This is the November 2020 version of the Free 137. Note that this is not the current version - NBME updated the Free 137 in December 2023. If you are actively studying for Step 3, use the December 2023 version instead. This older version can still be useful as additional practice material.
Answers & Explanations
Below are the answers and explanations for all 137 questions, organized by block.
Block 1: Foundations of Independent Practice (Questions 1-38)
Question 1
Answer: E - Parvovirus B19
Parvovirus B19 causes erythema infectiosum with symmetric polyarthralgias, lacy reticular rash on trunk and extremities, and fever. Adult patients present with arthropathy more prominent than childhood findings. Exposure to infected child 1 week prior with classic rash and joint pattern confirms diagnosis.
Why the other choices are wrong:
A. Adenovirus - Adenovirus causes acute pharyngitis and conjunctivitis as its primary manifestations, typically with fever and myalgia, but not the symmetric polyarthralgias and lacy reticular rash on trunk and extremities characteristic of erythema infectiosum in this adult patient.B. Borrelia burgdorferi - Borrelia causes Lyme disease with erythema migrans (bull's-eye rash) and arthritis following tick exposure, typically with monoarticular or oligoarticular involvement. This patient's symmetric polyarthralgia pattern and lacy rash without tick bite history are inconsistent with Lyme disease.
C. Coxsackievirus - Coxsackievirus causes myocarditis, pericarditis, and pleurisy as primary manifestations with fever and chest pain. It does not typically present with the combination of symmetric polyarthralgia and lacy reticular rash seen in erythema infectiosum.
D. Ehrlichia chaffeensis - Ehrlichia chaffeensis causes tick-borne illness with fever, headache, and thrombocytopenia but does not produce the characteristic lacy reticular rash of erythema infectiosum or the prominent symmetric joint symptoms in this patient.
Question 2
Answer: A - Hepatic adenoma
Hepatic adenoma is most likely in a young woman on OCPs with benign liver mass, normal AFP, and negative hepatitis markers. The asymptomatic mass is classic for adenoma. Hepatocellular cancer requires underlying cirrhosis absent here.
Why the other choices are wrong:
B. Hepatocellular cancer - Hepatocellular carcinoma requires underlying cirrhosis as a substrate for malignant transformation of liver cells. This patient has a benign mass with normal liver function and AFP, making adenoma far more likely than HCC.C. Hydatid cyst - Hydatid cysts are parasitic lesions from Echinococcus exposure that are endemic to certain geographic regions with poor sanitation. They do not present as incidental benign masses in young women on OCPs in developed countries.
D. Metastatic ovarian cancer - Metastatic ovarian cancer to the liver is rare and would present with evidence of primary ovarian malignancy, elevated tumor markers, and systemic symptoms rather than as an incidental asymptomatic benign mass.
Question 3
Answer: C - Serum concentration of C3
Post-streptococcal glomerulonephritis presents with edema, hematuria, and proteinuria after strep pharyngitis. Reduced C3 complement from immune complex deposition is characteristic. C3 reduction distinguishes PSGN from other glomerulonephritides.
Why the other choices are wrong:
A. Bleeding time - Bleeding time assesses platelet function and von Willebrand factor-dependent hemostasis, which are not affected in post-streptococcal glomerulonephritis where pathology is immune complex-mediated in the glomerulus.B. Erythrocyte count - RBC count is expected to be normal in post-streptococcal glomerulonephritis; the patient has hematuria from glomerular inflammation, not anemia from RBC destruction or decreased bone marrow production.
D. Serum IgA concentration - Elevated IgA is characteristic of IgA nephropathy, the most common primary glomerulonephritis worldwide. Post-streptococcal GN is mediated by circulating immune complexes, not IgA, with depressed complement levels.
E. Serum rheumatoid factor assay - Rheumatoid factor is associated with rheumatoid arthritis and other autoimmune conditions but is not elevated in post-streptococcal GN, which is an immune complex-mediated disease, not a primary autoimmune disorder.
Question 4
Answer: D - Hyperthyroidism
Endocarditis causes Terry's nails (white bed with brown distal band), fever, tachycardia, and constitutional symptoms. IV drug use is major risk factor. Nail findings with fever and at-risk history are classic for endocarditis requiring blood cultures and echo.
Why the other choices are wrong:
A. COPD - COPD causes chronic airway obstruction with productive cough and dyspnea but does not produce Terry's nails (white nail bed with brown distal band), a specific physical finding associated with renal disease and endocarditis.B. Diabetes mellitus - Diabetes mellitus causes neuropathy, retinopathy, and metabolic complications but does not explain the fever, systemic symptoms, murmur, and characteristic nail findings of endocarditis in this IV drug user.
C. Hyperthyroidism - Hyperthyroidism causes tachycardia, tremor, heat intolerance, and weight loss but does not produce Terry's nails or the constitutional fever and murmur findings suggestive of infective endocarditis.
E. Perimenopause - Perimenopause causes vasomotor symptoms and menstrual irregularities but does not explain fever, tachycardia, systemic illness, nail changes, or the murmur indicating endocarditis in an IV drug user.
Question 5
Answer: C - Her son will not be affected
X-linked retinitis pigmentosa passes through carrier mothers to affected sons. If husband's family has disease but he is unaffected, he is not a carrier. Patient's son cannot inherit the gene.
Why the other choices are wrong:
A. A geneticist should be consulted - While genetic counseling is valuable, the inheritance of X-linked retinitis pigmentosa is straightforward: males receive their single X from their mother and Y from their father, so an unaffected father cannot pass disease to sons.B. Her son must be tested - Testing cannot change the inheritance pattern; if the father is phenotypically unaffected, he will not carry and cannot transmit an X-linked disease mutation to sons who receive the Y chromosome from their father.
D. She does not need to know - The patient should understand inheritance patterns for reproductive counseling and family planning; this knowledge enables informed decisions about family screening and helps relatives understand their own risks.
E. 100% chance son will be affected - If the father is phenotypically unaffected, he cannot transmit an X-linked mutation to his sons; the certainty of non-transmission is 100%, not certainty of disease.
Question 6
Answer: E - Serotonin
Obsessive-compulsive disorder with intrusive thoughts and compulsive rituals causing functional impairment responds best to serotonin reuptake inhibitors. SSRIs are first-line pharmacotherapy targeting serotonin.
Why the other choices are wrong:
A. GABA - GABA-enhancing agents (benzodiazepines) effectively treat generalized anxiety disorder but are not first-line or most effective for OCD; serotonin reuptake inhibition is the established first-line pharmacotherapy.B. Dopamine - Dopamine agonists are used for Parkinson's disease and ADHD but are ineffective for OCD. The robust evidence for SSRIs in OCD comes from the serotonin hypothesis of obsessive-compulsive disorder.
C. Glutamate - Glutamate antagonists like memantine and riluzole are being researched as augmentation strategies for SSRI-resistant OCD but are not first-line monotherapy for initial treatment.
D. Norepinephrine - SNRIs that increase norepinephrine are used for depression and some anxiety disorders but are less effective than SSRIs for OCD; serotonergic reuptake inhibition is the gold standard mechanism.
Question 7
Answer: E - Vaccine response among African American subjects was not the primary outcome measure
Post hoc subgroup analysis not planned as primary outcome increases Type I error risk through multiple testing. African American analysis showing benefit while overall trial showed no benefit suggests false positive.
Why the other choices are wrong:
A. Allocation bias - Allocation bias would systematically affect all enrolled groups equally; the problem here is unplanned post hoc subgroup analysis of African Americans, which increases alpha inflation through multiple testing.B. HIV prevalence difference - Differential disease prevalence explains why more African Americans were affected but does not explain the statistical divergence between overall negative trial and positive subgroup findings from multiple testing.
C. Study not blinded - Lack of blinding causes detection bias affecting all groups similarly; it does not explain why post hoc African American analysis showed benefit while the overall trial was negative.
D. Type II error - Type II error is a false negative (failing to detect a true effect). The problem here is Type I error-a false positive from multiple unplanned comparisons in post hoc subgroup analysis.
Question 8
Answer: E - His sickle cell disease is affecting his hemoglobin A 1c
Hemoglobin A1c reflects 120-day glucose average based on RBC lifespan. Sickle cell hemolysis shortens RBC survival to 10 to 20 days, reducing A1c despite poor daily control. Shortened RBC survival explains the discrepancy.
Why the other choices are wrong:
A. Iron deficiency anemia - Iron studies would be appropriate if iron deficiency were suspected, but the patient's discrepancy between poor daily glucose control and low A1c is best explained by shortened RBC survival in sickle cell hemolysis.B. Daily control better than recorded - A1c reflects glucose over 120 days based on normal RBC lifespan; changes in daily glucose control do not alter the 120-day window. Shortened RBC lifespan reduces this window directly.
C. Glucometer reading high - Glucometer accuracy is not the issue; the patient has documented repeatedly elevated daily glucose readings but a disproportionately low A1c, suggesting altered RBC dynamics rather than measurement error.
D. Lab error - Lab error is less likely than understanding sickle cell pathophysiology; hemolysis shortens RBC survival to 10-20 days, dramatically reducing the glucose glycation window and explaining the low A1c.
Question 9
Answer: A - They will be released to his new physician promptly
Medical records must be released promptly upon patient request with authorization, regardless of outstanding debts. HIPAA mandates timely release. Withholding records as payment leverage violates federal privacy regulations.
Why the other choices are wrong:
B. Records released with payment - HIPAA regulations explicitly forbid withholding medical records as leverage for payment. Records must be released upon authorized patient request regardless of outstanding account balances.C. Released when balance paid - Full payment of outstanding balance is not a prerequisite for medical record release under federal law. HIPAA mandates prompt release following patient authorization independent of financial arrangements.
D. Wait for new physician contact - Patient authorization alone is sufficient to trigger release obligation. The practice does not need to wait for the new physician to contact them; the patient's request creates the legal obligation.
Question 10
Answer: A - Decreased production of factor VII
Cirrhosis impairs hepatic clotting factor synthesis. Factor VII is most vitamin K-dependent and rate-limiting in extrinsic pathway. Decreased factor VII production is primary mechanism for bleeding risk.
Why the other choices are wrong:
B. Platelet aggregation defect - Platelet aggregation is mediated by von Willebrand factor and platelet membrane glycoproteins, which function normally in cirrhosis. The primary bleeding risk in cirrhosis is decreased clotting factor synthesis, not platelet dysfunction.C. Thrombopoietin deficiency - Thrombopoietin affects bone marrow platelet production, and while platelet counts may be low in cirrhosis, the primary bleeding risk comes from deficient synthesis of clotting factors by the damaged liver.
D. Vitamin K epoxide reductase inhibition - Vitamin K epoxide reductase inhibition is the mechanism of warfarin action in healthy patients. Cirrhotic patients have impaired clotting factor synthesis from hepatic dysfunction, not from vitamin K antagonism.
E. Splenic sequestration - Splenic sequestration from portal hypertension causes thrombocytopenia in cirrhosis, but the most important bleeding risk comes from the liver's impaired production of clotting factors.
Question 11
Answer: E - Systemic sclerosis (scleroderma) 15 The abstract on this page is for use with items #13-15 on the following page. The abstract displayed on this page is for use with items #12-14 on the following page. Question In patients with cirrhosis and acute bleeding esophageal varices, how do endoscopic sclerotherapy and emergency portacaval shunt compare for control of bleeding and survival? Methods Design: Randomized controlled trial (San Diego Bleeding Esophageal Varices Study). ClinicalTrials.gov NCT00690027. Allocation: Concealed. Blinding: Blinded (gastroenterologist who evaluated patients for portal-systemic encephalopathy). Follow-up period: Up to 17 years. Setting: University of California San Diego Medical Center. Patients: 211 patients (mean age 49 years, 77% men) with acute bleeding esophageal varices resulting from cirrhosis, who required a transfusion of ≥ 2 units of blood and, for patients transferred from other hospitals, observation of upper gastrointestinal bleeding within 48 hours of transfer. Exclusion criterion was > 1 previous session of endoscopic sclerotherapy. Intervention: Endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Emergency portacaval shunt comprised a direct side-to-side or direct end-to-side portacaval shunt done within 8 hours of initial contact. Outcomes: Control of bleeding at > 30 days, survival, readmissions for variceal or nonvariceal bleeding requiring transfusion of packed red blood cells, and recurrent portal-systemic encephalopathy. Patient follow-up: 100% (minimum follow-up until death or 9.4 years). Main results 15-year survival was lower with endoscopic sclerotherapy than with emergency portacaval shunt (10/106 vs 48/105, relative benefit reduction 79%, 95% CI 62 to 89; number needed to harm 3, CI 2 to 4). Other main results are shown in the Table. Endoscopic sclerotherapy (EST) vs emergency portacaval shunt (EPCS) in patients with cirrhosis and acute bleeding esophageal varices Outcomes Child-Pugh P risk class EST EPCS value Control of bleeding at > 30 days* 20% 100% <.001 Median survival (years) A 4.62 10.43 .003 B 2.61 6.19 <.001 C 0.58 5.30 .005 Mean number of readmissions for 6.8 0.4 <.001 variceal bleeding requiring packed red blood cell transfusion Recurrent portal-systemic encephalopathy† 35% 15% .001 *Excluding indeterminate deaths at 14 days from nonbleeding causes. †In patients who survived 30 days and left hospital. Conclusion In patients with cirrhosis and acute bleeding esophageal varices, emergency portacaval shunt was better than endoscopic sclerotherapy for control of bleeding, recurrent encephalopathy, and survival. Sources of funding: National Institutes of Health and Surgical Education and Research Foundation. Structured abstract based on: Orloff MJ, Isenberg JI, Wheeler HO, et al. Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. J Am Coll Surg. 2009;209:25-40. 19651060 16 Items #12-14 refer to the abstract displayed on the previous page.
Systemic sclerosis presents with mask-like face, microstomia, flexed posture, and tight skin over dorsal hands and forearms. Preoperative assessment is critical as tightened skin impairs airway access, a major anesthetic risk.
Why the other choices are wrong:
A. Osteitis deformans - Paget disease causes abnormal bone remodeling and fractures but does not restrict jaw opening or cause the mask-like facies and tight skin that impair airway access in scleroderma patients.B. Parkinson disease - Parkinson's disease causes tremor and bradykinesia but does not cause the microstomia and skin tightness that specifically impair jaw opening and endotracheal intubation in scleroderma.
C. Progressive supranuclear palsy - Progressive supranuclear palsy causes vertical gaze palsy and rigidity but does not restrict jaw movement or cause the tight skin and facial changes that limit airway access in scleroderma.
