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2/12/2018 Quiz Sheet https://www.med-ed.virginia.edu/CourseSites/quiz/quizsheet.cfm?keywordID=1999&CourseID=19&num=1&start=1&noindex=1 1/32 Course: Family Medicine Clerkship Topic: Usmle Question 1 Select the single best answer to the numbered question. A 50 year old female with a ten year history of type II diabetes presents for regularly­scheduled follow up. She has no complaints, and just visited her ophthalmologist last week. Current medications include glyburide, metformin, and simvastatin. On physical exam, vital signs are virtually unchanged from previous visits, with temperature 37.1 C (99 F), HR 80, BP 140/83, RR 15, and O2 Sat 98% on room air. Neurological examination reveals diminished sensation to light touch and pinprick in a stocking distribution on the lower extremities bilaterally. Remainder of physical exam is benign. Laboratory evaluation reveals: Na+ 136, K+ 3.9 Cl­ 104, HCO3­ 25, BUN 15, Cr 1.0, Glucose 150; hemoglobin A1c: 7.1%; Urinalysis: negative for ketones, glucose, bilirubin, leukocyte esterase, or blood; moderate protein; Lipid profile: Total cholesterol 146, HDL 46, LDL 100. At this time, which of the following would be the most appropriate intervention? A . Increase simvastatin B . Increase glyburide C . Increase metformin D . Add hydrochlorothiazide E . Add lisinopril Next Question Question 2 Select the single best answer to the numbered question. A 55 year old female comes to the emergency department complaining of a headache for the past six hours. Her headache began abruptly after she finished eating breakfast, and quickly increased to 8/10 throbbing pain located mainly over her right temple. The pain has been associated with mild nausea but no vomiting. She denies chronic or recurrent headaches, but did have one headache similar to this one two weeks ago, which resolved after taking ibuprofen and lying in a quiet, dark room. She has smoked one pack of cigarettes daily for 38 years. On physical exam, the patient has temperature of 37.0 C (98.6 F), pulse of 99, and BP 147/95. Neurological examination is nonfocal, but mild photophobia and nuchal rigidity are noted. Fundoscopic examination reveals no papilledema. Skin exam shows no lesions. CT of the head, obtained without contrast, reveals no abnormalities. What is the most appropriate next step in the management of this patient? A . Obtain head CT with contrast B . Lumbar puncture C . Administer i.m. sumatriptan D . Administer oral ibuprofen E . Administer i.v. ceftriaxone Previous Question Next Question Question 3 Select the single best answer to the numbered question. A four week old male infant is brought by his mother to the physician following one week of emesis. The patient’s mother states that the patient has been vomiting non­ bilious material immediately after each feeding, but then becomes fussy and demands to be fed again. She denies ever seeing any blood in the emesis. Over the past two or three days, the infant’s vomiting has become increasingly sudden and forceful. The child is irritable, with few tears. The oropharynx is dry, the infant’s fontanelles appear sunken, and moderate skin tenting is noted. Capillary refill is approximately 2 seconds. On abdominal exam, visible peristaltic waves are observed, and a 1cm firm mass is palpated in the right upper quadrant. What is the most likely laboratory finding? A . Na+ 130, K+ 2.9, Cl­ 89, HCO3­ 35 B . Na+ 138, K+ 3.8, Cl­ 100, HCO3­ 26 C . Na+ 150, K+ 4.0, Cl­ 100, HCO3­ 24 D . Na+ 140, K+ 3.8, Cl­ 100, HCO3­ 15 E . Na+ 130, K+ 5.8, Cl­ 110, HCO3­ 20 Previous Question Next Question Question 4 Select the single best answer to the numbered question. A 30 year old female presents to her physician with a breast mass. She first noted a small “lump” in her left breast while showering about six weeks ago. She has noted no change in the size of the mass since that time, and she denies pain or nipple discharge. Family history is significant for a paternal grandmother who had breast cancer at age 79. Physical examination reveals a soft, round, mobile 1cm mass in the lower outer quadrant of the left breast. No skin changes are noted. What is the most appropriate next step in the management of this patient? A . Mammography B . Refer the patient for radical mastectomy C . Begin levonorgestrel/etinyl estradiol D . Genetic testing for BRCA1 and BRCA2 E . Ultrasound of breast mass Previous Question Next Question Question 5 Select the single best answer to the numbered question. An otherwise healthy 8 year old girl presents with two weeks of perianal pruritis. She has two younger brothers, one of whom has had similar complaints for the past few days. Physical exam reveals perianal erythema with mild excoriations. The “scotch tape test” reveals several bean­shaped white eggs. What is the most likely diagnosis in this patient? A . Trichuriasis B . Enterobiasis

