Questions
DIRECTIONS (Questions 1 through 22): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.
1. A 46-year-old patient has her serum cholesterol tested in your laboratory, and it is 280 mg/dL. Which of the following statements regarding this finding would be accurate to tell her?
(A) Elevated serum cholesterol is the most significant risk factor in the development of ischemic cardiac disease.
(B) Further evaluation will be needed.
(C) She needs to see an internist immediately.
(D) The pizza she had for lunch the previous day probably is responsible for the elevation.
(E) Unless there is a family history of cardiac disease, she is less likely to develop heart problems than the rest of the population.
2. A 70-year-old woman who is in good health comes to your office for the first time. Her only disease prevention issue is that she smokes. While discussing this with her, which of the following should you tell her?
(A) Assure her that 70 years of age is too old to be worrying about quitting smoking.
(B) At 70 years of age, smoking is up to her, and she is certainly mature enough to make her own decisions.
(C) If she got to be 70-year-old and smokes, it is probably good for her.
(D) Inform her that her life expectancy may be 15 to 20 more years or longer, and that if she would like to try to quit smoking, you will assist her.
(E) Thirty-five percent of people will die of cancer, and the greatest risk factor we know of for developing cancer is smoking.
3. There is a great deal of debate about what is the best screening strategy regarding the use of mammography. Which of the following is true about the most important feature of mammography?
(A) It allays fears in women.
(B) It can detect lesions as small as 1 mm.
(C) It essentially misses no cancer.
(D) It leads to a reduction in mortality in breast cancer in women aged 50 to 64 years.
(E) It provides the caregiver with a medical-legal safety screen.
4. Many common illnesses are related to life choices that increase risks for developing medical complications. Such life choices include smoking, overeating, and use of illegal substances. The clinician needs to determine where the patient is regarding approaching change in behavior to direct management. A pregnant patient who is smoking 10 cigarettes a day has already arranged with family not to smoke around her, has established a quit date, and is enquiring about nicotine replacement.
Which of the following best describes the mindset of this patient?
(A) action
(B) contemplative (C) maintenance (D) precontemplative (E) relapse
Questions 5 and 6 apply to the following patient:
A 43-year-old woman, 5 ft 4 in. tall (163 cm) and weighing 176 lb (80 kg), presents for her annual examination and assistance on losing weight.
5. She asks “How many calories would I have to cut out each day to lose 1 pound per week?” Which of the following choices is the best response?
(A)100 (B)500 (C)900 (D)1,300 (E)1,800
6. You also encourage her to exercise. Given her current status, which of the following is the best initial form of exercise for her to maximize the calories burned per week?
(A) bicycling
(B) jogging/running (C) swimming (D) tennis (E) walking
7. A 27-year-old woman presents for her annual examination and renewal of her oral contraceptive (OC) pills. Her history and physical examination were unremarkable except for a non-tender 4 × 4 cm
enlargement of the left lobe of her thyroid. Which of the following is key in the evaluation of this finding?
(A) TSH level
(B) free T4 and free T3 levels (C) radioactive iodine scan
(D) ultrasound with fine-needle aspirate (E) MRI of neck
8. As part of a premarital examination, a 24-year-old teacher would like a measles vaccination because she is nonimmune. She asks, “Do I need to avoid pregnancy after getting this vaccination?” Which of the following is the most appropriate response?
(A) no, it is a killed vaccine and unnecessary
(B) no, it is a form of passive immunization and therefore noninfective (C) yes, for 6 weeks
(D) yes, for 12 weeks because it is a live, attenuated vaccine
(E) yes, and if pregnancy is attained before 6 months, abortion is recommended
9. A 28-year-old woman who has been splenec-tomized as a result of a car accident wonders if there is
any special immunization she should have as a result. Of the following choices, how should you answer her?
(A) measles (B) mumps
(C) meningococcus (D) pertussis
(E) pneumococcus
10. A patient presents to you with excruciating pain, and you confirm the diagnosis of a kidney stone. You would like to provide the greatest amount of pain relief possible until the stone can be treated or
passes. Which of the following narcotics has the greatest analgesic potency (administered parenterally) when compared to morphine?