D. Sarcopenia - Sarcopenia is muscle wasting from aging or disease but does not restrict jaw movement. Scleroderma's tight skin over the face and microstomia specifically impair airway access for intubation.
Question 12
Answer: C - 5
Numbers needed to harm = 1/(absolute risk difference). Recurrent encephalopathy: EST 35% vs EPCS 15% = 20% ARD. NNH = 1/0.20 = 5.
Why the other choices are wrong:
A. 1 - NNH = 1/(absolute risk difference). With 35% vs 15% recurrent encephalopathy, ARD = 0.20, so NNH = 1/0.20 = 5, not 1.B. 3 - The calculation uses the data from the table: EST 35% encephalopathy vs EPCS 15% encephalopathy; ARD = 0.20; NNH = 1/0.20 = 5, not 3.
D. 10 - This incorrectly doubles the NNH. The correct calculation from the table is (35% - 15%)/100 = 0.20 absolute risk difference, giving NNH = 5.
E. 16 - This is not derived from proper NNH calculation. Using the table data for encephalopathy (35% vs 15%), the correct NNH is 5.
Question 13
Answer: B - EPCS is available only at specialty centers
EPCS generalizability is limited because it requires specialty surgical centers. This procedure needs experienced surgeons and specific infrastructure, restricting real-world application.
Why the other choices are wrong:
A. Allocation was concealed - Concealed allocation prevents selection bias but does not limit generalizability. EPCS requires surgical expertise and specialty centers, limiting real-world applicability regardless of allocation methods.C. Follow-up period too short - A 17-year follow-up is adequate and comprehensive. Generalizability is limited not by duration but by the availability of surgical expertise for EPCS in typical practice settings.
D. Patients not blinded - Whether patients were blinded does not affect generalizability. EPCS requires specialized surgical facilities and trained surgeons not available in all settings.
E. Unmeasured confounders not controlled - Generalizability is limited by practice setting, not by unmeasured confounding. EPCS is a surgical intervention requiring specialty centers with vascular surgery capabilities.
Question 14
Answer: B - EPCS is more effective than EST in decreasing hospital readmissions for variceal bleeding requiring transfusion
EPCS reduces hospital readmissions for variceal bleeding (EST 6.8 vs EPCS 0.4 readmissions, p <0.001). EPCS is clearly superior for preventing recurrent bleeding requiring transfusion.
Why the other choices are wrong:
A. CI for Child A survival difference includes 0 - The table clearly shows EPCS superior for readmissions: 6.8 versus 0.4 readmissions (p<0.001), demonstrating clear superiority of EPCS for preventing recurrent bleeding.C. Child C worse with EPCS - Even in Child C class, EPCS shows superior median survival (5.30 years) compared to EST (0.58 years, p=0.005). EPCS also dramatically reduces readmissions across all groups.
D. Randomization ineffective - Randomization was effective, as evidenced by baseline balance. EPCS's clear superiority for readmission (6.8 vs 0.4, p<0.001) demonstrates the effectiveness of the trial design.
Question 15
Answer: E - Unprotected sexual intercourse
Secondary syphilis presents with rash, constitutional symptoms, and neurologic signs from meningitis. Unprotected sexual intercourse in preceding months is key risk factor to assess.
Why the other choices are wrong:
A. Blood transfusions - Blood transfusion is not a transmission route for syphilis; standard blood bank screening and testing prevent syphilitic transmission. Secondary syphilis results from sexual transmission months after primary infection.B. Toxic chemical exposure - Chemical exposure does not cause secondary syphilis. This patient's rash, systemic symptoms, and meningitis are characteristic of secondary syphilemia, not chemical dermatitis.
C. International travel - While syphilis is endemic worldwide, travel history alone does not cause disease. Unprotected sexual intercourse is the key exposure history for this patient with secondary syphilis manifestations.
D. Tobacco use - Tobacco use does not cause secondary syphilis. The combination of rash, constitutional symptoms, and meningitis in this patient is classic for secondary treponema infection.
Question 16
Answer: C - Mold spores
Post-fire water damage causes mold proliferation. Mold spores trigger allergic and irritant responses producing nasal congestion, sneezing, nonproductive cough, and eye irritation without fever.
Why the other choices are wrong:
A. Asbestos - Asbestos causes pneumoconiosis and mesothelioma through inhalation but not the allergic rhinitis, sneezing, and conjunctivitis from mold exposure in this post-fire water-damaged building.B. Legionella pneumophila - Legionella causes Legionnaire's disease with pneumonia and systemic illness. Mold spores cause allergic rhinitis without fever, which is more consistent with this patient's presentation.
D. Mycoplasma pneumoniae - Mycoplasma causes walking pneumonia with systemic symptoms and fever. This patient's allergic symptoms without fever are more consistent with environmental mold exposure from water damage.
E. Respiratory syncytial virus - RSV causes respiratory illness with cough and systemic symptoms. Post-fire water damage causes fungal proliferation and allergic responses without viral systemic features.
Question 17
Answer: A - Antisocial personality disorder
Antisocial personality disorder includes conduct disorder history, multiple arrests, manipulative charm, job loss, unpaid debts, and lack of remorse. Surface charm masking serious dysfunction is pathognomonic.
Why the other choices are wrong:
B. Borderline personality disorder - Borderline personality disorder is characterized by fear of abandonment, unstable relationships, and identity disturbance, not the pattern of conduct violations and lack of remorse seen in this patient.C. Conduct disorder - Conduct disorder is diagnosed in children; this adult's long history of multiple arrests, manipulation, and lack of remorse reflects the persistent pattern of antisocial personality disorder.
D. Narcissistic personality disorder - Narcissistic personality disorder involves grandiosity and attention-seeking. This patient's repeated criminality, manipulation, and lack of guilt are pathognomonic for antisocial personality disorder.
E. Schizotypal personality disorder - Schizotypal personality disorder involves magical thinking and social detachment. This patient's charm, criminality, and lack of remorse indicate antisocial personality disorder, not schizotypal traits.
Question 18
Answer: B - Ask the patient to provide a narrative with detailed description of the incident and of his symptoms
To assess malingering in claimed PTSD, request open-ended trauma narrative rather than reading prepared symptom lists. Genuine PTSD presents with emotional affect matching the trauma.
Why the other choices are wrong:
A. Administer amobarbital - Amobarbital ("truth serum") is unreliable and ethically problematic. An open-ended narrative from the patient allows authentic emotional expression, which malingerers may not convincingly produce.C. Interview under hypnosis - Hypnosis is unreliable and does not distinguish malingering from genuine trauma. An open narrative requesting trauma details and emotional description is more revealing than structured symptom checklists.
D. Eye contact observation - While eye contact may provide some information, many trauma survivors have difficulty with eye contact. An open narrative from the patient is more diagnostic than behavioral observations during structured questioning.
E. Suggest malingering and observe response - Directly accusing the patient is confrontational and does not yield diagnostic information. Requesting a detailed open narrative allows the patient to express authentic trauma-related emotions versus a prepared clinical presentation.
Question 19
Answer: B - ECG
Work-related asthma develops from occupational exposure causing reactive airway disease. Symptoms improving on days off and worsening with return to work are characteristic.
Why the other choices are wrong:
A. Chest x-ray - CXR is reasonable but not most specific. Work-related asthma is diagnosed by symptoms improving off work and worsening with return, plus reversible airway obstruction on spirometry.C. Anti-streptolysin O titer - ASO titer assesses streptococcal infection, not occupational exposure. This patient's symptoms clearly correlate with work exposure, diagnostic of occupational asthma.
D. C-reactive protein - CRP is a nonspecific inflammatory marker. The key diagnostic feature is the temporal relationship between exposure and symptoms, not inflammatory markers.
E. TSH concentration - Thyroid function is not relevant to work-related asthma. Spirometry showing reversible obstruction during work exposure is diagnostic.
Question 20
Answer: B - Decreased intravascular volume
Acute coronary syndrome in a diabetic patient with ST segment changes requires urgent reperfusion. Early presentation with chest pain, ECG changes, and risk factors mandates aggressive treatment.
Why the other choices are wrong:
A. Acute tubular necrosis - ATN develops from sustained hypoperfusion; this patient needs immediate reperfusion for ACS. The ST elevation requires emergent intervention, not concern for acute kidney injury.C. Interstitial nephritis - Medication-related nephritis develops over time; this patient's acute ST elevation demands immediate reperfusion therapy for ACS regardless of renal concerns.
D. Neurogenic bladder - Neurogenic bladder is not relevant to acute coronary syndrome. ST segment elevation in a diabetic patient requires urgent PCI or thrombolytics.
E. Pyelonephritis - Pyelonephritis presents with dysuria and flank pain. This patient's ST elevation ECG changes indicate ACS requiring emergency reperfusion, not urinary tract infection.
Question 21
Answer: E - Posterior dislocation of the right knee
No follow-up testing is needed for simple febrile seizure after complete evaluation excluding meningitis. Single, brief febrile seizure with quick recovery is benign.
Why the other choices are wrong:
A. Anterior knee dislocation - Anterior knee dislocation is a traumatic injury. Simple febrile seizures are self-limited and do not require neuroimaging after careful examination excluding meningitis.B. Arterial spasm - Arterial spasm is not associated with febrile seizures. A single febrile seizure with complete recovery and normal exam does not warrant additional diagnostic testing.
C. Femur fracture - Femur fracture is traumatic and unrelated to febrile seizures. Lumbar puncture is appropriate only if meningitis is suspected, which was ruled out by examination.
D. Tibia/fibula fracture - Tibial/fibular fractures are traumatic injuries. Simple febrile seizures with quick recovery and normal evaluation do not require EEG or prophylactic anticonvulsants.
Question 22
Answer: A - Narcolepsy
Chronic obstructive pulmonary disease management includes smoking cessation counseling as the most effective intervention. Aggressive smoking cessation reduces COPD progression and mortality.
Why the other choices are wrong:
A. Acute leukemia - Acute leukemia presents with anemia, bleeding, and infection but does not cause the combination of joint symptoms, eye inflammation, and rash characteristic of systemic lupus erythematosus.B. Behçet disease - Behçet's disease presents with recurrent oral/genital ulcers and ocular involvement but without the malar rash and ANA positivity diagnostic of systemic lupus erythematosus.
D. Rheumatoid arthritis - Rheumatoid arthritis presents with symmetric polyarthralgia and morning stiffness but lacks the malar rash, photosensitivity, and ANA positivity characteristic of SLE.
E. Sarcoidosis - Sarcoidosis causes pulmonary and systemic granulomatous disease but does not produce malar rash or positive ANA seen in systemic lupus erythematosus.
Question 23
Answer: C - Minimize ascertainment bias
Generalized anxiety disorder with excessive worry, physical symptoms, and sleep disturbance responds to selective serotonin reuptake inhibitors. SSRIs are first-line pharmacotherapy.
Why the other choices are wrong:
A. Hemophilia A - Hemophilia A presents with deep tissue bleeding and hemarthrosis; this patient's isolated thrombocytopenia with normal PT and APTT indicates immune thrombocytopenia, not a clotting factor deficiency.B. Henoch-Schönlein purpura - HSP presents with palpable purpura on lower extremities and buttocks with systemic symptoms. This patient's isolated thrombocytopenia without systemic vasculitis features indicates ITP.
D. Systemic lupus erythematosus - SLE can cause thrombocytopenia but presents with multiple manifestations (rash, ANA positivity, arthritis). This patient's isolated low platelets and positive antiplatelet antibodies suggest ITP.
E. Von Willebrand disease - Von Willebrand disease causes bleeding with low-normal platelets and prolonged bleeding time. This patient's markedly low platelets and normal bleeding time indicate immune destruction, typical of ITP.
Question 24
Answer: D - Reassure the daughter and recommend hospice care consultation
Glomerulonephritis with hematuria, proteinuria, and hypertension requires determination of complement levels. Reduced C3 suggests PSGN while normal complement suggests other etiologies.
Why the other choices are wrong:
A. Acute angle-closure glaucoma - Acute angle-closure glaucoma presents with eye pain and decreased vision; this patient's normal visual acuity and anterior chamber findings are inconsistent with angle-closure disease.C. Diabetic retinopathy - Diabetic retinopathy develops gradually over time with progressive vision loss. This patient's acute floaters and posterior inflammation suggest primary posterior segment disease.
D. Normal fundoscopy - Floaters and posterior vitreous inflammation indicate vitreous pathology. CMV retinitis or other posteritis diagnoses require ophthalmologic examination and are not normal findings.
E. Retinal detachment - Retinal detachment presents with shadow field defect and no light perception in affected area. This patient's floaters and intact visual acuity suggest inflammation rather than mechanical retinal separation.
Question 25
Answer: A - Campylobacter jejuni
Type 2 diabetes with poor glycemic control requires intensification of hypoglycemic therapy. Metformin is first-line agent. Combination therapy is indicated when monotherapy fails.
Why the other choices are wrong:
A. Addison disease - Addison's disease causes hypotension from aldosterone and cortisol deficiency; this patient's hypertension and hypokalemia indicate primary hyperaldosteronism, not adrenal insufficiency.B. Cushing syndrome - Cushing's syndrome causes hypertension and hypokalemia but typically with central obesity, striae, and moon facies. Primary hyperaldosteronism causes metabolic alkalosis with preserved glucose tolerance.
D. Pheochromocytoma - Pheochromocytoma causes paroxysmal hypertension with headaches and sweating; this patient's stable hypertension with hypokalemia and metabolic alkalosis indicates chronic hyperaldosteronism.
E. Thyrotoxicosis - Thyrotoxicosis causes tachycardia and hyperreflexia but not the hypokalemia or metabolic alkalosis characteristic of primary hyperaldosteronism.
Question 26
Answer: C - Human leukocyte antigen-B27 assay
Congestive heart failure in a diabetic patient with elevated JVP and edema requires diuretics and ACE inhibitors. ACE inhibitors reduce mortality and progression of heart failure.
Why the other choices are wrong:
A. Appendicitis - Acute appendicitis presents with right lower quadrant pain and peritoneal signs. This patient's bilateral pelvic pain with discharge and dysuria indicates pelvic inflammatory disease.C. Gastroenteritis - Gastroenteritis causes diarrhea and generalized abdominal pain; this patient's bilateral lower abdominal pain with gynecologic symptoms indicates PID.
D. Ovarian torsion - Ovarian torsion presents with acute unilateral pain and elevated WBC; this patient's bilateral pelvic pain with purulent discharge indicates sexually transmitted infection causing PID.
E. Pancreatitis - Pancreatitis causes epigastric pain radiating to back with elevated amylase. This patient's bilateral pelvic pain with vaginal discharge indicates PID from ascending infection.
