-old male has
developed chest pain over 72 hours that worsens when laying down. He has no
associated dyspnea or nausea. On exam, he appears mildly ill. Oral temperature is 101.2
F, BP 145/76, pulse 92, respirations 12 and pulse oximetry 100% on room air. HEENT and
neck are nonfocal. Lungs are clear to auscultation bilaterally. Cardiac exam reveals a
regular rhythm and no murmurs. The chest wall is nontender to palpation. A CBC, BMP
and troponin are normal. A CRP is elevated. An EKG has 2-4 mm ST elevations
throughout all leads.
Which is the best initial management for this condition?
Answer choice:
A.
B.
C.
D.
E.
Admission for intravenous corticosteroids
Perform partial pericardiectomy
Start full dose oral aspirin daily
Give intravenous thrombolytics emergently
Begin oral ibuprofen and colchicine simultaneously
Answer: The answer is E
Explanation: Pericarditis is initially treated with a combination of oral NSAID and colchicine. Aspirin
alone nor corticosteroids will provide successful treatment. A procedure may be indicated if symptoms
are worsening after the start of treatment or a large pericardial effusion is found on further evaluation.
Thrombolytics may be indicated if ischemia was localized to a specific area of the heart and the troponin
was elevated.
References:
Bashore TM, Granger CB, Jackson KP, Patel MR. Heart Disease. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018 New York, NY: McGraw-Hill; .
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168190671. Accessed
November 21, 2017.
Organ System: Cardiovascular
Task Area: Pharmaceutical Therapeutics
Core Rotation: Internal Medicine
Topics: Traumatic, infectious, and inflammatory heart conditions, Acute pericarditis
225.
Stem: A 40-year-old women presents to urgent care with nausea, fever to 101.6
°F, abdominal discomfort, and diarrhea. Her symptoms have been present for 2 days.
Travel history includes a trip to India one month ago, during which time she took part in
a religious ritual that included drinking a small amount of water from the Ganges river.
She did not receive any specific pre-travel vaccinations. She has no vomiting or diarrhea.
Laboratory studies reveal:
ALT: 2900
AST: 2105
Total bili: 5.6
Alk phos: 350
What is the most likely etiology of her illness?
Answer choice:
a.
b.
c.
d.
e.
E. coli O157:H7
Epstein-Barr Virus
Hepatitis A
Hepatitis B
Hepatitis C
Answer: The answer is C.
Explanation: The patient’s history and labs are consistent with acute hepatitis (C). Her lack of travel
vaccination against hepatitis A, and her contaminated water exposure history, and the fecal-oral route
of transmission of hepatitis A, along with the average 28 day incubation period, support the diagnosis.
E. coli 0157:H7 (A) infection is characterized by bloody diarrhea, and fever is often absent. It is not
associated with marked LFT elevation, and incubation period is approximately 3–5 days. Hepatitis B (D)
and Hepatitis C (E) are transmitted by blood and body fluids, making these much less likely. Epstein-Barr
virus infection (B) is characterized by fever, malaise, headache, and acute pharyngitis. It can cause a mild
acute hepatitis as well, but given the degree of LFT abnormality and the patient’s high risk water
exposure, hepatitis A is much more likely.
References:
Lai M, and Chopra S. Hepatitis A virus infection in adults: An overview. In www.uptodate.com. Updated
October 17 2016, accessed September 29 2017.
Calderwood SB. Clinical Manifestations, Diagnosis, and Treatment of Enterohemorrhagic Escherichia coli
(EHEC) Infection. In www.uptodate.com. Updated September 21, 2017, accessed December 26, 2017.
Sullivan JL. Clinical Manifestations and Treatment of Epstein-Barr virus infection. In www.uptodate.com.
Updated April 4, 2017. Accessed December 26, 2017.
Organ System: Gastrointestinal/Nutritional
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Hepatic disorders, Acute Hepatitis
226.
Stem: A 35-year-old female immigrant with a history of rheumatic fever
presents to the clinic for a complete physical exam for life insurance. On cardiac exam, a
diastolic rumble murmur with an opening snap is appreciated at the apex of the heart in
the left lateral decubitus position. Which valvular abnormality you would expect to find
on echocardiogram?
Answer choice:
a.
b.
c.
d.
e.
Aortic regurgitation
Aortic stenosis
Mitral regurgitation
Mitral stenosis
Mitral valve prolapse
Answer: The answer is D.
Explanation: The mitral valve is the most commonly affected valve in rheumatic heart disease, although
any valve can be affected. Mitral stenosis (D) causes an opening snap and a diastolic murmur heard best
at the apex of the heart in the left lateral decubitus position.
Aortic regurgitation (A) is incorrect. The murmur of aortic regurgitation is described as a high-pitched,
blowing diastolic murmur heard best at the left sternal border. Aortic stenosis (B), mitral regurgitation
(C), and mitral valve prolapse (E) are all incorrect, because they result is systolic murmurs. The murmur
of aortic stenosis is described as a crescendo-decrescendo systolic murmur at the right sternal border
that radiates to the carotids. Mitral regurgitation results in a high-frequency, blowing holosystolic
murmur best identified at the apex. Mitral valve prolapse results in a mid-systolic click, followed by a
late systolic murmur best identified at the apex.
References:
Bashore TM, Granger CB, Jackson KP, Patel MR. Heart Disease. In: Papadakis MA, McPhee SJ, Rabow
MW, eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168190671. Accessed
January 02, 2018.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Valvular disorders—Mitral
227.
Stem: A 42-year-old female presents with complaints of bilateral milky nipple
discharge for three months duration. She had an unremarkable screening mammogram
six months ago. She has an IUD in place and does not get regular periods, so she is
unable to comment on her menstrual cycle. She does report more frequent headaches.
Pregnancy test is negative and breast exam is normal. What is the most appropriate
laboratory test to order?
Answer choice:
a.
b.
c.
d.
e.
Chemistry panel
Complete blood count
Hepatic function panel
Prolactin level
TSH
Answer: The answer is D.
Explanation: The patient’s symptoms of galactorrhea and headache with unremarkable mammogram
and negative pregnancy test are concerning for prolactinoma. Serum prolactin level (D) would be the
next test to order. CBC (B), chemistry panel (A), and hepatic function panel (C) are clinical tests that are
often ordered but offer no significant value in this case. Although hypothyroidism can cause
galactorrhea, the headaches raise more concern for prolactinoma.
References:
Melmed S, Jameson J. Anterior Pituitary Tumor Syndromes. In: Kasper D, Fauci A, Hauser S, Longo D,
Jameson J, Loscalzo J, eds. Harrison's Principles of Internal Medicine, 19e New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79751591. Accessed
January 31, 2018.
Organ System: Reproductive
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Obstetrics-Gynecology; Internal Medicine; Surgery
Topic(s): Breast disorders, Galactorrhea
228.
Stem: Which of the following is a complication of advanced chronic kidney
disease?
Answer choice:
A. Hypomagnesemia
B. Respiratory alkalosis
C. Hyperkalemia
D. Hypoparathyroidism
E. B12 deficiency
Answer: The answer is C.
Explanation: The kidneys maintain normal potassium serum levels by ensuring the same potassium
intake and potassium excretion. Potassium is filtered by the glomerulus and a majority of it is
reabsorbed in the proximal tubule and loop of Henle. Urinary excretion of potassium begins in the distal
convoluted tubule and is also controlled by the distal nephron and collecting duct. Consequently, loss of
nephron function due to kidney disease results in renal retention of potassium.
References:
Watnick S, Woddell T, Dirkx T. Kidney disease. In: McPhee SJ, Papadakis MA, eds. Current Medical
Diagnosis and Treatment. 57th ed. New York, NY: McGraw-Hill; 2018.
Organ System: Renal
Task Area: Applying Basic Science Concepts
Core Rotation: Internal Medicine, Family Medicine
Topic(s): Chronic Kidney Disease
229.
Stem: A positive predictive value is defined as which one of the following
statements?
Answer Choice:
A. Ability to measure if a test identifies patients without disease
B. Number of patients who need to be treated to prevent one adverse outcome
C. Ability to determine if a difference in outcomes between study groups is by chance
D. Percentage of people with a positive test who have disease
E. Ability of a test to correctly identify patients with disease
Answer: The answer is D.
Explanation: Positive predictive value is defined as the percentage of people with a positive test who
have the disease (D). The ability to measure if a test identifies patients without disease is the definition
of specificity (A). The number of patients who need to be treated to prevent one adverse outcome is the
definition of number needed to treat (NNT) (B). The ability to determine if a difference in outcomes
between study groups is by chance is the definition of p-value (C). The ability of a test to correctly
identify patients with disease is the definition of sensitivity (E).
Reference: Watkins E. Professional Practice for Physician Assistants. Kenmore, NY: RPSS Publishing;
2018.
Organ System:
Task Area: Professional Practice
Core Rotations:
Topic(s): Medical Informatics, Public Health
230.
Stem: Which of the following structures is most commonly adversely affected in
hypertrophic cardiomyopathy?
Answer choice:
a.
b.
c.
d.
e.
Left ventricle
Right ventricle
Interventricular septum
Left atrium
Right atrium
Answer: The answer is A.
Explanation: Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy (A) in
the absence of another systemic or cardiac disease to account for the change. It is caused by a genetic
mutation of the cardiac sarcomere, the basic functional unit of muscle structure. The natural history of
HCM is benign in most patients, but it is also the most common cause of sudden death in young
athletes. Asymmetric septal hypertrophy is most common; however, there is significant heterogeneity in
the pattern of left ventricular hypertrophy.
References:
Baxi A, Restrepo C, Vargas D, et al. Hypertrophic Cardiomyopathy from A to Z: Genetics,
Pathophysiology, Imaging, and Management. RadioGraphics 2016; 36:335–354.
Enriquez A, Goldman M. Management of Hypertrophic Cardiomyopathy. Ann Glob Health. 2014 JanFeb;80(1):35-45.
Organ System: Cardiovascular
Task Area: Applying Basic Science Concepts
Core Rotation: Family Medicine
Topic(s): Cardiomyopathy—Hypertrophic
231.
Stem: The presence of which positive serologic markers would be found in a
patient with a resolved acute HBV infection?
Answer choice:
a.
b.
c.
d.
e.
HBeAg and HBsAg
Anti-HBc IgM and Anti-HAV
Anti-HBc IgG and Anti-HBs
Anti-HBc IgG and HBsAg
Anti-HBc IgM and Anti-HBs
Answer: The answer is C
Explanation: Specific antibody to HBsAg (anti-HBs) appears in most individuals after clearance of HBsAg
and after successful vaccination against hepatitis B. Disappearance of HBsAg and the appearance of antiHBs signal recovery from HBV infection, noninfectivity, and immunity. IgG anti-HBc also appears during
acute hepatitis B but persists indefinitely. It can be found in a patient who has recovered from an acute
HBV infection (along with the appearance of anti-HBs in serum).
References:
Friedman LS. Liver, Biliary Tract, & Pancreas Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018 New York, NY: McGrawHill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=168015083.
Organ System: Gastrointestinal/Nutritional
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine, Family Medicine
Topic(s): Hepatic disorders, Acute/chronic hepatitis
232.
Stem: What is the treatment of choice for patients with acromegaly?
Answer choice:
a.
b.
c.
d.
e.
Pituitary transphenoidal surgery
Stereotactic radiosurgery
Octreotide administration
Corticosteroid administration
Aldosterone administration
Answer: The answer is A
Explanation: Pituitary transsphenoidal microsurgery is the treatment of choice for patients with
acromegaly.
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGrawHill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=167996562.
Organ System: Endocrine
Task Area: Clinical Intervention
Core Rotation: Internal Medicine
Topic(s): Pituitary disorders, Acromegaly
233.
Stem: A 26-year-old female patient presents to clinic today with continued
complaints of cough, dyspnea, and wheezing despite therapy with bronchodilators and
inhaled corticosteroids for the last year. She also reports that she has started to note
some blood in her sputum with coughing in the last 2 months. Her spirometry results
reveal a mild restrictive pattern. You are concerned about her continued symptoms and
order a CT scan of her chest. This reveals a nodule in the left primary bronchus causing a
partial obstruction. Which is the most appropriate next step in this patient’s
management?
Answer choice:
a.
b.
c.
d.
e.
Bronchoscopy with biopsy of bronchial nodule
Reassure patient and recommend watchful waiting x 6 months
Localized radiation therapy of bronchial nodule
Surgical excision of bronchial nodule
Treat with broad spectrum antibiotic and nebulized albuterol
Answer: The answer is A.
Explanation: This patient presents with signs and symptoms that are consistent with a malignancy, and
this presentation is consistent with carcinoid. Most patients who develop carcinoid tumors of the
bronchial airway are under the age of 60, and are the most frequent pulmonary neoplasm during
childhood and puberty. Men and women are affected equally. Common symptoms include cough, focal
wheezing, recurrent respiratory infections, and hemoptysis. Carcinoid syndrome (flushing, diarrhea,
wheezing, hypotension) is rare but can occur due to the neuroendocrine activity in the bronchial
epithelial cells of the originating tumor. These tumors are characterized by slow development and rare
metastasis to other organs. Diagnosis is established by bronchoscopy and biopsy (A). Possible
treatments for clinically symptomatic lesions include electrocautery or surgical excision to relieve
obstruction and possibly further resection depending on size and location of tumor. Most carcinoid
tumors are resistant to chemotherapy and radiation.
References:
Bronchial Carcinoid Tumors. In: Maxine A. Papadakis, et al., eds. Current Medical Diagnosis & Treatment
2018. New York, NY: McGraw-Hill, pp. 293–294.
Organ System: Pulmonary
Task Area: Clinical Intervention
Core Rotation: Family medicine, Internal medicine
Topic(s): Neoplasms, Carcinoid tumors
234.
Stem: A 31-year-old female presents to the urgent care clinic for a sore throat.
You form a differential diagnosis of strep throat, candidiasis, and herpes simplex 1
infection. Upon inspection of the mouth and pharynx, which of the following signs
would most help you rule in candidiasis?
Answer choice:
A.
B.
C.
D.
E.
Erythematous throat, tonsillar exudates, and foul breath
Pink throat, white plaques on the palate and tongue
Dull red throat and gray tonsillar exudates
Red-based, shallow ulcers on the lips and posterior pharynx
Unilateral tonsillar swelling, drooling, and hot potato voice
Answer: The answer is B.
Explanation: Oral candidiasis causes white plaques on mucosa and tongue, which may be removed by
scraping to reveal punctate bleeding beneath (B). Exudates and foul breath are more likely with strep
pharyngitis, gray exudates with diphtheria, shallow ulcers with HSV 1, and unilateral swelling with
tonsillar abscess (A, C, D, and E).
References:
Bickley LS and Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 12th ed. Philadelphia,
PA: Lippincott, Williams & Wilkins; 2016.
Organ System: EENT
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Emergency Medicine, Family Medicine
Topic(s): Oropharyngeal Disorders, Infectious/Inflammatory Disorders, Oral Candidiasis
235.
Stem: A 14-year-old female presents with 2 weeks of spells of barking cough
productive of yellow sputum, occasional post-tussive emesis, and denies fever. She has
no known drug allergies. Which of the following is the most appropriate first line
antibiotic for this patient?
Answer choice:
A.
B.
C.
D.
E.
Azithromycin 500 mg by mouth for one day, then 250 mg by mouth daily for 4 days
Erythromycin 500 mg by mouth four times daily for 14 days
Trimethoprim/sulfamethoxazole 800/160 one tablet by mouth twice daily for 14 days
Amoxicillin 500 mg by mouth twice daily for 10 days
Levofloxacin 750 mg by mouth daily for 5 days
Answer: The answer is A.
Explanation: The patient’s age and the barking nature, 2-week duration, and productivity of cough and
its accompanying emesis correlate with the diagnosis of pertussis. Pertussis is best treated within 3
weeks of cough onset and by use of azithromycin (A). Erythromycin covers it as well but causes GI upset
(E). Trimethoprim/sulfamethoxazole is second line and best reserved for patients with macrolide
intolerance (C). Amoxicillin does not cover pertussis well and levofloxacin is not indicated as first line
treatment for pertussis (D and E).
References:
Centers for Disease Control and Prevention. Recommended antimicrobial agents for the treatment and
postexposure prophylaxis of pertussis: 2005 CDC guidelines. MMWR 2005;54(No. RR-14): 1-13.
