3-1. A 5-year-old boy comes to the emergency department at midnight with a complaint of severe scrotal pain since 7 p.m. There is no history of trauma. Your first step is to a. Order a surgical consult immediately b. Order a radioisotope scan on an emergency basis c. Order a urinalysis and gram stain for bacteria d. Arrange for an ultrasound examination e. Order a Doppler examination

3-2. A 30-year-old woman in the last trimester of pregnancy suddenly develops massive swelling of the left lower extremity from the inguinal ligament to the ankle. The correct sequence of workup and treatment should be a. Venogram, bed rest, heparin b. Impedance plethysmography, bed rest, heparin c. Impedance plethysmography, bed rest, vena caval filter d. Impedance plethysmography, bed rest, heparin, warfarin (Coumadin)

e. Clinical evaluation, bed rest, warfarin

3-3. A 56-year-old woman has been treated for 3 years for wheezing on exertion, which was diagnosed as asthma. The chest radiograph shown below is obtained and reveals a midline mass compressing the trachea. The most likely diagnosis is a. Lymphoma b. Neurogenic tumor c. Lung carcinoma d. Goiter e. Pericardial cyst

Reproduced, with permission, from Geller PL: Surgery:PreTest Self-Assessment and Review, 9th ed. New York, McGraw-Hill, 2001.

3-4. You are a physician in charge of the patients who reside in a nursing home. Several of the patients have developed influenza-like symptoms, and the community is in the midst of an influenza A outbreak. None of the nursing home residents have received the influenza vaccine. What course of action is most appropriate?

a. Give the influenza vaccine to all residents of the nursing home who do not have a contraindication to the vaccine (allergy to eggs)

b. Give the influenza vaccine to all residents of the nursing home who do not have a contraindication to the vaccine; also give amantadine for a 2-wk period c. Give amantadine alone to all nursing home residents d. Do not give any prophylactic regimen

3-5. A preterm black male infant is found to be jaundiced 12 h after birth. At 36 h of age, his serum bilirubin is 18 mg/dL, hemoglobin concentration is 12.5 g/dL, and reticulocyte count is 9%. Many nucleated red cells and some sphe-rocytes are seen in the peripheral blood smear. The differential diagnosis should include which of the following?

a. Pyruvate kinase deficiency b. Hereditary spherocytosis c. Sickle-cell anemia d. Rh incompatibility e. Polycythemia

3-6. A 35-year-old woman undergoes her first screening mam-mogram. Which of the following mammographic findings would require a breast biopsy?

a. Breast calcifications larger than 2 mm in diameter b. Five or more clustered breast microcalcifications per square centimeter c. A density that effaces with compression d. Saucer-shaped microcalcifications e. Multiple round well-circumscribed breast densities

3-7. A 65-year-old woman who has a 12-year history of symmetrical polyarthritis is admitted to the hospital. Physical examination reveals splenomegaly, ulcerations over the lateral malleoli, and synovitis of the wrists, shoulders, and knees. There is no hepatomegaly. Laboratory values demonstrate a white blood cell count of 2500/^L and a rheumatoid factor titer of 1:4096. This patient's white blood cell differential count is likely to reveal a. Pancytopenia b. Lymphopenia c. Granulocytopenia d. Lymphocytosis e. Basophilia

3-8. A middle-aged man is chronically preoccupied with his health. For many years he feared that his irregular bowel functions meant he had cancer. Now he is very preoccupied about having a serious heart disease, despite his physician's assurance that the occasional "extra beats" he detects when he checks his pulse are completely benign. What is the most likely diagnosis?

a. Somatization disorder b. Hypochondriasis c. Delusional disorder d. Pain disorder e. Conversion disorder

Items 3-9 through 3-10

An 18-year-old high school football player is kicked in the left flank. Three hours later he develops hematuria. His vital signs are stable.

3-9. Initial diagnostic tests in the emergency room should include which of the following?

a. Retrograde urethrography b. Retrograde cystography c. Arteriography d. Intravenous pyelogram e. Diagnostic peritoneal lavage

3-10. The diagnostic tests performed reveal extravasation of contrast into the renal parenchyma. Treatment should consist of a. Resumption of normal daily activities, excluding sports b. Exploration and suture of laceration c. Exploration and wedge resection of left kidney d. Nephrostomy e. Antibiotics and serial monitoring of blood count and vital signs

3-11. A 7-year-old girl is brought to your office by her mother because of a rash that appeared 3 days ago. Her temperature is 37.2°C (99°F) and her face has an intense rash with a "slapped-cheek" appearance. The most likely etiologic agent is a. Adenovirus b. Rotavirus c. Parvovirus d. Coxsackievirus e. Echovirus

