(MTP) with Severe Pain Is MOST Likely Due to Which One Of

1) Acute monoarthritis of the first metatarsophalangeal joint (MTP) with severe pain is MOST likely due to which one of the following diseases? A. Pseudogout B. Gout C. Bacterial arthritis D. Osteoarthritis E. Rheumatoid arthritis 2) The simultaneous onset of a sash over the malar areas of the face and a migratory polyarthritis usually indicates the presence of which of the following diseases? A. Psoriatic arthritis B. Gonococcal arthritis C. Lyme disease D. Systemic lupus erythematosus E. Acute rheumatic fever

QUESTIONS 3-7 ARE MATCHING QUESTIONS: ANSWERS MAY BE USED ONCE, MORE THAN ONCE, OR NOT AT ALL

For each of the clinical scenarios below indicate which ONE of the infection control practices (A-E) is MOST appropriate for the health care worker caring for the patient?

A. Wear a special mask that filters droplets in the 1-5 micron range while the patient is in a negative pressure room B. Wash hands C. Double glove (i.e. wear 2 sets of gloves) D. Wear gloves, gown, mask and head cover while patient is in a negative pressure room E. Wear goggles

3) A 76 year-old woman is in the hospital for control of diabetes. An infection control nurse notes that the patient's anterior nares are colonized with methicillin- resistant Staphylococcus aureus.

4) A 24 year-old woman is admitted for drainage of a labial abscess. The resident suggests that you irrigate the wound using a water pic.

5) A 71 year-old patient who admits to heavy chronic alcohol intake complains of a 4 week history of productive cough and weight loss of 12 lbs. A cavitary lesion is noted in the right upper lobe on chest x- ray.

6) A 26 year-old sustains a severe, comminuted fracture of the left femur. You are called to the operating room to assist the orthopedist. You enter the OR after a careful surgical scrub of your hands.

7) In distinguishing petechiae, purpura, and ecchymosis, the MOST important criteria is: A) Platelet count is always less than 10,000 in the presence of petechiae B) Platelet count is always greater than 10,000 in the presence of petechiae, and lower with purpura and ecchymosis C) The age of the patient D) The size of the lesions E) The cause of the coagulopathy

1 8) A bulge sign is found to be positive when a small increase in synovial fluid is present in which joint? A. Knee B. Ankle C. Elbow D. Metacarpophalangeal joint (MCP) E. Metatarpophalangeal joint (MTP)

9) Small depressions in the nails (pitting) are found in which of the following disease? A. Lupus erythematosus B. Gout C. Psoriasis D. Erythema nodosum E. Dermatomyositis

10) "A-V nicking" is a sign that can be seen in the vessels of the retina and is associated with which disease? A. Diabetic retinopathy B. Ocular hypertension C. Systemic hypertension D. Chiasmal tumor E. Retinitis pigmentosa

11) Kesselbrach's plexus is: A. A frequent site of carcinoma B. A neural network responsible for olfaction C. A frequent site of epistaxis D. Located in the posterior reaches of the nasal cavity near the eustachian tube E. Located along the jugular vein

12) Dot and Blot hemorrhages in the retina are associated with which of the following diseases: A. Ocular hypertension B. Systemic hypertension C. Diabetic retinopathy D. Chiasmal tumor E. Retinitis pigmentosa

13) All of the following test the function of a specific cranial nerve or nerves EXCEPT: A. Having the patient stick out his tongue B. Touching a piece of cotton to the lateral portion of the cornea C. Visualizing the optic disc D. Having the patient shrug his shoulders E. Touching a Q-tip to the back of the pharynx

2 14) A 10 year-old boy developed a scaly red rash on his arms. It would best be described as: A. eczematous B. reticulated C. maculopapular D. morbilliform E. exanthematous

