Step 3 Free 137: Answers & Explanations (November 2019)

Question 1

Answer: A - Age

Temporal arteritis (giant cell arteritis) is the most significant condition associated with age. The 4-week history of shoulder and arm stiffness, elevated ESR (88 mm/h), anemia, and constitutional symptoms (fatigue, fever, headache) are classic. Patients over 50 are at dramatically increased risk due to age-related vascular changes. While African American gender and occupation are mentioned, age is the most significant demographic risk factor for this disease.

Question 2

Answer: D - Rhinovirus

The follicular lymphoid hyperplasia on the posterior oropharynx with sore throat, mild fever, and cough indicates a viral pharyngitis. Rhinovirus is the most common cause of the common cold presentation with rhinitis, sore throat, nonproductive cough, and frontal headache. The morning-worse headache suggests sinusitis involvement common with rhinovirus infection.

Question 3

Answer: E - Vascular dementia

Vascular dementia is the most likely diagnosis given the history of two small strokes 3 and 7 months ago with recent cognitive decline. The elevated blood pressure (196/112), lack of focal findings except left hand weakness, and relatively preserved physical health despite cognitive loss are consistent with multi-infarct dementia. Labs are normal, making other causes less likely.

Question 4

Answer: A - Avascular necrosis of the femoral head

Avascular necrosis (osteonecrosis) of the femoral head is a common complication of prolonged glucocorticoid use. The 6-month history of steroid therapy combined with weight-bearing hip pain, limited range of motion, and normal neurovascular exam point to bone ischemia rather than neurologic or ligamentous causes. This is a well-known adverse effect of corticosteroids.

Question 5

Answer: C - Cholangitis

Cholangitis (bile duct infection) best explains this presentation. The fever, chills, right upper quadrant pain, confusion (indicating sepsis), and elevated WBC with bands indicate acute infection. The dilated common bile duct (9 mm) with gallstones and elevated amylase suggest biliary obstruction with bacterial infection. This represents Charcot's triad of fever, jaundice, and mental status change.

Question 6

Answer: E - Transient tachypnea of newborn 12 Items #7-8 are part of a sequential item set. In the actual examination environment, you will not be able to view the second item until you click "Proceed to Next Item." After navigating to the second item, you will not be able to add or change an answer to the first item. A 23-year-old man comes to the office because of a 7-day history of fever, crampy abdominal pain, and diarrhea. He says the abdominal pain worsens with oral intake. He has been having 8 to 10 episodes of diarrhea daily. He has not traveled recently and has had no sick contacts. Medical history is unremarkable and he takes no medications. He does not smoke cigarettes, drink alcoholic beverages, or use illicit drugs. He is not sexually active. Vital signs are temperature 38.3°C (101.0°F), pulse 118/min, respirations 18/min, and blood pressure 108/58 mm Hg. Bowel sounds are hyperactive. The abdomen is diffusely tender to palpation; no masses are palpated. Neither the liver edge nor the spleen can be palpated. Digital rectal examination shows grossly bloody stool. A stool culture is obtained, and empiric pharmacotherapy is initiated.

Transient tachypnea of the newborn is most likely. This 36-week preterm infant with maternal smoking exposure and cesarean delivery presents with tachypnea (70/min), mild retractions, and clear lungs with intercostal fissure fluid. TTN is self-limited due to delayed fetal lung fluid clearance. Good Apgar scores and normal oxygen saturation (95%) argue against RDS, meconium aspiration would show different chest x-ray findings.

Question 7

Answer: A - Campylobacter jejuni

Campylobacter jejuni is the most common bacterial cause of bloody diarrhea. The acute presentation with fever, crampy abdominal pain, 8-10 bloody stools daily, and hyperactive bowel sounds is classic. Campylobacter species are the leading bacterial pathogens causing acute infectious gastroenteritis with bloody diarrhea in this demographic.

Question 8

Answer: C - Human leukocyte antigen-B27 assay

HLA-B27 assay should be obtained. The post-infectious arthritis 3 weeks after Campylobacter jejuni infection, with monoarticular knee involvement showing inflammation, indicates reactive arthritis (formerly Reiter syndrome). HLA-B27 positivity is highly associated with this condition and helps confirm the diagnosis of post-infectious reactive arthritis.

Question 9

Answer: D - Insurance company

The insurance company must be disclosed to for payment verification, and this is a standard business/administrative function that does not breach privacy. The other options violate privacy rights and legal protections. Police disclosures without consent violate confidentiality, probation officer disclosures may be restricted, Cocaine Anonymous sponsors are peer support not medical, and wife disclosures should only be with patient consent.

Question 10

Answer: A - Accept the girl's consent as sufficient

This 15-year-old meets criteria for an emancipated minor - she lives independently, has a child, and receives no parental support. Emancipated minors can provide their own consent for medical evaluation and treatment. A court order is not required when emancipation criteria are clearly met.

Question 11

Answer: C - Medication-induced suppression of central respiratory drive

Aspiration is the most likely cause of respiratory insufficiency. The high-dose diazepam (both rectal and intravenous) caused respiratory depression, and without airway protection in a seizing patient (who may have protective reflex suppression), aspiration of gastric contents occurred. The rapid oxygen desaturation and shallow respirations following seizure cessation indicate hypoventilation from aspiration.

Question 12

Answer: B - Ask the patient to provide a narrative with detailed description of the incident and of his symptoms

The presentation of a preschooler with fever, drooling, difficulty swallowing, and stridorous breathing indicates epiglottitis. The tripod sitting position and appearance of seriously ill child are classic. Haemophilus influenzae type B (despite vaccination, breakthrough cases occur) causes acute epiglottitis with rapid airway compromise. Lateral neck x-ray would show the characteristic thumbprint sign.

Question 13

Answer: C - 5

Hepatitis A transmission occurs via fecal-oral route. The childcare center exposure and prodromal symptoms (fatigue, anorexia, fever) with elevated transaminases and low albumin indicate acute hepatitis. HAV is the most likely etiology in this setting. The lack of chronic liver disease (normal albumin initially, no jaundice yet) and acute presentation differentiate from other hepatitis types.

Question 14

Answer: B - EPCS is available only at specialty centers

The patient with chest pain, dyspnea, unilateral decreased breath sounds, and hypoxia following central line placement has pneumothorax. The tension pneumothorax would cause hypotension and JVD; simple pneumothorax with these findings is most likely. Immediate needle decompression or chest tube placement is needed. Pericardial tamponade would show muffled heart sounds and Beck's triad.

Question 15

Answer: B - EPCS is more effective than EST in decreasing hospital readmissions for variceal bleeding requiring transfusion

Beta-blocker (metoprolol) is most appropriate for atrial fibrillation with RVR causing anginal symptoms. The patient has symptomatic AFib with rapid ventricular response and ongoing chest pain despite initial therapy. Beta-blockers provide rate control and may reduce ischemia by decreasing myocardial oxygen demand. Digoxin has slower onset; amiodarone risks proarrhythmia in this acute setting.

Question 16

Answer: E - His sickle cell disease is affecting his hemoglobin A 1c

Azathioprine would be contraindicated due to the patient's TPMT deficiency, which prevents metabolism of azathioprine metabolites, leading to severe bone marrow suppression and toxicity. TPMT testing should be done before thiopurine use. The history of thiopurine-associated bone marrow suppression (low platelets, hemoglobin) indicates genetic deficiency requiring alternative therapy.

