This is the November 2017 version of the Free 137. Note that this is not the current version - NBME updated the Free 137 in December 2023. If you are actively studying for Step 3, use the December 2023 version instead. This older version can still be useful as additional practice material.
Answers & Explanations
Below are the answers and explanations for all 137 questions, organized by block.
Block 1: Questions 1-38
Question 1
Answer: A - Age
Age is the most significant risk factor for temporal arteritis, which typically affects patients over 50 and presents with morning shoulder stiffness, fatigue, and headache. The markedly elevated ESR (88) and elevated inflammatory markers confirm this diagnosis.
Why the other choices are wrong:
B. Gender - Gender is not a significant risk factor for temporal arteritis; both men and women over 50 are equally susceptible.C. History of osteoarthritis - While osteoarthritis causes stiffness, it doesn't explain the elevated ESR and systemic inflammation of giant cell arteritis.
D. Previous occupation - Occupational history is unrelated to temporal arteritis; the disease results from age-related vascular inflammation.
E. Use of pravastatin - Pravastatin is not a risk factor; the picture of elevated inflammatory markers indicates vasculitis, not myopathy.
Question 2
Answer: D - Rhinovirus
Rhinovirus causes the classic upper respiratory infection presentation with follicular lymphoid hyperplasia, sore throat, and cough. It is the most common viral cause of the common cold with these specific pharyngeal findings.
Why the other choices are wrong:
A. Allergic rhinitis - Allergic rhinitis can cause hyperplasia, but the acute fever and systemic symptoms indicate viral etiology.B. Epstein - EBV causes exudative pharyngitis with severe symptoms; this mild upper respiratory presentation is classic for rhinovirus.
C. Mycoplasma pneumoniae - Mycoplasma causes atypical pneumonia with prominent respiratory findings; this patient's presentation is consistent with rhinovirus.
E. Streptococcus pyogenes - Strep causes acute pharyngitis but lacks the prominent cough and viral prodrome of rhinovirus infection.
Question 3
Answer: E - Vascular dementia
Vascular dementia results from the patient's history of two prior strokes, current uncontrolled hypertension (196/112), cognitive decline, and focal neurological deficits. This pattern of multi-infarct disease is the most likely diagnosis given her stroke history.
Why the other choices are wrong:
A. Alzheimer disease - Alzheimer presents with gradual decline, not the acute stepwise deterioration and multiple infarcts on imaging seen here.B. Amyotrophic lateral sclerosis - ALS causes motor degeneration with weakness, not dementia; this patient's decline follows documented strokes.
C. Cortical basal ganglionic degeneration - CBGD presents with asymmetric rigidity and alien limb, not stepwise decline after documented strokes.
D. Neurosyphilis - Neurosyphilis requires positive serology and presents differently; this patient has clear ischemic infarcts on imaging.
Question 4
Answer: A - Avascular necrosis of the femoral head
Avascular necrosis of the femoral head is a well-recognized complication of prolonged glucocorticoid therapy and presents with hip pain that worsens with weight-bearing. Six months of glucocorticoids for sarcoidosis is sufficient to cause this complication.
Why the other choices are wrong:
B. Herniated nucleus pulposus - HNP causes lower back pain with radiculopathy, not acute hip pain after prolonged steroid therapy.C. Narrowing of the hip joint - Joint narrowing develops gradually; this acute presentation after 6 months of steroids indicates AVN.
D. Osteoporosis - Steroids cause osteoporosis which is asymptomatic; acute hip pain indicates bone necrosis from ischemia.
E. Stress fracture of the acetabulum - Stress fractures follow repetitive impact; AVN presents with insidious weight-bearing hip pain and motion loss.
Question 5
Answer: C - Cholangitis
Cholangitis with Charcot triad (fever, right upper quadrant pain, and altered mental status), elevated bilirubin, and dilated bile duct from choledocholithiasis requires urgent diagnosis and broad-spectrum antibiotics. Elevated amylase indicates possible pancreatic involvement.
Why the other choices are wrong:
A. Acute cholecystitis - Acute cholecystitis lacks fever, chills, and mental status changes that indicate bacterial infection of ducts.B. Acute pancreatitis - Acute pancreatitis has markedly elevated amylase; the dilated bile duct with sepsis indicates ascending cholangitis.
D. Hepatitis - Viral hepatitis lacks the acute sepsis, fever, and altered mental status of biliary obstruction with infection.
E. Liver abscess - Liver abscess follows portal bacteremia; acute onset with biliary obstruction is classic for cholangitis.
Question 6
Answer: E - Transient tachypnea of newborn 11 Items #7-8 are part of a sequential item set. In the actual examination environment, you will not be able to view the second item until you click "Proceed to Next Item." After navigating to the second item, you will not be able to add or change an answer to the first item. A 56-year-old woman is brought to the office by her husband for a postoperative visit 2 weeks after undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy for leiomyomata uteri. She was discharged 6 days later after a 3-day course of antibiotics for a vaginal cuff cellulitis. However, since discharge, she has had fever, increasing weakness, and lower abdominal pain. She also has had six to seven episodes of diarrhea daily. She appears mildly uncomfortable. Vital signs are temperature 38.2°C (100.8°F), pulse 92/min, respirations 14/min, and blood pressure 132/80 mm Hg. Physical examination discloses diffuse abdominal tenderness. Test of the stool for occult blood is positive.
Transient tachypnea of the newborn is caused by delayed resorption of fetal lung fluid in preterm infants delivered by cesarean section. The chest x-ray shows fluid in the fissures and hyperinflation characteristic of this condition.
Why the other choices are wrong:
A. Chlamydial pneumonia - Chlamydial pneumonia develops gradually with staccato cough; TTN is acute at birth and self-resolves within 48-72 hours.B. Group B streptococcal sepsis - GBS sepsis presents with severe distress and shock; this infant's good Apgar scores contradict neonatal sepsis.
C. Meconium aspiration syndrome - Meconium aspiration causes severe distress and hyperinflation; TTN presents with clear lungs and mild findings.
D. Respiratory distress syndrome - RDS affects infants <32 weeks with severe distress; this 36-week infant with clear lungs has TTN.
Question 7
Answer: C - Metronidazole, orally
Metronidazole is the appropriate initial therapy for non-fulminant Clostridium difficile colitis in this postoperative patient with fever, diarrhea, and abdominal pain following antibiotic exposure. It is the first-line treatment for mild to moderate C. difficile infection.
Why the other choices are wrong:
B. Candida albicans - Candida causes thrush or esophagitis in immunocompromised patients, not bloody diarrhea with fever.C. Enterovirus - Enteroviruses cause watery self-limited diarrhea without blood; fever and bloody stools suggest bacterial etiology.
D. Giardia lamblia - Giardia causes watery foul-smelling diarrhea with malabsorption, not bloody stools with fever.
E. Salmonella can cause bloody diarrhea but is less common than Campylobacter with this severity.
Question 8
Answer: B - Recurrence of infection with the same organism
C. difficile recurrence after initial treatment occurs in approximately 20-25% of patients. The most common cause is recurrence from the same organism - residual spores in the colon germinate after antibiotic cessation. This is distinct from reinfection with a new strain from external contacts.
Why the other choices are wrong:
A. Blood cultures - Blood cultures are not indicated in post-infectious reactive arthritis diagnosis.B. CD4+ T - CD4 testing is irrelevant for diagnosing reactive arthritis in immunocompetent patients.
D. Serum rheumatoid factor assay - Rheumatoid factor is associated with RA's symmetric disease; monoarticular post-infectious arthritis requires HLA-B27.
E. Stool culture END OF SET - Stool culture is not indicated in established reactive arthritis; HLA-B27 confirms the diagnosis.
Question 9
Answer: D - Insurance company
Erythema nodosum, presenting as painful nodules on the shins in a patient with sarcoidosis, is a hypersensitivity reaction. It represents the most common cutaneous manifestation of acute sarcoidosis.
Why the other choices are wrong:
A. His Cocaine Anonymous sponsor - AA sponsors are peer support without medical credentials; cannot receive confidential information without consent.B. His probation officer - Probation officers represent law enforcement; disclosure without court order violates confidentiality.
C. His wife - Spouse disclosure requires explicit patient consent; marriage does not waive physician-patient confidentiality.
E. Police - Police disclosure of substance abuse violates confidentiality without court order.
Question 10
Answer: A - Accept the girl's consent as sufficient
Bilateral hilar lymphadenopathy with right paratracheal involvement on chest x-ray in acute sarcoidosis represents stage II disease. This is one of the most common radiographic findings at presentation.
Why the other choices are wrong:
B. Obtain a court order permitting evaluation - Court order is unnecessary when emancipation criteria are clearly met; seeking approval delays necessary care.C. Obtain the written consent of at least two licensed physicians - Two physician approval is not required for emancipated minors; they can authorize their own care.
D. Obtain written consent from at least one of her parents - Parents have no authority over emancipated minors living independently with a child.
E. Obtain written consent from her 28 - A cousin has no legal authority over medical decisions; only the emancipated minor can consent.
Question 11
Answer: C - Medication-induced suppression of central respiratory drive
A negative ACE level does not exclude sarcoidosis since it is elevated in only 60-70% of cases. Clinical diagnosis based on clinical-radiological presentation and tissue biopsy showing noncaseating granulomas is the standard.
Why the other choices are wrong:
A. Airway occlusion - While opioids suppress respiration, the unilateral breath sounds and hypoxia indicate aspiration obstruction.B. Encephalitis - Pulmonary embolism causes tachycardia and hypoxia but lacks the unilateral findings of foreign body aspiration.
D. Meningitis - Status epilepticus presents with visible seizure activity and abnormal EEG; this is aspiration.
E. Ongoing nonconvulsive seizure activity - Anaphylaxis presents with stridor and urticaria; unilateral breath loss indicates aspiration.
Question 12
Answer: B - Ask the patient to provide a narrative with detailed description of the incident and of his symptoms
Angiotensin-converting enzyme inhibitors should be avoided in sarcoidosis patients because they further increase serum calcium levels. Hypercalcemia from excessive vitamin D production by granulomas is a known complication.
Why the other choices are wrong:
A. Administer amobarbital and then interview the patient - Aggressive visualization can worsen airway compromise; gentle examination allows assessment in cooperative children.C. Interview the patient under hypnosis - Detailed history is important but cannot delay airway stabilization in epiglottitis with respiratory distress.
D. Interview the patient while paying close attention to his willingness to make eye contact - Blood cultures should be obtained after airway is secure; airway management takes precedence.
E. Tell the patient he is exhibiting behaviors that are suggestive of malingering and see how he responds 14 The abstract on this page is for use with items #13 - Lateral neck x-ray can help but delays critical airway management in epiglottitis.
Question 13
Answer: C - 5
The abnormal calcium metabolism in sarcoidosis results from extrarenal production of vitamin D by activated macrophages in granulomas. This causes hypercalcemia and hyperphosphaturia.
Why the other choices are wrong:
A. 1 - HBV and HCV are bloodborne pathogens, not fecal-oral like HAV.B. 3 - HEV is primarily in developing countries and not transmitted in childcare settings like HAV.
D. 10 - HCV is bloodborne and not transmitted through childcare; HAV spreads via fecal-oral route.
E. 16 - CMV is less likely to cause acute hepatitis with this timeline; HAV is classic in childcare.
Question 14
Answer: B - EPCS is available only at specialty centers
NSAIDs are the initial treatment for acute sarcoidosis-related arthralgia and erythema nodosum. Corticosteroids are reserved for progressive or systemic manifestations.
Why the other choices are wrong:
A. The allocation was concealed - Simple pneumothorax doesn't require empiric antibiotics; the findings indicate gas accumulation causing hypoxia.C. The follow - Pericardial tamponade presents with Beck's triad; unilateral breath sounds indicate pneumothorax.
D. The patients were not blinded - Acute coronary syndrome presents with EKG changes; unilateral breath loss follows line placement.
E. Unmeasured confounders were not controlled by the study design - Mediastinitis develops over days with fever; acute breath sound loss indicates pneumothorax.
Question 15
Answer: B - EPCS is more effective than EST in decreasing hospital readmissions for variceal bleeding requiring transfusion
Tuberculosis must be excluded in any patient with granulomatous disease, fever, and pulmonary infiltrates. Tuberculin testing and cultures are essential before initiating corticosteroids which could worsen TB.
Why the other choices are wrong:
A. The 95% confidence interval for the difference in survival between EPCS and EST for Child - CCBs are contraindicated in heart failure and less effective for rate control than beta-blockers.C. The median survival after EPCS is statistically significantly less for Child - Digoxin has slower onset and is less effective in acute AFib with RVR causing ischemia.
D. The randomization procedure was ineffective in decreasing bias in this study END OF SET - Amiodarone carries proarrhythmia risk in acute settings; not first-line for symptomatic AFib.
E. Verapamil is contraindicated in heart failure; not appropriate for acute AFib with angina.
Question 16
Answer: E - His sickle cell disease is affecting his hemoglobin A 1c
No further diagnostic testing is needed when sarcoidosis diagnosis is established with compatible clinical features, radiographic findings, and noncaseating granulomas on biopsy, plus negative AFB stains.
Why the other choices are wrong:
A. He has iron deficiency anemia - Iron deficiency presents with microcytic indices; this patient's bone marrow suppression after thiopurine indicates TPMT deficiency.B. His daily glucose control is better than recorded - Daily glucose control affects same-day glucose, not HbA1c; thrombocytopenia indicates TPMT toxicity.
C. His glucometer is reading falsely high and should be replaced - Glucometer malfunction wouldn't cause bone marrow suppression; TPMT deficiency prevents drug metabolism.
D. His hemoglobin A is likely a result of laboratory error and should be repeated 1c - HbA1c cannot be lab error alone; context of thiopurine bone marrow suppression indicates TPMT deficiency.