3-12. A 16-year-old girl with complex partial seizures and mild mental retardation has an area of deep red discoloration (port wine nevus) extending over her forehead and left upper eyelid. A computed tomography (CT) scan of her brain would be likely to reveal a. A hemangioblastoma b. A Charcot-Bouchard aneurysm c. An arteriovenous malformation d. A leptomeningeal angioma e. A fusiform aneurysm

3-13. A 27-year-old man presents with hoarseness for 6 mo. He has no other symptoms or complaints. He has no past medical history, takes no medications, and does not smoke cigarettes or drink alcohol. He uses no illicit drugs. He has been employed as a telephone operator for the last 8 mo. Which of the following is the most likely diagnosis?

a. Postnasal drip syndrome b. Cancer of the larynx c. Reflux esophagitis d. Voice strain e. Kallman syndrome

3-14. After an uneventful labor and delivery, an infant is born at 32 wk gestation weighing 1500 g (3 lb, 5 oz). Respiratory difficulty develops immediately after birth and increases in intensity thereafter. The child's mother (gravida 3, para 2, no abortions) previously lost an infant because of hyaline membrane disease. At 6 h of age, the patient's respiratory rate is 60 breaths/min. Examination reveals grunting, intercostal retraction, nasal flaring, and marked cyanosis in room air. Physiological abnormalities compatible with this data include a. Decreased lung compliance, reduced lung volume, left-to-right shunt of blood b. Decreased lung compliance, reduced lung volume, right-to-left shunt of blood c. Decreased lung compliance, increased lung volume, left-to-right shunt of blood d. Normal lung compliance, reduced lung volume, left-to-right shunt of blood e. Normal lung compliance, increased lung volume, right-to-left shunt of blood

3-15. A 6-year-old boy who had a mild respiratory tract infection for 2 days awakens in the middle of the night with shortness of breath and difficulty breathing, and his parents bring him to the emergency room. His respiratory rate is 36 breaths/ min and his heart rate is 150 beats/ min. He has a prolonged expiratory phase when breathing. He is afebrile. Lung auscultation reveals high-pitched, squeaky, musical breath sounds in all lung fields during inspiration and expiration. Which of the following is the most likely diagnosis?

a. Epiglottitis b. Asthma c. Croup d. Tonsillitis e. Pneumonia

3-16. A 28-year-old, otherwise healthy white woman on no medications presents to the emergency room with chest pressure, dizziness, numbness in both hands, and a feeling of impending doom that began while the patient was walking in the mall. The most likely diagnosis on the differential is a. Angina b. Congenital heart disease c. Gastroesophageal reflux d. Panic disorder e. Pulmonary embolus

3-17. Two brothers, 4 and 7 years of age, exhibit limb ataxia, nystagmus, and mental retardation. MRI of their brains reveals areas of abnormal signal in the white matter. Cere-bellar involvement is substantial. Both boys also have abnormally low serum cortisol levels. Select the most likely diagnosis.

a. Neuromyelitis optica (Devic's disease)

b. Central pontine myelinolysis c. Marchiafava-Bignami disease d. Acute disseminated encephalomye-litis e. Pelizaeus-Merzbacher disease f. Leber's optic atrophy g. Alexander's disease h. Adrenoleukodystrophy i. Canavan's disease

Items 3-18 through 3-19

A patient has been standing immobile for several hours. One of his arms is stretched upward, the other is wrapped around his neck. The patient does not appear aware of his surroundings and actively resists any attempt to make him change position.

3-18. This is an example of a. Apraxia b. Dystonia c. Sinesthesia d. Catatonia e. Trance

3-19. This symptom is usually seen in patients with a. Schizophrenia b. Parkinson's disease c. Delirium d. Neuroleptic malignant syndrome e. Huntington's disease

3-20. A 71-year-old man complains of occasional lower back pain. His blood pressure is 150/85 mm Hg and his pulse is 80 beats/min. Cardiac examination reveals an S4 gallop. Abdominal examination reveals a pulsatile mass approximately 5.0 cm in diameter palpable in the epigastric area. Peripheral pulses are normal. Which of the following is the most likely diagnosis?

a. Abdominal aortic aneurysm b. Cancer of the proximal colon c. Peptic ulcer disease d. Chronic pancreatitis e. Lipoma of the abdominal wall

3-21. A 9-year-old girl presents with precocious puberty and episodes of uncontrollable laughter. Which of the following mass lesions might explain her symptoms?