(A) codeine
(B) hydromorphone (C) meperidine (D) methadone (E) oxycodone
11. A 77-year-old woman comes to see you with her daughter. The mother has recently moved in with the daughter because it is difficult for her to care for herself completely. At night, the mother seems to become confused, does not know where she is, and cannot recognize her daughter. Which of the following is this?
(A) a normal variant of aging and should be accepted
(B) an indication that the mother needs to be restrained at night for fear of hurting herself
(C) an indication of possible early dementia or organic brain syndrome, needing further evaluation (D) controllable by administration of sleep medication early in the evening
(E) expected to resolve completely as the mother becomes more aware of her new surroundings 12. A 19-year-old patient comes in for an annual refill of her birth control pills. For the past 6 years her
family physician has treated her for nodular cystic acne with what the patient feels are poor results.
Which of the following should you recommend?
(A) isotretinoin (B) stopping her OCs (C) oral tetracycline
(D) topical benzoyl peroxide (E) topical clindamycin
13. A woman and her husband are planning a trip to Mexico for their 25th anniversary. She has heard about “traveler’s diarrhea” and wonders what advice you can give her. You should tell her to do which of the following?
(A) not to worry about it; very few people ever get it
(B) she will get it no matter what she does, and it will subside quickly on its own
(C) to be sure to drink plenty of water, not to eat uncooked meat or vegetables, and she will likely be fine
(D) to take oral clindamycin before they get to Mexico and all during their stay
(E) to take trimethoprim-sulfa tablets along and begin them at the first signs of diarrhea
14. A 39-year-old woman comes in complaining that every night just after going to bed she awakens with a severe, substernal burning that is relieved when she drinks a glass of milk. She is allergic to codeine and has a known gallstone. Physical examination shows she is 5 ft 4 in. tall and weighs 209 lb. Her general examination is normal. There is no abdominal tenderness. Her stool is guaiac negative. She would like to know what to do for long-term relief. Of the following choices, how should you advise her?
(A) antacids before bedtime
(B) an upper gastrointestinal X-ray series (C) cholecystectomy
(D) histamine blockers
(E) weight loss and no eating within 3 hours of bedtime
15. A 34-year-old multigravid patient comes to your office with two complaints. She has difficulty having bowel movements. They occur about twice weekly and are associated with significant straining. She has also noticed a painful mass at the anus and some bright red blood on her toilet paper. On
examination you see a bluish lump about 2 cm across the anus, a mild recto-cele, and a normal digital rectal examination. A stool specimen is guaiac negative. Of the following choices, how should you advise her?
(A) that a biopsy of the mass is necessary (B) to have a colonoscopy
(C) to drink 8 to 10 glasses of water each day, increase the amount of fiber in her diet, and soak the area in a tub of warm water twice daily
(D) to see a colorectal surgeon
(E) to use hydrocortisone suppositories for the discomfort
16. A 27-year-old woman has just begun a new job as an administrative assistant after working for years as an account representative at another bank. Over the last few weeks, she has developed a chronic, bilateral, nonpulsatile headache that begins every afternoon. Her 79-year-old aunt has recently died of a cerebral aneurysm, and she had a cousin who she believes died of a “brain tumor.” Her neurologic examination is within normal limits. What do you tell her about the origin of her headaches?
(A) Given her family history, an angiogram is indicated.
(B) It is a common migraine headache, and she will need further evaluation.
(C) She needs to see a neurologist.
(D) She needs to see a psychiatrist.
(E) The headaches are most likely stress-related and can be managed without further testing.
17. A 48-year-old patient (gravida 2, para 2) presents for an annual examination. She has had a tubal ligation for contraception. She reports her menses occur every 25 to 28 days and are “normal.” Her history and examination, including stool guaiac and skin, are unremarkable other than she appears somewhat pale on examination. Which of the following laboratory results should prompt an evaluation for a cause other than simply iron deficiency from menstrual loss?