15) A 76 year-old man with a long history of heavy smoking is found to have an esophageal carcinoma. For a long time his doctor told him he had esophagitis based on his history. Which of the following features of his history is LEAST consistent with esophagitis: A) Prominent heartburn B) Steadily worsening dysphagia without intermittent improvement C) Dysphagia below sternal notch D) Sometimes associated with chest pain E) Sometimes associated with nausea and vomiting

16) Herpes simplex virus most commonly presents as an eruption which is: A. papular B. exanthematous C. vesicular D. eczematous E. morbilliform

17) An itchy red rash with prominent scales and excoriations might best be described as: A. exanthematous B. reticulated C. serpiginous D. pruritic E. dysplastic

18) A 28 year-old woman presents with pain in her ears. Pathology in which of the following areas may refer pain to the ears: A. Teeth B. Temporomandibular joint C. Thyroid D. All of the above E. None of the above

19) A Weber tuning fork exam is performed on a patient with a left conductive hearing loss due to a serous middle ear infection. Which of the following would be the MOST likely finding: A. Sound will be heard louder in the right ear B. Sound will be heard equally in both ears C. Sound will be heard louder in the left ear D. No sound will be heard at all E. Unable to predict from this information

3 20) On greeting a 17 year-old patient in the emergency room, the medical student notes Kussmaul breathing. Which of the following is the most likely diagnosis: A. Guillain-Barre syndrome (neuromuscular weakness) B. diabetic ketoacidosis C. alpha-1 antiprotease deficiency (resulting in early emphysema) D. narcotic overdose E. tension pneumothorax

21) A 72 year-old man is noted to have Cheyne-Stokes breathing. Which of the following is the most likely diagnosis: A. diabetic ketoacidosis B. congestive heart failure C. kyphoscoliosis D. asthma E. interstitial lung disease

22) A 46 year-old woman was admitted for dyspnea and exercise intolerance of unclear etiology. On rounds it is noted that her abdomen moves inward on inspiration. The BEST explanation for this phenomenon is: A. This is the normal pattern of breathing, it is just more noticeable in women. B. This frequently occurs in individuals with chest wall deformities such as Pectus Excavatum. C. This is called paradoxical breathing because the rib cage and abdomen move in opposite directions on inspiration. The inward movement of the abdomen suggests bilateral phrenic nerve (diaphragm) paralysis. D. The finding is irrelevant because the work of breathing occurs on expiration, not inspiration. E. It is the result of her use of accessory muscles; thus, it is helpful only in that it corroborates her complaints of dyspnea.

23). A needle is about to be emergently placed in the 2nd intercostal space in the midclavicular line anteriorly to relieve a tension pneumothorax. How do you BEST find this space: A. It is in line with the scapula posteriorly B. Four finger breaths up from the lower costal margin C. Immediately below the clavicle D. First find the angle of Louis; then move directly laterally to find the 2nd rib, the 2nd intercostal space is immediately below E. Obtain a lateral chest x-ray

24. In a dyspneic 58 year-old male heavy smoker, percussion of the right lower chest posteriorly produces a dull thud. The left side is resonant. Which of the following is the MOST likely diagnosis: A. Pneumothorax B. Interstitial lung disease (e.g. Sarcoidosis) C. Pleural Effusion D. Severe Emphysema E. Pulmonary Embolus

4 25. Yesterday a febrile medical student complained of coughing up yellow green sputum. Today, examination demonstrates crackles over the left mid chest posteriorly and egophony, but no wheezes. The MOST likely diagnosis is: A. malingering in order to get out of taking an exam B. poorly controlled myasthenia gravis with progressive weakness of the muscles of respiration C. asthma D. pneumonia E. Adult respiratory distress syndrome

26. When asked to consult about persistent hypoxemia in a patient who underwent surgery 3 days ago for coronary artery bypass graft, you notice bronchial breath sounds over the left lower chest posteriorly. The MOST likely cause of this is: A. asthma B. acute fulminant cardiogenic pulmonary edema C. chronic obstructive lung disease D. atelectasis E. pulmonary embolus

