Item: 1 of 10 111 !

"Mark <:1 [::::>

Q, ld : 10543 Previous Next
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6 The following vignette applies to the next 2 items.
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8 A 43-year-old w oman comes to the physician for an initial evaluation . She has a history of chronic tension
9 headaches and hypothyroidism treated w ith levothyroxine. She is very w orried about her poor energy level
10 and has called in sick to w ork several times this past month because she felt too exhausted to get out of bed.
The patient also describes insomnia, urinary frequency, stomach discomfort, bloating, itchy skin, and
dizziness. She is w orried about her symptoms and w onders if all the doctors she has seen may have
"missed something." Physical examination is normal. Laboratory testing, including complete thyroid function
tests, show s no abnormalities.

Item 1 of 2

W hich of the follow ing is the most likely diagnosis?

r A. Factitious disorder
r B. Generalized anxiety disorder
r C. Illness anxiety disorder
r D. Malingering
r E. Somatic symptom disorder
 Item: 2 of 10 111 !"Mark <:1 [::::>
Q, ld : 10544 Previous Next
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6 Item 2 of 2
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8 The patient schedules an appointment 2 w eeks later and now complains about frequent headaches in addition
9 to her ongoing concerns. Physical examination is normal. She is very anxious and asks if the physician can
10 order a repeat brain MRI to figure out the diagnosis. Her records indicate that a brain MRI performed last year
w as normal. W hich of the follow ing is the best response to the patient?

r A. "I can reassure you that there is nothing medically w rong w ith you."
r B. "I can understand your distress; seeing a psychiatrist may help w ith your anxiety."
r C. "I w ill order a repeat brain scan to confirm that nothing has changed."
r D. "I w ould like to schedule a neurology consultation to get a second opinion ."
r E. "Let's set up regular office visits so w e can monitor your condition ."
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1~ m I
Q, ld : 10736 ] Previous Next
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. 6 An 18-month-old boy is brought to the physician for evaluation of a burn. His mother says that he sustained
. 7 the burn 45 minutes earlier w hile bathing and that "the w ater w as hotter than I thought." The child has no other
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medical conditions and takes no medications. He has not been to this clinic before. The mother says that
she did not bring him to his regular pediatrician because she w ants to sw itch offices. The boy lives w ith his
. 10 mother and 5-year-old sister during the w eekdays and stays w ith his father on the w eekend. The patient's
w eight is at the 5th percentile and his length is at the 50th percentile. The boy appears uncomfortable on
examination . He has clearly demarcated areas of uniform ery1hema on his buttocks, low er back, and low er
abdomen but not on the abdomen and groin creases or the center of the buttocks. Distinct uniform ery1hema
is also present on his ankles and heels. There are multiple blisters but no splash marks. During the visit, the
mother becomes extremely agitated, demands to know "w hat is taking so long", and says she has to leave
because "I have to pick up m y daughter from school." In addition to a detailed history and physical
examination, w hich of the follow ing is the most appropriate next step in the treatment of this child?

r A. Arrange ambulance transport to hospital for admission

r B. Ask the father to come to the clinic and evaluate the family dynamics
r C. Educate the mother about appropriate w ater heater temperature setting
r D. Have family take the child to the emergency department for burn care
r E. Refer the child for a skeletal survey
llJ Item: 4 of 10 • r~ Mark <:::] t::>

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6 A 34-year-old w oman comes to the physician during the 2nd trimester of pregnancy for evaluation of a rash on
7 her face. She noticed the rash 2 w eeks ago but has had an otherwise uneventful pregnancy. She has no
8 other medical conditions. Her medications include a prenatal multivitamin. The patient w orks as an interior
9 designer and enjoys outdoor gardening on the w eekends. She has no history of tobacco or alcohol use. Her
10 vital signs are w ithin normal limits. Skin examination is show n in the image below . The remainder of her
physical examination is unremarkable.

W hich of the follow ing is the best next step in management of this patient?

r A. Advise sunscreen use

r B. Obtain serum iron studies
r C. Skin biopsy for evaluation of skin cancer
r D. Topical metronidazole
r E. Topical retinoid cream
 Item: 5 of 10 111 !"Mark <:1 [::::>
Q, ld : 10582 [ Previous Next
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A 16-year-old girl is brought to the emergency department by her mother after a single episode of generalized
tonic-clonic seizure. The patient has been preparing intensively for midterm examinations and is somew hat
sleep deprived. She has had unusual jerking arm movements in the morning for the past 6 months but has
had no other recent symptoms. The patient does not use alcohol or illicit drugs. Her mother describes her as
10 being "anxious," but she has no know n medical problems. Her temperature is 36.7 C (98 F), blood pressure
is 120/60 mm Hg, and pulse is 72/min. On examination, the patient is drow sy but has no neurological
abnormalities. Electroencephalogram show s bilateral polyspike and slow discharge. W hich of the following is
the most appropriate next step in management?