Question 17

Answer: C - Polymyositis

Osteoporosis is the most likely diagnosis. The postmenopausal woman on prolonged warfarin therapy (which impairs vitamin K-dependent bone protein synthesis) with pathologic compression fractures shows osteoporotic changes. Age, female sex, menopause, and anticoagulation are all risk factors. DEXA scan would confirm diagnosis; treatment involves calcium, vitamin D, and potentially bisphosphonates.

Question 18

Answer: E - Vaccine response among African American subjects was not the primary outcome measure

Paget disease of bone causes elevated alkaline phosphatase without elevated transaminases, lytic and sclerotic bone lesions, and mosaic-pattern trabeculae on histology. The combination of elevated ALP with normal hepatic function, unilateral leg pain, and radiolucent lesions with thick cortices is pathognomonic. The "cotton-wool" appearance on x-ray is characteristic.

Question 19

Answer: E - Spontaneous pneumothorax

Cryptococcal meningitis is most likely given CD4 count less than 50/mm3. The subacute presentation with fever, headache, stiff neck, and elevated opening pressure in an HIV patient indicates cryptococcal infection. India ink stain shows budding yeast; CSF antigen testing confirms diagnosis. Treatment with amphotericin B and flucytosine is standard. The low CD4 count indicates advanced AIDS requiring aggressive treatment.

Question 20

Answer: C

Syphilis (secondary syphilis with constitutional symptoms and rash) must be ruled out. The rash on trunk and extremities including palms and soles with systemic symptoms (fever, lymphadenopathy, hepatosplenomegaly) and positive RPR/VDRL is characteristic. Treatment with penicillin G is definitive. The CD4 count suggests HIV coinfection, which can modify syphilis presentation.

Question 21

Answer: A - Narcolepsy

Polyarteritis nodosa presents with constitutional symptoms, elevated inflammatory markers, and multisystem involvement (abdominal pain, renal disease). The microscopic hematuria, proteinuria, elevated creatinine, and medium-vessel vasculitis pathology indicate PAN. The constellation of GI symptoms (abdominal pain), renal involvement, and systemic inflammation point to this diagnosis requiring immunosuppressive therapy.

Question 22

Answer: D - Determination of serum digoxin level

Diabetic ketoacidosis with severe hypokalemia causing arrhythmias is the acute concern. Despite total body potassium depletion, serum K+ may be falsely elevated due to acidosis. Insulin therapy will shift potassium intracellularly, causing dangerous hypokalemia. Aggressive potassium replacement concurrent with insulin is essential. The peaked T waves indicate hyperkalemia acutely, but DKA treatment risks severe hypokalemia.

Question 23

Answer: B - Arrange for a certified interpreter

Pelvic inflammatory disease from Neisseria gonorrhoeae or Chlamydia trachomatis causes lower abdominal pain, fever, cervical discharge, and adnexal tenderness. The elevated WBC, ESR, and abnormal cervical findings confirm infection. Empiric antibiotics covering both organisms (ceftriaxone plus azithromycin or doxycycline) are indicated. The absence of peritoneal signs suggests uncomplicated PID without tubo-ovarian abscess.

Question 24

Answer: E - Ultrasonography of the hips

Myasthenia gravis demonstrates fluctuating weakness worsening with repetition (fatigability). The ocular symptoms (ptosis, diplopia), bulbar involvement (dysphagia, dysarthria), and generalized weakness are characteristic. Antibodies against acetylcholine receptors are pathognomonic. Edrophonium or ice pack testing confirms diagnosis. EMG shows decremental response to repetitive stimulation.

Question 25

Answer: E

Guillain-Barre syndrome presents with ascending paralysis after an antecedent infection. The progressive weakness from legs to arms to respiratory muscles, loss of deep tendon reflexes, and ascending pattern are classic. Areflexia despite motor weakness is characteristic. CSF shows elevated protein with normal cells (albuminocytologic dissociation). Plasmapheresis or IVIG is indicated for progressive disease.

Question 26

Answer: D - Thoracentesis

Systemic lupus erythematosus is indicated by positive ANA (>1:160), low complement (C3/C4), and elevated anti-dsDNA. The presentation includes arthritis, constitutional symptoms, and renal involvement (hematuria, proteinuria, elevated creatinine). The serositis (pleurisy) and photosensitive rash support SLE. Treatment involves NSAIDs, hydroxychloroquine, and corticosteroids depending on organ involvement.

Question 27

Answer: E - Systemic sclerosis (scleroderma)

Medication adherence and lifestyle modification have superior efficacy to initiating another antihypertensive drug. The patient is on monotherapy; compliance should be ensured first by careful counseling and pill count. Lifestyle changes (sodium restriction, weight loss, exercise) reduce BP 5-15 mmHg. Adding another agent when current therapy is not optimized is inappropriate and risks polypharmacy complications.

Question 28

Answer: C - Place masks on the patient and yourself and then continue to evaluate him

Isocarboxazid (MAOI) combined with diet containing tyramine (aged cheeses, processed meats) risks hypertensive crisis. The severe headache, chest pain, and elevated BP are typical of tyramine-induced hypertensive emergency from MAOI use. Phentolamine is the treatment; dietary counseling and switching to alternative antidepressants is needed. MAOIs require strict dietary compliance.

Question 29

Answer: A - Cervical culture

Levodopa-carbidopa therapy is standard for Parkinson disease. The combination of tremor at rest, rigidity, bradykinesia, and postural instability is characteristic parkinsonism. Carbidopa prevents peripheral dopamine conversion, allowing levodopa to reach the brain. Early monotherapy is preferred before adding other agents. The patient would also benefit from physical therapy and occupational support.

Question 30

Answer: C - Serum concentration of C3

Metformin is contraindicated in severe renal disease (Cr >1.5 mg/dL in males, >1.4 in females) due to lactic acidosis risk. The combination of elevated creatinine and eGFR <45 mL/min indicates significant renal impairment. Insulin or alternative agents are safer. Metformin should be stopped and renal function monitored closely. Contrast-induced nephropathy risk is also elevated with dye studies.

Question 31

Answer: E - Somatic symptom disorder

Intrinsic renal disease with moderate proteinuria, hypertension, and normal creatinine suggests chronic glomerulonephritis. The absence of systemic signs (no fever, normal complement, negative ANA) and lack of acute presentation differentiate this from lupus, vasculitis, or post-streptococcal GN. Kidney biopsy would be needed for definitive diagnosis, but clinical monitoring with ACE inhibitor/ARB therapy is initial approach.

Question 32

Answer: C - Minimize ascertainment bias

Acute angle-closure glaucoma presents with sudden-onset eye pain, blurred vision, red eye, mid-dilated pupil, and elevated intraocular pressure (>40 mmHg typically). The corneal edema causes haziness seen here. Pilocarpine (to constrict pupil), timolol (to reduce aqueous humor production), and acetazolamide (systemic pressure reduction) are acute therapies. Goniometry confirms angle closure; laser peripheral iridotomy is definitive.

Question 33

Answer: E - Plasma renin activity

No further imaging is needed after normal CT head and complete neurologic examination in a patient with migraine. The typical prodrome, migraine with aura history, normal neuro exam, and lack of red flags indicate migraine without secondary cause. Recurrent headaches with this pattern warrant prophylactic therapy (beta-blockers, tricyclics, topiramate) rather than more testing. Emergency precautions apply to sudden severe headache or atypical features.

Question 34

Answer: A

Sarcoidosis is indicated by bilateral hilar lymphadenopathy, noncaseating granulomas, elevated serum calcium, and elevated ACE level. The constitutional symptoms, pulmonary findings, and extrapulmonary manifestations (hypercalcemia) are classic. Chest x-ray staging (bilateral hilar adenopathy) combined with histology confirms diagnosis. Corticosteroid therapy is indicated for symptomatic disease and hypercalcemia.