Question 17
Answer: C - Polymyositis
Bone marrow biopsy in this patient with sarcoidosis would show granulomas, which is expected and does not require intervention unless there are signs of bone marrow failure.
Why the other choices are wrong:
A. Fibromyalgia - Fibromyalgia causes diffuse pain without fractures; this patient has pathologic vertebral compressions.B. Myasthenia gravis - Myasthenia gravis presents with weakness and ptosis, not bone fractures from loss.
D. Scleroderma - Scleroderma causes skin fibrosis, not pathologic spinal fractures from osteoporosis.
Question 18
Answer: E - Vaccine response among African American subjects was not the primary outcome measure
Renal involvement in sarcoidosis primarily causes hypercalcemia-induced nephrolithiasis and interstitial nephritis. Standard treatment addresses the underlying hypercalcemia.
Why the other choices are wrong:
A. Allocation bias favored African American subjects - Allocation bias affects validity but not diagnostic findings confirming Paget disease.B. HIV infection is more prevalent among African American populations - HIV prevalence doesn't explain pathognomonic imaging of lytic/sclerotic lesions and mosaic pattern.
C. The study was not blinded - Lack of blinding doesn't affect this patient's diagnostic imaging and elevated ALP.
D. There was a Type II error - Type II error describes statistical power, not diagnostic laboratory and imaging findings.
Question 19
Answer: E - Spontaneous pneumothorax
Hepatic involvement in sarcoidosis is usually asymptomatic and discovered on imaging. It rarely requires specific treatment unless there is clinically significant liver dysfunction.
Why the other choices are wrong:
A. Acute pericarditis - Acute pericarditis presents with pleuritic chest pain, not meningitis with fever and elevated CSF pressure.B. Hyperventilation syndrome - Hyperventilation doesn't cause fever or meningeal signs; cryptococcal meningitis explains all findings.
C. Myocardial infarction - Myocardial infarction presents with cardiac chest pain and EKG changes, not meningitis.
D. Pulmonary embolism - Pulmonary embolism presents with dyspnea, not meningitis in severely immunocompromised patients.
Question 20
Answer: C
Treatment with corticosteroids is appropriate for symptomatic sarcoidosis with progressive pulmonary involvement, constitutional symptoms, and hypercalcemia to prevent complications.
Question 21
Answer: A - Narcolepsy
The elderly patient with new-onset diabetes, insulin resistance, and possible temporal arteritis requires glucocorticoids, which will further elevate glucose levels. Careful glucose monitoring is essential.
Why the other choices are wrong:
B. Primary hypersomnia - Post-infectious narcolepsy is extremely rare; the clinical picture with fever and multi-organ involvement indicates vasculitis.C. A seizure disorder - Takayasu arteritis typically affects younger women and the aorta; this patient's presentation is classic PAN.
D. Sleep paralysis - Giant cell arteritis typically spares the GI and renal systems; this multi-organ involvement indicates PAN.
E. Vasovagal syndrome - Temporal arteritis typically causes headache and jaw claudication; this patient's GI and renal findings are more consistent with PAN.
Question 22
Answer: D - Determination of serum digoxin level
Insulin glargine provides basal insulin coverage and is appropriate for managing steroid-induced hyperglycemia. It should be combined with short-acting insulin for meal-time coverage.
Why the other choices are wrong:
A. Chest x - While hyperglycemia occurs in DKA, the severe hypokalemia with arrhythmia is the acute life threat requiring immediate intervention.B. Complete blood count - Digoxin level is less critical than correcting severe hypokalemia which causes the current arrhythmia.
C. Determination of serum albumin concentration - Serum osmolality helps assess DKA severity but doesn't address the immediate arrhythmia risk from hypokalemia.
D. Anion gap calculation is useful for DKA assessment but doesn't guide urgent potassium repletion.
Question 23
Answer: B - Arrange for a certified interpreter
Lisinopril provides renal protection in diabetic patients and also has benefit in temporal arteritis for blood pressure control. It is a reasonable antihypertensive choice in this context.
Why the other choices are wrong:
A. Have the patient bring her son to the appointment to interpret - While examination is important, language barrier impairs communication; certified interpreters ensure accurate history and informed consent.C. Provide the patient with writing materials during the appointment - Chart notes in English won't overcome the current language barrier preventing adequate history and consent.
D. Talk with the patient face - Repeating questions slowly doesn't solve the fundamental communication problem requiring professional interpretation.
E. Obtain a history via a telecommunication device for the deaf before the appointment - Calling family members raises confidentiality concerns and may lack medical terminology needed for accurate history.
Question 24
Answer: E - Ultrasonography of the hips
Advanced age, new-onset diabetes, and uncontrolled hypertension all increase cardiovascular risk substantially. No additional interventions beyond standard risk factor modification are indicated beyond those already described.
Why the other choices are wrong:
A. Arthrography of the right hip - While MRI can assess CNS involvement, the fatigability and ocular symptoms point to neuromuscular junction disorder.B. CT scan of the abdomen - Electromyography would show decremental response in MG but doesn't clinically guide diagnosis from the presentation.
C. MRI of the lumbar spine - Chest CT is important for MG evaluation but less immediately relevant than anti-acetylcholine antibodies.
D. Radionuclide bone scan - Pulmonary function tests assess respiratory involvement but are secondary to confirming the MG diagnosis.
Question 25
Answer: E
Allopurinol is indicated for asymptomatic hyperuricemia only if the patient develops gout or has recurrent stones. A single kidney stone episode does not warrant allopurinol therapy.
Question 26
Answer: D - Thoracentesis
The patient with renal colic and reduced kidney function requires aggressive hydration but not aggressive diuresis. Urokinase has no role in treating kidney stones.
Why the other choices are wrong:
A. Bone marrow biopsy - While C3/C4 are depressed in SLE, they are not diagnostic alone; the full picture confirms lupus nephritis.B. Pericardiocentesis - Anti-dsDNA is highly specific for SLE but direct kidney biopsy provides histologic confirmation.
C. Pleurodesis - While useful, ESR elevation alone is nonspecific; serum complement and antibody findings establish SLE.
D. Anti-Ro/La antibodies occur in SLE but are less directly related to the renal involvement than complement levels.
Question 27
Answer: E - Systemic sclerosis (scleroderma)
A 4-mm kidney stone in the distal ureter without obstruction or infection can be managed conservatively with hydration and analgesia. Spontaneous passage is likely.
Why the other choices are wrong:
A. Osteitis deformans (Paget disease) - Initiating another antihypertensive adds medication burden without evidence of improved adherence to current therapy.B. Parkinson disease - Dietary sodium restriction has good evidence but alone doesn't address the medication adherence problem.
C. Progressive supranuclear palsy - ACE inhibitor enhancement provides better renal protection than adding second agent without proven benefit.
D. Sarcopenia - Home blood pressure monitoring doesn't overcome the fundamental adherence problem affecting control.
Question 28
Answer: C - Place masks on the patient and yourself and then continue to evaluate him
The postmenopausal woman with osteoporosis, kyphosis, and chronic back pain from vertebral compression fractures requires calcium and vitamin D supplementation, bisphosphonates, and physical therapy.
Why the other choices are wrong:
A. Arrange a direct admission to the hospital for this patient - Simply continuing evaluation without respiratory precautions risks transmission of airborne infection.B. Continue with obtaining a thorough history and examining this patient - Respiratory isolation isn't indicated for hypertensive emergency from tyramine-MAOI interaction.
D. Send this patient for chest x - Discussing medication interactions is important but doesn't address the immediate hypertensive emergency.
E. Transferring without respiratory protection risks exposure to airborne infection if present.
Question 29
Answer: A - Cervical culture
Tamoxifen use for breast cancer increases thrombotic risk. This patient's leg pain, unilateral swelling, and risk factors necessitate evaluation for deep venous thrombosis.
Why the other choices are wrong:
B. Culdocentesis - While CT can assess structural abnormalities, the clinical tremor, rigidity, and bradykinesia are diagnostic for Parkinson disease.C. Laparoscopy - EEG findings are nonspecific; the clinical presentation of resting tremor and rigidity is diagnostic.
D. Serum β - Dopamine agonists are alternatives but levodopa-carbidopa is first-line for symptomatic Parkinson disease.
E. Ultrasonography of the pelvis - While imaging can exclude secondary parkinsonism, clinical diagnosis suffices for initiating levodopa-carbidopa.
Question 30
Answer: C - Serum concentration of C3
Compression ultrasound is the gold standard for diagnosing DVT. It has high sensitivity and specificity without radiation exposure.
Why the other choices are wrong:
A. Bleeding time - HbA1c reflects long-term control but is less immediately relevant than assessing renal function before metformin.B. Erythrocyte count - While microalbumin suggests early nephropathy, serum creatinine is most critical for metformin safety.
D. Serum IgA concentration - Urine ketones would be present in uncontrolled DM but don't guide metformin use decisions.
E. Serum rheumatoid factor assay - While uric acid is relevant to gout risk, serum creatinine determines metformin safety.
Question 31
Answer: E - Somatic symptom disorder
Warfarin is contraindicated in the first trimester of pregnancy due to teratogenicity. Pregnant patients with DVT require unfractionated heparin throughout pregnancy and postpartum period.
Why the other choices are wrong:
A. Borderline personality disorder - Skin biopsy confirms diagnosis but doesn't guide urgent wound management in acute burn injury.B. Conversion disorder - Burn depth assessment by visual inspection and appearance guides initial management decisions.
D. Occult medical disorder - While fluid status is important, immediate assessment of burn depth and fluid requirements is more urgent.
E. Tetanus history is less immediately critical than assessing burn depth and fluid replacement needs.
Question 32
Answer: C - Minimize ascertainment bias
Adequate anticoagulation during pregnancy requires monitoring with activated partial thromboplastin time. Heparin dosing must be adjusted to therapeutic levels throughout pregnancy.
Why the other choices are wrong:
A. Address confounding - While smoking is a risk factor, recent thrombosis with normal PT/PTT suggests thrombophilia despite anticoagulation.C. Protein C deficiency is an inherited thrombophilia but antiphospholipid syndrome better explains recurrent thrombosis.
D. Reduce recall bias - While useful, Factor V Leiden alone doesn't fully explain thrombosis despite appropriate anticoagulation.
E. Platelet count is normal; recurrent thrombosis despite anticoagulation indicates hypercoagulable state.
Question 33
Answer: E - Plasma renin activity
Bone marrow aspiration would confirm the diagnosis in suspected hematologic malignancy if morphology and flow cytometry from peripheral blood are inconclusive.
Why the other choices are wrong:
A. Blood cultures - Normal temperature doesn't exclude overwhelming sepsis in children who may not mount fever response.C. Hemoglobin A level 1c - While splenectomy increases pneumococcal risk, this child's presentation requires immediate sepsis evaluation.
D. HIV antibody titer - Functional asplenia increases meningococcal risk; this febrile child needs immediate evaluation not reassurance.
E. Limited home antibiotics don't replace the need for full septic workup and appropriate hospital care.
Question 34
Answer: A
Acute leukemia presents with fever, easy bruising, bleeding, and pancytopenia. The diagnosis is confirmed by bone marrow examination showing excess blasts.
Question 35
Answer: D - Individuals who take Drug X have two times the risk of dying from this type of cancer
Neutropenic fever in a leukemia patient requires immediate broad-spectrum antibiotics after blood cultures, without waiting for culture results. This is empiric treatment for potentially life-threatening infection.
Why the other choices are wrong:
A. Individuals who take Drug X have an equal risk of dying from this type of cancer - Empiric antibiotics are needed but blood cultures must be obtained first for organism identification.C. Individuals who take Drug X have three times the risk of dying from this type of cancer - While imaging can guide intervention, empiric antibiotics take precedence in acute severe infection.
D. IV fluids support management but antibiotics address the underlying life-threatening infection.
E. The risk for dying cannot be determined from the data - Pediatric dosing of antibiotics is essential but doesn't change the need for immediate empiric coverage.
Question 36
Answer: D - Menstrual history
The patient with fever, cough, and hypoxia in the setting of leukemia and neutropenia could have PCP or other opportunistic infection. Empiric treatment should cover these possibilities.
Why the other choices are wrong:
A. Color, caliber, and frequency of bowel movements - While opioids provide analgesia, NSAIDs help reduce inflammatory pain without respiratory depression.B. Exposure to sexually transmitted diseases - Topical agents alone inadequately treat moderate to severe fracture pain.
C. Family history of irritable bowel syndrome - Benzodiazepines address anxiety but don't adequately treat acute fracture pain.
D. Immobilization reduces pain but doesn't provide adequate analgesia for emergency department management.
Question 37
Answer: C - Optic nerve
Fluconazole is appropriate empiric therapy for fungal infections in neutropenic patients with persistent fever unresponsive to antibacterial therapy. It covers most Candida species.
Why the other choices are wrong:
A. Medial longitudinal fasciculus - While mental health support is important long-term, acute suicidality requires immediate psychiatric evaluation.B. Oculomotor nerve - Reassurance alone is inadequate for active suicidal ideation; psychiatric evaluation is required.
D. Trigeminal nerve - Antidepressants take weeks to work; acute suicidality requires immediate psychiatric assessment.
E. Visual cortex - Improving life circumstances is long-term but doesn't address acute suicidal ideation risk.
Question 38
Answer: A - Displacement of the nucleus pulposus
Patients receiving chemotherapy require careful monitoring for tumor lysis syndrome with aggressive hydration, allopurinol, and electrolyte monitoring to prevent acute kidney injury.
Why the other choices are wrong:
A. Psychopharmacology is important but individual psychotherapy alone may be inadequate for severe depression.B. Hypertrophy of the facet joints - Group therapy can complement but is less effective alone for severe depression with suicidality.
C. Osteophyte formation - While supportive, religious counseling isn't a substitute for evidence-based psychiatric treatment.
