American Board of Family Medicine: TTT SAMPLE TTT

Name
American Board of Family Medicine
IN-TRAINING EXAMINATION
TIME4 HOURS
Read the instructions on the back first.
Do not break the seal until you are told to do so.
ttt SAMPLE ttt

1. Write your name in the blank at the top of the page.
2. Record your Program Number and ABFM Number
on the answer sheet, as shown in the sample on the
right. Be sure to fill in both the boxes and the
circles.
3. Write your name, your program name, and the date
on the answer sheet.
Publication or reproduction in whole or in part is strictly prohibited.

Copyright 2012 The American Board of Family Medicine. All rights reserved.
1. A 72-year-old white male develops a rapidly growing epithelial tumor just in front of his right
ear. He states that it began as a firm red papule about 6 weeks ago. It is now 1.5 cm in diameter
and has a horny plug in the center.
The most likely diagnosis is
A)
B)
C)
D)
E)
Bowens disease
basal cell carcinoma
keratoacanthoma
Kaposis sarcoma
seborrheic keratosis
2. An 8-year-old male is brought to the emergency department with an acute asthma attack that
began 48 hours earlier. His mother initiated his asthma action plan when the attack began,
starting oral prednisolone plus albuterol (Proventil, Ventolin) by metered-dose inhaler with a
spacer every 34 hours. In the emergency department the child is alert, with a respiratory rate
of 30 beats/min and an oxygen saturation of 94% on room air. He is audibly wheezing. Peak
flow is 40% of the predicted value.
Which one of the following should you do next?
A)
B)
C)
D)
E)
Continue the current albuterol treatment but switch to a nebulizer

Administer high-dose albuterol via nebulizer every 20 minutes for 1 hour
Administer intravenous corticosteroids within the first hour
Administer magnesium sulfate intravenously
Prescribe high-dose mucolytics and chest physiotherapy
3. A 56-year-old male with type 2 diabetes mellitus has normal cardiac and renal function but has
failed to achieve adequate control of his diabetes with diet and multiple oral agents. His BMI is
30.1 kg/m2 and his hemoglobin A1c level is 9.1%.
Which one of the following is most likely to be beneficial in combination with insulin and diet
therapy in this patient?
A)
B)
C)
D)
E)
Acarbose (Precose)
Glimepiride (Amaryl)
Metformin (Glucophage)
Pioglitazone (Actos)
Repaglinide (Prandin)
4. You see a 78-year-old male in the hospital the day after his hip-replacement surgery. He has not
voided in the past 12 hours. A urethral catheter is placed and 500 mL of urine is removed from
his bladder.
Which one of the following is most likely to improve the success rate of a voiding trial?
A)
B)
C)
D)
E)
Using a specialized catheter coud instead of a standard catheter

Leaving the catheter in place for at least 2 weeks
Immediately removing the catheter to prevent a urinary tract infection
Starting tamsulosin (Flomax), 0.4 mg daily, at the time of catheter insertion
Starting antibiotic prophylaxis at the time of catheter insertion
5. A 22-year-old college student comes to your office to discuss her several-year history of
abdominal pain and constipation. It has gotten worse since she returned to school this fall. She
describes crampy pain and bloating that eases after defecation. Her bowel movements are firm
and difficult to pass, and occur about every 3 days on average. Her symptoms have not included
vomiting, weight loss, blood in the stool, or melena. Her menses are regular and she is an
otherwise healthy young woman. Her family history is negative for any gastrointestinal or
genitourinary diseases. On examination you find her abdomen to be soft and without masses,
with no tenderness to palpation.
Which one of the following would be most appropriate at this time?
A)
B)
C)
D)
E)
A therapeutic trial of increased soluble fiber intake

A therapeutic trial of lubiprostone (Amitiza)
Abdominal ultrasonography
Abdominal CT
Colonoscopy
6. Which one of the following is a proven strategy to reduce anterior cruciate ligament tears in
high-school athletes?
A)
B)
C)
D)
E)
The use of neoprene knee sleeves by all athletes competing in high-risk sports
Consistent inclusion of long-distance running in practice sessions
Structured exercises stressing balance, muscle strength, and proprioception
Prohibiting girls from playing on boys sports teams
Increased enforcement of penalties involving dangerous plays
7. A 70-year-old female presents with recurrent episodes of cough, voluminous sputum, and
dyspnea. She is a nonsmoker and has never smoked, except for a few cigarettes in her teens.
Her past, family, and occupational histories do not suggest a cause for pulmonary or liver
disease. Her examination is within normal limits except for the lung examination, which reveals
crackles at both lung bases on auscultation. A chest radiograph shows nonspecific markings at
both bases.
The most appropriate next step in her workup would be
A)
B)
C)
D)
a PPD skin test

high-resolution CT
an "1-antitrypsin level
referral for bronchoscopy
8. A previously healthy 24-year-old female presents with a 10-day history of facial pain and fever.
On examination she has tenderness over the maxillary sinus on the left.
Which one of the following would be most appropriate for treatment of this patients condition?
A)
B)
C)
D)
E)
Intranasal saline flushes

Intranasal antihistamines
Oral antihistamines
Oral antibiotics
Reassurance only
9. A 50-year-old female presents with a 3-week history of a moderately pruritic rash, characterized
by flat-topped violaceous papules 34 mm in size. The lesions are located primarily on the volar
wrists and forearms, lower legs, and dorsa of both feet. Ten days after the rash first appeared
she went to the emergency department and was treated for possible scabies, but the treatment
has made little or no difference.
Which one of the following treatments is indicated at this time?
A)
B)
C)
D)
Clobetasol (Cormax, Temovate) 0.05% ointment

Permethrin 5% cream
Tacrolimus (Protopic) 0.1% ointment
Triamcinolone 0.1% cream
10. Which one of the following children should be referred immediately for evaluation of speech
delay?
A)
B)
C)
D)
E)
A 12-month-old who babbles but speaks no words

An 18-month-old who does not understand action words
A 2-year-old who has a vocabulary of 25 words
A 2-year-old who is unable to follow three-step directions
A 3-year-old who has a vocabulary of 50 words
11. A 23-year-old female presents with recurrent unprovoked epistaxis. The patients mother is
known to have hereditary hemorrhagic telangiectasia.
Contrast echocardiography is recommended to screen for which one of the following frequently
associated conditions?
A)
B)
C)
D)
E)
Atrioseptal defect
Ventricular septal defect
Aortic root aneurysm
Pulmonary arteriovenous malformation
Myocardial perfusion defects
12. A 65-year-old male who has been in good health presents to your office with a 2-day history of
a sensation of pressure and hearing loss in his left ear. A physical examination and a thorough
neurologic examination are both unremarkable. Both tympanic membranes are normal. An
audiogram shows a 30-decibel hearing loss at three consecutive frequencies in the left ear, with
normal hearing on the right. Placing a vibrating tuning fork in the midline of the forehead
reveals sound lateralizing to the right ear.
Which one of the following would be most appropriate at this point?
A)
B)
C)
D)
E)
CT
A CBC, metabolic profile, and thyroid studies
Nifedipine (Procardia)
Acyclovir (Zovirax)
Oral corticosteroids
13. Which one of the following is true concerning the use of hemoglobin A1c levels to diagnose
diabetes mellitus?
A)
B)
C)
D)
A level >6.0% is diagnostic of diabetes mellitus

Results can be misleading in patients with sickle cell disease
The test is equally sensitive in African-Americans and whites
The test is useful to diagnose diabetes during pregnancy
14. A 50-year-old female presents for evaluation of dyspnea that tends to occur with exercise. She
has a 40pack-year history of smoking and has been diagnosed with exercise-induced asthma.
She denies any other medical problems. You perform spirometry and find that the expiratory
loop is normal and that she has a flattened inspiratory loop.
What is the most likely diagnosis?
A)
B)
C)
D)
Vocal cord dysfunction

COPD
Asthma
Restrictive lung disease
15. A previously healthy 27-year-old female presents with dysuria and urinary urgency and
frequency. She also complains of right flank pain, fevers and chills, and nausea without
vomiting. She has a decreased appetite, but has been able to drink liquids.
On examination she has a temperature of 38.4C (101.2F), a heart rate of 102 beats/min, and
a blood pressure of 126/82 mm Hg. She has mild suprapubic tenderness and right costovertebral
angle tenderness. A urinalysis shows microscopic pyuria, hematuria, and a positive leukocyte
esterase test. Additional laboratory studies are notable for leukocytosis with a left shift, but are
otherwise normal, including a negative pregnancy test. The patient does not have allergies to any
antibiotics.
Which one of the following would be most appropriate for this patient?
A)
B)
C)
D)
E)
Outpatient management with oral amoxicillin

Outpatient management with oral ciprofloxacin (Cipro)
Outpatient management with oral nitrofurantoin (Macrodantin)
Inpatient management with intravenous ceftriaxone (Rocephin)
Inpatient management with intravenous levofloxacin (Levaquin)
16. An 82-year-old female is hospitalized for pneumonia and sepsis. She has advance directives in
place.
Should it become necessary, the patients decision-making capacity is determined by
A)
B)
C)
D)
E)
the spouse or next of kin

the attending physician
a consulting psychiatrist
the hospital ethics committee
a judge, at the request of hospital social services or the physician
17. A 67-year-old female presents with the inability to smell. She is in good health, and her only
medical problem is osteoporosis, treated with alendronate (Fosamax). She says she has no sinus
or nasal symptoms. A physical examination is normal including an ear, nose, and throat
examination.
A)
B)
C)
D)
Discontinuing the alendronate

An anti-tissue transglutaminase antibody test
A serum vitamin D level
MRI of the brain
18. The American Heart Association recommends a goal blood pressure of 130/80 mm Hg for
patients with
A)
B)
C)
D)
E)
heart failure
pulmonary hypertension
atrial fibrillation
angina pectoris
chronic kidney disease
19. A 78-year-old female has chronic symptomatic orthostatic hypotension, likely related to diabetic
autonomic dysfunction, which has failed to respond to nonpharmacologic treatment. Her current
medications include metformin (Glucophage), 1000 mg twice daily; atorvastatin (Lipitor), 40 mg
daily; aspirin, 81 mg daily; and insulin glargine (Lantus), 24 units at bedtime.
Which one of the following would be the most effective therapy for her orthostatic hypotension?
A)
B)
C)
D)
E)
Clonidine (Catapres)
Midodrine
Pseudoephedrine
Terbutaline
Theophylline
20. A 34-year-old white female who works as an engineer for a major corporation complains of
fatigue, low energy, and a depressed mood. She states that she has felt this way for most of her
life. She feels depressed most of the time but denies any recent stresses or significant losses in
her life. She reports that she is doing well at work and that she recently received a promotion.
She has no interests other than her job and states that she has no happy thoughts and that her
self-esteem is very low. She denies suicidal thoughts but states that she does not care if she dies.
She has had no sleep disturbance, change in appetite, or difficulty concentrating. She is taking
no medications and denies substance abuse. Results of a recent medical evaluation required by
her employer were all normal, including a physical examination, EKG, multiple chemical
profile, CBC, urinalysis, and TSH level.
Which one of the following is the most likely diagnosis?
A)
B)
C)
D)
E)
Major depression
Dysthymic disorder
Bipolar disorder
Cyclothymia
Adjustment disorder with depressed mood
21. A 35-year-old female immigrant from a rural village in Southeast Asia visits your clinic shortly
after arriving in the United States. She presents with a 1-week history of low-grade fever and
a nonproductive cough, and has crackles but no signs of consolidation or pleural effusion on
examination. You order a chest radiograph and see several oval infiltrates, 12 cm in size.
Which one of the following is the most likely cause of these symptoms?
A)
B)
C)
D)
E)
Ascaris lumbricoides
Enterobius vermicularis (pinworm)
Taenia saginata
Taenia solium
Diphyllobothrium latum
22. A new first-time mother calls for advice on nipple pain with breastfeeding. She is 6 days post
partum after an uncomplicated delivery.
Which one of the following would be most effective?
A)
B)
C)
D)
E)
Lanolin cream
Expressed breast milk
Tea bag compresses
Hydrogel dressing
Education on positioning
23. A previously healthy 29-year-old pediatric nurse has a 3-day history of malaise, arthralgias, and
a nonpruritic rash. The rash is a faint, maculopapular, irregular, reticulate exanthem that covers
her thighs and the inner aspects of her upper arms. Symmetric synovitis is present in several
distal and proximal interphalangeal joints and in her metacarpophalangeal joints. Small
effusions, warmth, and tenderness are noted in her left wrist and right elbow. No other joints
are affected.
The most likely cause of this problem is
A)
B)
C)
D)
E)
varicella-zoster virus
measles (rubeola) virus
parvovirus B19
adenovirus
human immunodeficiency virus (HIV)
24. For 2 weeks, a 62-year-old male with biopsy-documented cirrhosis and ascites has had diffuse
abdominal discomfort, fever, and night sweats. His current medications are furosemide (Lasix)
and spironolactone (Aldactone). On examination his temperature is 38.0C (100.4F), his blood
pressure is 100/60 mm Hg, and his heart rate is 92 beats/min and regular. Examination of the
heart and lungs is normal. The abdomen is soft with vague tenderness in all quadrants. There
is no rebound or guarding. The presence of ascites is easily verified. Bowel sounds are quiet.
The rectal examination is normal, and the stool is negative for occult blood.
You perform diagnostic paracentesis and send a sample of the fluid for analysis. Which one of
the following findings would best support the suspected diagnosis of spontaneous bacterial
peritonitis?
A)
B)
C)
D)
E)
pH <7.2
Bloody appearance
Neutrophil count >250/mL
Positive cytology
Total protein >1 g/dL
25. A 67-year-old female has a bone density study that indicates a T score of 3.5. You prescribe
alendronate (Fosamax) but at her next visit she says she cannot tolerate the side effects and asks
about other therapies.
Which one of the following has the best evidence for prevention of both vertebral fractures and
hip fractures?
A)
B)
C)
D)
Calcitonin-salmon (Miacalcin)
Raloxifene (Evista)
Teriparatide (Forteo)
Zoledronic acid (Reclast)
26. A 65-year-old Asian male with a long history of cigarette smoking presents with weakness,
lethargy, and mental confusion. A physical examination is normal. There are no signs of
dehydration, edema, or pigmentary changes.
Laboratory Findings
Serum sodium. . . . . . . . . . . . . . . . . . . . . . . . .
Urine osmolality. . . . . . . . . . . . . . . . . . . . . . .
Plasma osmolality. . . . . . . . . . . . . . . . . . . . . .
Urine sodium. . . . . . . . . . . . . . . . . . . . . . . . . .
BUN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Serum potassium. . . . . . . . . . . . . . . . . . . . . . .
122 mEq/L (N 135145)

280 mOsm/kg H2O (N 501400)
260 mOsm/kg H2O (N 285295)
25 mEq/L
4 mg/dL (N 825)
4.1 mEq/L (N 3.55.0)

A)
B)
C)
D)
sodium depletion
syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
primary polydipsia
adrenal insufficiency
8
27. A 38-year-old female has spontaneous rupture of the membranes with thick meconium just prior
to delivery of a male infant at 40 weeks gestation. Oropharyngeal suctioning of the infant is
performed prior to delivery of the shoulders. Upon delivery the infant is noted to have
spontaneous respirations, a heart rate of 120 beats/min, cyanosis of the hands and feet, and good
tone.
Which one of the following would be most appropriate in the immediate management of the
newborn?
A)
B)
C)
D)
Intubation and tracheal suctioning below the vocal cords

