QUESTIONS 1 AND 2 REFER TO THE FOLLOWING SCENARIO:
A 31 year old female truck driver recovering from a flu like illness made a cross country
trip delivering an overdue payload. Several hundred miles short of her destination she abruptly
developed a single shaking chill and subsequently fever, productive cough, chest pain and
shortness of breath which worsened progressively over the next two hours. She drove to your
emergency room where you met her. On further questioning, she states she is now coughing up
copious amounts of thick greenish-pink sputum. On examination she appears in moderate
distress with frequent spasms of coughing while holding her left chest. Her temperature is 103°
orally, blood pressure is 150/100, pulse 110/minute and regular, and respiratory rate is 28/minute.
There is no tracheal deviation. On examining her chest there is increased fremitus and dullness to
percussion at the left base. E to A changes are noted at the left base as well. After you complete
your examination, you order a Chest X-ray.
1. The X-ray is MOST LIKELY to show which of the following findings:
a. Left Pleural effusion
b. Left Pneumothorax
c. Left Pulmonary Embolus
d. Left Lobar Consolidation
e. Left apical cavity
For administration of antibiotics, a subclavian catheter is placed on the left. Shortly thereafter she
becomes acutely dyspneic and cyanotic. On examination you notice her trachea is deviated to the
right. There is now decreased fremitus over the left chest. Areas of the left chest are now
hyperresonant with absent breath sounds.
2. A repeat Chest X-Ray is MOST LIKELY to demonstrate which of the following;
a. Hydropneumothorax
b. Massive pulmonary embolus
c. Bilateral pneumonia
d. Miliary Tuberculosis
e. Bronchiectasis
Match the following disease state to the most likely area of lymphatic drainage;
3. Tonsillar abscess
4. Nasopharyngeal carcinoma
a. Anterior Neck triangle
b. Posterior Neck triangle
c. None of the above
QUESTIONS 5-7 ARE MATCHING QUESTIONS
For each of the isolation precautions listed below indicate which ONE of the infection control
practices (A-E) is MOST appropriate for the health care worker caring for the patient?
5. Airborne precautions
6. Droplet precautions
7. Contact precautions
a. Wear a special mask that filters droplets in the 1-5 micron range while the patient
is in a negative pressure room
b. Wash hands
1
c. Wear a surgical mask when working within 3 feet of the patient
d. Wear gloves and gown and leave them in room before leaving
e. Wear goggles
MATCH THE FOLLOWING DISEASE PROCESSES WITH THE APPROPRIATE
PHYSICAL FINDINGS;
8. A 70 year old previous smoker with emphysema
9. A 12 year old boy with an acute asthma attack
a. Increased fremitus, dull to percussion, crackles present
b. Decreased fremitus, dull to percussion, no crackles
c. Normal fremitus, normal percussion, diffuse inspiratory and expiratory wheezes
d. Decreased fremitus, Resonant or hyperresonant to percussion, decreased
vesicular sounds
e. Normal fremitus, normal percussion, normal vesicular sounds
MATCH THE FOLLOWING FUNDOSCOPIC FINDINGS WITH THE PATHOLOGY
BELOW
10. Fluffy white spots with indistinct borders (cotton wool spots)
11. Hard Exudates
12. Dot and Blot hemorrhages
a. Retinal infarcts
b. Lipid/protein deposits
c. Deep retinal bleeds
d. Superficial retinal bleeds
e. Vitreous bleeds
13. To test for accommodation:
a. Use a swinging flashlight
b. Have the patient look across the room and then suddenly fix on an object held 6
inches from his/her nose
c. Both of the Above
d. Neither of the Above
14. An elderly gentleman is admitted to the hospital with left sided weakness. The
neurologist states that he has had a stroke. On examination he is lethargic and you notice short
periods of apnea alternating with periods of very deep breathing. After observing this repetitive
pattern for several minutes you conclude:
a. The patient is hyperventilating due to his anxiety of being in the hospital
b. The patient has Kussmaul breathing
c. The patient has Cheyne-Stokes breathing
d. The patient has obstructive airways disease
15. Of the following, the best tuning fork to use when testing posterior column integrity is;
a. 128 frequency
b. 512 frequency
c. 1024 frequency
d. All of the above are equally good
2
16. A 15 year old boy presents with a fever and productive cough. Which of the following
signs would suggest consolidation;