E. Thickening of ligamentum flavum NOTE: THIS IS THE END OF BLOCK 1. ANY REMAINING TIME MAY BE USED TO CHECK ITEMS IN THIS BLOCK. 24 Block 2: FIP Items 39-77; Time - Environmental changes help but don't address the underlying severe depression and suicidality.
Block 2: Questions 39-77
Question 39
Answer: D - Serum calcium concentration of 6.6 mg/dL
The patient with alcohol-related liver cirrhosis, ascites, and hematemesis has esophageal variceal bleeding. Immediate therapy includes blood product replacement and vasoactive drugs.
Why the other choices are wrong:
A. Serum alanine aminotransferase (ALT) concentration of 106 U/L - While history is important, the clear clinical presentation of cyanosis and hypoxia requires immediate management.B. Serum amylase concentration of 2000 U/L - Maternal history of diabetes increases cardiac risk but doesn't change the immediate management of cyanosis.
D. While respiratory monitoring is part of management, it doesn't address the underlying cardiac lesion.
E. Serum glucose concentration of 200 mg/dL - Obtaining consent is necessary but cannot delay urgent stabilization of a critically hypoxic infant.
Question 40
Answer: D - Help the mother deal with her anger and educate her regarding the potential benefit to her son and others if the father's chromosome studies are done
Propranolol reduces portal pressure and prevents variceal rebleeding. Long-term beta-blocker therapy is standard secondary prophylaxis for patients with variceal hemorrhage.
Why the other choices are wrong:
A. Attempt to identify the father's physician and work with that physician to obtain chromosome studies on the father - While PGE1 helps maintain ductus arteriosus patency, it's adjunctive to definitive surgical or catheter intervention.B. Contact the father by telephone and arrange for him to give a blood sample at a local hospital - Positive pressure ventilation supports oxygenation but doesn't address the underlying anatomic defect.
C. Document your attempts to work with the mother but proceed no further, since you have no physician - ECMO is rescue therapy for cardiogenic shock but doesn't provide definitive anatomic correction.
E. Send the father a letter (expressing few details about the patient) and suggest that he contact your office for an appointment and further discussion of his child - Diuretics may help pulmonary edema but don't address the critical ductal-dependent circulation.
Question 41
Answer: E - Sexual activity
Acute coronary syndrome is excluded by normal cardiac biomarkers and EKG findings. The patient's chest pain in this context is likely musculoskeletal or from alcohol-related gastritis.
Why the other choices are wrong:
A. Details of his weight training - While O2 improves saturation, it doesn't address right-to-left shunting; prostaglandin keeps ductus open.B. Fever and chills - Positive pressure may worsen pulmonary blood flow in ductal-dependent lesions.
C. Mood symptoms - Intubation is supportive but doesn't maintain ductal patency needed for systemic circulation.
D. School performance - Sodium restriction is part of chronic heart failure management, not acute stabilization.
Question 42
Answer: D - Herpes zoster
The young patient with recurrent chest pain and normal cardiac workup likely has anxiety or panic disorder. Reassurance and evaluation for anxiety are appropriate next steps.
Why the other choices are wrong:
A. Acalculous cholecystitis - Aspiration precautions are supportive but don't address the underlying seizure disorder.B. Chronic relapsing pancreatitis - Lorazepam is preferred for acute seizure control; phenytoin is long-acting for maintenance.
D. While imaging may be needed, acute seizure management takes precedence over diagnostic workup.
E. Penetrating duodenal ulcer - Protecting airway is essential during seizure but doesn't establish long-term seizure control.
Question 43
Answer: B - Order a chest x-ray
Metformin is the initial first-line pharmacotherapy for type 2 diabetes based on current guidelines. It provides glycemic control without weight gain or hypoglycemia.
Why the other choices are wrong:
A. Call her previous physician to obtain more history - Phenytoin is appropriate maintenance therapy; however, lorazepam addresses acute seizure activity more rapidly.C. Order a test for HIV antibody - Imaging can identify etiology but doesn't control acute ongoing seizures.
D. Repeat the PPD skin test - Propofol sedation is ICU management; lorazepam is standard emergency seizure control.
E. Schedule gastric aspiration for culture on successive days - Acetazolamide is used for certain seizure types but not first-line for acute status epilepticus.
Question 44
Answer: D - Methanol intoxication
HbA1c of 7% indicates good glycemic control over the preceding three months. Further intensification of therapy may increase hypoglycemia risk without benefit.
Why the other choices are wrong:
A. Alcoholic ketoacidosis - While antipyretics help symptom management, they don't address the underlying bacterial infection.B. Diabetic ketoacidosis - Hydration supports therapy but antibiotics are critical for meningococcal meningitis.
C. Isopropyl alcohol intoxication - While important, seizure prophylaxis is secondary to antibiotic treatment of meningitis.
D. Ceftriaxone is the appropriate antibiotic; however, dexamethasone reduces neurologic complications.
Question 45
Answer: C - Atlanto-axial instability
Aspirin is indicated for primary prevention in patients with diabetes, hypertension, and other cardiovascular risk factors. It reduces cardiovascular events significantly.
Why the other choices are wrong:
A. Adrenal insufficiency - While antipyretics provide symptomatic relief, antibiotics treat the underlying infection causing sepsis.B. Anxiety - Hydration is supportive; antibiotics are definitive therapy for meningococcal disease.
C. Benzodiazepines address seizures if present but don't treat the underlying bacterial infection.
E. Cerebral ischemia - ICU transfer is appropriate but antibiotic initiation cannot be delayed.
Question 46
Answer: B - Keratoacanthoma
The patient with diabetes and hypertension requires an ACE inhibitor for cardiovascular and renal protection. Lisinopril is appropriate as part of antihypertensive regimen.
Why the other choices are wrong:
A. Basal cell carcinoma - While fluid resuscitation is supportive, antibiotics address the underlying infection of meningococcal sepsis.B. Positive pressure ventilation supports respiration but doesn't treat the underlying sepsis.
C. Leukoplakia - Vasopressors support blood pressure but don't replace early antibiotics in sepsis management.
D. Melanoma - Corticosteroids may help some sepsis presentations but antibiotics are primary therapy.
Question 47
Answer: E
The elderly patient with stable CAD and preserved ejection fraction does not require aggressive beta-blocker therapy. Continuation of current regimen is appropriate.
Question 48
Answer: A - Adverse effect of fluoxetine therapy
The symptomatic patient with significant aortic stenosis requires echocardiography to assess valve area and gradient. Aortic valve replacement is indicated if severe.
Why the other choices are wrong:
A. While diuretics reduce fluid volume, they don't address the precipitant of acute decompensation.B. Bereavement reaction - Inotropes support cardiac output but don't treat the underlying cause of decompensation.
C. Early Parkinson disease - While useful, beta-blockers slow rate but don't address acute volume overload management.
D. Increase in alcohol consumption - ACE inhibitors are important chronic therapy but don't provide acute decompensation management.
Question 49
Answer: E - Mitral stenosis complicated by atrial fibrillation
In the asymptomatic patient with mild aortic stenosis, serial echocardiography is appropriate to monitor progression. Activity restriction is not necessary.
Why the other choices are wrong:
A. Atrial septal defect with development of pulmonary hypertension - While hydration is supportive, the specific electrolyte and acid-base derangements require directed therapy.B. Chronic mitral regurgitation secondary to rheumatic heart disease - Insulin helps glucose control but doesn't address the life-threatening acidosis and hyperkalemia.
C. Coarctation of the aorta - Diuretics may help fluid overload but don't address the acute metabolic derangements.
E. Antibiotics address infection if present but don't treat the metabolic emergency of DKA.
Question 50
Answer: B - Transient lactase deficiency
The patient with fever and new murmur in the setting of recent dental work has infective endocarditis. Blood cultures before antibiotics and echocardiography are essential.
Why the other choices are wrong:
A. Fructose intolerance - While pain control is important, the acute hypercalcemia and volume depletion require immediate intervention.B. Bisphosphonates are useful for chronic hypercalcemia but take days to work in acute toxicity.
C. Magnesium deficiency - While loop diuretics enhance calcium excretion, they require aggressive hydration first.
D. Regional enteritis - NSAIDs can worsen renal function in hypercalcemia; hydration is the cornerstone of management.
Question 51
Answer: A - The risk for inpatient mortality is greater for patients with hypotension than for those without hypotension
The patient with recurrent breast cancer and pleural effusion has metastatic disease. Chemotherapy targeting the specific histology and receptor status offers the best chance for response.
Why the other choices are wrong:
A. While thiamine is important to prevent Wernicke syndrome, glucose administration first prevents acute worsening.B. The risk for inpatient mortality is increased more by hypoxemia than by hypotension - Phenytoin is for seizure control but doesn't address the acute altered mental status cause.
C. The risk for inpatient mortality is increased when there is a pulmonary infiltrate present on chest x - Benzodiazepines help seizures but don't treat the underlying alcohol withdrawal process.
E. Environmental modification helps but pharmacologic management is essential for seizure and tremor control.
Question 52
Answer: E - Serum 25-hydroxyvitamin D assay
The patient with stage IV breast cancer and good performance status may benefit from palliative chemotherapy. The decision should include discussion of goals and expected outcomes.
Why the other choices are wrong:
A. DEXA scan - While thiamine is important preventively, the acute tremor and autonomic symptoms require benzodiazepines.B. Electromyography and nerve conduction studies - Glucose addresses hypoglycemia but doesn't treat alcohol withdrawal syndrome.
C. MRI of the cervical spine - Antipsychotics may worsen withdrawal; benzodiazepines are the standard of care.
E. Environmental support helps but pharmacologic management is essential for alcohol withdrawal.
Question 53
Answer: B - Mucosal edema
Hormonal therapy with tamoxifen or aromatase inhibitors is appropriate first-line treatment for estrogen receptor-positive metastatic breast cancer, less toxic than chemotherapy.
Why the other choices are wrong:
A. Eustachian tube dysfunction - While pain control is important, imaging to exclude serious pathology takes precedence in new-onset headache.B. Antibiotics are premature without confirmation of meningitis; imaging is first for new severe headache.
C. Nasal polyps - While LP is important for diagnosis, imaging must exclude mass or increased ICP first.
E. Tonsillar hyperplasia - Migraine management is premature for new-onset severe headache without excluding dangerous causes.
Question 54
Answer: A - Ductography
The patient with rapidly progressive symptoms and altered mental status has metastatic brain disease. MRI of the brain with gadolinium is essential for diagnosis and treatment planning.
Why the other choices are wrong:
A. While reassurance is helpful, the description suggests organic pathology requiring evaluation.B. Excisional biopsy of glandular tissue - Referral is appropriate but emergency evaluation is first for sudden severe new headache.
C. Repeat mammography - Antidepressants treat chronic pain but are premature for acute new-onset severe headache.
E. No further workup is indicated - Lifestyle modification helps chronic headaches but doesn't address acute severe new headache.
Question 55
Answer: A - Ankle brachial index
The ankle-brachial index (ABI) is the most appropriate initial non-invasive test for evaluating peripheral arterial disease in this patient. It compares systolic blood pressure at the ankle to the arm, providing objective assessment of lower extremity perfusion.
Why the other choices are wrong:
A. Acute bacterial endocarditis - While reassurance is helpful, chest pain requires evaluation to exclude serious cardiac pathology.B. Acute myocardial infarction - Antacids may help if gastroesophageal but don't exclude cardiac causes of chest pain.
C. Anxiolytics treat anxiety but don't exclude organic pathology as cause of chest pain.
D. Esophageal reflux with spasm - Analgesics mask symptoms; evaluation for serious causes is necessary first.
Question 56
Answer: C - Dissection of the aorta
Aortic dissection presents with sudden, severe, tearing chest pain radiating to the back. Risk factors include hypertension, connective tissue disorders, and bicuspid aortic valve. The classic finding of blood pressure differential between arms and widened mediastinum on chest X-ray supports this diagnosis.
Why the other choices are wrong:
A. Reassurance without evaluation risks missing serious pathology as cause of chest discomfort.B. Arteriography - While GI causes are possible, cardiac and pulmonary causes must be excluded first.
C. ECG - Anxiolytics don't exclude organic disease; cardiac evaluation is first.
D. Echocardiography - Pain relief is supportive but evaluation for serious causes takes precedence.
Question 57
Answer: D - Neck stiffness
Morphine is the appropriate opioid for cancer pain management. Dose escalation is appropriate to achieve adequate analgesia as tolerance develops.
Why the other choices are wrong:
A. Abdominal striae - While pain management is important, fracture reduction must precede prolonged pain relief.B. Expiratory wheezes - Reduction is urgent to restore circulation and reduce pain; analgesia complements but doesn't replace it.
C. Midsystolic click - Vascular assessment is important but doesn't replace the need for immediate fracture reduction.
D. Extremity elevation helps but urgent reduction of the deformity is the priority.
Question 58
Answer: C - Pneumonia caused by Streptococcus pneumoniae
The terminally ill patient with family disagreement about code status requires a palliative care meeting. Goals of care discussion should guide decision-making.
Why the other choices are wrong:
A. Legionnaires disease - While stabilization is important, assessment for neurovascular compromise and fracture characteristics is first.B. Pneumonia caused by Pneumocystis jiroveci - Imaging is necessary to guide reduction technique and assess fracture pattern.
C. While splinting is part of initial care, imaging and assessment precede definitive immobilization.
D. Pulmonary embolism - Pain control is appropriate but assessment and imaging guide reduction technique.
Question 59
Answer: D - Essepro should not be prescribed because the patient has severe liver disease
The family requesting "everything be done" for a terminal patient requires education about prognosis and discussion of what is medically possible versus beneficial.
Why the other choices are wrong:
A. Essepro should be prescribed because she can get it for free - Reassurance is inappropriate without evaluation for serious underlying pathology.B. Essepro should not be prescribed because it can worsen her psoriasis - Referral may be appropriate but emergency evaluation is first for acute dyspnea.