(A) hemoglobin < 11.5g/dL
(B) increased total iron-binding capacity (TIBC) (C) microcytic hypochromic cells on peripheral smear
(D) normal indices on an automatic analysis of peripheral smear (E) normal to high reticulocyte count once corrected for the anemia
18. A 19-year-old woman (gravida 0, para 0) presents for her annual sports physical. She is 5 ft 10 in.
tall and weighs 110 lb. She states that she has been having this weight for “a while” and attributes it to being the star forward for her nationally ranked college soccer team. She does note her last menses was more than 3 months ago. Her urine human chorionic gonadotropin (hCG) is negative. Which of the
following findings would be inconsistent that her presentation is due to athletic involvement and instead raise the concern of an anorexic disorder?
(A) increased exercise tolerance (B) increased physical activity (C) lanugo hair
(D) low body weight
(E) resting bradycardia and hypotension
19. A 14-year-old patient presents complaining of knee pain that has been increasing over the past few months. Since she is the goalie for the high school soccer team, you suspect patellofemoral dysfunction.
Which of the following would decrease a postpubertal girl’s risk for this problem?
(A) hyperelastic joints
(B) increased angle from knee to pelvic girdle (C) shallow trochlear groove configuration (D) tight vastus lateralis musculature
(E) tight vastus medialis obliquus musculature
20. A 38-year-old woman presents with the complaints of symmetric polyarthritis, especially in the hands and wrists, marked morning stiffness that lasts for up to an hour, and nodules over her elbows. These complaints have been present and increasing over the past 3 to 4 months. Of the following differential list, which is the most likely diagnosis?
(A) ankylosing spondylitis (B) gout
(C) osteoarthritis (D) Reiter syndrome (E) rheumatoid arthritis
21. A patient asks what she can do to minimize her risks of developing skin cancer. You inform her of which of the following?
(A) application of sunscreen is best just before sun exposure
(B) high altitudes are less dangerous for sun exposure dermal injury (C) one will get sun damage on overcast days
(D) she should use a sunblocker with a sun protection factor (SPF) rating of 8 or less (E) tanning booths use a form of ultraviolet (UV) radiation that is safer than sun exposure 22. During her annual examination, a patient states that she is very concerned about developing skin
cancer due to a strong family history. You instruct her in the components of a skin examination that involves evaluating a lesion for danger signs for melanoma, which would include which of the following?
(A) asymmetry of appearance
(B) consistent dark black pigmentation (C) diameter of 4 mm
(D) nonraised surface
(E) smooth border
DIRECTIONS (Questions 23 through 36): The following groups of questions are preceded by a list of lettered options. For each question, select the one lettered option that is most closely associated with it. Each lettered option may be used once, multiple times, or not at all.
Questions 23 through 26 apply to the following patient:
Match the diagnosis to each of the following patients.
(A) alopecia areata (B) androgenic alopecia (C) syphilitic alopecia
(D) systemic lupus-related alopecia (E) telogen effluvium
(F) traumatic alopecia
23. A patient presents with acute hair loss in patches. Inspection of the patches shows complete hair loss without signs of inflammation and scarring. Hair can be easily plucked at the edge of these patches.
24. A patient complains of thinning of her hair on her crown over the past months. She reports her mother had a similar problem.
25. A patient presents 3 months’ postpartum complaining that she is going bald. She describes large amounts of hair in her brush each morning and her hairdresser says her hair is thinner.
26. A patient presents complaining of temporal balding. She is African American and has worn her hair in plaited braids for years.
Questions 27 through 30
The development of a rash in a pregnant woman can represent a simple uncomplicated infectious or allergic response or it can represent a disease process that
can place the mother or the fetus at significant risk.
Choose the best diagnosis for each patient presentation.
(A) drug rash
(B) erythema multiforme (C) Lyme disease
(D) measles
(E) pityriasis rosea (F) rubella
(G) varicella
27. A 24-year-old woman presents with a generalized eruption of small oval lesions that are aligned along skin lines. She denies any constitutional symptoms. She did note a single large lesion a few days prior to the generalized rash.