Suctioning of the stomach to remove any swallowed meconium
Positive pressure ventilation
Expectant management only
28. An 84-year-old female presents for follow-up of multiple chronic medical problems. She is
usually accompanied by her daughter, who lives nearby, but today is brought in by her son and
daughter-in-law, who live out of town. They are supportive, but are insistent that the patient see
a specialist for a problem that she has previously decided not to pursue further. The patient
wants to avoid conflict but does not want to see any other physicians.
Which one of the following is the most appropriate way to deal with this situation?
A)
B)
C)
D)
E)
Speak with the son and daughter-in-law privately

Maintain neutrality and avoid triangulation
Call the daughter to discuss the situation
Try to talk your patient into seeing the specialist
Schedule the appointment to appease the family, then cancel it later
29. A 50-year-old male presents to your office with erythroderma and fever. He has not had a sore
throat, rhinorrhea, cough, or urinary tract symptoms. His current medications include lisinopril
(Prinivil, Zestril), atenolol (Tenormin), and allopurinol (Zyloprim). On examination he has a
blood pressure of 110/90 mm Hg, a pulse rate of 90 beats/min, and a temperature of 38.6C
(101.5F). The skin is remarkable for marked erythema over 90% of the body, with tenderness
to touch. His mental status is clear and his neck is supple. Mildly tender adenopathy is noted in
the neck, axillae, and groin. He has no oral ulcerations or ocular symptoms.
A CBC shows a WBC count of 15,000/mm3 (N 430010,800) with 20% eosinophils. A
metabolic profile shows an AST (SGOT) level of 100 U/L (N 1040) and an ALT (SGPT) level
of 110 U/L (N 1055), but is otherwise normal.
A)
B)
C)
D)
E)
Stevens-Johnson syndrome
Erysipelas
Red man syndrome
Toxic shock syndrome
Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)
30. An unconscious 22-year-old male is brought into the emergency department. His respiratory
rate is 8/min, his pulse rate is 60 beats/min and regular, and his pupils are miotic.
The most likely cause of his condition is
A)
B)
C)
D)
organophosphate poisoning
scopolamine overdose
narcotics overdose
benzodiazepine overdose
31. A 39-year-old male with a history of alcoholism presents to your office with complaints of
abdominal pain, vomiting, and nausea following a recent binge. He has eaten little since the
onset of his symptoms 3 days ago. Laboratory findings suggest alcoholic ketoacidosis. His serum
bicarbonate level is 16.3 mEq/L (N 22.026.0).
In addition to thiamine, what other treatment should be provided for this patient?
A)
B)
C)
D)
Bicarbonate and insulin

Glucagon (GlucaGen) and hydrocortisone
Normal saline and glucose
N-acetylcysteine and pyridoxine (vitamin B6)
32. A previously normotensive 20-year-old primigravida is admitted to the hospital at 39 weeks

gestation with a headache, a blood pressure of 170/110 mm Hg, and proteinuria. Which one of
the following is the most effective agent for preventing eclamptic seizure while preparing for
expedited delivery?
A)
B)
C)
D)
Benzodiazepines
Fosphenytoin (Cerebyx)
Magnesium sulfate
Nimodipine
33. A 71-year-old white male with COPD and lung cancer is discharged from the hospital. In
addition to a medical diagnosis, which one of the following criteria is used to determine whether
Medicare will pay for his home oxygen therapy?
A)
B)
C)
D)
Oxygen saturation
PCO2
FEV1
The patients finances
10
34. Which one of the following findings on examination of the head, oral cavity, and neck is
associated with diabetes mellitus?
A)
B)
C)
D)
E)
Parotid enlargement
Tooth erosion
Diffuse melanin pigmentation
Cobblestone oral mucosa
Painful oral ulcers
35. A 53-year-old female is concerned about a skin lesion that has recently been changing in size and
shape. On examination she is found to have a 7-mm, asymmetric, darkly pigmented lesion with
some color variegation and irregular borders.
Which one of the following skin biopsy techniques is most appropriate for confirming the
diagnosis?
A)
B)
C)
D)
A shave biopsy
Electrodesiccation and curettage
Elliptical excision
Mohs surgery
36. A 22-year-old female in her second trimester of pregnancy presents with a 48-hour history of
a sore throat. She has also had coryza and a nonproductive cough. A physical examination
reveals a temperature of 37.3C (99.2F) and a blood pressure of 110/70 mm Hg. A HEENT
examination reveals tonsillar and pharyngeal erythema with no exudate. There is no adenopathy.
Her chest is clear.
Which one of the following would be most appropriate for this patient?
A)
B)
C)
D)
E)
Reassurance and symptomatic treatment only

A routine throat culture
A rapid antigen detection test for Streptococcus
Azithromycin (Zithromax) for 5 days
Penicillin V for 10 days
37. A 34-year-old female has a history of many years of diffuse pain, debilitating fatigue, and
disrupted sleep. You suspect she may have fibromyalgia. Laboratory tests and imaging studies
have been negative. She is confused about why she is in so much pain even though everything
is normal.
What do you tell her is currently thought to be the etiology of fibromyalgia?
A)
B)
C)
D)
E)
Diffuse inflammation of soft tissues

A chronic viral infection
An exaggerated response to tactile stimuli by the central nervous system
A malfunction of pain receptors in the dermis, causing excess sensitivity
A psychological disorder in which the patient imagines the pain
11
38. A 12-year-old African-American male is brought to your office by his parents because he has
been limping for the past month. He says he has pain in the groin and knee, but the pain is
poorly localized. On examination he is noted to be obese, with normal findings on examination
of the knee. There is some decrease in internal rotation of the hip on the involved side. His gait
is antalgic.
The most likely cause of this problem is
A)
B)
C)
D)
E)
unreported trauma
aseptic necrosis of the femoral head
reactive arthritis
juvenile rheumatoid arthritis
slipped capital femoral epiphysis
39. Of the following cardiovascular parameters, which one increases with normal aging?
A)
B)
C)
D)
E)
Maximum heart rate

Heart rate variability
Left ventricular ejection fraction
Arterial wall elasticity
Blood pressure
40. A 68-year-old male with type 2 diabetes mellitus has failed to control his diabetes with diet and
exercise. His most recent serum creatinine level was 1.9 mg/dL (N 0.61.5).
Which one of the following agents is most likely to cause symptomatic hypoglycemia in this
patient?
A)
B)
C)
D)
E)
Glimepiride (Amaryl)
Glipizide (Glucotrol)
Glyburide (DiaBeta)
41. A healthy 47-year-old female presents with a 3-day history of moderately severe low back pain
after attempting to lift a heavy container of potting soil in her garden. She has no history of back
problems. Her pain is in the right lower back with radiation to the buttock. She denies urinary
or bowel incontinence, urinary retention, and numbness or tingling. A physical examination
confirms low back muscular strain.
Which one of the following interventions has been shown to be beneficial in this situation?
A)
B)
C)
D)
E)
Bed rest
Massage therapy
Lumbar traction
Prednisone
Cyclobenzaprine (Flexeril)
12
42. A 40-year-old male complains of a cough that has persisted for more than 3 months. He is
otherwise asymptomatic. A chest radiograph and pulmonary function tests are normal.
Which one of the following is the most likely cause?
A)
B)
C)
D)
E)
Bronchiectasis
Tuberculosis
Sarcoidosis
Asthma
Gastroesophageal reflux disease
43. A 45-year-old male asks you to evaluate his cardiovascular health status. He is currently
asymptomatic, but wants to do everything he can to prevent heart disease and to understand his
potential cardiovascular risk. His Framingham score indicates that he is at low risk (10-year risk
<6%), and his physical examination is normal.
He asks which laboratory and imaging tests he should have, and you recommend a lipid profile.
According to the American College of Cardiology Foundation and the American Heart
Association, which one of the following should also be recommended for this patient at this
time?
A)
B)
C)
D)
E)
Lipoprotein and apolipoprotein levels

A C-reactive protein level
Measurement of cardiac calcium
An ankle-brachial index
No further testing
44. In an adult who has a critical illness but no history of cardiac disease, the threshold for
transfusion of red blood cells should be a hemoglobin level of
A)
B)
C)
D)
E)
6 g/dL
7 g/dL
8 g/dL
9 g/dL
10 g/dL
45. A 67-year-old female hospitalized with pneumonia develops the rapid onset of dyspnea, pleuritic
chest pain, tachypnea, and hypoxemia not responding to oxygen and requiring intubation. A
physical examination is notable for rales throughout both lung fields with no peripheral edema
noted. A chest radiograph shows bilateral pulmonary infiltrates. Her BNP level is 90 ng/L.
Which one of the following is the most likely reason for her worsening clinical situation?
A)
B)
C)
D)
E)
Heart failure
Hypersensitivity pneumonitis
Acute respiratory distress syndrome
Pulmonary embolus
Pneumothorax
13
46. A 64-year-old male with a previous history of hypertension and atrial fibrillation presents with
an acute onset of ataxia, headache, mild confusion, and restlessness. His only current
medications are lisinopril (Prinivil, Zestril) and warfarin (Coumadin). On examination his blood
pressure is 160/100 mm Hg, pulse rate 86 beats/min, respirations 12/min, and temperature
36.7C (98.1F). A CBC, serum electrolyte levels, and cardiac enzyme levels are normal. His
INR is 1.1. Noncontrast CT shows a cerebellar hemorrhage with a hematoma volume of 50 mL.
Which one of the following should be performed urgently?
A)
B)
C)
D)
E)
Neurosurgical consultation for posterior cerebellar hematoma decompression

A reduction in blood pressure to 140/90 mm Hg
Administration of vitamin K, 10 mg intravenously
Administration of mannitol (Osmitrol), 0.51.0 mg/kg intravenously
Induction of hypothermia to achieve a body temperature of 34.4C (94.0F)
47. You prescribe enalapril (Vasotec) for a 68-year-old male with heart failure. At a follow-up visit
6 weeks later the patients serum creatinine level is 2.5 mg/dL (N 0.61.5) and his serum
potassium level is 5.7 mEq/L (N 3.44.8). His baseline values were normal.
Which one of the following is a side effect of ACE inhibitors that is the most likely cause of
these changes in renal function?
A)
B)
C)
D)
E)
Toxicity to the proximal renal tubules

Impaired autoregulation of glomerular blood flow
Microangiopathic arteriolar thrombosis
Rhabdomyolysis
Interstitial nephritis
48. A 46-year-old African-American female sees you because of a history of excessive uterine
bleeding and irregularity in her menstrual cycle. She has three children and had a tubal ligation
after her last delivery. A pelvic examination does not reveal any pathology to explain her
symptoms. Further laboratory evaluation indicates that she is mildly anemic. You perform an
endometrial biopsy in the office that confirms your suspicion of endometrial hyperplasia without
atypia.
Which one of the following is the treatment of choice for this patient?
A)
B)
C)
D)
E)
Elective hysterectomy
Hysteroscopic endometrial laser ablation
High-dose oral estrogen supplementation
Antifibrinolytic therapy
Progestational drugs
14
49. The diagnosis of Osgood-Schlatter disease (osteochondritis of the tibial tubercle apophysis) is
best made on the basis of findings from
A)
B)
C)
D)
E)
the history and examination

evaluation by an orthopedic specialist
radiographs
ultrasonography
MRI
50. A 35-year-old primigravid schoolteacher awakens with a rash clinically consistent with varicella
early in the 38th week of her pregnancy. She had a negative varicella titer early in her
pregnancy. The clinical course is mild and all vesicles have either crusted over or healed 1 week
later. She has an uncomplicated labor and vaginal delivery at 40 weeks gestation, and delivers
a healthy-appearing male.
Of the following options, which one is the most appropriate initial management for the newborn?
A)
B)
C)
D)
Intravenously administered varicella immune globulin

A weight-appropriate dose of intravenous acyclovir (Zovirax)
Varicella vaccine
Combination treatment with varicella vaccine, intravenous acyclovir, and varicella
immune globulin
E) Close observation only
51. Travelers diarrhea can be effectively treated in the great majority of cases with which one of
the following?
A)
B)
C)
D)
Erythromycin
Penicillin V
Sulfacetamide
Ciprofloxacin (Cipro)
52. The primary indication for joint replacement surgery in patients with osteoarthritis is
A)
B)
C)
D)
intractable pain
joint laxity
limited range of motion
recurrent subluxation
53. In a child, which one of the following findings on cardiac auscultation is most likely to be
associated with structural heart disease?
A)
B)
C)
D)
E)
Increased murmur intensity with standing

An early systolic murmur
A murmur limited to a small area
An S2 with a variable split duration
A musical or low pitch
15
54. A 7-year-old white male is brought to your office about 5 hours after a dog bit him on the
forearm. You examine the wound and decide not to suture it. His last tetanus immunization
brought him up to date at 4 years of age.
Which one of the following is most appropriate?
A)
B)
C)
D)
Culture the wound

Scrub the wound with povidone-iodine (Betadine) surgical scrub
Irrigate the wound
Administer tetanus immune globulin and DTaP immunization
55. A 50-year-old female is hospitalized with severe, diffuse abdominal pain without nausea or
vomiting. Vital signs on admission include a pulse rate of 110 beats/min, a respiratory rate of
35/min, and a temperature of 38.2C (100.8F). Laboratory findings include a WBC count of
21,000/mm3 (N 430010,800) with 80% segmented neutrophils, and a serum amylase level of
4000 U/L (N 53123). CT of the abdomen is consistent with cholelithiasis and necrotizing
pancreatitis without an abscess.
Which one of the following measures is best supported by evidence?
A)
B)
C)
D)
Corticosteroids
Placement of a nasogastric tube
Intravenous antibiotics
Surgery if repeat CT shows development of a pseudocyst
56. In your role as team physician, you are attending a high-school basketball game. A player
suffers an inversion injury of her ankle while coming down after reaching for a rebound. You
examine her immediately and diagnose a grade 2 ankle sprain.
Which one of the following is the most successful treatment for this injury?
A)
B)
C)
D)
Use of a weight-bearing short leg cast for 2 weeks, then progressively increased activity
Nonweight bearing, with crutches and an elastic wrap for 2 weeks
Ankle taping, an elastic wrap, and partial weight bearing for 6 weeks
Icing, a gel or air splint, and mobilization within 48 hours
57. Which one of the following features in an elderly patient with cognitive problems is more
suggestive of depression than of Alzheimers disease?
A)
B)
C)
D)
A long duration of cognitive problems

A slow progression of cognitive problems
Delusions that are congruent with mood
No past history of psychiatric problems
16
58. You are considering adding sitagliptin (Januvia) to the regimen of a patient with type 2 diabetes
mellitus. Which one of the following best describes the mechanism of action of this drug?
A)
B)
C)
D)
E)
It increases glucagon levels

It slows inactivation of incretin hormones
It reduces the absorption of glucose in the gastrointestinal tract
It reduces insulin resistance in skeletal muscle
It reduces insulin resistance in the liver
59. Examination of a patient with COPD and a complaint of increased shortness of breath reveals
dullness to percussion in the left lower lung field, with decreased fremitus and decreased breath
sounds. This is most compatible with
A)
B)
C)
D)
pulmonary consolidation
pleural effusion
emphysematous bleb formation
pneumothorax
60. In patients with mild to moderate allergic rhinitis, which one of the following is the most
effective treatment?
A)
B)
C)
D)
E)
First-generation antihistamines such as diphenhydramine (Benadryl)