C. Essepro should not be prescribed because it is similar to her other medications - While anxiety is possible, organic cardiopulmonary causes must be excluded first.
D. Oxygen may help but diagnostic evaluation takes precedence for acute dyspnea.
Question 60
Answer: D - There is no clinically important difference in blood pressure reduction between the three dose groups
Antibiotics in advanced dementia patients with aspiration pneumonia do not prolong meaningful survival. Comfort care with hydration and symptom management is appropriate.
Why the other choices are wrong:
A. Blood pressure reduction from the three doses of Essepro cannot be compared to reduction with placebo because the number of patients on active drugs are higher than the number of patients on placebo - While anxiety is possible, evaluation for serious cardiopulmonary pathology is first.B. Doubling the highest dose of Essepro will decrease diastolic pressure from baseline by at least 15 mm Hg - Reassurance without evaluation risks missing life-threatening conditions.
C. The highest dose of Essepro should be used because it offers the greatest benefit - Antidepressants may help chronic anxiety but don't exclude organic causes of acute dyspnea.
D. Breathing exercises help anxiety symptoms but may dangerously delay needed treatment.
Question 61
Answer: A - Karyotype from peripheral leukocytes
The 68-year-old man with moderate cognitive impairment and stable living situation can be managed in the community with close follow-up. Nursing home is not yet indicated.
Why the other choices are wrong:
A. While splinting is supportive, reduction of the posterior dislocation is urgent to restore hip circulation.B. Serum estrogen and testosterone concentrations - X-rays confirm diagnosis but reduction cannot be delayed; urgent reduction prevents avascular necrosis.
C. Serum follicle - Pain control is appropriate but urgent reduction takes precedence to prevent vascular complications.
D. Serum prolactin concentration - Traction is supportive but immediate reduction of posterior dislocation prevents AVN.
Question 62
Answer: E - No additional study is indicated
Advanced directives should be reviewed and updated regularly, especially as health status changes. The patient should designate a healthcare proxy for decision-making.
Why the other choices are wrong:
A. Cystoscopy - While weight-bearing precautions are important, they don't address the underlying shoulder dislocation.B. Echocardiography - X-rays confirm diagnosis but reduction is urgent; diagnostic imaging shouldn't delay reduction.
C. MRI of the abdomen - Physical therapy is appropriate after reduction but immediate reduction takes precedence.
D. Renal ultrasonography - Sling immobilization is part of care but reduction of the anterior dislocation is urgently needed.
Question 63
Answer: B - Impaired sweat gland function with reduced ability to regulate heat loss
The 42-year-old with hypertension, obesity, and family history of early MI requires aggressive risk factor modification. Statin therapy should be initiated for primary prevention.
Why the other choices are wrong:
A. Adrenal insufficiency with salt wasting - While stabilization is important, urgent reduction and neurovascular assessment are priorities.B. Imaging confirms diagnosis but urgent reduction of knee dislocation prevents vascular injury.
C. Invasion of the central nervous system by gram - Pain control is appropriate but urgent reduction to restore circulation takes precedence.
D. Mucous plugging of the airway resulting in secondary infection with Pseudomonas species - Elevation helps but urgent reduction of the dislocation prevents catastrophic vascular compromise.
Question 64
Answer: D - Polycystic ovarian syndrome
The patient with documented CAD and chest pain requires coronary angiography to assess for obstructive disease. The extent of disease will guide revascularization decisions.
Why the other choices are wrong:
A. Androgen - While pain control is needed, urgent reduction of the open ankle dislocation takes precedence.B. Cushing syndrome - Antibiotics for open injury are important but immediate reduction and vascular assessment are first.
C. Hypothyroidism - Imaging can guide reduction but this open injury requires urgent reduction to restore circulation.
D. Splinting is supportive but urgent reduction of the dislocation is the priority.
Question 65
Answer: E - Determination of urine sodium concentration 36 A 62-year-old man comes to the office for follow-up of benign prostatic hypertrophy (BPH), which was diagnosed 1 week ago. He had described a 6-month history of increased nocturia, double voiding, and decreased strength of urinary flow; he had not had these symptoms before. He has no personal or family history of prostate cancer. He takes no medications and he has no allergies. Physical examination 1 week ago was remarkable for an enlarged prostate without nodularity. Urinalysis and prostate-specific antigen tests were normal. Today, he has brought some newspaper articles about saw palmetto and wonders about its use in treatment of his symptoms. You recall a recent meta-analysis about the effectiveness of saw palmetto for BPH. In this study, saw palmetto was compared with placebo. The results are shown. Saw Palmetto Versus Placebo in the Symptomatic Treatment of Benign Prostatic Hypertrophy Treatment Improvement in Symptoms Placebo Saw Palmetto Statistical Significance Patient-reported 191/330 (58%) 242/329 (74%) p<0.001 Physician-assessed 100/262 (38%) 165/262 (63%) p<0.001
PCI with stent placement is appropriate for the patient with significant stenosis causing symptoms. Drug-eluting stents reduce restenosis compared to bare metal stents.
Why the other choices are wrong:
A. 24 - While reassurance is helpful for anxiety, objective signs (tachycardia, diaphoresis, tremor) suggest organic etiology.B. Determination of AM serum cortisol concentration - Anxiety treatment alone risks missing serious cardiopulmonary or metabolic pathology.
C. Determination of serum iron concentration - While hyperventilation occurs, the vital signs suggest organic disease not pure anxiety.
D. Determination of serum magnesium concentration - Family reassurance isn't appropriate without excluding serious underlying pathology.
Question 66
Answer: A - Improvement is seen in both physician-assessed and in patient-reported symptoms
Post-PCI, dual antiplatelet therapy with aspirin and P2Y12 inhibitor is mandatory for at least 12 months. Stopping these agents prematurely increases stent thrombosis risk.
Why the other choices are wrong:
A. Reassurance without evaluation risks missing serious life-threatening conditions causing symptoms.B. Patient - While anxiety is possible, the objective findings and vital signs suggest organic etiology.
C. Statistical significance is not important compared with symptom improvement - Anxiolytics may mask symptoms; evaluation for serious causes takes precedence.
D. Statistically significant changes in physician - Breathing exercises help panic attacks but don't exclude serious organic pathology.
Question 67
Answer: A - 4
Cardiac rehabilitation program including exercise, education, and risk factor management improves outcomes post-MI. It should be offered to all eligible patients.
Why the other choices are wrong:
A. While reassurance is potentially helpful, acute vertigo requires evaluation for serious neurologic causes.B. 6 - While peripheral causes are common, central causes must be excluded in acute vertigo.
C. 12 - Observation alone risks missing serious central pathology causing vertigo.
D. 25 - Medication without diagnosis can be harmful; determining cause takes precedence.
Question 68
Answer: B - Increased intensity of the murmur with deep inspiration
The patient with diabetes and prior MI requires aggressive lipid lowering beyond LDL target of 70. High-intensity statin therapy is appropriate.
Why the other choices are wrong:
A. Decreased intensity of S - While rehabilitation helps recovery, determining cause and acute management takes precedence.B. Reassurance without evaluation is inappropriate for acute neurologic symptoms.
C. Increased intensity of the murmur with forced expiration - Imaging may not always change acute management but helps determine etiology and prognosis.
D. Positive Kussmaul sign (rise in jugular venous pulse with inspiration) - Observation without targeted evaluation risks missing serious diagnoses.
Question 69
Answer: D - Use of rubber urethral catheters
Beta-blocker therapy post-MI reduces reinfarction and sudden cardiac death risk. Long-term beta-blockers are indicated for all MI survivors with preserved ejection fraction.
Why the other choices are wrong:
A. Administration of injectable medications with disposable syringes - While reassurance may help, objective findings of altered mentation require urgent evaluation.B. Preparation of food by outside contractors - Psychiatric evaluation is appropriate but medical causes must be excluded first.
C. Type of cleaning agents used to sterilize bed linens - Sedation can mask serious organic pathology; diagnostic evaluation takes precedence.
D. Family involvement is supportive but urgent medical evaluation and management take precedence.
Question 70
Answer: E - Spleen
The elderly patient with prior MI and atrial fibrillation requires anticoagulation for stroke prevention. The choice of agent depends on renal function and other factors.
Why the other choices are wrong:
A. Aorta - While behavioral support is helpful, acute altered mental status requires medical evaluation.B. Epigastric artery - Psychiatric referral is premature without excluding serious medical causes of altered mentation.
C. Liver - Supportive care is appropriate but diagnostic evaluation for serious medical etiologies is first.
D. Middle colic artery - Medication without diagnosis can be harmful; determining etiology takes precedence.
Question 71
Answer: D - Rotator cuff detachment
Warfarin remains appropriate for patients with mechanical heart valves. The INR goal is 2 to 3 for aortic valves, 2.5 to 3.5 for mitral valves.
Why the other choices are wrong:
A. Acromioclavicular joint dysfunction - Insufficient INR allows clot formation. - Acromioclavicular joint dysfunction - Insufficient INR allows clot formation. doesn't fit this patient's presentation and clinical findings. Rotator cuff detachment is the correct answer.B. Damage to the capsular ligaments - Aspirin is inadequate for mechanical valves. - Damage to the capsular ligaments - Aspirin is inadequate for mechanical valves. doesn't fit this patient's presentation and clinical findings. Rotator cuff detachment is the correct answer.
C. Osteoarthritis of the glenohumeral joint - Reduced intensity increases thrombosis risk. - Osteoarthritis of the glenohumeral joint - Reduced intensity increases thrombosis risk. doesn't fit this patient's presentation and clinical findings. Rotator cuff detachment is the correct answer.
Question 72
Answer: B
The patient with atrial fibrillation, hypertension, and diabetes has high stroke risk. Rate control with beta-blockers or calcium channel blockers and anticoagulation are essential.
Question 73
Answer: C - Infant HIV infection was the only significantly associated factor
Amiodarone provides rhythm control in patients with atrial fibrillation but has significant side effects. It is reserved for symptomatic patients with failed first-line therapies.
Why the other choices are wrong:
A. All factors appeared to have an effect on HCV transmission - Beta-blockers are first-line, not amiodarone. - All factors appeared to have an effect on HCV transmission - Beta-blockers are first-line, not amiodarone. doesn't fit this patient's presentation and clinical findings. Infant HIV infection was the only significantly associated factor is the correct answer.B. Fetal electrode monitoring was protective against HCV - Digoxin has limited efficacy in AFib. - Fetal electrode monitoring was protective against HCV - Digoxin has limited efficacy in AFib. doesn't fit this patient's presentation and clinical findings. Infant HIV infection was the only significantly associated factor is the correct answer.
D. Maternal chorioamnionitis was the most significantly associated factor - Observation risks hemodynamic deterioration. - Maternal chorioamnionitis was the most significantly associated factor - Observation risks hemodynamic deterioration. doesn't fit this patient's presentation and clinical findings. Infant HIV infection was the only significantly associated factor is the correct answer.
Question 74
Answer: B - Arrange for consultation with a home hospice team
Radiofrequency ablation of atrial fibrillation offers cure in selected patients, particularly those with paroxysmal AF. Success rates are highest with earlier intervention.
Why the other choices are wrong:
A. Admit the patient to the hospital - No intervention allows continued arrhythmia. - Admit the patient to the hospital - No intervention allows continued arrhythmia. doesn't fit this patient's presentation and clinical findings. Arrange for consultation with a home hospice team is the correct answer.C. Consult with the hospital ethics committee - Medical therapy failure warrants ablation. - Consult with the hospital ethics committee - Medical therapy failure warrants ablation. doesn't fit this patient's presentation and clinical findings. Arrange for consultation with a home hospice team is the correct answer.
D. Order a home continuous positive airway pressure machine and instruct the daughter in its use - Rate control without rhythm control suboptimal. - Order a home continuous positive airway pressure machine and instruct the daughter in its use - Rate control without rhythm control suboptimal. doesn't fit this patient's presentation and clinical findings. Arrange for consultation with a home hospice team is the correct answer.
Question 75
Answer: D - Initiate a family meeting to discuss the parents' concerns with their son
The patient with new-onset atrial fibrillation and rapid ventricular response requires rate control. IV diltiazem or beta-blockers are effective options.
Why the other choices are wrong:
A. Advise the parents not to influence their son's decision in this matter - Verapamil is less effective than diltiazem. - Advise the parents not to influence their son's decision in this matter - Verapamil is less effective than diltiazem. doesn't fit this patient's presentation and clinical findings. Initiate a family meeting to discuss the parents' concerns with their son is the correct answer.B. Arrange for evaluation of their son's competency - Beta-blockers are first-line for rate control. - Arrange for evaluation of their son's competency - Beta-blockers are first-line for rate control. doesn't fit this patient's presentation and clinical findings. Initiate a family meeting to discuss the parents' concerns with their son is the correct answer.
C. Enroll their son in a smoking cessation program - Digoxin has limited efficacy for rapid AFib. - Enroll their son in a smoking cessation program - Digoxin has limited efficacy for rapid AFib. doesn't fit this patient's presentation and clinical findings. Initiate a family meeting to discuss the parents' concerns with their son is the correct answer.
Question 76
Answer: D - Explain that waiving the required copayment could be interpreted as insurance fraud
Routinely waiving insurance copayments can constitute insurance fraud, as it misrepresents the actual charges to the insurance company. The physician should explain this legal and ethical issue to the patient. Copayments exist as part of the insurance contract, and waiving them without proper documentation of financial hardship violates that agreement.
Why the other choices are wrong:
A. Agree to bill only the insurance company this one time, but not in the future - Even a one-time waiver without documentation misrepresents charges. - Agree to bill only the insurance company this one time, but not in the future - Even a one-time waiver without documentation misrepresents charges. doesn't fit this patient's presentation and clinical findings. Explain that waiving the required copayment could be interpreted as insurance fraud is the correct answer.B. Bill only the insurance company on a routine basis as the patient requests - This is the definition of insurance fraud through routine copayment waiver. - Bill only the insurance company on a routine basis as the patient requests - This is the definition of insurance fraud through routine copayment waiver. doesn't fit this patient's presentation and clinical findings. Explain that waiving the required copayment could be interpreted as insurance fraud is the correct answer.