a. Craniopharyngioma b. Choroid plexus papilloma c. Giant aneurysm d. Metastatic carcinoma e. Hypothalamic hamartoma

3-22. A 27-year-old patient previously treated with external beam radiation for stage IB cervix cancer has a central recurrence 2 years later. A curative surgical procedure is contemplated in which the uterus, both adnexa, the rectum, and the bladder will be removed, diverting the fecal stream with a colostomy and the urinary stream with an ileal conduit. Such a procedure is called a a. Radical hysterectomy b. Supraradical hysterectomy c. Hemiexenteration d. Total pelvic exenteration e. Radical exenteration

3-23. A healthy 2-mo-old infant is brought to the office for routine child care. The child has a normal growth curve. She received the first dose of hepatitis B vaccine at birth as well as a dose of hepatitis B im-munoglobulin (HBIg) because the mother was hepatitis B surface antigen (HBsAg) positive. Which of the following vaccine series should be administered at this time?

a. MMR, OPV DTP, Hepatitis B

c. Hepatitis B, DTaP, Hib, IPV

e. IPV, DTaP, Hepatitis B

3-24. An attractive and well-dressed 22-year-old woman is arrested for prostitution, but on being booked at the jail, she is found to actually be a male. The patient tells the consulting physician that he is a female trapped in a male body and he has felt this way since he was a child. He has been taking female hormones and is attempting to find a surgeon who will remove his male genitals and create a vagina. The most likely diagnosis is a. Homosexuality b. Gender identity disorder c. Transvestite fetishism d. Delusional disorder e. Schizophrenia

3-25. A previously healthy 80-year-old woman presents with early satiety and abdominal fullness. The CT scan shown below is obtained. The lesion is most likely a a. Pancreatic pseudocyst b. Pancreatic adenocarcinoma c. Pancreatic cystadenocarcinoma d. Retroperitoneal lymphoma e. Pancreatic serous cystadenoma



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Reprinted, with permission, from Geller PL: Surgery: PreTest Self-Assessment and Review, 9th ed. New York, McGraw-Hill, 2001.

Reprinted, with permission, from Geller PL: Surgery: PreTest Self-Assessment and Review, 9th ed. New York, McGraw-Hill, 2001.

You Should Have Completed Approximately 25 Questions and Have 30 Minutes Remaining.

3-26. A 30-year-old woman complains of palpitations, fatigue, and insomnia. On physical exam, her extremities are warm and she is tachycardic. There is diffuse thyroid gland enlargement and prop-tosis. There is an orange thickening of the skin in the pretibial area. Which of the following lab values would you expect in this patient?

a. Increased TSH, total thyroxine, and total T3

b. Decreased TSH, increased total thy-roxine c. Increased T3 uptake, decreased T3

d. Normal T4, decreased TSH

3-27. A 20-year-old patient presents to the office for contraception counseling. Her history reveals no past medical problems. Her physical and pelvic examinations are normal. She has been sexually active with the same partner for 9 mo. Which of the following contraceptive methods is most appropriate?

a. Barrier method b. Combined oral contraceptives c. Progestin-only contraceptives d. Intrauterine device (IUD)

e. Barrier method and combined oral contraceptives

3-28. A 23-year-old Japanese man attends a party where he drinks three glasses of wine. In a short period of time, he develops facial erythema and experiences severe facial flushing. Which of the following is the most likely diagnosis?

a. Alcohol dehydrogenase deficiency b. Glucoronyl tranferase deficiency c. Aldehyde dehydrogenase deficiency d. Angioedema e. Photosensitivity reaction

3-29. A young man with multiple sclerosis exhibits paradoxical dilation of the right pupil when a flashlight is redirected from the left eye into the right eye. Swinging the flashlight back to the left eye produces constriction of the right pupil. This patient apparently has a. Early cataract formation in the right eye b. Occipital lobe damage on the left c. Oscillopsia d. Hippus e. Optic atrophy

3-30. A 56-year-old woman with bipolar disorder, who has been managed with lithium for years, is brought to the emergency room by her relatives with clear signs of lithium toxicity. She is tremulous, ataxic, and somnolent, and her lithium level is 1.8. There were no recent changes in dosage and the patient is not dehydrated. During the previous week she has been taking several daily doses of an over-the-counter medication. What medication has she used?

a. Acetylsalicylate b. Acetaminophen c. Ibuprofen d. Diphenhydramine e. Pseudoephedrine

Items 3-31 through 3-32

About 1% of boys are born with undescended testes. To determine whether prenatal exposure to tobacco smoke is a cause of unde-scended testes in newborns, the mothers of 100 newborns with undescended testes and the mothers of 100 newborns whose testes had descended were questioned about smoking habits during pregnancy. The study revealed an odds ratio of 2.6 associated with exposure to smoke, with 95% confidence intervals from 1.1 to 5.3.