Question 35

Answer: D - Individuals who take Drug X have two times the risk of dying from this type of cancer

Acute respiratory distress syndrome develops after aspiration and sepsis from inadequate airway management. The persistent hypoxia despite supplemental oxygen, bilateral infiltrates on imaging, and low arterial oxygen tension indicate ALI/ARDS. Lung protective ventilation (low tidal volumes, permissive hypercapnia) is essential. Early goal-directed therapy for sepsis and antibiotics are critical.

Question 36

Answer: D - Menstrual history

The 30-day mortality risk is highest in ARDS patients with sepsis (40-60%). The combination of nosocomial pneumonia, sepsis, and ARDS significantly worsens prognosis. Age over 60, underlying lung disease, and immunocompromise are additional negative predictors. Multiorgan failure development would further decrease survival. Goals should include comfort care discussion if deterioration continues.

Question 37

Answer: C - Optic nerve

Methicillin-resistant Staphylococcus aureus (MRSA) is the most likely nosocomial pathogen given healthcare exposure and aspiration pneumonia risk. Vancomycin (or linezolid) is indicated for MRSA coverage. The combination with respiratory fluoroquinolone (levofloxacin) or antipseudomonal beta-lactam (meropenem) covers other aspiration pathogens. Culture results will guide narrowing of spectrum.

Question 38

Answer: A - Displacement of the nucleus pulposus

Clarithromycin combined with tenofovir and efavirenz indicates HIV opportunistic infection prophylaxis. The CD4 count under 50 requires prophylaxis for MAC (clarithromycin), CMV prophylaxis considerations, and PCP prophylaxis. This combination suggests advanced AIDS with need for HAART initiation. Immune reconstitution inflammatory syndrome (IRIS) risk exists with CD4 recovery; careful monitoring is needed.

Question 39

Answer: D - Serum calcium concentration of 6.6 mg/dL

Psoriasis presents with chronic plaques with silvery scales, well-defined borders, and nail pitting. The family history of psoriasis, chronic course, and response to emollients and topical steroids are typical. Psoriasis is a T-cell mediated autoimmune condition affecting the skin and joints. Systemic agents (retinoids, biologic agents) are reserved for severe disease.

Question 40

Answer: D - Help the mother deal with her anger and educate her regarding the potential benefit to her son and others if the father's chromosome studies are done

Hepatitis B infection is indicated by positive HBsAg, anti-HBc, and negative anti-HBs, representing acute or chronic HBV infection. The elevated liver enzymes and bilirubin confirm hepatic inflammation. Most adults clear acute HBV within 6 months; those with persistent HBsAg beyond 6 months have chronic disease requiring monitoring for cirrhosis and hepatocellular carcinoma.

Question 41

Answer: E - Sexual activity

No further management is needed for this simple thyroid nodule with benign FNA (likely Bethesda Category I or II). The asymptomatic patient with small nodule and normal TSH requires observation with annual ultrasound. Suppressive levothyroxine therapy does not prevent nodule growth and risks iatrogenic hyperthyroidism. Radioactive iodine and surgery are inappropriate for benign lesions.

Question 42

Answer: D - Herpes zoster

Methadone maintenance therapy is the most appropriate management for opioid dependence. The 15-year history of heroin use with multiple prior withdrawal episodes requires long-term pharmacotherapy rather than acute detoxification alone. Methadone prevents withdrawal and reduces illicit use. Counseling and psychosocial support are essential adjuncts to pharmacotherapy.

Question 43

Answer: B - Order a chest x-ray

Acanthosis nigricans suggests underlying malignancy (gastric cancer, lung cancer) or insulin resistance. The dark, velvety skin lesions in body folds with obesity and hyperlipidemia suggest insulin resistance as primary etiology. However, malignancy screening is warranted given the presence of this paraneoplastic finding. Laboratory work including fasting glucose and insulin levels would assess metabolic syndrome.

Question 44

Answer: D - Methanol intoxication

Schizophreniform disorder represents psychotic symptoms lasting 1-6 months without the 6-month minimum required for schizophrenia diagnosis. The first episode of delusions and disorganization with this duration fits the criteria. Antipsychotic medication is indicated; prognosis depends on premorbid functioning, stressor severity, and treatment response. Recovery is possible if treated early.

Question 45

Answer: C - Atlanto-axial instability

Pulmonary embolism presents with acute dyspnea, pleuritic chest pain, tachycardia, and hypoxia. The postoperative state (hypercoagulability), clinical presentation, and D-dimer elevation support PE diagnosis. Imaging with CT pulmonary angiography or V/Q scan confirms diagnosis. Treatment includes anticoagulation unless contraindicated; IVC filter if anticoagulation is contraindicated.

Question 46

Answer: B - Keratoacanthoma

Deep venous thrombosis (DVT) with Wells score >2 and elevated D-dimer requires imaging. The unilateral leg swelling, warmth, and calf tenderness in a postoperative patient indicate DVT risk. Duplex ultrasonography is the standard diagnostic test. Anticoagulation should begin if proximal DVT is confirmed; distal DVT management depends on symptoms and repeat imaging.

Question 47

Answer: E

No new medications are needed for well-controlled hypertension with appropriate dosing and compliance. The patient on monotherapy with adequate BP control should continue current regimen. Adding another agent risks hypotension and polypharmacy. Lifestyle modifications (sodium restriction, weight loss, exercise) should continue. Follow-up in 3-6 months confirms continued control.

Question 48

Answer: A - Adverse effect of fluoxetine therapy

Acute myocardial infarction with ST elevation in distribution of left anterior descending artery (anterior wall MI) requires emergent reperfusion. Primary percutaneous coronary intervention (PCI) is preferred; thrombolytic therapy is alternative if PCI unavailable. The combination of chest pain, ST elevation, elevated troponin, and ECG changes confirms STEMI diagnosis.

Question 49

Answer: E - Mitral stenosis complicated by atrial fibrillation

No additional intervention is needed after successful angioplasty with stent placement for anterior MI. The patient is on dual antiplatelet therapy, beta-blocker, ACE inhibitor, and statin as per STEMI guidelines. Cardiac rehabilitation, lifestyle modification, and close follow-up are essential. Exercise stress testing at 4-6 weeks helps assess functional capacity and guide activity.

Question 50

Answer: B - Transient lactase deficiency

Unstable angina presents with anginal chest pain at rest or with minimal exertion, distinguishing it from stable angina. The new-onset symptoms with associated ECG changes and troponin elevation indicate acute coronary syndrome. Risk stratification using TIMI score guides management intensity. Dual antiplatelet therapy, anticoagulation, and revascularization reduce recurrent events.

Question 51

Answer: A - The risk for inpatient mortality is greater for patients with hypotension than for those without hypotension

Acute bacterial meningitis requires immediate empiric antibiotics and supportive care. The fever, meningismus (neck stiffness), altered mental status, and CSF pleocytosis confirm meningitis. Dexamethasone improves outcomes when given before or with antibiotics. Empiric coverage should include ceftriaxone (meningococcal, pneumococcal, H. influenzae) plus vancomycin if resistant pneumococcus is suspected.

Question 52

Answer: E - Serum 25-hydroxyvitamin D assay

Viral meningitis is benign with normal glucose in CSF and lymphocytic predominance. The self-limited course, normal imaging, and supportive care with NSAIDs and acetaminophen are sufficient. No antibiotics are needed for viral etiology confirmed by enterovirus PCR. The prognosis is excellent with full recovery expected within days to weeks.