2/12/2018 Quiz Sheet https://www.med-ed.virginia.edu/CourseSites/quiz/quizsheet.cfm?keywordID=1999&CourseID=19&num=1&start=1&noindex=1 2/32 C . Child abuse D . Fecal soilage E . Atopic dermatitis Previous Question Next Question Question 6 Select the single best answer to the numbered question. A 66 year old male presents to the emergency department with chest pain. The pain began two hours ago as the patient was watching television. The pain is described as "squeezing" and is located primarily substernally with radiation to the jaw. Past medical history includes diabetes mellitus, hypertension, hyperlipidemia, and a 50 pack/year smoking habit. On physical exam, the patient appears anxious and diaphoretic. The patient is given supplemental oxygen by nasal cannula, and aspirin, morphine, and nitroglycerin are administered. EKG obtained on presentation to the ED is shown. Of the following, which is the most appropriate study to obtain next? A . Aortogram B . Troponin I C . Stress echo D . Exercise stress test E . CT angiogram of chest Previous Question Next Question Question 7 Select the single best answer to the numbered question. A 73 year old male presents to his physician complaining of cough and fatigue. His cough began 6 months ago and has steadily worsened, and is now associated with occasional expectoration of mucus streaked with bright red blood. Patient has also noted worsening dyspnea on exertion and a weight loss of 15 lbs. The patient has smoked a pack and a half of cigarettes every day for the past 60 years. Past medical history is significant for bipolar disorder treated with lithium. Physical exam shows unilateral localized wheezing on the left chest and clubbing of the distal extremities. Capillary refill is brisk. No skin tenting is observed. Chest X­ray is obtained, which shows a large mass at the left hilum. Labs show: Glucose 130, Na+ 125, K+ 4.0, Cl­ 91, HCO3­ 25, BUN 15, Creatinine 1.0; Plasma osmolality 270 (Normal: 282­295 mOsm/kg); Urine osmolality 650 mOsm/kg (Normal: 50 ­ 1400 mOsm/kg). Which of the following is the most likely mechanism for this patient's hyponatremia? A . Increased oral intake of hypotonic fluids B . Decreased oral intake of solutes C . Impaired secretion of ADH in the posterior pituitary D . Ectopic overproduction of vasopressin E . Resistance to ADH action on the cortical and medullary collecting tubules Previous Question Next Question Question 8 Select the single best answer to the numbered question. A 25 year old student presents with three days of vulvar pruritis. She has had a total of six lifetime partners, and is currently sexually active with one partner and states that they “occasionally” use condoms. One year ago, she was successfully treated for a Chlamydia infection. The patient denies vaginal odor or increased vaginal discharge. Physical exam reveals slight vulvar erythema, and speculum exam shows moderate clumpy white discharge. Vaginal discharge pH is 4.0. Whiff test is negative. Wet mount results: KOH prep shows occasional budding yeast and hyphae. Saline prep shows 3 WBCs, occasional squamous cells, and no bacteria. What is the next best step in the management of this patient?

2/12/2018 Quiz Sheet https://www.med-ed.virginia.edu/CourseSites/quiz/quizsheet.cfm?keywordID=1999&CourseID=19&num=1&start=1&noindex=1 3/32 A . Clotrimazole vaginal cream B . Azithromycin and recommend that her partner see a physician for Chlamydia screening and treatment C . Metronidazole D . Ceftriaxone E . Reassurance and follow up in two weeks Previous Question Next Question Question 9 Select the single best answer to the numbered question. A seven year old female is brought to the physician by her mother because of facial swelling and dark, cola­colored urine. These symptoms began abruptly two days ago and have been associated with anorexia and malaise. There have been no known sick contacts. Her mother states that the child is up to date with her immunizations and has been in good health except for a runny nose and sore throat around two weeks ago, which resolved after a few days without treatment. Vital signs are temperature 37.2 C (98.9 F), heart rate 95, and blood pressure of 148/86. There is diffuse edema of the lower extremities, face, and eyelids. Lungs and heart are clear to auscultation. Urinalysis shows moderate hematuria and proteinuria, and dysmorphic RBCs and occasional RBC casts are noted on microscopic examination. Based on these findings, what is the most likely diagnosis? A . IgA nephropathy B . Alport syndrome C . Thin basement membrane nephropathy D . Postinfectious glomerulonephritis E . Henoch­Schonlein purpura Previous Question Next Question Question 10 Select the single best answer to the numbered question. A 71 year old male comes to his physicians office complaining