3-31. Some reviewers are concerned that the study may overstimate the association between maternal smoking and undescended testes in the offspring because of potential a. Confounding b. Nondifferential misclassification c. Differential misclassification d. Selection bias e. Loss to follow-up

3-32. What is the most appropriate conclusion to be drawn from the study?

a. There is no association between maternal smoking and undescended testes in the offspring b. The study results, if accurate, suggest that an offspring whose mother smoked is about 2.6 times more likely to be born with undescended testes than an offspring whose mother did not smoke c. The P value is >0.05

d. The 90% confidence interval for these results would probably include 1.0

e. A larger sample size would increase the confidence interval

Items 3-33 through 3-34

A patient has been complaining of fatigue and night sweats associated with itching for 2 mo. On physical exam there is diffuse, nontender lymphadenopathy, including small supraclavicular, epitrochlear, and scalene nodes. A chest x-ray shows hilar lymphadenopathy.

3-33. The next step in evaluation is a. Excisional lymph node biopsy b. Monospot test c. Toxoplasmosis IgG

d. Angiotension converting enzyme

3-34. The patient described is found on biopsy to have mixed-cellularity Hodgkin's lymphoma. Liver function tests are normal and the spleen is nonpalpable. The next step in evaluation is a. CT scan or MRI

b. Liver biopsy c. Repeat node biopsy d. Erythrocyte sedimentation rate

3-35. A newborn infant develops respiratory distress immediately after birth. His abdomen is scaphoid. No breath sounds are heard on the left side of his chest, but they are audible on the right. Immediate intubation is successful with little or no improvement in clinical status. Emergency chest x-ray is shown (A) along with an x-ray 2 hours later (B). The most likely explanation for this infant's condition is

Reprinted, with permission, from Yetman RJ: Pediatrics:PreTest Self-Assessment and Review, 9th ed. New York, McGraw-Hill, 2001:62-63.

a. Pneumonia b. Cyanotic heart disease c. Diaphragmatic hernia d. Choanal atresia e. Pneumothorax

3-36. A 62-year-old man presents for his annual health maintenance visit. The review of systems is positive for occasional fatigue and headache. The patient admits to generalized pruritus following a warm bath or shower. He has plethora and engorgement of the retinal veins. A spleen is palpated on abdominal examination. Hematocrit is 63%. The patient has a leukocytosis and thrombocytosis. Peripheral blood smear is normal. The patient does not smoke. Which of the following is the most likely diagnosis?

a. Spurious polycythemia b. Essential thrombocytosis c. Myelofibrosis d. Polycythemia vera e. Secondary polycythemia f. Chronic myeloid leukemia g. Erythropoietin-secreting renal tumor

3-37. A 39-year-old woman, gravida 3, para 3, complains of severe, progressive secondary dysmenor-rhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Results of en-dometrial biopsy are normal. This patient most likely has a. Endometriosis b. Endometritis c. Adenomyosis d. Uterine sarcoma e. Leiomyoma

3-38. One month after her mother's death from heart failure, a 25-year-old woman with no prior psychiatric history is still very sad and tearful. She has difficulty concentrating and falling asleep at night and she has lost 3 lb. The most likely diagnosis is a. Major depression b. Dysthymia c. Posttraumatic stress disorder d. Adjustment disorder e. Uncomplicated bereavement

3-39. During a diving expedition to explore sunken ships, one of the divers starts to experience light-headedness, dizziness, ataxia, and nausea after reaching 110 ft of depth. Which of the following is the most likely diagnosis?

a. Nitrogen narcosis b. Barotrauma c. Vertigo d. Barosinusitis e. Bends

3-40. A little girl who was underweight and hypotonic in infancy is obsessed with food, eats compulsively, and at age 4 is already grossly overweight. She is argumentative, oppositional, and rigid. She has a narrow face, almond-shaped eyes, and a small mouth. What is her diagnosis?

a. Down syndrome b. Fragile X syndrome c. Fetal alcohol syndrome d. Hypothyrodism e. Prader-Willi syndrome

3-41. A 50-year-old man complaining of dizziness is found to have a cyst occupying 50% of his posterior fossa and incomplete fusion of the cerebellar elements inferiorly. There is no evidence of an obstructive hydrocephalus. His longevity can be estimated to be a. Less than 3 mo b. Less than 1 year c. Less than 5 years d. Less than 10 years e. Unaffected by this finding