r A. Check serum prolactin level

r B. Perform lumbar puncture
r C. Reassurance and sleep hygiene instructions
r D. Start gabapentin
r E. Start valproic acid
 Item: 6 of 10 111 !"Mark <:1 [::::>
Q, ld : 10514 [ Previous Next
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A 2-year-old boy is brought to the physician due to bloody stools. The child began having frequent,
blood-streaked stools 2 days ago. Today, the stools increased in frequency and the child began having
crampy abdominal pain. The boy has been eating "a little bit" and drinking w ater and sports drinks. The
parents report that he has been tired and "clingy" but is otherwise acting appropriately. The family has not
travelled recently, but several children at the boy's daycare center have had similar symptoms. The patient
had an ear infection 2 months ago that w as treated w ith antibiotics. He does not take any medications
currently. His temperature is 38.1 C (100.5 F), blood pressure is 100/60 mm Hg, and pulse is 120/min. On
examination, the boy is tired-appearing but follow s commands appropriately. His capillary refill time is 2
seconds. Abdominal examination show s hyperactive bow el sounds. There is no rigidity, focal tenderness, or
mass. Bacterial stool culture is obtained. W hich of the follow ing is the most appropriate next step in
management of this patient?

r A. Abdominal ultrasound
r B. Empiric antibiotic therapy
r C. Oral rehydration therapy
r D. Ova and parasites assay
r E. Viral stool culture
 Item: 7 of 10 111 !"Mark <:1 [::::>
Q, ld : 10555 Previous Next
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A 45-year-old man comes to the physician because of difficulty w alking. Over the last several months, he has
had increased falls due to feeling off balance. He also has shooting and burning pains in his legs. He does
not have a recent history of fevers/chills, trauma, headache, visual changes, slurred speech, or trouble
sw allow ing. The patient also has no history of insect bites, skin rash, or genital lesions. He w orks as a truck
driver in the Mid-Atlantic region of the United States. His temperature is 36.7 C (98 F), blood pressure is
140/90 mm Hg, and pulse is 92/min. His neurologic examination reveals bilateral small pupils that reduce in
size w ith accommodation but not w hen exposed to bright light. His muscle bulk and strength are normal. He
has reduced sensation to pain, temperature, vibration, and proprioception in the low er extremities. Ankle
reflexes are absent bilaterally. He is unstable during the Romberg test. W hich of the follow ing is most likely to
establish the diagnosis?

r A. Alcohol use screening questionnaire

r B. Folic acid and vitamin 8 12 levels

r C. Hemoglobin A,. measurement

r. D. Lyme ELISA antibody testing
r E. Testing for Treponema pa/lidum infection
 Item: 8 of 10 111 !"Mark <:1 [::::>
Q, ld : 10673 Previous Next
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6 A study compares the detection of colon polyps in 50 subjects by using both CT colonography and

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conventional colonoscopy (gold standard). As a part of the study, 2 independent radiologists assess the CT
images to diagnose polyps. Each radiologist is blinded to the other radiologist's reading. The kappa statistic
for these raters is 0.73. W hich of the follow ing does the kappa statistic best describe?

r A. Pow er
r B. Reliability
r C. Specificity
r D. Statistical significance
r E. Validity
 Item: 9 of 10 111 !"Mark <:1 [::::>
Q, ld : 10705 [ Previous Next
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6 A 46-year-old woman comes to the physician for diarrhea and occasional fecal incontinence. She has had
7 3-4 loose stools a day and vague rectal discomfort for the last 2 months. The patient says, "I often feel a

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painful urge to go but only pass a small amount of mucus." She has noticed bright red blood mixed with the
stool on several occasions. The patient w as treated for cervical cancer with surgery and chemoradiation a
year ago. She is afebrile. On examination, there is mild tenderness in left lower quadrant but no guarding or
rebound. Rectal examination show s guaiac-positive brown stool. Her stool Clostridium difficile toxin
polymerase chain reaction testing is negative. Rectosigmoidoscopy show s pale rectal mucosa, several
serpiginous telangiectasias, and small areas of mucosal hemorrhage. Which of the following is the most
likely diagnosis?

r A. Angiodysplasia
r B. Crohn disease
r C. Ischemic colitis
r D. Pseudomembranous colitis
r E. Radiation proctitis
 Item: 10 of 10 111 f>Mark <:1 [::::>
Q. ld : 10531 Previous Next
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6 A 24-year-old man comes to the emergency department w ith palpitations. He has had short-lived episodes of
7 palpitations for several years, but this one is persistent. He has no past medical history and takes no
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medications. Electrocardiogram (ECG) show s regular narrow -complex tachycardia (QRS duration of 90
9 msec) at a rate of 175/min. His blood pressure is 135/80 mm Hg and physical examination is notable for
tachycardia but otherwise unremarkable. Vagal maneuvers are ineffective in breaking the tachycardia. The
patient receives a rapid intravenous push of adenosine (6 mg) follow ed by saline chaser. Soon after the
bolus, his heart rate becomes 230/min and irregular, and the rhythm rapidly degenerates into ventricular
fibrillation. The patient loses consciousness, and the pulse is not palpable. He is immediately defibrillated and
regains consciousness. He has poor recollection of the recent events but has no other complaints. Repeat
ECG show s normal sinus rhythm at a rate of 89/min, short PR interval of 11 0 msec, prolonged QRS complex
of 130 msec, and delta w aves in multiple leads. W hich of the following best classifies this patient's
encounter?

r A. Medicolegal error
r B. Near-miss
r C. Negligent adverse event
r D. Non-preventable adverse event
r E. "Save" event