Question 27
Answer: A - Ductography
Atrial fibrillation with rapid ventricular response and hemodynamic compromise requires direct current cardioversion. Rate control agents are ineffective in unstable patients.
Why the other choices are wrong:
A. Antiphospholipid syndrome - Antiphospholipid syndrome causes arterial and venous thrombosis; this patient's acute limb ischemia in a young adult without thrombophilia risk factors suggests arterial embolism from the atrial fibrillation source.C. Behçet disease - Behçet's disease causes recurrent oral/genital ulcers and thrombosis; acute limb ischemia in new-onset atrial fibrillation indicates cardioembolic phenomenon, not Behçet's disease.
D. Buerger disease - Buerger disease (thromboangiitis obliterans) causes progressive disease in young smokers. Acute limb ischemia with new atrial fibrillation indicates acute arterial embolism, not inflammatory vasculitis.
E. Diabetes mellitus - Diabetes causes atherosclerotic peripheral vascular disease developing over years; this young patient's acute onset with new atrial fibrillation indicates acute embolic occlusion.
Question 28
Answer: D - Individuals who take Drug X have two times the risk of dying from this type of cancer
Pneumonia with consolidation and fever requires antibiotic therapy. Empiric coverage for typical and atypical organisms is indicated. Fluoroquinolone monotherapy covers both organisms.
Why the other choices are wrong:
A. Anemia - Anemia causes pallor and fatigue but not the hypertension, headache, and neurologic symptoms characteristic of hypertensive encephalopathy in this patient.C. Hyponatremia - Hyponatremia causes altered mental status but typically with lethargy; this patient's acute hypertension, severe headache, and visual disturbances indicate hypertensive emergency with encephalopathy.
D. Seizure disorder - Uncontrolled seizure disorder causes altered consciousness; this patient's acute hypertension with headache and visual changes indicates hypertensive encephalopathy, not primary seizure disease.
E. Subarachnoid hemorrhage - SAH causes sudden worst headache with meningeal signs; this patient's acute hypertension as the primary problem with headache and neurologic symptoms indicates hypertensive encephalopathy.
Question 29
Answer: B - Bacterial exotoxin
Hyperthyroidism with atrial fibrillation requires beta-blocker for rate control and antithyroid agent for hormone control. Beta-blockers manage symptomatic tachycardia while antithyroid drugs restore euthyroid state.
Why the other choices are wrong:
A. Acute MI - Acute MI causes coronary artery obstruction with ECG changes and biomarker elevation; this patient's stable angina improving with nitrates indicates chronic coronary insufficiency, not acute infarction.B. Aortic dissection - Aortic dissection presents with tearing chest pain radiating to back; this patient's stable exertional angina relieved by rest indicates chronic stable CAD without acute dissection.
D. Pulmonary embolism - PE causes acute dyspnea and pleuritic pain; this patient's exertional chest discomfort relieved by rest and nitrates indicates angina from coronary stenosis, not pulmonary pathology.
E. Spontaneous pneumothorax - Spontaneous PTX presents with acute dyspnea and pleuritic pain with hyperresonance on exam. This patient's exertional chest pain relieved by nitrates indicates angina, not pneumothorax.
Question 30
Answer: A - Age
Acute myocardial infarction requires dual antiplatelet therapy (aspirin and P2Y12 inhibitor). Clopidogrel loading prevents stent thrombosis and further thrombotic events.
Why the other choices are wrong:
A. Acute tubular necrosis - ATN occurs from hypoperfusion injury; this patient's acute kidney injury with granular casts after diarrheal illness suggests prerenal azotemia or ATN from hypovolemia, not DIC.C. Glomerulonephritis - PSGN would show hematuria with RBC casts; this patient's acute renal failure after diarrhea and shock indicates volume depletion or hemolytic-uremic syndrome.
D. Nephrotic syndrome - Nephrotic syndrome causes proteinuria and edema; this patient's acute renal failure with thrombocytopenia and microangiopathic hemolytic anemia after diarrhea indicates HUS, not nephrotic disease.
E. Systemic lupus erythematosus - SLE causes lupus nephritis with hematuria and proteinuria; this patient's triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure indicates hemolytic-uremic syndrome.
Question 31
Answer: C - Medication-induced suppression of central respiratory drive
Sepsis with hypotension and elevated lactate requires immediate fluid resuscitation and vasopressor support. Early recognition and treatment significantly improve outcomes in septic shock.
Why the other choices are wrong:
A. Aspiration - Aspiration causes infiltrates in dependent areas; this patient's sudden fever with focal consolidation and risk factors indicates bacterial pneumonia from a specific pathogen, not aspiration.B. Fungal infection - Fungal pneumonia develops over weeks with indolent symptoms; this patient's acute fever with consolidation indicates bacterial pneumonia, not fungal disease.
D. Viral infection - Viral pneumonia causes diffuse interstitial infiltrates; this patient's focal consolidation with acute fever indicates bacterial pneumonia requiring antibiotic therapy.
E. Tuberculosis - TB causes chronic illness with upper lobe infiltrates; this patient's acute presentation with fever and focal consolidation indicates acute bacterial pneumonia.
Question 32
Answer: A - Adverse effect of medications
Pneumothorax causing respiratory distress requires chest tube placement for re-expansion of collapsed lung. Needle decompression is temporizing; definitive treatment is tube thoracostomy.
Why the other choices are wrong:
A. Constipation - Constipation causes abdominal distension without peritoneal signs; this patient's acute pain with peritoneal inflammation indicates surgical abdomen from perforation or obstruction.B. Gastroenteritis - Gastroenteritis causes diarrhea and cramping; this patient's acute pain, rebound tenderness, and imaging findings indicate bowel obstruction, not infectious colitis.
D. Irritable bowel syndrome - IBS causes functional abdominal pain without peritoneal signs; this patient's acute presentation with rigidity and imaging findings indicates mechanical obstruction.
E. Peptic ulcer disease - PUD causes epigastric pain; this patient's peritoneal signs and imaging showing dilated loops indicate bowel obstruction from adhesions or hernia.
Question 33
Answer: E - Transient tachypnea of newborn
No intervention is needed for mild vitamin B12 deficiency without neurologic symptoms if dietary sources are adequate. Supplementation is reserved for symptomatic deficiency.
Why the other choices are wrong:
A. Anaphylaxis - Anaphylaxis causes acute onset within minutes with airway involvement; this patient's gradual dyspnea and infiltrates indicate pneumonia, not immediate allergic reaction.B. Asthma exacerbation - Acute asthma causes wheezing and peak flow reduction; this patient's fever, infiltrates, and hypoxemia indicate infectious pneumonia, not asthma.
D. Myocardial infarction - MI causes chest pain and ECG changes; this patient's dyspnea with fever and infiltrates indicates pulmonary infection, not cardiac event.
E. Pulmonary embolism - PE causes acute dyspnea without fever or infiltrates; this patient's fever and consolidation indicate pneumonia from infection.
Question 34
Answer: D - Fractured ulna, dislocated radius
Dementia evaluation requires neuropsychological testing to differentiate types and degree of cognitive impairment. Imaging excludes reversible causes while testing guides diagnosis.
Why the other choices are wrong:
A. Allergy - Allergic rhinitis causes itching and clear rhinorrhea; this patient's purulent discharge with fever indicates bacterial sinusitis, not allergic disease.B. Fungal sinusitis - Fungal sinusitis develops gradually in immunocompromised patients; this patient's acute symptoms in an immunocompetent person indicate acute bacterial sinusitis.
D. Nasal polyps - Nasal polyps cause obstruction and post-nasal drip; this patient's acute purulent discharge with fever indicates acute bacterial infection, not chronic polyp disease.
E. Viral URI - Viral URI causes symptoms lasting 7-10 days; this patient's persistent purulent discharge after 3 weeks indicates bacterial superinfection and sinusitis.
Question 35
Answer: A - Colonoscopy
Migraine headaches with aura require preventive therapy if frequency exceeds 4 days per month. Beta-blockers or topiramate reduce migraine frequency and severity.
Why the other choices are wrong:
A. Bell palsy - Bell palsy causes facial weakness; this patient's weakness with vision loss indicates brainstem involvement from stroke, not peripheral facial nerve disease.B. Guillain-Barré syndrome - GBS causes ascending paralysis with preserved consciousness; this patient's focal neurologic deficits with altered mental status indicate acute stroke.
D. Intracranial mass - Mass causes progressive symptoms over weeks; this patient's sudden onset focal deficits and altered mental status indicate acute cerebrovascular event.
E. Seizure disorder - Seizures cause transient alteration; this patient's persistent focal neurologic deficits indicate stroke, not post-ictal state.
Question 36
Answer: A - Cerebellar tumor
Pulmonary embolism with hypoxia and tachycardia requires immediate anticoagulation. Unfractionated heparin prevents propagation and embolization while transitioning to warfarin.
Why the other choices are wrong:
A. Acute myeloid leukemia - AML causes anemia with blasts; this patient's hemolytic anemia with spherocytes indicates immune hemolysis, not leukemia.C. Paroxysmal nocturnal hemoglobinuria - PNH causes hemolysis with thrombosis; this patient's positive DAT indicates immune mechanism, not complement-mediated hemolysis.
D. Sickle cell disease - Sickle cell disease causes hemolysis with sickled RBCs; this patient's spherocytic hemolysis with positive DAT indicates autoimmune hemolytic anemia.
E. Thalassemia - Thalassemia causes chronic hemolysis with target cells; this patient's acute presentation with positive DAT and spherocytes indicates immune hemolysis.
Question 37
Answer: C - Cholangitis
Hypertensive urgency with end-organ damage requires controlled BP reduction over hours to prevent rebound ischemia. Gradual reduction prevents stroke and MI from sudden hypotension.
Why the other choices are wrong:
A. Addison disease - Addison's causes hypotension and hyperpigmentation; this patient's hypertension with hypokalemia indicates primary hyperaldosteronism, not adrenal insufficiency.B. Cushing syndrome - Cushing's causes central obesity and purple striae; this patient's hypertension with hypokalemia indicates hyperaldosteronism, often from Conn adenoma.
D. Pheochromocytoma - Pheochromocytoma causes paroxysmal hypertension with headaches; this patient's hypokalemia and metabolic alkalosis indicate chronic aldosterone excess.
E. Thyroid cancer - Thyroid cancer causes hypothyroidism when ablated; this patient's hypertension with hypokalemia indicates primary aldosteronism, not thyroid dysfunction.
Question 38
Answer: A - Adverse effect of fluoxetine therapy
Acute angle-closure glaucoma requires emergency treatment to lower intraocular pressure. Pilocarpine drops and systemic carbonic anhydrase inhibitors reduce aqueous production.
Why the other choices are wrong:
B. Bereavement reaction - Timolol reduces aqueous but slower.C. Early Parkinson disease - Acetazolamide auxiliary therapy.
D. Increase in alcohol consumption - Mannitol for cerebral edema, not glaucoma.
E. Mini-strokes NOTE: THIS IS THE END OF BLOCK 1. ANY REMAINING TIME MAY BE USED TO CHECK ITEMS IN THIS BLOCK. 28 Block 2: FIP Items 39-77; Time - 1 hour ALL ITEMS REQUIRE SELECTION OF ONE BEST CHOICE. - Dorzolamide oral less effective than IV.
Block 2: Foundations of Independent Practice (Questions 39-77)
Question 39
Answer: D - Thoracentesis
Large pleural effusion with atrial fibrillation requires diagnostic thoracentesis to assess the fluid. Pleural fluid analysis determines if effusion is exudative or transudative and guides further management.
Why the other choices are wrong:
A. Atrial fibrillation - Afib causes irregular pulse; this patient's regular tachycardia indicates sinus tachycardia or SVT, not atrial fibrillation.B. Atrial flutter - Atrial flutter causes flutter waves on ECG; this patient's regular narrow complex tachycardia indicates atrioventricular reentrant tachycardia (AVNRT).
D. Sinus tachycardia - Sinus tachycardia is appropriate response to illness; this patient's paroxysmal regular tachycardia with abrupt onset indicates reentrant SVT.
E. Ventricular tachycardia - VT causes wide complex tachycardia; this patient's narrow complex regular tachycardia with abrupt onset indicates supraventricular reentrant tachycardia.
Question 40
Answer: D - Ultrasonography of the abdomen
Postoperative patient with fever, elevated WBC, and abdominal tenderness after AAA repair may have infection or ischemia. Blood cultures identify bacteremia; early diagnosis guides empiric antibiotic therapy.
Why the other choices are wrong:
A. Acute bronchitis - Acute bronchitis causes cough with clear/white sputum; this patient's pneumonia risk and systemic symptoms indicate need for chest imaging and antibiotics.C. Influenza - Influenza causes myalgia and systemic symptoms but may progress to pneumonia; this elderly patient's infiltrate requires antibiotic therapy for bacterial superinfection.
D. Viral pneumonia - Viral pneumonia causes diffuse infiltrates; this patient's focal consolidation indicates bacterial pneumonia requiring specific antibiotic therapy.
E. Common cold - Common cold causes rhinorrhea and sore throat; this patient's fever with pulmonary infiltrate indicates bacterial pneumonia requiring treatment.
Question 41
Answer: E - Ultrasonography of the hips
Drug reaction with eosinophilia and systemic symptoms (DRESS) presents with fever, rash, lymphadenopathy, and eosinophilia. Discontinuation of offending agent is essential for management.
Why the other choices are wrong:
A. Gastroesophageal reflux - GERD causes heartburn and regurgitation; this patient's dysphagia to solids indicates mechanical obstruction, not acid reflux.B. Infectious esophagitis - Infectious esophagitis causes odynophagia and fever; this patient's mechanical dysphagia suggests structural disease like achalasia.
D. Myocardial infarction - MI causes chest pain radiating to arm; this patient's dysphagia indicates esophageal pathology, not cardiac disease.
E. Peptic ulcer - PUD causes epigastric pain; this patient's dysphagia to solids indicates esophageal motility disorder or obstruction.
Question 42
Answer: E - Mitral stenosis complicated by atrial fibrillation
Elevated transaminases and rash suggest drug-induced liver injury. Discontinuation of the causative medication is the primary intervention; supportive care allows hepatic recovery.
Why the other choices are wrong:
A. Bacteremia - Bacteremia from transient seeding does not cause persistent fever; this patient's prolonged fever with weight loss indicates chronic infection like endocarditis or TB.B. Common viral infection - Viral illness causes 3-5 day fever; this patient's 3-week fever with weight loss indicates serious infection or malignancy.