3-42. A 19-year-old woman attending school in Massachusetts presents with the chief complaint of bloody diarrhea for 2 mo. She has abdominal discomfort and feels she has lost some weight. She also complains of tenesmus. Abdominal examination is normal. The rectal exam reveals stool containing blood and pus. Which of the following is the most likely diagnosis?

a. Irritable bowel syndrome b. Ulcerative colitis c. Giardiasis d. Hemorrhoids e. Diverticulosis

3-43. A 55-year-old woman complains of seborrhea, acne, and mild facial hirsutism since menopause 2 years ago. Her serum andros-tenedione and estrone levels are moderately elevated. Which of the following is the most likely cause of her condition?

a. Amount of body fat b. Increased ovarian steroid secretion c. Increased adrenal steroid secretion d. Diminished renal steroid elimination e. Diminished hepatic steroid clearance

3-44. A 44-year-old woman presents with diffuse myalgias and excessive fatigue. She has morning stiffness and pain of all her joints, especially her wrists, elbows, shoulders, hips, knees, and neck. She does not sleep well at night. Her symptoms have been progressing for over 4 years. On physical examination, the patient has 13 tender points at the elbows, knees, shoulders, and hips. Which of the following is the most likely diagnosis?

a. Polymyalgia rheumatica b. Fibromyalgia syndrome c. Rheumatoid arthritis d. Scleroderma e. Polymyositis

3-45. A 23-year-old woman presents for evaluation of a 7-mo history of amenorrhea. Examination discloses bilateral galactorrhea and normal breast and pelvic examinations. Pregnancy test is negative. Which of the following classes of medication is a possible cause of the patient's condition?

a. Antiestrogens b. Gonadotropins c. Phenothiazines d. Progestogens e. GnRH analogs

3-46. A term, 4200-g female infant is delivered via cesarean section because of cephalopelvic disproportion. The amniotic fluid is clear and the infant cries almost immediately after birth. Within the first 15 min of life, however, the infant's respiratory rate increases to 80 breaths/min and she begins to display intermittent grunting respirations. The infant is transferred to the level 2 nursery and is noted to have an oxygen saturation of 94%. The chest radiograph shows fluid in the fissure, overaera-tion, and prominent pulmonary vascular markings. The most likely diagnosis in this infant is a. Diaphragmatic hernia b. Meconium aspiration c. Pneumonia d. Idiopathic respiratory distress syndrome e. Transient tachypnea of the newborn

3-47. A 42-year-old woman presents to the emergency room complaining of the sudden onset of right upper abdominal pain. Her pain started after eating a hamburger for lunch. She is nauseated and vomited twice at home. She denies diarrhea. Her temperature is 102.2 °F, blood pressure is 140/90 mm Hg, and pulse is 110 beats/min. The patient appears anxious and distressed. She is not jaundiced. Abdominal examination reveals normal bowel sounds. While you are palpating under her right costal margin, the patient abruptly arrests her inspiration and pulls away because of sharp pain. Which of the following is the most appropriate next step in management?

a. Abdominal radiograph b. Ultrasound of the abdomen c. HIDA scan d. MRI of the abdomen e. Upper endoscopy

3-48. A 64-year-old woman presents with vaginal bleeding similar to spotting, which has occurred daily for 1 mo. Her last menses was at age 50 and she has been healthy her entire life. She denies fever, weight loss, or abdominal pain. Physical examination is normal. Which of the following is the most likely diagnosis?

a. Atrophic vaginitis b. Endometriosis c. Uterine leiomyoma d. Endometrial carcinoma e. Polycystic ovarian syndrome

3-49. A 55-year-old woman who has a history of severe depression and who had radical mastectomy for carcinoma of the breast 1 year ago develops polyuria, nocturia, and excessive thirst. Laboratory values are as follows:

Serum calcium: 9.5 mg/dL

Blood glucose: 110 mg/dL

Blood urea nitrogen: 30 mg/dL

Urine osmolality: 150 mOsm/kg

The most likely diagnosis is a. Psychogenic polydipsia b. Renal glycosuria c. Hypercalciuria d. Diabetes insipidus e. Inappropriate antidiuretic hormone syndrome

3-50. Your 60-year-old male patient, followed for chronic stable angina on aspirin, nitrates, and a beta blocker, presents to the ER with history of two to three episodes of more severe and long-lasting anginal chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. The best course of action of the following is to a. Admit the patient and begin intravenous digoxin b. Admit the patient and begin intravenous heparin c. Admit the patient and give prophylactic thrombolytic therapy d. Admit the patient for observation with no change in medication e. Discharge the patient with increases in nitrates and beta blockers

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