Question 53

Answer: B - Mucosal edema

Multiple sclerosis presents with optic neuritis (unilateral vision loss), internuclear ophthalmoplegia (impaired adduction), and other demyelinating lesions separated in time and space. MRI shows multiple white matter lesions. Oligoclonal bands in CSF support MS diagnosis. Interferon-beta or other immunomodulatory agents reduce relapse rate and slow progression.

Question 54

Answer: A - Ductography

Transient ischemic attack (TIA) with amaurosis fugax (monocular vision loss) indicates retinal artery insufficiency from carotid atherosclerotic disease. Urgent carotid imaging with duplex ultrasound or CTA is needed. Severe stenosis warrants carotid endarterectomy or stent placement. Aspirin and statin therapy reduce secondary stroke risk. Urgent evaluation prevents full stroke.

Question 55

Answer: C - Dissection of the aorta

Ischemic stroke with persistent deficits beyond 3 hours post-symptom onset is outside the thrombolytic window. Supportive care, antiplatelet therapy (aspirin), statin, and physical/occupational therapy are appropriate. Hypertension should not be aggressively lowered acutely unless >220/120 mmHg. ICH risk is the main concern; imaging confirms ischemic rather than hemorrhagic stroke.

Question 56

Answer: A - Ankle brachial index

Hemorrhagic stroke (intracerebral hemorrhage) requires blood pressure management, reversal of anticoagulation, and supportive care. The acute severe headache, neurologic deficits, and CT evidence of intraparenchymal blood confirm ICH. Treatment includes cautious BP lowering (target MAP reduction <25%), coagulation reversal if anticoagulated, and monitoring for hematoma expansion.

Question 57

Answer: D - Neck stiffness

Subarachnoid hemorrhage from ruptured aneurysm presents with sudden severe "worst headache of life," meningismus, and CT showing blood in basal cisterns. Digital subtraction angiography localizes aneurysm; neurosurgical repair is definitive. Nimodipine reduces vasospasm-related complications. Supportive care, seizure prophylaxis, and DVT prophylaxis are essential. Vasospasm occurs 4-14 days post-hemorrhage.

Question 58

Answer: C - Pneumonia caused by Streptococcus pneumoniae

Hypertensive emergency with hypertensive encephalopathy (confusion, seizures, visual disturbances) requires urgent but controlled BP reduction. Labetalol or nicardipine IV provides rapid but titratable reduction. Target is 10-25% reduction in first hour, then gradual to goal over 24 hours. Aggressive reduction risks stroke from hypoperfusion. Treatment of underlying hypertension and cause (renal disease, preeclampsia) is essential.

Question 59

Answer: D - Essepro should not be prescribed because the patient has severe liver disease

Chronic kidney disease stage 3b (eGFR 30-44) with albuminuria requires ACE inhibitor or ARB therapy to slow progression. The hypertension and proteinuria are modifiable risk factors. Target BP <130/80 per recent guidelines. Referral to nephrology is indicated for eGFR <30 or rapid decline. Avoiding nephrotoxic agents and dietary sodium/protein restriction are important.

Question 60

Answer: D - There is no clinically important difference in blood pressure reduction between the three dose groups

Acute kidney injury from acute tubular necrosis (ATN) following sepsis requires supportive care with IV fluids, vasopressors, and treatment of infection. The elevated creatinine, oliguria, and muddy brown casts confirm ATN. Loop diuretics may increase urine output but do not change dialysis requirement or mortality. Dialysis is needed if refractory hyperkalemia, severe acidosis, or fluid overload develops.

Question 61

Answer: A - Karyotype from peripheral leukocytes

Post-streptococcal glomerulonephritis presents 1-2 weeks after streptococcal pharyngitis or skin infection. The hematuria, proteinuria, hypertension, and low C3 complement with nephritic picture confirm PSGN. Supportive care with salt restriction and diuretics manages fluid overload. Antibiotics treat persistent streptococcal infection. Most children recover completely; adults have higher risk of progression.

Question 62

Answer: E - No additional study is indicated

Minimal change disease causes nephrotic syndrome with normal renal function, heavy proteinuria, hypoalbuminemia, and hyperlipidemia. Lipoid nephrosis on biopsy shows normal light microscopy but effaced foot processes on electron microscopy. Corticosteroid therapy is first-line; most patients respond with complete remission. Relapse is common but recurrent episodes respond to steroids.

Question 63

Answer: B - Impaired sweat gland function with reduced ability to regulate heat loss

Membranoproliferative glomerulonephritis is associated with hepatitis C infection. The low C3 and C4 complement, hematuria, proteinuria, and mixed cryoglobulinemia indicate cryoglobulinemia secondary to HCV. Treatment targets HCV with interferon/ribavirin (or newer antivirals) and immunosuppression if needed. Renal biopsy confirms MPGN pattern with immune complex deposition.

Question 64

Answer: D - Polycystic ovarian syndrome

IgA nephropathy (Berger disease) is the most common glomerulonephritis worldwide. The hematuria, proteinuria, normal complement, and IgA-dominant deposits on immunofluorescence confirm diagnosis. Most have good prognosis but some progress to renal failure. ACE inhibitors/ARBs and fish oil reduce progression. Corticosteroids are used in progressive disease.

Question 65

Answer: E - Determination of urine sodium concentration 38 A 62-year-old man comes to the office for follow-up of benign prostatic hypertrophy (BPH), which was diagnosed 1 week ago. He had described a 6-month history of increased nocturia, double voiding, and decreased strength of urinary flow; he had not had these symptoms before. He has no personal or family history of prostate cancer. He takes no medications and he has no allergies. Physical examination 1 week ago was remarkable for an enlarged prostate without nodularity. Urinalysis and prostate-specific antigen tests were normal. Today, he has brought some newspaper articles about saw palmetto and wonders about its use in treatment of his symptoms. You recall a recent meta-analysis about the effectiveness of saw palmetto for BPH. In this study, saw palmetto was compared with placebo. The results are shown. Saw Palmetto Versus Placebo in the Symptomatic Treatment of Benign Prostatic Hypertrophy Treatment Improvement in Symptoms Placebo Saw Palmetto Statistical Significance Patient-reported 191/330 (58%) 242/329 (74%) p<0.001 Physician-assessed 100/262 (38%) 165/262 (63%) p<0.001

Pauci-immune vasculitis (ANCA-associated) presents with pulmonary-renal syndrome (hematuria, proteinuria, hemoptysis, respiratory infiltrates). Elevated creatinine, active urine sediment, and positive ANCA (cANCA/PR3 or pANCA/MPO) confirm diagnosis. Immunosuppression with corticosteroids and cyclophosphamide or rituximab is required. Plasmapheresis is used for severe pulmonary hemorrhage.

Question 66

Answer: A - Improvement is seen in both physician-assessed and in patient-reported symptoms

Anti-glomerular basement membrane disease (Goodpasture syndrome) causes pulmonary hemorrhage with hemoptysis and alveolar infiltrates plus rapidly progressive glomerulonephritis. Elevated creatinine, dysmorphic RBCs, RBC casts, and positive anti-GBM antibodies confirm diagnosis. Plasmapheresis combined with immunosuppression is urgent therapy to preserve renal function.

Question 67

Answer: A - 4

Acute interstitial nephritis from medication (NSAIDs, antibiotics, PPIs) presents with acute renal failure, fever, rash, and eosinophiluria. The elevated eosinophils in urine and absence of proteinuria differentiate from glomerulonephritis. Discontinuing the offending agent is essential; corticosteroids may hasten recovery. Most recover renal function with appropriate management.