C. Bill the patient a reduced total fee for the visit - Reducing the total fee rather than collecting the copayment still misrepresents charges to the insurer. - Bill the patient a reduced total fee for the visit - Reducing the total fee rather than collecting the copayment still misrepresents charges to the insurer. doesn't fit this patient's presentation and clinical findings. Explain that waiving the required copayment could be interpreted as insurance fraud is the correct answer.
Question 77
Answer: C - Heparin-induced thrombocytopenia
Acute ischemic stroke within three hours of symptom onset is treated with IV thrombolytics if no contraindications. This patient meets criteria for rt-PA therapy.
Why the other choices are wrong:
A. Disseminated intravascular coagulation - Delayed thrombolytics increase infarct size. - Disseminated intravascular coagulation - Delayed thrombolytics increase infarct size. doesn't fit this patient's presentation and clinical findings. Heparin-induced thrombocytopenia is the correct answer.B. Factor IX deficiency - No intervention allows progression to LBBB. - Factor IX deficiency - No intervention allows progression to LBBB. doesn't fit this patient's presentation and clinical findings. Heparin-induced thrombocytopenia is the correct answer.
D. Idiopathic protein C deficiency - Observation beyond three hours wastes window. - Idiopathic protein C deficiency - Observation beyond three hours wastes window. doesn't fit this patient's presentation and clinical findings. Heparin-induced thrombocytopenia is the correct answer.
Block 3: Questions 78-107
Question 78
Answer: A - Administer atropine
The patient with risk factors for carotid disease and TIA requires carotid imaging. Carotid endarterectomy reduces stroke risk for significant stenosis (>70%).
Why the other choices are wrong:
B. Administer isoproterenol - Duplex ultrasound alone guides intervention. - Administer isoproterenol - Duplex ultrasound alone guides intervention. doesn't fit this patient's presentation and clinical findings. Administer atropine is the correct answer.C. Begin synchronized cardioversion - Observation risks recurrent stroke. - Begin synchronized cardioversion - Observation risks recurrent stroke. doesn't fit this patient's presentation and clinical findings. Administer atropine is the correct answer.
D. Insert a pacemaker - Antiplatelet therapy alone is insufficient. - Insert a pacemaker - Antiplatelet therapy alone is insufficient. doesn't fit this patient's presentation and clinical findings. Administer atropine is the correct answer.
Question 79
Answer: E
Long-term management of stroke prevention requires antiplatelet therapy with aspirin or clopidogrel. Aggressive management of hypertension is also critical.
Question 80
Answer: A - Amputation
The patient with lacunar stroke from chronic hypertension requires long-term blood pressure control. ACE inhibitors provide stroke risk reduction beyond blood pressure lowering.
Why the other choices are wrong:
B. Application of topical collagenase - Metoprolol lacks stroke risk reduction. - Application of topical collagenase - Metoprolol lacks stroke risk reduction. doesn't fit this patient's presentation and clinical findings. Amputation is the correct answer.C. Debridement of necrotic skin over the toes - Thiazide diuretics worsen glucose control. - Debridement of necrotic skin over the toes - Thiazide diuretics worsen glucose control. doesn't fit this patient's presentation and clinical findings. Amputation is the correct answer.
D. Hyperbaric oxygen - Observation without BP control risks recurrence. - Hyperbaric oxygen - Observation without BP control risks recurrence. doesn't fit this patient's presentation and clinical findings. Amputation is the correct answer.
Question 81
Answer: B - Imiquimod
The patient with large ischemic stroke and cerebral edema may develop herniation. Osmotic therapy with mannitol or hypertonic saline can temporarily reduce intracranial pressure.
Why the other choices are wrong:
A. Acyclovir - Hypertonic saline has less proven efficacy. - Acyclovir - Hypertonic saline has less proven efficacy. doesn't fit this patient's presentation and clinical findings. Imiquimod is the correct answer.C. Levofloxacin - Sedation alone does not reduce ICP. - Levofloxacin - Sedation alone does not reduce ICP. doesn't fit this patient's presentation and clinical findings. Imiquimod is the correct answer.
D. Metronidazole - Hyperventilation is temporary measure only. - Metronidazole - Hyperventilation is temporary measure only. doesn't fit this patient's presentation and clinical findings. Imiquimod is the correct answer.
Question 82
Answer: E - No treatment is needed at this time
The patient with hemorrhagic stroke requires reversal of anticoagulation if appropriate. Neurosurgical consultation is indicated for potential interventions.
Why the other choices are wrong:
A. Immediate application of braces - Observation risks continued intracranial hemorrhage. - Immediate application of braces - Observation risks continued intracranial hemorrhage. doesn't fit this patient's presentation and clinical findings. No treatment is needed at this time is the correct answer.B. Increased intake of vitamin D - Blood pressure elevation worsens hemorrhage. - Increased intake of vitamin D - Blood pressure elevation worsens hemorrhage. doesn't fit this patient's presentation and clinical findings. No treatment is needed at this time is the correct answer.
C. A special exercise program - Medical therapy alone is insufficient. - A special exercise program - Medical therapy alone is insufficient. doesn't fit this patient's presentation and clinical findings. No treatment is needed at this time is the correct answer.
Question 83
Answer: C - Continuous humidified oxygen
The patient with subarachnoid hemorrhage and vasospasm requires management to prevent ischemic complications. Calcium channel blockers like nimodipine reduce cerebral infarction risk.
Why the other choices are wrong:
A. Azathioprine therapy - Vasodilators increase intracranial pressure. - Azathioprine therapy - Vasodilators increase intracranial pressure. doesn't fit this patient's presentation and clinical findings. Continuous humidified oxygen is the correct answer.B. Bronchoscopy - Anticonvulsants do not prevent vasospasm. - Bronchoscopy - Anticonvulsants do not prevent vasospasm. doesn't fit this patient's presentation and clinical findings. Continuous humidified oxygen is the correct answer.
D. Nocturnal continuous positive airway pressure (CPAP) - Hypertensive therapy risks rebleeding. - Nocturnal continuous positive airway pressure (CPAP) - Hypertensive therapy risks rebleeding. doesn't fit this patient's presentation and clinical findings. Continuous humidified oxygen is the correct answer.
Question 84
Answer: D - Seizures
Hypertensive emergencies with end-organ damage require immediate blood pressure reduction. IV labetalol or nitroprusside are appropriate agents for rapid control.
Why the other choices are wrong:
A. Atrioventricular nodal reentrant tachycardia - Rapid BP reduction risks stroke. - Atrioventricular nodal reentrant tachycardia - Rapid BP reduction risks stroke. doesn't fit this patient's presentation and clinical findings. Seizures is the correct answer.B. Pancreatitis - Gradual reduction with IV labetalol preferred. - Pancreatitis - Gradual reduction with IV labetalol preferred. doesn't fit this patient's presentation and clinical findings. Seizures is the correct answer.
C. Pulmonary edema - Esmolol has short duration inadequate for emergencies. - Pulmonary edema - Esmolol has short duration inadequate for emergencies. doesn't fit this patient's presentation and clinical findings. Seizures is the correct answer.
Question 85
Answer: B - Administration of diltiazem
The elderly patient with severe headache and elevated blood pressure has hypertensive emergency. Careful, gradual reduction of blood pressure prevents stroke from overcorrection.
Why the other choices are wrong:
A. Administration of amiodarone - Rapid reduction risks stroke progression. - Administration of amiodarone - Rapid reduction risks stroke progression. doesn't fit this patient's presentation and clinical findings. Administration of diltiazem is the correct answer.C. Cardioversion - Slow reduction risks continued organ damage. - Cardioversion - Slow reduction risks continued organ damage. doesn't fit this patient's presentation and clinical findings. Administration of diltiazem is the correct answer.
D. Consultation with a cardiologist - Nitroprusside causes tachyphylaxis. - Consultation with a cardiologist - Nitroprusside causes tachyphylaxis. doesn't fit this patient's presentation and clinical findings. Administration of diltiazem is the correct answer.
Question 86
Answer: C
Dipyridamole combined with aspirin provides superior stroke prevention compared to aspirin alone in secondary prevention after TIA.
Question 87
Answer: A - Incision and drainage
The patient with unstable angina requires hospitalization, continuous cardiac monitoring, and antiplatelet therapy. Beta-blockers and nitrates provide symptom relief and ischemia reduction.
Why the other choices are wrong:
B. Psychiatric consultation - NSAIDs increase cardiac event risk. - Psychiatric consultation - NSAIDs increase cardiac event risk. doesn't fit this patient's presentation and clinical findings. Incision and drainage is the correct answer.C. Topical silver sulfadiazine - Calcium channel blockers lack ischemia reduction. - Topical silver sulfadiazine - Calcium channel blockers lack ischemia reduction. doesn't fit this patient's presentation and clinical findings. Incision and drainage is the correct answer.
D. Transfer to a burn center - Observation risks MI or death. - Transfer to a burn center - Observation risks MI or death. doesn't fit this patient's presentation and clinical findings. Incision and drainage is the correct answer.
Question 88
Answer: E - Reposition the chest tube
The patient with elevated troponin and EKG changes has acute MI. Immediate reperfusion therapy with PCI is indicated if STEMI; dual antiplatelet therapy is essential.
Why the other choices are wrong:
A. Add 4 cm of positive end-expiratory pressure - Delayed reperfusion worsens outcomes. - Add 4 cm of positive end-expiratory pressure - Delayed reperfusion worsens outcomes. doesn't fit this patient's presentation and clinical findings. Reposition the chest tube is the correct answer.B. Administer β-blocking medications - Medical therapy alone is insufficient for STEMI. - Administer β-blocking medications - Medical therapy alone is insufficient for STEMI. doesn't fit this patient's presentation and clinical findings. Reposition the chest tube is the correct answer.
C. Administer alprazolam - Observation risks cardiogenic shock. - Administer alprazolam - Observation risks cardiogenic shock. doesn't fit this patient's presentation and clinical findings. Reposition the chest tube is the correct answer.
Question 89
Answer: B - Influenza
The patient with non-STEMI requires risk stratification with biomarkers and stress testing. Dual antiplatelet therapy and anticoagulation are standard of care.
Why the other choices are wrong:
A. Hepatitis - Observation risks progression to cardiogenic shock. - Hepatitis - Observation risks progression to cardiogenic shock. doesn't fit this patient's presentation and clinical findings. Influenza is the correct answer.C. Pertussis - Medical therapy alone insufficient for NSTEMI. - Pertussis - Medical therapy alone insufficient for NSTEMI. doesn't fit this patient's presentation and clinical findings. Influenza is the correct answer.
D. Poliomyelitis - Delayed angiography increases ischemia. - Poliomyelitis - Delayed angiography increases ischemia. doesn't fit this patient's presentation and clinical findings. Influenza is the correct answer.
Question 90
Answer: B - Order CT scan of the head
The patient with stable angina and positive stress test requires coronary angiography. The location and extent of stenosis will guide revascularization decisions.
Why the other choices are wrong:
A. Begin a trial of a β-blocking medication - Ischemic preconditioning is not therapeutic. - Begin a trial of a β-blocking medication - Ischemic preconditioning is not therapeutic. doesn't fit this patient's presentation and clinical findings. Order CT scan of the head is the correct answer.C. Order EEG - Order EEG doesn't fit this patient's presentation and clinical findings. Order CT scan of the head is the correct answer.
D. Refer him for consultation with a neurologist - Observation allows disease progression. - Refer him for consultation with a neurologist - Observation allows disease progression. doesn't fit this patient's presentation and clinical findings. Order CT scan of the head is the correct answer.
Question 91
Answer: C - Smoking cessation program
The patient with critical LAD stenosis and ejection fraction <35% is a candidate for CABG. This provides superior outcomes compared to medical management alone in this subset.
Why the other choices are wrong:
A. Biofeedback-based stress reduction program - PTCA alone has high restenosis rate. - Biofeedback-based stress reduction program - PTCA alone has high restenosis rate. doesn't fit this patient's presentation and clinical findings. Smoking cessation program is the correct answer.B. More rigorous and consistent exercise program - Medical therapy alone is inadequate. - More rigorous and consistent exercise program - Medical therapy alone is inadequate. doesn't fit this patient's presentation and clinical findings. Smoking cessation program is the correct answer.
D. Strict low-calorie diet - Observation risks sudden cardiac death. - Strict low-calorie diet - Observation risks sudden cardiac death. doesn't fit this patient's presentation and clinical findings. Smoking cessation program is the correct answer.
Question 92
Answer: B - Methotrexate, orally
Endocarditis in IVDU requires prolonged IV antibiotics targeted to the organism. TEE is more sensitive than TTE for detecting vegetations and complications.
Why the other choices are wrong:
A. Cyclosporine, orally - Oral antibiotics are inadequate for IVDU endocarditis. - Cyclosporine, orally - Oral antibiotics are inadequate for IVDU endocarditis. doesn't fit this patient's presentation and clinical findings. Methotrexate, orally is the correct answer.C. Phototherapy - Three-week course is insufficient duration. - Phototherapy - Three-week course is insufficient duration. doesn't fit this patient's presentation and clinical findings. Methotrexate, orally is the correct answer.
D. Vitamin D, orally - Observation allows septic emboli. - Vitamin D, orally - Observation allows septic emboli. doesn't fit this patient's presentation and clinical findings. Methotrexate, orally is the correct answer.
Question 93
Answer: E
The patient with community-acquired bacterial meningitis requires empiric antibiotics covering common organisms. Dexamethasone given with antibiotics improves outcomes.
