► 1. A 63-year-old man comes in for a follow-up visit 2 weeks after being discharged from the hospital following urgent coronary artery bypass grafting (CABG) for atypical angina. The CABG was successful, and the recovery course was as expected, with only a transient shortness of breath on postoperative day 3. Now he complains of restlessness, especially at night when recumbent, and shortness of breath with even the slightest exertion. He prefers sitting upright in his recliner. He denies chest pain, cough, or fever. Chest examination reveals the trachea is midline, nearly absent breath sounds from the left lower lung, with E-to-A change (egophony), and dullness to percussion halfway up the back. The electrocardiogram (ECG) is unchanged from his last ECG 2 weeks ago, abdominal examination is normal, and there is no peripheral edema. What is the most probable explanation for these clinical findings?

1. Pulmonary embolus
2. Large pleural effusion
3. Pneumothorax
4. Pneumonia

► 2. A woman comes to your office with her 12-year-old daughter seeking information regarding the new human papillomavirus (HPV) vaccination. Which one of the following statements is not an American Cancer Society (ACS) recommendation regarding the administration of this vaccine?

1. Routine HPV vaccination is recommended for girls aged 11 or older
2. Women should continue to follow the ACS recommendations for cervical cancer screening, whether or not they have received the vaccine
3. HPV vaccination is not currently recommended for women older than 26 years or for males
4. HPV testing before initiating vaccination is recommended by the ACS

► 3. A 3-year-old girl with a history of eczema presents with a "bump" on her inner thigh. The bump appeared 1 week ago and has grown progressively larger; it is now red and painful. On examination, you note dry skin and evidence of excoriation on her antecubital fossa and knees. A 1-cm necrotic nodule, with cloudy drainage, is seen on the inner thigh. Around the nodule, the skin is red and tender. What should be your next step in management?

1. Intensive treatment of eczema with oral steroids
2. Culture of the drainage, followed by treatment with oral cephalexin (Keflex)
3. Treatment as a possible brown recluse spider bite
4. Empiric treatment with trimethoprim/sulfamethoxazole (TMP/SMX; Bactrim, Cotrim, Septra)

► 4. What is the most common cause of death in patients with Kawasaki disease?

1. Renal failure
2. Cardiac sequelae
3. Encephalitis and seizures
4. Hepatic failure

► 5. A 5-month-old infant is brought to your office with a 2-day history of cough and nasal congestion. Physical examination shows: temperature, 99°F; pulse, 120 beats/ min; respirations, 35 breaths/min. The heart rate and rhythm are regular, with no murmur. The breath sounds are coarse, with occasional bilateral mild expiratory wheezes heard. No nasal flaring or retractions are evident. A clear nasal discharge is noted. Tympanic membranes appear normal. What is the next best step in management?

1. Nebulizer treatment using levalbuterol HCl (Xopenex) 0.31 mg/3 mL
2. Obtain a blood culture and administer ceftriaxone intramuscularly
3. Assess oral intake and blood oxygenation level
4. Obtain respiratory syncytial virus (RSV) swab and chest radiographs

► 6. A 17-year-old adolescent girl comes to your office for a routine check-up before leaving for college. She has no significant health problems. She will be residing in the college dormitory. At her last visit 6 years ago, she completed her hepatitis B vaccination series and received her only varicella vaccination and second measles, mumps, and rubella (MMR) vaccine. Which of the following cluster of vaccinations should be offered at this point?

1. Diphtheria and tetanus toxoids with acellular pertussis (DTaP) vaccine, meningococcal conjugate vaccine, check varicella immunity, start HPV series
2. Tetanus, diphtheria, and pertussis (Tdap) vaccine; meningococcal conjugate vaccine; a second varicella vaccination; start HPV series
3. Tdap vaccine, meningococcal conjugate vaccine, check varicella immunity, start HPV series
4. DTaP vaccine, a third MMR vaccine, a second varicella vaccination, start HPV series

► 7. An 18-year-old woman is seen in the office for an obstetrics visit at 18 weeks gestation. She was diagnosed 3 years ago with moderate depression and was taking paroxetine (Paxil) 20 mg/day up until 6 months ago. She stopped it on her own when she was feeling better. Because of significant life changes related to her pregnancy, she says she "hasn't slept in weeks" and feels lethargic and apathetic. Questioning reveals no suicidal ideation. She thinks she may breastfeed after her baby is born, but she is not sure. Which of the following options would be the best treatment for her depression?