a. Whispered pectoriloquy
b. Egophony
c. Both of the above
d. Neither of the above
17. The parotid duct (also called Stenson's duct) is located:
a. opposite the canine
b. opposite the second mandibular molar
c. opposite the second maxillary molar
d. floor of the mouth
e. in an inconsistent location
18. Which of the following cause pain upon moving the auricle?
a. Acute otitis media
b. Acute otitis externa
c. Chronic mastoiditis
d. Bullous myringitis
e. None of the above
19. A febrile medical student complained of coughing up yellow green sputum. On
examination of the chest, there are no rhonchi or wheezes but you hear crackles over the left mid
chest posteriorly. The MOST likely diagnosis is;
a. malingering in order to get out of taking an exam
b. congestive heart failure
c. asthma
d. pneumonia
e. bronchitis
20. To test the cardinal gazes of vision, you should ask the patient to look at all of the
following directions except;
a. to the left
b. to the right
c. straight up
d. to the right and up
21. A 6 year old girl is brought to the eye doctor because of a "lazy eye”. In primary gaze, her
right eye is looking straight ahead but her left eye is deviated laterally. The best term to describe
this finding is;
a. esotropia
b. hypertropia
c. exotropia
d. left lateral rectus paralysis
e. right lateral rectus paralysis
22. Tests of cerebellar function include all of the following except:
a. Babinski test
b. finger to nose
c. heel to shin
d. rapid alternating movements
e. Romberg test
3
23. Clubbing of the fingers is least likely to be found in which of the following conditions;
a. Bronchogenic carcinoma
b. Chronic obstructive lung disease
c. Metastatic disease of the colon to the lung
d. Cyanotic congenital heart disease
24. Select the list that is correctly ordered from most lucent (black on radiograph) to most
radioopaque (white on radiograph):
b. metal/ calcium/ soft tissue/ air
c. fat/ air/ fluid/ bone
d. air/ fat/ soft tissue/ bone
e. air/ soft tissue/ iodinated contrast/ fat
25. The term "glue ear" is used to describe;
a. Thick cerumen in the ear
b. Chronic otitis media with serous effusion
c. An affliction of swimmers
d. An affliction of boxers
26. A 66 year old man presents for a routine examination. He has no complaints. On
otoscopic exam, you see white spots on the tympanic membrane. The least likely diagnosis is;
a. choleastoma
b. scarring of the membrane from old infections
c. tympanosclerosis
d. external otitis
27. A 77 year old man presents complaining of sudden loss of vision in his right eye. On
examination of the fundus, the retina appears pale and opaque and there is a cherry red spot at the
macula. The most likely diagnosis is;
a. Diabetic retinopathy
b. Vitreous hemorrhage
c. Central retinal vein occlusion
d. Central retinal artery occlusion
e. Hypertensive retinopathy
28. A 44 year old man complains of fever, dyspnea and pleuritic pain 3 days after an
appendectomy. A chest X-ray demonstrates collapse of the left upper lobe with loss of volume.
The best term to describe this finding is;
a. Bronchiectasis
b. Apical cavity
c. Atelectasis
d. Interstitial edema
29. A 50 year old man presents with complaints of daytime fatigue, sometimes falling asleep
at work. If he had obstructive sleep-apnea, you would least expect to find which of the
following;
a. A history of loud snoring
b. Short stocky neck
c. Tall, thin stature
d. Enlarged tonsils
4
30. A 66 year old man presents with a right facial droop. You are concerned he may have
had a stroke. Which of the following findings would be least consistent with an upper motor
neuron lesion;
a. Flattening of the nasolabial folds on right
b. Inability to tightly close eye completely on right
c. Decreased corneal reflex on right
d. Ability to wrinkle forehead on right
e. Difficulty with whistling or puffing out cheeks on the right
31. A 30 year old man presents to the eye doctor for new glasses. On fundoscopic
examination, arteriolar narrowing, AN nicking, and copper wiring is seen. The test that would
be the most helpful in defining the cause of these findings would be;
a. Measuring the blood sugar
b. Measuring the intraocular pressure
c. Measuring the cholesterol
d. Measuring the blood pressure
e. Checking the visual fields
32. A 70 year old man presents with acute loss of vision in his left eye. He states that he has
noticed increased floaters associated with specks, rings, lightning flashes and luminous bodies
over the last few weeks and then noticed the sensation of a curtain falling over a portion of his
visual field. The most likely diagnosis is;
a. Papilledema
b. Migraine
c. Glaucoma
d. Retinal detachment
e. Cataract
33. A 60 year old man presents with a chief complaint of a headache. It started suddenly,
feels like it is in and around his right eye, is aching in character, and associated with nausea,
vomiting, and decreased vision in the right eye. He states that he sees a halo around objects and
lights. Which of the following would be MOST helpful in diagnosing the problem;
a. Dilate the pupils for a fundoscopic exam
b. Auscultate the carotid arteries
c. Transilluminate the maxillary sinuses
d. Measure the intraocular pressure
e. Measure the systemic blood pressure
34. A 74 year old man is thought to have parkinsonism. Which of the following gaits would
you most LIKELY observe in this gentleman;
a. The gait is broad based and the patient may stagger or lurch irregularly.