D. Medication side effect - Drug fever typically resolves within days of stopping medication; this patient's persistent 3-week fever indicates infection or malignancy.
E. Thermal dysregulation - Hypothalamic dysfunction would not cause 3-week fever; this patient's prolonged fever requires investigation for serious underlying disease.
Question 43
Answer: B - Decreased gastric myoelectrical activity
Pneumocystis pneumonia prophylaxis is indicated in HIV patients with CD4 count below 200. TMP-SMX is first-line; alternatives include dapsone or pentamidine.
Why the other choices are wrong:
A. Acute tubular necrosis - ATN presents with muddy brown casts; this patient's minimal proteinuria with hematuria indicates glomerulonephritis, not tubular injury.B. Prerenal azotemia - Prerenal disease causes elevated BUN:Cr ratio; this patient's hematuria and dysmorphic RBCs indicate intrinsic glomerular disease.
D. Interstitial nephritis - Interstitial nephritis causes WBC casts and eosinophiluria; this patient's hematuria and RBC casts indicate primary glomerulonephritis.
E. Post-streptococcal GN - PSGN causes low complement levels; this patient's ANA positivity and anti-dsDNA antibodies indicate lupus nephritis.
Question 44
Answer: E - Serum 25-hydroxyvitamin D assay
Opportunistic infection risk in HIV is related to CD4 count nadir. Even with immune reconstitution, previous opportunistic infections may recur if adherence to antiretroviral therapy lapses.
Why the other choices are wrong:
A. Acute leukemia - AML causes blasts in marrow; this patient's megaloblastic features with B12/folate deficiency indicate macrocytic anemia.C. Autoimmune hemolytic anemia - AIHA causes spherocytes with elevated indirect bilirubin; this patient's macrocytic anemia indicates B12 or folate deficiency.
D. Iron deficiency anemia - IDA causes microcytic hypochromic anemia; this patient's macrocytic hypersegmented neutrophils indicate B12 or folate deficiency.
E. Thalassemia - Thalassemia causes microcytic anemia with target cells; this patient's macrocytic anemia with neurologic symptoms indicates B12 deficiency.
Question 45
Answer: D - Ventilation-perfusion mismatch and shunt
Delirium in hospitalized patients commonly results from medication effects, infections, or metabolic derangements. Discontinuation of causative agents and treatment of underlying conditions resolve delirium.
Why the other choices are wrong:
A. Acute appendicitis - Appendicitis causes RLQ pain with peritoneal signs; this patient's LLQ pain with diarrhea indicates inflammatory bowel disease or infectious colitis.B. Diverticulitis - Diverticulitis typically occurs in older patients; this patient's chronic diarrhea indicates inflammatory bowel disease, not acute diverticular inflammation.
D. Irritable bowel syndrome - IBS causes functional symptoms without inflammation; this patient's bloody diarrhea and inflammation indicate true organic disease like IBD.
E. Peptic ulcer disease - PUD causes epigastric pain; this patient's colitis with bloody diarrhea indicates inflammatory bowel disease.
Question 46
Answer: C - Relieve the physician of duty and alert the hospital's patient safety officer
Dementia with Lewy bodies presents with hallucinations, parkinsonism, and cognitive fluctuation. Cholinesterase inhibitors improve cognitive function and behavioral symptoms.
Why the other choices are wrong:
A. Acute myocardial infarction - MI causes chest pain with elevated troponin; this patient's pneumonia risk with hypoxemia indicates respiratory cause, not cardiac event.C. Asthma exacerbation - Asthma causes wheezing and airway obstruction; this patient's fever with infiltrate indicates pneumonia requiring antibiotics.
D. Congestive heart failure - CHF causes orthopnea and edema; this patient's fever and infiltrate indicate infectious pneumonia.
E. Pulmonary embolism - PE causes acute dyspnea without fever; this patient's fever with consolidation indicates bacterial pneumonia.
Question 47
Answer: D - Plain x-ray of the left hip
Osteoporosis screening is indicated in postmenopausal women using DEXA scan. Treatment depends on T-score and fracture risk; bisphosphonates are first-line agents.
Why the other choices are wrong:
A. Acute angle-closure glaucoma - Angle-closure causes eye pain and decreased vision; this patient's asymptomatic elevated IOP indicates open-angle glaucoma.B. Corneal abrasion - Corneal abrasion causes pain and tearing; this patient's asymptomatic elevated IOP indicates glaucomatous disease.
D. Hyphema - Hyphema causes blood in AC from trauma; this patient's elevated IOP without trauma indicates open-angle glaucoma.
E. Iritis - Iritis causes pain and photophobia; this patient's asymptomatic elevated IOP indicates open-angle glaucoma without inflammation.
Question 48
Answer: B - High Low Low High
Insomnia in elderly patients often results from sleep architecture changes or medication effects. Cognitive-behavioral therapy for insomnia is preferred over sedative-hypnotic medications.
Why the other choices are wrong:
A. Acute gastroenteritis - Gastroenteritis causes diarrhea and cramping; this patient's chronic diarrhea with malabsorption indicates celiac disease or IBS.C. Colorectal cancer - CRC causes weight loss and blood in stool; this patient's celiac serology and improvement with gluten avoidance indicate celiac disease.
D. Crohn disease - Crohn's causes transmural inflammation; this patient's positive celiac serology and mucosal-only involvement indicate celiac disease.
E. Irritable bowel syndrome - IBS is functional without positive serology; this patient's positive tissue transglutaminase indicates celiac disease.
Question 49
Answer: C - Order a urine toxicology screening
Chronic pain management requires multimodal approach combining pharmacotherapy, physical therapy, and behavioral interventions. Opioids are reserved for moderate to severe pain unresponsive to other agents.
Why the other choices are wrong:
A. Addison disease - Addison's causes hypotension and hyperpigmentation; this patient's hypertension indicates secondary hypertension from hyperaldosteronism.C. Hypothyroidism - Hypothyroidism causes weight gain and cold intolerance; this patient's hypertension with hypokalemia indicates aldosterone excess.
D. Pheochromocytoma - Pheochromocytoma causes episodic hypertension with headaches; this patient's consistent hypertension with hypokalemia indicates primary hyperaldosteronism.
E. Thyroid cancer - Thyroid cancer affects hormone levels; this patient's hypertension with metabolic alkalosis indicates Conn adenoma.
Question 50
Answer: A - "I am concerned that you are abusing pain medicine. I would like for you to consider a substance abuse treatment program."
Atrial fibrillation requires anticoagulation assessment by CHA2DS2-VASc score. CHADS2 score less than 2 may not require anticoagulation; high scores require warfarin or DOAC.
Why the other choices are wrong:
A. Acute myocarditis - Myocarditis causes chest pain with elevated troponin; this patient's exertional angina relieved by rest indicates stable CAD, not acute inflammation.B. Aortic dissection - Aortic dissection causes sudden tearing pain; this patient's exertional angina indicates chronic coronary disease.
D. Myocardial infarction - MI is acute coronary event; this patient's stable exertional symptoms indicate chronic CAD without acute infarction.
E. Pulmonary embolism - PE causes acute dyspnea; this patient's exertional chest discomfort relieved by rest indicates angina from stenosis.
Question 51
Answer: C - Chlamydial cervicitis
Acute coronary syndrome requires risk stratification and early reperfusion or antiplatelet therapy. High-risk features include ST elevation, positive troponin, and hemodynamic instability.
Why the other choices are wrong:
A. Acute leukemia - AML causes blasts and cytopenias; this patient's megaloblastic features indicate B12/folate deficiency, not leukemia.B. Anemia of chronic disease - Chronic disease anemia is normocytic; this patient's macrocytic anemia indicates B12 or folate deficiency.
D. Iron deficiency - IDA causes microcytic hypochromic RBCs; this patient's macrocytic with hypersegmented neutrophils indicates B12/folate deficiency.
E. Thalassemia trait - Thalassemia trait causes microcytic anemia; this patient's macrocytic anemia indicates megaloblastic disease.
Question 52
Answer: A - Ankle brachial index
Heart failure with reduced ejection fraction requires ACE inhibitors, beta-blockers, and diuretics. Aldosterone antagonists improve survival in systolic heart failure.
Why the other choices are wrong:
A. Acute appendicitis - Appendicitis causes RLQ pain with peritoneal signs; this patient's epigastric pain indicates gastric or duodenal pathology.B. Cholecystitis - Cholecystitis causes RUQ pain; this patient's epigastric pain indicates peptic ulcer or gastritis.
D. Mesenteric ischemia - Mesenteric ischemia causes severe pain out of proportion; this patient's epigastric pain indicates PUD or gastritis.
E. Pancreatitis - Pancreatitis causes epigastric pain with elevated amylase; this patient's ulcer on endoscopy indicates peptic ulcer disease.
Question 53
Answer: D - A negative D-dimer assay has a high negative predictive value for excluding the diagnosis of pulmonary embolism
Chronic kidney disease management includes blood pressure control, glycemic management, and proteinuria reduction. ACE inhibitors slow CKD progression in diabetic and nondiabetic kidney disease.
Why the other choices are wrong:
A. Acute viral infection - Viral illness causes self-limited fever; this patient's prolonged fever indicates chronic infection or malignancy.B. Common bacterial infection - Acute bacterial infection typically resolves with antibiotics; this patient's persistent fever indicates endocarditis or TB.
D. Medication side effect - Drug fever resolves shortly after stopping medication; this patient's prolonged fever indicates serious infection.
E. Thermal dysregulation - Hypothalamic fever is rare; this patient's 3-week fever requires investigation for serious disease.
Question 54
Answer: D - Insurance company
Hypertension with target organ damage requires aggressive BP control. ACE inhibitors or ARBs provide renal protection in diabetic and nondiabetic kidney disease.
Why the other choices are wrong:
A. Acute tubular necrosis - ATN causes elevated creatinine; this patient's microscopy shows RBC casts indicating glomerulonephritis.B. Prerenal azotemia - Prerenal disease shows elevated BUN:Cr ratio; this patient's hematuria indicates glomerular disease.
D. Interstitial nephritis - Interstitial disease shows WBC casts; this patient's RBC casts and hematuria indicate glomerulonephritis.
E. Lupus nephritis - Lupus shows low complement and ANA positivity; this patient's PSGN has recent strep infection and normal complement.
Question 55
Answer: C - Infant HIV infection was the only significantly associated factor
Thyroid cancer with elevated thyroglobulin after total thyroidectomy indicates persistent disease. Radioactive iodine ablation eliminates remnant thyroid and metastatic disease.
Why the other choices are wrong:
A. Acute appendicitis - Appendicitis causes RLQ pain; this patient's left lower quadrant pain indicates diverticulitis or colitis.C. Crohn disease - Crohn's causes chronic inflammation; this patient's acute diverticulitis requires surgical consideration.
D. Irritable bowel syndrome - IBS is functional; this patient's acute inflammation indicates organic disease.
E. Peptic ulcer - PUD causes epigastric pain; this patient's LLQ pain with inflammation indicates diverticulitis.
Question 56
Answer: C - Place masks on the patient and yourself and then continue to evaluate him
Adrenal insufficiency presents with hypotension, hyponatremia, and elevated ACTH. Cortisol replacement and mineralocorticoid supplementation restore hemodynamic stability.
Why the other choices are wrong:
A. Acute myocardial infarction - MI causes chest pain; this patient's dyspnea with infiltrate indicates pneumonia.B. Atypical pneumonia - Atypical pneumonia causes gradual symptoms; this patient's fever with consolidation indicates bacterial pneumonia.
D. Congestive heart failure - CHF causes orthopnea; this patient's fever and infiltrate indicate infection.
E. Pulmonary embolism - PE causes acute dyspnea; this patient's fever indicates pneumonia.
Question 57
Answer: E - No further evaluation is necessary
Cushing syndrome with hypertension, hypokalemia, and metabolic alkalosis suggests glucocorticoid excess. Low-dose dexamethasone suppression test confirms diagnosis.
Why the other choices are wrong:
A. Acute hepatitis - Acute hepatitis elevates transaminases acutely; this patient's chronic elevation with cirrhosis indicates advanced liver disease.B. Alcoholic cirrhosis - Both can coexist but PSC causes cholestasis pattern; this patient's elevated alkaline phosphatase and bilirubin indicate PSC.
D. Hemochromatosis - Hemochromatosis causes iron overload; this patient's PSC diagnosis is confirmed by elevated cholestatic enzymes and imaging.
E. Viral hepatitis C - HCV causes elevated transaminases; this patient's cholestatic pattern and autoimmune features indicate primary sclerosing cholangitis.
Question 58
Answer: A - The risk for inpatient mortality is greater for patients with hypotension than for those without hypotension
Pheochromocytoma presents with episodic hypertension, diaphoresis, and anxiety. Plasma free metanephrines and 24-hour urine metanephrines confirm diagnosis; imaging localizes tumor.
Why the other choices are wrong:
A. Acute leukemia - AML causes blasts; this patient's lymphocytosis indicates infectious mononucleosis, not leukemia.B. Chronic lymphocytic leukemia - CLL causes progressive lymphocytosis; this patient's acute presentation with fever indicates infectious mononucleosis.
D. Lymphoma - Lymphoma causes lymphadenopathy with painless masses; this patient's atypical lymphocytes and positive heterophile indicate EBV infection.
E. Pertussis - Pertussis causes paroxysmal cough; this patient's sore throat and atypical lymphocytes indicate infectious mononucleosis.
Question 59
Answer: C - Serum free metanephrine concentration
Hyperthyroidism with atrial fibrillation requires beta-blockade and antithyroid drugs. Propranolol is preferred as it also inhibits peripheral T4 to T3 conversion.
Why the other choices are wrong:
A. Acute appendicitis - Appendicitis causes RLQ pain; this patient's epigastric ulcer pain indicates PUD.B. Cholecystitis - Cholecystitis causes RUQ pain; this patient's epigastric pain indicates gastric ulcer.
D. Mesenteric ischemia - Mesenteric ischemia causes severe pain; this patient's ulcer on endoscopy confirms PUD.
E. Pancreatitis - Pancreatitis causes epigastric pain radiating to back; this patient has confirmed peptic ulcer on endoscopy.
Question 60
Answer: B - "Everyone makes mistakes. In your case, though, that doesn't mean you always mess things up."
Primary hyperparathyroidism with hypercalcemia and nephrolithiasis requires parathyroidectomy. Preoperative imaging localizes the abnormal gland.
Why the other choices are wrong:
A. Acute arterial occlusion - Arterial occlusion causes acute limb ischemia; this patient's progressive claudication indicates chronic atherosclerotic disease.C. Aortic dissection - Aortic dissection causes acute pain; this patient's exertional claudication indicates peripheral artery disease.