Second-generation antihistamines such as fexofenadine (Allegra)
Montelukast (Singulair)
Intranasal corticosteroids
Prednisone
61. A 58-year-old female presents with significant nausea and abdominal cramping 1 month after
beginning lithium carbonate. Her symptoms have not been relieved by multiple doses of
antacids. A physical examination is remarkable only for the appearance of discomfort and a
resting pulse rate of 92 beats/min.
You suspect lithium toxicity and advise her to discontinue the lithium immediately and submit
blood samples for a lithium level and complete metabolic panel. When you review her results
that afternoon you find that her lithium level is in the mid-therapeutic range and the only
abnormal laboratory findings are a calcium level of 13.0 mg/dL (N 8.810.0), an albumin level
of 3.0 g/dL (N 3.85.0), a BUN level of 35 mg/dL (N 718), and a creatinine level of 1.6
mg/dL (N 0.61.2).
Of the options listed below, the best immediate intervention is
A)
B)
C)
D)
E)
cinacalcet (Sensipar)
furosemide (Lasix)
glucocorticoids
intravenous saline infusion
intravenous zoledronic acid (Zometa)
17
62. A 57-year-old male with a BMI of 37.1 kg/m2 was found to have a fasting blood glucose level
of 115 mg/dL on a screening test. His mother and three siblings have type 2 diabetes mellitus.
A follow-up hemoglobin A1c (HbA1c) level is 6.2%. Six months later, after lifestyle
interventions, the patients BMI is 35.5 kg/m2 and his HbA1c is 6.1%. On a lipid panel, his
triglyceride level is 457 mg/dL and his HDL-cholesterol level is 32 mg/dL. His serum creatinine
level is 1.0 mg/dL (N 0.61.2). You consider the use of pharmacologic therapy.
Which one of the following would be the best initial medication?
A)
B)
C)
D)
E)
Acarbose (Precose)
Exenatide (Byetta)
63. A 16-year-old male comes to your office with a 1-month history of increasingly severe lower
back pain. He plays on his schools soccer team, but denies any history of injury.
Hyperextension is particularly painful, and now the pain occurs during normal daily activities.
Examination reveals a hyperlordotic posture, limited range of motion, and tight hamstrings. The
remainder of the examination is unremarkable.
Which one of the following should be done initially?
A)
B)
C)
D)
E)
A complete blood profile

Rheumatoid factor and HLA-B27 testing
Plain radiography
MRI
A radionuclide bone scan
64. A 2-year-old female visiting with her parents from Mexico presents with a 1-week history of
repeated episodes of forceful coughing followed by emesis. Her immunization status is
unknown. Her mother reports that a runny nose and cold preceded the onset of the cough. The
child is currently afebrile and appears mildly ill; her lungs are clear.
Your management would include which one of the following?
A)
B)
C)
D)
Hospitalization for ribavirin aerosol therapy

Reassurance that the cough will abate over the next week
Oral erythromycin therapy for 2 weeks
Administration of immune serum globulin intramuscularly
18
65. The fluid of choice for resuscitation after a significant burn injury is
A)
B)
C)
D)
E)
lactated Ringers solution

hypertonic saline
packed RBCs
whole blood
5% albumin
66. A 52-year-old male comes to your office with a 2-month history of hoarseness that began with
the onset of a head cold. His other symptoms resolved but the hoarseness has continued. He has
smoked for 32 years and drinks 4 beers per day, and has had gastroesophageal reflux disease
(GERD) for several years.
A)
B)
C)
D)
E)
Voice rest
Laryngoscopy
Upper endoscopy
Inhaled corticosteroids
High doses of a proton pump inhibitor
67. Four weeks after successful initial treatment of unilateral otitis media in a 2-year-old white male
enrolled in a local day-care center, you reevaluate the child. He is asymptomatic, but you detect
a middle ear effusion in the affected ear. The tympanic membrane is otherwise normal.
The best management at this time would be
A)
B)
C)
D)
E)
inflation of the eustachian tube by the Valsalva maneuver

an antihistamine daily for 30 days
low-dose corticosteroids for 30 days
referral to an ENT specialist
no further treatment, with reevaluation in 2 months
68. A previously healthy 26-year-old white male carpenter reports episodes of chest tightness and
dyspnea. He states that he feels better on weekends.
He most likely has
A)
B)
C)
D)
E)
hypersensitivity pneumonitis
toxic pneumonitis
byssinosis
benign pleural effusion
occupational asthma
19
69. A 67-year-old female who is a recently retired college professor takes warfarin (Coumadin)
because of chronic atrial fibrillation. She asks you about the possibility for self-management of
her anticoagulation using a portable monitor at home.
Which one of the following is true regarding self-management of anticoagulation therapy
compared to standard monitoring?
A)
B)
C)
D)
E)
It decreases the number of thromboembolic events

It increases the number of bleeding events
It increases all-cause mortality
It increases the patients level of anxiety
When cost, complication rates, and mortality rates are considered, it is inferior to
standard monitoring
70. You are following a 60-year-old female for osteopenia. Which one of the following tests is best
for assessing her vitamin D status?
A)
B)
C)
D)
E)
1,25-Dihydroxyvitamin D
24,25-Dihydroxyvitamin D
25-Hydroxyvitamin D
Parathyroid hormone
Phosphate
71. A 45-year-old male presents to your office for a health maintenance visit. Other than mild
fatigue, which he attributes to long hours at work and lack of exercise, he has no complaints.
He is married, and says he takes no routine medications and does not smoke or drink. His
examination is unremarkable except for a BMI of 32.3 kg/m2. A CBC is unremarkable, but a
fasting metabolic profile shows a glucose level of 115 mg/dL, an AST (SGOT) level of 100 U/L
(N 540), and an ALT (SGPT) level of 112 U/L (N 756). The remainder of the profile is
normal.
Which one of the following is the most likely cause of the abnormal laboratory findings?
A)
B)
C)
D)
E)
Acetaminophen toxicity
Hepatitis B or C
Herbal preparations containing kava
Alcohol use
Nonalcoholic fatty liver disease
72. A 60-year-old male is started on simvastatin (Zocor) for elevated cholesterol. He mentions that
he takes several herbal and dietary supplements.
Which one of the following should this patient be advised to avoid?
A)
B)
C)
D)
Ginkgo biloba
Ginseng
Garlic
St. Johns wort
20
73. Treatment with which one of the following antihypertensive medications may mimic the effects
of primary hyperparathyroidism?
A)
B)
C)
D)
E)
Amlodipine (Norvasc)
Doxazosin (Cardura)
Hydrochlorothiazide
Lisinopril (Prinivil, Zestril)
Metoprolol (Lopressor, Toprol-XL)
74. A 67-year-old female comes to your office to establish care after recently moving to your
community. Her medical history includes hypertension, nonobstructive coronary artery disease,
and heart failure, with an ejection fraction of 35% on an echocardiogram done last year. She
does not have diabetes mellitus or lung disease and she has never had a myocardial infarction.
She tolerates her medications well and is active, walking about 2 miles daily. Her medications
include aspirin, 81 mg daily; lisinopril (Prinivil, Zestril), 40 mg daily; and simvastatin (Zocor),
40 mg daily.
Which one of the following possible additions to her medication regimen has the best evidence
for reducing mortality?
A)
B)
C)
D)
E)
Clopidogrel (Plavix)
Ezetimibe (Zetia)
Losartan (Cozaar)
Metoprolol succinate (Toprol-XL)
Spironolactone (Aldactone)
75. An 85-year-old male is brought to your office by his family for a follow-up visit for Alzheimers
dementia. His dementia has been present for 4 years. He has been experiencing increasing
agitation and delusions over the past several weeks, and the family requests a medication to
calm him down.
Which one of the following is indicated in this situation according to FDA guidelines?
A)
B)
C)
D)
E)
Aripiprazole (Abilify)
Haloperidol
Olanzapine (Zyprexa)
Risperidone (Risperdal)
No antipsychotic drugs
76. Physicians are more likely than the general population to suffer from which one of the
following?
A)
B)
C)
D)
Depression
Alcoholism
Prescription drug abuse
Illicit drug abuse
21
77. In symptomatic young children with Campylobacter enterocolitis that is refractory to

conservative management, the preferred treatment is
A)
B)
C)
D)
E)
erythromycin
ciprofloxacin (Cipro)
ampicillin
trimethoprim (Primsol)
metronidazole (Flagyl)
78. A 42-year-old male was admitted to the hospital yesterday for an extensive deep-vein thrombosis
and treated with unfractionated heparin anticoagulation. The nurse alerts you that the patient has
had multiple episodes of passing moderate amounts of maroon blood per rectum. He has a
previous history of diverticulosis. He is hemodynamically stable.
The initial treatment of choice for this patient is
A)
B)
C)
D)
E)
cryoprecipitate
dabigatran (Pradaxa)
protamine sulfate
vasopressin (Pitressin)
vitamin K
79. A 55-year-old nonsmoking male presents with a 2-month history of a nonproductive cough. He
has no other respiratory tract symptoms, including dyspnea, and no history of fever. He takes
hydrochlorothiazide and metoprolol succinate (Toprol-XL) for hypertension, and is otherwise
healthy. A physical examination, including vital signs with pulse oximetry, is unremarkable.
Which one of the following should you do next?
A)
B)
C)
D)
E)
Discontinue metoprolol
Begin empiric antibiotic treatment for atypical pathogens
Perform a complete spirometry evaluation
Order a chest radiograph
Order CT of the chest with contrast
80. In neonatal resuscitation, chest compressions should begin if the heart rate drops below a
threshold of
A)
B)
C)
D)
E)
120 beats/min
100 beats/min
80 beats/min
60 beats/min
40 beats/min
22
81. According to the most recent American Diabetes Association guidelines, which one of the
following groups of patients with diabetes mellitus should take aspirin for primary prevention
of cardiovascular events?
A)
B)
C)
D)
All patients
All patients over the age of 55
Only those whose risk for cardiovascular disease events is >10%
Only those whose risk for cardiovascular disease events is >20%
82. Which one of the following has the highest sensitivity and specificity for carpal tunnel
syndrome?
A) A positive Phalen maneuver
B) Distal tingling with percussion (Tinels sign)
C) A history of shaking the hand or flicking the wrist to alleviate nighttime pain (the flick
sign)
D) Thenar atrophy
83. In patients with systolic heart failure, which one of the following $-blockers is best for reducing
mortality and hospitalization rates?
A)
B)
C)
D)
Atenolol (Tenormin)
Carvedilol (Coreg)
Labetalol (Trandate)
Nebivolol (Bystolic)
84. An 80-year-old male comes to your office for evaluation of neck stiffness with a sensation of
grinding when turning his head. He has had this for several years, and has now developed dull
aching in his arms and numbness in his fingers. He also has noted stiffness in his legs.
Examination reveals that flexion of the neck results in a sensation that the patient says feels like
an electric shock going down his back. You note some wasting of the intrinsic musculature of
the hands, as well as hyperreflexia.
Which one of the following should you do now?
A)
B)
C)
D)
E)
Order EMG of both upper extremities

Order plain films of the cervical spine
Order MRI of the cervical spine
Refer for cervical corticosteroid injections
Reevaluate the patient after 4 weeks of cervical bracing
23
85. A full-term infant weighing 6 lb 8 oz at birth will typically weigh 20 lb at what age?
A)
B)
C)
D)
E)
6 months
9 months
12 months
15 months
18 months
86. One of your patients is planning to fly from Nebraska to Israel and asks about measures to
prevent or reduce jet lag. Which one of the following is supported by the best evidence?
A) Melatonin should be started on the morning of departure and taken every morning for
1 week
B) Melatonin should be taken nightly for 25 nights, beginning on the first night at the
destination
C) Melatonin will help only on the return flight
D) A dose of caffeine equivalent to 3 cups of coffee should be taken every morning,
beginning on the morning of departure
87. A 13-year-old male with a history of mild intermittent asthma reports escalating use of his
short-acting $-agonist inhaler. He routinely uses it at least 510 times per week for symptom
relief. He has been experiencing wheezing and chest tightness with only minimal exertion, and
sometimes at rest, which is a new problem for him.
You recommend that he add which one of the following to his asthma medication regimen?
A)
B)
C)
D)
E)
Intermittent use of an inhaled long-acting $-agonist

Daily use of an inhaled long-acting $-agonist
Daily use of an inhaled corticosteroid
Daily use of an oral corticosteroid
Daily use of an oral immunomodulator
88. A 14-year-old female is concerned because she is unable to gain weight. A review of systems
reveals intermittent diarrhea and chronic dermatitis previously diagnosed as eczema. Her past
and family histories are unremarkable. A laboratory workup is negative, including a complete
metabolic profile, a TSH level, and a sweat chloride test. A stool sample is negative for WBCs,
ova, and parasites.
Which one of the following is true regarding this patient?
A)
B)
C)
D)
She should be tested for IgA anti-tissue transglutaminase

She should be placed on a lactose-free diet
She should be referred to an eating disorders specialist
She should have a colonic mucosal biopsy
24
89. A 48-year-old white male has experienced five episodes of right upper quadrant pain during the
past year. The most recent episode occurred 2 weeks ago. The episodes last 24 hours and are
associated with nausea and vomiting.
Which one of the following is most likely to provide an explanation for the patients symptoms?
A)
B)
C)
D)
E)
A serum bilirubin level

An AST (SGOT) level
A plain film of the abdomen
A HIDA scan
Abdominal ultrasonography
90. A 4-year-old female is brought to your office with a 5-day history of a cough and low-grade
fever. She appears mildly anxious but in no respiratory distress, and the physical examination
is notable for a temperature of 38.1C (100.6F), a respiratory rate of 44/min, and a spot O2
saturation of 94% with decreased breath sounds and fine crackles in the left lower lobe. You
decide to prescribe amoxicillin. When you give the prescription to the mother she mentions that
her 12-year-old son was given azithromycin (Zithromax) for pneumonia last year when he had
similar symptoms and findings, and she asks why the children were given different antibiotics.
What explanation would you give the mother for choosing amoxicillin?
A) Younger children are more likely to have gram-negative pathogens
B) Younger children usually have more virulent bacteria
C) Younger children are less likely to have infections caused by atypical bacteria such as
Mycoplasma
D) The half-life of azithromycin is shortened in children younger than 5 years
91. Effective therapy for myocarditis-induced dilated cardiomyopathy includes
A)
B)
C)
D)
E)
ibuprofen
lisinopril (Prinivil, Zestril)
methotrexate
oseltamivir (Tamiflu)
prednisone
92. A 6-year-old male is brought to your office with a 1-day history of bloody diarrhea. The cause
is determined to be enterohemorrhagic Escherichia coli, which is producing Shiga toxin.
Which one of the following is the most appropriate treatment?
A)
B)
C)
D)
E)
Supportive treatment only

Clindamycin (Cleocin)
Doxycycline
Trimethoprim/sulfamethoxazole (Bactrim, Septra)
25
93. A 2-year-old male is brought to your office for a well child check. He was born with pectus
excavatum, which has progressed somewhat as he has grown. You and the parents are concerned
about the potential for abnormal cardiopulmonary function and body image issues as the child
grows.
Repair of mild to moderately symptomatic pectus excavatum ideally should be considered when
the patient is
A)
B)
C)
D)
a toddler
preschool age
in elementary school
an adolescent
94. Which one of the following outcomes is associated with hospital palliative care programs?
A)
B)
C)
D)
Shortened hospital stays