b. The patient may have difficulty getting started, then he may take short shuffling
steps.
c. The patient lifts his feet high, bending at the knees.
d. There is circumduction of the leg with the knee stiff, often with scraping of the
outside of the foot.
e. The patient may take short uneven high steps in a jerking fashion.
35. The most common cancer-related cause of death for women is;
a. Breast cancer
b. Lung cancer
c. Colon cancer
d. Endometrial cancer
5
36. On examination of the retina by direct fundoscopy, which of the following is likely to be
a normal finding;
a. A cup size greater than three-fourths the size of the disc
b. Veins that are narrower than the arteries
c. Both of the above
d. Neither of the above
37. After sustaining a needle stick, the recommended procedure would be;
a. Do not tell anyone about it, but document it in the medical record of the patient
b. Do not tell anyone about it, but immediately start taking AZT (ziduvdine)
c. Inform only the resident working with you and let him/her start treatment
d. Immediately call the 24 hour needlestick hot line pager number
e. Inform the student health service on the last day you are on the service
38. A third year medical student is asked to draw some blood from a patient that is late for
another doctor's appointment and anxious to leave. After drawing several tubes of blood, the
student accidentally sticks himself with the needle while attempting to recap. Which of the
following statements is the most appropriate way to avoid getting a needle stick:
a. Recapping of needles should always be done with both hands.
b. Two people are recommended while recapping, one holding the needle and the
other the cap
c. After drawing blood, all material should be taken into another room to do the
recapping.
d. Do not recap a needle unless a sharps container is not available, otherwise use a
one-handed scoop technique.
39. While examining a patient, the Angle of Louis is BEST used as a landmark to;
a. Determine the exact location of the thyroid
b. Accurately number the ribs and interspaces
c. Determine the exact location of the midclavicular line
d. Determine the exact location of the midaxillary line
40. A 69 year old woman complains of decreased hearing in her left ear. You place a tuning
fork at the top of her head and she hears it better on the right. The BEST interpretation of these
observations is;
a. Sensorineural hearing loss on Right
b. Sensorineural hearing loss on Left
c. Conduction loss on Right
d. Conduction loss on Left
41. A 66 year old woman presents with vertical and horizontal diplopia. On examination her
left pupil is dilated and does not respond to light or accommodation. The right pupillary reflex is
normal. There is also ptosis of the left eye. On primary gaze, the left eye is abducted and
depressed. The most likely diagnosis is;
a. Paralysis of the inferior oblique muscle
b. Paralysis of cranial nerve III
c. Paralysis of cranial nerve IV
d. Homer's syndrome
e. Argyll-Robertson pupil
6
42. A 30 year old woman has a long history of rhinitis and sinusitis. On examination of the
nasal passages, you observe a grape like cluster of mucosa from the middle meatus. This is most
likely;
a. the inferior turbinate
b. a nasal polyp
c. kesselbach's plexus
d. an ectopic thyroid
43. A 24 year old woman has a several year history of monthly attacks of seeing flashes of
light in the right eye followed by nausea and severe headache. The most likely diagnosis is;
a. Glaucoma
b. Retinal detachment
c. Migraine
d. Vitreous hemorrhage
44. On greeting a 17 year old patient in the emergency room, the medical student notes
Kussmaul breathing. Which of the following is the most likely diagnosis:
a. Guillain-Barre syndrome (neuromuscular weakness)
b. diabetic ketoacidosis
c. asthma
d. narcotic overdose
e. obstructive sleep-apnea
Questions 45 and 46 are related to the same patient
45. A 16 year old boy complains of acute onset of chest pain which is worse on deep inspiration
and improves on sitting up and leaning forward. On physical examination, a scratchy, three
component sound is heard along the left sternal border. The most likely diagnosis is;
A) acute bacterial endocarditis
B) acute pulmonary embolus
C) acute pericarditis
D) acute myocardial infarction
E) acute costochondritis
46. On further examination of the above patient, it is noticed that his blood pressure drops 30
mm/hg when he takes a deep breath. This phenomenon is called:
A) Orthostatic hypotension
B) Sinus arrythmia
C) Pulsus paradoxus
D) Pulsus alternans
E) Auscultatory gap
47. A 44 year old man is found to have severe aortic stenosis due to a bicuspid aortic valve.
On examination, you would most likely find;
A) Slow and delayed upstroke of the carotid artery
B) Accentuated first component of the second heart sound
C) Both of the above
D) Neither of the above
7
48) A 33 year old woman presents with palpitations. In writing up a history and physical,
which of the following would be best placed in the Review of Systems;
A)Appendectomy at age 12
B) Normal Chest Xray on admission
C) Smoked 3 packs/day for 20 years
D) Works as a chemist
E) Developed an earache yesterday
49) A 22 year old man with a history of intravenous drug use presents with dyspnea. On exam
t2has a 3/6 holosystolic murmur at the lower left sternal border that increases with inspiration.
His liver is pulsatile. On examination of his jugular veins, you would most likely find;
A) No jugular venous distension
B) Prominent systolic waves (c-v merger)
C) Kussmaul' sign (increased jugular venous distension on inspiration)
D) Absence of hepatojugular reflex (decrease in jugular venous distension on
compression of the liver).
QUESTIONS 50-51 REFER TO THE FOLLOWING CASE HISTORY:
A 68 year old comes to the clinic for evaluation of dyspnea at rest. He had been in his
usual state of health until 4 days prior to admission when he noted dyspnea on walking around
his house. He states that he has had mild shortness of breath on exertion for 4-5 years and has
gradually limited his walking to about 1 mile on flat ground at a time. He states that he has a
chronic productive cough for at least the last 8 years and generally coughs up about 1 cup of
white sputum each morning. He has smoked 2 packs per day for 45 years. He denies fever or
change in the character of his sputum, but has been getting dyspneic with less and less activity.
50. Which of the following physical findings might you least expect to find on examination;
a. Generalized dullness to percussion over the chest
b. Decreased respiratory excursion of diaphragm
c. Barrel chest (increased AP diameter)
d. Accessory muscle use
e. Paradoxical abdominal breathing
51. On examination, the patient is cachectic and appears older than his stated age. He is in
moderate respiratory distress. His neck veins are distended to his jaw when he is sitting at 45°
and collapse with inspiration. His PMI (point of maximum impulse or apex) is not palpable and
his heart sounds are distant. The liver edge is palpable 3 cm below the right costal margin and the
entire span is 10 cm. There is 4+ pitting edema of both feet up to the knees.
The above physical findings are most likely due to;
a. Acute Pneumonia
b. Cor Pulmonale
c. Congestive heart failure
d. Acute bronchitis
e. Acute bronchospasm
MATCH THE SPECIFIC CRANIAL NERVE(S) WITH THE APPROPRIATE ELICITING
TECHNIQUE:
52. Cranial nerve V
53. Cranial nerve VII
54. Cranial nerve XI
55. Cranial nerve XII
8
a. Ask patient to smile
b. Touch the posterior pharyngeal wall and watch for a gag reflex
c. Ask patient to clench their teeth
d. Have the patient shrug the shoulders
e. Ask patient to stick out tongue
56. Which of the following conditions will most likely cause a decrease in visual acuity?
a. pterygium
b. heavily pigmented retina
c. pingueculae
d. macular degeneration
e. drusens
57. Flourescein staining of to cornea is least helpful in examining;
a. for evidence of trauma
b. painful eyes after extended contact lens wear
c. for astigmatism
d. for a foreign body
58. You are about to exam a frail 86-year-old patient who has been in the hospital for the past
3 weeks. On listening to the patient's lungs you hear crackles at both bases. These disappear after
the patient coughs. The BEST explanation for this phenomenon is:
a. The patient has congestive heart failure
b. The patient has bilateral pneumonia
c. The patient has bilateral pulmonary emboli
d. The patient had not adequately expanded her lungs because of her feeble
bedridden condition
e. The patient had bilateral silicosis from working in the mines
59. A Weber tuning fork exam is performed on a patient with a left hearing loss due to a
serous middle ear infection. Which of the following would be the MOST likely finding;
a. Sound will be heard louder in the right ear
b. Sound will be heard equally in both ears
c. Sound will be heard louder in the left ear
d. No sound will be heard at all
e. Unable to predict from this information
60. Which of the following fundoscopic findings is least likely to be seen in a 35 year old
male with a 16 year history of diabetes?
a. microaneurysms
b. hard exudates
c. dot/blot hemorrhages
d. papilledema
61. Which of the following is least likely to be seen in Parkinson's disease
a. bradykinesia
b. cogwheeling
c. Intention tremor of upper limbs, lower limbs, and head
d. retropulsion
e. decreased arm swing on walking
9
62. A 32 year old male returns from a skiing accident where he fractured his femur. He has
been at bed rest in a long leg cast for the past 10 days. He suddenly develops acute dyspnea. On
examination he is in moderate distress, breathing at 30/minute. Examination of his chest reveals
tachycardia with a prominent P2 louder than A2.There was no cardiac gallop or rub. His trachea
is midline. His lungs were clear to auscultation. Percussion was resonant throughout. The MOST
LIKELY diagnosis is;
a. Large pneumothorax
b. Acute bacterial Pneumonia
c. Acute pulmonary embolus
d. Myocardial infarction
e. Pericarditis
63. A 55 year old man was thought to have tuberculosis because of a history of chronic
cough, hemoptysis, weight loss, and an abnormal Chest X-ray. The X-ray demonstrated a cavity
in the left apex with a thick wall, lobulation, and spiculation. He did not respond to
anti-tuberculous therapy and all of his sputum cultures were negative for acid-fast organisms.
The most likely diagnosis is;
a. Adenocarcinoma of the lung
b. Squamous cell carcinoma of the lung
c. Metastatic carcinoma of the colon to the lung
d. Small cell carcinoma
64. A 74 year old man with a history of diabetes presents with horizontal diplopia. In primary
gaze, his eyes are aligned normally, but when he looks to his right, his right eye does not abduct
completely. The most likely diagnosis is
a. Right cranial IV palsy
b. Right cranial III palsy
c. Right cranial VI palsy
d. Left cranial III palsy
e. Right Bell's palsy
65. A 42 year old man, previously healthy, awakens with a room-spinning sensation. He is
unable to get out of bed and starts to feel nauseated as soon as he sits up. He is seen in the
emergency room and diagnosed with an inner ear disorder. All of the following are consistent
with this diagnosis except;
a. Nystagmus
b. Lightheadedness only on standing
c. Tinnitus
d. Hearing loss
e. Vertigo
66. A 50 year old man with a long history of alcoholism is admitted to the hospital with a
productive cough and placed in a negative pressure private room near the nurses’ station because
of a suspicion of tuberculosis. You are assigned to do an admission history and physical
examination. Which of the following would be the best way to protect yourself from infection;
a. Wear a surgical mask
b. Wear a surgical mask and gown
c. Wear goggles, surgical mask, gown and gloves
d. Place a PPD skin test on yourself, and if negative enter without precautions
e. None of the above
10
67. A 44 year old man has been in the hospital for 6 weeks recovering from a motor vehicle