D. Buerger disease - Buerger's disease is associated with smoking; this patient's atherosclerotic disease pattern indicates PAD.
E. Raynaud phenomenon - Raynaud's causes episodic color changes; this patient's claudication indicates arterial obstruction.
Question 61
Answer: A - Displacement of the nucleus pulposus
Vitamin B12 deficiency with neurologic symptoms requires parenteral replacement. Intramuscular cyanocobalamin bypasses absorption defects present in pernicious anemia.
Why the other choices are wrong:
A. Acute epiglottitis - Epiglottitis is medical emergency with difficulty swallowing; this patient's cough indicates croup with laryngeal involvement.B. Diphtheria - Diphtheria causes pseudomembrane; this patient's barky cough and inspiratory stridor indicate croup.
D. Foreign body aspiration - Foreign body causes acute onset; this patient's viral croup develops over days.
E. Peritonsillar abscess - Abscess causes sore throat and dysphagia; this patient's laryngitis with stridor indicates croup.
Question 62
Answer: E - Vascular dementia
Polycystic ovary syndrome presents with irregular menses, hyperandrogenism, and ovarian cysts. Lifestyle modification and metformin reduce insulin resistance and improve fertility.
Why the other choices are wrong:
A. Acute cholecystitis - Acute cholecystitis causes RUQ pain with fever; this patient's chronic fatty food intolerance indicates chronic biliary disease.B. Cholangitis - Cholangitis causes fever with jaundice; this patient's postprandial pain indicates biliary colic.
D. Peptic ulcer - PUD causes epigastric pain; this patient's RUQ pain with ultrasound findings indicates cholelithiasis.
E. Renal colic - Renal colic causes flank pain with hematuria; this patient's RUQ pain with gallstones indicates biliary disease.
Question 63
Answer: A - Airway compression
Osteoarthritis of the knee with joint space narrowing requires weight loss, physical therapy, and NSAIDs. Intra-articular corticosteroids provide temporary relief.
Why the other choices are wrong:
A. Acute myocarditis - Myocarditis causes chest pain with elevated troponin; this patient's hypertension indicates essential hypertension or secondary cause.B. Aortic stenosis - AS causes systolic murmur; this patient's hypertension requires evaluation for secondary causes.
D. Mitral regurgitation - MR causes systolic murmur; this patient's hypertension with left ventricular hypertrophy indicates essential hypertension.
E. Pulmonary hypertension - PH causes right heart strain; this patient's systemic hypertension with LVH indicates systemic arterial hypertension.
Question 64
Answer: D - Instructing the patient to stop driving
Rheumatoid arthritis with elevated ESR and RF requires DMARDs to prevent joint damage. Methotrexate is first-line; TNF inhibitors added for inadequate response.
Why the other choices are wrong:
A. Acute glomerulonephritis - AGN causes hematuria; this patient's asymptomatic proteinuria indicates chronic kidney disease or nephrotic syndrome.B. Acute tubular necrosis - ATN causes muddy brown casts; this patient's selective proteinuria indicates minimal change disease.
D. Diabetic nephropathy - Diabetic disease shows basement membrane thickening; this patient's minimal change disease is idiopathic.
E. Lupus nephritis - Lupus shows low complement; this patient's minimal change disease is idiopathic without systemic disease.
Question 65
Answer: D - 90%
Systemic lupus erythematosus with positive ANA and low complement requires hydroxychloroquine and NSAIDs. Severe manifestations require corticosteroids and immunosuppressants.
Why the other choices are wrong:
A. Acute appendicitis - Appendicitis causes RLQ pain; this patient's diffuse abdominal pain indicates peritonitis from perforation.B. Cholecystitis - Cholecystitis causes RUQ pain; this patient's diffuse peritonitis indicates perforated viscus.
D. Mesenteric ischemia - Mesenteric ischemia causes severe pain; this patient's free air on imaging confirms perforation.
E. Pancreatitis - Pancreatitis causes epigastric pain; this patient's peritonitis with free air indicates perforated peptic ulcer.
Question 66
Answer: D - Essepro should not be prescribed because the patient has severe liver disease
Sjögren syndrome with dry eyes and mouth has positive anti-SSA and anti-SSB antibodies. Supportive care with artificial tears and saliva substitutes is primary management.
Why the other choices are wrong:
A. Acute leukemia - AML presents with blasts and cytopenias; this patient's megaloblastic features indicate B12 or folate deficiency.C. Autoimmune hemolytic anemia - AIHA causes spherocytes and positive DAT; this patient's macrocytic anemia indicates B12/folate deficiency.
D. Iron deficiency anemia - IDA is microcytic; this patient's macrocytic anemia with hypersegmented neutrophils indicates megaloblastic disease.
E. Thalassemia major - Thalassemia is microcytic; this patient's macrocytic anemia indicates B12 or folate deficiency.
Question 67
Answer: D - There is no clinically important difference in blood pressure reduction between the three dose groups
Vasculitis with palpable purpura and elevated inflammatory markers requires immunosuppression. Corticosteroids and cyclophosphamide induce remission in systemic vasculitis.
Why the other choices are wrong:
A. Acute myocardial infarction - MI causes chest pain; this patient's exertional dyspnea indicates valvular disease.B. Aortic dissection - Dissection causes acute tearing pain; this patient's exertional dyspnea indicates valvular pathology.
D. Mitral stenosis - MS causes diastolic murmur and dyspnea; this patient's systolic murmur indicates aortic stenosis.
E. Pulmonary hypertension - PH causes right heart failure; this patient's systolic murmur indicates aortic stenosis.
Question 68
Answer: B - Mucosal edema
ARDS with severe hypoxemia and bilateral infiltrates requires mechanical ventilation with low tidal volumes. Lung-protective ventilation reduces mortality.
Why the other choices are wrong:
A. Acute appendicitis - Appendicitis causes RLQ pain; this patient's LLQ pain with diarrhea indicates inflammatory bowel disease.B. Diverticulitis - Diverticulitis is acute inflammation; this patient's chronic diarrhea indicates inflammatory bowel disease.
D. Irritable bowel syndrome - IBS is functional; this patient's bloody diarrhea indicates organic disease like IBD.
E. Peptic ulcer disease - PUD causes epigastric pain; this patient's colitis indicates inflammatory bowel disease.
Question 69
Answer: C - Polymyositis
Acute interstitial pneumonia with dyspnea and bilateral ground-glass opacities requires careful diagnosis. High-dose corticosteroids may be beneficial if diagnosis is confirmed.
Why the other choices are wrong:
A. Acute viral infection - Viral illness causes self-limited fever; this patient's prolonged fever indicates endocarditis or TB.B. Bacterial pneumonia - Pneumonia causes fever and infiltrate; this patient's prolonged fever without respiratory findings indicates systemic infection.
D. Lymphoma - Lymphoma causes constitutional symptoms; this patient's heart murmur indicates endocarditis.
E. Tuberculosis - TB causes chronic illness with weight loss; this patient's new murmur indicates endocarditis.
Question 70
Answer: C - 13
Polymyositis presents with proximal muscle weakness, elevated creatine kinase, and myositis on muscle biopsy. Corticosteroids and steroid-sparing agents induce remission.
Why the other choices are wrong:
A. NSAIDs alone - NSAIDs are insufficient for inflammatory myopathy; this patient requires immunosuppression with steroids and steroid-sparing agents.B. Immunosuppression insufficient - Steroid-sparing agents added for steroid-resistant cases; initial steroid monotherapy is often effective for polymyositis.
D. Prolonged biologics - Biologics are reserved for inadequate response to conventional therapy; most cases respond to steroids and azathioprine.
E. High-dose biologics - Biologics are not first-line for polymyositis; conventional immunosuppression is standard initial therapy.
Question 71
Answer: B - Fine-needle aspiration of the nodule
Likelihood ratio = sensitivity/(1-specificity). For biomarker >100 U/mL: Sensitivity = 120/336; Specificity = 1 to (10/375). LR+ = (120/336)/(10/375) = 13.4, approximately 13.
Why the other choices are wrong:
A. CT scan of the neck - CT provides imaging but cannot calculate likelihood ratios derived from test sensitivity and specificity data.C. Radionuclide thyroid scan - Radionuclide imaging shows function but does not provide the 2x2 contingency table needed to compute specificity.
D. Thyroidectomy - Surgery is a treatment, not a diagnostic test; it cannot generate statistical measures for likelihood ratio calculations.
E. Observation only - Observation without testing produces no data on test performance metrics needed for likelihood ratio analysis.
Question 72
Answer: D - Serologic study for Coccidioides immitis
Screening tests in asymptomatic individuals should have high sensitivity to avoid false negatives. The test should effectively identify disease in early stages when intervention is most beneficial.
Why the other choices are wrong:
A. Bacterial culture of sputum - Bacterial sputum culture has poor sensitivity in early coccidioidomycosis before significant respiratory involvement.B. CT scan of the chest - CT imaging misses early infection before radiographic infiltrates appear, defeating the screening purpose.
C. Fungal culture of the blood - Fungal blood cultures have very low sensitivity in coccidioidomycosis unless disseminated disease is present.
E. Sputum cytologic study - Sputum cytology examines cell morphology but does not identify fungal organisms or antigens effectively.
F. Urine assay for Legionella antigen - Legionella antigen testing detects a different organism entirely and would miss Coccidioides infection.
Question 73
Answer: D - Initiate a family meeting to discuss the parents' concerns with their son
Cost-effectiveness analysis compares costs and outcomes of competing interventions. The intervention with the lowest cost per quality-adjusted life year (QALY) is most cost-effective.
Why the other choices are wrong:
A. Advise the parents not to influence their son's decision in this matter - Instructing non-participation ignores the need for economic analysis comparing intervention costs to QALYs.B. Arrange for evaluation of their son's competency - Competency evaluation assesses decision-making capacity but does not perform cost-utility comparison.
C. Enroll their son in a smoking cessation program - Program enrollment is a treatment intervention itself, not economic analysis; cost-benefit uses dollars, not QALYs.
E. Obtain legal advice regarding guardianship - Guardianship decisions address autonomy but do not constitute the cost-utility economic comparison needed.
Question 74
Answer: E - Over-the-counter cold medication
Evidence-based medicine integrates individual clinical expertise with best available evidence and patient values. Clinical decision-making requires synthesis of research evidence and individual patient factors.
Why the other choices are wrong:
A. Acute viral illness - Individual expertise without evidence risks perpetuating outdated or ineffective clinical practices.B. Chronic sinusitis - Research evidence alone, without patient values and risk tolerance, leads to impersonal care ignoring preferences.
C. Essential hypertension - Patient preferences alone without evidence support may withhold beneficial treatments based purely on patient wishes.
D. Her alcohol intake - Even expert clinicians cannot make good decisions without current research evidence about effective interventions.
Question 75
Answer: E - No additional study is indicated
Patient safety requires systems-based approaches addressing medication errors, wrong site surgery, and communication failures. Root cause analysis identifies system failures preventing future errors.
Why the other choices are wrong:
A. Cystoscopy - Additional patient testing does not address the system-level process failure that allowed the medication error.B. Echocardiography - Acknowledging error to the patient is ethically important but does not prevent the same error with other patients.
C. MRI of the abdomen - New policies lack impact without implementation mechanisms, training, and ongoing verification of compliance.
D. Renal ultrasonography - Individual discipline may feel appropriate but ignores the systems failures that enabled any provider to make the error.
Question 76
Answer: F - Sympathetic underactivity
Why the other choices are wrong:
A. Parasympathetic overactivity - Testing does not treat the risk of opportunistic infections in patients with CD4<200.B. Parasympathetic underactivity - Counseling about risks without OI prophylaxis leaves the severely immunocompromised patient unprotected.
C. Postsynaptic neuromuscular junction defect - Additional TB agents are appropriate but do not immediately prevent opportunistic infections.
D. Presynaptic neuromuscular junction defect - Prophylaxis is important, but immune reconstitution through antiretroviral therapy is the fundamental priority.
E. Sympathetic overactivity - This distractor does not relate to the immunological deficit; immune reconstitution is the needed intervention.
Question 77
Answer: E - Urine protein concentration NOTE: THIS IS THE END OF BLOCK 2. ANY REMAINING TIME MAY BE USED TO CHECK ITEMS IN THIS BLOCK. 49 Block 3: ACM Items 78-107; Time - 45 minutes ALL ITEMS REQUIRE SELECTION OF ONE BEST CHOICE.
HIV patients with CD4 count below 200 require prophylaxis against opportunistic infections. Immune reconstitution after antiretroviral therapy increases CD4 count and reduces OI risk.
Why the other choices are wrong:
A. Echocardiography - Echocardiography is not used to detect or prevent opportunistic infections in immunocompromised patients.B. HIV antibody study - Repeated HIV antibody testing does not provide immune reconstitution; CD4<200 requires OI prophylaxis.
C. Serum B-type natriuretic peptide concentration - BNP measures cardiac strain, not relevant to opportunistic infection prevention; prophylaxis is needed if CD4<200.
D. Toxicology screening of the urine - Urine toxicology screening is not indicated for OI prevention; prophylaxis requires specific OI agents based on CD4 level.
Block 3: Advanced Clinical Medicine (Questions 78-107)
Question 78
Answer: A - Carbamazepine
Trigeminal neuralgia presents with brief, unilateral, severe shooting pain triggered by light touch, cold air, or chewing. The hallmark feature is pain lasting seconds to less than a minute. Carbamazepine is the first-line anticonvulsant, blocking sodium channels to reduce neuronal hyperexcitability and pain episodes.
Why the other choices are wrong:
B. Lamotrigine - Lamotrigine has slower onset requiring days to weeks compared to carbamazepine's rapid pain relief.C. Levetiracetam - Levetiracetam is less effective for trigeminal neuralgia; carbamazepine remains the gold-standard first-line choice.
D. Topiramate - Topiramate is an alternative if carbamazepine fails, but has slower efficacy and is not first-line.
E. Zonisamide - Zonisamide is not standard treatment; carbamazepine provides superior pain control for this condition.
Question 79
Answer: C - Measurement of lower extremity compartment pressures
Post-marathon rhabdomyolysis with progressive pain in the anterior tibial compartment despite IV fluids indicates developing compartment syndrome. Elevated CK and pain on passive toe flexion are key findings. Compartment pressure measurement is the diagnostic gold standard to confirm the diagnosis and determine need for fasciotomy.
Why the other choices are wrong:
A. Application of ice to the right lower extremity - Ice therapy is supportive but does not diagnose compartment syndrome or determine if fasciotomy is needed.B. Cyclobenzaprine therapy - Cyclobenzaprine is a muscle relaxant inappropriate for rhabdomyolysis-induced compartment syndrome.
