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1. A 16-year-old girl comes from a very religious family and denies any sexual activity. She has severe acne unresponsive to previous treatment of conventional therapy. Which of the following laboratory studies should be performed by prior to prescribing isotretinoin?
A) Lipid profile
B) Liver function studies
C) Measurement of serum urea nitrogen (BUN)
D) Complete blood count
E) Measurement of urine b-hCG

STRATEGY: Understanding what's really being asked. You are dealing with a young woman who may be sexually active, therefore, it is always necessary to check for pregnancy before prescribing a drug. Knowing this, you could correctly answer this item (E) without knowing much if anything about the specific properties of isotretinoin.

2. A 30-year-old woman with no significant past medical history presents with serosanguinous discharge from one of her breasts. She is not lactating and has no family history of breast disease. Physical exam reveals a moderate amount of serosanguinous discharge expressed from the left nipple. Cytological exam of the fluid is negative. What is the most appropriate next step in management?
A) Advise the patient to return in 6 months for re-evaluation
B) Obtain a mammogram
C) Perform a chest x-ray
D) Perform an excisional biopsy of the retroareolar area
E) Perform a needle biopsy of the retroareolar area

STRATEGY: This item illustrates one of the common themes in clinical items--understanding the proper sequence of lab ordering. Here, while a mammogram may not provide definitive diagnostic information about the patient's problem, it is standard procedure to order a mammogram before ordering more invasive or expensive tests.

3. A 4-year old boy is admitted with respiratory difficulty. He has had several previous admissions for pneumonia. History is significant for the failure to pass meconium at birth. Temp is 101.1 F, respiration rate is 35. Physical exam reveals a thin, malnourished boy < 5th percentile for height and weight. Rales heard over the left lower lobe and percussion over the region is dull. Sputum culture grows Pseudomonas aeruginosa. Which test would confirm the diagnosis?
A) Bronchoscopy
B) Chloride sweat test
C) CT scan of the thorax
D D-xylose absorption test
E) Pulmonary function tests

STRATEGY: This item illustrates the USMLE policy of portraying diseases in their most classical presentation. The boy's history and symptoms are textbook indications of CF, so the answer is B. Notice also, however, that as with many other clinical items, one doesn't receive direct credit for knowing what the boy has, but for reaching that conclusion THEN using that knowledge to answer what's actually being asked, which is what test would clinch that diagnosis.

4. An 8-year-old boy is seen for a routine check-up. His vaccinations are current and he has been healthy. The child is at the 5th percentile for height and at the 20th percentile for weight. His thumbs are disproportionately small compared to his other digits. There are several round, smooth, flat, light-brown areas ranging in size from 3 to 5 cm on his trunk and extremities. For which of the following genetic disorders is the child most likely at risk?
A) Down's syndrome
B) Fanconi's syndrome
C) Fetal alcohol syndrome
D) Trisomy 18
C) Cri du chat

STRATEGY: If you have even the most general knowledge of the symptoms of Down's, Fetal alcohol, Trisomy 18 and Cri du chat, then it is obvious that these severe syndromes would have been evident and diagnosed long before this child reached the age of 8. By exclusion, then, if not through knowledge of Fanconi's syndrome, this would be the best answer (B)

5. A 62-year old man is complaining of fatigue of 4 months duration. He was recently seen by another physician for nephrolithiasis. He takes no medications and is otherwise healthy, except for mild hypertension controlled with diet. CBC is normal. Which of the following lab values would suggest primary hyperparathyroidism?
A) Decreased calcium, decreased phosphorus, and increased parathyroid hormone
B) Decreased calcium, increased phosphorus, and increased parathyroid hormone
C) Increased calcium, decreased phosphorus, and increased parathyroid hormone
D) Increased calcium, increased phosphorus, and increased parathyroid hormone
E) Increased calcium, decreased phosphorus, and decreased parathyroid hormone

STRATEGY: This item illustrates how even on Step 2 or Step 3, you could be asked basic science information. This item also shows how a straightforward endocrine physiology question (The final sentence in the stem), can be made to "look" clinical but attaching a vignette introduction. But none of that information is necessary to answer the question. The correct answer is C.