Organ System: Pulmonary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Emergency Medicine, Pediatrics
Topic(s): Infectious Disorders—Pertussis
236.
Stem: A young female patient presents to the clinic with her mother. The
mother has concerns about the patient’s episodic uncontrolled ingestion of large
quantities of food followed by strict dieting and vigorous exercise to prevent weight
gain. Which of the following additional findings would be most likely present in this
patient?
Answer Choice:
A.
B.
C.
D.
E.
Physiologic hyperarousal, including startle reactions
Poor dentition
Repetitive actions such as washing the hands many times
Excessive demands for attention
Fear of rejection
Answer: The answer is B.
Explanation: Patients with PTSD can experience physiologic hyperarousal, including startle reactions,
illusions, overgeneralized associations, sleep problems, nightmares, dreams about the precipitating
event, impulsivity, difficulties in concentration, and hyper-alertness. The symptoms may be precipitated
or exacerbated by events that are a reminder of the original traumatic event (A). Bulimia nervosa is the
episodic uncontrolled ingestion of large quantities of food followed by recurrent inappropriate
compensatory behavior to prevent weight gain such as self-induced vomiting, diuretic or cathartic use,
or strict dieting or vigorous exercise. Vomiting can result in poor dentition, pharyngitis, esophagitis,
aspiration, and electrolyte abnormalities (B). Obsessive-compulsive disorder (OCD), classified as an
anxiety disorder in the DSM-IV, now is part of a separate category of obsessive-compulsive disorder and
related disorders in DSM-5. In OCD, the irrational idea or impulse repeatedly and unwantedly intrudes
into awareness. Obsessions (recurring distressing thoughts, such as fear of exposure to germs) and
compulsions (repetitive actions such as washing the hands many times or cognitions such as counting
rituals) are usually recognized by the individual as unwanted or unwarranted and are resisted, but
anxiety often is alleviated only by ritualistic performance of the compulsion or by deliberate
contemplation of the intruding idea or emotion (C). Patients with a narcissistic personality disorder may
exhibit clinical findings of exhibitionism, grandiosity, preoccupation with power, lacking interest in
others, and excessive demands for attention (D). Patients with an avoidant personality disorder may
exhibit clinical findings of fear of rejection, hyperreaction to rejection and failure, poor social endeavors,
and low self-esteem (E).
References: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment
2019. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2449&sectionid=194317615. Accessed
February 12, 2019.
Organ System: Psychiatry/Behavioral
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine, Pediatrics
Topic(s): Feeding and eating disorders, Bulimia Nervosa
237.
Stem: A 55-year-old construction worker is in the office for his annual physical.
He is otherwise healthy. On physical exam, the provider notes dilated, tortuous looking
bluish-green veins in the left leg. He admits that his mother had similar findings on her
legs. Which one of the following is the most common clinical presentation for
varicosities of the leg?
Answer choice:
a.
b.
c.
d.
e.
Aching pain in the leg while standing
Deep vein thrombosis
Skin ulceration
Superficial phlebitis
Worsening of pain with leg raising
Answer: The answer is A
Explanation: The vignette describes a patient with varicose veins, for which the most common
presentation is pain in the legs (A). Pain may be described by the patient as aching or burning. As the
varicosities worsen, it may be only a few minutes of standing before pain is precipitated. Pain is relieved
with elevation of the limb, distinguishing it from peripheral arterial disease. Worsening of pain on leg
raising (E) negates this disease as the cause of leg pain. As the disease progresses, complications can
arise, such as venous eczema, skin pigmentation changes, lipodermatosclerosis, and ulcerations, (B), (C),
and (D).
References:
Banga S, Banga P, and Mungee S. Diseases of the Peripheral Vessels. In: Elmoselhi A. eds. Cardiology: An
Integrated Approach. New York, NY: McGraw-Hill.
Organ System: Cardiovascular
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine
Topic(s): Vascular Disease, Varicose Veins
238.
Stem: A 42-year-old female comes to your office as a new patient. She
complains of stiffness in the morning for several hours and swelling in both of her hands
intermittently over the past year. Furthermore, she notes feeling more tired recently.
What is the most appropriate first line treatment to prevent progression of the patient’s
disease?
<CATCH: Insert Photo G>
<CATCH: Insert credit line underneath the photo: Reproduced with permission from JE South-Paul, SC
Matheny, EL Lewis: CURRENT Diagnosis & Treatmnent: Family Medicine, 4th ed, www.
Accessmedicine.com. Copright © McGraw-Hill Education. All rights reserved. Figure 24-4>
Answer choice:
A.
B.
C.
D.
E.
Methotrexate
Prednisone
Naprosyn
Indomethacin
Colchicine
Answer: The answer is A.
Explanation: Treatment of rheumatoid arthritis involves disease modifying anti-rheumatic drugs
(DMARDs) such as methotrexate (A). DMARDs are used with the purpose of slowing disease progression
and preventing severe joint deformities and other manifestations of rheumatoid arthritis. DMARDs are
the first line therapy for patients with newly diagnosed rheumatoid arthritis. Prednisone, naprosyn, and
indomethacin may be used in the treatment of rheumatoid arthritis for their anti-inflammatory effects
and pain relief, but they do not modify the disease progression or result in a remission (B, C, and D).
Colchicine is used in the treatment of gout.
References:
Johnson BE. Arthritis: Osteoarthritis, Gout, & Rheumatoid Arthritis. In: South-Paul JE, Matheny SC, Lewis
EL, eds. CURRENT Diagnosis & Treatment: Family Medicine. 4th ed. New York, NY: McGraw-Hill; 2015.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1415&sectionid=77056695. Accessed
September 04, 2018.
Organ System: Musculoskeletal
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal medicine
Topic(s): Rheumatoid Arthritis Treatment
239.
Stem: An 85-year-old female presents to her family practice provider with a
mass on her anterior neck that has rapidly enlarged over the past three weeks. She has
also noticed changes in her voice for the past week. On physical exam, she was noted to
have a large thyroid mass that is firm and fixed, with associated cervical and
supraclavicular lymphadenopathy. What form of cancer would most most likely be
found on a fine needle aspiration biopsy of the mass?
Answer choice:
a. Papillary
b.
c.
d.
e.
Follicular
Anaplastic
Medullary
Adenoma
Answer: The answer is C
Explanation: Anaplastic thyroid cancer usually presents in an older patient as a rapidly enlarging mass in
a goiter associated with dysphagia or vocal cord paralysis. It also metastasizes early to surrounding
nodes. Other choices do not develop in the manner when compared to anaplastic carcinoma.
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGrawHill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=167996562.
Organ System: Endocrine
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Neoplasms, Neoplastic syndrome
240.
Stem: A 69-year-old female presents with a complaint of constipation. She
states she has increased her fiber and started taking over-the-counter stool softeners
and has not had a bowel movement in 4 days. She states that this morning she noted
the abdominal discomfort she had been having has progressed to bilateral lower
quadrant pain, and she now has nausea and vomiting. Her past medical history is
consistent with uterine cancer, for which she had a hysterectomy 8 months ago, and is
now undergoing chemotherapy. She also has diabetes, for which she takes metformin.
Her vital signs are as follows: BP: 135/68, Temp: 99.8 °F, Pulse: 101 BPM, Pulse Ox: 97%
on ambient air.
On physical exam, you note an overweight woman in no acute distress. Her GI exam
demonstrates a distended abdomen with hypoactive verses absent bowel sounds to all
quadrants, noted tympany on percussion, and tenderness to palpation. The remainder of
her exam is noncontributory. Which of the following diagnostic evaluations are not likely to
yield a diagnosis of colonic bowel obstruction in this patient?
Answer choice:
a. High Resolution CT scan
b. A flat and upright abdominal x-ray
c. A CT scan of the abdomen with IV contrast
d. A CT scan of the abdomen without contrast
e. A CT scan of the abdomen with oral and IV contrast
Answer: The answer is A.
Explanation: The patient has a colonic obstruction secondary to her history of cancer, chemotherapy,
and abdominal surgery. The diagnostic study of choice is CT scan with or without contrast (C), (D), (E). A
rapid assessment can be done with an abdominal x-ray (B) in the ER. A high resolution CT scan (A) is
used to evaluate lung abnormalities.
References:
Price TG, Orthober RJ. Bowel Obstruction. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM,
Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e.
New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109430820.
Accessed December 20, 2017.
Organ System: Gastrointestinal
Task Area: Using Laboratory and Diagnostic Studies
Core Rotation: Internal Medicine, Surgery
Topic(s): Small intestine disorders, Obstruction
241.
Stem: In which of the following settings could the use of an ACE inhibitor be
contraindicated?
Answer choice:
A.
B.
C.
D.
E.
Diabetic nephropathy
Hypertensive nephrosclerosis
Hypokalemia
Polycystic kidney disease
Significant renal artery stenosis
Answer: The answer is E.
Explanation: ACE inhibition is a great method of treating hypertension. ACE inhibitors cause systemic
vasodilation, and thus lower systemic blood pressure, via the inhibition of the enzyme angiotensin II.
ACE inhibitor-induced acute kidney injury occurs in settings where glomerular afferent arteriolar blood
flow is reduced, and glomerular filtration is dependent on efferent arteriolar vasoconstriction, which is
inhibited by the use of ACE inhibitors. In patients with bilateral renal artery stenosis, it is usually
impossible to use ACE inhibitor therapy without an unacceptable loss of renal function (greater than
30% from baseline). Therefore, it should be avoided as an option of antihypertensive treatment in
patients with significant renal artery stenosis (E).
References:
Benowitz NL. Antihypertensive agents. In: Katzung BG, Masters SB, Trevor AJ, eds. Basic and Clinical
Pharmacology. 11th ed. New York, NY: McGraw-Hill Medical; 2009.
Organ System: Cardiovascular
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Hypertension
242.
Stem: The initial sign of chronic kidney disease (CKD) is which of the following?
Answer choice:
A.
B.
C.
D.
E.
Albuminuria
Hypertension
Microscopic hematuria
Hyperphosphatemia
Hyperkalemia
Answer: The answer is A.
Explanation: Albuminuria is pathognomonic of kidney damage (A). The international chronic kidney
disease guidelines, Kidney Disease Improving Global Outcomes (KDIGO), state regarding the definition
and classification of CKD, that albuminuria is the most predictive risk factor for the loss of kidney
function. Studies of CKD progression have shown repeated relationships with albuminuria and
progression of kidney disease. Serum creatinine can be affected by outside and/or laboratory factors
and is less predictive. Albuminuria is the earliest marker of glomerular disease.
References:
Kidney Disease: Improving Global Outcomes (KDIGO), CKD-MBD Work Group. KDIGO 2012 clinical
practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl.
2013;3:1–150. http://www.kdigo.org/ clinical_practice_guidelines/pdf/KDIGO%20AKI%20 Guideline.pdf.
Accessed January 23, 2018.
Organ System: Renal
Task Area: Applying Basic Scientific Concepts
Core Rotation: Internal Medicine, Family Medicine
Topic(s): Chronic Kidney Disease
243.
Stem: A 22-year-old known drug abuser presents to the ED with complaints of
fever and shaking chills for the past 3 days. His past medical history is unremarkable. On
physical exam, his temperature is 39.5 °C. HEENT exam is unremarkable. Lungs are clear
to auscultation. Cardiac exam reveals a new 3/6 systolic heart murmur best heard at the
2nd intercostal space, right sternal border. Skin exam is positive for track marks on the
forearms bilaterally and petechiae beneath the fingernails. His labs show a leukocytosis.
Blood cultures are pending. Which of the following is the most likely causative organism
of this illness?
Answer choice:
a.
b.
c.
d.
e.
Enterococcus faecalis
Haemophilus influenza
Staphylococcus aureus
Streptococcal pneumoniae
Streptococcus viridans
Answer: The answer is C
Explanation: S. aureus (C) is the most common cause of endocarditis in the developed world (33% of
cases). Major risk factors for S. aureus infection include intravenous drug injections. Endocarditis
involving streptococci accounts for 20%, but S. pneumoniae (D) is rarely associated with endocarditis. S.
viridans (E) tends to present as a more subacute endocarditis. Enterococcal endocarditis (A) accounts for
only 10% of endocarditis cases and is more commonly linked to procedures manipulating the urinary
and gut sources. It can be seen in IV drug use, but not as commonly as S. aureus. The gram-negative
HACEK organisms, which include the haemophilus species (B), account for only 5% of endocarditis cases
and usually cause subacute endocarditis.
References:s
Crawford, MH, and Doernberg, S. Infective Endocarditis. In: Crawford, MH. ed. CURRENT Diagnosis &
Treatment: Cardiology, 5th Ed. New York, NY: McGraw-Hill.
Organ System: Cardiovascular
Task Area: Applying Basic Science Concepts
Core Rotation: Internal Medicine
Topic(s): Traumatic, infectious, and inflammatory heart conditions, Acute endocarditis
244.
Stem: A 38-year-old, otherwise healthy African American female presents to the
office with a 6-week history of dry cough and fatigue. She denies any recent upper
respiratory tract infection associated with the cough. She has also noticed small bumps
on her lower legs that began appearing over the past 2 weeks. As part of her work-up, a
PPD was placed and a chest x-ray was ordered. The PPD was negative and the chest xray was positive for bilateral hilar adenopathy. Which of the following is the most likely
diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Coccidiomycosis
Idiopathic pulmonary fibrosis
Pneumocystis pneumonia
Sarcoidosis
Tuberculosis
Answer: The answer is D
Explanation: Sarcoidosis (D) is an inflammatory disease characterized by noncaseating granulomas. The
disease can be multi-system. Findings of granulomas is not specific for sarcoidosis; other conditions such
as TB (E) need to be ruled out. Sarcoidosis often occurs in young, healthy adults and is commonly
reported in African Americans, with women being slightly more susceptible than men. Cough and
dyspnea are the most common presenting symptoms. Nonspecific symptoms of fatigue, fever, and night
sweats are also seen. PA chest x-ray often shows bilateral hilar adenopathy in early disease, stage 1. Skin
lesions such as erythema nodosum can be found in those with skin involvement.
References:
Baughman RP. Lower EE. Sarcoidosis. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, and Loscalzo
J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill.
Organ System: Pulmonary
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Restrictive Pulmonary Disease—Sarcoidosis
245.
Stem: A 38-year-old female presents with complaints of progressive fatigue.
Medical history is significant for recent childbirth and post-partum obesity. The patient
states she has not been eating a balanced diet, and does not take multivitamins or any
other medications. She also admits to heavy alcohol use to cope with her stressors. You
decide to order labs and find that she has the following:
CBC smear: low hemoglobin, low hematocrit, elevated MCV, normal platelets and white
blood cells
TSH: normal
Basic chemistry panel: normal
Serum B-12: low normal
RBC Folate: low
To distinguish folate deficiency from vitamin B deficiency, which lab(s) should be ordered?
Answer choice:
A.
B.
C.
D.
E.
Autoantibodies to intrinsic factor
Hemoglobin A1c
Homocysteine
Homocysteine and methylmalonic acid
Methylmalonic acid
Answer: The answer is D.
Explanation: Folate deficiency usually results from nutritional deficiencies, poor absorption, or
medications. Clinically it may be difficult to distinguish vitamin B12 deficiencies from folate deficiencies,
but when one or both levels are borderline, both methylmalonic acid (MMA) and homocysteine levels
should be tested. In folate deficiency anemia, the MMA is usually normal and the homocysteine level is
elevated (D). In vitamin B12 deficiencies, both the MMA and homocysteine levels are elevated. If the
MMA and homocysteine levels were both normal it would exclude both vitamin B12 and folate
deficiencies (C and E). Autoantibodies to intrinsic factor is used to identify pernicious anemia, which
leads to impaired vitamin B12 and subsequent deficiency (A). Hemoglobin A1c is a test used to reflect
glycemia over the preceding 8 to 12 weeks, to assess glucose control in the diabetic (B).
References:
Schrier SL. Clinical manifestations and diagnosis of vitamin B12 and folate deficiency. In: UpToDate.
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-vitamin-b12-and-folatedeficiency?search=folate%20deficiency%20anemia&sectionRank=1&usage_type=default&anchor=H135
9778670&source=machineLearning&selectedTitle=1~150&display_rank=1#H2329087791. Accessed
June 28, 2017.