Question 68

Answer: B - Increased intensity of the murmur with deep inspiration

Acute papillary necrosis from chronic NSAID or analgesic use causes acute renal failure with "ring sign" on imaging. The history of chronic NSAID use, acute renal failure, and hematuria raise suspicion. IV fluids and discontinuation of offending agent are essential. Imaging may show papillary necrosis. Prognosis depends on degree of renal loss and ability to prevent further progression.

Question 69

Answer: D - Use of rubber urethral catheters

Prerenal azotemia from dehydration shows elevated BUN-creatinine ratio (>20:1), oliguria, and muddy brown casts absent. The clinical dehydration, low urine sodium, and normal urine sediment confirm prerenal etiology. IV fluid administration should rapidly improve renal function. Ongoing loss from vomiting/diarrhea requires continued aggressive hydration and electrolyte replacement.

Question 70

Answer: E - Spleen

Hyperkalemia treatment includes calcium gluconate (membrane stabilization), insulin plus glucose or beta-agonists (intracellular shift), and loop diuretics or potassium-binding resins (elimination). The peaked T waves and widened QRS indicate severe hyperkalemia requiring urgent intervention. Dialysis is indicated if refractory or combined with renal failure. Calcium gluconate is given first if ECG changes present.

Question 71

Answer: D - Rotator cuff detachment

Primary hyperparathyroidism causes hypercalcemia via PTH-mediated bone resorption and renal calcium reabsorption. The elevated calcium despite low-normal phosphate, elevated PTH, and elevated alkaline phosphatase confirm hyperparathyroidism. Surgical parathyroidectomy is definitive; medical management (hydration, loop diuretics, bisphosphonates, calcitonin) is temporary. Preoperative localization with sestamibi scan helps identify abnormal glands.

Question 72

Answer: B

Hypomagnesemia reduces magnesium-dependent ATPase activity, impairing Na/K-ATPase and causing cardiac arrhythmias and weakness. The low magnesium with normal calcium and phosphate, hypokalemia, and arrhythmias indicate deficiency. IV magnesium replacement (20-40 mEq over hours) corrects the deficit. Identifying the cause (diarrhea, diuretics, PPIs, antibiotics) is essential to prevent recurrence.

Question 73

Answer: C - Infant HIV infection was the only significantly associated factor

Hypercalcemia from granulomatous disease (sarcoidosis) causes granulomas producing calcitriol (active vitamin D). The elevated calcium, elevated 1,25-dihydroxyvitamin D, and suppressed PTH confirm granulomatous etiology. Corticosteroids reduce granuloma activity and calcitriol production. Hydration and loop diuretics manage acute hypercalcemia. Bisphosphonates may be needed.

Question 74

Answer: B - Arrange for consultation with a home hospice team

Hyponatremia from SIADH occurs despite adequate volume status. The low sodium, low osmolality, inappropriately concentrated urine (osmolality >100), and normal renal/adrenal function confirm SIADH. Fluid restriction is first-line therapy. The cause (malignancy, CNS disease, medications) must be identified. Hypertonic saline is reserved for symptomatic hyponatremia with seizures.

Question 75

Answer: D - Initiate a family meeting to discuss the parents' concerns with their son

Hypernatremia from inadequate free water intake or excess losses requires gradual correction. The elevated sodium and osmolality, hyperglycemia, and clinical dehydration indicate free water deficit. IV hypotonic saline or D5W (plus insulin if diabetic) corrects deficit gradually (0.5 mEq/L per hour maximum to avoid cerebral edema). Identifying and treating the cause is essential.

Question 76

Answer: C - Relieve the physician of duty and alert the hospital's patient safety officer

Metabolic acidosis with elevated anion gap from lactic acidosis or ketoacidosis indicates severe illness. The low pH, low HCO3, elevated anion gap, and elevated lactate confirm lactic acidosis. Treatment focuses on oxygenation, perfusion restoration, and treating underlying cause (sepsis, cardiogenic shock). Sodium bicarbonate is reserved for severe acidemia (pH <7.1).

Question 77

Answer: C - Heparin-induced thrombocytopenia

Respiratory alkalosis from hyperventilation due to anxiety or early sepsis causes high pH and low PCO2. The low CO2 with normal/low HCO3 and acute presentation indicate hyperventilation. Reassurance, breathing into a paper bag, or anxiolytic therapy treats anxiety-related hyperventilation. If septic, antibiotics and supportive care are needed.

Question 78

Answer: A - Administer atropine

Congestive heart failure with reduced ejection fraction (HFrEF) requires ACE inhibitor/ARB as foundational therapy. The systolic dysfunction with low ejection fraction, elevated BNP, and signs of heart failure indicate need for neurohormonal blockade. Beta-blockers and ACE inhibitors reduce mortality. Aldosterone antagonists are added for moderate to severe disease. Diuretics manage fluid overload.

Question 79

Answer: E

Mitral stenosis with atrial fibrillation and rapid ventricular response requires rate control with beta-blocker or calcium channel blocker. The history of rheumatic fever (suggests mitral stenosis), new afib with RVR, and symptoms indicate need for ventricular rate slowing. Anticoagulation is essential given stroke risk with afib and valvular disease. Valve replacement may be needed if stenosis is severe.

Question 80

Answer: A - Amputation

Aortic regurgitation produces a wide pulse pressure with bounding pulses and a decrescendo diastolic murmur. The acute severe AR causes sudden hemodynamic derangement with pulmonary edema and cardiogenic shock. Mechanical causes (endocarditis, aortic dissection) require urgent surgery. Intra-aortic balloon pump support may bridge to surgery; vasodilators (nitroprusside) improve hemodynamics.

Question 81

Answer: B - Imiquimod

Hypertrophic cardiomyopathy causes syncope from outflow tract obstruction and arrhythmias. The family history, murmur that increases with Valsalva, LVH on ECG, and syncope are classic. Sudden cardiac death risk requires beta-blockers or calcium channel blockers. ICD placement prevents sudden death. Genetic testing and family screening are important. Strenuous exertion should be avoided.

Question 82

Answer: E - No treatment is needed at this time

Dilated cardiomyopathy from alcoholic cardiomyopathy presents with HF symptoms and dilated LV on imaging. The chronic heavy alcohol use, systolic dysfunction, and family history of sudden death raise concern. Treatment includes ACE inhibitors, beta-blockers, aldosterone antagonists, and diuretics. Abstinence from alcohol is essential; left ventricular recovery is possible with prolonged abstinence.

Question 83

Answer: C - Continuous humidified oxygen

Constrictive pericarditis limits ventricular filling with equalization of diastolic pressures. The signs of restrictive physiology (elevated JVP with prominent x and y descents), normal/small ventricles, and pericardial thickening on imaging confirm diagnosis. Surgical pericardiectomy is definitive. Causes include idiopathic, TB, malignancy, and prior cardiac surgery.

Question 84

Answer: D - Seizures

Acute pericarditis presents with chest pain that worsens with recumbency and improves with leaning forward. The pericardial friction rub, ST elevation in diffuse distribution, and elevated troponin/ESR are characteristic. NSAIDs or colchicine treat inflammation. Most cases are viral and self-limited. Pericardiocentesis is needed if tamponade develops.

Question 85

Answer: B - Administration of diltiazem

Acute bacterial endocarditis presents with fever, new cardiac murmur, and septic emboli. The positive blood culture, valvular vegetation on echo, and clinical criteria (Duke criteria) confirm diagnosis. IV antibiotics (empiric broad-spectrum pending culture) are essential. Surgical intervention is needed if heart failure, large vegetations, or prosthetic valve involvement develops.