D. MRI of the right lower extremity - MRI is not urgently available and delays diagnosis; compartment pressure measurement is the gold standard.
E. Nonsteroidal anti-inflammatory drug therapy - NSAIDs do not address the elevated compartment pressure risking permanent tissue damage.
Question 80
Answer: C - Systemic hypertension
Coarctation of the aorta presents with weak femoral pulses, strong brachial pulses, radiofemoral delay, systolic murmur, and LVH. The greatest long-term complication is systemic hypertension from increased afterload proximal to the coarctation, leading to stroke and other hypertensive complications.
Why the other choices are wrong:
A. Atrial fibrillation - Atrial fibrillation is a consequence of prolonged hypertension, not the primary complication.B. Cor pulmonale - Cor pulmonale is rare with coarctation; systemic hypertension is the main long-term problem.
D. Tricuspid valve regurgitation - Tricuspid regurgitation results from other complications, not a primary manifestation of coarctation.
Question 81
Answer: E - Serial serum β-hCG concentrations
Positive pregnancy test with RLQ pain, vaginal spotting, no intrauterine gestational sac, and thickened endometrium suggests ectopic pregnancy. Serial beta-hCG measurements distinguish between normal rising levels, plateau suggesting ectopic pregnancy, or declining levels indicating spontaneous abortion.
Why the other choices are wrong:
A. Admission to the hospital for observation - Hospital admission may be needed, but serial beta-hCG is diagnostic before considering surgery.B. Diagnostic laparoscopy - Laparoscopy is invasive; non-invasive serial hCG testing helps distinguish ectopic from other causes.
C. Dilatation and curettage - D&C risks inducing bleeding in ectopic pregnancy; hCG trends guide safer diagnostic and management decisions.
D. Follow-up pelvic ultrasonography in 1 week - Waiting one week delays diagnosis and risks tubal rupture; serial hCG can diagnose within days.
Question 82
Answer: C - History of psychosis
Postpartum mood disorders range from baby blues to postpartum depression to postpartum psychosis. A prior history of postpartum psychosis strongly predicts recurrence of severe psychotic symptoms or severe depression, indicating highest risk for poor prognosis and need for intensive monitoring.
Why the other choices are wrong:
A. Anorexia - Anorexia is a symptom of depression but not specifically predictive of postpartum psychosis.B. Depressed mood - Prior depression is a risk factor, but psychotic symptoms carry worse prognosis and higher recurrence.
D. Multiparity - Multiparity is not a risk factor; prior psychosis is the strongest predictor of severe recurrence.
Question 83
Answer: C - Recommend diet and low-impact exercise
A 47-year-old with elevated cholesterol, elevated triglycerides, and no cardiovascular risk factors should start with lifestyle modifications. Diet and exercise (weight loss, low-impact exercise for knee pain) are first-line interventions before pharmacotherapy for mild to moderate dyslipidemia.
Why the other choices are wrong:
A. Prescribe atorvastatin - Statin therapy is premature for mild-to-moderate dyslipidemia before first-line lifestyle modification.B. Prescribe cholestyramine - Cholestyramine is less effective than statins, but pharmacotherapy is premature before lifestyle intervention.
D. Refer the patient to a cardiologist - Cardiology referral is unnecessary for mild-to-moderate dyslipidemia manageable with lifestyle changes.
E. Repeat fasting laboratory studies in 1 month - Repeating labs does not constitute treatment; lifestyle intervention must be implemented first.
Question 84
Answer: C - Do endotracheal intubation
Massive hematemesis from esophageal varices with hemodynamic instability requires immediate management. Broad-spectrum antibiotics (ceftriaxone) reduce bacterial infection risk and mortality in variceal bleeding by preventing spontaneous bacterial peritonitis and hepatic encephalopathy.
Why the other choices are wrong:
A. Arrange for transjugular intrahepatic portal vein shunting - TIPS is a rescue procedure for refractory bleeding, not initial management of massive hematemesis.B. Begin intravenous vasopressin therapy - Vasopressin alone does not achieve hemostasis; endoscopy with banding is required to stop bleeding.
D. Do upper endoscopy - Endoscopy is essential, but it must be preceded by airway protection and concurrent vasoactive drugs.
E. Insert an esophageal tube for balloon tamponade - Esophageal balloon tamponade is temporary; endoscopy is required for definitive hemostasis.
Question 85
Answer: C - Pain reduction
Post-thoracotomy patients are at risk for pulmonary complications from inadequate ventilation due to pain and sedation. Pain reduction through adequate analgesia restores effective breathing, enables secretion clearance, and prevents pneumonia and hypoxemia.
Why the other choices are wrong:
A. Administration of broad-spectrum antibiotics - Prophylactic antibiotics are not indicated; pain control enables effective breathing and secretion clearance.B. Initiation of tube feedings - Tube feedings bypass oral intake but do not improve pulmonary ventilation or secretion clearance.
D. Physical therapy - Physical therapy helps mobilization, but adequate analgesia is the critical first step enabling breathing.
E. Psychological evaluation for post-traumatic stress disorder - Psychiatric evaluation is not relevant to preventing post-thoracotomy pulmonary complications.
Question 86
Answer: E - Order echocardiography
Tuberculous pericarditis with signs of constrictive physiology (elevated JVD, hepatomegaly, lower extremity edema) after 9 weeks of antimicrobial therapy. Corticosteroids (prednisone) reduce inflammation and prevent fibrosis leading to permanent constrictive pericarditis.
Why the other choices are wrong:
A. Add furosemide therapy and reevaluate in 4 weeks - Diuretics treat fluid overload but do not prevent progression to permanent constrictive pericarditis.B. Add prednisone therapy - Colchicine is ineffective for tuberculosis; corticosteroids reduce inflammation and prevent fibrosis.
C. Add streptomycin and cycloserine therapy - Additional TB medications without anti-inflammatory agents do not prevent the fibrotic response.
D. Order bronchoscopy for brushings and cytology - Bronchoscopy is not indicated; echocardiography shows hemodynamic consequences of pericarditis.
Question 87
Answer: A - Compression stockings
A woman with gradually enlarging varicose veins presents with no pain and normal examination. Compression stockings provide conservative management for symptomatic varicose veins before considering invasive interventions like ligation or sclerotherapy.
Why the other choices are wrong:
B. Surgical ligation of the largest veins - Ligation is invasive and reserved for symptomatic disease; conservative management suits asymptomatic varicosities.C. Venography - Venography is not needed for diagnosis; compression therapy is first-line for asymptomatic varicose veins.
D. Venous duplex ultrasonography - Duplex ultrasound is diagnostic if needed, but conservative management is first-line before imaging.
E. Warfarin therapy - Warfarin is anticoagulation, not treatment for varicose veins; compression therapy is appropriate.
Question 88
Answer: A - Ampicillin-sulbactam
Cat bite wounds carry high infection risk from Pasteurella multocida, especially in diabetics with impaired immunity. Ampicillin-sulbactam provides beta-lactamase stable coverage against Pasteurella and is appropriate for cat bite prophylaxis and treatment.
Why the other choices are wrong:
B. Cefazolin and gentamicin - Cefazolin lacks Pasteurella coverage; ampicillin-sulbactam is superior for cat bite prophylaxis.C. Dicloxacillin and clindamycin - Dicloxacillin lacks Pasteurella coverage; fluoroquinolones or ampicillin-sulbactam are better choices.
D. Levofloxacin - Levofloxacin covers Pasteurella but ampicillin-sulbactam is more predictable for this common organism.
E. Vancomycin and metronidazole - Vancomycin covers Staph but not Pasteurella; metronidazole treats anaerobes not typical in cat bites.
Question 89
Answer: E - Stage of disease
A 39-year-old with copious foul-smelling discharge, progressive heavy vaginal bleeding, friable cervix, and exophytic cervical mass for 6 months indicates cervical cancer. The critical factor for management is staging (determining extent of disease) to guide treatment decisions.
Why the other choices are wrong:
A. Future fertility plans - Future fertility is important but secondary to determining disease stage for treatment planning.B. Hypertension - Hypertension is a comorbidity; stage determines whether chemotherapy, radiation, or both is appropriate.
C. Obesity - Obesity is relevant for planning but does not take priority over establishing disease extent.
D. Patient age - Age 39 does not contraindicate aggressive treatment; stage determines treatment intensity.
Question 90
Answer: D - Lowering blood pressure
A 28-year-old with newly diagnosed hypertension (156/98), obesity (BMI 38), and family history of CAD, diabetes, and hypertension needs aggressive risk factor modification. Lowering blood pressure is the priority given the elevated readings and multiple cardiovascular risk factors.
Why the other choices are wrong:
A. Aiding with metabolism of glucose - Glucose metabolism is important but less urgent than treating severely elevated BP 156/98.B. Decreasing pulse rate - Lowering resting heart rate is less critical than reducing dangerously elevated blood pressure.
C. Decreasing serum LDL-cholesterol concentration - LDL cholesterol is a risk factor, but immediate blood pressure control takes priority with readings this high.
E. Suppressing appetite - Appetite suppression does not address the underlying hypertension driving cardiovascular risk.
Question 91
Answer: D - Prescribe metronidazole therapy
The girlfriend has confirmed trichomoniasis vaginalis, which is highly transmissible. The asymptomatic male partner should receive presumptive metronidazole therapy regardless of symptoms, as untreated asymptomatic infection perpetuates transmission and reinfection.
Why the other choices are wrong:
A. Obtain a urethral swab for potassium hydroxide preparation - KOH microscopy confirms diagnosis but does not treat; presumptive therapy is standard for partners.B. Order urinalysis and urine culture - Testing confirms infection but does not treat asymptomatic disease perpetuating transmission.
C. Prescribe ceftriaxone and doxycycline therapy - Ceftriaxone and doxycycline treat gonorrhea and chlamydia, not Trichomonas vaginalis.
E. Reassure the patient that no treatment is necessary - Observation allows continued transmission and reinfection; metronidazole is the standard partner treatment.
Question 92
Answer: A - Antiretroviral therapy
Oral candidiasis (thrush unable to scrape off) with unintentional weight loss of 4.5 kg over 6 months and positive HIV test indicates advanced immunosuppression. Antiretroviral therapy (ART) addressing the underlying immunodeficiency is the critical intervention; CD4 of 128 indicates AIDS.
Why the other choices are wrong:
B. Liquid nitrogen therapy applied to the tongue lesions - Liquid nitrogen does not treat oral candidiasis; CD4<200 requires immune restoration as priority.C. Micafungin therapy - PCP prophylaxis is indicated, but antiretroviral therapy addressing immunodeficiency is paramount.
D. Surgical excision of the tongue lesions - Surgical excision is not appropriate; antifungal therapy and immune reconstitution are needed.
E. Systemic chemotherapy with liposomal doxorubicin - Chemotherapy is for AIDS-related malignancies, not for treating oral candidiasis.
Question 93
Answer: A - Recommend behavioral therapy
Urinary frequency and incontinence occurring only around anxiety-provoking events (air travel) with normal urinalysis and no organic pathology indicate psychogenic symptoms. Reassurance that the symptoms are functional and addressing underlying anxiety disorder are appropriate management.
Why the other choices are wrong:
B. Recommend psychoanalytic psychotherapy - Psychoanalytic exploration is deep; behavioral therapy directly addresses anxiety-triggered symptoms.C. Recommend that the patient avoid any stressful activities that cause the problem - Avoidance reinforces anxiety disorder rather than addressing the underlying condition.
D. Review the patient's sexual history - Sexual history is not relevant to incontinence provoked by anxiety during air travel.
E. Reassure the patient that her symptoms will resolve in time - Spontaneous resolution is unlikely without treatment; early behavioral intervention is more effective.
Question 94
Answer: A - Incision and drainage
A 22-year-old with 5-day sore throat, fever to 40°C, odynophagia, trismus, anterior soft palate displacement, and exudate indicates likely peritonsillar abscess. Incision and drainage is the definitive treatment to relieve airway obstruction and allow recovery.
Why the other choices are wrong:
B. Intravenous methylprednisolone therapy - Corticosteroids reduce inflammation but do not drain the abscess causing airway obstruction.C. Oral nystatin therapy - Nystatin treats candidiasis, not bacterial peritonsillar abscess requiring surgical drainage.
D. Salt water gargle - Salt water gargling provides comfort but cannot drain pus causing airway obstruction.
E. Tonsillectomy - Tonsillectomy is elective surgery; acute abscess requires immediate drainage to prevent obstruction.
Question 95
Answer: C - The sons of their daughters will be at risk for a clinically evident coagulation disorder
A 26-year-old man with lifelong excessive bruising, prolonged bleeding after dental extraction, and family history of "bleeders" with normal platelets, bleeding time, and PT but prolonged PTT indicates Factor VIII or IX deficiency (hemophilia A or B). This is X-linked recessive inheritance.
Why the other choices are wrong:
A. Anticoagulation therapy - Immediate anticoagulation in a young patient without symptoms of thrombosis is inappropriate.B. Blood transfusion - Transfusion may be needed for anemia but does not prevent hemarthrosis or address bleeding risk.
D. Splenectomy - Splenectomy may help some hemolytic anemias but is inappropriate for a bleeding disorder.
E. Observation only - Observation without treatment ignores the significant bleeding risk with low factor levels.
Question 96
Answer: E - Observation only
An 18-month-old who swallowed a coin 2 hours ago with no symptoms (no choking, feeding problems, or pain) should be managed conservatively with observation. Most coins pass spontaneously through the GI tract without intervention.
Why the other choices are wrong:
A. Aggressive removal of the coin - Aggressive removal risks causing perforation, erosion, or airway complications in a young child.B. Endotracheal intubation - Endotracheal intubation is unnecessary for a stable asymptomatic child who swallowed a coin.
C. Gastric lavage - Gastric lavage risks coin aspiration into the airway in an unintubated child.
D. Immediate surgical intervention - Immediate surgical intervention is not indicated for a coin likely to pass spontaneously.
Question 97
Answer: D - Recommend beginning a weight loss program
A 29-year-old gravida with recurrent low back pain every 2 to 3 months and obesity (BMI 37) who walks 3 miles daily should undergo imaging to rule out structural pathology. MRI of lumbosacral spine is the most sensitive imaging to evaluate for disc herniation or stenosis.
Why the other choices are wrong:
A. Application of ice to the lower back - Ice application provides comfort but does not address structural pathology like disc herniation.B. Cyclobenzaprine therapy - Muscle relaxants like cyclobenzaprine do not evaluate or treat underlying structural problems.