of muscle weakness. The weakness began insidiously several weeks ago, and has now progressed to the point where he has difficulty with normal activities such as brushing his hair or sitting unsupported. Past medical history is significant for hyperlipidemia, chronic renal insufficiency, coronary artery disease, and coronary artery bypass and grafting. Current medications include atorvastatin, fosinopril, metoprolol, aspirin, and spironolactone. Physical examination reveals diminished deep tendon reflexes and decreased motor strength. Laboratory evaluation shows Na+ 143, K+ 7.4, Cl­ 101, HCO3­ 28, BUN 30, and creatinine 1.8. EKG is obtained on presentation and is seen here. What is the most appropriate initial step in the management of this patient? A . Administer i.v. insulin and glucose B . Administer p.o. sodium polystyrene sulfate C . Administer i.v. sodium bicarbonate D . Administer i.v. calcium gluconate E . Urgent hemodialysis Previous Question Next Question Question 11 Select the single best answer to the numbered question. A 30 year old female comes to her physician's office for a routine health examination. She has been in good health recently and is up to date with her gynecological examinations. Her only medication is loratadine for seasonal allergies and ibuprofen for occasional headaches. Physical examination shows temperature 37.1 C (98.8 F), pulse 80, BP 170/92, RR 14, oxygen saturation of 99% on room air. A 3/6 mid­systolic ejection murmur is present. Abdomen is nontender with a soft systolic­diastolic bruit that lateralizes to the left side. The patient is grossly intact neurologically, and fundoscopic examination shows sharp optic disc margins. Laboratory evaluation shows Na+ 141, K+ 3.9, Cl­ 106, HCO3­ 27, BUN 18, Cr 1.0, glucose 98. Urinalysis shows trace proteinuria and no casts. What is the most likely pathological mechanism causing this patient's hypertension? A . Fibromuscular dysplasia B . Oversecretion of aldosterone C . Exogenous administration of corticosteroids D . Atherosclerotic disease E . Catecholamine­producing tumor Previous Question Next Question

2/12/2018 Quiz Sheet https://www.med-ed.virginia.edu/CourseSites/quiz/quizsheet.cfm?keywordID=1999&CourseID=19&num=1&start=1&noindex=1 4/32 Question 12 Select the single best answer to the numbered question. A 23 year old male presents with syncope. He reports that while walking briskly to his car, he felt his heart “racing” in his chest, and shortly thereafter passed out. The patient denies any prior syncopal episodes, but does note occasional episodes of palpitations that occur after moderate activity or during periods of increased stress. There is no family history of neurological disease, cardiac disease, or sudden cardiac death. On physical examination, pulse is 85 and regular, BP is 124/74, respiratory rate is 16, and oxygen saturation is 98% on room air. Cardiac examination reveals pulsation at the fifth intercostal space at the left parasternal area in the midclavicular line. S1 is within normal limits, and S2 is heard to split on inspiration. The remainder of the physical exam is unremarkable. EKG taken in the office shows the following tracing in lead II. Which of the following would be the most appropriate treatment for this patient's disorder? A . Radiofrequency ablation of pre­excitation pathway B . Urgent DC cardioversion C . Heart transplant D . Biventricular pacemaker placement E . Coronary angioplasty Previous Question Next Question Question 13 Select the single best answer to the numbered question. A 20 year old healthy female presents to her family physician for routine annual gynecological exam. She is sexually active with her monogamous male partner and currently uses the withdrawal method for contraception. Although this is her first sexual partner, she thinks her boyfriend has probably had intercourse with other women prior to their relationship. Her LMP was 2 days ago. She agrees to routine gonorrhea and Chlamydia testing. On speculum exam after swabbing for the test, some bleeding from the cervical mucosa is noted. Bimanual exam is normal. The test returns positive for N. gonorrheae. What is the best initial step in the management of this patient? A . Reassurance and encourage condom use B . Start and oral contraceptive pill (OCP) C . Ceftriaxone and azithromycin D . Doxycycline E . Ciprofloxacin Previous Question Next Question Question 14 Select the single best answer to the numbered question. A 74 year old man presents with double vision. He first noticed this several months ago, and although his symptoms wax and wane, he now experiences daily episodes of “seeing double,” most frequently in the evenings. He also reports increased generalized fatigue and notes that he sometimes gets so tired at dinner that he “can hardly chew” his food. Past medical history includes