Masharani U. Diabetes Mellitus and Hypoglycemia. In: Papadakis M & McPhee S, eds. Current Medical
Diagnosis & Treatment 2018.
http://accessmedicine.mhmedical.com.proxy.westernu.edu/content.aspx?bookid=2192&sectionid=167
998145.
Organ System: Hematologic
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Anemias, Folate Deficiency
246.
Stem: A 67-year-old, retired male complains of recent onset of unexplained
nonproductive cough and increasing dyspnea. After historical review, he was noted to
have a 15-pack a year history of smoking cigarettes, a past occupational history of
sandblasting, and rheumatoid arthritis. Initial high-resolution CT imaging reveals diffuse
ground-glass opacities, consolidation, and a "crazy paving" pattern with interlobar lines
and septal thickening. You are concerned about interstitial lung disease and the
increased risk for developing which associated sequelae?
Answer choice:
A.
B.
C.
D.
E.
Asbestosis
Berylliosis
Chronic bronchitis
Malignant mesothelioma
Tuberculosis
Answer: The answer is E.
Explanation: This scenario is most consistent with silicosis, a type of pneumoconiosis that presents with
delayed features of interstitial/restrictive lung disease, resulting from exposure to crystalline silica, often
seen in those with occupational exposures from mining, quarrying, drilling and sandblasting. This
condition is often associated with other autoimmune disorders and has up to a 25% risk of developing
tuberculosis—thought to be a result of a weakened immune system and increased susceptibility to
mycobacteria (E). Asbestosis commonly has pleural plaques on imaging and berylliosis comes from
manufacturing exposures (i.e. aerospace, nuclear, dental, computer industries) and radiographically
presents as a noncaseating granulomatous lung disease (A and B). Chronic bronchitis would feature a
productive cough and its clinical picture is consistent with obstructive lung disease (C). Malignant
mesothelioma is an associated malignancy that results from asbestosis exposure, not silicosis (D).
References:
Stark P. Imaging of Occupational Lung Diseases. In: UpToDate.
https://www.uptodate.com/contents/imaging-of-occupational-lungdiseases?search=pneumoconiosis&source=search_result&selectedTitle=1~117&usage_type=default&dis
play_rank=1. Accessed September 18, 2017.
Organ System: Pulmonary
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Internal Medicine
Topic(s): Restrictive Pulmonary Disease, Pneumoconiosis
247.
Stem: A 40-year-old female is incidentally found to have a 1.5 cm, irregular,
solid thyroid nodule during a carotid ultrasound exam. A thyroid function panel was
ordered and results were all within normal limits. What would be the appropriate next
step in the evaluation of this nodule?
Answer choice:
a.
b.
c.
d.
e.
CT scan of head and neck with contrast
MRI of head and neck without contrast
PET scan of whole body
Fine needle aspiration biopsy of the nodule
Radioactive iodine uptake scan
Answer: The answer is D
Explanation: For solitary thyroid nodules, fine needle aspiration biopsy is indicated for nodules larger
than 0.5 cm diameter with a suspicious appearance on ultrasound. The nodule in this scenario is
suspicious because it is both solid and irregularly shaped. Radiologic testing (A, B, C, E) all would not
yield enough information to make a definitive diagnosis.
References:
Fitzgerald PA. Endocrine Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds.Current Medical
Diagnosis & Treatment 2018 New York, NY: McGrawHill. http://accessmedicine.mhmedical.com.libproxy.uthscsa.edu/content.aspx?bookid=2192&sectionid
=167996562.
Organ System: Endocrine
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Neoplasms, Neoplastic syndrome
248.
Stem: A 59-year-old male with a long-term history of chronic nonproductive
cough, dyspnea, periodic facial flushing, and more recently hemoptysis presents for an
evaluation. His past medical history is significant for recurrent pneumonia and negative
for smoking. His vital signs are BP 100/62, Pulse 92, Temperature 98.9, Respirations 18,
and O2 sat 96%. His physical exam is positive for a focal wheeze over the mediastinum
and negative for cyanosis, skin lesions, abdominal pain, or peripheral edema. CT scan
revealed an ill-defined lesion warranting endoscopic evaluation. Bronchoscopy reveals a
pink, well-vascularized sessile growth in the central airway. This scenario is most
consistent with which finding?
Answer choice:
A. Adenocarcinoma
B. Bronchial carcinoid tumor
C. Hamartoma
D. Lung abscess
E. Ranke complex
Answer: The answer is B.
Explanation: Adenocarcinoma is a form of cancer that is an appropriate differential diagnosis, but it
usually results from cigarette smoking (A). The median age of adenocarcinoma is also typically higher (70
years). Presenting symptoms are usually anorexia, weight loss, or asthenia. Hamartomas are benign
lesions that have minimal malignant potential and are mostly asymptomatic (C). They usually present as
a well-defined mass with a pattern of popcorn calcification on radiography. Lung abscess may present
with associated hemoptysis, but typically presents with acute findings, such as fever, productive cough
with foul-smelling sputum, and weight loss (D). Ranke complex is a calcified granulomatous lesion
resulting from prior tuberculosis infection and ipsilateral hilar lymph node (E).
References:
Chesnutt MS, Prendergast TJ. Pulmonary Disorders. In: Papadakis M & McPhee S, eds. Current Medical
Diagnosis & Treatment 2017. San Francisco, CA: McGraw-Hill Education; 2017:288.
Organ System: Pulmonary
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Surgery, Internal Medicine
Topic(s): Neoplasms, Carcinoid Tumors
249.
Stem: A patient presents with a chief complaint of cough, described as a
productive quality for a duration of 5 days and getting worse. He has tried menthol
cough drops with no relief and has the associated symptoms of congestion and
lymphadenopathy. He denies chest pain, shortness of breath, fever, fatigue, and emesis
on review of systems. He states a past history of asthma. Which of the following would
be the most appropriate evaluation and management level for this history based solely
on this information?
Answer Choice:
A.
B.
C.
D.
E.
Problem-focused
Expanded problem-focused
Detailed
Comprehensive
High complexity
Answer: The answer is C.
Explanation: When determining the level of evaluation and management (E/M) for history, the
following components are considered: chief complaint (CC), history of present illness (HPI), review of
systems (ROS), and past, family, and social history (PFSH). The CC is required for all levels. The HPI
includes eight elements: location, quality, severity, duration, timing, context, modifying factors, and
associated signs/symptoms. The ROS includes fourteen systems: constitutional, eyes,
ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal,
integumentary (which includes the breast), neurologic, psychiatric, endocrine, hematologic/lymphatic,
and allergic/immunologic. Medical necessity, as deemed by the treating provider in light of the patient’s
current or previous conditions, determines the number of systems required for review. For PFSH, the
past history includes documentation of previous illnesses, hospitalizations, surgeries, medications,
allergies, and immunizations. The family history provides information regarding potential hereditary
illnesses. The social history may list details of the patient’s substance use (tobacco/alcohol/illicit drugs),
sexual history, employment status, level of education, marital status, or living arrangements. Problemfocused levels include HPI: brief (≤3), ROS: none, and PFSH: none (A). Expanded problem-focused levels
include HPI: brief (≤3), ROS: problem pertinent (1), and PFSH: none (B). Detailed levels include HPI:
extended (≥4), ROS: extended (2-9), and PFSH: pertinent (1) (C). Comprehensive levels include HPI:
extended (≥4), ROS: complete (≥10), and PFSH: complete (2 or 3) (D). High complexity is only associated
with medical decision-making levels (E).
References: Pohlig C, Manaker S. Professional Coding and Billing Guidelines for Clinical
Documentation. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB, eds. Principles and Practice of
Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1872&sectionid=137531571. Accessed
February 12, 2019.
Organ System:
Task Area: Professional Practice
Core Rotation: Family Medicine, Internal Medicine, Pediatrics
Topic(s): Medical Informatics, Infectious Disorders, Acute Bronchitis
250.
Stem: Which of the following is the most common histologic type of cancer of
the ovary?
Answer choice:
a.
b.
c.
d.
e.
Epithelial cell
Germ cell
Stromal cell
Granulosa-theca cell
Sertoli-Leydig cell
Answer: The answer is A
Explanation: Epithelial carcinoma is the most common histologic type of cancer of the ovary. It accounts
for 90% of all cancers at the ovary, fallopian tube, and peritoneum. Germ and stromal cell have a lower
incidence. Granulosa-theca and Sertoli-Leydig cells are distractors since they are actually types of benign
stromal cell neoplasms.
References:
Chen L, Berek JS. Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and
diagnosis. In: UpToDate, Goff B, Dizon DS, Falk SJ. (Eds.), UpToDate, Waltham, MA. Available at
http://www.uptodate.com (Accessed on December 1, 2017.)
Zerden, M. Ovarian and adnexal disease. In: Link FW, Carson SA, Flower WC, Snyder RR., eds. Step-Up to
Obstetrics and Gynecology. Philadelphia, PA: Wolters Kluwer Health; 2015: 357-366.
Organ System: Reproductive
Task Area: Applying Basic Science Concepts
Core Rotation: Obstetrics-Gynecology
Topic(s): Neoplasms of the breast and reproductive tract
251.
Stem: A 21-year-old, otherwise healthy college student comes to clinic with 4
days of productive cough, with rust-colored sputum, fever, chills, and headache. Vital
signs are as follows: BP 122/78, P 101, RR 24, SpO2 96%, Temp 101.3 °F. Chest
auscultation reveals diminished breath sounds in the right lower lobe. CXR is ordered,
and reveals a consolidation in the right lower lobe. Of the following, which is the most
likely causative agent of the patient’s illness?
Answer choice:
a.
b.
c.
d.
e.
Streptococcus pneumoniae
Staphylococcus aureus
Klebsiella pneumoniae
Pseudomonas aeruginosa
Mycoplasma pneumoniae
Answer: The answer is A.
Explanation: Streptococcus pneumoniae (A) is the most common bacterial cause of pneumonia in all age
groups except newborn infants. The most common presenting symptoms is productive cough, usually
with a rust-colored tinge. Other common pathogens include Staphylococcus aureus, Haemophilus
influenzae, Enterobacteriaceae, Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila
pneumoniae. Sputum color with these pathogens can range from green if Pseudomonas and
Haemophilus species are present, to red currant-jelly color if Klebsiella species is the causative agent.
References:
Amin AN, Cerceo EA, Deitelzweig SB, et al. The hospitalist perspective on treatment of communityacquired bacterial pneumonia. Postgrad Med. 2014 Mar;126(2):18-29.
Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired
pneumonia. A meta-analysis. JAMA. 1996;275(2):134-41.
Organ System: Pulmonary
Task Area: Applying Basic Science Concepts
Core Rotation: Family Medicine
Topic(s): Infectious Disorders, Bacterial Pneumonia
252.
Stem: A 25-year-old, otherwise healthy woman comes to clinic with a complaint
of cough, mild sputum, runny nose, low-grade fever, chills, and fatigue for the past 3
days. Vital signs are as follows: BP 123/78, P 90, R 12, SpO2 97%, Temp 99.2 °F. Physical
examination reveals a tired-appearing female, with red, runny nose and intermittent
cough. Lungs are clear to auscultation bilaterally. What is the most appropriate
treatment for this patient?
Answer choice:
a.
b.
c.
d.
e.
Supportive care
7-day course of oral antibiotics
14-day course of oral antibiotics
Oseltamavir (Tamiflu®)
Zanamivir (Relenza®)
Answer: The answer is A.
Explanation: Bronchitis occurs when the airways of the lungs swell and produce mucus, leading to
cough. Acute bronchitis is the most common type of bronchitis. Symptoms usually last less than 3
weeks. The cause of acute bronchitis is most often viral, so there is typically no role for antibiotics (B, C)
in the management of symptoms. The condition usually resolves on its own. Supportive care (A) with
rest, fluids, and over-the-counter cough medications are recommended. Acetaminophen can be used to
treat fever. There is no role for flu medications (D, E) in the management of acute bronchitis.
References:
Harris AM, Hicks LA, Qaseem A. High Value Care Task Force of the American College of Physicians and
for the Centers for Disease Control and Prevention. Appropriate Antibiotic Use for Acute Respiratory
Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the
Centers for Disease Control and Prevention. Ann Intern Med. 2016 Mar 15;164(6):425-34.
Organ System: Pulmonary
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine
Topic(s): Infectious Disorders, Acute Bronchitis
253.
Stem: A 33-year-old male with a history of ulcerative colitis comes to clinic with
a complaint of fever, anorexia, malaise, and abdominal pain for the past 24 hours. Vital
signs are as follows: BP 99/70, Pulse 120, Respirations 18/minute, SpO2 98%, Temp
101.2 °F. Physical examination reveals a lethargic-appearing male with distended
abdomen. Labs are pending. Of the following, what is the most appropriate next step in
evaluation of the patient?
Answer choice:
a.
b.
c.
d.
e.
Colonoscopy
Flexible sigmoidoscopy
Barium enema
Gastrograffin enema
Abdominal radiograph
Answer: The answer is E.
Explanation: The patient presents with signs of systemic toxicity in the setting of ulcerative colitis and a
large, distended abdomen, making toxic megacolon high on the differential. Plain abdominal
radiographs (E) are essential for the diagnosis of toxic megacolon, and can be repeated as necessary to
follow the progress or resolution of the disease after treatment has been instituted. The most common
radiographic findings in toxic megacolon include transverse colon dilation >6 cm and loss of colonic
haustrations. Free air would indicate perforation. If the diagnosis of toxic megacolon is in doubt and the
patient is otherwise stable, colonoscopy (A, B) may be attempted. Given the high risk of perforation,
however, colonoscopy should only be attempted if the patient has no or minimal inflammation in the
rectum and sigmoid colon. Enemas (C, D) are not used in acute management of toxic megacolon.
References:
Autenrieth D, Baumgart D. Toxic megacolon. Inflamm Bowel Dis. 2012 Mar;18(3):584-91.
Organ System: Gastrointestinal/Nutritional
Task Area: Clinical Intervention
Core Rotation: Internal Medicine
Topic(s): Colorectal disorders, Toxic Megacolon
254.
Stem: A 43-year-old female comes to clinic for her annual physical. In taking her
history, you find that she has experienced modest weight gain and stretch marks around
her midsection, fatigue, proximal muscle weakness, irritability, and abnormal periods.
She has also developed facial hair, and is quite bothered by this. Your examination of
the patient reveals truncal obesity with striae, facial hirsutism and hypertension. You
order bloodwork, and it is notable for hyperglycemia and hypokalemia. What is the gold
standard test for diagnosing this patient’s condition?
Answer choice:
a.
b.
c.
d.
e.
Overnight dexamethasone suppression test
24-hour urine cortisol excretion
CRH (corticotropin-releasing hormone) stimulation
Late-night salivary cortisol concentration
Random serum cortisol level
Answer: The answer is B.
Explanation: Cushing syndrome is a complex metabolic disorder that results from excess glucocorticoids,
from either exogenous (eg, medications) or endogenous (eg, excess production of cortisol by the
adrenal glands) sources. The measurement of 24-hour urine cortisol excretion (B) is the gold-standard
test for diagnosing Cushing’s syndrome, because it provides an estimate of cortisol production, which is
a central feature of Cushing’s syndrome. A 3-fold to 4-fold increase over normal values is diagnostic of
Cushing’s syndrome; if this increase is present, no additional testing is required to confirm the diagnosis.
For less dramatic increases in the urinary free-cortisol level, another diagnostic approach for
hypercortisolism, such as the overnight dexamethasone suppression test (A) or the measurement of
late-night salivary cortisol concentration (D), is required.
References:
Bansal V, El Asmar N, et al. Pitfalls in the diagnosis and management of Cushing’s syndrome. Neurosurg
Focus. 2015 Feb;38(2):E4.
Organ System: Endocrine
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Adrenal disorders, Cushing’s Syndrome
255.
Stem: Following a long weekend of swimming with friends, an otherwise
healthy 21-year-old female comes to clinic with a complaint of right ear pain and
discharge. She denies any constitutional symptoms at present. Physical examination
reveals edema and erythema of the auditory canal, as well as tenderness with
manipulation of the tragus. Which of the following is the most common causative agent
of this condition?
Answer choice:
a.
b.
c.
d.
e.