6. A 52-year old man with a ten year history of hypertension complains of abdominal and back pain for the past 6 months, a 10 pound weight loss and greasy, foul-smelling stools. He smokes 2 packs of cigarettes and drinks a pint of whiskey/day. On physical exam, he is afebrile with mild epigastric tenderness but no guarding, rigidity, or distension. Bowels sounds are present and rectal exam is normal. Hematocrit: 48%, sodium: 141 mEq/L, potassium: 3.9 ,mEq/L, glucose: 148 mg/dl, ALT: 16, AST: 24, albumin: 4.7 g/dl, prothrombin time: 11 seconds. Chest x-ray is normal, abdominal plain film shows pancreatic calcifications. Which of the following is most likely responsible for his weight loss?
A) Alcoholic hepatitis
B) Duodenal ulcer
C) Gastric ulcer
D) Pancreatic insufficiency
E) thiamin deficiency

STRATEGY: People who have really struggled to do well on multiple choice exams before often carry around some emotion about having to take these kinds of tests. Sometimes they feel items are designed to trick them into choosing wrong answers. Here, such experiences would lead to avoiding answer D because the stem lists "pancreatic calcifications," so the suspicious test-taker reasons that this couldn't possibly be the correct answer and must be there to lure them. They choose another answer, and get the item wrong. Notice also how the true distractors (wrong answers) each agree with some part of the findings or history clues--the patient drinks heavily, so A and E relate to this fact. The patient has abdominal symptoms, so B and C relate to those symptoms. In a well-written test, nearly every distractor fits at least part of the stem information, but only the correct answer fits ALL the clues given in the stem.

7. A neonate has a flat, dark-pigmented area of skin over the sacral region.
The area is roughly oval, has a clearly defined border, and differs from
surrounding skin only in color. Which of the following is the most
likely diagnosis?
A) Diastematomyelia
B) Mongolian spot
C) Nevus flammeus
D) Pilonidal cyst
E) Spina bifida

STRATEGY: Using reasoning strategies doesn't ever guarantee a correct answer. However, they allow you to extrapolate from what you recall to the specifics of a given question. Here, if you didn't know the answer (B), you could still probably eliminate E as the findings would be more drastic for spina bifida. You might also reason that it wouldn't be a cyst as the stem states that the area differs only in color and with a cyst, you would expect there to be a palpable mass as well. Knowing some word structure might help you eliminate C because flammeus suggests either redness or heat, which aren't present in the stem clues. This would leave you with a guess between A or B and B is correct. Over a long test, using these techniques yields more correct guesses and a higher score.

8. A 55-year-old woman with no significant medical history complains
of difficulty in keeping her balance. Cranial nerve, motor and mental
status exam are all within normal limits. There is diminished
proprioception in the joints of all 4 extremities, with a greater deficit
on the right side. She is able to stand with a narrow base with her arms
extended and eyes open. However, when she stands in a similar manner with
her eyes closed, she immediately begins to fall. Which of the following is
the most likely site of the lesion?
A) Cerebellum
B) Cerebral cortex
C) Peripheral nerve
D) Posterior column
E) Pons

STRATEGY: I used a combination of strategies to figure out this item, even though I've never studied neuroanatomy. This is a problem with balance, so for that reason, it isn't likely to be C because peripheral nerves aren't CNS. It also isn't likely to be B, since the cortex functions involve higher order thought and this is a balance or coordination, not a thought disrupting problem. The correct answer is D, and I chose it because of a mnemonic I heard from a med student many years ago, that the body, like a temple, stands because of its "columns."

9. A 20-year-old football player is sent to the campus health clinic by his coach after
complaining of neck pain following a hard tackle during
practice. He has a normal neurological exam, but his posterior neck is
tender. Which of the following would be the best initial step in management?
A) Administer non-steroidal anti inflammatory agents
B) Apply a hard-cervical collar and immobilize his spinal cord
C) Apply a soft cervical collar and order bed rest
D) Send him to the hospital for cervical spine x-ray
E) Apply ice directly to the affected area

STRATEGY: This item illustrates the theme of recognizing potentially serious findings and dealing with them first. The test-writer has hidden the seriousness, though, by making the situation a campus clinic rather than an emergency room. Use a systematic decision-making process by asking yourself first, What do I know? In this case, do I really know the extent of the young man's injuries here? No? Then it is wisest to act cautiously by applying a hard collar until the injuries can be further explored at a hospital (answer B).