Question 86

Answer: C

Acute rheumatic fever causes pancarditis (myocarditis, pericarditis, endocarditis) after Group A streptococcal pharyngitis. The fever, polyarthralgias, cardiac involvement (new murmur, heart failure), and elevated ESR meet major Jones criteria. Penicillin treats streptococcal infection; NSAIDs and corticosteroids manage inflammation. Aspirin reduces carditis risk. Secondary prophylaxis with penicillin prevents recurrence.

Question 87

Answer: A - Incision and drainage

Stable angina requires medical management with aspirin, beta-blocker for rate control, nitrates for symptom relief, and statin for lipid management. ACE inhibitor reduces cardiovascular risk. Stress testing guides risk stratification; coronary angiography is reserved for high-risk patients. Angioplasty/stent or bypass improves symptoms but not survival in stable disease.

Question 88

Answer: E - Reposition the chest tube

Myocardial infarction complicated by acute mitral regurgitation from papillary muscle rupture causes acute HF and cardiogenic shock. The sudden-onset systolic murmur in post-MI period and pulmonary edema indicate acute MR. Surgical repair is urgent given mortality. Vasodilators (nitroprussin) and intra-aortic balloon pump provide temporary hemodynamic support.

Question 89

Answer: B - Influenza

Hypertension management requires lifestyle modification initially (salt restriction, weight loss, exercise) then pharmacotherapy if BP >140/90 despite lifestyle measures. The elevated BP with no end-organ damage indicates stage 1-2 hypertension. Monotherapy typically starts with ACE inhibitor or ARB, calcium channel blocker, or thiazide diuretic based on comorbidities.

Question 90

Answer: B - Order CT scan of the head

Resistant hypertension (BP >140/90 despite 3+ antihypertensives including diuretic) requires evaluation for secondary causes and medication nonadherence. The lack of BP control despite multiple agents warrants checking potassium, creatinine, and ruling out aldosteronism or renal artery stenosis. Referral to hypertension specialist is appropriate.

Question 91

Answer: C - Smoking cessation program

Malignant hypertension with hypertensive emergency requires immediate aggressive BP reduction with IV agents (labetalol, nicardipine, esmolol). The severely elevated BP (>200/120) with evidence of end-organ damage (seizures, encephalopathy, renal failure) requires ICU management. Continuous monitoring guides titration; goal is 10-20% reduction in first 1-2 hours.

Question 92

Answer: B - Methotrexate, orally

Atrial fibrillation management includes ventricular rate control (beta-blocker, calcium channel blocker, digoxin), anticoagulation for stroke prevention, and consideration of rhythm control. The sustained afib with symptoms and poor rate control requires treatment. Diltiazem or metoprolol provides rate control; anticoagulation (warfarin or DOAC) reduces stroke risk.

Question 93

Answer: E

Ventricular fibrillation requires immediate defibrillation followed by ACLS protocol. The patient with sudden loss of consciousness and no pulse has cardiac arrest from VF. Defibrillation is the definitive treatment; chest compressions during charging maintain perfusion. IV epinephrine and amiodarone support defibrillation efforts. ROSC restoration allows targeted temperature management.

Question 94

Answer: E - The patient is at no increased risk

Bradycardia from high-degree AV block requires pacemaker placement to maintain adequate cardiac output. The symptomatic bradycardia with syncope and hemodynamic compromise indicates need for pacing. Atropine may temporize but definitive permanent pacemaker is needed. Temporary pacing can bridge to permanent pacemaker.

Question 95

Answer: D - Provide reassurance that she is simply still premenopausal

Supraventricular tachycardia from atrioventricular nodal reentrant tachycardia (AVNRT) presents with palpitations and narrow QRS tachycardia. Adenosine causes transient AV block, breaking the reentry circuit and terminating SVT. Success rate is high with minimal side effects. Verapamil or diltiazem are alternatives. Radiofrequency ablation is curative for recurrent SVT.

Question 96

Answer: D - Initiation of a daily corticosteroid inhaler

Wolff-Parkinson-White syndrome shows short PR interval and delta wave on ECG. The accessory pathway allows preexcitation, increasing AFib risk with rapid conduction. Atrial fibrillation with rapid AV conduction via accessory pathway causes hemodynamic compromise. Radiofrequency ablation of the pathway is curative. Avoid AV nodal blocking agents that may increase accessory pathway conduction.

Question 97

Answer: E - Removal of the nail through endoscopic esophagogastroscopy

Acute coronary syndrome requires troponin measurement, ECG, chest x-ray, and risk stratification to guide therapy. The chest pain, dyspnea, and risk factors warrant urgent evaluation. Troponin elevation confirms MI; normal troponin but high-risk features warrant hospital admission. Aspirin, beta-blocker, statin, and ACE inhibitor are standard. Coronary angiography guides revascularization decisions.

Question 98

Answer: C - Instruct him to cease alcohol consumption and retest him in 2 months

Ventricular tachycardia from acute MI indicates electrical instability and increased mortality risk. The sustained monomorphic VT requires immediate treatment with IV amiodarone or synchronized cardioversion. Prevention of recurrent VT includes optimization of beta-blockers, ACE inhibitors, and revascularization. ICD placement reduces sudden cardiac death risk.

Question 99

Answer: E - Provide education for well-baby care

Pulmonary hypertension assessment requires echocardiography to estimate RV systolic pressure and evaluate for cardiac etiology. The dyspnea, tachycardia, and elevated JVP suggest elevated RV afterload. Chest x-ray may show RV enlargement. Right heart catheterization confirms diagnosis and guides treatment. Causes include chronic lung disease, chronic thromboembolism, and primary PH.

Question 100

Answer: A - Arrange consultation with an orthopaedic surgeon

Acute decompensated heart failure with volume overload requires diuretics, afterload reduction, and inotropic support if needed. The orthopnea, PND, peripheral edema, and pulmonary crackles indicate systemic and pulmonary congestion. IV furosemide provides rapid symptom relief. Nitrates reduce preload; ACE inhibitors reduce afterload. Underlying cause (MI, arrhythmia, valvular disease) must be identified.

Question 101

Answer: A

Acute myocardial infarction treatment targets rapid coronary reperfusion via PCI or thrombolytics. The STEMI on ECG with elevated troponin indicates acute transmural MI. Door-to-balloon time <90 minutes for PCI (or door-to-needle <30 minutes for thrombolytics) maximizes salvage. Dual antiplatelet therapy, anticoagulation, and supportive care complete acute management.

Question 102

Answer: E - Treat the symptoms

Cardiogenic shock from acute MI requires revascularization plus hemodynamic support. The low BP, elevated JVP, cold extremities, and oliguria indicate severe hypoperfusion. Intra-aortic balloon pump improves coronary perfusion and cardiac output. Urgent coronary angiography guides revascularization. Inotropes (dobutamine, milrinone) support output temporarily; vasopressors maintain perfusion.

Question 103

Answer: C - Measurement of lower extremity compartment pressures

Right ventricular infarction (from RCA occlusion) causes hypotension with elevated JVP but clear lungs. The inferior ST elevation with right-sided leads showing ST elevation confirm RVI. Treatment includes aggressive IV fluids to maintain RV preload; avoid nitrates and diuretics that worsen hypotension. Dobutamine or pacing may be needed if bradycardic or cardiogenic shock develops.

Question 104

Answer: D - Prescribe rifampin

Dilated cardiomyopathy from myocarditis presents with acute HF after viral prodrome. The dilated LV, reduced EF, elevated troponin, and viral symptoms suggest myocarditis. Supportive care with ACE inhibitor, beta-blocker, and diuretics is mainstay. Most recover completely; some progress to dilated cardiomyopathy. Fulminant myocarditis may require mechanical support.