Staphylococcus aureus
Pseudomonas aeruginosa
Escheria coli
Candida albicans
Aspergillus
Answer: The answer is B.
Explanation: Otitis externa (OE), also called swimmer’s ear, is an infection of the external auditory canal,
the auricle, or both. Common risk factors include high humidity, retained water in the auditory canal,
and local trauma. OE tends to occur more often in the summer months, when swimming is more
common. The most common signs and symptoms of OE are ear pain, pruritus, discharge, and hearing
impairment. Tenderness when pressure is applied to the tragus or when the auricle is pulled are
indicative of OE. While all of the causative agents listed among the possible answer choices can cause
OE, P. aeruginosa (B) is the most common. Treatment should include pain management, removal of
debris from the external auditory canal, administration of topical medications to control inflammation
and infection, and avoidance of contributing factors. In some situations, canal swelling may inhibit
proper treatment and supply of topical medications to penetrate. In these instances, insertion of an ear
wick to keep the canal patent is warranted.
References:
Rosenfeld RM, Schwartz SR, Cannon CR. Clinical practice guideline: acute otitis externa. Otolaryngol
Head Neck Surg. 2014; 150(1 Suppl):S1-S24.
Schaffer P, Baugh R. Acute Otitis Externa: An Update. Am Fam Physician. 2012; 86(11):1055-61.
Organ System: EENT
Task Area: Applying Basic Science Concepts
Core Rotation: Family Medicine
Topic(s): Ear Disorders, External ear, Otitis Externa
256.
Stem: An otherwise healthy 55-year-old female presents with a complaint of
intermittently itchy perianal skin for the last few months. She attributed the discomfort
to hemorrhoids, and so did not seek medical attention initially. However, while
showering a few days ago, she noticed several small bumps on the affected skin. There
has been no bleeding or other discharge. She is otherwise in good health. Physical
examination of the perianal skin reveals:
<CATCH: Insert Photo H>
<CATCH: Insert credit line underneath the photo: Reprinted with permission from Priscilla
Marsicovetere>
Which of the following is the causative agent of this condition?
Answer choice:
a.
b.
c.
d.
e.
Human immunodeficiency virus
Herpes simplex virus
Cytomegalovirus
Human papillomavirus
Human parvovirus
Answer: The answer is D.
Explanation: Anal condyloma acuminatum (also known as anal warts) is caused by the human
papillomavirus (HPV), (D), and is the most common sexually transmitted infection in the United States. It
affects the mucosa and skin of the anorectum and genitalia. There are more than 100 HPV types, with
HPV-6, 10, and 11 predominately found in the anogenital region and causing approximately 90% of
genital warts. Risk factors include multiple sex partners, anal intercourse, and immunosuppression. The
virus may remain latent for months to years. Patients may be asymptomatic or present with presence of
painless bumps, itching, and discharge or bleeding. Diagnosis is made clinically or by detection of HPV
DNA.
References:
McCutcheon T. Anal condyloma acuminatum. Gastroenterol Nurs. 2009 Sep-Oct;32(5):342-9.
Organ System: Dermatologic
Task Area: Applying Basic Science Concepts
Core Rotation: Family Medicine
Topic(s): Infectious disease, Condyloma Acuminatum
257.
Stem: A current or prior diagnosis of which of the following conditions is most
strongly associated with developing giant cell arteritis?
Answer choice:
a.
b.
c.
d.
e.
Atherosclerosis
Polymyalgia rheumatica
Migraine headache
Lymphoma
Herpes zoster
Answer: The answer is B.
Explanation: Giant cell arteritis (GCA), also known as temporal arteritis, is a systemic inflammatory
vasculitis that can result in a wide variety of systemic, neurologic, and ophthalmic complications. It is the
most common form of systemic vasculitis in adults. The precise etiology is unknown. GCA typically
involves medium and small arteries, especially the superficial temporal arteries. Common signs and
symptoms include visual disturbances, headache, jaw claudication, neck pain, and scalp tenderness. The
gold standard for diagnosis is a temporal artery biopsy. GCA and polymyalgia rheumatica (B) frequently
occur together—up to 26% of cases of PMR also involve GCA, and up to 53% of GCA involve PMR.
References:
Caylor T, Perkins A. Recognition and Management of Polymyalgia Rheumatica and Giant Cell Arteritis.
Am Fam Physician. 2013;88(10):676-684.
Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. Lancet. 2008;
372(9634):234-45.
Organ System: Cardiovascular
Task Area: Applying Basic Science Concepts
Core Rotation: Family Medicine
Topic(s): Vascular Disease, Giant Cell Arteritis
258.
Stem: You are seeing a 4-year-old male patient in the pediatric office. This is his
third visit in six weeks for a persistent cough. Mom reports that the cough is dry and
non-productive but frequent. His teacher has sent a note home complaining that it
often disrupts his pre-school classroom. On his first visit, the diagnosis of asthma was
made and he was prescribed nebulized albuterol without any benefit. On the second
visit, inhaled corticosteroid was added to the regimen and mom reports no change in his
symptoms. Which of the following patient history/physical exam findings would lead
you to consider foreign body aspiration as a possible cause for his symptoms?
Answer choice:
a.
b.
c.
d.
e.
Nasal congestion
Nocturnal cough
Unilateral wheezing
Wheezing after eating
Weight loss
Answer: The answer is C.
Explanation: Unilateral wheezing (C) suggests the possibility of a foreign body in a main stem bronchus.
Nasal congestion (A) suggests an infectious cause. Nocturnal cough (B) suggests asthma. Wheezing after
eating (D) suggests gastro-esophageal reflux disorder. Weight loss (E) suggests cystic fibrosis.
References:
Lucia D, Glenn J. Pediatric Emergencies. In: Stone C, Humphries RL, eds. CURRENT Diagnosis &
Treatment: Emergency Medicine, 8e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165071200. Accessed
January 31, 2018.
Shefrin A, Busuttil A, Zemek R. Wheezing in Infants and Children. In: Tintinalli JE, Stapczynski J, Ma O,
Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,
8e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109406796. Accessed
January 31, 2018.
Organ System: Pulmonary
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Pediatrics
Topic(s): Other Pulmonary Disorders, Foreign Body Aspiration
259.
Stem: You are evaluating a 63-year-old male for persistent left-sided lower back
pain with radiation down his left leg. He has had no change in the level of his pain with
conservative treatment, which includes NSAIDs and physical therapy, so an MRI of the
L/S spine is ordered. MRI reveals a solid hypodense lesion in the right kidney, which is
later proven to be renal cell carcinoma by CT guided biopsy. Given this clinical scenario,
which of the following is the most significant risk factor for development of this
carcinoma?
Answer choice:
a.
b.
c.
d.
e.
History of bladder carcinoma
History of cystic kidney disease
History of nephritis
History of nephrolithiasis
History of pyelonephritis
Answer: The answer is B.
Explanation: Smoking, obesity, HTN, acquired cystic kidney disease (B), and family history of renal cell
carcinoma are risk factors for development of renal cell carcinoma. Most renal cell carcinomas are
incidental findings, as this one was. Bladder carcinoma (A), nephritis (C), nephrolithiasis (D), and
pyelonephritis (E) are all part of the differential diagnosis of a renal mass, but are not risk factors for
renal call carcinoma.
References:
Cooper CS, Joudi FN, Katz MH. Urology. In: Doherty GM, eds. CURRENT Diagnosis & Treatment: Surgery,
14e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1202&sectionid=71525716. Accessed
January 31, 2018.
Cornett PA, Dea TO. Cancer. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis
& Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168004201. Accessed
January 31, 2018.
Organ System: Renal
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine; Internal Medicine; Surgery
Topic(s): Neoplasms, Renal Cell Carcinoma
260.
Stem: A 15-year-old boy suffered a mild head injury during a rugby match 3
months ago. He presents to the primary care office today for a follow-up. At today’s
visit, he reports persistent generalized headaches, insomnia, and difficulty concentrating
in school. He is still interested in sports but feels like his fatigue interferes with his ability
to participate. Physical exam is unremarkable. What is the most likely diagnosis?
Answer Choice:
A.
B.
C.
D.
E.
Attention-deficit disorder
Depression
Post-concussive syndrome
Substance abuse
Myopia
Answer: The answer is C.
Explanation: Postconcussive syndrome is characterized by the presence of headache, fatigue, and poor
concentration that persist for three months or longer after a mild traumatic brain injury (C). Attention
deficit disorder may also present with difficulty concentrating as a chief complaint, but the symptoms
are often evident earlier in childhood (A). Because this is classified as a neurodevelopmental disorder, a
traumatic brain injury is not an etiologic requirement. Patients with depression also have abnormal
sleep patterns and poor concentration (B). This diagnosis is less likely because a common complaint of
patients is anhedonia. This patient reports the desire to participate in activities, which makes depression
less likely. Substance abuse is unlikely in this patient without significant personal or family history of the
disease (D). Patients with uncorrected myopia may also experience headache and difficulty
concentrating, but vision changes would be the predominant symptom and the history of a mild head
injury would be insignificant (E).
References:
Manley GT, Hauser SL, McCrea M. Concussion and Other Traumatic Brain Injuries. In: Jameson J, Fauci
AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th
ed. New York, NY: McGraw-Hill; 2018. http://usjezproxy.usj.edu:2195/content.aspx?bookid=2129&sectionid=192533001.Accessed February 27, 2019.
Ropper AH, Samuels MA, Klein JP. Chapter 28. Normal Development and Deviations in Development of
the Nervous System. In: Ropper AH, Samuels MA, Klein JP, eds. Adams & Victor's Principles of Neurology.
10th ed. New York, NY: McGraw-Hill; 2014.
http://accessmedicine.mhmedical.com/content.aspx?bookid=690&sectionid=50910878. Accessed
February 28, 2019.
Ropper AH, Samuels MA, Klein JP. Chapter 52. Depression and Bipolar Disease. In: Ropper AH, Samuels
MA, Klein JP, eds. Adams & Victor's Principles of Neurology. 10th ed. New York, NY: McGraw-Hill; 2014.
http://accessmedicine.mhmedical.com/content.aspx?bookid=690&sectionid=50910905. Accessed
February 28, 2019.
Usatine RP, Chumley HS, Foulkrod KH, Speedlin SL. Substance Abuse Disorder. In: Usatine RP, Smith MA,
Mayeaux, Jr. EJ, Chumley HS, eds. The Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY:
McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2547&sectionid=206783152. Accessed
February 28, 2019.
Organ System: Neurologic System
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Primary Care
Topic(s): Postconcussive Syndrome
261.
Stem: A 40-year-old woman presents to her primary care office for evaluation of
left-sided back pain. She also reports the sensation of an “electric shock” that radiates
down the lateral aspect of her left thigh to the patella. She reports the pain started 2
days ago while shoveling snow. The back and left leg pain decreases with flexion of the
back and increases with hyperextension. Physical exam is unremarkable except for
increased back and left leg pain when the left leg is passively raised to 20 degrees while
the patient is supine. What is the most likely diagnosis?
Answer Choice:
A.
B.
C.
D.
Cauda equina syndrome
Herniated nucleus pulposus
Spondylolisthesis
Spinal stenosis
E. Sacroiliac strain
Answer: The answer is B.
Explanation: Herniated nucleus pulposus is often the result of a twisting and lifting moment and
presents with back pain that radiates down an extremity (B). Reproduction of the radiating leg pain by
passively raising the leg (positive straight leg raise) supports the diagnosis of HNP. The most common
complaint associated with a sacroiliac strain is joint pain or pain in the upper inner quadrant of the
buttock making this answer less likely because of the location of the patient’s pain (E). Cauda equina
syndrome is less likely because the pain associated with this diagnosis is usually confined to the sacrum
and inner thigh (A). This patient does not report bowel or bladder incontinence, retention, or hesitancy
making the diagnosis of cauda equina syndrome unlikely. Spinal stenosis is not the correct answer
because the patient does not report buttock, bilateral posterior thigh, or calf pain that is worsened by
standing or walking (D).
References:
LeBlond RF, Brown DD, Suneja M, Szot JF. The Spine, Pelvis, and Extremities. In: LeBlond RF, Brown DD,
Suneja M, Szot JF, eds. DeGowin’s Diagnostic Examination. 10th ed. New York, NY: McGraw-Hill; 2014.
http://usj-ezproxy.usj.edu:2195/content.aspx?bookid=1192&sectionid=68669600. Accessed December
08, 2018.
Luke A, Ma C. Sports Medicine & Outpatient Orthopedics. In: Papadakis MA, McPhee SJ, Rabow
MW, eds. CURRENT Medical Diagnosis & Treatment 2019. New York, NY: McGraw-Hill; 2018. http://usjezproxy.usj.edu:2195/content.aspx?bookid=2449&sectionid=194859670. Accessed February 27, 2019.
Organ System: Musculoskeletal
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Primary Care, Internal Medicine, Emergency Medicine
Topic(s): Herniated Nucleus Pulposus
262.
Stem: A 32-year-old female patient presents to the family practice clinic to
discuss her diagnosis of multiple sclerosis (MS). She was diagnosed with relapsing MS
four years ago at the age of 28. She is currently managed with Interferon β and wants to
discuss the possibility of getting pregnant with her husband. Which of the following is
most accurate when advising her about pregnancy related concerns and MS?
Answer Choice:
A.
B.
C.
D.
E.
Often, symptoms of MS improve during pregnancy and worsen after delivery.
Disease progression is enhanced during pregnancy.
Symptoms of MS do not change during pregnancy.
It is not advisable for patients with MS to seek pregnancy.
The patient will need to continue Interferon β while pregnant.
Answer: The answer is A.
Explanation: Multiple sclerosis (MS) is an autoimmune disease that attacks the central nervous system.
There are three subtypes: relapsing MS, primary progressive MS, and secondary progressive MS.
Relapsing MS is the most common clinical subtype. MS has a varied onset and a wide range of clinical
symptoms and signs. These are the result of chronic inflammation, nerve demyelination, development
of CNS plaques, and neuronal loss. In regards to pregnancy, patients experience fewer attacks while
pregnant, only to see a rise in attack frequency in the three months following delivery (A and C). Overall
disease progression is stable over the course of pregnancy and the postpartum period (B). Current
recommendations for patients considering pregnancy include a discussion of maternal health, ability to
take care of an infant, and availability social support. Patients should not be told to avoid pregnancy or
that they cannot become pregnant (D). They should understand, however, that disease modifying
medications are typically halted while pregnant (E).
References: Cree BC, Hauser SL. Multiple Sclerosis. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo
DL, Loscalzo J. eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=2129
&sectionid=192533073. Accessed February 13, 2019.
Organ System: Neurologic System
Task Area: Health Maintenance
Core Rotation: Emergency Medicine, Obstetrics-Gynecology
Topic(s): Multiple Sclerosis
263.
Stem: An 8-year-old girl is brought to her pediatrician due to behavioral
problems, which have been progressively worsening over the past 6 months. She is
concerned because her daughter doesn’t follow directions, argues when she doesn’t like
something, annoys her sister for no reason, gets angry easily over minor things, and
destroys things including her own toys. She also noted that last week her daughter
broke a vase out of spite because her mother refused to give it to her. She has
previously been tested for attention deficit disorder at age 5 and was found to be
negative. What historical information would support your suspected diagnosis?
Answer choice:
A.
B.
C.
D.
E.
Marital discord
Eczema
Diet with sweets daily
Lack of exercise
Allergic rhinitis
Answer: The answer is A.
Explanation: The patient exhibits signs of oppositional defiant disorder. The etiology may be related to
stress due to parental marital discord, psychological problems with the parent, socioeconomic
disadvantage, or potentially from child abuse (A). The other choices are not associated with an increased
risk of oppositional defiant disorder. Attention deficit disorder may co-exist with oppositional defiant
disorder and the patient may benefit from retesting (B, C, D, and E).
References:
Nurcombe B. Chapter 36. Oppositional Defiant Disorder and Conduct Disorder. In: Ebert MH, Loosen PT,
Nurcombe B, Leckman JF, eds. CURRENT Diagnosis & Treatment: Psychiatry. 2nd ed. New York, NY:
McGraw-Hill; 2008.
http://accessmedicine.mhmedical.com.evms.idm.oclc.org/content.aspx?bookid=336&sectionid=397179
09. Accessed September 7, 2018.
Organ System: Psychiatry/Behavioral
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Pediatrics, Psychiatry
Topic(s): Oppositional Defiant Disorder
264.