1. Recommend counseling, begin sertraline HCl (Zoloft) 50 mg/day, follow-up in 4 weeks
2. Recommend counseling, begin paroxetine 10 mg/ day, increase to 20 mg/day after 1 week, follow-up in 2 weeks
3. Recommend counseling, begin bupropion HCl extended-release (Wellbutrin XL) 150 mg/day, follow-up in 4 weeks
4. Recommend counseling, but do not prescribe medications at this time because of excess fetal risk

► 8. A 10-year-old girl presents to the office with a 2-day history of fever up to 102°F and a sore throat. She can swallow liquids, but anything else hurts too much. She has not had any cough or difficulty breathing but has had occasional headaches and mild, diffuse abdominal pain. You order a rapid antigen detection test, since you suspect streptococcal pharyngitis. The test result is positive. The patient has no known medication allergy. What should you prescribe?

1. Oral azithromycin (Zithromax) 10 mg/kg daily for 3 days
2. Oral clindamycin (Cleocin) 25 mg/kg daily in 3 divided doses each day for 10 days
3. Oral penicillin V (Veetids) 250 mg 3 times daily for 10 days
4. Oral cefaclor (Ceclor, Raniclor) 20 mg/kg in 2 divided doses daily for 5 days

► 9. A 44-year-old man has a pigmented lesion on his neck that his wife thinks should be removed, but it does not bother him, and he does not want it taken off. He is light-skinned, blond, and spends a lot of time gardening. He describes himself by saying, "I was always ‘moley.'" The lesion is variegated in color, 7 by 10 mm in diameter, flat, and asymmetric, with an irregular border. What should you do next?

1. Punch biopsy
2. Shave biopsy
3. Excisional biopsy
4. No biopsy, since the patient is unconcerned about it

► 10. A 91-year-old woman is diagnosed with community-acquired pneumonia (CAP). She has not taken any antibiotics for the past 3 months and has a true allergy to erythromycin. The patient weighs 72 kg, which is ideal for her height. Laboratory test results include a serum creatinine level of 1.5 mg/dL. The patient has no comorbidities. Which of the following drug regimens is the appropriate treatment for this patient?

1. Levofloxacin (Levaquin) 750 mg/day
2. Doxycycline (eg, Adoxa, Doryx, Periostat) 100 mg twice daily
3. Azithromycin 500 mg/day plus amoxicillin/clavulanate potassium 875 mg twice daily
4. Amikacin sulfate (Amikin) 150 mg every 8 hours

► 11. A 68-year-old woman with hypercholesterolemia that is controlled by diet complains of several weeks of diffuse stiffness and pain, particularly around her shoulders and hips. She is slow in getting out of bed. Examination of her joints is unremarkable, and she appears to have mild reduction in strength. Based on this clinical picture, what is the most useful test to order at this point?

1. Creatine phosphokinase
2. Erythrocyte sedimentation rate (ESR)
3. Radiographs of the shoulders and hips
4. Urine myoglobin

► 12. A right adnexal mass is found during the pelvic examination of a 60-year-old woman. Transvaginal ultrasonography reveals a complex ovarian cyst, with both solid and cystic components. Which one of the following statements is correct?

1. If the cancer antigen (CA)-125 blood test is normal, the physician can be reassured that this is a benign cyst
2. Since the mass is partially cystic, it can be followed by transvaginal sonograms every 3 months
3. A percutaneous biopsy of the solid component of the mass is indicated
4. The mass requires surgical excision for definitive diagnosis

► 13. A 41-year-old woman complains of "bleeding too much" from her vagina. She reports a history of menstrual cycles lasting between 19 and 23 days, with a period length of 8 days. Sometimes, she must change sanitary napkins every hour, and occasionally she needs to go home from work to change her clothes. She also has some light, apparently random, bleeding between periods. What would be the best course of management?

1. Reassure her that she is probably perimenopausal, and that it is normal to have menstrual changes at this time. Prescribe birth control pills to regulate her bleeding
2. Perform pelvic ultrasound to look for fibroids and evaluate the endometrial stripe
3. Check thyroid-stimulating hormone (TSH) level, complete blood cell (CBC) count, and follicle-stimulating hormone (FSH) level to evaluate for thyroid dysfunction, anemia, and confirm perimenopause
4. Rule out pregnancy, perform endometrial biopsy

► 14. A 24-year-old male swimmer presents to the office saying he developed otitis externa 1 week ago. He stopped swimming and tried using 2% acetic acid otic solution, which did not relieve his symptoms. Examination of the external canal reveals significant erythema and moderate exudate. What is the best treatment you should prescribe at this time?

1. Hydrocortisone otic drops
2. Initiate amoxicillin/clavulanate potassium therapy
3. The patient should complete a 14-day course of otic acetic acid drops
4. Initiate otic fluoroquinolone plus hydrocortisone drops

► 15. A 54-year-old man with a history of myocardial infarction presents for a follow-up visit after being hospitalized 1 month ago. His symptoms at admission were shortness of breath, orthopnea, and leg swelling. Examination revealed bibasilar crackles, evidence of pulmonary edema on chest radiographs, and an elevated brain natriuretic peptide level. A parenteral diuretic improved his symptoms, producing higher urine output. Echocardiography revealed an ejection fraction of 30%. He was discharged home with prescriptions for low-dose furosemide (Lasix) and lisinopril (Prinivil, Zestril).