C. Nonsteroidal anti-inflammatory drug therapy - NSAIDs reduce pain but do not visualize the spine to exclude serious pathology like tumor or infection.
E. Reassurance that the pain is musculoskeletal - Waiting and rechecking without imaging may miss serious structural or malignant processes.
Question 98
Answer: C - Endometrial biopsy
A 46-year-old in perimenopause with irregular vaginal bleeding every 2 weeks and irregular uterine shape should undergo endometrial evaluation. Hysteroscopy with dilatation and curettage allows direct visualization and tissue sampling to exclude endometrial malignancy.
Why the other choices are wrong:
A. Observation only - Observation without tissue evaluation risks missing endometrial cancer or polyps.B. Transvaginal ultrasonography - Transvaginal ultrasound alone lacks the tissue diagnosis possible with biopsy or D&C.
D. Reassurance and hormonal therapy - Reassurance without evaluation is inappropriate for irregular bleeding and irregular uterine shape in perimenopausal woman.
E. Systemic hormone replacement therapy - Hormone therapy may suppress bleeding but does not evaluate the underlying abnormality.
Question 99
Answer: C - Smoking cessation program
A 36-year-old with elevated cholesterol, strong family history of early CAD, heavy smoking, and high stress. Smoking cessation is the most essential intervention for CAD prevention, reducing cardiovascular risk more significantly than any other single intervention.
Why the other choices are wrong:
A. Stress management program - Stress management is helpful but less critical than eliminating tobacco, the single largest modifiable risk factor.B. Hormone replacement therapy - HRT may improve symptoms but does not reduce CAD risk in this high-risk patient; smoking must stop first.
D. Lipid-lowering drug therapy - Statins reduce cholesterol but smoking cessation prevents more CAD events than any medication.
E. Regular aerobic exercise program - Exercise is beneficial but smoking cessation prevents more cardiovascular events than exercise alone.
Question 100
Answer: A - Adjustment of the ventilator settings
An intubated COPD patient with ventilator alarm and dropping blood pressure likely has either tension pneumothorax or auto-PEEP. Adjustment of ventilator settings (decreasing rate/tidal volume to reduce air-trapping) is the first step to address these life-threatening issues.
Why the other choices are wrong:
B. Endotracheal intubation - Endotracheal intubation is already performed; this addresses critical ventilator settings, not intubation.C. Fluid restriction and diuretics - Fluid restriction may worsen perfusion in a hypotensive patient needing urgent hemodynamic stabilization.
D. Portable chest x-ray - Chest X-ray delays management of acute life-threatening auto-PEEP or pneumothorax.
E. Sedation and paralysis - Sedation may worsen hemodynamic instability in a critically ill hypotensive patient.
Question 101
Answer: D - Oral docusate
A 32-year-old with severe burning rectal pain worse with bowel movements, bleeding on wiping, and small anal tear on anoscopy indicates anal fissure. Oral docusate (stool softener) reduces pain by preventing straining and hard stools, allowing the tear to heal.
Why the other choices are wrong:
A. Osmotic laxative therapy - Osmotic laxatives increase stool volume, worsening pain and straining with acute anal fissure.B. Topical antibiotic therapy - Topical antibiotics are not indicated; fissures are not infected and analgesia is needed.
C. Topical anesthetic therapy - Topical anesthetics provide temporary relief but do not address the straining causing pain.
E. Surgical therapy - Surgical intervention is premature before conservative measures with stool softening.
Question 102
Answer: A - Administration of intravenous calcium
A post-operative child with serum potassium of 6.4 mEq/L and ECG changes of hyperkalemia requires urgent treatment. Intravenous calcium stabilizes the cardiac membrane, protecting against arrhythmias as the first step before other interventions to lower potassium.
Why the other choices are wrong:
B. Intravenous insulin therapy with glucose - Insulin and glucose therapy (without calcium first) delays membrane stabilization needed immediately.C. Loop diuretic therapy - Loop diuretics without calcium stabilization risk cardiac arrhythmias from hyperkalemia.
D. Oral sodium polystyrene sulfonate (Kayexalate) - Sodium polystyrene sulfonate removes potassium slowly; calcium is needed urgently for membrane protection.
E. Sodium bicarbonate therapy - Sodium bicarbonate shifts potassium intracellularly slowly; calcium is the immediate priority.
Question 103
Answer: D - Prescribe rifampin
A 16-year-old with close exposure (shared hotel room) to meningococcal meningitis requires prophylaxis. Rifampin is the most appropriate prophylactic antibiotic for close contacts to prevent secondary meningococcal disease.
Why the other choices are wrong:
A. Ciprofloxacin - Ciprofloxacin is for traveler's diarrhea and atypical coverage but not meningococcal prophylaxis.B. Doxycycline - Doxycycline requires awareness of Stevens-Johnson syndrome risk; rifampin is safer and preferred.
C. Minocycline - Minocycline is an alternative but not preferred for meningococcal prophylaxis.
E. Trimethoprim-sulfamethoxazole - Trimethoprim-sulfamethoxazole lacks adequate meningococcal coverage for prophylaxis.
Question 104
Answer: E - Transfusion of packed red blood cells
A 27-year-old with sickle cell anemia, daily vaginal bleeding, lower abdominal pain, shortness of breath, and sternal pain (10/10) with low hemoglobin (5.7) indicates acute chest syndrome and severe anemia. Packed RBC transfusion restores oxygen-carrying capacity and relieves symptoms.
Why the other choices are wrong:
A. Oxygen therapy alone - Oxygen therapy helps but does not address the severe anemia (Hgb 5.7) requiring transfusion.B. Diuretic therapy - Diuretics worsen anemia and decrease oxygen delivery in severe acute chest syndrome.
C. Intravenous antibiotic therapy - Antibiotics treat infection but do not restore hemoglobin for oxygen-carrying capacity.
D. Hydroxyurea therapy - Hydroxyurea is a maintenance agent; acute severe anemia requires immediate transfusion.
Question 105
Answer: B - Obtain a swallowing evaluation
A 67-year-old with Parkinson's disease, fever, pneumonia, and orthostatic hypotension (100/60 supine to 80/50 standing) has developed dysphagia. Swallowing evaluation is critical to assess aspiration risk and prevent further pneumonia before discharge planning.
Why the other choices are wrong:
A. Dietary changes - Dietary changes without swallowing evaluation miss aspiration risk from dysphagia.C. Adjustment of levodopa dose - Levodopa dose adjustment does not address aspiration risk from Parkinson's-related dysphagia.
D. Fluid restriction - Fluid restriction without swallow study may cause dehydration without addressing aspiration.
E. Initiation of antibiotic therapy - Antibiotics for pneumonia should accompany, not replace, swallowing evaluation.
Question 106
Answer: E - Metoprolol
A patient with atrial fibrillation whose heart rate accelerated from 90 to 160 bpm after metoprolol needs additional rate control. Intravenous metoprolol can be repeated to achieve adequate rate control (target rate less than 110 bpm at rest).
Why the other choices are wrong:
A. Amiodarone - Amiodarone is for refractory AFib but slower onset than additional metoprolol dosing.B. Diltiazem - Diltiazem is appropriate but beta-blockers are first-line; additional metoprolol is preferred.
C. Propranolol - Propranolol is longer-acting; IV metoprolol allows dose titration for acute rate control.
D. Verapamil - Verapamil is appropriate but beta-blockers are first-line rate-control agents.
Question 107
Answer: C - Echocardiography
A 23-year-old with history of Hodgkin lymphoma treated with radiation and chemotherapy (doxorubicin, methotrexate) 10 years ago is at risk for late cardiovascular toxicity. Echocardiography screens for doxorubicin-related cardiomyopathy and radiation-related heart disease.
Why the other choices are wrong:
A. Cardiac magnetic resonance (CMR) imaging - Cardiac MRI is excellent but echocardiography is the standard initial screening for cardiotoxicity.B. Serum troponin assay - Serum troponin is elevated late; echocardiography detects functional impairment earlier.
D. Electrocardiography (ECG) - EKG may show voltage changes but does not assess cardiac function or ejection fraction.
Block 4: Advanced Clinical Medicine (Questions 108-137)
Question 108
Answer: D - Refer the patient to a child psychiatrist
A 5-year-old with toxoplasmosis confirmed by serology, pica (eating dirt/sand), headaches, and cervical lymphadenopathy needs evaluation for CNS involvement and developmental assessment. Referral to a child psychiatrist addresses behavioral and developmental concerns alongside medical treatment.
Why the other choices are wrong:
A. Antifungal therapy - Antifungal therapy is needed for toxoplasmosis regardless of psychiatric symptoms.B. Antiretroviral therapy - Antiretroviral therapy addresses underlying immunodeficiency, not psychiatric sequelae.
C. Anticonvulsant therapy - Anticonvulsants may be needed if seizures develop but don't address behavioral issues.
E. Physical therapy - Physical therapy does not address toxoplasmosis infection or behavioral/developmental concerns.
Question 109
Answer: D - MRI of the thoracic spine
A 55-year-old with breast cancer history on tamoxifen, midback pain, lower extremity weakness (3/5 on right), and sensory changes indicates spinal cord compression from metastatic disease. MRI of thoracic spine is required urgently to confirm diagnosis and prevent permanent paralysis.
Why the other choices are wrong:
A. Computed tomography (CT) of the thoracic spine - CT has lower sensitivity for spinal cord compression and myelopathy than MRI.B. Physical therapy and pain management - Physical therapy may help chronic pain but urgent imaging is needed to prevent spinal cord damage.
C. Radiation therapy - Radiation therapy is appropriate but must follow imaging diagnosis of metastatic compression.
E. Conservative management with observation - Conservative management risks permanent paraplegia with spinal cord compression.
Question 110
Answer: C - MRI of the lumbar spine
A 7-year-old with recurrent fever, back pain, and bone tenderness 2 days after hospitalization for vaso-occlusive crisis likely has osteomyelitis. MRI is most sensitive for detecting bone marrow edema, abscess formation, and confirms osteomyelitis diagnosis.
Why the other choices are wrong:
A. Blood cultures - Antibiotics alone without imaging may miss the diagnosis and delay treatment.B. Blood cultures - Blood cultures are appropriate but imaging (MRI) is needed for diagnosis and localization.
D. Plain radiography of the spine - Plain radiographs have low sensitivity; MRI is superior for detecting bone marrow edema.
E. Conservative management with observation - Conservative management risks abscess formation and permanent bone damage.
Question 111
Answer: E - Vancomycin and cefotaxime END OF SET
Sickle cell patients with osteomyelitis require broad-spectrum antibiotics covering Salmonella (atypical for sickle cell) and Staphylococcus. Vancomycin and cefotaxime provide coverage for both organisms and achieve good bone penetration.
Why the other choices are wrong:
A. Ampicillin-sulbactam - Ampicillin-sulbactam provides gram-positive coverage but misses atypical Salmonella in sickle cell.B. Ceftriaxone - Ceftriaxone monotherapy lacks Staph coverage needed for this polymicrobial infection.
C. Fluoroquinolones - Fluoroquinolones have good bone penetration but lack Staph coverage for sickle cell osteomyelitis.
D. Trimethoprim-sulfamethoxazole - Trimethoprim-sulfamethoxazole is an alternative but not optimal for serious bone infection.
Question 112
Answer: D - Administer morphine
A 24-year-old with acute RLQ pain and fever in the setting of likely appendicitis requires adequate analgesia for pain control. Morphine provides effective pain relief without interfering with surgical assessment (modern teaching refutes the old teaching that analgesia impairs surgical exam).
Why the other choices are wrong:
A. NPO status and observation - NPO status and waiting delay analgesia without improving surgical outcome.B. Aspirin - Aspirin provides inadequate analgesia for acute appendicitis pain.
C. Heat application - Heat application provides comfort but delays definitive surgical management.
E. Observation without assessment - Waiting without assessment and analgesia worsens suffering unnecessarily.
Question 113
Answer: C - Topical lactic acid lotion
A 20-year-old with dry skin on lower extremities (absent behind knees and over ankles), family history (father and brother affected), and winter worsening indicates ichthyosis vulgaris. Topical lactic acid lotion provides moisturizing and keratolytic benefits.
Why the other choices are wrong:
A. Petrolatum - Petrolatum is too basic; lactic acid provides both hydration and gentle exfoliation.B. Salicylic acid lotion - Salicylic acid is keratolytic but less ideal than lactic acid for ichthyosis vulgaris.
D. Topical corticosteroid - Topical steroids can cause atrophy with chronic use and are not first-line.
E. Systemic retinoid therapy - Systemic retinoids are for severe disease; topical lactic acid is first-line.
Question 114
Answer: D - Placement of a suprapubic catheter
An elderly post-stroke patient with failed catheterization attempts, reduced urine output, elevated creatinine, hyperkalemia, abdominal fullness, and bilateral hydronephrosis indicates urinary retention with obstructive nephropathy. Suprapubic catheter placement provides definitive drainage and renal protection.
Why the other choices are wrong:
A. Foley catheter - Foley catheter attempts have failed; alternative drainage is needed.B. Oral medications - Oral medications do not address acute urinary retention and renal failure.
C. Lifestyle changes - Lifestyle changes do not acutely relieve obstruction causing hydronephrosis.
E. Observation only - Observation risks worsening renal failure and hyperkalemia.
Question 115
Answer: A - Incision and drainage
A 47-year-old with swelling, erythema, warmth, and fluctuance near the fingernail indicates paronychia with abscess formation. Incision and drainage releases pus, relieves pain, and allows healing.
Why the other choices are wrong:
B. Antibiotic therapy - Antibiotics treat infection but do not drain accumulated pus.C. Antifungal therapy - Topical antifungals are for fungal paronychia, not bacterial abscess.
D. Warm soaks - Warm soaks are supportive but do not drain pus with fluctuance.
E. Observation only - Observation allows abscess to worsen and risks osteomyelitis.
Question 116
Answer: E - Mannitol
A 12-year-old with DKA who deteriorated (became somnolent, developed headache, incontinence) after aggressive fluid and insulin therapy likely developed cerebral edema. Mannitol reduces intracranial pressure and is indicated for altered mental status/headache during DKA treatment.
Why the other choices are wrong:
A. Fluids and insulin continuation - Fluids alone during DKA do not treat cerebral edema developing after treatment.B. Insulin therapy adjustment - Insulin therapy is appropriate for DKA but caused the edema; mannitol is needed urgently.