Stem: Gastric outlet obstruction, mucosal perforation, and gastrointestinal
hemorrhage are complications more commonly associated with which condition?
Answer choice:
A.
B.
C.
D.
E.
GERD
H. pylori gastritis
Esophageal varices
Peptic ulcer disease
Ulcerative colitis
Answer: The answer is D.
Explanation: Peptic ulcer disease (PUD) is associated with gastric outlet obstruction, perforation, and
gastrointestinal (GI) hemorrhage as potential complications (D). GERD is commonly associated with
upper GI bleeding, commonly presenting as hematemesis, coffee grounds emesis, or bloody aspirate (A).
H. pylori gastritis can cause PUD and gastric carcinoma (B). Esophageal varices often present with GI
bleeding, but do not pose risk for gastric outlet obstruction or perforation of the GI mucosa (C).
Ulcerative colitis does not impact the gastric mucosa (E).
References:
McQuaid KR. Gastrointestinal Disorders. In: Papadakis M & McPhee S, eds. Current Medical Diagnosis &
Treatment 2017. San Francisco, CA: McGraw-Hill Education; 2017:614,620,629-631.
Organ System: Gastrointestinal/Nutritional
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Internal Medicine, Family Medicine
Topic(s): Gastric Disorders, Peptic Ulcer Disease
265.
Stem: In the assessment of hearing loss, a patient that hears sounds at the level
of a "normal spoken voice" would be expected to have what corresponding level of
hearing (dB) on an audiometric evaluation?
Answer choice:
A.
B.
C.
D.
E.
0–20 dB
20–40 dB
40–60 dB
60–80 dB
> 80 dB
Answer: The answer is C.
Explanation: By definition, the vocal equivalent of a normal spoken voice is defined at the 40–60
decibel range and this represents moderate hearing loss (C). This is different than a having a normal
capacity for hearing, which can hear the vocal equivalent of a soft whisper measured at the 0–20 decibel
range (A). Mild hearing loss is equivalent to hearing a soft-spoken voice at 20–40 decibels (B). Severe
hearing loss has the vocal equivalent of a loud spoken voice measured at 60–80 decibels (D). Profound
hearing loss has the vocal equivalent of a shout, is hearing at decibels >80 (E).
References:
Lustig LR, Schindler JS. Ear, Nose, & Throat Disorders. In: Papadakis M & McPhee S eds. Current Medical
Diagnosis & Treatment 2018. San Francisco, CA: McGraw-Hill Education; 2018:206.
Organ System: EENT
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Family Medicine
Topic(s): Ear Disorders, Hearing Impairment
266.
Stem: An 18-year-old boy presents to the clinic concerning skin changes to his
hands over the last year. He reports a negative medical history and has no new
exposures or identifiable contributors. The patient states the lesions began as small
white spots on the back of his hands that have enlarged. He denies itching, erythema,
scales, or systemic signs. Exam reveals patches of macular hypopigmentation with
scalloped, well-defined borders in a somewhat symmetrical pattern on the dorsum of
both hands. A few of the patches coalesce without associated inflammation or regional
lymphadenopathy. What skin care advisement is best for this patient’s condition?
Answer choice:
A.
B.
C.
D.
E.
Treat with oral corticosteroids
Use emollients
Use daily sunscreen
Wash hands in cold water
Wear gloves
Answer: The answer is C.
Explanation: This scenario depicts vitiligo, a condition characterized by progressive loss of skin color.
Use of daily sunscreen is widely advocated to prevent sunburn and decrease likelihood of skin cancer
due to excess UV light exposure (C). There is a role for topical corticosteroids, but not oral
corticosteroids (A). Emollients will aid in maintaining the skin barrier but won’t directly impact the
vitiligo (B). Washing skin in cold water or wearing gloves are not recommendations given to patients
with vitiligo (D and E).
References:
Usatine RP, Hughes KA, Smith MA. Vitiligo and Hypopigmentation. In: The Color Atlas of Pediatrics. 2015;
167.
http://accesspediatrics.mhmedical.com/content.aspx?sectionid=79847380&bookid=1443&jumpsectioni
d=94716023&resultclick=2.
Mayo Clinic. Vitiligo. https://www.mayoclinic.org/diseases-conditions/vitiligo/diagnosis-treatment/drc20355916. Accessed May 18, 2017.
Organ System: Dermatologic
Task Area: Health Maintenance
Core Rotation: Family Medicine
Topic(s): Pigment Disorders, Vitiligo
267.
Stem: In contrast to chronic arterial insufficiency, which finding would more
likely be present in a patient with chronic venous insufficiency of the lower extremities?
Answer choice:
A.
B.
C.
D.
Claudication
Hair loss over feet
Gangrene
Normal palpable pulses
E. Pallor with foot elevation
Answer: The answer is D.
Explanation: Arterial pulses are usually unaffected in venous insufficiency, whereas in arterial
insufficiency pulses are usually diminished or absent (D). Claudication is often associated with arterial
insufficiency due to insufficient blood flow to meet increased tissue demand (A). Hair loss can be seen
due to diminished tissue perfusion (B). Gangrene results from prolonged tissue ischemia, resultant
tissue breakdown, and susceptibility to infection; this can be seen in both chronic arterial and venous
insufficiency (C). Pallor with foot elevation is seen in arterial insufficiency due to vessel occlusion (E).
References:
Gasper WJ, Rapp JH, Johnson MD. Blood Vessel & Lymphatic Disorders. In: Papadakis M & McPhee S eds.
Current Medical Diagnosis & Treatment 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168192658#1145433772
Organ System: Cardiovascular
Task Area: History Taking & Performing Physical Examination
Core Rotation: Family Medicine, Internal Medicine, Surgery
Topic(s): Vascular Disease, Venous Insufficiency
268.
Stem: Mr. Allen, a 41-year-old homeless, disheveled male, presents to the
emergency department for an acute asthma exacerbation. The PA on duty believes Mr.
Allen would benefit from some free medication samples secondary to his current
financial situation. However, despite knowing the right course of action, the PA on duty
is unable to provide Mr. Allen with free samples secondary to hospital policy and
resources available. This clinical scenario best describes what common type of ethical
problem in healthcare?
Answer Choice:
A.
B.
C.
D.
E.
Conflicts of interest
Ethical dilemmas
Moral distress
Claims of conscience
Occupational risk
Answer: The answer is C.
Explanation: The correct answer is moral distress (C). Providers can experience moral distress when they
ethically feel the appropriate action to take (in this case, providing samples to the homeless patient) is
hindered by institutional policies, limited resources, or other reasons. Conflicts of interest occur when
acting in a patient’s best interest conflicts with the provider’s self-interest or the interest of third parties
(e.g., financial incentives or relationships) (A). An ethical dilemma occurs when a situation that requires
a medical provider to make a decision which violates one of the four principles of medical ethics
(beneficence, autonomy, justice, nonmaleficence) to adhere to another one of the four principles arises
(B). Claims of conscience occurs when a provider conscientiously objects to providing or referring
patients for certain treatments (D). Claims of conscience should not hinder patients from receiving
appropriate medical treatment and timely access to care. Occupational risk occurs when a provider fears
a fatal infection from patients with certain disease states (i.e., HIV, Ebola) (E). This risk is reduced
through proper training, utilization of protective equipment, and proper supervision.
References:
1. Lo B, Grady C. Ethical Issues in Clinical Medicine. In: Jameson J, Fauci AS, Kasper DL, Hauser SL,
Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY:
McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.ezproxy.lynchburg.edu/content.aspx?bookid=2129&sect
ionid=192279783.
2. Ethics and Rationing of Health Care. In: Bodenheimer T, Grumbach K, eds. Understanding Health
Policy: A Clinical Approach. 7th ed. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com.ezproxy.lynchburg.edu/content.aspx?bookid=1790&sect
ionid=121192090.
Organ System:
Task Area: Professional Practice
Core Rotation: Family Medicine, Emergency Medicine, Internal Medicine, Surgery
Topic(s): Professional Development
269.
Stem: A 45-year-old female with a history of hypertension presents to your
clinic with multiple complaints. For the past 4 weeks she has had feelings of being
hopeless. She describes a decreased interest in all activities, especially playing with her
children and running. She describes trouble sleeping at night, every night, and has taken
melatonin without any improvement. On physical examination, the patient is tearful and
explains how she is tired all the time and states her husband is always upset at her
because she cannot make any decisions. Upon further questioning, the patient states
she was recently fired from her job because she did not show up for the entire month.
The patient states she was seen by her primary care physician one week ago and
underwent significant testing, which was all within normal limits included TSH and
vitamin D levels. Based on the most likely diagnosis, what other history would need to
be asked to confirm major depressive disorder in this patient?
Answer Choice: A
A.
B.
C.
D.
E.
Does the patient have a history of any other psychiatric disorder?
Does the patient smoke tobacco products?
Does the patient have a well-balanced diet?
Does the patient partake in aerobic exercise three times a week?
Does the patient have thoughts of suicide?
Answer: The answer is A.
Explanation: DSM-5 diagnostic criteria for major depressive disorder (MDD) is five (or more) depressivelike symptoms that have been present during the same two-week period and represents a change from
previous functioning (A). At least one of the symptoms must be depressed mood or loss of interest or
pleasure and the episode cannot be attributable to the direct physiological effects of a substance or
another medical condition/psychiatric disorder. Although tobacco products are discouraged for health
reasons, this question is not essential to establishing the diagnosis of MDD (B). Although a well-balanced
diet and a regular exercise regimen are important preventative measures and a healthy lifestyle is
encouraged, they are not essential elements in the history needed to establish the diagnosis of MDD (C
and D). Although a provider would want to ask if a patient has thoughts of suicidal or homicidal ideation
during their history taking, especially after initiating treatment for MDD, this is not criteria needed to
make a diagnosis of MDD (E).
References: Loosen PT, Shelton RC. Mood Disorders. In: Ebert MH, Leckman JF, Petrakis IL, eds.
CURRENT Diagnosis & Treatment: Psychiatry. 3rd ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com.ezproxy.lynchburg.edu/content.aspx?bookid=2509&sectionid=2
00804247.
Organ System: Psychiatry/Behavioral
Task Area: History Taking & Performing Physical Examinations
Core Rotation:
Topic(s): Major Depressive Disorder
270.
Stem: A 44-year-old female reports to the clinic for evaluation of multiple
lesions on her back. She states they began two years ago, but now have multiplied and
become raised, and occasionally bleed when she scratches them off. Her family history
is negative for cancer, but her dad has a similar pattern of lesions on his body. On exam,
you note widespread, multiple hyperpigmented, papular, verrucous-like lesions varying
in size on the anterior and posterior trunk. Some lesions appear to be “stuck on” and
range from being flat to raised. There is no associated inflammation, vascularity, or
scales, but there are plugged follicles. Of the following, which treatment option would
be considered first line?
Answer choice:
A.
B.
C.
D.
E.
Acyclovir
Punch biopsy
Cryotherapy
Excision
Exfoliant
Answer: The answer is C.
Explanation: The condition depicted in this scenario is seborrheic keratosis. There are various medical
and surgical options, but cryotherapy is often considered an early first line option for improved
cosmesis, though it may come with the risk of pigmentary changes and scarring (C). Acyclovir will not
resolve or prevent recurrence or the appearance of new lesions (A). Punch biopsy will provide histologic
data to confirm diagnosis, but will not resolve the lesions (B). Excisional biopsy would be a consideration
in few or more local presentations (D). It is not the best option in widespread involvement. Exfoliants
simply won’t remove the lesions.
References:
Balin AK. Seborrheic Keratosis. Medscape. https://emedicine.medscape.com/article/1059477treatment#d7. Accessed December 18, 2017.
Organ System: Dermatologic
Task Area: Pharmaceutical Therapeutics
Core Rotation: Family Medicine
Topic(s): Keratotic Disorders, Seborrheic Keratosis
271.
Stem: A 36 year-old G5P5 has just given birth after a precipitous labor. After 30
minutes, you are called to the bedside because of bleeding. The uterus is boggy and not
responding to vigorous fundal and bimanual massage nor rapid infusion of oxytocin. Due
to the amount of blood loss, the emergency protocol for management of severe
obstetric hemorrhage is initiated. Which of the following is indicated next?
Answer choice:
a.
b.
c.
d.
e.
Balloon tamponade
Exploratory laparotomy
Hysterectomy
Uterine artery embolization
Uterotonics
Answer: The answer is E
Explanation: This scenario describes postpartum hemorrhage due to uterine atony (most common
cause of hemorrhage and suspicious with a “boggy” uterus). Following rapid infusion of oxytocin,
bimanual massage, and activation of emergency protocols (i.e., OB alerts, fluid initiation, transfusion
protocol, etc.), uterotonic administration is next. Agents such as ergonovine maleate, carboprotost, and
misoprostol are used. Balloon tamponade and uterine artery embolization is options following
uterotonic failure especially if a patient is hemodynamically stable. Hysterectomy is an approach in
hemodynamically unstable patients. Exploratory laparotomy is a distractor since this is a procedure used
to determine an unknown bleeding source.
References:
Belfort MA. Overview of postpartum hemorrhage. In: UpToDate, Lockwood CJ, Barss, VA (Eds.),
UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed on January 2, 2018.)
Organ System: Reproductive
Task Area: Clinical Intervention
Core Rotation: Obstetrics-Gyencology
Topic(s): Complicated Pregnancy, Postpartum hemorrhage
272.
Stem: An 11-year-old female patient is in your office after colliding with another
child playing flag football. She complains of shoulder pain and bruising without
numbness or tingling, and there are no open wounds. An x-ray demonstrates a middle
third clavicle fracture with a 1 cm overlap. Your initial treatment modality includes
which of the following?
Answer choice:
A.
B.
C.
D.
Figure 8 dressing
Closed reduction and sling
Sling
Referral to orthopedics for urgent consultation
Answer: The answer is C.
Explanation: There is little evidence to support any primary care management of a clavicle fracture
other than a sling (C). The figure 8 bandage has morbidity associated with its application and
maintenance, leading to skin necrosis and pressure sores (A). Additionally, it should not be removed till
fracture healing is evident once applied, and mid clavicle fractures are typically under the chest strap.
Closed reductions are not likely with the amount of chest wall musculature and the underlying thorax
(B). Immediate referral should be reserved for open fractures and neurovascular compromise (D).
References:
UpToDate, July 2018.
Organ System: Musculoskeletal
Task Area: Health Maintenance
Core Rotation: Family Medicine, Emergency Medicine, Pediatrics
Topic(s): Upper Extremity Disorders, Fractures/Dislocations
273.
Stem: An 8-year-old girl is brought to her pediatrician due to behavioral
problems, which have been progressively worsening over the past 6 months. She is
concerned because her daughter doesn’t follow directions, argues when she doesn’t like
something, annoys her sister for no reason, gets angry easily over minor things, and
destroys things including her own toys. She also noted that last week her daughter
broke a vase out of spite because her mother refused to give it to her. She has
previously been tested for attention deficit disorder at age 5 and was found to be
negative. What additional historical information would support a diagnosis of
movement to conduct disorder?
Answer choice:
A.
B.
C.
D.
E.
Kicking the family dog
Staying up past bedtime
Refusing to do her homework
Screaming in response to being told no
Eating candy despite being advised to wait until she finishes dinner
Answer: The answer is A.
Explanation: Kicking the family dog demonstrates aggression toward animals (A). Aggression toward
animals as well as people including physical aggression, bullying, intimidation, and threats may indicate
movement from oppositional defiant disorder to conduct disorder. The patient’s behavior has changed
from reactive to proactive. The other answer choices are behaviors commonly associated with
oppositional defiant disorder (B, C, D, and E).
References:
Nurcombe B. Chapter 36. Oppositional Defiant Disorder and Conduct Disorder. In: Ebert MH, Loosen PT,
Nurcombe B, Leckman JF, eds. CURRENT Diagnosis & Treatment: Psychiatry. 2nd ed. New York, NY:
McGraw-Hill; 2008.
http://accessmedicine.mhmedical.com.evms.idm.oclc.org/content.aspx?bookid=336&sectionid=397179
09. Accessed September 7, 2018.
Organ System: Psychiatry/Behavioral
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Pediatrics
Topic(s): Conduct Disorder
274.
