Sample Items and Explanations
Sample Questions

  A 31-year-old obese female with a history of asthma comes to your office complaining of severe shortness of breath and wheezing. She produces from her purse a number of active medications including a beclomethasone metered dose inhaler (MDI) and salmeterol MDI. She also appears to be taking zafirlukast daily. She tells you that she has been hospitalized many times for asthma flares and was once intubated. Her review of systems is pertinent for asthma attacks of increasing severity over the past few weeks but she denies any fever, cough, chills, or pleuritic chest pain. On exam, the patient demonstrates audible expiratory wheezes with a markedly prolonged expiratory time. Her respiratory rate is 20-24/min and she is acutely short of breath, using accessory muscles of respiration to breathe. Her vital signs are otherwise stable. Which of the following is the most beneficial management of this patient?

(A) Obtain a chest radiograph to rule out pneumonia
(B) Obtain a peak flow estimate
(C) Albuterol nebulizer therapy in the office
(D) Refer the patient to the local hospital for admission
(E) Refer the patient to the local emergency room for evaluation and treatment

  A 69-year-old man is brought to the clinic for progressively worsening memory loss and confusion. The patient has a long history of hypertension and coronary artery disease. He has not seen a physician in a number of years and has not been taking any medications. The family reports a step-wise decline in his cognitive function over the past few years. He has long periods where he appears stable and then suddenly worsens over a few days. On physical examination, he is a thin but not cachectic appearing man with a blood pressure of 185/110 mm Hg. His physical examination is notable for a faint carotid pulsation on the left with a prominent right carotid bruit. He has an S4 gallop on precordial examination.

Which of the following is the appropriate first step in the management of this patient?

(A) Initiate donepazil therapy
(B) Initiate atenolol therapy
(C) Initiate warfarin therapy
(D) Order a carotid ultrasound study
(E) Order a head CT scan




  A 43-year-old African-American man comes to the clinic for the first time as part of a neighborhood-screening program for hypertension. He reports that he has no past medical history but has not seen a physician routinely for the past ten years. He smokes two packs of cigarettes per day but denies ethanol or any substance abuse. He takes no medicines regularly. The nurse measures his blood pressure as 165/90 mm Hg in the left arm while sitting. The physician has a long discussion with the patient concerning the possibility that his blood pressure has been elevated for some time and that he may need medical therapy in order to lower it to appropriate levels. A careful physical examination is performed looking for possible end-organ manifestations of long-standing untreated hypertension. Which of the following signs is suggestive of long standing hypertension?

(A) S3 gallup
(B) Abdominal bruit
(C) Carotid bruit
(D) S4 gallup
(E) Systolic ejection murmur



  A 19-year-old gravida 0 presents to the student health center complaining of lower abdominal pain and urinary urgency of three days duration. She has not had this condition before. She is sexually active, and sometimes uses condoms for contraception. She has intercourse about three times a week; her last intercourse was three days ago. Her last menstrual period was three weeks ago. Her periods are regular at 28-day intervals, and last about 5 days. She does not have any gastrointestinal symptoms. Her temperature is 1010F (38.30C), pulse 100, respirations are 20/min, and her blood pressure is 100/60. On physical examination, the abdomen is soft, but there is tenderness to deep palpation in both lower quadrants with slight rebound tenderness as well. The liver, kidney, and spleen are not palpable. Bowel sounds are active. The vulva is clean; there is no evidence of discharge or irritation. The vaginal is well supported, uninflamed, and clean. The cervix is nulliparous, and there is a mucopurulent discharge in the os. A cervicovaginal PAP smear is taken. Cultures are also taken from the vagina and cervix. There is tenderness to cervical motion. The uterus is of normal size, shape and position. The adnexa are difficult to palpate, and are not well felt, but there is bilateral tenderness. Rectovaginal examination is confirmatory. Trichomonads are identified on microscopic examination of vaginal secretions. Her white blood count is 10,000 with a left shift; urinalysis shows 1-2 WBC, trichomonads, and 1+ proteinuria. Which of the following is the next best step in her management?

(A) Admit to the hospital for parenteral antibiotic treatment
(B) Begin 7 days of metronidazole, 500 mg TID po for the patient and her partner
(C) Order ceftriaxone 250 mg IM and doxycyline 100 mg b.i.d. po for 10 days
(D) Prescribe acetaminophen for pain and intermittent heat to the lower abdomen; re-evaluate when cultures return
(E) Schedule for a transvaginal ultrasound



  On the morning of the second day after delivering a 3,500-g infant, a 16-year old gravida 1, para 0 develops a temperature of 1010 F (38.30C). Her antepartum course was unremarkable. Membranes ruptured shortly after hospital admission and the onset of labor was spontaneous but desultory. Oxytocin augmentation was necessary. The first stage of labor was 22 hours; the second stage was 3 hours and 45 minutes. Delivery of the vertex was expedited by vacuum forceps over an intact perineum under pudendal block anesthesia. The placenta delivered spontaneously. Since delivering, she had been ambulating and eating well. Physical examination reveals a temperature of 1020F (38.80C), a pulse of 108 bpm, respirations 22/min, and a blood pressure of 110/60. Breasts are full with moderate colostrum secretion from the nipples. The abdomen is soft; there is no liver, kidney, or spleen palpable. The perineum is clean, and the lochia rubra has a foul odor. Pelvic examination is within normal limits for postpartum status except for uterine tenderness to motion and foul lochia. Examination of the extremities, including previous intravenous sites, is within normal limits. Which of the following is the next best step in her management?

(A) Begin oral methylergonovine, encourage fluid intake, re-evaluate in four hours
(B) Culture the lochia and start acetaminophen; await culture report
(C) Initiate imipenem/cilastatin intravenous therapy
(D) Order a CBC, encourage fluid intake, re-evaluate in four hours
(E) Start a first-generation cephalosporin orally