MATCH THE FOLLOWING FINDINGS TO THE APPROPRIATE SECTION IN THE HISTORY AND PHYSICAL:

A 47 year-old man comes to you with a chief complaint of "Chest pain". As you write up his history, match the following findings to the MOST appropriate section of the write-up:

A. History of Present Illness B. Past Medical History C. Review of Systems D. Physical Exam E. Problem list

27) Smokes one pack per day for the past 20 years

28) Abnormal electrocardiogram

29) Pain on urination 6 weeks ago

30) Appears pale and anxious

31) Palpitations

32) Regularly irregular rhythm

33) Several people at work have lost their jobs and he is concerned about losing his job

5 34) The major channel of lymphatic drainage of the head and neck follows the: A. Spinal accessory nerve B. Pharyngeal mucosa C. Jugular vein D. Phrenic nerve E. Carotid artery

35) A 16 year-old high school football quarterback, previously healthy, became acutely short of breath after being tackled and is brought to the emergency room. On examination there is decreased tactile and vocal fremitus at the left lower chest posteriorly and increased resonance compared to the right side. Breath sounds are absent on the left. The MOST likely disease process is:

A. Pulmonary embolus B. Bronchiectasis C. Pleural Effusion D. Pneumothorax E. Atelectasis

36) A 42 year-old woman is found to have xanthelasmas bilaterally on examination of her eyes. Which of the following would be the MOST appropriate response from the physician: A) A focused history of the patient's visual problems B) A review of the family history focused on blindness C) A review of the family history focused on autoimmune diseases D) A review of the family history focused on premature atherosclerosis E) Reassurance and a referral to a plastic surgeon for removal

37) In general, the recommended sequence of examining a body area is: Inspection, Palpation, Percussion and Auscultation. Which of the following statements is TRUE: A) The above noted sequence is critical for correctly interpreting the examination of the lungs B) The above noted sequence is critical only in diagnosing certain diseases of the Heart C) The above noted sequence must be changed for appropriate examination of the Abdomen D) The sequence is just a convention and has no medical rationale E) The order of the first three is not critical as long as auscultation is always done last

6 QUESTIONS 38 AND 39 RELATE TO THE SAME PATIENT

38) The nurse hands you a chart on a new patient while stating that she is 27 years old, appears anxious, and complains of chest pain. On entering the examining room, the MOST appropriate initial response from you would be: A) How long have you been having chest pain? B) Tell me about the chest pain. C) Who referred you to me? D) What can I help you with? E) What do you mean by chest pain?

39) After initiating the interview with the above patient, she tells you that the pain started last week and has been getting worse. The MOST appropriate response from you would be: A) "Do antacids help?" B) "Does it get worse with exertion?" C) "Tell me about the stress in your life." D) Lean forward, make eye contact, and say "I'm listening". E) "I will start with a cardiogram, but you will likely need a cardiologist".

40) The following phrase best describes which one of the following diseases?

"A chronic, additive, symmetrical polyarthritis".

A. Rheumatoid arthritis B. Osteoarthritis C. Psoriatic arthritis D. Gonococcal arthritis E. Viral arthritis

41) A 60 year-old man presents with chief complaints of a headache. It started suddenly, feels like it is in and around his right eye, is aching in character, and associated with nausea, vomiting, and decreased vision in the right eye. Which of the following would be MOST helpful in diagnosing the problem: A) Dilating the pupils for a fundoscopic exam B) Auscultate the carotid arteries C) Transilluminate the maxillary sinuses D) Measure the intraocular pressure E) Measure the systemic blood pressure

7 42) A 30 year-old woman with a history of rheumatic fever as a child presents to you with complains of getting easily fatigued. On examination of the heart, you hear an accentuated S1, a murmur that starts with S1 and continues with the same intensity to S2, and then abruptly stops. This murmur is BEST described as: A) Crescendo-Decrescendo murmur B) Ejection murmur C) Holosystolic murmur D) Continuous machinery murmur E) Diastolic rumble