Question 94
Answer: E - The patient is at no increased risk
Prophylactic antibiotics are indicated for close contacts of meningococcal meningitis. Rifampin, ciprofloxacin, or ceftriaxone are appropriate options.
Why the other choices are wrong:
A. Cold intolerance - Delayed prophylaxis increases secondary cases. - Cold intolerance - Delayed prophylaxis increases secondary cases. doesn't fit this patient's presentation and clinical findings. The patient is at no increased risk is the correct answer.B. Hypertension - Limited duration prophylaxis risks continued transmission. - Hypertension - Limited duration prophylaxis risks continued transmission. doesn't fit this patient's presentation and clinical findings. The patient is at no increased risk is the correct answer.
C. Polyuria - No prophylaxis allows spread to contacts. - Polyuria - No prophylaxis allows spread to contacts. doesn't fit this patient's presentation and clinical findings. The patient is at no increased risk is the correct answer.
Question 95
Answer: D - Provide reassurance that she is simply still premenopausal
The patient with severe headache and fever with positive Kernig sign has meningitis. CSF analysis with Gram stain and culture is essential for diagnosis.
Why the other choices are wrong:
A. Order fine-needle biopsy of the endometrium - Delayed lumbar puncture risks deterioration. - Order fine-needle biopsy of the endometrium - Delayed lumbar puncture risks deterioration. doesn't fit this patient's presentation and clinical findings. Provide reassurance that she is simply still premenopausal is the correct answer.B. Order pelvic ultrasonography - No antibiotics allows fulminant meningitis. - Order pelvic ultrasonography - No antibiotics allows fulminant meningitis. doesn't fit this patient's presentation and clinical findings. Provide reassurance that she is simply still premenopausal is the correct answer.
C. Order serum estradiol and follicle-stimulating hormone concentrations - Observation without cultures risks misdiagnosis. - Order serum estradiol and follicle-stimulating hormone concentrations - Observation without cultures risks misdiagnosis. doesn't fit this patient's presentation and clinical findings. Provide reassurance that she is simply still premenopausal is the correct answer.
E. Recommend losing weight to help facilitate the onset of menopause - No treatment risks death. - Recommend losing weight to help facilitate the onset of menopause - No treatment risks death. doesn't fit this patient's presentation and clinical findings. Provide reassurance that she is simply still premenopausal is the correct answer.
Question 96
Answer: D - Initiation of a daily corticosteroid inhaler
The patient with tuberculosis meningitis requires prolonged anti-TB therapy with at least four drugs initially. Dexamethasone improves outcomes in TB meningitis.
Why the other choices are wrong:
A. Chest x-ray - Observation risks neurologic deterioration. - Chest x-ray - Observation risks neurologic deterioration. doesn't fit this patient's presentation and clinical findings. Initiation of a daily corticosteroid inhaler is the correct answer.B. Fexofenadine therapy - Two-drug therapy is inadequate for TB meningitis. - Fexofenadine therapy - Two-drug therapy is inadequate for TB meningitis. doesn't fit this patient's presentation and clinical findings. Initiation of a daily corticosteroid inhaler is the correct answer.
C. Increased use of the albuterol inhaler - No dexamethasone increases permanent disability. - Increased use of the albuterol inhaler - No dexamethasone increases permanent disability. doesn't fit this patient's presentation and clinical findings. Initiation of a daily corticosteroid inhaler is the correct answer.
Question 97
Answer: E - Removal of the nail through endoscopic esophagogastroscopy
The patient with fever, neck stiffness, and seizure has meningitis. Anticonvulsants are used for acute seizure management but not for long-term prophylaxis in this setting.
Why the other choices are wrong:
A. Administration of a cathartic agent to induce passage of the nail through the gut - Observation without treatment risks status epilepticus. - Administration of a cathartic agent to induce passage of the nail through the gut - Observation without treatment risks status epilepticus. doesn't fit this patient's presentation and clinical findings. Removal of the nail through endoscopic esophagogastroscopy is the correct answer.B. Administration of ipecac to induce vomiting and expectoration of the nail - No antibiotics allow untreated meningitis. - Administration of ipecac to induce vomiting and expectoration of the nail - No antibiotics allow untreated meningitis. doesn't fit this patient's presentation and clinical findings. Removal of the nail through endoscopic esophagogastroscopy is the correct answer.
C. Observation to allow passage of the nail via normal peristalsis - Long-term prophylaxis is unnecessary. - Observation to allow passage of the nail via normal peristalsis - Long-term prophylaxis is unnecessary. doesn't fit this patient's presentation and clinical findings. Removal of the nail through endoscopic esophagogastroscopy is the correct answer.
Question 98
Answer: C - Instruct him to cease alcohol consumption and retest him in 2 months
The patient with HIV and CD4 <50 has high risk for CMV infection. CMV retinitis causes "pizza pie" appearance on fundoscopy and requires urgent treatment.
Why the other choices are wrong:
A. Begin interferon-alfa therapy - Immediate treatment prevents vision loss. - Begin interferon-alfa therapy - Immediate treatment prevents vision loss. doesn't fit this patient's presentation and clinical findings. Instruct him to cease alcohol consumption and retest him in 2 months is the correct answer.B. Begin corticosteroid therapy - Delayed treatment worsens outcomes. - Begin corticosteroid therapy - Delayed treatment worsens outcomes. doesn't fit this patient's presentation and clinical findings. Instruct him to cease alcohol consumption and retest him in 2 months is the correct answer.
D. Order hepatitis B virus polymerase chain reaction test - Observation risks progression to blindness. - Order hepatitis B virus polymerase chain reaction test - Observation risks progression to blindness. doesn't fit this patient's presentation and clinical findings. Instruct him to cease alcohol consumption and retest him in 2 months is the correct answer.
Question 99
Answer: E - Provide education for well-baby care
The patient with advanced AIDS and opportunistic infections requires HAART. CD4 recovery with effective antiretroviral therapy is essential for immune reconstitution.
Why the other choices are wrong:
A. Begin oral ferrous sulfate - Medical management alone inadequate for AIDS. - Begin oral ferrous sulfate - Medical management alone inadequate for AIDS. doesn't fit this patient's presentation and clinical findings. Provide education for well-baby care is the correct answer.B. Begin oral methyldopa - Observation risks opportunistic infections. - Begin oral methyldopa - Observation risks opportunistic infections. doesn't fit this patient's presentation and clinical findings. Provide education for well-baby care is the correct answer.
C. Institute fundal massage - Antiretroviral monotherapy is insufficient. - Institute fundal massage - Antiretroviral monotherapy is insufficient. doesn't fit this patient's presentation and clinical findings. Provide education for well-baby care is the correct answer.
Question 100
Answer: A - Arrange consultation with an orthopaedic surgeon
The patient with newly diagnosed HIV requires baseline CD4 count and viral load. Antiretroviral therapy should be initiated regardless of CD4 count in current guidelines.
Why the other choices are wrong:
B. Have her see her primary care physician in 1 week - Delayed therapy allows disease progression. - Have her see her primary care physician in 1 week - Delayed therapy allows disease progression. doesn't fit this patient's presentation and clinical findings. Arrange consultation with an orthopaedic surgeon is the correct answer.C. Order arthrography of the wrist - CD4 threshold-based approach is outdated. - Order arthrography of the wrist - CD4 threshold-based approach is outdated. doesn't fit this patient's presentation and clinical findings. Arrange consultation with an orthopaedic surgeon is the correct answer.
D. Order MRI of the wrist - Observation risks opportunistic infections. - Order MRI of the wrist - Observation risks opportunistic infections. doesn't fit this patient's presentation and clinical findings. Arrange consultation with an orthopaedic surgeon is the correct answer.
Question 101
Answer: A
Prophylaxis for PCP with TMP-SMX is indicated when CD4 <200. This is one of the most effective prophylactic strategies in HIV management.
Question 102
Answer: E - Treat the symptoms
The patient with CD4 <50 and fever requires workup for MAC and other opportunistic infections. Azithromycin prophylaxis is indicated at this CD4 level.
Why the other choices are wrong:
A. Determine the erythrocyte sedimentation rate - Observation risks MAC at CD4 <50. - Determine the erythrocyte sedimentation rate - Observation risks MAC at CD4 <50. doesn't fit this patient's presentation and clinical findings. Treat the symptoms is the correct answer.B. Determine the serum IgE concentration - Clarithromycin monotherapy risks resistance. - Determine the serum IgE concentration - Clarithromycin monotherapy risks resistance. doesn't fit this patient's presentation and clinical findings. Treat the symptoms is the correct answer.
C. Determine the total eosinophil count - Azithromycin alone is first-line agent. - Determine the total eosinophil count - Azithromycin alone is first-line agent. doesn't fit this patient's presentation and clinical findings. Treat the symptoms is the correct answer.
Question 103
Answer: C - Measurement of lower extremity compartment pressures
The patient with HIV and headache requires CSF analysis to evaluate for meningitis. Cryptococcal antigen testing is essential in this patient population.
Why the other choices are wrong:
A. Application of ice to the right lower extremity - Observation risks cryptococcal meningitis. - Application of ice to the right lower extremity - Observation risks cryptococcal meningitis. doesn't fit this patient's presentation and clinical findings. Measurement of lower extremity compartment pressures is the correct answer.B. Cyclobenzaprine therapy - Lumbar puncture is necessary for diagnosis. - Cyclobenzaprine therapy - Lumbar puncture is necessary for diagnosis. doesn't fit this patient's presentation and clinical findings. Measurement of lower extremity compartment pressures is the correct answer.
D. MRI of the right lower extremity - CT brain may miss early meningitis. - MRI of the right lower extremity - CT brain may miss early meningitis. doesn't fit this patient's presentation and clinical findings. Measurement of lower extremity compartment pressures is the correct answer.
Question 104
Answer: D - Prescribe rifampin
The patient with CNS lymphoma in HIV presents with focal neurologic deficits. MRI showing ring-enhancing lesion with CSF analysis confirms diagnosis.
Why the other choices are wrong:
A. Administer the meningococcal vaccine - Observation risks mass effect deterioration. - Administer the meningococcal vaccine - Observation risks mass effect deterioration. doesn't fit this patient's presentation and clinical findings. Prescribe rifampin is the correct answer.B. Prescribe doxycycline - Biopsy risks hemorrhage unnecessarily. - Prescribe doxycycline - Biopsy risks hemorrhage unnecessarily. doesn't fit this patient's presentation and clinical findings. Prescribe rifampin is the correct answer.
C. Prescribe penicillin - No imaging misses diagnosis. - Prescribe penicillin - No imaging misses diagnosis. doesn't fit this patient's presentation and clinical findings. Prescribe rifampin is the correct answer.
Question 105
Answer: D - Phenoxybenzamine
The patient with HIV and CD4 <100 is at risk for CMV infection. Ganciclovir is used for treatment of CMV end-organ disease.
Why the other choices are wrong:
A. Labetalol - Observation risks CMV retinitis blindness. - Labetalol - Observation risks CMV retinitis blindness. doesn't fit this patient's presentation and clinical findings. Phenoxybenzamine is the correct answer.B. A loading dose of potassium chloride - Foscarnet is less preferred than ganciclovir. - A loading dose of potassium chloride - Foscarnet is less preferred than ganciclovir. doesn't fit this patient's presentation and clinical findings. Phenoxybenzamine is the correct answer.
C. Nifedipine - Observation risks vision loss. - Nifedipine - Observation risks vision loss. doesn't fit this patient's presentation and clinical findings. Phenoxybenzamine is the correct answer.
Question 106
Answer: C - Echocardiography
The patient with AIDS requiring MAC prophylaxis should receive azithromycin. Other agents like clarithromycin are alternatives for macrolide-sensitive organisms.
Why the other choices are wrong:
A. Cardiac catheterization - Observation risks disseminated MAC. - Cardiac catheterization - Observation risks disseminated MAC. doesn't fit this patient's presentation and clinical findings. Echocardiography is the correct answer.B. CT scan of the chest - Azithromycin monotherapy causes resistance. - CT scan of the chest - Azithromycin monotherapy causes resistance. doesn't fit this patient's presentation and clinical findings. Echocardiography is the correct answer.
D. MUGA scan - Clarithromycin lacks adequate CNS penetration. - MUGA scan - Clarithromycin lacks adequate CNS penetration. doesn't fit this patient's presentation and clinical findings. Echocardiography is the correct answer.
Question 107
Answer: D - Pulmonary hypertension
The patient with AIDS wasting syndrome benefits from testosterone or anabolic steroids. Combined with nutritional support and exercise, these improve outcomes.
Why the other choices are wrong:
A. Chronic pulmonary emboli - Observation risks continued wasting. - Chronic pulmonary emboli - Observation risks continued wasting. doesn't fit this patient's presentation and clinical findings. Pulmonary hypertension is the correct answer.B. Hypertrophic cardiomyopathy - Thalidomide lacks efficacy in wasting. - Hypertrophic cardiomyopathy - Thalidomide lacks efficacy in wasting. doesn't fit this patient's presentation and clinical findings. Pulmonary hypertension is the correct answer.
C. Interstitial lung disease - Medical management alone is inadequate. - Interstitial lung disease - Medical management alone is inadequate. doesn't fit this patient's presentation and clinical findings. Pulmonary hypertension is the correct answer.
Block 4: Questions 108-137
Question 108
Answer: B - Breast-feeding will increase the risk for transmitting HIV to the infant
The patient with bipolar disorder and acute mania requires mood stabilizer therapy. Lithium remains first-line despite requiring monitoring of levels and renal function.
Why the other choices are wrong:
A. Amniocentesis is recommended to rule out congenital HIV infection - Amniocentesis is recommended to rule out congenital HIV infection doesn't fit this patient's presentation and clinical findings. Breast-feeding will increase the risk for transmitting HIV to the infant is the correct answer.C. Immediate termination of pregnancy will decrease her risk for progression to AIDS - Valproate is second-line after lithium. - Immediate termination of pregnancy will decrease her risk for progression to AIDS - Valproate is second-line after lithium. doesn't fit this patient's presentation and clinical findings. Breast-feeding will increase the risk for transmitting HIV to the infant is the correct answer.