10. A 52-year-old physician whom you know socially has taken secobarbital, 2 g daily, for 7 years despite several attempts to stop using the drug. He has been abstinent from alcohol for 10 years. The patient weighs 72 kg (158 lb). Exam shows no abnormalities. Which of the following is the most appropriate next course of action?
A) Detoxification as an outpatient and referral for group treatment
B) Discontinuation of secobarbital and prescription for a benzodiazepine
in equivalent doses
C) Hospitalization for detoxification
D) Psychotherapy
E) Suggest that he gradually reduce the dosage of secobarbital

STRATEGY: Watch out for the tactic displayed in this question. The stem clearly states that this man has a history of addictive behavior (alcohol, drugs) which he has not successfully been able to deal with on his own. But by making the patient a fellow physician the test-writer is testing the strength of your convictions--are you willing to hospitalize him (correct answer is C) even though this would be difficult for you. Since the patient has responsibility for the well-being of others, actually, it is even more important to do the tough, but appropriate, right thing so that his addiction won't affect patients welfare.

11. A 65-year-old man was diagnosed with carcinoma of the colon 7 months ago.
An operation was successful, but he continues to receive adjunctive
chemotherapy with methotrexate. Over the past several months, he has
developed insomnia, fatigue, crying spells, feelings of guilt and anhedonia.
Which of the following is the most likely cause of this patient's behavior?
A) Normal adjustment
B) Metastatic cancer
C) Reaction to methotrexate
D) Personality disorder
E) Major depressive disorder

STRATEGY: If you can recognize that his depression developed quite a while after he was put on the drug, then it is logical to rule out answer C. Since colon cancer doesn't easily spread to the brain, it isn't B either. So this is a psychiatry question and the correct answer is likely to be either D or E. His symptoms seems more those of depression than personality disorder, so this would be the best guess, and is the correct answer.

12. A 4-year-old boy with a displaced supracondylar fracture of the humerus without neurovascular complication is placed in skeletal traction. Six hours later, he has severe pain in the forearm and increased pain on passive extension of the wrist and fingers.
Which of the following is the most appropriate next step in management?
A) Increased weight on the traction apparatus
B) Administration of analgesic medication
C) Exploration of the fracture and fasciotomy of the flexor
compartment of the forearm
D) Closed reduction with the patient under anesthesia
E) Open reduction and internal fixation of the fracture

STRATEGY: Once again, this item can be worked through with a systematic, logical series of questions. Ask yourself, What do I actually know about the boy's injuries. If the treatment thus far was appropriate but now the symptoms are worsening, what do I need at this point? More information (about the true nature of the fracture damage), so therefore, look for an answer that will give you more information. Only C will do this, and is the correct response.

13. A 16-year-old boy is brought to the emergency room after the sudden onset of severe abdominal and scrotal pain. There is severe tenderness in the region of the inguinal canal on the right; the right side of the scrotum is empty. Urinalysis is normal. Which of the following is the most effective management?
A) Administration of analgesics and observation
B) Administration of gonadotropic hormones
C) Insertion of a nasogastric tube
D) Cytoscopy
E) Immediate operation

STRATEGY: Because I have only general and sketchy medical knowledge, I rely very much on the information given in question stems and on logical reasoning from basic principles and concepts in biology. In this item, using the concepts of acute and chronic, I can reason that the "sudden onset" of these symptoms means something has recently changed to create the problem. So it's logical that some action will need to be taken. This rules out A and B since neither immediately resolves anything. It's difficult to see how inserting a nasogastric tube will help manage this patient's problem, so I tossed out C as well. D would give more information about what cells are lurking in the affected area, but it sounds as though the scrotum's contents have gone elsewhere, so I would reason that it would take an operation, probably, to put the contents back in place. Correct answer is E. The only choice that offers immediate restorative action for an acute condition.

14. A convenience store clerk is hit in the face multiple times with a baseball bat
during a robbery. On arrival in the ER, the patient is cyanotic and stridorous, with copious amounts of blood in his mouth. He has a markedly displaced mandible and midface, and clear fluid is draining from his nose. Two attempts at orotracheal intubation
fail. Which of the following is the most appropriate next step in management?
A) Administer a high concentration of oxygen delivered through a tight-fitting
face mask
B) Administration of humidified oxygen and bronchodilator treatment
C) Intubate with a fiber-optic scope
D) Perform an emergency cricothyroidotomy
E) Perform a nasotracheal intubation

STRATEGY: Visualization of stem information is critically important to getting more items correct. If you picture what this patient's face must look like, and what's already been tried, then choices A , B and C and even E all seem unlikely to be possible. So the only way to establish an airway with any certainty of success, thus keeping your patient alive for his other injuries to be treated, is choice D, which is the correct answer.