43) A 50 year-old man with a history of chronic lung disease presents with shortness of breath and palpitations. On examination he is found to have an irregularly irregular rhythm with a ventricular rate of 130/minute. You would LEAST expect to find which of the following: A) Loud P2 B) Soft S3 C) S4 D) Jugular vein distension E) Bibasilar crackles at lung bases

44) A 55 year-old woman completed a cardiac evaluation and was found to have mitral stenosis with no other valves affected. Which of the following are present exclusively with mitral stenosis: A) Holosystolic murmur at apex B) Opening snap and diastolic rumble at apex C) A blowing diastolic murmur along the left sternal border D) A left ventricular heave E) All of the above

45) After treatment of bacterial endocarditis, a 28 year-old man is left with tricuspid regurgitation. On palpation, you would expect to find which of the following physical findings: A) A thrill at the apex B) A palpable P2 C) A pulsatile liver D) A left ventricular lift E) A pericardial knock

46) An 18 year-old man presents to the emergency room and is found to have a blood pressure of 170/40. A pulse pressure such as this is consistent with which of the following states: A) Hyperthyroidism B) Aortic insufficiency C) Anemia D) All of the Above E) None of the Above

8 47) During a physical diagnosis practice session, you take the blood pressure of a classmate and find it to be 150/100. This is consistent with all of the following EXCEPT; A) The student was talking and laughing during the procedure B) The student has essential hypertension C) The student's arm was not supported during the procedure D) The cuff was too big for the student's arm E) The cuff was quickly inflated to 240 mm Hg and slowly deflated

MATCH THE FOLLOWING TO THE BEST WAY OF ELICITING THOSE FINDINGS OR MANEUVERS:

48) Pulsus paradoxus

49) Kussmaul's sign

50) Valsalva maneuver

51) Pulsus alternans

A) Have the patient take a deep breath and note the distension of the neck veins B) Take the blood pressure and note the decrease in pressure on inspiration C) Have the patient bear down while holding her breath D) Have the patient stand up and compare blood pressures lying and standing E) None of the above

MATCH THE FOLLOWING TO THE BEST WAY OF ELICITING THOSE FINDINGS OR MANEUVERS:

52) Pectoriloquy

53) Egophony

54) Stridor

55) Wheezes A) Have the patient say "EEE" in a high octave and listen for a nasal "AAAy" B) Have the patient take a deep breath and listen for musical sounds primarily on expiration suggestive of bronchospasm C) Have the patient whisper "ninety nine" and listen for louder, clearer sounds associated with increased fremitus D) Listen over the trachea while the patient is inspiring when concerned about upper airway obstruction E) Have the patient take a deep breath and listen at end inspiration at the lung bases for non-musical discontinuous sounds (like a lock of hair between your fingers)

9 56) A 60 year-old man presents with headaches, joint aches, frequent sweating and visual disturbances. On examination, he has coarse features with a large nose and macroglossia, prognathism, and large spade-like hands. Which of the following would you be MOST likely to find on examination: A) Papilledema B) Bitemporal Hemianopsia C) Homonymous Hemianopsia D) Ataxic gait E) Hemiplegia with muscle atrophy

MATCH THE FOLLOWING CARDIAC SOUNDS WITH THE TIMING:

57) S1 58) S2 59) S3 60) OS (Opening Snap) 61) Ejection sound

62) Click of mitral valve prolapse A) Beginning of systole B) End of systole C) During early systole D) During early diastole E) Mid-systolic

MATCH THE FOLLOWING CARDIAC SOUNDS WITH THE PHYSIOLOGIC EVENTS: 63) S1

64) S2

65) OS (Opening Snap)

66) Ejection sound

67) S4 A) Opening of mitral valve B) Opening of aortic valve C) Closure of mitral valve D) Closure of aortic valve E) atrial contraction