D. Repeat cesarean delivery may increase the risk for vertical transmission of HIV - Lamotrigine is for depression not mania. - Repeat cesarean delivery may increase the risk for vertical transmission of HIV - Lamotrigine is for depression not mania. doesn't fit this patient's presentation and clinical findings. Breast-feeding will increase the risk for transmitting HIV to the infant is the correct answer.
Question 109
Answer: D - 0.9% Saline
The patient with depression and suicidal ideation requires psychiatric hospitalization. Antidepressants alone may increase suicide risk and require close monitoring.
Why the other choices are wrong:
A. Bicarbonate - Antidepressants alone risk suicide increase. - Bicarbonate - Antidepressants alone risk suicide increase. doesn't fit this patient's presentation and clinical findings. 0.9% Saline is the correct answer.B. Calcium gluconate - Observation with suicidal ideation is unsafe. - Calcium gluconate - Observation with suicidal ideation is unsafe. doesn't fit this patient's presentation and clinical findings. 0.9% Saline is the correct answer.
Question 110
Answer: E - Urine protein concentration
The patient with anxiety disorder and panic attacks benefits from SSRIs or other antidepressants. CBT is also effective and often used in combination with pharmacotherapy.
Why the other choices are wrong:
A. Echocardiography - Benzodiazepines are not first-line for anxiety. - Echocardiography - Benzodiazepines are not first-line for anxiety. doesn't fit this patient's presentation and clinical findings. Urine protein concentration is the correct answer.B. HIV antibody study - Observation risks continued panic symptoms. - HIV antibody study - Observation risks continued panic symptoms. doesn't fit this patient's presentation and clinical findings. Urine protein concentration is the correct answer.
C. Serum B-type natriuretic peptide concentration - MAOI are not first-line choice. - Serum B-type natriuretic peptide concentration - MAOI are not first-line choice. doesn't fit this patient's presentation and clinical findings. Urine protein concentration is the correct answer.
Question 111
Answer: D - Her suitability for home dialysis
The patient with PTSD requires trauma-focused therapy like prolonged exposure or cognitive processing therapy. SSRIs are the pharmacologic agents of choice.
Why the other choices are wrong:
A. Her eligibility to receive Medicare - Observation risks PTSD chronification. - Her eligibility to receive Medicare - Observation risks PTSD chronification. doesn't fit this patient's presentation and clinical findings. Her suitability for home dialysis is the correct answer.B. Her history of an abdominal operation - Benzodiazepines prevent emotional processing. - Her history of an abdominal operation - Benzodiazepines prevent emotional processing. doesn't fit this patient's presentation and clinical findings. Her suitability for home dialysis is the correct answer.
C. Her history of arthritis - Sertraline is first-line SSRI. - Her history of arthritis - Sertraline is first-line SSRI. doesn't fit this patient's presentation and clinical findings. Her suitability for home dialysis is the correct answer.
Question 112
Answer: A - Administer intravenous antibiotics
The patient with schizophrenia and positive symptoms requires antipsychotic medication. Second-generation antipsychotics are preferred due to lower extrapyramidal side effect risk.
Why the other choices are wrong:
B. Await contact with the caregiver before proceeding with management - First-generation antipsychotics risk EPS. - Await contact with the caregiver before proceeding with management - First-generation antipsychotics risk EPS. doesn't fit this patient's presentation and clinical findings. Administer intravenous antibiotics is the correct answer.C. Obtain CT scan of the head - Clozapine is for treatment-resistant disease. - Obtain CT scan of the head - Clozapine is for treatment-resistant disease. doesn't fit this patient's presentation and clinical findings. Administer intravenous antibiotics is the correct answer.
D. Obtain echocardiography - Observation risks psychotic decompensation. - Obtain echocardiography - Observation risks psychotic decompensation. doesn't fit this patient's presentation and clinical findings. Administer intravenous antibiotics is the correct answer.
Question 113
Answer: A - Carbamazepine
The patient with schizophrenia and negative symptoms may benefit from clozapine if conventional antipsychotics are ineffective. It has unique benefits for negative symptoms.
Why the other choices are wrong:
B. Lamotrigine - Haloperidol risks extrapyramidal effects. - Lamotrigine - Haloperidol risks extrapyramidal effects. doesn't fit this patient's presentation and clinical findings. Carbamazepine is the correct answer.C. Levetiracetam - Conventional antipsychotics less effective for negative symptoms. - Levetiracetam - Conventional antipsychotics less effective for negative symptoms. doesn't fit this patient's presentation and clinical findings. Carbamazepine is the correct answer.
D. Topiramate - Observation risks continued negative symptoms. - Topiramate - Observation risks continued negative symptoms. doesn't fit this patient's presentation and clinical findings. Carbamazepine is the correct answer.
Question 114
Answer: D - Subcutaneous enoxaparin
The patient with acute agitation and psychosis requires IM antipsychotics for rapid sedation. Haloperidol or ziprasidone IM are appropriate choices.
Why the other choices are wrong:
A. Continuous application of bilateral lower extremity pneumatic compression devices - Observation prolongs agitation and risk. - Continuous application of bilateral lower extremity pneumatic compression devices - Observation prolongs agitation and risk. doesn't fit this patient's presentation and clinical findings. Subcutaneous enoxaparin is the correct answer.B. Continuous intravenous infusion of heparin titrated to a PTT of 1.5 to 2.0 times the control value - Oral medication not absorbed with agitation. - Continuous intravenous infusion of heparin titrated to a PTT of 1.5 to 2.0 times the control value - Oral medication not absorbed with agitation. doesn't fit this patient's presentation and clinical findings. Subcutaneous enoxaparin is the correct answer.
C. Oral warfarin - Lorazepam alone inadequate for acute psychosis. - Oral warfarin - Lorazepam alone inadequate for acute psychosis. doesn't fit this patient's presentation and clinical findings. Subcutaneous enoxaparin is the correct answer.
Question 115
Answer: C - Systemic hypertension
The patient with tardive dyskinesia from chronic antipsychotic use has permanent movement disorder. Dose reduction or switching agents may provide some benefit.
Why the other choices are wrong:
A. Atrial fibrillation - Dose increase worsens tardive dyskinesia. - Atrial fibrillation - Dose increase worsens tardive dyskinesia. doesn't fit this patient's presentation and clinical findings. Systemic hypertension is the correct answer.B. Cor pulmonale - Benztropine does not treat tardive dyskinesia. - Cor pulmonale - Benztropine does not treat tardive dyskinesia. doesn't fit this patient's presentation and clinical findings. Systemic hypertension is the correct answer.
Question 116
Answer: E - Stage of disease
The patient with neuroleptic malignant syndrome has elevated CK and altered mental status. Treatment includes discontinuing the antipsychotic and supportive care with dantrolene.
Why the other choices are wrong:
A. Future fertility plans - Observation risks irreversible damage. - Future fertility plans - Observation risks irreversible damage. doesn't fit this patient's presentation and clinical findings. Stage of disease is the correct answer.B. Hypertension - Benztropine alone does not treat NMS. - Hypertension - Benztropine alone does not treat NMS. doesn't fit this patient's presentation and clinical findings. Stage of disease is the correct answer.
C. Obesity - Cooling measures alone are inadequate. - Obesity - Cooling measures alone are inadequate. doesn't fit this patient's presentation and clinical findings. Stage of disease is the correct answer.
Question 117
Answer: B - Obtain a swallowing evaluation
The patient with OCD requiring treatment benefits from SSRIs at higher doses than typical antidepressant dosing. Cognitive-behavioral therapy with exposure and ritual prevention is also effective.
Why the other choices are wrong:
A. Obtain CT scan of the chest - Lower doses inadequate for OCD symptoms. - Obtain CT scan of the chest - Lower doses inadequate for OCD symptoms. doesn't fit this patient's presentation and clinical findings. Obtain a swallowing evaluation is the correct answer.C. Place a percutaneous endoscopic gastrostomy (PEG) tube - Benzodiazepines should not be monotherapy. - Place a percutaneous endoscopic gastrostomy (PEG) tube - Benzodiazepines should not be monotherapy. doesn't fit this patient's presentation and clinical findings. Obtain a swallowing evaluation is the correct answer.
D. Prescribe fludrocortisone - Antipsychotics alone inadequate for OCD. - Prescribe fludrocortisone - Antipsychotics alone inadequate for OCD. doesn't fit this patient's presentation and clinical findings. Obtain a swallowing evaluation is the correct answer.
Question 118
Answer: C - Dicloxacillin and clindamycin
The patient with adjustment disorder with depressed mood requires supportive psychotherapy. Antidepressants are not first-line unless symptoms are severe or persistent.
Why the other choices are wrong:
A. Ampicillin-sulbactam - Observation risks chronification. - Ampicillin-sulbactam - Observation risks chronification. doesn't fit this patient's presentation and clinical findings. Dicloxacillin and clindamycin is the correct answer.B. Cefazolin and gentamicin - Psychotropics unnecessary for adjustment disorder. - Cefazolin and gentamicin - Psychotropics unnecessary for adjustment disorder. doesn't fit this patient's presentation and clinical findings. Dicloxacillin and clindamycin is the correct answer.
D. Levofloxacin - Observation alone insufficient for severe disease. - Levofloxacin - Observation alone insufficient for severe disease. doesn't fit this patient's presentation and clinical findings. Dicloxacillin and clindamycin is the correct answer.
Question 119
Answer: A
The patient with dementia and behavioral disturbances should first have medical causes ruled out. Environmental modifications and behavioral approaches are preferred over pharmacotherapy.
Question 120
Answer: D - Order a transthoracic echocardiography
The patient with dementia requires evaluation for reversible causes including hypothyroidism, B12 deficiency, and normal pressure hydrocephalus.
Why the other choices are wrong:
A. Decrease the dose of metoprolol - Observation risks missing reversible dementia. - Decrease the dose of metoprolol - Observation risks missing reversible dementia. doesn't fit this patient's presentation and clinical findings. Order a transthoracic echocardiography is the correct answer.B. Increase the dose of prednisone - Limited workup misses B12 deficiency. - Increase the dose of prednisone - Limited workup misses B12 deficiency. doesn't fit this patient's presentation and clinical findings. Order a transthoracic echocardiography is the correct answer.
Question 121
Answer: A - Advise the patient to discontinue his bedtime drink of alcohol
The patient with mild cognitive impairment has intermediate risk of progression to dementia. Serial cognitive testing and neuropsychologic evaluation assist in management.
Why the other choices are wrong:
B. Advise the patient to read and snack in bed to relax - Acetylcholinesterase inhibitors not first-line for MCI. - Advise the patient to read and snack in bed to relax - Acetylcholinesterase inhibitors not first-line for MCI. doesn't fit this patient's presentation and clinical findings. Advise the patient to discontinue his bedtime drink of alcohol is the correct answer.C. Prescribe a vigorous pre-bedtime exercise regimen - Observation risks faster progression. - Prescribe a vigorous pre-bedtime exercise regimen - Observation risks faster progression. doesn't fit this patient's presentation and clinical findings. Advise the patient to discontinue his bedtime drink of alcohol is the correct answer.
D. Prescribe sertraline - No monitoring allows undetected decline. - Prescribe sertraline - No monitoring allows undetected decline. doesn't fit this patient's presentation and clinical findings. Advise the patient to discontinue his bedtime drink of alcohol is the correct answer.
Question 122
Answer: B - The infant has a 50% risk for hemophilia
Cholinesterase inhibitors like donepezil provide modest cognitive benefits in early to moderate Alzheimer disease. They are used as adjunctive therapy with other interventions.
Why the other choices are wrong:
A. The infant will neither have hemophilia nor be a carrier - Donepezil monotherapy is suboptimal. - The infant will neither have hemophilia nor be a carrier - Donepezil monotherapy is suboptimal. doesn't fit this patient's presentation and clinical findings. The infant has a 50% risk for hemophilia is the correct answer.C. The infant has a 50% risk for being a carrier - Memantine is less effective than donepezil. - The infant has a 50% risk for being a carrier - Memantine is less effective than donepezil. doesn't fit this patient's presentation and clinical findings. The infant has a 50% risk for hemophilia is the correct answer.
D. The infant has a 75% risk for hemophilia - Vitamin E lacks efficacy in dementia. - The infant has a 75% risk for hemophilia - Vitamin E lacks efficacy in dementia. doesn't fit this patient's presentation and clinical findings. The infant has a 50% risk for hemophilia is the correct answer.
Question 123
Answer: A - Incision and drainage
The patient with Parkinson disease and tremor benefits from anticholinergic medications initially. Levodopa is reserved for when disability becomes more significant.
Why the other choices are wrong:
B. Oral cefazolin therapy - Levodopa causes motor complications. - Oral cefazolin therapy - Levodopa causes motor complications. doesn't fit this patient's presentation and clinical findings. Incision and drainage is the correct answer.C. Topical neomycin therapy - Dopamine agonists alone inadequate long-term. - Topical neomycin therapy - Dopamine agonists alone inadequate long-term. doesn't fit this patient's presentation and clinical findings. Incision and drainage is the correct answer.
Question 124
Answer: A - Administer normal saline and add potassium once urinary output is adequate
The patient with Parkinson disease and motor complications from levodopa may benefit from deeper brain stimulation. This provides better symptomatic control than medication adjustments alone.
Why the other choices are wrong:
B. Correct the acidosis with oral bicarbonate solution - Medical optimization alone inadequate for tremor. - Correct the acidosis with oral bicarbonate solution - Medical optimization alone inadequate for tremor. doesn't fit this patient's presentation and clinical findings. Administer normal saline and add potassium once urinary output is adequate is the correct answer.C. Correct the dehydration with hypotonic saline solution - Thalamotomy is permanent and destructive. - Correct the dehydration with hypotonic saline solution - Thalamotomy is permanent and destructive. doesn't fit this patient's presentation and clinical findings. Administer normal saline and add potassium once urinary output is adequate is the correct answer.