28. A 22-year-old schoolteacher presents complaining of a rash that started as a bull’s-eye pattern that rapidly enlarged. She had a flulike illness prior to the rash. Although she often hikes, she denies any
tick bites.
29. A 19-year-old woman presents with vesicular pustular pruritic lesions on an erythematous base. The rash followed a high temperature. The rash started in the hairline and has rapidly spread to the entire body.
30. An 18-year-old college student from Vietnam presents with the complaint of a maculopapular rash that started on her face and spread rapidly. The rash followed a day of malaise, fever, headache, and
conjunctivitis. Lymphadenopa-thy is evident in the postauricular and suboccipital nodes.
Questions 31 through 33
Of the following which is the primary cause of mortality for each of the age groups?
(A) accidents (B) cancer
(C) cerebral vascular disease
(D) chronic obstructive lung disease (E) heart disease
(F) human immunodeficiency virus (HIV) infection (G) homicide
(H) suicide
31. Women aged 15 to 34 32. Women aged 35 to 54 33. Women aged 55 to 64 Questions 34 through 36
Back pain is a common complaint for women much of which is attributed to pregnancy, obesity, activity related, or osteoporosis. The ability to differentiate by history and physical examination those that require further imaging and treatment is necessary for providers who provide care for women. What is the diagnosis for the following patients?
(A) degenerative disease (B) disk disease
(C) nerve root pain
(D) ankylosing spondylitis
(E) referred pain from pelvic viscera
34. A 65-year-old patient presents with complaints of back pain that is worse after exercise or at the end of the day.
35. A 30-year-old patient complains of back pain that is worse in the morning. Her examination reveals decreased range of motion of the spine and tenderness over the sacroiliac joints. There is a loss of lordosis.
36. A 45-year-old woman presents complaining of back pain that radiates down her legs and is
accompanied by numbness, paresthesia, and some weakness. The pain is increased with normal activities and improved with rest.
Answers and Explanations
1. (B) A serum cholesterol of 280 mg/dL is well outside the normal range. Cholesterol as a risk factor may be greatly overemphasized, but further evaluation is needed. You will need to fractionate it to determine her levels of low-density lipoprotein (LDL) and high-density lipoprotein (HDL). You will need to assess any other cardiac risk factors, such as a positive family history, 30% or more over ideal weight, smoking, exercise level, blood pressure, dietary intake, and other medical conditions (diabetes, hypothyroidism, hyperuricemia, and so forth).
2. (D) Smoking is associated with heart disease, chronic respiratory disease, and multiple cancers (head, neck, lung, and cervix). While no one lives forever, a 70-year-old woman could easily live to be 90.
Would not you help a 20-year-old live to age 40? Offer this woman smoking cessation therapy; she may be more interested than one might think. About 23% of all deaths in the United States are due to cancer.
3. (D) Mammography is the most common method of detecting asymptomatic malignant disease in the breast, the second most prevalent of cancers deaths in women. It can be wrong and seldom finds cancer of less than 0.5 cm. It may create as much anxiety as it solves. Given the prevalence of breast cancer, its age-related incidence, the cost of mammography and the ability of mammogram to correctly identify women at significant risk for cancer, there has been a great deal of controversy as to which population of women benefits the greatest from this screening and when it is most cost-effective. Although there is general agreement of screening between ages 50 and 65, there is a great deal of disagreement as to when testing should start (ages 40 or 50) and frequency (every 1 or 2 years in low-risk women). This debate is representative of many of the debates that will be occurring over the next decade as screening strategies are critically reviewed for cost-effectiveness.