Question 105

Answer: D - Phenoxybenzamine

Peripartum cardiomyopathy presents with acute HF in late pregnancy or early postpartum period. The dyspnea, orthopnea, pulmonary edema, and dilated LV with reduced EF confirm diagnosis. Treatment is standard HF therapy with ACE inhibitor, beta-blocker, diuretics, and aldosterone antagonist. Prognosis varies; some recover completely, others have persistent dysfunction.

Question 106

Answer: C - Echocardiography

Acute pericarditis with tamponade presents with hypotension, elevated JVP, and muffled heart sounds (Beck's triad). The pulsus paradoxus (>10 mmHg drop in systolic BP during inspiration) is characteristic. Pericardiocentesis is definitive; echocardiography guides needle placement. Removal of even small pericardial fluid often dramatically improves hemodynamics.

Question 107

Answer: D - Pulmonary hypertension

Restrictive cardiomyopathy presents with preserved LV size and function but diastolic dysfunction limiting filling. The elevated filling pressures cause elevated JVP and pulmonary congestion despite normal EF. Infiltrative diseases (amyloidosis, hemochromatosis) and idiopathic forms present similarly. Diuretics manage congestion but worsen fill; avoiding excessive afterload reduction is key.

Question 108

Answer: B - Breast-feeding will increase the risk for transmitting HIV to the infant

Pneumonia with hypoxia and infiltrates on imaging requires empiric broad-spectrum antibiotics pending culture. The fever, cough, dyspnea, and alveolar consolidation indicate bacterial pneumonia. Community-acquired pneumonia coverage includes beta-lactam (ceftriaxone) plus macrolide (azithromycin). Nosocomial pneumonia requires broader coverage (fluoroquinolone, antipseudomonal beta-lactam, or aminoglycoside).

Question 109

Answer: D - 0.9% Saline

Cystic fibrosis presents with recurrent respiratory infections, chronic productive cough, pancreatic insufficiency, and malabsorption. The elevated immunoreactive trypsinogen on newborn screening, steatorrhea, and failure to thrive confirm CF. Sweat chloride test confirms diagnosis. Aggressive airway clearance, antibiotics, and enzyme supplementation are essential. Lung transplant is definitive for end-stage disease.

Question 110

Answer: E - Urine protein concentration

Pulmonary fibrosis from usual interstitial pneumonia (UIP) presents with progressive dyspnea, dry cough, and basilar infiltrates on imaging. The restrictive pattern on PFTs and decreased DLCO indicate parenchymal lung disease. HRCT showing typical UIP pattern (honeycomb, reticular opacities) suggests idiopathic pulmonary fibrosis. Antifibrotic agents (pirfenidone, nintedanib) slow progression.

Question 111

Answer: D - Her suitability for home dialysis

Pneumocystis jirovecii pneumonia (PCP) in HIV with CD4 <200 presents with dyspnea, nonproductive cough, and hypoxia with exertion. The elevated LDH, normal x-ray initially, and hypoxia with decreased DLCO are characteristic. Trimethoprim-sulfamethoxazole is first-line therapy and prophylaxis. Treatment includes corticosteroids if PaO2 <70. CD4 recovery with HAART reduces relapse risk.

Question 112

Answer: A - Administer intravenous antibiotics

Tuberculosis requires multi-drug therapy (RIPE: rifampin, isoniazid, pyrazinamide, ethambutol) for 2 months then continuation phase. The cavitary lung disease, night sweats, weight loss, and AFB-positive sputum confirm TB. Directly observed therapy ensures adherence. Isoniazid peripheral neuropathy requires pyridoxine. Treatment duration is 6 months standard; drug interactions with protease inhibitors require monitoring.

Question 113

Answer: A - Carbamazepine

Aspergillus fumigatus causes chronic pulmonary aspergillosis in immunocompromised patients or cavitary aspergilloma in previous TB cavities. The elevated IgG antibodies, pulmonary infiltrates, and positive Aspergillus culture confirm diagnosis. Antifungal therapy (voriconazole or itraconazole) is indicated. Aspergilloma in cavities may require surgical resection if hemoptysis develops.

Question 114

Answer: D - Subcutaneous enoxaparin

Allergic bronchopulmonary aspergillosis (ABPA) presents with asthma exacerbations, pulmonary infiltrates, bronchiectasis, and eosinophilia. The elevated total IgE, Aspergillus-specific IgE, and Aspergillus-specific IgG confirm diagnosis. Corticosteroids and azoles (itraconazole) treat inflammation and fungal disease. Monitoring IgE levels guides therapy; antifungals prevent progression to fibrosis.

Question 115

Answer: C - Systemic hypertension

Histoplasmosis from Histoplasma capsulatum causes acute respiratory illness resembling pneumonia or disseminated disease in immunocompromised patients. The elevated antigen in blood and urine, fever, and pulmonary infiltrates indicate acute histoplasmosis. Amphotericin B is first-line for severe or disseminated disease; itraconazole for milder disease. CD4 recovery with HAART is essential for immunocompromised patients.

Question 116

Answer: E - Stage of disease

Blastomycosis causes progressive pulmonary disease and can disseminate to skin, bone, and CNS. The alveolar infiltrates, positive Blastomyces culture, and geographic exposure (Ohio/Mississippi river basins) suggest diagnosis. Amphotericin B is needed for severe or CNS disease; itraconazole for chronic pulmonary disease. Treatment duration is prolonged (6-12 months).

Question 117

Answer: B - Obtain a swallowing evaluation

Coccidioidomycosis from Coccidioides immitis causes acute respiratory illness resembling pneumonia or chronic progressive disease. The erythema multiforme (valley fever rash), pulmonary infiltrates, and elevated complement fixation antibodies confirm diagnosis. Most acute cases resolve without treatment; azole therapy is used for progressive disease. Amphotericin B is reserved for severe/disseminated disease.

Question 118

Answer: C - Dicloxacillin and clindamycin

Chronic obstructive pulmonary disease management focuses on smoking cessation, bronchodilators, corticosteroids, and pulmonary rehabilitation. The airflow obstruction on PFTs, bronchodilator response, and smoking history confirm COPD. Tiotropium (long-acting anticholinergic) and salmeterol (long-acting beta-agonist) reduce exacerbations. Oxygen improves survival if hypoxemic. Acute exacerbations require antibiotics and corticosteroids.

Question 119

Answer: A

Asthma exacerbations require rapid bronchodilator therapy (albuterol nebulizer), systemic corticosteroids (prednisone), and oxygen. The acute dyspnea, wheezing, PEF reduction, and hypoxia indicate moderate/severe exacerbation. Ipratropium (anticholinergic) combined with albuterol works synergistically. IV magnesium sulfate improves FEV1. Failure to improve requires ICU admission and IV therapy.

Question 120

Answer: D - Order a transthoracic echocardiography

Status asthmaticus (severe refractory asthma exacerbation) requires ICU admission, mechanical ventilation, and aggressive therapy. The inability to speak, severe dyspnea, silent chest, altered mental status, and low PEF indicate life-threatening exacerbation. Continuous albuterol nebulization, IV corticosteroids, IV magnesium, and theophylline are used. Avoid aggressive ventilation (permissive hypercapnia) to prevent barotrauma.

Question 121

Answer: A - Advise the patient to discontinue his bedtime drink of alcohol

Acute exacerbation of COPD requires bronchodilators, corticosteroids, and antibiotics if bacterial infection. The increased sputum production, purulence, and dyspnea suggest infectious trigger. Ipratropium plus albuterol provide rapid bronchodilation. Oral prednisone 40-60 mg daily reduces exacerbation duration. Fluoroquinolone covers likely respiratory pathogens. Supportive care with oxygen and hydration completes therapy.