Reduced use of nonphysician personnel
Increased ICU utilization
Lower overall hospital costs
95. A 55-year-old female is concerned about variations in her heartbeat. She describes fluttering,
flip-flopping, and sometimes pounding sensations in her chest, with occasional delays
between beats. Her symptoms are episodic, and have been occurring for several months. They
have not been present for the past week.
The patients family history is negative for thyroid disease, but she recalls some heart trouble
in several family members that was accompanied by fainting spells, and at least one relative died
suddenly. She takes no medications, has a negative psychiatric review of systems, and has a
normal physical examination.
A)
B)
C)
D)
E)
Reassurance that her symptoms are associated with a benign condition

A standard 12-lead EKG
Echocardiography
Intermittent event (loop) cardiac monitoring
Admission to a hospital-based cardiac monitoring unit
96. Which one of the following would disqualify a patient from being considered homebound, using
Medicares definition for the purpose of conducting a home visit?
A)
B)
C)
D)
Participating in a state-licensed adult day care program

Regularly attending religious services
Being able to leave home with help from another person
Being able to leave home without help, but requiring occasional use of a cane
26
97. You are discussing job-related exposure to human immunodeficiency virus (HIV) with your
certified nursing assistants. Exposure to which one of the following from an HIV-positive patient
would require consideration of post-exposure prophylaxis?
A)
B)
C)
D)
E)
Breast milk
Saliva
Sweat
Urine
Feces
98. A 26-year-old gravida 3 at 29 weeks gestation presents with painless vaginal bleeding. A sterile
speculum examination reveals a small amount of blood in the cervix and dilation estimated at 1
cm. A sonogram shows a complete placenta previa. Her blood pressure is normal, she is not
orthostatic, and her hemoglobin level is 10.7 mg/dL (N 12.016.0). The fetal heart rate is
around 130 beats/min with good variability and no decelerations. No contractions are shown on
the tocometer.
In addition to hospital admission for monitoring, which one of the following would be most
appropriate?
A)
B)
C)
D)
E)
Magnesium
Calcium channel blockers
Corticosteroids
Antibiotics
Urgent cesarean section
99. A 25-year-old previously healthy female presents to the urgent care clinic with swelling of her
lips and tongue, wheezing, dyspnea, and urticaria that developed after she was stung by a wasp.
Her only medication is atenolol (Tenormin), which she takes for migraine prophylaxis. You
immediately administer epinephrine 1:1000 dilution subcutaneously, but the patient does not
improve even after two more injections 10 minutes apart. She continues to be hypotensive
despite administration of an intravenous normal saline bolus, intramuscular diphenhydramine,
and nebulized albuterol (Proventil, Ventolin).
Which one of the following intravenous medications is most appropriate for treating this patients
hypotension?
A)
B)
C)
D)
E)
Aminophylline
Diphenhydramine
Epinephrine
Glucagon (GlucaGen)
Hydrocortisone
27
100. Which one of the following statements is consistent with current U.S. Preventive Services Task
Force recommendations for skin cancer screening for the adult general population with no
history of premalignant or malignant lesions?
A)
B)
C)
D)
Whole-body examination should be conducted by a primary care provider every 3 years

Whole-body patient self-examination should be performed every 6 months
Benefits from screening have been established only for high-risk patients
The evidence is currently insufficient to determine whether early detection reduces
mortality and morbidity from skin cancer
E) The harms of detection and early treatment outweigh the benefits
101. A 72-year-old female presents with a 2-month history of constipation. She says she has to strain
to evacuate at least half the time and reports that her stools have become clay-like in consistency
and narrower in caliber. At least half the time she has the sensation that evacuation is not
complete, and she has occasionally used manual maneuvers to complete evacuation. She had a
normal colonoscopy 8 years ago.
An abdominal examination is normal, and stool with a clay-like consistency is palpated during
a rectal examination. No prolapse is seen with straining, and the anal wink is present. Screening
laboratory tests indicate a mild microcytic, hypochromic anemia.
Which one of the following would be most appropriate at this time?
A)
B)
C)
D)
E)
A trial of lactulose
Lifestyle modifications
Phosphosoda enemas
Colonoscopy
Pelvic floor muscle exercises
102. A 45-year-old male recently recovered from a second episode of left lower extremity cellulitis.
He has onychomycosis on his left foot but is otherwise in good health.
Which one of the following treatments is best overall if eradication of the onychomycosis is
necessary?
A)
B)
C)
D)
E)
Ciclopirox topical (Penlac Nail Lacquer)

Oral fluconazole (Diflucan)
Oral griseofulvin (Grifulvin V)
Oral itraconazole (Sporanox)
Oral terbinafine (Lamisil)
28
103. Effective communication with patients from other countries requires knowledge of
communication styles within various cultures. Which one of the following is consistently
appropriate for all patients from nonEnglish-speaking countries?
A)
B)
C)
D)
Discouraging the use of family members as interpreters

Expecting patients to make their own decisions regarding care
Discussing test results with the patient only
Maintaining eye contact with the patient
104. A 55-year-old male with type 1 diabetes mellitus is being treated in the wound care clinic for a
skin ulcer on his lower right leg. The ulcer is slow to improve. He comes to see you in the office
because over the past 2 days his right knee has become swollen, red, warm, painful, and difficult
to flex. When you examine him, his right knee is swollen, erythematous, indurated, and held
in full extension. Active and passive ranges of motion are limited. Areas of erythema and
induration continue to surround his leg ulcer. His WBC count is mildly elevated, but his
erythrocyte sedimentation rate and C-reactive protein level are normal.
A)
B)
C)
D)
E)
Plain radiographs
Ultrasonography
MRI
Arthrocentesis
Antinuclear antibody studies
105. In addition to fluid resuscitation, which one of the following is the recommended first-line agent
for the management of hypotension in a patient with sepsis?
A)
B)
C)
D)
E)
Albumin
Dopamine
Epinephrine
Norepinephrine (Levophed)
Phenylephrine (Neo-Synephrine)
106. The husband of a 25-year-old white female consults you about his wife. Eighteen months ago,
her last pregnancy was complicated by placental abruption, hemorrhagic shock, and the birth of
a stillborn infant. She did not lactate and has not menstruated since the delivery. Since that time
she has become increasingly fatigued and apathetic and has noticed a marked decrease in her
libido.
A)
B)
C)
D)
Prolonged grief reaction

Postpartum pituitary necrosis
Postpartum depression
Iron deficiency anemia
29
107. A 58-year-old postmenopausal female sees you for an initial health maintenance visit. Her
examination is normal and she has no complaints. You perform a Papanicolaou (Pap) test, which
she has not had done in 15 years. The smear is read as negative for intraepithelial lesion and
malignancy, benign endometrial cells present.
What would be the most appropriate follow-up for this finding?
A)
B)
C)
D)
E)
A repeat Pap test in 46 months

A repeat Pap test in 1 year
HPV testing
An endometrial biopsy
Colposcopy and endocervical curettage
108. Which one of the following is most likely to cause hypoglycemia when used as monotherapy?
A)
B)
C)
D)
E)
Acarbose (Precose)
Exenatide (Byetta)
Sitagliptin (Januvia)
109. During hospital rounds you are called to attend the resuscitation of one of your patients, a
chronic alcoholic with known esophageal varices secondary to hepatic cirrhosis, who just
experienced sudden massive hematemesis that resulted in aspiration and respiratory arrest.
Endotracheal intubation and suctioning appear to improve her respiratory crisis momentarily,
but her pulse quickly becomes too weak to palpate. After 20 minutes of resuscitative effort,
cardiac monitoring fails to detect any cardiac electrical activity, no spontaneous respiratory
activity is noted, and the process is halted.
When completing the death certificate for this patient, the diagnosis most appropriately listed as
the immediate cause of death is
A)
B)
C)
D)
E)
cardiac arrest
respiratory arrest
upper gastrointestinal hemorrhage
esophageal varices
cirrhosis of the liver
110. Which one of the following patients is eligible for the Medicare hospice benefit?
A)
B)
C)
D)
A patient with end-stage COPD with a life expectancy of 6 months

A patient with amyotrophic lateral sclerosis with a life expectancy of 9 months
A patient on hemodialysis with a life expectancy of 12 months
A patient with stage IV breast cancer with a life expectancy of 18 months
30
111. A 16-year-old male asthmatic with no other medical problems presents with a severe attack of
respiratory distress and a peak expiratory flow rate <40%. After 1 hour of acute treatment his
respiratory distress has resolved, but he complains of blurred vision.
Which one of the following therapeutic agents would be the most likely cause?
A)
B)
C)
D)
E)
Nebulized albuterol (Proventil, Ventolin)

Nebulized ipratropium bromide
Nebulized levalbuterol (Xopenex)
Subcutaneous terbutaline
Intravenous methylprednisolone
112. A 77-year-old male presents for a periodic health evaluation. Your practice is organized as a
patient-centered medical home, and this is the patients initial visit. His records indicate that he
received all recommended screening tests and immunizations 4 years ago, and he asks what
screening tests are necessary at his age.
The U.S. Preventive Services Task Force recommends that this patient be screened for which
one of the following?
A)
B)
C)
D)
E)
Prostate cancer
Colorectal cancer
Abdominal aneurysm
Dementia
Depression
113. An 82-year-old white male consults you following several syncopal episodes that are clearly
orthostatic in nature. During the course of your evaluation you find that he has a large tongue,
mild cardiomegaly, and findings suggestive of bilateral carpal tunnel syndrome.
The most likely diagnosis at this time is
A)
B)
C)
D)
E)
pernicious anemia
cervical spondylosis
amyloidosis
cardiomyopathy
polymyalgia rheumatica
114. Which one of the following is true concerning people in the United States who do not have health
insurance?
A) Most uninsured people are members of a family with at least one working adult
B) Most uninsured people who are employed full-time work for large companies
C) Most uninsured people who work part-time and have incomes below the poverty line are
eligible for Medicaid
D) On average, uninsured people have as much access to routine health care as those with
insurance
31
115. A 36-year-old male requests further testing for infertility. His female partner has undergone all
testing, and her results are normal. He has recently undergone a semen analysis, which revealed
azoospermia. Suspecting hypogonadism, you evaluate morning levels of FSH and total serum
testosterone levels to help distinguish between primary and secondary causes.
Which one of the following would you expect with primary hypogonadism?
A)
B)
C)
D)
E)
Normal levels of both FSH and testosterone

Low levels of both FSH and testosterone
Low FSH and increased testosterone
High FSH and low testosterone
High levels of both FSH and testosterone
116. A 32-year-old female presents with a history of recurring headaches. They are usually unilateral,
last for 2448 hours, have a pulsatile quality, and are associated with nausea. She sometimes
experiences photophobia as well. The patient describes the headaches as intense, usually
requiring her to limit her activities. She has tried several over-the-counter migraine medications
that have been minimally effective in aborting these headaches, and requests a prescription for
an abortive therapy.
Which one of the following would be the best choice for first-line therapy?
A)
B)
C)
D)
E)
Acetaminophen
Acetaminophen/oxycodone (Percocet)
Butalbital/aspirin/caffeine (Fiorinal)
Prednisone
Sumatriptan (Imitrex)
117. A 24-year-old female presents to your office for a health maintenance evaluation. She mentions
that she has had several episodes of indigestion after meals and started taking an over-the-counter
proton pump inhibitor, which she feels has been helpful. She asks if it would be harmful to take
this medicine on a long-term basis.
You tell her that evidence has shown that continuing to take this medication will increase her risk
for which one of the following?
A)
B)
C)
D)
E)
Hypomagnesemia
Vitamin B12 deficiency
Clostridium difficile colitis
Having a child with birth defects (if taken in the first trimester)
Colon cancer
118. For adolescents with scoliosis, observation is always indicated for a curve below a threshold of
A)
B)
C)
D)
20
30
40
50
32
119. A 40-year-old male presents with a 3-month history of persistent low back pain and stiffness.
He cannot recall any specific episode associated with the onset of the pain, and intermittent
ibuprofen has provided little benefit. The pain does not radiate into his legs. He has experienced
similar back pain before, but it had always resolved within 2 weeks with rest, cutting back on
his activities, and taking ibuprofen. During his third episode about a year ago MRI of his
lumbosacral spine did not show any significant pathology.
When you examine the patient he describes mild, generalized discomfort with palpation
throughout his lumbosacral region, but has full range of motion of his back, normal deep tendon
reflexes, and good muscle strength in his legs. The straight legraising test produces mild low
back discomfort but does not result in any leg pain.
Which one of the following treatment options has the best evidence for restoring function in this
situation?
A)
B)
C)
D)
E)
Acupuncture
Back school
Back exercises
Spinal manipulation
Epidural corticosteroid injection
120. A 63-year-old white male has been diagnosed with myasthenia gravis and is experiencing
progressive muscle weakness despite maximum pharmacotherapy. Which one of the following
surgical options would be most likely to improve his condition?
A)
B)
C)
D)
E)
Thyroidectomy
Radioactive thyroid ablation
Adrenalectomy
Removal of a pituitary microadenoma
Thymectomy
121. You are preparing to evaluate a patient in the emergency department. A BNP level was ordered
by the physician from the previous shift who handed the patient over to you. The level is
reported as 459 pg/mL. You have not yet interviewed or examined the patient.
Based upon the information you have at this point, which one of the following is true regarding
this patient?
A)
B)
C)
D)
E)
The patient has diastolic heart failure

The patient has systolic heart failure
The patient has acute heart failure
The patient does not have heart failure
The patients diagnosis is uncertain
33
122. A 45-year-old patient develops acute erythema and pain in the first metatarsophalangeal joint,
the second such episode in 4 months. There is no apparent joint effusion. Results of a standard
laboratory profile are normal, including an erythrocyte sedimentation rate, CBC, liver enzymes,
BUN/creatinine, electrolytes, calcium, and uric acid. A radiograph is read as normal.
A)
B)
C)
D)
hydroxyapatite crystal disease

Mortons neuroma
systemic lupus erythematosus
acute gouty arthritis
123. A 73-year-old female presents with signs of an acute ischemic stroke, which began 2 hours
earlier. She has a National Institutes of Health Stroke Scale score of 14. Noncontrast head CT
shows no sign of hemorrhage.
Which one of the following treatments is recommended and FDA approved for patients with this
problem who have no contraindications?
A)
B)
C)
D)
E)
Intravenous tissue plasminogen activator (tPA)

Warfarin (Coumadin)
Glycoprotein IIb/IIIa receptor antagonists
Aspirin and clopidogrel (Plavix)
Heparin
124. Which one of the following jaundiced infants can be treated expectantly without a full workup
for pathologic causes?
A)
B)
C)
D)
A 12-hour-old term infant with a total bilirubin of 10 mg/dL

A 1-day-old term infant with a total bilirubin of 20 mg/dL
A 2-day-old term infant with a total bilirubin of 10 mg/dL
A 1-week-old term infant with a total bilirubin of 25 mg/dL
125. Your laboratory reports a borderline low vitamin B12 level in an anemic patient. Which one of
the following tests can confirm vitamin B12 deficiency?
A)
B)
C)
D)
E)
LDH
Methylmalonic acid
Mean corpuscular volume
Serum ferritin
Homocysteine
34
126. A clinical trial reports that a new therapy is non-inferior to your usual choice of treatment. You
can assume which one of the following?
A)
B)
C)
D)
E)
The new treatment has proven efficacy