4. (A) Behavioral change requires a great deal of motivation and investment by the patient. A model commonly used to determine if a patient is ready to try and change is the “stages of change.” This allows the provider to determine where the patient is in his or her approach to the problem and the physician can direct the intervention accordingly. Directing intervention inappropriately can create barriers between the physician and the patient. The stages are (1) precontemplative (they really are not considering change at this time—physician input at this stage is to provide information as to why they may want to consider change); (2) contemplative (the patient is considering change but has not
developed a plan or time line for initiating change—the provider can provide information to reinforce the benefits of change and help to develop a plan; (3) action (the patient has already initiated steps for change such as setting a date or has initiated behavioral change; (4) maintenance (the patient has successfully achieved change but is at risk for relapse and needs support and monitoring for relapse);
and (5) relapse (patients need to be supported that a relapse is not a failure but an opportunity to learn more about why they have the behavior that needs changing. It is important to help them return to action stage with a more focused plan for change).
5. (B) This is a very simple calculation. A negative calorie balance of 3,500 kcal is required to lose 1 lb.
So 3,500 kcal /lb divided by 7 means 500 kcal less per day loses about 1 lb per week. She would need to maintain the same level of exercise.
6. (E) Although bicycling or swimming will use up to 200 cal/h and tennis and jogging even more, it is
difficult for an overweight person who has not been exercising to do these activities for more than a few minutes. However, walking (at 150 cal/h) is more consistent with their abilities. Thus, the patient will typically be more successful at walking for 30 or more minutes per session and do it three or four times per week. As their conditioning improves, they can change to more demanding activities if they prefer.
7. (D) An asymmetric enlargement of a lobe of the thyroid is a nodule till proven otherwise. A patient with a hyperthyroidism from Graves or hypothyroidism goiter will have a diffusely enlarged thyroid.
Given that the patient is asymptomatic makes it unlikely that this is a case of multinodular thyroiditis. It is essential that a thyroid ultrasound is done and if a discrete nodule is found that a fine-needle
aspiration is done to evaluate for cancer. If cancer is found and lymph nodes are appreciated, an MRI might be indicated. Radioactive iodine scans are rarely used since the FNA under ultrasound guidance provides a more accurate diagnosis compared to the classification of a hot or cold nodule. Thyroid cancer rates seem to be increasing and is one of the cancers found in younger women. Given the low cost of a thyroid examination at the well woman examination, the low rate of false-positive
examinations, the increasing incidence of thyroid cancer and effectiveness of surgery to cure the cancer, it is probably reasonable to continue to do thyroid examinations for screening at annual well women examinations.
8. (D) Measles is a live, attenuated vaccine. It is given as a single subcutaneous (SQ) dose. It is
recommended for all persons born after 1956 who are nonimmune. Pregnancy is recommended to be avoided for 3 months. If a pregnancy does occur, there is no need for a termination solely due to the vaccine exposure since there is no documented congenital anomalies due to congenital rubella from a vaccine.
9. (E) Pneumococcus vaccine is given as a single dose of purified capsular polysaccharide to people more than 2 years of age who are at increased risk of infection with pneumococcus. Splenectomy,
chronic cardiovascular disease or pulmonary disease (excluding asthma), metabolic or hepatic disease, or immunocompromised state (e.g., HIV) increases that risk. Meningococcus vaccine is typically
offered to college students, especially those students living in dormitories or other residential living facilities on college campuses. The others are part of a routine immunization program.
10. (B) The relative potency of a parenteral dose of the listed medications would be (most potent to least potent): hydromorphone > oxycodone = methadone > meperidine > codeine. For pain as intense as a kidney stone and a sure diagnosis, maximum pain relief is indicated.
11. (C) This is referred to as “sundowning.” Confusion in the late afternoon or early evening is the key symptom. It can be associated with dementia, organic brain syndrome, unfamiliar environments, and aging. In this case, the fact that the mother does not recognize her daughter is most worrisome and
would lead you to pursue a more detailed cause than simply aging. It may improve over time, but it may well need to be treated. Restraints (physical or chemical) are not the answer. More specific therapy can be recommended.
12. (A) Isotretinoin is a vitamin A derivative that is indicated for just this problem. You should be certain that other therapies (especially C, D, and E) have been tried and failed, failing because of
ineffectiveness rather than noncompliance. The patient should also be informed of the need to continue effective contraception when using this medication because of its known teratogenicity. Also, OCs will