15. A 27-year-old male is brought to the ER by paramedics after being thrown from the back of a pickup truck at high speed. He received 2 L of IV fluid in transit. His pulse on arrival is 120 and BP is 60/40. He is awake and without focal neurological signs. He has a distended tender abdomen and a stable pelvis, with no deformities of the lower extremities. Portable chest x-ray is normal. Which of the following is the most appropriate next step in management?
A) CT scan of the abdomen and head
B) Diagnostic peritoneal lavage and fluid administration while awaiting
cell counts on lavage fluid
C) Dopamine infusion to improve blood pressure followed by observation
D) Exploratory laparotomy and administration of blood products
E) Spine films to rule out vertebral fracture

STRATEGY: If you visualize this patient's injuries, it should be rather obvious that he is bleeding into the abdominal area because his BP is still low despite IV and the abdomen is tender and distended. This must be dealt with ASAP or a rupture could kill him, so it isn't a time for scheduling diagnostic tests (rules out A and E). C is clearly wrong as it won't stop his bleeding to wait and observe. So I would guess either B or D but would probably pick D since B also mentions waiting for cell counts. The correct answer is D.

16. A 2-year-old boy with several episodes of rectal bleeding is brought to the clinic by his mother. Evaluation with a technetium-99m perfusion scan reveals a 3-cm ileal out-pouching located 60 cm from the ileocecal valve. This structure most likely contains which of the following types of ectopic tissue?
A. Duodenal
B. Esophageal
C. Gastric
D. Hepatic
E. Jejunal

STRATEGY: A vital clue here is the fact that the boy has bleeding. This suggests that tissue has been damaged, rupturing blood vessels in the area. It's logical that gastric tissue (Choice C) is correct since gastric tissue would produce acid, eroding the surrounding area and resulting in bleeding at some point in the process. The correct answer is, in fact, C

17. In the two oxygen-hemoglobin dissociation curves shown below, normal findings are represented by the solid line, and abnormal findings are represented by the dotted line, indicating a situation in which the curve has been shifted. Shifts such as this can occur under which of the following circumstances?
A. Carbon monoxide poisoning
B. Decreased pH
C. Increased 2,3-diphosphoglycerate (2,3-DPG)
D. Increased pCO2
E. Increased temperature

STRATEGY: If you recall that shifting left causes oxygen to load, while a right shift causes oxygen to unload, then you can figure out the answer to this item. Look at B-E, all of which occur when a person exercises. With exercise, more oxygen is needed, so you would want a right shift. So the factor causing a left shift must be Choice A, carbon monoxide. Choice A is the correct answer.

18. A 33-year-old man complains that recently his chest hurts when he eats, especially when he eats meat. An x-ray shows a dilated esophagus and achalasia is suspected. Esophageal manometry is used to confirm the diagnosis. Swallowing induced relaxation is most likely to have been reduced at which anatomic location in this patient?
A. Lower esophageal sphincter
B. Lower esophagus
C. Middle esophagus
D. Pharynx
E. Upper esophageal sphincter
F. Upper esophagus

STRATEGY: The problem here seems to be that food gets into the upper GI tract, but is blocked in such a way that it is trapped in the esophagus. Picturing this, it seems logical that the lower esophageal sphincter is the problem as this would allow food to get into the esophagus but then trap it there if the lower esophageal sphincter wouldn't allow it to move on out. The correct answer is A. Picturing what's happening in a clear, concrete way is often a big help in answering multiple choice questions.

19. A 60-year-old man with heart disease is brought to the ER by paramedics because he is short of breath. Cardiovascular evaluation reveals a resting O2 consumption of 200 mL/min, a peripheral arterial O2 content of 0.20 mLO2/mL of blood, and a mixed venous O2 content of 0.15 O2/mL of blood. What is his cardiac output?
A. 2.5 L/min
B. 4 L/min
C. 10 L/min
D. 25 L/min
E. 100 L/min

STRATEGY: You already know this elderly man has heart disease, making his heart less efficient. Even if you can't recall the formula for calculating cardiac output, if a normal heart pumps about 5 L/min, then his output is likely to be decreased. So choices A or B are the most likely to be correct. The correct answer is B. Choices D and E would both mean that his damaged heart pumps more blood than normal, so they can't be correct.

20. As part of an exercise tolerance test, a 27-year-old healthy male has just jogged 2 miles on a treadmill. As a result, his mean arterial blood pressure has increased (95 to 130mmHg). Similarly, his cardiac output has doubled. Which of the following would most accurately describe what has happened to his total peripheral resistance?
A. It is one-half the resistance at rest
B. It is the same as the resistance at rest
C. It is twice as great as the resistance at rest
D. It is between 50% and 100% of the resistance at rest
E. It is between 100% and 150% of the resistance at rest

STRATEGY: Think like biological engineer creating the body - you would want the resistance to that increased blood flow to go down, to supply those hard working muscles, right? So this narrows it to choices A or D. Second tactic is to select D, because it's consistent with the fact that physiologic variables normally fluctuate with a range, so D is a better choice than A.