A large placebo group was studied
The study was both double blind and placebo controlled
The new therapy is not superior to what you are currently using
The new therapy is not less effective than what you are currently using
127. A 35-year-old white female schoolteacher presents with anxiety, fatigue, and insomnia. The
symptoms began after a heart murmur was discovered on a routine physical examination. An
echocardiogram revealed mild mitral valve prolapse. A student at her school recently died
suddenly on a school field trip because of undiagnosed idiopathic hypertrophic cardiomyopathy
and the patient is now afraid she will die in a similar manner. She is anxious, sleepless, and
fearful of physical activity. You perform a physical examination and EKG, with normal results.
A)
B)
C)
D)
E)
Reassurance regarding the benign course of her condition

A stress test
Clonazepam (Klonopin)
Referral to a cardiologist
Referral for group psychotherapy
128. A 37-year-old male returns for his first follow-up visit after being diagnosed with major
depression 4 weeks earlier. The patient is taking citalopram (Celexa), 20 mg/day. He is
tolerating the medication well and his energy level and sleep are improved, but he still complains
of anhedonia. He has no other health problems and takes no other medications.
The most reasonable management at this point is to
A)
B)
C)
D)
add aripiprazole (Abilify)

increase the dosage of citalopram
add bupropion (Wellbutrin)
add levothyroxine (Synthroid)
129. You have recently diagnosed rheumatoid arthritis in a 49-year-old female. She has started
methotrexate (Rheumatrex) for disease-modifying therapy.
You counsel her that she is at increased risk for various diseases related to her arthritis, but that
the leading cause of death in patients with rheumatoid arthritis is
A)
B)
C)
D)
infection
cardiovascular disease
lymphoma
lung cancer
35
130. A 25-year-old male graduate student develops an acute headache, fever, and rash while visiting
his parents during fall break. When he comes to the emergency department he has a widespread
petechial rash and a stiff neck, and his blood pressure is 78/40 mm Hg. He is treated with
appropriate empiric antibiotics, and the spinal fluid from a tap reveals a large number of
polynuclear leukocytes and gram-negative diplococci.
What is the most appropriate treatment at this point?
A)
B)
C)
D)
E)
Ceftriaxone (Rocephin)
Rifampin (Rifadin)
Amoxicillin
Doxycycline
131. While on vacation you get up for an early morning swim and find a young man face down in the
hotel lap pool. He is flaccid and unresponsive when you pull him from the water. You are alone,
there is no automated external defibrillator (AED) available, and the telephone is at the opposite
side of the room.
Which one of the following actions is most consistent with American Heart Association 2010
guidelines for resuscitation?
A)
B)
C)
D)
E)
Turning the victim on his side to drain upper airway fluid before starting CPR
Performing the Heimlich maneuver before starting CPR
Performing 10 minutes of CPR before activating emergency medical services
Attempting ventilation before chest compression
Maintaining cervical spine immobilization with whatever is available
132. Which one of the following is most appropriate for the treatment of gonorrhea?
A)
B)
C)
D)
Azithromycin (Zithromax)
Azithromycin plus ceftriaxone (Rocephin)
Cefixime (Suprax)
133. A 63-year-old male presents with increasing shortness of breath over the past year. He smokes
a pack of cigarettes a day, and has done so since he was 18 years old. Your evaluation leads to
a diagnosis of COPD.
Which one of the following interventions has been shown to slow the decline in lung function
in this situation?
A)
B)
C)
D)
E)
Smoking cessation
Regular use of an inhaled short-acting $2-agonist
Regular use of an inhaled long-acting $2-agonist
Regular use of an inhaled long-acting anticholinergic agent
Regular use of oral corticosteroids
36
134. A 25-year-old medical assistant presents with a 3-month history of a tremor that began shortly
after the death of her husband. The tremor starts abruptly and then spontaneously remits. It is
not an action tremor and has no association with posture.
On examination you notice the tremor severity increases with questions calling attention to her
tremor symptoms and lessens when she is distracted with questions about her hobbies and
summer plans. Her neurologic examination is completely normal, including no signs of dystonia,
and she has no laboratory or radiologic evidence of disease. She denies taking any medications
or using any substances that might cause a tremor. The patient also reports that the tremor does
not improve with moderate alcohol consumption, and it did not respond to a trial of anti-tremor
medications prescribed by another physician.
Based on your findings, you suspect this patient most likely has which type of tremor?
A)
B)
C)
D)
E)
Cerebellar
Dystonic
Essential
Parkinsonian
Psychogenic
135. Which one of the following is associated with testosterone replacement for men with
hypogonadism?
A)
B)
C)
D)
E)
Osteoporosis
Depression
Reduced cognitive function
Increased fat deposition
Infertility
136. A 70-year-old male sees you for a preoperative evaluation 3 days prior to iliofemoral bypass
surgery. He has a 54pack-year history of cigarette smoking, and has a long-term history of
hypertension and peripheral vascular disease. His current medications include lisinopril (Prinivil,
Zestril), hydrochlorothiazide, and low-dose aspirin. He has no past history of myocardial
infarction, diabetes mellitus, or hyperlipidemia.
His blood pressure is 156/84 mm Hg and his pulse rate is 80 beats/min. The cardiopulmonary
examination is normal. Foot pulses are diminished but present bilaterally.
In order to reduce this patients risk of perioperative cardiac complications, which one of the
following is recommended prior to his surgery?
A)
B)
C)
D)
E)
A pharmacologic cardiac stress test

Discontinuation of aspirin
Starting a $-blocker
Starting enoxaparin (Lovenox)
Starting a statin
37
137. In counseling a 35-year-old female about smoking cessation, you find that her greatest concern
is that she will gain weight. Among the following therapies, which one is most strongly
associated with weight gain after smoking cessation?
A)
B)
C)
D)
Bupropion (Wellbutrin)
Varenicline (Chantix)
Nicotine gum
138. You make a diagnosis of polymyalgia rheumatica in a 72-year-old female. This is a new
diagnosis for this patient and she has not received any treatment for this condition up to this
point.
Which one of the following prednisone regimens would be the best initial treatment?
A)
B)
C)
D)
E)
15 mg daily with a slow taper

15 mg daily with a rapid taper
30 mg daily with a slow taper
139. An otherwise healthy 53-year-old male presents with acute shortness of breath and pleuritic chest
pain. His O2 saturation on room air is 85%, and he is hemodynamically stable. The patient
underwent an appendectomy 2 weeks ago and his postoperative course was complicated by an
abscess, which required a week-long hospital stay.
Which one of the following should be the initial test to further evaluate this patient?
A)
B)
C)
D)
D-dimer
CT angiography of the chest
Pulmonary angiography
Venous ultrasonography
140. A 52-year-old male presents with major depressive disorder. He reports a decrease in his libido
and is concerned about the impact of medication on his sex life.
Which one of the following antidepressants is least likely to cause sexual dysfunction?
A)
B)
C)
D)
E)
Duloxetine (Cymbalta)
Fluoxetine (Prozac)
Mirtazapine (Remeron)
Paroxetine (Paxil)
38
141. A hospitalized 75-year-old white male with well-controlled type 2 diabetes mellitus is scheduled
for abdominal CT with oral and intravenous iodinated contrast. Which one of the following
medications should be withheld for at least 48 hours after the procedure?
A)
B)
C)
D)
E)
Acarbose (Precose)
Glyburide (Micronase, DiaBeta)
Rosiglitazone (Avandia)
142. An adult male has obvious gynecomastia, without galactorrhea, that has been present for the past
10 years. A careful drug history, physical examination, and endocrine and malignancy workups
are negative. He wants the problem resolved.
Which one of the following is the treatment of choice?
A)
B)
C)
D)
E)
Clomiphene (Clomid, Serophene)

Danazol
Tamoxifen (Soltamox)
Topical testosterone (AndroGel)
Surgery
143. A 46-year-old African-American male presents to your office with a 1-day history of the sudden
onset of severe dizziness. His symptoms include a sensation of abnormal rotation of his
environment, as well as occasional headaches. He has felt nauseated but has not vomited. On
examination he has resting nystagmus. There is no hearing loss, and a thorough neurologic
examination is otherwise normal. He is vertiginous in all positions.
A)
B)
C)
D)
E)
Basilar artery migraine with vertigo

Benign positional vertigo
Vestibular neuronitis
Menieres disease
Eustachian tube dysfunction
144. A 48-year-old female has had no menses for the past 12 months. She complains of hot flashes,
especially at night, which significantly interfere with sleep. She also complains of fatigue,
decreased appetite, unrefreshed sleep, and feeling down 4 or 5 days per week. A physical
examination and laboratory findings are unremarkable. The patient prefers not to take estrogen
replacement therapy.
Which one of the following medications would be appropriate for this patient?
A)
B)
C)
D)
Nortriptyline (Pamelor)
Escitalopram (Lexapro)
Imipramine (Tofranil)
39
145. Which one of the following can cause a persons normal hemoglobin level to be lower than the
reference range?
A)
B)
C)
D)
Hemochromatosis
African-American ethnicity
Cigarette smoking
Living at a high altitude
146. When stratifying patient risk to determine whether an implantable cardioverter-defibrillator is

indicated for the primary prevention of sudden cardiac death, which one of the following is
associated with the greatest risk?
A)
B)
C)
D)
Atrial fibrillation
Heart failure, with an ejection fraction 35%
Uncontrolled hypertension
Complete heart block
147. A 72-year-old male is hospitalized for pneumonia. During his hospitalization he develops
diarrhea due to Clostridium difficile infection. Appropriate antibiotics are prescribed.
What other measures should be taken to prevent the spread of infection in the hospital?
A)
B)
C)
D)
Contact precautions with gown and gloves plus handwashing with soap and water
Contact and respiratory precautions with gown, gloves, and face mask
Use of hand sanitizers before and after patient contact
Placing the patient in a reverse airflow room
148. A 23-year-old male comes to your office accompanied by his girlfriend to talk about
attention-deficit disorder. He minimizes the concerns she raises, which include sleeping less
(sometimes just 23 hours a night), rambling on tangentially during conversations, and being
highly irritable. When you ask him about these observations, he agrees that they are true and
reflect a change in his usual behavior. However, he explains that he is just becoming more social
and that his girlfriend is probably jealous of his new popularity. The patient has no family
history of attention-deficit disorder. His father died at a young age as a result of alcoholism. He
denies stimulant use and a urine drug screen is negative.
Which one of the following mental disorders is most likely in this patient?
A)
B)
C)
D)
E)
Attention-deficit disorder
Attention-deficit/hyperactivity disorder
Generalized anxiety disorder
Major depressive disorder
Bipolar disorder
40
149. A 73-year-old white female sees you for a routine visit. The patient is on multiple medications,
and on examination her blood pressure is 140/80 mm Hg and her heart rate is 75 beats/min. She
also has a systolic heart murmur, osteoarthritic changes of the knees, and a trace of peripheral
edema. Her free T4 level is elevated, and her TSH level is <0.01 :U/mL (N 0.55.0).
Which one of the following medications the patient is taking is most likely to cause abnormal
thyroid hormone levels?
A)
B)
C)
D)
E)
Amiodarone (Cordarone)
Digoxin
Enalapril (Vasotec)
Furosemide (Lasix)
Lithium
150. You are writing a prescription for amoxicillin for a 6-year-old female with acute otitis media.
Her mother has had an anaphylactic reaction to penicillin in the past and is concerned that she
may have passed this trait down to her daughter. You reassure her that this is not usually the
case but warn her about potential signs of an allergic reaction.
Which one of the following is the most concerning early symptom of a dangerous drug reaction?
A)
B)
C)
D)
E)
Tachycardia and elevated blood pressure

Small, bright, erythematous macules diffusely over the trunk
Pruritus around the mouth and on the palms of the hands and soles of the feet
Eczematous patches in the antecubital and popliteal fossae
Diarrhea with blood on the tissue paper
151. A 52-year-old female presents with vulvovaginal dryness and pain with intercourse. She has not
menstruated for 6 months and denies hot flashes, insomnia, or other vasomotor symptoms. She
has no past history of cancer or surgery. Her examination is consistent with vaginal atrophy.
Which one of the following is the recommended first-line treatment for this patient?
A)
B)
C)
D)
Oral estrogen
Oral estrogen and progestogen
Vaginal estrogen
Vaginal estrogen and oral progestogen
152. A 1-year-old female has head lice. She has three siblings who have been treated unsuccessfully
for this problem with permethrin (Nix).
Which one of the following would be the best alternative treatment for this child?
A)
B)
C)
D)
E)
Benzyl alcohol lotion (Ulesfia)

Malathion 0.5% lotion (Ovide)
Permethrin cream rinse
Pyrethrin shampoo (Pronto)
Spinosad (Natroba)
41
153. A 32-year-old female presents with complaints of moderate irritability and anxiety during the
week before nearly all of her menstrual periods. During this time she also has problems with
weight gain and breast tenderness. She says she is her usual happy self at other times during
the month. You diagnose premenstrual syndrome (PMS).
Which one of the following complementary and alternative therapies has been shown to be
helpful in reducing the symptoms of this problem?
A)
B)
C)
D)
E)
Saffron
St. Johns wort
Soy
Pyridoxine (vitamin B6)
Vitamin E
154. During a routine office visit, a 65-year-old female asks if she should be screened for carotid
artery stenosis. The patient has a history of controlled hypertension and hypercholesterolemia,
and a family history of stroke. Physical examination of the carotid artery is normal and the
patient is asymptomatic.
Which one of the following is consistent with U.S. Preventive Services Task Force and
American Heart Association recommendations regarding carotid artery ultrasonography for this
patient?
A)
B)
C)
D)
She does not need screening ultrasonography at this time

She should have one-time screening ultrasonography now
She should have routine screening ultrasonography now and every 5 years
She should have routine screening ultrasonography now and every 10 years
155. A 35-year-old white female comes to your office with a 3-month history of the gradual onset of
pain and tenderness in her wrists and hands. She also complains of 1 hour of morning stiffness.
She denies rash, fever, or skin changes. On physical examination she has symmetric swelling
of the proximal interphalangeal joints and metacarpophalangeal joints. Motion of these joints is
painful. She has no rash or mouth ulcers. Radiographs of the hands and wrists are negative, and
a chest film is unremarkable. A CBC is normal, but the erythrocyte sedimentation rate is
elevated at 40 mm/hr. Latex fixation for rheumatoid factor is negative, and an antinuclear
antibody (ANA) test is negative.
The most likely diagnosis in this patient is
A)
B)
C)
D)
E)
rheumatoid arthritis
systemic lupus erythematosus
sarcoidosis
Lyme disease
calcium pyrophosphate deposition disease
42
156. A 68-year-old female with a previous history of multiple medical problems presents to your
office with dizziness. She describes this dizziness as an off-balance or wobbly feeling. She
has not had a sensation of spinning or motion, or loss of consciousness. She is not anxious or
depressed. She takes the following medications:
Lovastatin (Mevacor), 20 mg daily for hypercholesterolemia
Metoprolol succinate (Toprol-XL), 25 mg daily
Chlorthalidone, 12.5 mg daily
Lisinopril (Prinivil, Zestril), 20 mg daily for hypertension
Sertraline (Zoloft), 25 mg daily for menopausal symptoms
Alendronate (Fosamax), 70 mg weekly
Calcium, 600 mg 2 times daily
Vitamin D, 1000 units daily for osteoporosis
Oxybutynin (Ditropan XL), 10 mg daily for overactive bladder
Acetaminophen, 1000 mg 2 times daily for osteoarthritis
Meclizine (Antivert, Bonine), 25 mg 3 times daily as needed for dizziness
Cyclobenzaprine (Flexeril), 5 mg 3 times daily as needed for muscle spasm
Zolpidem (Ambien), 5 mg at bedtime as needed
A physical examination is normal, including a neurologic examination, and the patient has a
normal gait. There is no evidence of peripheral neuropathy, and Romberg testing is normal.
There is no orthostatic decrease in blood pressure. The Dix-Hallpike maneuver is negative. A
CBC, chemistry profile (CMP), TSH level, and vitamin B12 level are normal.
A)
B)
C)
D)
E)
A 24-hour heart monitor