D. Give phenobarbital to prevent hyponatremic seizures - Observation risks progressive disability. - Give phenobarbital to prevent hyponatremic seizures - Observation risks progressive disability. doesn't fit this patient's presentation and clinical findings. Administer normal saline and add potassium once urinary output is adequate is the correct answer.
Question 125
Answer: D - Clindamycin
The patient with multiple sclerosis and relapsing-remitting course benefits from disease-modifying therapy. Interferon-beta or glatiramer acetate reduce relapse rate and disability progression.
Why the other choices are wrong:
A. Amoxicillin - Observation risks disease progression. - Amoxicillin - Observation risks disease progression. doesn't fit this patient's presentation and clinical findings. Clindamycin is the correct answer.B. Ciprofloxacin - Corticosteroids alone inadequate for RRMS. - Ciprofloxacin - Corticosteroids alone inadequate for RRMS. doesn't fit this patient's presentation and clinical findings. Clindamycin is the correct answer.
C. Clarithromycin - Plasma exchange is for fulminant disease. - Clarithromycin - Plasma exchange is for fulminant disease. doesn't fit this patient's presentation and clinical findings. Clindamycin is the correct answer.
Question 126
Answer: D - Phentolamine
The patient with cocaine-induced chest pain and hypertension requires blood pressure control and cardiac imaging. Calcium channel blockers and nitrates are appropriate; beta-blockers are contraindicated (unopposed alpha effects).
Why the other choices are wrong:
A. Carvedilol - Alpha-blockers cause unopposed vasodilation. - Carvedilol - Alpha-blockers cause unopposed vasodilation. doesn't fit this patient's presentation and clinical findings. Phentolamine is the correct answer.B. Furosemide - Sedation increases cardiac risk. - Furosemide - Sedation increases cardiac risk. doesn't fit this patient's presentation and clinical findings. Phentolamine is the correct answer.
C. Metoprolol - NSAIDs increase coronary vasoconstriction. - Metoprolol - NSAIDs increase coronary vasoconstriction. doesn't fit this patient's presentation and clinical findings. Phentolamine is the correct answer.
Question 127
Answer: D - Intraoperative angiography
The patient with post-operative pulselessness in the foot after femoral-popliteal bypass has graft occlusion. Intraoperative angiography identifies the problem for surgical exploration or revision.
Why the other choices are wrong:
A. Bedside compartment pressure measurements - Bedside monitoring misses graft occlusion. - Bedside compartment pressure measurements - Bedside monitoring misses graft occlusion. doesn't fit this patient's presentation and clinical findings. Intraoperative angiography is the correct answer.B. Doppler ultrasonography of the left lower extremity - Duplex ultrasound cannot confirm patency. - Doppler ultrasonography of the left lower extremity - Duplex ultrasound cannot confirm patency. doesn't fit this patient's presentation and clinical findings. Intraoperative angiography is the correct answer.
C. Intra-arterial tissue plasminogen activator (tPA) therapy - Observation risks tissue necrosis. - Intra-arterial tissue plasminogen activator (tPA) therapy - Observation risks tissue necrosis. doesn't fit this patient's presentation and clinical findings. Intraoperative angiography is the correct answer.
Question 128
Answer: C - Nystatin
The 3-week-old infant with white mouth patches not scraping off has oral candidiasis. Nystatin suspension is the appropriate first-line treatment for thrush.
Why the other choices are wrong:
A. Acyclovir - Acyclovir treats herpes, not thrush. - Acyclovir - Acyclovir treats herpes, not thrush. doesn't fit this patient's presentation and clinical findings. Nystatin is the correct answer.B. Fluconazole - Fluconazole is systemic agent, not topical. - Fluconazole - Fluconazole is systemic agent, not topical. doesn't fit this patient's presentation and clinical findings. Nystatin is the correct answer.
D. Valacyclovir - Valacyclovir is for herpes infection. - Valacyclovir - Valacyclovir is for herpes infection. doesn't fit this patient's presentation and clinical findings. Nystatin is the correct answer.
Question 129
Answer: D - Refer the patient to a child psychiatrist
The 5-year-old with pica (eating dirt) and confirmed toxoplasmosis requires pyrimethamine and sulfadiazine. Additionally, referral to a child psychiatrist addresses the pica behavior.
Why the other choices are wrong:
A. Prescribe fluoxetine - Fluconazole alone does not address pica. - Prescribe fluoxetine - Fluconazole alone does not address pica. doesn't fit this patient's presentation and clinical findings. Refer the patient to a child psychiatrist is the correct answer.B. Prescribe methylphenidate - Sulfadiazine requires TMP combination. - Prescribe methylphenidate - Sulfadiazine requires TMP combination. doesn't fit this patient's presentation and clinical findings. Refer the patient to a child psychiatrist is the correct answer.
C. Prescribe risperidone - Spiramycin is not effective for toxoplasmosis. - Prescribe risperidone - Spiramycin is not effective for toxoplasmosis. doesn't fit this patient's presentation and clinical findings. Refer the patient to a child psychiatrist is the correct answer.
Question 130
Answer: D - This is probably due to the volume of intravenous fluid she has received; you will give her a dose of furosemide and discharge her home
The 45-year-old with acute foot pain, erythema, and 50,000 WBC in joint fluid has acute gout. NSAIDs like indomethacin are the first-line treatment for acute flares.
Why the other choices are wrong:
A. The sensation is probably due to the lidocaine spreading through the subcutaneous tissue and that she can be discharged home - Acetaminophen lacks anti-inflammatory effect. - The sensation is probably due to the lidocaine spreading through the subcutaneous tissue and that she can be discharged home - Acetaminophen lacks anti-inflammatory effect. doesn't fit this patient's presentation and clinical findings. This is probably due to the volume of intravenous fluid she has received; you will give her a dose of furosemide and discharge her home is the correct answer.B. This is a life-threatening clostridial infection; antibiotic therapy and an emergency operation will be arranged - Allopurinol worsens acute gout. - This is a life-threatening clostridial infection; antibiotic therapy and an emergency operation will be arranged - Allopurinol worsens acute gout. doesn't fit this patient's presentation and clinical findings. This is probably due to the volume of intravenous fluid she has received; you will give her a dose of furosemide and discharge her home is the correct answer.
C. This is a routine problem after surgical incisions and tissue dissection to obtain biopsy material - Colchicine takes days to work. - This is a routine problem after surgical incisions and tissue dissection to obtain biopsy material - Colchicine takes days to work. doesn't fit this patient's presentation and clinical findings. This is probably due to the volume of intravenous fluid she has received; you will give her a dose of furosemide and discharge her home is the correct answer.
Question 131
Answer: E
The post-biopsy patient with "spongy" skin and air on chest x-ray has subcutaneous emphysema from pleural puncture. Hospital admission for observation is appropriate; it usually resolves spontaneously.
Question 132
Answer: D - Oral dexamethasone therapy
The 2-year-old with stridor and respiratory distress despite oxygen has croup. Dexamethasone and racemic epinephrine provide rapid improvement in symptoms.
Why the other choices are wrong:
A. Intravenous aminophylline therapy - Aminophylline has narrow therapeutic window. - Intravenous aminophylline therapy - Aminophylline has narrow therapeutic window. doesn't fit this patient's presentation and clinical findings. Oral dexamethasone therapy is the correct answer.B. Intravenous antibiotic therapy - Antibiotics unnecessary without bacterial infection. - Intravenous antibiotic therapy - Antibiotics unnecessary without bacterial infection. doesn't fit this patient's presentation and clinical findings. Oral dexamethasone therapy is the correct answer.
C. Intubation - Intubation doesn't fit this patient's presentation and clinical findings. Oral dexamethasone therapy is the correct answer.
Question 133
Answer: B - Endoscopic evaluation and decompression
Endoscopic decompression is the initial management for cecal volvulus without signs of peritonitis or bowel necrosis. Colonoscopic decompression can relieve the obstruction and allow for assessment of mucosal viability before determining if surgical intervention is needed.
Why the other choices are wrong:
A. CT scan of the abdomen - Diagnosis is already established; CT would delay treatment without changing management. - CT scan of the abdomen - Diagnosis is already established; CT would delay treatment without changing management. doesn't fit this patient's presentation and clinical findings. Endoscopic evaluation and decompression is the correct answer.C. Intravenous fluid therapy and nasogastric tube placement with suction for 12 hours - Conservative management alone does not address the volvulus and risks progression to ischemia. - Intravenous fluid therapy and nasogastric tube placement with suction for 12 hours - Conservative management alone does not address the volvulus and risks progression to ischemia. doesn't fit this patient's presentation and clinical findings. Endoscopic evaluation and decompression is the correct answer.
D. Intravenous fluids and morphine therapy - Pain management alone does not treat the obstruction and morphine masks peritoneal signs. - Intravenous fluids and morphine therapy - Pain management alone does not treat the obstruction and morphine masks peritoneal signs. doesn't fit this patient's presentation and clinical findings. Endoscopic evaluation and decompression is the correct answer.
Question 134
Answer: E - Mannitol
The 12-year-old in DKA with falling glucose but persistent metabolic acidosis may develop cerebral edema. Mannitol is appropriate to manage increased intracranial pressure.
Why the other choices are wrong:
A. Bicarbonate - Bicarbonate worsens cerebral edema. - Bicarbonate - Bicarbonate worsens cerebral edema. doesn't fit this patient's presentation and clinical findings. Mannitol is the correct answer.B. Dexamethasone - Dexamethasone alone inadequate for DKA. - Dexamethasone - Dexamethasone alone inadequate for DKA. doesn't fit this patient's presentation and clinical findings. Mannitol is the correct answer.
C. 50% Dextrose - Dextrose drops glucose further. - 50% Dextrose - Dextrose drops glucose further. doesn't fit this patient's presentation and clinical findings. Mannitol is the correct answer.
Question 135
Answer: D - Recommend beginning a weight loss program
The 29-year-old woman with recurrent low back pain and obesity benefits from weight loss. This reduces mechanical stress on the spine and likelihood of recurrent episodes.
Why the other choices are wrong:
A. Administer an epidural injection of methylprednisolone - Epidural injection is invasive first-line. - Administer an epidural injection of methylprednisolone - Epidural injection is invasive first-line. doesn't fit this patient's presentation and clinical findings. Recommend beginning a weight loss program is the correct answer.B. Order MRI of the lumbosacral spine - MRI is not therapeutic intervention. - Order MRI of the lumbosacral spine - MRI is not therapeutic intervention. doesn't fit this patient's presentation and clinical findings. Recommend beginning a weight loss program is the correct answer.
C. Order x-rays of the lumbosacral spine - X-rays do not guide treatment. - Order x-rays of the lumbosacral spine - X-rays do not guide treatment. doesn't fit this patient's presentation and clinical findings. Recommend beginning a weight loss program is the correct answer.
Question 136
Answer: A - Recommend behavioral therapy
The 24-year-old with urinary symptoms related to anxiety about flying has somatic symptom disorder. Behavioral therapy and reassurance that the symptom is anxiety-related is appropriate management.
Why the other choices are wrong:
B. Recommend psychoanalytic psychotherapy - Psychoanalytic therapy is lengthy and expensive. - Recommend psychoanalytic psychotherapy - Psychoanalytic therapy is lengthy and expensive. doesn't fit this patient's presentation and clinical findings. Recommend behavioral therapy is the correct answer.C. Recommend that the patient avoid any stressful activities that cause the problem - Avoidance reinforces anxiety response. - Recommend that the patient avoid any stressful activities that cause the problem - Avoidance reinforces anxiety response. doesn't fit this patient's presentation and clinical findings. Recommend behavioral therapy is the correct answer.
D. Review the patient's sexual history - Sexual history review is not treatment. - Review the patient's sexual history - Sexual history review is not treatment. doesn't fit this patient's presentation and clinical findings. Recommend behavioral therapy is the correct answer.
Question 137
Answer: E - Metoprolol NOTE: THIS IS THE END OF BLOCK 4. ANY REMAINING TIME MAY BE USED TO CHECK ITEMS IN THIS BLOCK. 66 Answer Key for USMLE Step 3 Sample Questions Block 1: FIP
The 47-year-old with atrial fibrillation after failed beta-blocker therapy requires adenosine. This provides rapid rate control by blocking AV nodal conduction.
Why the other choices are wrong:
A. Adenosine - Adenosine causes tachycardia, not rate control. - Adenosine - Adenosine causes tachycardia, not rate control. doesn't fit this patient's presentation and clinical findings. Metoprolol NOTE: THIS IS THE END OF BLOCK 4. ANY REMAINING TIME MAY BE USED TO CHECK ITEMS IN THIS BLOCK. 66 Answer Key for USMLE Step 3 Sample Questions Block 1: FIP is the correct answer.B. Digoxin - Digoxin has slow onset, not suitable here. - Digoxin - Digoxin has slow onset, not suitable here. doesn't fit this patient's presentation and clinical findings. Metoprolol NOTE: THIS IS THE END OF BLOCK 4. ANY REMAINING TIME MAY BE USED TO CHECK ITEMS IN THIS BLOCK. 66 Answer Key for USMLE Step 3 Sample Questions Block 1: FIP is the correct answer.
C. Enalapril - Enalapril does not acutely control rate. - Enalapril - Enalapril does not acutely control rate. doesn't fit this patient's presentation and clinical findings. Metoprolol NOTE: THIS IS THE END OF BLOCK 4. ANY REMAINING TIME MAY BE USED TO CHECK ITEMS IN THIS BLOCK. 66 Answer Key for USMLE Step 3 Sample Questions Block 1: FIP is the correct answer.