accident. He has a large left leg wound that needs to be dressed twice daily. The surgical resident
asks you to change the dressing. He tells you it is 10 cm by 5 cm large and 3 cm deep. It has been
draining large amounts of a purulent material that is growing staph Aureus. The recommended
isolation precautions would be:
a. Wearing a surgical mask only
b. Washing hands only
c. Wearing gloves and surgical mask only
d. Wearing gown and gloves but no mask
e. Moving patient to a negative pressure room
68. A 23 year old man who is known to be HIV positive was admitted to the medical
intensive care unit with pneumocystis carinii pneumonia. After several days he is improving and
about to be transferred to the general medicine floor. He has no skin lesions, and three sputum
smears for acid fast organisms were negative. No other source of infection was found. The most
appropriate isolation precautions at this time would be;
a. Standard precautions
b. Airborne precautions
c. Droplet precautions
d. Contact precautions
69. A 70 year old man presents with acute onset of hemiparesis. On a detailed neurologic
examination you notice an abnormality of visual fields. Using a red match head and testing each
of the patient's eyes separately, you notice that the left visual field of each eye is restricted when
compared to your own. This defect is BEST described as;
a. a scotoma
b. Bitemporal hemianopsia
c. Homonymous hemianopsia
d. Strabismus
70. A sensorineural hearing loss may be due to;
a. dislocation of the ossicular chain
b. cerumen in the external auditory canal
c. otitis media with effusion
d. external otitis
e. None of the above
71. The red reflex is most likely to be present in which of the following conditions:
a. cataract of the lens
b. subconjunctival hemorrhage
c. detached retina
d. vitreous hemorrhage
e. leucocoria
72. Which of the following ocular findings are suggestive of an increased risk for
atherosclerotic disease;
a. Xanthelasma
b. Pterygium
c. Both of the above
d. Neither of the above
11
73. On testing the pupillary reflex with a swinging flashlight, you notice that the left pupil
constricts when you shine the light into it, but the right pupil dilates when you swing the light
over to it. The best explanation for this is;
a. This is a Marcus-Gunn pupil (afferent defect).
b. This is an Argyll-Robertson pupil (accommodation defect)
c. This is an Adie's pupil
d. The left eye is abnormal
e. This is a normal finding
74. A patient's vision improves when he looks through a pinhole. This is most consistent
with:
a. Retinal abnormalities
b. Vascular abnormalities
c. Neurologic abnormalities
d. Hysteria
e. Refractive abnormalities
75. A 35 year old woman presents with severe headaches. Which of the following signs are
indicative of papilledema on examination of the fundus;
a. blurring and loss of a distinct disc margin
b. presence of spontaneous retinal vein pulsations
c. Both of the above
d. Neither of the above
76. A 62 year old woman presents to the hospital with a pulmonary embolus. After
appropriate therapy, she recovers. Her discharge Chest X-ray demonstrates a small linear scar in
the periphery. Several years later, another chest X-ray demonstrates that the shadow has grown
considerably. The most likely diagnosis is;
a. Recurrent pulmonary emboli
b. Adenocarcinoma of the lung
c. Squamous cell carcinoma of the lung
d. Metastatic carcinoma of the colon to the lung
e. Small cell carcinoma
77. A 68 year old woman is found to have multiple pulmonary nodules in the periphery of her
lung fields bilaterally. The most likely diagnosis is;
a. Bronchogenic carcinoma
b. Metastatic carcinoma to the lung
c. Chronic bronchitis
d. Pneumonia
78. A 46 year old woman was admitted for dyspnea and exercise intolerance of unclear
etiology. On rounds it is noted that her abdomen moves inward on inspiration (Hoover's sign).
The BEST explanation for this phenomenon is;
a. This is the normal pattern of breathing.
b. This is due to a congenital chest wall abnormality
c. This is due to a flattened or paralyzed diaphragm
d. This is a sign of hysteria
12
ANSWERS:
1. D
2. A
3. B
4. A
5. A
6. C
7. D
8. B
9. C
10. A
11. B
12. D
13. B
14. B
15. B
16. C
17. C
18. B
19. E
20. C
21. C
22. A
23. C
24. D
25. B
26. C
27. D
28. C
29. C
30. D
31. D
32. D
33. D
34. B
35. B
36. C
37. D
38. D
39. A
40. D
41. D
42. B
43. C
44. A
45. C
46. C
47. A
48. E
49. B
50. C
51. B
52. C
53. A
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
13
D
E
E
A
D
A
B
D
C
A
C
B
C
D
A
C
C
B
A
A
A
A
B
B
C