A tilt table test
Carotid ultrasonography
Medication reduction
Increasing the dosage of sertraline to 50 mg daily
157. A 54-year-old male presents to your office with a chief complaint of vomiting and diarrhea,
along with stomach cramps. He has not noticed blood in his stool or vomit.
His symptoms began in the middle of the night, approximately 4 hours after he ate at a local
delicatessen. He has not been out of the country and has not eaten any exotic foods or foods that
are not part of his normal diet. His vital signs include a temperature of 37.0C (98.6F), a pulse
rate of 90 beats/min, and a blood pressure of 130/80 mm Hg.
Which one of the following organisms is implicated in this patients presumed case of food
poisoning?
A)
B)
C)
D)
Staphylococcus aureus
Clostridium botulinum
Campylobacter jejuni
Enterohemorrhagic Escherichia coli
43
158. A 45-year-old male with type 1 diabetes mellitus receives a corticosteroid injection for
osteoarthritis of the left knee. Which one of the following is true regarding monitoring of his
blood glucose levels?
A)
B)
C)
D)
Glucose levels should be closely monitored for 48 hours

Glucose levels should be closely monitored for 7 days
Glucose levels should be closely monitored for 14 days
No additional monitoring is necessary
159. A 14-year-old male with Tanner stage 1 pubic hair has prepubertal-size testes. His height is at
the 3rd percentile. The physical examination is otherwise unremarkable.
Which one of the following additional findings would be most consistent with constitutional delay
of growth and puberty?
A)
B)
C)
D)
E)
Impairment of the sense of smell

Delayed bone age
Elevated LH and FSH
Elevated thyrotropin
Elevated prolactin
160. A 52-year-old African-American male sees you for a routine visit. His only medical problem is
hypercholesterolemia. Because you wish to initiate a statin, you order a liver profile with the
following results:
Total bilirubin. . . . . . . . . . . . . . . . . . . . . . . . .
Direct bilirubin. . . . . . . . . . . . . . . . . . . . . . . .
Albumin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
LDH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AST (SGOT). . . . . . . . . . . . . . . . . . . . . . . . . .
ALT (SGPT). . . . . . . . . . . . . . . . . . . . . . . . . .
Alkaline phosphatase. . . . . . . . . . . . . . . . . . . .
2.0 mg/dL (N 0.01.0)

0.2 mg/dL (N 0.00.4)
4.0 g/dL (N 3.55.0)
250 U/L (N 4590)
25 U/L (N 727)
15 U/L (N 121)
25 U/L (N 1339)
Which one of the following would best explain these results?

A)
B)
C)
D)
E)
Alcoholic hepatitis
Steatohepatitis
Chronic hepatitis C
Hemolysis
Gilberts syndrome
44
161. A 44-year-old female has recently lost her best friend to ovarian cancer. She has no family
history of cancer in her siblings, parents, or grandparents. She requests screening for ovarian
cancer. Her physical examination, including a pelvic examination, is normal.
According to current guidelines, which one of the following would be best for this patient?
A)
B)
C)
D)
E)
CA-125 testing
CA-125 testing and ovarian ultrasonography
Ovarian ultrasonography alone
CT of the pelvis
No screening
162. A pregnant 32-year-old gravida 2 para 1 develops an acute deep-vein thrombosis in the left lower
extremity during the third trimester. The patient had a cesarean delivery with her first pregnancy
and wants to breastfeed.
Which one of the following is the treatment of choice?
A)
B)
C)
D)
Low molecular weight heparin

Unfractionated heparin
Warfarin (Coumadin)
A vena cava filter
163. A 40-year-old male presents with a new rash. On examination you note multiple
erythematous-to-yellow dome-shaped papules on the extensor surfaces of his extremities, on his
buttocks, and on his hands. The papules are tender and pruritic. A biopsy reveals foamy
macrophages and dermal extracellular lipids.
This patients rash is associated with
A)
B)
C)
D)
E)
endocarditis
systemic vasculitis
a viral infection of the skin
hypertriglyceridemia
urticaria
164. For most patients, which one of the following is the most effective treatment for anemia of
chronic disease?
A)
B)
C)
D)
E)
Elemental iron
Erythropoietin
Prednisone
Optimal management of the underlying disorder
Combined therapy with oral iron, vitamin B12, folic acid, and erythropoietin
45
165. Which one of the following interventions for bed-wetting in children should be recommended
as initial therapy?
A)
B)
C)
D)
E)
Waking a child during the night and carrying him or her to the toilet
Restriction of fluids during the day
An enuresis alarm
Imipramine (Tofranil)
Oxybutynin (Ditropan)
166. Which one of the following is a contraindication to the use of combined hormonal
contraceptives?
A)
B)
C)
D)
E)
A family history of breast cancer in a first degree relative

Rheumatoid arthritis treated with immunosuppression
Morbid obesity
Migraine headaches with aura
Ovarian cancer
167. A 5-month-old child begins to cough and wheeze. He has no previous history of respiratory
problems, although he has had upper respiratory symptoms for the past 2 days. On physical
examination you note tachypnea and mild intercostal retractions and wheezes.
A)
B)
C)
D)
E)
asthma
bronchiolitis
croup
pertussis
pneumonia
168. Which one of the following cardiac arrhythmias is associated with antipsychotic use?
A)
B)
C)
D)
E)
Third degree heart block

Paroxysmal atrial tachycardia
Atrial fibrillation
Ventricular fibrillation (torsades de pointes)
Wolff-Parkinson-White syndrome
46
169. A 16-year-old female has had foot pain for the past 3 weeks. She has no known history of
trauma, but is participating in cross-country running events for her high school and has
significantly increased her training schedule over the past 2 months. An examination reveals
tenderness at the base of the fifth metatarsal, but no swelling. Radiographs are negative, but a
radionuclide bone scan shows increased uptake in the proximal portion of the fifth metatarsal.
Which one of the following would be most appropriate?
A)
B)
C)
D)
E)
A reduced training schedule for 1 month

A DXA scan to evaluate bone mineral density
A wooden cast shoe
Ice and NSAID therapy only
Referral to an orthopedist
170. You are treating a 68-year-old male for COPD, hypertension, systolic heart failure, and
coronary artery disease. You are considering adding a $-blocker but you are concerned that it
could affect his COPD.
Which one of the following options would be most appropriate for this patient?
A)
B)
C)
D)
E)
Metoprolol tartrate (Lopressor), 12.5 mg twice daily

Nadolol (Corgard), 20 mg daily
Sotalol (Betapace), 40 mg twice daily
Timolol, 5 mg daily
Avoiding $-blocker use
171. A 77-year-old white female complains of fatigue and mild dyspnea with exertion. After a
thorough evaluation you conclude that she has early heart failure. She has no edema or evidence
of volume overload, and echocardiography reveals an ejection fraction of 34%.
Which one of the following would be most appropriate as INITIAL treatment?
A)
B)
C)
D)
E)
Digoxin
Furosemide (Lasix)
Hydrochlorothiazide
Isosorbide dinitrate
172. For a 1-year-old patient, pneumococcal 13-valent conjugate vaccine (Prevnar) is preferred rather
than polyvalent pneumococcal vaccine (Pneumovax) because of which one of the following
advantages?
A)
B)
C)
D)
E)
It is available in an oral form

It is less expensive
It requires only one dose
It can be combined with MMR in a single injection
It is more immunogenic
47
173. A 49-year-old female with type 1 diabetes mellitus presents to your office with a 1-week history
of a red, hot, swollen foot. She recalls twisting her ankle when stepping off a curb the day
before the swelling began. She denies fever or significant pain. She has difficulty walking due
to stiffness in the foot.
On examination you find the patient is in no distress. Her temperature is 36.7C (98.1F), blood
pressure 144/82 mm Hg, and heart rate 80 beats/min. Her right foot is edematous,
erythematous, and excessively warm. Monofilament testing reveals significant impairment of
sensation of both feet. She has restricted range of motion of the right ankle and foot compared
to the left. No skin lesions are present. Dorsalis pedis pulses are brisk and symmetric. A
radiograph of the right foot is normal.
Laboratory Findings
Hemoglobin A1c. . . . . . . . . . . . . . . . . . . . . . . .
Capillary blood glucose.. . . . . . . . . . . . . . . . .
Hematocrit. . . . . . . . . . . . . . . . . . . . . . . . . . . .
WBCs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Platelets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Erythrocyte sedimentation rate. . . . . . . . . . . .
8.2%
213 mg/dL
37.2% (N 36.046.0)
11,000/mm3 (N 430010,800)
350,000/mm3 (N 150,000350,000)
30 mm/hr (N 125)

A)
B)
C)
D)
Osteomyelitis
Osteoarthritis
Acute gout
Charcot foot
174. A 37-year-old male returns for follow-up after an episode of nephrolithiasis. He passed a 3-mm
calcium oxalate stone and requests information about preventing further stones.
You would advise that he
A)
B)
C)
D)
drink up to 2 L of water/day
increase his consumption of meats and grains
increase the level of fructose in his diet
restrict foods high in oxalate, such as spinach and rhubarb
175. When discussing end-of-life issues with patients, physicians may inadvertently send the wrong
message. Which one of the following has the greatest potential to be misinterpreted by a patient?
A)
B)
C)
D)
We can offer many options to control your symptoms

If you become extremely ill, would you like to be put on artificial life support?
The cancer has not responded to the treatment as we had hoped
We want to provide coordinated care with a team of professionals to help you remain
comfortable
E) It is time to consider withdrawal of care
48
176. A 32-year-old secretary complains of wrist pain at rest and when holding a pen. She says it feels
like her thumb locks up at times. On examination you note tenderness on the radial side of her
right wrist. A radiograph shows multiple sesamoid bones around her first metacarpophalangeal
joint.
You suspect
A)
B)
C)
D)
E)
rheumatoid arthritis
carpal joint arthritis
de Quervains tenosynovitis
cervical radiculopathy
carpal tunnel syndrome
177. A 45-year-old female presents to your office with a complaint of hair loss. Examination reveals
thinning of the hair over the central superior portion of the scalp. Her frontal hairline is
preserved. There are no oval patches of baldness and no scarring. She has a history of hirsutism,
infertility, irregular menses, and cystic acne. Her testosterone, dehydroepiandrosterone sulfate,
and prolactin levels are normal, as are thyroid and iron levels.
Of the following, which one would be most appropriate for treatment of this patients hair loss?
A)
B)
C)
D)
E)
Oral estrogen
Oral corticosteroids
Topical corticosteroids
Finasteride (Propecia)
Topical minoxidil (Womens Rogaine)
178. Tourettes syndrome is associated with which one of the following comorbidities?
A)
B)
C)
D)
E)
Cardiac arrhythmias
Partial or complex seizures
Hypertension
Attention-deficit disorder
Hypothyroidism
179. An overweight 42-year-old female complains of foot pain. Which one of the following would
be most suggestive of plantar fasciitis?
A)
B)
C)
D)
A sudden onset of ecchymosis and plantar heel pain

Sharp, stabbing pain with palpation of the medial plantar calcaneal area
Posterior medial ankle pain
Burning pain in the medial plantar region
49
180. Which one of the following is most consistent with the rash of infantile seborrheic dermatitis?
A)
B)
C)
D)
E)
Sparing of the diaper area

An onset after 6 months of age
Pruritus at the time of onset
Resolution within weeks to months
Progression to atopic dermatitis
181. A 38-year-old white female who complains of abdominal pain insists that she be referred for
surgical evaluation. She has a history of multiple unexplained physical symptoms that began in
her late teenage years. She is vague concerning past medical evaluations, but a review of her
thick medical chart reveals multiple normal blood and imaging tests, several surgical procedures
that have failed to alleviate her symptoms, and frequent requests for refills of narcotic
analgesics.
This history is most compatible with which one of the following?
A)
B)
C)
D)
E)
Hypochondriasis
Malingering
Panic disorder
Generalized anxiety disorder
Somatization disorder
182. A concerned father brings his 20-month-old daughter to see you because of the overnight onset
of a barky cough along with hoarseness, a runny nose, and a fever to 100.8F. She is an
otherwise healthy child who is up to date on her vaccinations. During the course of the visit you
observe her to be coughing intermittently, and on examination you note clear lungs with
occasional stridor and no retractions. She is not tachypneic or tachycardic. Her oxygen
saturation is 95% on room air.
Appropriate medical management of this patient includes which one of the following?
A)
B)
C)
D)
E)
Inhaled albuterol (Proventil, Ventolin)

Inhaled epinephrine
Oral azithromycin (Zithromax)
Oral dexamethasone
Oral oseltamivir (Tamiflu)
50
183. A 75-year-old male complains of loose stools and pain with defecation. This problem seems to
have developed gradually over the last several months. His past medical history includes prostate
cancer treated with radiation therapy 5 years ago, hypertension, and osteoarthritis. His
medications include hydrochlorothiazide, a $-blocker, and acetaminophen. Colonoscopy is
negative for polyps and cancer, but the rectal and sigmoid areas show pallor with friability and
telangiectasia.
A)
B)
C)
D)
E)
familial angiodysplasia
Osler-Weber-Rendu syndrome
radiation proctitis
late-onset ulcerative colitis
sensitivity to acetaminophen breakdown products
184. A 40-year-old female with chronic asthma presents for a 6-month follow-up visit. For the past
year she has done very well on fluticasone/salmeterol (Advair), 250/50 :g, except for when she
had to use an albuterol (Proventil, Ventolin) inhaler for 2 days because of cold symptoms 5
months ago.
The most reasonable change to this patients medication regimen would be to
A)
B)
C)
D)
add montelukast (Singulair)

replace fluticasone/salmeterol with fluticasone (Flovent)
replace fluticasone/salmeterol with budesonide/formoterol (Symbicort)
replace fluticasone/salmeterol with tiotropium (Spiriva)
185. A 52-year-old African-American female has a chest radiograph after a PPD test is equivocal.
She is a schoolteacher, and a child in her classroom has been confirmed as a TB contact. The
radiograph shows large bilateral hilar nodes. She has recently been diagnosed with psoriatic
arthritis on the basis of a scaly skin rash and arthralgias. A physical examination also reveals
nodular skin lesions on her shins, and scattered, slightly enlarged lymph nodes.
Which one of the following would be the most appropriate next step for confirming the
diagnosis?
A)
B)
C)
D)
E)
A lymph node biopsy

