1.

A 62-year-old female is brought to the ED by EMS for confusion,

headache, and vomiting over the past 12 hours. Vital signs are as follows:
Temperature = 96.9, HR = 100, RR = 22, BP = 220/150. She is disoriented
and uncooperative. Examination is otherwise unremarkable. What is the
most likely diagnosis, and what is the most appropriate management?
A. Hypertensive urgency; gradual lowering of blood pressure with oral agents
B. Hypertensive urgency; rapid lowering of blood pressure with IV agents
C. Hypertensive emergency; gradual lowering of blood pressure with oral
agents
D. Hypertensive emergency; rapid lowering of blood pressure with IV agents
E. Hypertension; gradual lowering of blood pressure with oral agents

2. A 61-year-old woman was diagnosed with hepatorenal syndrome. Which

of the following fi ndings best describes the earliest manifestation of
hepatorenal syndrome (HRS)?
A. Activation of the renin–angiotensin–aldosterone system
B. Increased creatinine levels
C. Peripheral vasodilation
D. Renal vasoconstriction
E. Retention of ssodium

3. A 17-year-old male presents to the ED with severe pain in his right leg
and back that began suddenly a few days ago. The pain is sharp and
throbbing. He has a history of sickle cell disease with frequent painful
crises requiring hospitalization once or twice per year. He has no other
medical problems. Vital signs are as follows: Temperature = 101.6, HR =
94, RR = 20, BP = 132/84. Oxygen saturation is 97% on room air. His right
shin is very tender, as is his low back in the midline. His examination is
otherwise unremarkable. CBC results are as follows: Hb = 7, Hct = 21%,
MCV = 94. Osteomyelitis of the right tibia is ultimately diagnosed. What is
the most likely cause of this patient’s osteomyelitis?
A. Listeria
B. Salmonella
C. Shigella
D. Cryptosporidium
E. Campylobacter

4. A 74-year-old male is brought to your office by his daughter, who is

having increasing problems caring for him at home. She reports that he has
recently had urinary incontinence and has been “clumsier” than usual. She
states that he behaves inappropriately at times, and on two occasions he
has wandered outside the home and has gotten lost. He misplaces items
frequently, and his personality has changed to being more belligerent and
demanding. He seems to lack judgment in social situations, and he never
had this problem in the past. She states that these problems have become
worse gradually over the past 4 months. Physical examination is
unremarkable. What is the likely diagnosis?
A. Pseudotumor cerebri
B. Alzheimer disease
C. Normal pressure hydrocephalus
D. Multi-infarct dementia
E. Lewy body dementia

5. A 20-year-old male presents for evaluation after an episode of dark

urine. He felt well up until 2 weeks ago when he had a sore throat and mild
fever for which he did not seek medical care. Urinary symptoms started the
day prior to evaluation. He denies cough, dyspnea, hemoptysis, joint pains,
dysuria, and flank pain. He does have two recent sexual partners but uses
condoms. He has no prior medical history and denies any family history of
renal diseases. BP 145/90 mm Hg, HR 65, T 37°C. Physical examination
reveals a well-appearing male with normal heart sounds, clear lungs, and
mild lower extremity edema. There are no skin lesions. Urinalysis that is
obtained is dark red in color. Microscopic examination is positive for
deformed RBCs and RBC casts. Cr is 1.6 mg/dL. What is the most likely
test to help aid in the diagnosis of this patient?
A. ANCA
B. Anti-GBM
C. HIV
D. Antistreptolysin titer
E. IgA levels

6. A 61-year-old male presents to your office with the chief complaint of

“coughing up blood and weakness” for the past 3 weeks. He reports at least
five to six episodes every 2 to 3 days of coughing of bright red blood,
approximately one to two tablespoons each time. The patient denies any
chest pain, fevers, chills, or recent travel. He has mild dyspnea at baseline.
He has recently developed lower extremity muscle cramps and he has
difficulty rising from a chair. Past medical history is significant for COPD
diagnosed 5 years ago and HTN. He has a 40-pack-year smoking history
and currently smokes 1 pack per day. Examination is notable for end-
expiratory wheezing and a prolonged expiratory phase on lung
auscultation. He has 3/5 hip flexion and decreased deep tendon reflexes
bilaterally in lower extremities. Laboratory tests are normal including
electrolytes. CXR reveals typical changes seen in COPD (flattened
diaphragms, hyperinflation) and a perihilar mass. What is the most likely
diagnosis?
A. Bronchial carcinoid
B. Adenocarcinoma
C. Large cell carcinoma
D. Squamous cell carcinoma
E. Small cell carcinoma
7. A 64-year-old female presents to the ED with sudden onset of severe
chest pain that occasionally radiates to her back. She has a history of
angina and takes nitroglycerin, but this time the pain is much worse and is
not relieved with nitroglycerin. PMH is significant for HTN. She is afebrile,
and HR = 105, BP = 160/105, RR = 17. Cardiac enzymes are negative. CXR
shows a widened mediastinum. What is the likely diagnosis?
A. Myocardial infarction
B. Aortic dissection
C. Stroke
D. Acute aortic regurgitation
E. Hypertensive emergency

8. A 63-year-old female is brought to the ED by the rescue squad after an

episode of syncope at home. Her husband witnessed the event. He describes
the patient as falling suddenly to the floor from a standing position. She lost
consciousness for about 5 seconds, after which she rapidly regained
consciousness and was oriented and appropriate. The patient remembers
feeling lightheaded, nauseous, and developing “tunnel vision” prior to the
event. No bowel or bladder incontinence was noted. PMH is significant for
DM, HTN, and depression. She denies any chest pain or SOB. Vital signs
are: Temperature = 100.2, BP = 118/68, pulse = 84, RR = 18. Oxygen
saturation on room air is 96%. Physical examination is significant only for
bruising of her left wrist and thigh. Heart and lung examination is normal.
Which of the following is the most likely diagnosis?
A. Arrhythmia
B. Orthostatic hypotension
C. Seizure
D. Vasovagal syncope
E. Aortic stenosis
9. A 54-year-old male with a history of parathyroid adenoma presents to
the ED with severe pain in his right knee. He says that the pain is extreme
and intolerable, and he is in obvious distress. On examination, there is
exquisite tenderness, erythema, and swelling of the right knee joint and it
feels very warm to the touch. The pain began suddenly a few hours ago. He
denies any previous episodes or pain in any other joints. He denies any
trauma. Medical history is significant for osteoarthritis of his left knee, for
which he takes ibuprofen. He drinks 6 to 7 glasses of wine per day. He does
not take any other medications. Vital signs are as follows: Temperature =
100.5, RR = 16, BP = 140/85, pulse = 78. Which of the following is the best
next step in management for this patient?
A. Indomethacin
B. Joint aspiration with synovial fluid analysis
C. Uric acid levels
D. Knee x-ray

10. A 24-year-old female presents to your office for a routine examination.

She reports a history of heavy menstrual bleeding since menarche. Her
mother had similar symptoms. On further questioning, she states that she
has episodes of epistaxis about once every 2 weeks or so and has a tendency
to bruise easily. Her physical examination is unremarkable. CBC results
are as follows: Hgb = 7.9 g/dL, Hct = 23.9%, MCV = 69 fL. Platelet count is
230,000/μL. PT—12 seconds (normal). PTT—30 seconds (normal). LFTs
including bilirubin are normal. What is the most appropriate test to
order?
A. Fibrinogen
B. Coombs antibody
C. Factor IX level
D. Mixing study
E. Ristocetin cofactor activity
GOODLUCK!