68) A 6 year-old girl is found to have a thrill and a loud high pitched holosystolic murmur heard best at the apex. Which of the following is the MOST likely diagnosis: A) Coarctation of the Aorta B) Mitral insufficiency C) Aortic insufficiency D) Mitral Stenosis E) Aortic Stenosis

10 69) A 68 year-old woman was mugged outside of the medical center and brought to the emergency room. She says someone hit her on the head and she feels funny. Which of the following neurologic findings would be MOST suggestive of a serious neurologic condition requiring further evaluation: A. Red reflex in both eyes B. Hyperreflexia in all extremities C. Weber test does not lateralize D. Bilateral babinski E. One beat of nystagmus on extreme lateral gaze bilaterally

70) A 28 year-old man presents with Bell's palsy on the right (paralysis of cranial nerve VII). You would expect to note all of the following findings EXCEPT: A) Flattening of the nasolabial fold on right B) Inability to close eye completely on right C) Decreased corneal reflex on right D) Inability to wrinkle forehead on right E) Decreased sensation on right

71) A 17 year-old boy is stopped by the police because of erratic driving. The officer suspects he has been drinking alcohol and asks him to step out of the car and perform several maneuvers. All of the following are tests of cerebellar function EXCEPT: A) Walk heel to toe B) Touch fingertips to nose with eyes closed C) Walk on toes and then on heels D) Stand with feet together and eyes closed E) Raise one hand, strike the thigh, raise it again and turn it over and repeat as rapidly as possible (rapid alternating movements)

72) After the above patient fails the maneuvers the officer. requested, a blood alcohol level is drawn and is found to be undetectable. All of the following would suggest a serious neurologic disorder EXCEPT: A) Bilateral babinski present B) Fasciculation in the muscles of his hands C) Intention tremors D) Difficulty to elicit any deep tendon reflexes E) Vertical nystagmus

11 QUESTIONS 73-76 RELATE TO THE SAME PATIENT

73) A 45 year-old woman presents to the clinic with a one day history of severe abdominal pains. Which of the following questions would be MOST helpful in supporting the diagnosis of peptic ulcer disease: A. Are you under more stress lately? B. Does spicy food make it worse? C. What does the pain feel like? D. Does eating affect the pain? E. Where exactly is the pain?

74) As you are interviewing the above patient, you notice that her eyes appear somewhat yellow. Which of the following statements would be MOST helpful in suggesting the presence of ASCITES: A. "The last doctor told me I had cirrhosis, and it would get worse unless I stopped drinking" B. "I had a liver biopsy that showed cirrhosis" C. "My stomach gets so swollen after I eat, and I've gained 10 lbs. in the past 6 months" D. "My ankles and legs are swollen" E. "I had hepatitis when I was 20"

75) On examining the above patient, all of the following will help in establishing the presence of ascites EXCEPT: A. Being able to ballotte the liver B. Finding increased bowel sounds C. Testing for shifting dullness D. Percussing for dullness in dependent areas of the abdomen E. Testing for a fluid wave

76) Which of the following BEST describes the recommended fashion to test for shifting dullness? A. Have the patient lie on his back, percuss the liver span, then have the patient lie on his side and repeat the maneuver

B. Have the patient lie on his back, percuss starting from the midline and proceed laterally until dullness is perceived, then repeat the maneuver with the patient on his side

C. Have the patient lie on his back, percuss starting from the midline and proceed laterally until dullness is perceived, then repeat the maneuver with the patient sitting up

D. Have the patient kneel on knees and elbows and percuss the flanks

E. Have the patient sit up and using the ball of your hand percuss the flanks

12 QUESTIONS 77-78 RELATE TO THE SAME PATIENT

77) A 33 year-old woman comes to your office. During the interview she makes the following statements: "I started having back pain about 2 weeks ago...it's in my lower back and it's getting worse...the first time I had it, it lasted about 30 minutes, but now it will last most of the day... it's sharp, burning pain that starts in my lower back...it shoots down my right buttock and leg, all the way down to my foot"