An antinuclear antibody test
CT angiography of the chest
Pulmonary function tests
An echocardiogram
51
186. Most of the gait disturbances identified in geriatric patients in the outpatient primary care setting
are related to which one of the following?
A)
B)
C)
D)
E)
Sensory ataxia
Parkinsons disease
Osteoarthritis
Multiple strokes
Myelopathy
187. A 23-year-old female becomes pregnant while using a copper T 380A intrauterine device
(ParaGard) for contraception. Ultrasonography indicates an estimated gestational age of 8 weeks
and confirms the location of the intrauterine device (IUD) within the uterus. A speculum
examination shows the string coming through the cervix.
Which one of the following is the best management strategy?
A)
B)
C)
D)
E)
Remove the IUD now

Remove the IUD during the second trimester
Remove the IUD after 37 weeks gestation
Remove the IUD when the patient goes into labor
Leave the IUD in place until delivery
188. A 20-year-old white male states that he was physically abused by his natural parents, and as a
result of running away from home on several occasions he was placed in a series of foster
homes. His schooling was sporadic, and he was frequently in trouble for truancy, vandalism,
initiating fights, and stealing. He dropped out of school at the age of 16, and during that year
he was arrested for car theft and driving while intoxicated. He has not worked at any job for
more than 6 months, and has had frequent changes of address due to failure to pay rent and other
financial obligations. He brags that he has fathered three children by three different women, but
has not provided any support or made any contact with any of them since their pregnancies. He
has used several aliases, one of which he had printed on a business card listing his occupation
as Barroom Brawler and Superstud. IQ testing is normal and there is no history of a psychotic
break.
The most accurate diagnosis of this patients condition is
A)
B)
C)
D)
E)
borderline personality disorder

unipolar manic disorder
antisocial personality disorder
abused child reaction formation
schizotypal personality disorder with psychoactive substance abuse
52
189. You see a 75-year-old male for his Medicare annual wellness visit. Which one of the following
satisfies the Medicare requirement for vision screening?
A)
B)
C)
D)
E)
Questioning the patient about vision changes

Use of the Amsler grid to detect age-related macular degeneration
Use of the Snellen eye chart to evaluate visual acuity
Use of an ophthalmoscope to detect cataracts
Use of tonometry to detect glaucoma
190. Which one of the following combination hormonal contraceptives is most effective in obese
women?
A)
B)
C)
D)
E)
The etonogestrel/ethinyl estradiol vaginal ring (NuvaRing)

The norelgestromin/ethinyl estradiol transdermal patch (Ortho Evra)
Oral norethindrone/ethinyl estradiol (Aranelle, Brevicon)
Oral levonorgestrel/ethinyl estradiol (Aviane, Seasonale)
Oral drospirenone/ethinyl estradiol (Ocella, Yaz)
191. An asymptomatic 30-year-old female has developed hypertension that has been difficult to
control despite the use of hydrochlorothiazide, lisinopril (Prinivil, Zestril), atenolol (Tenormin),
and hydralazine. She sees you for a follow-up visit, and her blood pressure is 165/98 mm Hg.
The examination is otherwise unremarkable, including cardiac auscultation and distal pulses. Her
CBC, TSH level, complete metabolic panel, and urinalysis are all normal.
Which one of the following tests would be best to confirm the most likely diagnosis?
A)
B)
C)
D)
E)
An aldosterone/renin ratio
A renal biopsy
24-hour urinary free cortisol
24-hour urinary total metanephrines
CT angiography
192. A 17-year-old female comes to your office with an 8-month history of amenorrhea. Menarche
occurred at age 12 and her menses were regular until the past year. The patients vital signs are
in the normal range for her age except for a BMI of 16.1 kg/m2 (below the third percentile for
age). She is a high-school senior who dances with the local ballet company. She practices dance
several hours a day and works out regularly. She admits that she follows a strict 800-calorie/day
diet to keep in shape for ballet.
You order a CBC, a complete metabolic profile, a urine $-hCG level, FSH and LH levels, and
a TSH level. Which one of the following is also recommended as part of the workup?
A)
B)
C)
D)
E)
An EKG
Pelvic ultrasonography
Abdominal/pelvic CT
A DXA scan
A nuclear bone scan
53
193. To decrease stroke risk in patients undergoing coronary artery bypass grafting (CABG) who
have concomitant carotid stenosis, current evidence supports which one of the following?
A)
B)
C)
D)
Carotid endarterectomy at the same time as CABG

Postoperative $-blockers
Postoperative aspirin
Postoperative statins
194. With regard to screening mammography, which one of the following is lower in women 4049
years of age compared to women age 50 and older?
A)
B)
C)
D)
Radiation risk
The false-positive rate
The false-negative rate
The absolute risk reduction for breast cancer mortality
195. In otherwise healthy, nonsmoking, previously unimmunized 65-year-olds, current Centers for
Disease Control and Prevention recommendations for immunization with pneumococcal vaccine
(Pneumovax) recommend administration of the vaccine
A)
B)
C)
D)
E)
yearly
every 3 years
every 5 years
once
only for patients who are immunocompromised
196. A 67-year-old female sees you for a routine follow-up visit for hypertension. Her chemistry
profile and other laboratory studies are normal except for a serum calcium level of 10.9 mg/dL
(N 8.410.4). This result is confirmed on repeat testing and is elevated when adjusted for her
albumin level.
Her current medications are lovastatin (Mevacor), 20 mg daily for hypercholesterolemia, and
lisinopril (Prinivil, Zestril), 10 mg daily for hypertension. Her medical history is otherwise
negative. Her parathyroid hormone level is 74 pg/mL (N 1575), her serum creatinine level is
1.1 mg/dL (N 0.61.5), and her 25-hydroxyvitamin D level is 26 ng/mL (N 1460).
A)
B)
C)
D)
E)
Primary hyperparathyroidism
Occult malignancy
Sarcoidosis
Pagets disease of bone
Hypervitaminosis D
54
197. A 7-year-old male is brought to your office by his mother because she is concerned about his
ability to focus and stay still in school all day. She has paperwork from school and home,
including his report card, Connor Rating Scales, behavioral screening, IQ tests, and performance
testing. Your evaluation leads to a diagnosis of attention-deficit/hyperactivity disorder (ADHD)
with no apparent comorbidities. As you discuss management options the mother expresses
concern because her parents tell her that medications for ADHD are overprescribed and
addictive. She asks you for further guidance.
After providing the mother with comprehensive educational material, which one of the following
would you recommend as first-line treatment?
A)
B)
C)
D)
E)
Cognitive-behavioral therapy
Atomoxetine (Strattera)
Methylphenidate (Ritalin LA, Concerta)
198. A 65-year-old male has complaints of insomnia and fatigue. His past medical history is
significant only for hypertension and osteoarthritis. His physical examination is normal except
for a blood pressure of 145/90 mm Hg and a heart rate of 105 beats/min. He has a normal BMI,
does not smoke or drink alcohol, and denies any pain or chest pressure. He has not changed his
daily exercise routine or diet, and has not traveled recently. Routine blood work is normal except
for a TSH level of 0.3 :U/mL (N 0.55.0).
A)
B)
C)
D)
E)
Order a repeat TSH level and instruct the patient to fast beforehand
Order a thyroglobulin level
Order free T3 and free T4 levels
Order a 24-hour radioactive iodine uptake test
Begin treatment with levothyroxine (Synthroid)
199. A 50-year-old male presents to your office with recurrent irritative voiding symptoms that are
accompanied by testicular, perineal, and low back discomfort. He also reports occasional distal
penile pain. Four months ago he visited another physician because of a similar episode. He was
told then that he had a urinary tract infection, based on a positive urine culture that grew
Escherichia coli, and was given a prescription for an antibiotic to take for 2 weeks. His
symptoms improved but never completely resolved. On examination the patient is afebrile. His
prostate is slightly enlarged, boggy, and moderately tender.
Which one of the following is the most appropriate management step at this time?
A)
B)
C)
D)
E)
A prostate-specific antigen level prior to initiating treatment

Transrectal ultrasonography of the prostate prior to initiating treatment
Tamsulosin (Flomax)
High-dose oral ampicillin
55
200. A 46-year-old male admits to consuming at least 4 alcoholic drinks a day. He states that he
doesnt think his alcohol use is a problem, and that he has read that drinking helps keep the heart
healthy.
The cardiovascular effects of this level of alcohol use include
A)
B)
C)
D)
E)
a decrease in blood pressure while drinking

a decreased risk for acute coronary events
an increased risk of valvular disease
an increased risk of heart failure
no apparent effect on stroke risk
201. A 22-year-old female has a 4-month history of suprapubic pain, urinary frequency, urinary
urgency, dysuria, and dyspareunia. She has been empirically treated with antibiotics for a
urinary tract infection despite the fact that multiple urine tests have been negative for infection
or other abnormalities. You suspect the patient has interstitial cystitis.
A)
B)
C)
D)
E)
Fluoxetine (Prozac)
Ibuprofen
Nitrofurantoin (Macrobid)
Pentosan polysulfate sodium (Elmiron)
202. Which one of the following is a risk factor for depression during pregnancy?
A)
B)
C)
D)
E)
High socioeconomic status

Nonsmoking
Age over 25
A family history of hyperthyroidism
Childhood abuse
203. A 62-year-old female presents with painful lesions at both corners of her mouth characterized
by redness, scaling, and deep cracks. The cracks sometimes bleed when she opens her mouth.
She has treated them with bacitracin/neomycin/polymyxin B ointment (Neosporin) but says it
has not helped.
A)
B)
C)
D)
A biopsy of the lesions

An anticandidal medication
Bacitracin
Vitamin B12
56
204. A 40-year-old male presents with right eye pain and redness. There is no history of trauma or
injury.
Which one of the following should be done initially?
A)
B)
C)
D)
E)
Irrigation
Funduscopic examination
Visual acuity testing
Fluorescein staining
Application of a local anesthetic
205. While vacationing, a 27-year-old white male was exposed to poison ivy. Between 48 and 72
hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms
and neck. He began treating himself with an over-the-counter topical hydrocortisone cream, and
when the eruption did not improve after 24 hours of treatment he sought help from the local
emergency department. He was given oral methylprednisolone (Medrol Dosepak), starting with
24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day
6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and
vesiculation, involving extensive areas of his arms, neck, and face.
The most appropriate management at this time would be to
A)
B)
C)
D)
E)
prescribe a superpotent topical corticosteroid

repeat the oral methylprednisolone treatment
begin diphenhydramine (Benadryl), 4 times a day
begin high-dose oral prednisone and taper over 2 weeks
discontinue all medications and recommend cool compresses
206. A 56-year-old male sees you for a health maintenance visit. He inquires about the options for
colon cancer screening. He has not had any screening tests performed in the past and has no
personal or family history of colon cancer. You tell him that there are several alternatives, but
according to the U.S. Preventive Services Task Force, recommendations regarding the optimal
screening intervals vary by test. He opts for fecal occult blood testing.
You recommend he repeat this test at which one of the following intervals?
A)
B)
C)
D)
E)
Yearly
Every 5 years
Every 7 years
Every 10 years
Never, if the results are negative
57
207. Which one of the following is the leading cause of death among adolescents age 1219 in the
United States?
A)
B)
C)
D)
E)
Accidents
Suicide
Homicide
Cancer
Heart disease
208. An 80-year-old female who lives independently at home is admitted to the hospital with acute
pyelonephritis. When she is taken to her hospital room she is incontinent, unsteady when
walking, and somewhat disoriented. Her past medical history includes hypertension with
evidence of diastolic dysfunction on echocardiography and asymptomatic glucose intolerance.
Which one of the following orders would be appropriate for this patient?
A)
B)
C)
D)
E)
Telemetry
Continuous pulse oximetry
Foley catheter placement
A regular diet
Bed rest
209. A 70-year-old male sees you because his left leg feels tender and swollen. Questioning reveals
that a few days ago he returned from a long road trip with his wife, and that they had spent
several days driving to visit relatives. On examination there is marked asymmetry between his
left calf and his right calf; there is also a slight discoloration around the area of his left calf
where it is most tender.
You suspect the edema may be due to a deep-vein thrombosis (DVT). The patient has no
personal or family history of blood clots. Further investigation reveals a high pretest probability
score on the Wells Clinical Prediction Rule test for DVT.
Which one of the following would be the most appropriate diagnostic test at this point?
A)
B)
C)
D)
E)
D-dimer
Contrast venography
Compression ultrasonography
Helical CT
MRI
58
210. A 45-year-old female with type 1 diabetes mellitus currently takes NPH insulin (Humulin,
Novolin) twice a day. She expresses a desire to change to insulin glargine (Lantus). Her diabetes
has always been well controlled, and her current hemoglobin A1c of 7.4% is typical for her.
Which one of the following is most likely to be reduced if this change is made?
A)
B)
C)
D)
E)
Quality of life
Hemoglobin A1c
Morbidity from all causes
Treatment costs
Her risk for hypoglycemia
211. A 52-year-old female sees you for the first time to establish care for her stable COPD. Since
losing her insurance 4 months ago she has been off all medications except for a short-acting
bronchodilator. She stopped smoking 2 years ago. She has a frequent, chronic cough and is
dyspneic when climbing stairs. Pulmonary function testing reveals an FEV1 of 55%. Her O2
saturation is 90% on room air.
In addition to the short-acting inhaled bronchodilator, recommended maintenance monotherapy
for this patient would be either an inhaled long-acting anticholinergic agent or an inhaled
A)
B)
C)
D)
corticosteroid
long-acting $-agonist
mast-cell stabilizer
antihistamine
212. A 62-year-old female presents to your office because of painless rectal bleeding. Over the past
several months she has occasionally noted blood on the toilet tissue and in her stool after bowel
movements. She also reports periodic anal itching and discharge, and protrusion of rectal tissue
during bowel movements that resolves spontaneously. She had a normal colonoscopy at age 50.
An abdominal examination is normal and a digital rectal examination is not painful and no mass
is palpated. However, her stool is positive for occult blood. Anoscopy demonstrates dilated
purplish-blue veins above the dentate line.
Which one of the following has the best evidence for reducing symptoms in this situation?
A)
B)
C)
D)
E)
Sitz baths
Fiber supplementation
Topical 1% hydrocortisone
Topical diltiazem (Cardizem)
Topical lidocaine cream (LidaMantle)
59
213. Which one of the following reflects the percentage of patients with a disease who have a positive
test for the disease in question?
A)
B)
C)
D)
E)
Likelihood ratio
Sensitivity
Specificity
Positive predictive value
Negative predictive value
214. Patients with which one of the following platelet disorders should be hospitalized and treated
emergently?
A)
B)
C)
D)
E)
Drug-induced thrombocytopenia
Congenital thrombocytopenia
Gestational thrombocytopenia
Thrombotic thrombocytopenic purpura
Thrombocytopenia associated with Lyme disease
215. A 12-year-old male presents to the office with a 2-day history of fever, myalgias, and
rhinorrhea. He is otherwise healthy, and you suspect influenza.
Which one of the following is the most appropriate next step in the management of this patient?
A)
B)
C)
D)
E)
Symptomatic treatment only

Diagnostic testing to confirm influenza infection
Oseltamivir (Tamiflu)
Amantadine (Symmetrel)
Antibiotics to prevent bacterial coinfection
216. A 40-year-old male with diabetes mellitus has the following fasting lipid profile:
Total cholesterol. . . . . . . . . . . . . . . . . . . . . . .
Triglycerides. . . . . . . . . . . . . . . . . . . . . . . . . .
Low-density lipoprotein (LDL).. . . . . . . . . . .
High-density lipoprotein (HDL). . . . . . . . . . .
204 mg/dL
223 mg/dL
112 mg/dL
42 mg/dL
The patient is currently on simvastatin (Zocor), 40 mg, for management of his dyslipidemia.
Which one of the following would be most appropriate?
A)
B)
C)
D)
Continuing the current medication regimen