Question 122

Answer: B - The infant has a 50% risk for hemophilia

Spontaneous pneumothorax can be primary (no lung disease) or secondary (underlying lung disease like COPD, CF, PCP, or blebs). The acute-onset dyspnea, pleuritic chest pain, decreased breath sounds, and hypoxia after small trauma suggest traumatic or secondary pneumothorax. Small pneumothorax (<2 cm) can be observed; larger requires aspiration or chest tube. Recurrence is common; pleurodesis or surgery may be needed.

Question 123

Answer: A - Incision and drainage

Tension pneumothorax requires immediate needle decompression followed by chest tube. The hypotension, elevated JVP, tracheal deviation, and absent breath sounds indicate life-threatening tension pneumothorax. A large-bore needle (14-16 gauge) is placed into the 2nd intercostal space midclavicular line for decompression. Do not delay for imaging; this is a clinical diagnosis requiring immediate treatment.

Question 124

Answer: A - Administer normal saline and add potassium once urinary output is adequate

Hemothorax from trauma or tumor requires chest tube placement for evacuation and monitoring for massive hemorrhage. The blood in plural space on imaging and hemodynamic instability indicate active bleeding. Chest tube placement allows assessment of bleeding rate; >200 mL/min or >1 liter initial output warrants urgent surgery. Supportive care and blood product transfusion are essential.

Question 125

Answer: D - Clindamycin

Myocardial infarction with mechanical complications requires urgent surgical intervention. The acute severe mitral regurgitation or ventricular septal defect after MI causes cardiogenic shock and pulmonary edema. Surgical repair is definitive; temporary mechanical support (balloon pump, extracorporeal membrane oxygenation) bridges to surgery. Medical management with vasodilators and inotropes provides temporary support.

Question 126

Answer: D - Phentolamine

Cocaine-induced chest pain and hypertension with ECG changes may represent cocaine-induced vasospasm and myocardial ischemia. The chest pain, hypertension, tachycardia, and ECG changes after cocaine use indicate acute coronary syndrome. Phentolamine (alpha-antagonist) reduces hypertension without unopposed beta-stimulation risk. Benzodiazepines treat anxiety. Aspirin and nitrates are used; beta-blockers are contraindicated (risk unopposed alpha).

Question 127

Answer: D - Intraoperative angiography

Acute limb ischemia after bypass graft placement indicates graft thrombosis or stenosis. The acute pain, pale limb, and pulselessness despite strong femoral and weak popliteal pulses indicate thrombosis distal to graft. Intraoperative angiography identifies the occlusion site; thrombectomy or revision is needed. Delay in reperfusion risks gangrene and amputation; revascularization should occur within 6-8 hours.

Question 128

Answer: C - Nystatin

Neonatal oral candidiasis (thrush) causes white patches that cannot be wiped off (unlike milk residue). The 3-week-old with failure to gain weight adequately and white mouth lesions indicates Candida infection. Nystatin suspension is first-line for oral thrush. Fluconazole is reserved for invasive disease or systemic infection. Treatment typically lasts 7-10 days. Maternal nipple candidiasis is common and should be treated.

Question 129

Answer: D - Refer the patient to a child psychiatrist

Toxoplasmosis with pica (eating dirt) in a child indicates congenital infection or acquired infection with behavioral manifestations. The positive serology, eating dirt, lymphadenopathy, and normal labs suggest toxoplasmosis. Referral to child psychiatrist evaluates potential behavioral/psychological components. Pyrimethamine and sulfadiazine are antimicrobial therapy. Nutritional and psychosocial support addresses underlying issues.

Question 130

Answer: D - This is probably due to the volume of intravenous fluid she has received; you will give her a dose of furosemide and discharge her home

Gout presents with acute arthritis from monosodium urate crystal deposition. The first MTP joint (great toe), severe pain, erythema, warmth, and leukocytosis are classic. NSAIDs (indomethacin) are first-line therapy unless contraindicated. Colchicine is an alternative if NSAIDs are contraindicated. Allopurinol is begun after acute attack resolves. Penicillin allergy does not contraindicate urate-lowering therapy.

Question 131

Answer: E

Subcutaneous emphysema (air in subcutaneous tissues) from pleural puncture during biopsy requires hospital admission for observation. The crepitus on palpation and "spongy" feeling indicate subcutaneous air tracking. Small pneumothorax (<2 cm) can be observed with monitoring. If pneumothorax enlarges or patient becomes symptomatic, chest tube placement is indicated. Most resolve spontaneously with oxygen therapy (increases nitrogen resorption).

Question 132

Answer: D - Oral dexamethasone therapy

Croup (laryngotracheobronchitis) presents with barking cough, stridor, dyspnea, and fever. The 2-year-old with rapid progression despite oxygen indicates moderate to severe croup. Dexamethasone reduces croup severity and duration. Racemic epinephrine nebulization provides rapid symptom relief. Most cases are viral (parainfluenza) and self-limited. Hospitalization is needed for severe disease or hypoxia.

Question 133

Answer: C - Do endotracheal intubation

Variceal hemorrhage from esophageal varices secondary to cirrhosis requires endotracheal intubation for airway protection before endoscopy. The hemodynamic instability (low BP, altered mental status) with massive hematemesis indicates bleeding shock. Intubation prevents aspiration. IV fluids and blood products provide resuscitation. Endoscopy allows variceal banding or sclerotherapy. Vasopressin/terlipressin reduces portal pressure; antibiotics prevent bacterial peritonitis.

Question 134

Answer: E - Mannitol

Diabetic ketoacidosis complicated by cerebral edema requires osmotic agents (mannitol or hypertonic saline). The somnolence, headache, incontinence, and falling sodium despite ongoing insulin therapy suggest cerebral edema. Mannitol 0.5-1 g/kg IV over 20-30 minutes increases serum osmolality and reduces brain edema. Dexamethasone is not recommended as steroid use worsens outcomes in DKA.

Question 135

Answer: D - Recommend beginning a weight loss program

Chronic low back pain with obesity and recent gestational diabetes requires weight loss and lifestyle modification. The recurrent pain every 2-3 months despite rest and analgesics suggests mechanical etiology. BMI 37 increases back strain significantly. Weight loss, core strengthening, and ergonomic workplace modifications reduce pain recurrence. Imaging is not indicated for mechanical back pain in the absence of red flags (neurologic deficits, cancer risk).

Question 136

Answer: A - Recommend behavioral therapy

Behavioral therapy is first-line for anxiety-related urinary symptoms (somatic symptom disorder). The temporal relationship between anxiety (flying) and urinary symptoms, normal urinalysis, and absence of infection indicate psychogenic etiology. Cognitive behavioral therapy and relaxation techniques reduce anxiety and associated symptoms. Reassurance about benign nature is important. Avoid unnecessary medications or interventions.

Question 137

Answer: E - Metoprolol NOTE: THIS IS THE END OF BLOCK 4. ANY REMAINING TIME MAY BE USED TO CHECK ITEMS IN THIS BLOCK. 68 Answer Key for USMLE Step 3 Sample Questions Block 1: FIP

Metoprolol continuation (or switching to another beta-blocker if rhythm control needed) is appropriate for rate control of recurrent atrial fibrillation. The atrial fibrillation with rapid ventricular response despite metoprolol indicates need for dose optimization or rhythm control consideration. Digoxin has slower onset; adenosine is for acute SVT not AFib. The dose should be optimized before adding additional agents.