Today he is no longer symptomatic. His blood pressure (BP) is 135/90 mm Hg and his pulse, 90 beats/min. He has lost 5 lb since he left the hospital. Examination reveals no abnormal lung sounds or peripheral edema. The serum creatinine level has increased from 1.0 to 1.2 mg/dL. Which of the following interventions would be the most appropriate approach?

1. No change in therapy, but follow-up closely
2. Increase the dose of lisinopril
3. Add low-dose metoprolol (Lopressor)
4. Add digoxin (Digitek, Lanoxin)

► 16. A 56-year-old man presents with a 3-day history of increasing shortness of breath, cough, and sputum production. He has not had fever or chills. He has been using his beta₂-agonist metered-dose inhaler every 2 to 3 hours. He quit smoking 2 years ago. Pulse oximetry reveals an oxygen saturation of 89%. He is audibly wheezing, using accessory muscles of respiration. He is also tachypneic. You diagnose an exacerbation of chronic obstructive pulmonary disease (COPD). All the following statements are true, except:

1. Supplemental oxygen should be used to correct the hypoxia
2. Corticosteroids can reduce the risk of treatment failure
3. Antibiotics should be withheld, since the patient has been afebrile
4. Inhaled beta₂-agonists or anticholinergics are a mainstay of treatment

► 17.The positive likelihood ratio of a test is defined as the ratio of A/B, where A is the proportion of patients who truly have the disease and a positive test result, and B is the proportion of patients without the disease who still have a positive test. How is this expressed in standard statistical terminology?

1. Sensitivity/specificity
2. Positive predictive value/negative predictive value
3. Specificity/positive predictive value
4. Sensitivity/(1 minus specificity)

► 18. A 43-year-old woman presents with an asymptomatic vaginal discharge. She is scheduled for a hysterectomy the following week because of the presence of large fibroids and heavy bleeding. Physical examination shows a thin, white discharge coating the vaginal walls. The discharge has a "fishy" odor, and clue cells are identified on the wet mount test. Which of the following statements is true?

1. Treatment before her hysterectomy will decrease the risk of infectious complications
2. One of the recommended treatments is a single dose of metronidazole (Flagyl) 2 g
3. Treatment of the patient's partner is indicated to prevent recurrent infection
4. Restoring normal flora using Lactobacillus suppositories is effective treatment for her condition

► 19. A 31-year-old male recreational basketball player suffered an inversion injury to his ankle. When initially seen shortly after the injury, he was unable to fully bear weight on the affected leg and had point tenderness over the tip of his lateral malleolus. Swelling was noted over the lateral aspect of his ankle. Radiographs obtained at the time of injury showed no fracture or widening of the joint space. The ankle was immobilized, ice was applied, and he was told to use crutches and come back in 3 days.

At this follow-up visit, examination reveals swelling and ecchymosis over the lateral ankle. The anterior drawer sign is weakly positive when compared with the uninjured ankle. He is now able to partially bear weight on the injured ankle and has discarded his crutches. What would you recommend next?

1. Apply heat to the ankle
2. Immobilize the ankle in a walking cast for 6 weeks
3. Begin range-of-motion and strengthening ankle exercises
4. Repeat ankle radiographs

► 20. A 25-year-old woman presents to your office with a 2-day history of a flulike illness, with fever, headache, myalgias, nausea, and chills. There is currently a flulike illness in the community, and she reports several sick contacts. Physical examination shows an ill-appearing young woman with mild splenomegaly. CBC count and chemistry panel screening demonstrate mild anemia (hemoglobin, 10.9 g/dL) and hypoglycemia (glucose, 54 mg/dL). Further questioning reveals that she returned home to the United States 6 weeks ago after serving 2 years in Mozambique with the Peace Corps. During those 2 years she lived in a rural village and had been exposed to many biting insects. She insists that she took mefloquine HCl (Lariam) weekly for malaria prevention as directed, before and during her trip, as well as for the first 4 weeks after returning from Africa. What is your next step in management?

1. Reassure her that she has a flulike illness and ask her to return in 3 days if she is not feeling better
2. Check titers for tick-borne diseases (Rocky Mountain spotted fever and ehrlichiosis)
3. Check titers for Chagas' disease
4. Obtain thin and thick blood smears for malaria

► 21. The number needed to treat (NNT) using a given therapeutic intervention can be calculated as:

1. 1/Absolute risk reduction
2. 1/Relative risk reduction
3. Positive predictive value minus negative predictive value
4. 1/(sensitivity minus specificity)