Increasing the dosage of simvastatin
Switching to atorvastatin (Lipitor)
Adding gemfibrozil (Lopid)
60
217. An obese 32-year-old female has not conceived after more than 4 years of unprotected
intercourse. You perform an appropriate workup and diagnose polycystic ovary syndrome.
Of the following, the most effective management for her infertility would be
A)
B)
C)
D)
E)
spironolactone (Aldactone)
luteinizing hormone
basal body temperature monitoring
clomiphene (Clomid)
bromocriptine (Parlodel)
218. A patient has fatigue and joint pain and is concerned about the possibility of systemic lupus
erythematosus (SLE) after reading about this condition on the Internet. After taking a brief
history you decide that further evaluation is appropriate.
In addition to the history and physical findings, which one of the following laboratory findings
would most support the diagnosis of SLE?
A)
B)
C)
D)
E)
An abnormal C-reactive protein level

An erythrocyte sedimentation rate of 48 mm/hr
A positive antimicrosomal antibody test
A positive test for antiphospholipid antibodies
A positive test for rheumatoid factor
219. A 54-year-old female presents with a new onset of headaches. She rates her pain as severe and
reports that the headaches frequently awaken her in the early morning. The patient has a history
of hypertension and stage 4 chronic kidney disease. Her glomerular filtration rate is 24 mL/min.
You suspect the patient has a brain tumor and order gadolinium-enhanced MRI of the head.
Which one of the following is the patient at high risk for developing with the use of gadolinium
contrast?
A)
B)
C)
D)
E)
Nephrogenic systemic fibrosis

Anaphylaxis to contrast dye
Dermatomyositis
Focal seizures
Hypertensive crisis
220. You suspect mild Pneumocystis jiroveci pneumonia in a patient whose past medical history is
significant for HIV infection. He has not been compliant with his disease management and is not
on any medications.
What is the recommended treatment for this patients pneumonia?
A)
B)
C)
D)
Azithromycin (Zithromax)
Clindamycin (Cleocin)
Rifampin (Rifadin)
61
221. A 66-year-old white female presents to your office for a routine physical examination. Her
medical problems include hypertension, diabetes mellitus, hypercholesterolemia, and
gastroesophageal reflux, all controlled with medications. A bone density study is consistent with
osteopenia. She is taking a multivitamin and calcium carbonate, 1200 mg daily.
Which one of her medications would reduce her calcium carbonate absorption?
A)
B)
C)
D)
E)
Atorvastatin (Lipitor)
Hydrochlorothiazide
Omeprazole (Prilosec)
222. A 3-year-old male is brought to your office by his father for evaluation of 5 days of knee pain
and fever up to 101.6F. There was no known trauma preceding these symptoms. The pain and
fever respond well to oral acetaminophen but continue to recur 4 hours after each dose.
On examination the child appears well and is afebrile. He had a dose of acetaminophen about
2 hours ago. There are no signs of upper respiratory infection. Examination of the knee reveals
no redness, warmth, or swelling, and you see no other skin changes. He has full range of motion
of both the knee and hip without pain. You note tenderness to firm palpation of the proximal
tibia. He is able to bear weight and walk but refuses to jump due to anticipation of pain in his
knee. Plain films of the knee are normal.
The next step in the evaluation of this patient should include which one of the following?
A)
B)
C)
D)
E)
Close monitoring at home

A CBC, a C-reactive protein level, and an erythrocyte sedimentation rate
Ultrasonography of the hip
Knee joint aspiration
MRI of the knee
223. A 58-year-old female with diabetes mellitus complains of 2 years of right shoulder pain, which
is worse with activity. There has been no trauma. She tells you one of her friends had a similar
problem and was treated successfully with some sort of shock wave treatments.
Which one of the following diagnoses is most likely to be successfully treated with
extracorporeal shock wave therapy?
A)
B)
C)
D)
E)
Calcific tendinitis
Gout
Partial rotator cuff tear
Frozen shoulder
Hooked acromion
62
224. A 24-year-old female presents with a 10-day history of cough productive of green sputum. Her
past medical history is unremarkable and she is up to date on all immunizations. The patients
temperature is 37.2C (98.9F), blood pressure 127/76 mm Hg, pulse rate 89 beats/min,
respiratory rate 24/min, and O2 saturation 95% on room air. Her physical examination is
unremarkable except for a loose cough.
Which one of the following is best supported by evidence for management of this patients
condition?
A)
B)
C)
D)
E)
A macrolide antibiotic such as azithromycin (Zithromax)

An oral corticosteroid such as prednisone
An inhaled $-agonist such as albuterol (Proventil, Ventolin)
An expectorant such as guaifenesin
Reassurance that symptoms will likely resolve on their own within 3 weeks
225. You are managing a patient who is critically ill and is being placed on a ventilator. Management
should include which one of the following to reduce the occurrence of ventilator-associated
pneumonia?
A)
B)
C)
D)
E)
Continuous sedation
Nasotracheal intubation
Metoclopramide (Reglan) prophylaxis
Elevation of the head of the bed
Initiation of tube feedings within 24 hours
226. Which one of the following has good evidence of effectively improving borderline personality
disorder?
A)
B)
C)
D)
SSRIs
Second-generation antipsychotics
Omega-3 fatty acids
No currently available pharmacotherapy
227. A 32-year-old gravida 2 para 1 with long-standing untreated hypertension presents at 8 weeks
gestation for prenatal care. Her physical examination is normal except for a blood pressure of
156/114 mm Hg.
Which one of the following would be most appropriate as initial treatment?
A)
B)
C)
D)
E)
Labetalol (Trandate)
Losartan (Cozaar)
Metoprolol (Lopressor, Toprol-XL)
Nifedipine, immediate release (Procardia)
63
228. A 26-year-old male presents to the emergency department with a fever, and he appears acutely
ill. After a previously undocumented grade 3 murmur is detected on examination, a transthoracic
echocardiogram is ordered and reveals a 1.5-cm vegetation on the tricuspid valve.
Which one of the following is the most likely causative organism?
A)
B)
C)
D)
E)
Cardiobacterium hominis
Enterococcus faecalis
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus viridans
229. A neurologically intact 77-year-old female presents with severe low back pain following a fall
2 days ago that caused her to land on her buttocks. A radiograph of her lower spine shows a
compression fracture of L3 with a loss of about 50% of the vertebral body height.
Which one of the following is most appropriate at this point?
A)
B)
C)
D)
E)
Referral for kyphoplasty

Referral for vertebroplasty
Back bracing
Bed rest
Calcitonin-salmon (Miacalcin)
230. Which one of the following is the most common cause of death for African-American males in
the United States?
A)
B)
C)
D)
E)
Heart disease
Stroke
Cancer
Accidental injuries
Homicide
231. A 45-year-old female has an alkaline phosphatase level that is twice the normal level on a
chemistry panel ordered for evaluation of pruritus. Other tests of liver function are within
normal limits, including bilirubin and ALT (SGPT) levels, and repeat testing 2 months later
shows no change. A (-glutamyltransferase level is also significantly elevated, as is an
antimitochondrial antibody titer. Hepatic ultrasonography is unremarkable.
Which one of the following diagnoses is most likely?
A)
B)
C)
D)
E)
Primary biliary cirrhosis

Pagets disease of the bone
Sarcoidosis
Choledocholithiasis
Drug-induced cholestasis
64
232. A 19-year-old sexually active female comes to your office for a routine checkup. She is
generally healthy with no chronic conditions and does not smoke.
For this patient, screening for which one of the following is supported by the best evidence?
A)
B)
C)
D)
E)
Hypercholesterolemia
Cervical cancer
Chlamydia infection
HPV infection
Intimate partner violence
233. You see a 72-year-old male for follow-up after his third hospital admission for heart failure
within the past 4 months. He is a widower and lives alone, but he wants to talk about options for
in-home nursing care. He is accompanied today by his sister and his neighbor. This is the first
time you have seen the patient.
Which one of the following is the best choice regarding your interactions with the three of them?
A)
B)
C)
D)
Construct a family genogram to determine how to proceed with the patients care
Speak privately with the sister and neighbor to determine possible ulterior motives
Determine the reason each person is present today
Discuss the patients health information freely, as he willingly brought the neighbor and
sister along
Items 234240: Refer to Pictorial Atlas insert, center of book.

234. An 80-year-old male presents with a 4-hour history of generalized abdominal pain, vomiting,
and fever to 101F. On examination you note normal cardiovascular findings, generalized
moderate abdominal tenderness, absent bowel sounds, and a normal rectal examination.
Figure 1 shows a diagnostic abdominal film, which suggests
A)
B)
C)
D)
E)
a leaking abdominal aortic aneurysm

toxic megacolon
small bowel obstruction
diverticulitis
a perforated viscus
235. The EKG shown in Figure 2 reveals

A)
B)
C)
D)
E)
sinus tachycardia
paroxysmal atrial tachycardia
multifocal atrial tachycardia
atrial fibrillation
atrial flutter
65
236. A 37-year-old previously healthy male presents with a 1-week history of a painful swollen area
on his left eye, associated with redness (see Figure 3). He complains of dull aching in the eye
that radiates to his ipsilateral temple. He denies any ocular discharge or vision changes. His
visual acuity is normal.
Which one of the following is the most appropriate first step in managing this patients
condition?
A)
B)
C)
D)
E)
A topical mydriatic agent

A topical cycloplegic agent
A topical antibiotic
An oral NSAID
An oral antibiotic
237. The most likely diagnosis of the condition shown in the radiographs in Figure 4 is
A)
B)
C)
D)
E)
dislocation of the trapezium

dislocation of the scaphoid
dislocation of the lunate
fracture of the distal radius
fracture of the distal ulna
238. A 28-year-old white male alcoholic presents with a 4-week history of fever, malaise, cough,
sputum production, and weight loss. Twelve hours ago his cough increased and he noted frank
blood in his sputum, along with a foul taste. Sputum is obtained for routine culture. A chest
radiograph is shown in Figure 5.
Which one of the following diagnostic procedures should be performed prior to the initiation of
therapy?
A)
B)
C)
D)
A culture of expectorated sputum

An open lung biopsy
Immediate bronchoscopy
Transtracheal aspiration
239. A 58-year-old African-American male presents to the emergency department with a 6-hour
history of substernal pain. He has a previous history of hypertension. His blood pressure drops
to 60 mm Hg systolic after three sublingual nitroglycerin tablets. His EKG is shown in Figure
6.
In addition to nitrate side effects, which one of the following should be the first diagnostic
consideration?
A)
B)
C)
D)
E)
Right ventricular infarction

Pericarditis with tamponade
Papillary muscle rupture
Ventricular free wall rupture
Ventricular septal rupture
66
240. During a follow-up visit for a 72-year-old white female with type 2 diabetes mellitus, her
daughter asks you to treat the lesions shown in Figure 7. These lesions bother the patient and
she complains of itching, especially at night.
A)
B)
C)
D)
E)
chronic, reactive scabies infestation

eczema craquel (xerotic eczema)
neurodermatitis
necrobiosis lipoidica
lichen sclerosus
END OF BOOK
Please check the top of your answer sheet to insure that your
Program Number and ABFM Number are filled in correctly.
67
GENERAL INSTRUCTIONS
Each of the questions or incomplete statements in this book is followed by four or five answers or
completions. Select the ONE that is BEST in each case. You are advised to respond to all items. Even
though you may be in doubt about the correct answer, selecting the choice that you consider to be the best
will maximize the likelihood of your examination scores reflecting the breadth of your knowledge.
You may make preliminary notes or calculations in the test book, but credit is given only for answers
marked on the answer sheet. Only one choice should be marked for each response set. Double answers
are treated as wrong answers. After you have decided upon the best answer, completely fill in the circle
containing the corresponding letter on the answer sheet. Use only the pencil that was supplied with the
examination; do not use a pencil with hard lead or a ballpoint or felt-tipped pen. Make no stray marks on
your answer sheet. Do not fold or damage the answer sheet.
If you wish to change an answer, erase your first mark completely and mark your new choice. Take
care in marking your answers since SOME ITEMS HAVE FEWER THAN 5 OPTIONS.
This book contains a pictorial atlas for use with questions 234240. It may be removed from the book for
easier handling.
EXAMPLE
1. To which one of the following systems of the body does the heart belong?
A)
B)
C)
D)
E)
Digestive
Circulatory
Central nervous
Endocrine
Musculoskeletal
DO NOT BREAK THE SEAL UNTIL YOU ARE TOLD TO DO SO.

American Board of Family Medicine: TTT SAMPLE TTT

Diunggah oleh

Informasi Dokumen

Deskripsi Asli:

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

American Board of Family Medicine: TTT SAMPLE TTT

Diunggah oleh

Hak Cipta:

Format Tersedia

Name

American Board of Family Medicine

ttt SAMPLE ttt

Publication or reproduction in whole or in part is strictly prohibited.

Continue the current albuterol treatment but switch to a nebulizer

Using a specialized catheter coud instead of a standard catheter

A therapeutic trial of increased soluble fiber intake

a PPD skin test

Intranasal saline flushes

Clobetasol (Cormax, Temovate) 0.05% ointment

A 12-month-old who babbles but speaks no words

A level >6.0% is diagnostic of diabetes mellitus

Vocal cord dysfunction

Outpatient management with oral amoxicillin

the spouse or next of kin

Discontinuing the alendronate

122 mEq/L (N 135145)

The most likely diagnosis is

Intubation and tracheal suctioning below the vocal cords

Speak with the son and daughter-in-law privately

Bicarbonate and insulin

32. A previously normotensive 20-year-old primigravida is admitted to the hospital at 39 weeks

Reassurance and symptomatic treatment only

Diffuse inflammation of soft tissues

Maximum heart rate

Lipoprotein and apolipoprotein levels

Neurosurgical consultation for posterior cerebellar hematoma decompression

Toxicity to the proximal renal tubules

the history and examination

Intravenously administered varicella immune globulin

Increased murmur intensity with standing

Culture the wound

A long duration of cognitive problems

It increases glucagon levels

First-generation antihistamines such as diphenhydramine (Benadryl)

A complete blood profile

Hospitalization for ribavirin aerosol therapy

lactated Ringers solution

inflation of the eustachian tube by the Valsalva maneuver

It decreases the number of thromboembolic events

77. In symptomatic young children with Campylobacter enterocolitis that is refractory to

Order EMG of both upper extremities

Intermittent use of an inhaled long-acting $-agonist

She should be tested for IgA anti-tissue transglutaminase

A serum bilirubin level

Supportive treatment only

Shortened hospital stays

Reassurance that her symptoms are associated with a benign condition

Participating in a state-licensed adult day care program

Whole-body examination should be conducted by a primary care provider every 3 years

Ciclopirox topical (Penlac Nail Lacquer)

Discouraging the use of family members as interpreters

Prolonged grief reaction

A repeat Pap test in 46 months

A patient with end-stage COPD with a life expectancy of 6 months

Nebulized albuterol (Proventil, Ventolin)

Normal levels of both FSH and testosterone

The patient has diastolic heart failure

hydroxyapatite crystal disease

Intravenous tissue plasminogen activator (tPA)

A 12-hour-old term infant with a total bilirubin of 10 mg/dL

The new treatment has proven efficacy