Stem: A 74-year-old male is brought to the Emergency Room via EMS after he
developed sudden onset of lower abdominal pain while mowing his lawn. The pain does
radiate to his back. PMH includes HTN, hyperlipidemia, and a previous CVA with
uneventful recovery. He has a 45 pack-year history of smoking, although he quit 20
years ago. BP is 178/100, pulse is 90 and regular in the right arm but difficult to palpate
in the left arm, RR is 16 and regular, and pulse oxygenation is 95% on room air. Bowel
movements have been normal. He denies melena, hematochezia, fever, chills, nausea,
vomiting, and hematuria. CXR shows a widened mediastinum. What is the most likely
diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Acute coronary syndrome
Aortic aneurysm
Aortic dissection
Boerhave’s syndrome
Intestinal ischemia
Answer: The answer is C.
Explanation: The peak incidence of aortic dissection (C) is in the sixth and seventh decades. Men are
more affected than women by a ratio of 2:1. This patient is noted to have hypertension and discordant
pulses plus he has a history of previous vascular issues. A widened mediastinum may be observed on
chest x-ray in both dissections of the ascending aorta and the descending thoracic aorta. Abdominal pain
has been noted to be the chief complaint in a third of patients with aortic dissection. Generally, the
widening of the mediastinum would not be an acute finding in either Boerhave’s syndrome (D) or
intestinal ischemia (E). Acute coronary syndrome (A) can produce a variant abdominal pain, but
generally does not cause a widened mediastinum either. Not all patients with an aortic dissection
present with the classic tearing back pain, which is partly why the diagnosis is one that is often missed.
References:
Buckley II C, Diviney J. Vascular Emergencies. In: Stone C, Humphries RL, eds. CURRENT Diagnosis &
Treatment: Emergency Medicine, 8e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165066846. Accessed
January 31, 2018.
Johnson GA, Prince LA. Aortic Dissection and Related Aortic Syndromes. In: Tintinalli JE, Stapczynski J,
Ma O, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide, 8e. New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109429195. Accessed
January 31, 2018.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine
Topic(s): Vascular Disease, Aortic Dissection
275.
Stem: A 51-year-old female comes to clinic after falling and landing on her right
leg 2 days ago. She reports pain from the hip to the knee. Patient also reports tingling in
her right toes. Ambulation has become almost impossible due to the pain. In taking her
history, you learn that she has been experiencing generalized muscle weakness, joint
aches, and fatigue, which she attributes to “just getting older.” Past medical history is
notable only for kidney stones. You order a CMP as part of her workup, which reveals:
Na
K
138 3.8
Cl
CO2 Gluc BUN Creat Total
Alb
Protein
103 25
120 19
1.3
7.1
3.3
Cal
Bili
11.4 0.3
AST ALT Alk
Phos
15
28
103
Based on the patient’s history and the bloodwork results, what test should be ordered next
to confirm the diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Ultrasound of the thyroid
Bone mineral density
Thyroid hormone
Parathyroid hormone
24-hour urine collection
Answer: The answer is D.
Explanation: Parathyroid glands are 4 pea-sized glands located on or near the thyroid gland in the neck.
These glands produce a hormone called PTH, parathyroid hormone (D), which helps maintain the correct
balance of calcium in the body by regulating the amount of calcium in the bloodstream, the release of
calcium from bone, the absorption of calcium in the small intestine, and the excretion of calcium in
urine. Hyperparathyroidism is an excess of parathyroid hormone in the bloodstream due to overactivity
of one or more of the parathyroid glands. Elevated levels of PTH triggers the bones to release increased
amounts of calcium into the blood. Bones can become weakened when they lose too much calcium. In
response to the high amounts of calcium in the blood, the kidneys will excrete more calcium in urine,
leading to kidney stones. While most people with hyperparathyroidism will be asymptomatic, others can
experience muscle weakness, joint aches and pains, fatigue, and depression. Primary
hyperparathyroidism is diagnosed biochemically, through blood tests, so an ultrasound of the thyroid (A)
would be premature. High blood calcium is usually the first indication that a person has
hyperparathyroidism. Once that is detected, a PTH should be ordered to confirm the diagnosis.
References:
Al-Azem H and Khan A. Primary hyperparathyroidism. CMAJ. 2011 Jul 12; 183(10): E685-89.
Organ System: Endocrine
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Parathyroid disorders, Hyperparathyroidism
276.
Stem: An intrapartum fetal heart rate (FHR) tracing is reviewed. There is a
gradual decrease and return to baseline of the FHR associated with a uterine
contraction. The nadir of the deceleration and the peak of contraction occur
simultaneously. Which of the following is this pattern most often associated with?
Answer choice:
a.
b.
c.
d.
Uteroplacental insufficiency
Fetal head compression
Umbilical cord compression
Oligohydramnios
Answer: The answer is B
Explanation: The pattern described is that of an early deceleration which is considered physiologic and
caused by fetal head compression. Uteroplacental insufficiency is associated with late decelerations
(nadir of the deceleration occurs after the peak of contraction). Umbilical cord compression and
oligohydramnios are associated with variable decelerations (abrupt decal and vary with contractions).
References:
Macones G. Management of intrapartum category I, II, and III fetal heart rate tracings. In: UpToDate,
Lockwood CJ, Barss, VA (Eds.), UpToDate, Waltham, MA. Available at http://www.uptodate.com
(Accessed on January 2, 2018.)
Nyholm, JL. Intrapartum fetal surveillance. In: Link FW, Carson SA, Flower WC, Snyder RR., eds. Step-Up
to Obstetrics and Gynecology. Philadelphia, PA: Wolters Kluwer Health; 2015: 85-89.
Organ System: Reproductive
Task Area: Applying Basic Science Concepts
Core Rotation: Obstetrics-Gynecology
Topic(s): Complicated Pregnancy, Fetal Distress
277.
Stem: A 58-year-old male with a long history of alcohol abuse comes to clinic
with a complaint of malaise, dark and tarry stool, and occasional lightheadedness. He
denies hematemesis, but recalls an episode several weeks ago when there was a small
amount of blood in his saliva after he had been coughing. Physical examination reveals
mild scleral icterus and a protuberant abdomen with visible dilated veins. You order lab
work to further assess the patient. Among the following choices, what is the most
appropriate next step in his management?
Answer choice:
a.
b.
c.
d.
e.
Colonoscopy
Transjugular intrahepatic portosystemic shunt
Antibiotic prophylaxis
Esophagogastroduodenoscopy
Endoscopic treatments (sclerotherapy or rubber band ligation)
Answer: The answer is D.
Explanation: Esophageal varices (abnormal, dilated veins) are most commonly due to serious liver
disease. They develop when normal blood flow to the liver is blocked. To bypass the blockage, blood will
flow into smaller vessels that are not designed to carry large volumes of blood. The increased pressure
on the walls of these vessels (portal hypertension) makes the vessels susceptible to leaking or bleeding.
Esophageal varices tend to be asymptomatic until they bleed, at which point they can become life
threatening. Given this patient’s history of an episode of upper GI bleeding, and his long history of
alcohol abuse and physical exam findings, esophagogastroduodenoscopy (EGD), (D), should be
performed to assess for esophageal varices. Once the diagnosis is made, the other interventions listed
may need to be included in his management, depending on the severity of his disease. The development
of black, tarry stools implies an upper GI bleeding source, so colonoscopy (A) is not warranted. More
invasive treatments such as intrahepatic shunts (B) and rubber band ligation (E) are indicated when a
more definitive diagnosis has been established.
References:
de Franchis R. Acute variceal haemorrhage: Practice guidelines and real-life management. Dig Liver Dis.
2014 May;46(5):398-9.
Garcia-Tsao G, Sanyal A, Grace N, et al. Prevention and Management of Gastroesophageal Varices and
Variceal Hemorrhage in Cirrhosis. Am J Gastroenterol. 2007 Sep;102(9):2086-102.
Organ System: Gastrointestinal/Nutritional
Task Area: Clinical Intervention
Core Rotation: Internal Medicine
Topic(s): Esophageal disorders, Varices
278.
Stem: Certain radiographic features are more commonly associated with
pneumonia due to a bacterial, atypical bacterial, or viral etiology. Of the following,
which radiographic feature is least commonly observed with a viral pneumonia?
Answer choice:
a.
b.
c.
d.
e.
Lobar consolidation
Alveolar infiltrates
Small pleural effusions
Kerley B lines
Bronchial wall thickening
Answer: The answer is A.
Explanation: The radiologic manifestations of viral pneumonia can be nonspecific and difficult to
differentiate from those of other infections. Chest radiograph findings range from normal to unilateral
or patchy bilateral areas of consolidation. Nodular opacities, bronchial wall thickening, and small pleural
effusions (C) can also be present. Kerley B lines (D)—which are horizontal lines 1–2 cm long that
represent thickened, edematous interlobar septa—can also be caused by viral pneumonia. Lobar
consolidation (A), however, is uncommon in patients with viral pneumonia.
References:
Barson W. Community-acquired pneumonia in children: Clinical features and diagnosis. Up To Date.
Franquet T. Imaging of Pulmonary Viral Pneumonia. Radiology. 2011;260(1):18–39.
Organ System: Pulmonary
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Family Medicine
Topic(s): Infectious Disorders, Viral Pneumonia
279.
Stem: A 40-year-old woman with no significant past medical history presents
with 3 weeks of fatigue and progressive dyspnea on exertion that resolves at rest. She
denies fever, chills, weight gain, chest pain, palpitations, or syncope. Vital signs are
within normal limits. Cardiac exam reveals a right ventricular lift, a fixed and widely split
S2, and a loud systolic ejection murmur at the second intercostal space parasternally,
and peripheral edema. The murmur does not decrease with Valsalva or handgrip. CBC,
BMP, and TFTs are all within normal limits. ECG shows normal sinus rhythm, right
ventricular hypertrophy, and right bundle branch block. Chest radiograph shows
increased pulmonary vascularity, an enlarged right atrium and right ventricle, as well as
a small aortic knob. What congenital heart defect would you expect to find in this
patient?
Answer choice:
a.
b.
c.
d.
e.
Atrial septal defect
Coarctation of the aorta
Patent ductus arteriosus
Tetralogy of Fallot
Ventricular septal defect
Answer: The answer is A.
Explanation: Atrial septal defect (ASD), (A), is a form of congenital heart disease that is characterized by
a defect in the interatrial septum, resulting in shunting of blood from the left to the right atrium. Many
patients with ASD are asymptomatic at birth. Exertional dyspnea or heart failure may develop, most
commonly in the fourth decade of life or later. A systolic ejection murmur can be heard as a result of
increased flow through the pulmonary valve. Chronic volume overload of the right heart chambers,
along with delayed closure of the pulmonary valve, results in a fixed split S2. Right bundle branch block
is found in most patients with ASD.
Coarctation of the aorta (B) is incorrect. Coarctation of the aorta would present in an adult patient with
hypertension in the arms, decreased or normal blood pressure in the lower extremities, weak and
delayed femoral pulsations in comparison to brachial or radial pulses, bilateral claudication, headache,
left ventricular hypertrophy on ECG, and rib notching on chest radiograph. Cardiac failure is common in
infancy and in older untreated patients.
Patent ductus arteriosis (C) is incorrect. The ductus arteriosis allows shunting of blood from the
pulmonary artery to the aorta in utero, and normally closes immediately after birth. Patent ductus
arteriosis (PDA) is rarely symptomatic in adult patients, unless left ventricular failure or pulmonary
hypertension develops. A continuous machine-like murmur is best heard at the left sternal border, at
the first or second intercostal space. ECG is likely to show left ventricular hypertrophy.
Tetralogy of Fallot (D) is incorrect. Tetralogy of Fallot is characterized by a ventricular septal defect, right
ventricular hypertrophy, right ventricular outflow obstruction from infundibular stenosis, overriding
aorta, and right-sided aortic notch. It usually presents in infancy with severe cyanosis and a classic bootshaped heart on chest radiograph.
Ventricular septal defect (E) is incorrect. Ventricular septal defect (VSD) is a defect in the ventricular
septum between the left and right ventricles, and smaller defects may persist asymptomatically into
adulthood. The murmur associated with VSD is described as a loud, high pitched holosystolic murmur at
the left lower sternal border and may decrease with Valsalva or handgrip. In addition, the S2 heart
sound is physiologically split, rather than fixed.
References:
Bashore TM, Granger CB, Jackson KP, Patel MR. Heart Disease. In: Papadakis MA, McPhee SJ, Rabow
MW, eds. Current Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168190671. Accessed
December 29, 2017.
Atrial Septal Defect. Emedicine.https://emedicine.medscape.com/article/162914overview?pa=PZRApqQZYU%2FB9NjDtCEKHvqKpdDTqJ9x3s3CrLPAuC9X2yKKsRF1tPHC4RdStL8FSoFLLsKI
Ds540s%2B2hWhlFJkQX8%2BpKxaTdQdy9ZGt7Vc%3D Updated May 1, 2017. Accessed December 29,
2017.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Congenital Heart Disease, Atrial Septal Defect
280.
Stem: A 49-year-old man presents with gradually deteriorating vision bilaterally.
His past medical history is significant for diabetes mellitus, for which he has been insulin
dependent the past 3 years. Ophthalmic exam reveals a clear lens and no vitreous
abnormalities, as well as decreased vision bilaterally. After review of the fundoscopic
exam below, what is the most likely diagnosis?
http://accessmedicine.mhmedical.com/ViewLarge.aspx?figid=98732666
Answer choice:
a.
b.
c.
d.
e.
Age-related macular degeneration
Central retinal artery occlusion
Central retinal vein occlusion
Chronic glaucoma
Diabetic retinopathy
Answer: The answer is E.
Explanation: The correct answer is diabetic retinopathy (E), which is present in one-third of patients
with a diagnosis of diabetes. The image shows characteristic findings of proliferative retinopathy on
fundoscopic exam: retinal hemorrhages, yellow exudates, and neovascularization.
Age-related macular degeneration (A) is incorrect and is more likely in elderly patients. Macular
degeneration results in a loss of central vision only, and macular abnormalities are seen on fundoscopic
exam.
Central retinal artery occlusion (B) is incorrect and results in a sudden, painless, unilateral loss of vision.
Fundoscopic exam reveals a cherry red spot at the fovea.
Central retinal vein occlusion (C) is incorrect and results in sudden, painless, unilateral loss of vision.
Fundoscopic exam reveals widespread retinal hemorrhages, retinal venous dilation and tortuosity,
retinal cotton-wool spots, and optic disk swelling.
Chronic glaucoma (D) is incorrect and results in a subtle, progressive, bilateral loss of peripheral vision.
Fundoscopic exam reveals pathologic cupping of the optic disks.
References:
Riordan-Eva P. Disorders of the Eyes & Lids. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current
Medical Diagnosis & Treatment 2018. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=167995926. Accessed
January 16, 2018.
Organ System: EENT
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Internal Medicine
Topic(s): Eye Disorders, Retinal disorders, Retinopathy
281.
Stem: Upon delivery of the fetal head onto the perineum, the fetal head retracts
tightly against the perineum. Which of the following is contraindicated?
Answer choice:
a.
b.
c.
d.
e.
McRoberts maneuver: hyperflex maternal hips to increase anteroposterior dimeter
Delivery of posterior arm
Apply fundal pressure
Zavanelli maneuver: fetus pushed back into uterus for Cesarean
External cephalic version
Answer: The answer is C
Explanation: This scenario describes shoulder dystocia; the “turtle sign” is when the fetal head retracts
tightly against the perineum. Fundal pressure is contraindicated because it can worsen dystocia and
stretch/injury the brachial plexus. The other options (McRoberts, delivery of posterior arm, and
Zavanelli maneuver) are steps taken to disengage the anterior shoulder. An external cephalic version is
not indicated for dystocia.
References:
Rodis JF. Shoulder dystocia: Intrapartum diagnosis, management, and outcome. In: UpToDate,
Lockwood CJ, Barss, VA (Eds.), UpToDate, Waltham, MA. Available at http://www.uptodate.com
(Accessed on December 20, 2017.)
Patel S. Abnormal labor and malpresentation. In: Link FW, Carson SA, Flower WC, Snyder RR., eds. StepUp to Obstetrics and Gynecology. Philadelphia, PA: Wolters Kluwer Health; 2015: 96-100.