21. A patient in chronic renal failure has 5 relatives as potential donors. A one-way mixed lymphocyte reaction is performed, isolating lymphocytes from each relative and treating the cells with mitomycin-C to prevent DNA replication. The cells are incubated with the patient's untreated lymphocytes in the presence of titrated thymidine for 2 days. The DNA is isolated and the radioactive counts (CPM) are measured. Based on the assays, who is the best potential donor?
A. Father (lymphocytes 24,000 CPM)
B. Mother (lymphocytes 18,000 CPM)
C. Grandfather (lymphocytes 30,000 CPM)
D. Brother (lymphocytes 1,500 CPM)
E. Sister (lymphocytes 6,000 CPM)

STRATEGY: Item writers love to make a question look complex. Boils down to knowing that rejection is the big worry in transplants. So when mix cells, would want smallest number as indicates least interaction between the cell types.

22. A 20-year-old pregnant woman (para 1, gravida 0) presents in your office at 23 weeks gestation complaining of polyuria. Concerned about gestational diabetes, you order a glucose tolerance test. The following values are obtained:
Time Glucose (mg/dl) Normal (mg/dl
0 115 <105
1 hour 180 <175
2 hours 144 <145
3 hours 133 <140
The polyuria this patient is experiencing is most likely due to

A. The baseline value
B. The 3 hour value
C. The average of all values
D. Increased GFR and plasma volume

STRATEGY: This is an example of what I call the myopia trap because it gets you to focus too closely on the data so that you will lose sight of the big picture. Answer is D because it's the only choice that relates to her pregnancy.

23. In recent years, most HMOs have instituted plans involving patient co-payments. A local HMO has just raised co-payments by $15 in an attempt to reduce costs. Studies have shown that the effect of increasing patient co-payments in the US has been to
A. Decrease utilization in direct proportion to the required co-payment
B. Decrease utilization of unnecessary services only
C. Decrease use of tertiary services but increase use of primary services
D. Increase utilization in a non-linear fashion
E. Increase utilization in a linear fashion

STRATEGY: This is a good bait and switch example. The item writer is hoping that you will take the medical profession's viewpoint. But actually, this is a question about the impact, not the intent of instituting co-payments. So the correct answer is A, not B.

24. Malpractice insurance rates have continued to soar in recent years, adding to the overall cost of health care in the US. It is recommended that physicians become more knowledgeable about this issue in order to exert peer influence on their medical colleagues. In this context, which of the following cases represents the best grounds for malpractice?
A. A 19-year-old model undergoes breast augmentation and is left with breasts of unequal size
B. A 27-year-old man dies from penicillin allergy after he receives a shot for strep throat in the emergency room
C. A 51-year-old woman is diagnosed with breast cancer metastatic to her lungs. One month earlier, her mammogram was read as normal
D. A 55-year-old businessman suffers peritonitis when operative sponges were not removed during his appendectomy
E. A 77-year-old woman falls out of bed in the hospital and suffers a hip fracture

STRATEGY: This is another example of the bait and switch in the point of view again. The trap is to evaluate choices from the medical viewpoint when the question is actually asked from a malpractice attorney's viewpoint. So D is obvious answer because only in D would there be concrete physical evidence to show a jury (the sponge). This makes it the easiest case to prove legally.

25. A 13-year-old boy with poor impulse control is brought to you for an evaluation. During the interview, the boy expresses concern at his ability to control his temper, but he subsequently becomes enraged. With clenched fists and in a trembling voice, he tells you to "Stop bugging me or I'll hit you!" Which of the following would be your best response?
A. "You shouldn't ever hit people."
B. "Do you think you are really going to hit me?"
C. "It must be frightening to be that angry."
D. "I don't believe that you really want to hit me."
E. Sit quietly, watching the patient attentively, but doing nothing.

STRATEGY: Only choice C shows empathy with the boy and therefore, by not judging his behavior, the doctor encourages him to confide and doesn't provoke him into further negative emotions. Choice C is correct. On questions dealing with communication skills, always search for the answer that is most likely to lead to the patient saying more, or the most open-ended, non-judgmental statement on the part of the physician. Similarly, if the question deals with an ethical situation, search for the choice that is most reverent or consistent with the ethical principle involved in the situation, such as patient confidentiality, patient autonomy, etc.

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