Which of the following statements would be the MOST helpful in looking for a cause for the pain: A. "My mother had multiple myelomal B. "I do a lot of housework" C. "My sister has rheumatoid arthritis" D. "The fingers of my right hand get numb when I type for a long time" E. "When I sunbathe, I get a rash on my face that looks like a butterfly"

78) On examining the above patient, which of the following physical exam findings would you be MOST likely to find; A. Synovial thickening of the PIP joints B. Decreased achilles reflex on right C. Babinski present on right D. Tophus on right foot E. Tenderness to palpation of both sacroiliac joints

79) While examining a 15 year-old girl with right ear pain, you are about to insert the otoscope into the ear canal when you notice that pulling on the auricle increases the pain. This finding is MOST suggestive of: A. External otitis B. Otitis media C. Neoplasm D. Serous middle ear effusion E. This finding has no significance in this patient

80) An 18 year-old woman presents with weakness, fatigue and heavy menstrual periods. She is found to have iron- deficiency anemia. Which of the following would you be LEAST likely to find on examination: A. cheilosis B. history of pica C. clubbing D. spoon nails (or Koilonychia) E. pallor of nail beds

MATCH THE FOLLOWING CLINICAL SCENARIOS WITH THE APPROPRIATE NEUROLOGIC TERM

81) A 30 year-old woman has frequent twitches of the right side of her face

82) A 40 year-old man with a history of alcohol abuse is

13 jaundiced, confused, and has ascites. When he is asked to hold up his hands as if he is stopping traffic, he makes quick flexion movements of his wrists as if he is "flapping"

83) An elderly man is noted to have some coarse rhythmic movement of his fingers when he is resting. It gets worse when he is excited and disappears when he is sleeping.

A) Intention tremor B) Asterixis C) Tic D) Hemiballismus E) Parkinsonian tremor

MATCH THE FOLLOWING CLINICAL SCENARIOS TO THE APPROPRIATE MEDICAL TERM

84) An elderly woman complains of a buzzing/humming sound in her ear

85) A 45 year-old alcoholic vomits coffee ground appearing material

86) A 28 year-old man has several stools with bright red blood per rectum

87) A 79-year old woman has fecal urgency and the sensation of stool in her rectum

A) Tenesmus B) Tinnitus C) Hematochezia D) Hematobilia E) Hematemesis

FOR QUESTIONS 88-91, MATCH THE TERM WITH THE CORRECT DEFINITION.

88) Flexion

89) Abduction

90) External rotation

91) Supination

A) Moving away from the median place B) Bending toward the body C) Turning the palm upward D) Turning the palm downward E) Turning away from the body

MAKE SURE YOUR NAME IS ON PAPER AND VERSION IS ON ANSWER SHEET THE END!!!!!!!!!!!!!!!THE END!!!!!! !!!!!!!!!THE END!!!!!!!!

14 ANSWERS: 31. A 62. E 1. B 32. D 63. C 2. D 33. A 64. D 3. B 34. C 65. A 4. E 35. D 66. B 5. A 36. D 67. E 6. D 37. C 68. B 7. D 38. D 69. D 8. A 39. D 70. E 9. C 40. A 71. B 10. C 41. D 72. C 11. C 42. C 73. D 12. C 43. C 74. B 13. C 44. B 75. E 14. A 45. C 76. B 15. B 46. D 77. B 16. C 47. D 78. B 17. D 48. B 79. A 18. D 49. E 80. C 19. C 50. C 81. C 20. B 51. E 82. B 21. B 52. C 83. E 22. C 53. A 84. B 23. D 54. D 85. E 24. C 55. B 86. C 25. D 56. B 87. A 26. D 57. A 88. B 27. A 58. B 89. A 28. E 59. D 90. E 29. C 60. D 91. C 30. D 61. C