Organ System: Reproductive
Task Area: Clinical Intervention
Core Rotation: Obstetrics-Gynecology
Topic(s): Complicated Pregnancy, Dystocia
282.
Stem: A 70-year-old woman presents to the ED complaining of numbness and
tingling over the entire right side of her body. The symptoms started about 3 hours ago
and have been persistent since their onset. She denies headache, weakness, or difficulty
speaking. Her past medical history is significant for hypertension and
hypercholesterolemia. What is the most likely etiology of her symptoms?
Answer Choice:
A.
B.
C.
D.
E.
Infarct of the ventral thalamus
Hemorrhage in the pons
Cerebellar contusion
Disruption of the middle meningeal artery
Fracture of the cribriform plate
Answer: The answer is A.
Explanation: An infarct of the ventral thalamus results in a pure sensory stroke, described as unilateral
numbness and tingling on the same side as the injury. An intracerebral hemorrhage in the area of the
pons would most likely result in quadriplegia (B). A cerebellar contusion would more likely result in
symptoms of ataxia, nausea, vomiting, or headache (C). Disruption of the middle meningeal artery leads
to the development of an epidural hemorrhage (D). The typical presentation of a bleed related to
disruption of the middle meningeal artery is loss of consciousness followed by a lucid interval. Impaired
smell, not impaired sensation, is the most common symptom associated with a cribriform plate injury
because of the proximity to the olfactory nerves (E).
References:
Smith WS, Johnston S, Hemphill, III J. Ischemic Stroke. In: Jameson J, Fauci AS, Kasper DL, Hauser SL,
Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill;
2018. http://usj-ezproxy.usj.edu:2195/content.aspx?bookid=2129&sectionid=192532037. Accessed
February 27, 2019.
Waxman SG. The Limbic System. In: Waxman SG, ed. Clinical Neuroanatomy. 28th ed. New York, NY:
McGraw-Hill; 2017. http://usjezproxy.usj.edu:2195/content.aspx?bookid=1969&sectionid=147037591. Accessed February 28, 2019.
Organ System: Neurologic
Task Area: Applying Basic Science Concepts
Core Rotation: Emergency Medicine
Topic(s): Intracranial Hemorrhage
283.
Stem: A 55-year-old male patient presents to your family medicine practice with
questions about vaccinations required for travel. He will be travelling to Uganda on a
safari. He is up to date on his routine immunizations, including measles/mumps/rubella
(MMR), diphtheria-tetanus-pertussis, varicella, and polio vaccines. He has had an annual
influenza vaccination. He received hepatitis A and hepatitis B vaccines prior to a
previous trip. Which of the following vaccines is most important for this patient to
receive?
Answer Choice:
A.
B.
C.
D.
E.
F.
Hepatitis B
Japanese encephalitis
Malaria
Meningococcus
Typhoid
Rabies
Answer: The answer is E.
Explanation: Although hepatitis B vaccine is recommended by the CDC, the patient has already
completed the series (A). No routine booster is indicated. Japanese encephalitis is endemic to rural Asia
and Southeast Asia (B). Although malaria is endemic to many areas of Africa, including Uganda, there is
no vaccine for it (C). It is treated with medical prophylaxis. Meningococcal vaccine is not on the list of
vaccines recommended by the CDC for travel to Uganda (D). Typhoid vaccine is recommended by the
CDC for most travelers to Uganda (E).
References: Health Information for Travelers to Uganda - Traveler view | Travelers' Health | CDC.
wwwnc.cdc.gov. https://wwwnc.cdc.gov/travel/destinations/traveler/none/uganda. Published 2019.
Accessed February 14, 2019.
Keystone JS, Kozarsky PE. Health Recommendations for International Travel. In: Jameson J, Fauci AS,
Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New
York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192019385. Accessed
February 13, 2019.
Organ System:
Task Area: Professional Practice
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Population Health (Population/Society), Travel Health, and Epidemiology of Disease States
284.
Stem: A 3-year-old boy presents with his parents for a well-child check. No
significant family history is noted. Initial impression is a well-developed child with
normal vital signs. On abdominal examination, you notice a smooth, firm, well-
demarcated mass on the right side. The remainder of the physical exam is within normal
limits. CBC and CMP are normal, and urinalysis reveals 1+ hematuria. Which of the
following is the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Ewing sarcoma
Hodgkin lymphoma
Renal cell carcinoma
Von Hippel-Lindau disease
Wilms tumor
Answer: The answer is E.
Explanation: The correct answer is Wilms tumor (E), which is the second most common abdominal
tumor in children, behind neuroblastoma. The mean age at diagnosis is 4 years old. Most children
present with abdominal enlargement or an asymptomatic unilateral abdominal mass. Microscopic
hematuria is present in about 25% of cases.
Ewing sarcoma (A) is a primary malignant bone tumor that typically presents in white males in the
second decade of life. The most common finding is pain at the site of the tumor, but fevers and weight
loss may also be present.
Hodgkin lymphoma (B) is rare in children younger than 5 and typically presents as painless cervical
lymphadenopathy.
While renal cell carcinoma (C) may present with an abdominal mass and hematuria, it typically presents
at age 40 years and older, with a peak in the sixth decade of life.
Von Hippel-Lindau Disease (D) is a rare, autosomal dominant condition with retinal and cerebellar
hemangioblastomas; cysts of the kidneys, pancreas, and epididymis; and sometimes renal cancers.
Presenting symptoms may include ataxia, slurred speech, and nystagmus.
References:
Graham DK, Craddock JA, Quinones RR, Keating AK, Maloney K, Foreman NK, Giller RH, Greffe BS.
Neoplastic Disease. In: Hay WW, Jr., Levin MJ, Deterding RR, Abzug MJ, eds. CURRENT Diagnosis &
Treatment Pediatrics 2016, 23e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1795&sectionid=125746363. Accessed
January 18, 2018.
Kedia S, Knupp K, L. Schreiner T, Yang ML, Toler J, G. Moe P. Neurologic & Muscular Disorders. In: Hay
WW, Jr., Levin MJ, Deterding RR, Abzug MJ, eds. CURRENT Diagnosis & Treatment Pediatrics 2016, 23e.
New York, NY: McGraw-Hill; 2016.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1795&sectionid=125744005. Accessed
January 18, 2018.
Organ System: Renal
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Pediatrics
Topic(s): Neoplasms, Wilms Tumor
285.
Stem: A 45-year-old man presents to his primary care practitioner with a pruritic
raised rash, which spares the face and palms/soles. His clinical history includes hot tub
exposure 2 days prior, completion of a 14 day course of trimethoprim/sulfamethoxazole
for acute prostatitis 1 day prior, and a household contact with recent MRSA
furunculosis. What is the most likely cause of his rash (see image)?
<CATCH: Insert Photo I>
<CATCH: Insert credit line underneath the photo: Reproduced with permission from Carol Soutor, Maria
K. Hordinsky: Clinical Dermatology. Copyright © McGraw-Hill Education. All rights reserved. Figure 146.>
Answer choice:
a.
b.
c.
d.
e.
Allergic contact dermatitis
Drug eruption from the trimethoprim/sulfamethoxazole
Hot tub folliculitis
MRSA furunculosis
Viral exanthem
Answer: The answer is B.
Explanation: The appearance of the rash is most consistent with a drug eruption, with a maculopapular
appearance, sparing the face and palms/soles. Sulfa drugs and antibiotics are the most common
medications to cause drug eruptions. The image shows the appearance of a classic drug eruption (B).
Allergic contact dermatitis (A) is pruritic and can be local or diffuse depending on area of exposure,
though the patient’s history does not include reports of any new allergen exposure. Hot tub folliculitis
(C) is characterized by tender and itchy papules and pustules originating from the hair follicles. MRSA
furunculosis (D) is characterized by larger pustular lesions, approximately 1–2 cm in size, which is not
the rash seen in this image. Viral exanthems (E) can have various appearances including macular and/or
maculopapular, but are seen most often in association with childhood illnesses such as measles, roseola,
parvovirus B19, as well as others.
References:
Samel AD, and Chu CY. Drug eruptions. In www.uptodate.com. Updated October 3, 2016, accessed
September 29, 2017.
Kanj SS, Sexton DJ. Pseudomonas aeruginosa skin and soft tissue infections. In www.uptodate.com.
Updated November 1, 2017. Accessed December 26, 2017.
Organ System: Dermatologic
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Family Medicine
Topic(s): Papulosquamous Disorders, Drug Eruptions
286.
Stem: A 20-year-old soccer player was knocked unconscious during a game and
subsequently developed a persistent headache, nausea, and difficulty concentrating. His
symptoms completely resolved after approximately 48 hours. He presents to the
primary care office for medical clearance to return to collegiate soccer. What
intervention would have the biggest impact on decreasing his risk of developing diffuse,
fatal cerebral swelling?
Answer Choice:
A.
B.
C.
D.
E.
Avoiding TV and loud music for the next month
Slow return to activity in about five to seven days
Initiation of an atypical antipsychotic
Referral to a psychiatrist
Immediate return to high-level cognitive tasks
Answer: The answer is B.
Explanation: The best way to prevent second impact syndrome, or diffuse cerebral swelling that occurs
in the setting of another mild head injury, is to remove the player from sports for five to seven days (B).
While avoiding excessive stimulation in the form of TV or loud music may help prevent postconcussive
syndrome and quicken healing time, these interventions have no effect on preventing a serious,
potentially fatal outcome, if the patient was to suffer another head injury (A). Initiation of an
antipsychotic has no preventative effect on brain swelling in the setting of a second head injury, nor
does interaction with a psychiatrist (C and D). Immediate return to intense cognitive work will not
protect against damage from a second TBI, and in fact, it may increase the risk of developing
postconcussive syndrome associated with the initial head injury (E).
References:
Manley GT, Hauser SL, McCrea M. Concussion and Other Traumatic Brain Injuries. In: Jameson J, Fauci
AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th
ed. New York, NY: McGraw-Hill; 2018. http://usjezproxy.usj.edu:2195/content.aspx?bookid=2129&sectionid=192533001.Accessed February 28, 2019.
Organ System: Neurologic
Task Area: Health Maintenance
Core Rotation: Primary Care, Internal Medicine
Topic(s): Traumatic Brain Injury
287.
Stem: A 66-year-old woman presents with shortness of breath, L sided chest
pain, and orthopnea for the last 3 days. She had a recent viral upper respiratory
infection, and a pericardial effusion is suspected. Which imaging modality would provide
a definitive diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Echocardiogram
Electrocardiogram
CXR, PA, and Lat views
L lateral decubitus CXR
Radionuclide myocardial perfusion imaging
Answer: The answer is A.
Explanation: Echocardiogram (A) is sensitive and specific in diagnosing a pericardial effusion.
An electrocardiogram may show low voltage QRS changes, sinus tachycardia, and electrical alternans.
The presence of electrical alternans and sinus tachycardia is highly specific for pericardial effusion, but in
the setting of cardiac tamponade.
ECG alone (B) has a low sensitivity for diagnosis of a pericardial effusion. CXR (C) may be unremarkable
in small effusions, while an enlarged cardiac silhouette may be seen in larger effusions, though is not
very sensitive or specific. L lateral decubitus CXR (D) would be helpful in the diagnosis of a pleural
effusion, but would have a limited if any role in the diagnosis of a pericardial effusion. Radionuclide
myocardial perfusion imaging (E) is used to assess myocardial perfusion and ventricular function, and
would not have a role in purely diagnosing a pericardial effusion.
References:
Hoit BD. Diagnosis and treatment of pericardial effusion. In www.uptodate.com. Updated May 21, 2017,
accessed September 29, 2017.
Organ System: Cardiovascular
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Traumatic, infectious, and inflammatory heart conditions, Pericardial Effusion
288.
Stem: A 69-year-old male with PMH of hypertension and type II diabetes
mellitus complains of right sided chest pain for 48 hours. The pain is worse with deep
breathing and he is fatigued. There has been no trauma and he has not had this pain in
the past. He does not have a cough nor nausea and vomiting. There is some mild nonpainful bilateral leg edema that is baseline. He is alert and appears well, blood pressure
156/92, pulse 92, respirations 24, pulse oximetry 94% on room air and afebrile. He
recently traveled from Florida to the New England area by car over the course of 2 days.
Serum lab studies reveal an elevated D-dimer assay.
Which is the best choice to further evaluate the patient’s symptoms?
Answer choice:
a.
b.
c.
d.
e.
Chest radiograph
Computed tomography pulmonary angiography
Bilateral lower extremity doppler ultrasound
Further evaluation not warranted because PERC rule places patient in low risk category
Empiric treatment can begin without further evaluation due to abnormal D-dimer
Answer: The answer is B
Explanation: The patient should undergo a CT-PA to determine if his symptoms are due to pulmonary
embolism. A chest radiograph will help identify other causes of chest pain but not PE. Ultrasound can be
used to identify the source of PE but cannot diagnose the condition. The PERC rule is not met due to
patient’s age. A D-dimer can be elevated due to other conditions and cannot be relied upon to solely
diagnose PE.
References:
Chesnutt AN, Chesnutt MS, Prendergast TJ. Pulmonary Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2018 New York, NY: McGraw-Hill;
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168189660. Accessed
December 07, 2017.
Organ System: Pulmonary System
Task Area: Using Laboratory & Diagnostic Studies
Core Rotation: Internal Medicine
Topic(s): Pulmonary Circulation, Pulmonary embolism
289.
Stem: A G1P0 woman at 39 weeks gestational age has arrest of descent; the
fetus transitioned from a brow presentation to face presentation with the mentum
posterior from the maternal abdomen. Which of the following is indicated?
Answer choice:
a. McRoberts maneuver to hyperflex the maternal hips
b. Change in maternal pushing position to knee-chest
c. Oxytocin administration
d. Cesarean delivery
e. Application of fundal pressure
Answer: The answer is D
Explanation: Face presentation (head is hyperextended) in a term nulliparous woman where the
mentum (fetal chin) is posterior, Cesarean Delivery (answer choice D) is recommended. Answer choices
A and B are interventions used in shoulder dystocia. Answer choices C and E are not indicated as this will
not change the fetal presentation.
References:
Julien S, Galerneau F. Face and brow presentations in labor. In: UpToDate, Berghella V, Barss VA (Eds.),
UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed on December 22, 2017.)
Patel S. Abnormal labor and malpresentation. In: Link FW, Carson SA, Flower WC, Snyder RR., eds. StepUp to Obstetrics and Gynecology. Philadelphia, PA: Wolters Kluwer Health; 2015: 96-100.
Organ System: Reproductive
Task Area: Clinical Intervention
Core Rotation: Obstetrics-Gynecology
Topic(s): Complicated Pregnancy—Cesarean delivery
290.
Stem: The mother of a 12-year-old adolescent female brings her daughter to
your office for “uneven shoulders.” You suspect scoliosis and confirm this with an
Adams forward bending test, and a scoliometer. Which finding in the history and
physical would be most concerning for underlying adverse pathology?
Answer choice:
A.
B.
C.
D.
A right thoracic curve (convex to the right)
No pain symptoms
A left thoracic curve (convex to the left)
A single nevus over the scapula
Answer: The answer is C.
Explanation: Right thoracic curves are the most common, left are more associated with spinal cord
tumors and neuromuscular pathology (C). Adolescent idiopathic scoliosis is often painless, and a single
skin lesion is worrisome only if it is midline.
References:
Horne JP, Flannery R, & Usman S. Adolescent idiopathic scoliosis: Diagnosis and management. American
Family Physician. 2014;89:193-198. www.aafp.org/afp.
Organ System: Musculoskeletal
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Family Medicine, Pediatrics
Topic(s): Spinal Disorders, Scoliosis
291.
Stem: An 85-year-old male patient is brought into the Emergency Department
by EMS for cardiac arrest. EMS reports that they have been providing advanced cardiac
life support for the patient for a total of 45 minutes while at his home and then in route
to the hospital. His cardiac monitor reveals that he is in asystole. He has a medical
history that includes metastatic prostate cancer, dementia, and heart failure. Which of
the following answer choices represents potentially unethical behavior on the part of
the ED providers at this juncture in patient care?
Answer Choice:
A.
B.
C.
D.
E.