C. Sodium bicarbonate - Sodium bicarbonate does not reduce intracranial pressure.
D. Hyperthermia treatment - Hyperthermia treatment is not relevant to cerebral edema during DKA.
Question 117
Answer: B - Conjugated estrogen
A 54-year-old with hot flushes, night sweats, prior hysterectomy with normal TB skin test and chest x-ray findings consistent with granulomata has tuberculosis causing constitutional symptoms. Isoniazid and rifampin treat TB and eliminate these symptoms (not estrogen or raloxifene).
Why the other choices are wrong:
A. Raloxifene - Raloxifene is for osteoporosis; constitutional symptoms indicate active TB.C. Acetaminophen - Acetaminophen is symptomatic only and does not treat tuberculosis.
D. Calcitriol - Calcitriol is for hypocalcemia; TB requires antituberculous drugs.
E. Estrogen replacement therapy - Estrogen is not indicated; TB treatment with isoniazid and rifampin resolves symptoms.
Question 118
Answer: E - Topical corticosteroids
A 44-year-old with scaly red rash on elbows and knees with prior joint pain indicates psoriasis. Topical corticosteroids provide first-line treatment for mild psoriatic plaques without systemic toxicity.
Why the other choices are wrong:
A. Aspirin - Aspirin is not for psoriasis; it may worsen disease in some patients.B. Antibiotic therapy - Antibiotics are not indicated unless bacterial superinfection occurs.
C. Phototherapy - Phototherapy is for extensive disease; mild plaques respond to topical steroids.
D. Sulfasalazine - Sulfasalazine is for arthritis, not skin manifestations of psoriasis.
Question 119
Answer: D - Provide reassurance that she is simply still premenopausal
A 55-year-old with regular menses (premenstrual symptoms, normal flow) and delayed menopause compared to peers should simply receive reassurance. She is premenopausal; the wide range of normal menopausal age (45 to 55 years) explains her delayed menopause.
Why the other choices are wrong:
A. Estrogen replacement therapy - Estrogen replacement is not indicated; menopause hasn't occurred yet.B. Hysterectomy - Hysterectomy is not appropriate for normal premenopausal symptoms.
C. Progesterone supplementation - Progesterone is not indicated without evidence of anovulation.
E. Psychiatric evaluation - Psychiatric evaluation is not indicated for normal premenopausal experience.
Question 120
Answer: D - Phentolamine
A 25-year-old with cocaine use causing hypertension (200/100), chest pain, and tachycardia needs alpha-blockade before beta-blockade. Phentolamine (alpha-blocker) safely reduces hypertension and relieves coronary vasoconstriction without unopposed alpha effects.
Why the other choices are wrong:
A. Beta-blocker therapy alone - Beta-blockade alone worsens coronary vasoconstriction from cocaine without alpha blockade first.B. Diuretic therapy - Diuretics do not address the acute hypertension and coronary ischemia.
C. Nitroprusside - Nitroprusside requires ICU monitoring and is not first-line for cocaine-induced hypertension.
E. Nifedipine - Nifedipine monotherapy lacks adequate alpha blockade for cocaine effects.
Question 121
Answer: D - 0.9% Saline
An elderly hospitalized patient with levofloxacin-associated diarrhea (likely C. difficile), dehydration (elevated BUN, creatinine), and electrolyte abnormalities (high Na, low K, low HCO3) requires IV rehydration. Normal saline replaces deficits and restores perfusion.
Why the other choices are wrong:
A. Albumin - Albumin is not indicated; crystalloid repletion is first-line for dehydration.B. Lactated Ringer's solution - Lactated Ringer's is appropriate but normal saline is standard for diarrheal fluid losses.
C. Dextrose 5% in water - Dextrose 5% in water is hypotonic and inappropriate for electrolyte abnormalities.
E. Hypertonic saline - Hypertonic saline is not indicated and risks hyperchloremic acidosis.
Question 122
Answer: C - Nystatin
A 3-week-old with white mouth patches that don't scrape off indicates oral candidiasis (thrush). Nystatin suspension provides topical antifungal treatment, is safe in infants, and effectively treats oral thrush.
Why the other choices are wrong:
A. Acyclovir - Acyclovir is for viral infections; thrush requires antifungal therapy.B. Clotrimazole tablets - Clotrimazole tablets are not appropriate for infants who may aspirate.
D. Miconazole powder - Miconazole powder is ineffective for oral candidiasis in infants.
E. Fluconazole - Fluconazole is reserved for resistant or systemic candidiasis.
Question 123
Answer: B - Fluoxetine
A 55-year-old with major depression (Beck score 35), suicidal ideation, guilt, auditory hallucinations of a condemning nature, and psychotic features needs antidepressant plus antipsychotic therapy. Fluoxetine adds antidepressant effect to complement the olanzapine.
Why the other choices are wrong:
A. Sertraline - Sertraline is appropriate but fluoxetine at higher doses may have better psychotic-depressive overlap benefit.C. Venlafaxine - Venlafaxine works but lacks the psychotic symptom coverage when added to antipsychotic.
D. Paroxetine - Paroxetine is effective but fluoxetine has better evidence in this scenario.
E. Bupropion - Bupropion is contraindicated in psychosis due to seizure risk.
Question 124
Answer: D - Order a transthoracic echocardiography
A 78-year-old with new exertional dyspnea, prior CAD, murmur discovered at age 18, and late systolic murmur now audible at right upper sternal border indicates aortic stenosis. Transthoracic echocardiography assesses severity and guides management decisions.
Why the other choices are wrong:
A. Computed tomography - CT has lower resolution; echocardiography is gold standard for valve assessment.B. Electrocardiography - EKG shows LVH but cannot assess valve morphology or gradient.
C. Stress testing - Stress test may be useful but echocardiography is needed first for valve severity.
E. Cardiac catheterization - Cardiac catheterization is invasive and reserved for surgical planning after echo.
Question 125
Answer: E - The patient is at no increased risk
Combining a nicotine patch with bupropion is a well-established and safe smoking cessation strategy. Studies show this combination does not significantly increase the risk of adverse effects compared to either agent alone. The combination is recommended by guidelines for patients with heavy tobacco use who have difficulty quitting with monotherapy.
Why the other choices are wrong:
A. Bupropion alone - Bupropion plus nicotine patch is safe and effective; interactions are minimal.B. Varenicline with nicotine patch - Varenicline with nicotine patch increases nausea but is not absolutely contraindicated.
C. Nicotine patch plus combined oral therapy - Nicotine patch plus combined oral therapy increases side effects.
D. Abrupt cessation without pharmacotherapy - Cold turkey without pharmacotherapy has lower success rates than combination therapy.
Question 126
Answer: C - She has an 80% chance of complete recovery within the next 12 months without treatment
A 25-year-old with acute unilateral facial weakness (Bell's palsy) has an 80% chance of complete spontaneous recovery within 12 months regardless of treatment. The prognosis is favorable, though corticosteroids may modestly improve outcomes.
Why the other choices are wrong:
A. Some residual facial weakness persists - Some residual weakness may persist in minority of cases despite good prognosis.B. Improvement in symptoms occurs - Complete recovery without treatment occurs in 80%, not improvement in symptoms.
D. Corticosteroid therapy hastens recovery - Most patients recover without corticosteroids; prognosis is favorable regardless.
E. Recovery takes several years - Recovery takes 12 months typically, not years, for Bell's palsy.
Question 127
Answer: E - Prednisone
A 20-year-old with asthma exacerbation (peak flow 70% to 80% baseline, increased albuterol use, wheezing) triggered by upper respiratory infection needs oral corticosteroids. Prednisone reduces airway inflammation and prevents further deterioration.
Why the other choices are wrong:
A. Albuterol - Albuterol is helpful but oral corticosteroids provide essential anti-inflammatory effect.B. Oxygen - Oxygen helps oxygenation but corticosteroids prevent further airway inflammation.
C. Ipratropium - Ipratropium adds benefit but prednisone is essential for inflammation control.
D. Magnesium sulfate - Magnesium may help but corticosteroids are standard first-line intervention.
Question 128
Answer: A - Gestational diabetes
A 34-year-old at 26 weeks gestation with prior delivery of 10-pound macrosomic infant, current weight 99 kg, and 14-kg pregnancy weight gain is at highest risk for gestational diabetes. Obesity and prior macrosomia are strong risk factors requiring screening.
Why the other choices are wrong:
B. Preeclampsia - Preeclampsia risk is not elevated by obesity and prior macrosomia alone.C. Gestational hypertension - Gestational hypertension can occur but gestational diabetes is higher risk with this history.
D. Placental insufficiency - Placental insufficiency is less likely than gestational diabetes in this scenario.
E. Preterm labor - Preterm labor is not specifically indicated by obesity and prior macrosomia.
Question 129
Answer: E - Oxytocin
A woman after placental delivery with uterine atony, increased bleeding, and hypotension needs uterotonic therapy. Oxytocin causes sustained myometrial contraction, controls postpartum hemorrhage, and is the first-line agent.
Why the other choices are wrong:
A. Ergotamine - Ergotamine is contraindicated if placenta is undelivered; uterine atony is post-placental.B. Prostaglandins - Prostaglandins are alternatives but oxytocin is first-line for uterine atony.
C. Misoprostol - Misoprostol can be used but oxytocin has faster onset and is preferred.
D. Blood transfusion - Transfusion addresses bleeding but does not cause uterine contraction.
Question 130
Answer: A - Counseling for avoidance of reexposure to cold
A 33-year-old with "welts" on neck, chest, and shoulders appearing after cold exposure, history of cold-induced facial redness, and no pruritus indicates cold urticaria. Counseling for cold avoidance prevents recurrent episodes.
Why the other choices are wrong:
B. Antihistamine prophylaxis - Antihistamine prophylaxis may help but avoidance is most effective.C. Topical corticosteroid - Topical corticosteroids treat established lesions but avoidance prevents recurrence.
D. Nonsteroidal anti-inflammatory drugs - NSAIDs are not first-line for cold urticaria management.
E. Intramuscular epinephrine - Epinephrine is for anaphylaxis; counseling addresses cold urticaria prevention.
Question 131
Answer: B - Cefuroxime and azithromycin
A 32-year-old returning from Midwest with fever, cough, SOB, abdominal symptoms, low iron saturation, and leukopenia likely has histoplasmosis. Cefuroxime and azithromycin empirically cover atypical pneumonia pending fungal cultures.
Why the other choices are wrong:
A. Ampicillin - Ampicillin does not cover atypical organisms or histoplasmosis adequately.C. Ciprofloxacin - Ciprofloxacin monotherapy lacks coverage for histoplasmosis.
D. Doxycycline - Doxycycline is appropriate but less reliable than combination therapy.
E. Metronidazole - Metronidazole is for anaerobes; histoplasmosis requires broader coverage.
Question 132
Answer: D - Subcutaneous enoxaparin
A 72-year-old post-operative patient with low ejection fraction (0.20) and VT on ECG at high thrombosis risk needs DVT prophylaxis. Subcutaneous enoxaparin is safe, effective, and doesn't require monitoring in acute post-operative period.
Why the other choices are wrong:
A. Warfarin - Warfarin requires INR monitoring and is not preferred in acute post-op period.B. Unfractionated heparin - Unfractionated heparin requires aPTT monitoring; enoxaparin is simpler.
C. Fondaparinux - Fondaparinux is appropriate but enoxaparin is standard for post-op VT prophylaxis.
E. Inferior vena cava filter - IVC filter is not prophylaxis; enoxaparin provides chemical prophylaxis.
Question 133
Answer: C - Hydrocortisone
A 45-year-old with fatigue, weakness, weight loss, bronze skin darkening on sun-exposed areas, and hypotension with hyponatremia and hyperkalemia indicates Addison disease. Hydrocortisone replaces deficient cortisol and is critical acute management.
Why the other choices are wrong:
A. Fludrocortisone - Fludrocortisone is important but requires underlying cortisol replacement first.B. DHEA supplementation - DHEA replacement is adjunctive; acute management requires cortisol.
D. Licorice root - Licorice root is not standard therapy; hydrocortisone is essential.
E. Observation only - Observation risks vascular collapse from severe hyponatremia and hypotension.
Question 134
Answer: D - Indomethacin
A 45-year-old with gout (severe foot pain, erythema, swelling of first MTP joint, elevated WBC, joint aspirate with 50K leukocytes) triggered by alcohol use and thiazide diuretic. Indomethacin provides rapid pain relief and reduces inflammation.
Why the other choices are wrong:
A. Colchicine - Colchicine is alternative but NSAIDs are preferred for first attack of gout.B. Allopurinol - Allopurinol prevents future attacks but does not treat acute gout pain.
C. Aspirin - Aspirin can worsen gout by raising uric acid; indomethacin is preferred.
E. Observation - Observation without anti-inflammatory therapy worsens pain unnecessarily.
Question 135
Answer: D - Oral dexamethasone therapy
A 2-year-old with croup (barky cough, stridor, respiratory distress) unresponsive to oxygen needs additional treatment. Dexamethasone reduces subglottic edema and improves symptoms within hours.
Why the other choices are wrong:
A. Oxygen therapy - Oxygen is supportive but does not reduce subglottic edema in croup.B. Nebulized epinephrine - Nebulized epinephrine is adjunctive; dexamethasone reduces edema directly.
C. Endotracheal intubation - Intubation may be needed if severe but dexamethasone often prevents it.
E. Observation - Observation allows progression; dexamethasone rapidly improves symptoms.
Question 136
Answer: B - Serum HIV antibody test
A 30-year-old with vesicular rash over left V1 distribution (doesn't cross midline) consistent with herpes zoster, sexually active with multiple partners. Serum HIV antibody test screens for immunosuppression predisposing to herpes zoster at young age.
Why the other choices are wrong:
A. Varicella-zoster serology - Varicella-zoster serology confirms diagnosis but does not explain immunocompromise.C. Herpes simplex serology - Herpes simplex serology is not indicated; this is varicella-zoster distribution.
D. Syphilis testing - Syphilis testing is appropriate in sexually active patients but HIV is more relevant.
E. Hepatitis B testing - Hepatitis B testing is appropriate but HIV best explains zoster in young adult.
Question 137
Answer: B - Imiquimod
A 31-year-old with HIV and CD4 350 presenting with anal pain, bleeding, tender fleshy perianal lesions indicates anogenital condylomas (genital warts). Imiquimod stimulates local immune response and is topical treatment for condylomas in HIV patients.
Why the other choices are wrong:
A. Laser therapy - Laser therapy is destructive but imiquimod stimulates immune response actively.C. Topical 5-fluorouracil - Topical 5-FU is not standard for condylomas; imiquimod is preferred.
D. Systemic interferon - Systemic interferon is not first-line; topical imiquimod is preferred.
E. Podofilox - Podofilox is harsh and can cause severe ulceration; imiquimod is safer.