Deciding to cease further resuscitative efforts
Inserting a central venous line
Attempting to contact the patient’s next-of-kin
Allowing an available family member to witness resuscitative efforts
Allowing a resident to practice chest compressions during resuscitation
Answer: The answer is B.
Explanation: Resuscitation from cardiac arrest has a low likelihood of success. Providers must weigh
many factors when deciding to perform or continue resuscitative efforts including the likelihood of
success and expected quality of life. In this case, further resuscitation may be seen as “futile” and given
the patient’s underlying medical conditions, ceasing efforts would be a reasonable decision (A).
Furthermore, attempting to contact the patient’s family or allowing family members to see the patient
during resuscitation are both appropriate (C and D). Family members allowed to witness the
resuscitative efforts should be provided a liaison to help explain the process. Teaching is an integral part
of healthcare (E). Allowing appropriately trained students and residents to assist in such procedures is
not unethical. Inserting a central line, despite the exceedingly low chance of survival, is potentially an
ethical violation. This is an invasive, costly procedure with almost no likelihood of changing the
outcome.
References: Marco CA. Ethical Issues of Resuscitation. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM,
Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New
York, NY: McGraw-Hill; 2015.
http://accessmedicine.mhmedical.com.wingatehealthsciences.idm.oclc.org/content.aspx?bookid=1658
&sectionid=109427375. Accessed February 07, 2019.
Organ System:
Task Area: Professional Practice
Core rotation:
Topic(s): Legal/Medical Ethics
292.
Stem: A 3-month-old male presents for a well child check. His mother states
that the child is eating well. On physical exam, the infant weights 10 lbs. 2 oz. This is a 1
lb. increase since the last visit 4 weeks ago. There is no evidence of cyanosis in the nails
or lips. On cardiac exam, there is a pansystolic murmur audible at the left mid sternal
border. Echocardiography is ordered and reveals a small (<3 mm) ventricular septal
defect without left atrial enlargement. Which one of the following is the best
management plan for this infant?
Answer choice:
a.
b.
c.
d.
e.
Prescribe a diuretic and angiotensin converting enzyme inhibitor (ACEI)
Start Indomethacin to initiate closure of the defect
Reassure the parents about the nature of the defect and recheck in one month
Refer for placement of pulmonary artery band
Refer for ventriculostomy
Answer: The answer is C
Explanation: In an infant with VSD, follow up appointments are important for detecting signs of volume
overload or growth failure (C). Surgical intervention with ventriculostomy (E) or placement of pulmonary
artery bands (D) is recommended if child is not gaining weight, is having repeated lower respiratory tract
infections, or the pulmonary artery systolic pressure is greater than half of the systemic systolic
pressure. Clinical improvement with weight gain and echo evidence that the VSD is getting smaller
means the patient can be medically managed until the age of 2 years, (A) and (B). If VSD has not closed
at that time, corrective procedures should be considered.
References:
Harikrishnan, KN and Vettukattil, JJ. Congenital Heart Diseases. In: Elmoselhi A. ed. Cardiology: An
Integrated Approach. New York, NY: McGraw-Hill.
Organ System: Cardiovascular
Task Area: Clinical Interventions
Core Rotation: Pediatrics
Topic(s): Congenital Heart Disease, Ventricular Septal Defect
293.
Stem: A 64-year-old man presents to the Emergency Department via ambulance
for decreased mental status. His niece found him unconscious when she arrived to his
house to visit today. His vitals are stable, but he remains unresponsive during physical
exam. A non-contrast head CT scan reveals a large subarachnoid hemorrhage and
angiography confirms it was the result of a ruptured berry aneurysm. What diagnosis is
most likely to be present in his past medical history?
Answer Choice:
A.
B.
C.
D.
E.
Hypercholesterolemia
Hydrocephalus
Vitamin D deficiency
Hypertension
Insomnia
Answer: The answer is D.
Explanation: Spontaneous subarachnoid hemorrhages are commonly the result of a ruptured saccular
aneurysm. Risk factors for aneurysmal rupture resulting in a subarachnoid hemorrhage include
hypertension, smoking, and connective tissue disease (D). Hypercholesterolemia is associated with an
increased risk of ischemic stroke, but not subarachnoid hemorrhage resulting from ruptured aneurysm
(A). Hydrocephalus is not associated with an increased risk of aneurysm development or spontaneous
intracerebral hemorrhages (B). Although vitamin D deficiency and insomnia may be present in the
patient’s past medical history, they do not have an association with an increased risk of subarachnoid
hemorrhage or aneurysm formation (D and E).
References:
Bhat L, Humphries RL. Neurologic Emergencies. In: Stone C, Humphries RL, eds. CURRENT Diagnosis &
Treatment: Emergency Medicine. 8th ed. New York, NY: McGraw-Hill; 2017. http://usjezproxy.usj.edu:2195/content.aspx?bookid=2172&sectionid=165065601. Accessed February 28, 2019.
Organ System: Neurologic
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Emergency Medicine
Topic(s): Intracranial Hemorrhage
294.
Stem: A 60-year-old male carpenter presents for evaluation of ongoing
nonproductive cough and exertional dyspnea for the past 6 months. He is a non-smoker.
On physical exam, there are fine inspiratory crackles without digital clubbing. A chest xray taken in the office reveals reticular opacities in the lower lung fields. His pulmonary
function tests show a decrease in total lung capacity, functional residual capacity, and
residual volume. Which one of the following is the most likely diagnosis?
Answer choice:
a.
b.
c.
d.
e.
Asthma
Chronic bronchitis
Emphysema
Idiopathic pulmonary fibrosis
Hyaline membrane disease
Answer: The answer is D
Explanation: IPF (D) is seen more often in men over the age of 60 years old. Many are cigarette smokers,
but it can also occur in people with environmental exposures (i.e., wood dust). The symptoms are
prolonged (>6 months before many seek treatment) and include dry cough with dyspnea that occurs
with exertion. The chest x-ray can include a ground-glass appearance, nodular or reticular opacities. In
this case, the PFTs reveal a restrictive pattern. Hyaline membrane disease (E) is a result of lack of
surfactant and would be suspected in premature infants. COPD and asthma (A), (B), and (C) do not have
opacities on CXR.
References:
Tighe RM, Meltzer EB, Noble PW. Idiopathic Pulmonary Fibrosis. In: Grippi MA, Elias JA, Fishman JA,
Kotloff RM, Pack AI, Senior RM, and Siegel MD. eds. Fishman's Pulmonary Diseases and Disorders, Fifth
Edition. New York, NY: McGraw-Hill.
Organ System: Pulmonary
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Internal Medicine
Topic(s): Restrictive Pulmonary Disease, Idiopathic Pulmonary Fibrosis
295.
Stem: Which of the following vaccinations is recommended during pregnancy?
Answer choice:
a.
b.
c.
d.
e.
Attenuated Influenza
Measles-Mumps-Rubella combination (MMR)
Rubella
Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap)
Varicella zoster
Answer: The answer is D
Explanation: Tdap is recommended for all pregnant women during each pregnancy between 27-36
weeks gestation to provide protection against infant pertussis. Live (termed attenuated) vaccinations
such as the MMR, Rubella, Varicella, and attenuated influenza (Influenza LAIV) are contraindicated in
pregnancy. For protection against the flu during pregnancy, the inactivated influenza (Influenza IIV) is
recommended.
References:
Barss VA. Immunizations during pregnancy. In: UpToDate, Lockwood CJ, Weller PF, Bloom A (Eds.),
UpToDate, Waltham, MA. Available at http://www.uptodate.com (Accessed on December 22, 2017.)
Organ System: Reproductive
Task Area: Health Maintenance
Core Rotation: Obstetrics-Gynecology
Topic(s): Uncomplicated Pregnancy, Preconception/prenatal care
296.
Stem: A 39-year-old woman presents to the Emergency Department for a
sudden onset of dizziness that has lasted three days. The patient complains of the
dizziness being constant and accompanied by a loud ringing in her right ear, making if
difficult to hear. She further complains of nausea and vomiting, which presented today,
as well as feeling as if she is walking funny. Her vital signs are all within normal range.
Her HEENT reveals TMs that are without erythema, edema, or exudate, and have a cone
of light at the 12 o’clock position. The only abnormal finding noted on physical exam is
that the patient’s gait is swaying to the left during ambulation. What is the appropriate
management for this patient?
Answer choice:
a.
b.
c.
d.
e.
Amoxicillin
Meclizine
Levofloxacin
Fluconazole
Loperamide
Answer: The answer is B.
Explanation: This patient is suffering from labyrinthitis, as made evident by the gait instability, sudden
and progressive dizziness, and tinnitus. The patient has a normal ear exam, which suggests that this is
not a bacterial labyrinthitis; therefore, antibiotics are not necessary in treatment (A) and (C).
Fluconazole (D) is not indicated in the treatment of labyrinthitis, nor is treatment with an anti-diarrheal
(E).
References:
Lustig LR, Schindler JS. Ear, Nose, & Throat Disorders. In: Papadakis MA, McPhee SJ, Rabow
MW. eds. Current Medical Diagnosis & Treatment 2017. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1843&sectionid=135700660.
Accessed December 13, 2017.
Furman, J. (2017). Vestibular neuritis and labyrinthitis. UpToDate
https://www.uptodate.com/contents/vestibular-neuritis-andlabyrinthitis?search=labyrinthitis&source=search_result&selectedTitle=1~55&usage_type=defa
ult.
Goldman B. Vertigo. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.
Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109436887.
Accessed December 19, 2017.
Organ System: EENT
Task Area: Clinical Intervention
Core Rotation: Emergency Medicine, Internal Medicine
Topic(s): Ear Disorders, Inner ear, Labyrinthitis
297.
Stem: A 54-year-old female complains of dry eyes, which has prevented her
from wearing her contacts over the past three years. She reports sucking on lemon
drops often due to problems with her mouth seeming dry. She was advised by her
dentist to be evaluated by her primary care physician due to multiple cavities over the
past year despite brushing her teeth regularly. What finding on physical exam would
best support your suspected diagnosis?
Answer choice:
A.
B.
C.
D.
E.
Parotid gland enlargement
Cervical lymphadenopathy
Rhinorrhea
Exophthalmos
Lid lag
Answer: The answer is A.
Explanation: This patient’s exhibits typical sicca symptoms that are associated with Sjogren’s syndrome
including xerostomia and dry eye. A finding of parotid gland enlargement would support your diagnosis
(A). Cervical lymphadenopathy is a nonspecific finding although it is important to note that there is a
higher risk of lymphoma in patients with Sjogren’s syndrome. Although rare, lymphoma tends to occur
later in the disease. Rhinorrhea is a nonspecific finding. Nasal dryness would more likely be associated
with Sjogren’s syndrome. Exophthalmos and lid lag are associated with Grave’s disease.
References:
Moutsopoulos HM. Sjögren’s Syndrome. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL,
Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill; 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192285278. Accessed
September 04, 2018.
Organ System: Musculoskeletal
Task Area: History Taking and Performing Physical Examinations
Core Rotation: Family Medicine, Internal Medicine
Topic(s): Sjogren’s Syndrome
298.
Stem: Following a motor vehicle collision, a 27-year-old male was diagnosed
with a concussion. During a follow-up appointment approximately 6 months later, he
reports that he has been unable to complete his dissertation defense in his PhD
program because of difficulty concentrating and persistent fatigue. A physical exam
reveals no focal deficits and a normal mini-mental status examination. What is the best
information to provide to the patient regarding his condition?
Answer Choice:
A. Temporarily reduced workload may aid in resolution of symptoms in a few months
B. His condition is permanent and will require him to abandon his doctoral work
C. With intense inpatient psychiatric admission, he may regain some higher cognitive function over
the next two years
D. His symptoms are likely unrelated to his injury and will improve with cognitive behavioral
therapy
E. Neurosurgical intervention will provide immediate resolution of his symptoms
Answer: The answer is A.
Explanation: Postconcussive syndrome is most commonly managed with patient education and
recommendations to reduce workload or physical activity and then gradually return to the pre-injury
level of activity, which usually occurs over a few weeks (A). It is important to reassure the patient
repeatedly that his current symptoms will improve and are not indicative of chronic dementia (B).
Postconcussive syndrome usually improves within months (C). In addition, there has been no evidence
that inpatient psychiatric treatment will have an effect on symptom resolution. The symptoms described
by the patient in relation to his earlier head injury make (D) less likely to be correct. The patient has no
evidence of intracerebral hemorrhage or other structural abnormality, such as focal neurological deficit
or worsening mental status, that would be amenable to surgical intervention (E).
References:
Ropper AH, Samuels MA, Klein JP. Chapter 35. Craniocerebral Trauma. In: Ropper AH, Samuels MA, Klein
JP, eds. Adams & Victor's Principles of Neurology. 10th ed. New York, NY: McGraw-Hill; 2014. http://usjezproxy.usj.edu:2195/content.aspx?bookid=690&sectionid=50910886. Accessed February 28, 2019.
Organ System: Neurologic
Task Area: Health Maintenance
Core Rotation: Primary Care, Internal Medicine
Topic(s): Postconcussive Syndrome
299.
Stem: Which of the following conditions is associated with posterior blepharitis?
Answer choice:
A.
B.
C.
D.
E.
Angle closure glaucoma
Cataracts
Chronic glaucoma
Keratoconjunctivitis sicca
Posterior uveitis
Answer: The answer is D.
Explanation: Keratoconjunctivitis sicca is a dry eye syndrome resulting from meibomian gland
dysfunction (posterior blepharitis) (D). This dysfunction causes a disruption in tear film stability and
results in subsequent ocular surface discomfort and inflammation. Angle closure glaucoma causes a
rapid rise in intraocular pressure resulting from acute narrowing or closure of the angle of the anterior
chamber (A). This is an internal ocular disorder. Cataracts is a disorder of the intraocular lens (B).
Chronic glaucoma is a progressive rise in the intraocular pressure and is not caused or impacted by
blepharitis (an external disorder) (C). Posterior uveitis is also an internal eye disorder and is not
impacted or associated with blepharitis (E).
References:
Lowery RS. Acute Blepharitis. Medscape. https://emedicine.medscape.com/article/1211763overview#a4. Accessed December 29, 2017.
Foster CS. Dry Eye Disease (Keratoconjunctivitis Sicca). Medscape.
https://emedicine.medscape.com/article/1210417-overview. Accessed October 9, 2017.
Organ System: EENT
Task Area: History Taking & Performing Physical Examinations
Core Rotation: Family Medicine, Emergency Medicine
Topic(s): Eye Disorders, Lid Disorders, Blepharitis
300.
Stem: An obese 36-year-old male presents for evaluation of a tender left calf
where “I got hit by a baseball” 5 days before. He reports pain that is worsening and a
“red line” going up his lower leg. He denies edema, gait disturbance, or fever. On exam,
you notice brawny skin of the lower extremities, a few tortuous veins, and a welldefined, linear area of erythematous induration and moderate inflammation along the
medial calf that extends to the knee. The scenario is most consistent with which
diagnosis?
Answer choice:
A.
B.
C.
D.
Acute arterial occlusion
Deep vein thrombosis
Hemarthrosis
Superficial thrombophlebitis
Answer: The answer is D.
Explanation: Superficial thrombophlebitis (D) is characterized by induration, redness, and tenderness
along a superficial vein. It may result from intravenous catheter sites or spontaneously in pregnant or
postpartum women or individuals with varicosities, trauma, or in those with systemic
hypercoagulopathies. Acute arterial occlusion (A) would not produce superficial induration or skin
changes. Deep vein thrombosis (B) would generally result in edema, tenseness, and/or pain and it
typically would not produce focal skin changes. Hemarthrosis (C) would produce symptoms localized to
the joint. Cellulitis would not be well-defined or linear in presentation. It is often accompanied by fever.
References:
Gasper WJ, Rapp JH, Johnson MD.. Blood Vessel & Lymphatic Disorders. In: Papadakis M & McPhee S,
eds. Current Medical Diagnosis & Treatment 2018.
http://accessmedicine.mhmedical.com/content.aspx?bookid=2192&sectionid=168192658#1145433772.
Organ System: Cardiovascular
Task Area: Formulating Most Likely Diagnosis
Core Rotation: Emergency Medicine, Family Medicine
Topic(s): Vascular Disease, Phlebitis/Thrombophlebitis