osteoarthritis, hypertension, and abdominal aortic aneurysm repair. Physical examination reveals a comfortable, age­appropriate elderly gentleman with mild dysarthria. Cardiac auscultation reveals both an S4 and a 2/6 holosystolic murmur heard best at the left upper sternal border with radiation to the carotids. On neurologic exam, the patient has 5/5 strength proximally and distally. Sensation is intact and reflexes are 2+ throughout. Ocular movements are sluggish but intact in all directions. The patient has mild bilateral ptosis, which is noted to increase with sustained upward gaze. Stroking the bottom of the foot results in downward deflection of the great toe bilaterally. Which of the following is the most appropriate next step in diagnosis? A . Administer i.v. edrophonium B . CT of chest C . MRI/MRA of brain and cerebral vessels D . Temporal artery biopsy E . CSF examination for oligoclonal bands Previous Question Next Question Question 15 Select the single best answer to the numbered question. On routine examination, a five year old child is noted to have a loud S1 with a fixed and widely split S2 that does not vary with respiration. A soft, mid­systolic ejection murmur is heard best on the left in the second intercostal space. Remainder of physical exam is otherwise unremarkable. There is no nail clubbing, hepatomegaly, or jugular venous distension. The child is healthy and active and her mother has no health concerns. Which of the following is the most likely diagnosis in this patient? A . Mitral valve prolapse B . Pulmonic regurgitation C . Tetralogy of Fallot D . Atrial septal defect E . Ventricular septal defect Previous Question Next Question Question 16 Select the single best answer to the numbered question.

2/12/2018 Quiz Sheet https://www.med-ed.virginia.edu/CourseSites/quiz/quizsheet.cfm?keywordID=1999&CourseID=19&num=1&start=1&noindex=1 5/32 A 62 year old woman with COPD presents to her physician complaining of two days of increasing dyspnea and cough. She uses supplemental oxygen at home and has had to increase her oxygen flow to relieve her shortness of breath. Recently, her cough has been productive of copious amounts of thick, dark yellow sputum. Although she never checked her temperature at home, she thinks she might have had a fever last night. Past medical history includes hypertension and peripheral arterial disease. She has smoked 1 ½ ­2 packs of cigarettes per day for the last 45 years and continues to smoke. Current medications include nebulized albuterol, tiotropium, inhaled fluticasone/salmeterol, lisinopril, and pentoxyfylline. Physical examination reveals an uncomfortable, thin female appearing older than her stated age. Vital signs are: temperature 37.2 C (99.0 F), pulse 80, blood pressure 136/70, respirations 20/min, oxygen saturation 88% on 2 L O2 by nasal cannula. The patient is using accessory muscles to breathe, and prolonged expirations and faint expiratory wheezes throughout the lung fields. Coarse crackles are heard at the lung bases. The patient’s chest X­ ray is shown. Which of the following is the most appropriate treatment for this patient? A . Methylprednisolone B . Prednisone and amoxicillin C . Guaifenasin D . Trimethoprim/sulfamethoxazole E . Aminophylline Previous Question Next Question Question 17 Select the single best answer to the numbered question. A 64 year old male presents for routine health evaluation. He has been feeling well and has no complaints. Past medical history includes hypertension, osteoarthritis, and generalized anxiety disorder. Medications include hydrochlorothiazide, ibuprofen, atenolol, and paroxetine. Physical exam shows temperature 37.9 C (99.3 F), pulse 61, blood pressure 131/70, and respirations 15/min. Laboratory evaluation shows: Na+ 141; K+ 3.9; Cl­ 103; HCO3­ 25; BUN 18; Creatinine 1.2; WBC 9.7; Hemoglobin 10.1; Platelets 179; MCV 73 fL. Which of the following is the most appropriate next step in the management of this patient? A . Add lisinopril B . Measure reticulocyte count C . Test B12 and folate levels D . Endoscopy E . Indirect and direct Coombs' tests Previous Question Next Question Question 18 Select the single best answer to the numbered question. A 36 year old African­American male comes to the clinic complaining of fatigue and dark, cola­colored urine for the past five days. He denies fever, nausea or vomiting, recent travel, and i.v. drug use. Past medical history includes ulcerative colitis. Medications include sulfasalazine as well as trimethoprim/sulfamethoxazole which the patient began taking one week ago for a presumed Staphylococcal skin infection. Vital signs are temperature 36.8 C (98.2 F), pulse 78, blood pressure 118/72, respirations 14/min. Physical examination shows scleral icterus and a nontender abdomen without organomegaly. Laboratory evaluation shows: WBC 8.6; Hgb 9.1; Hct 27.3; Platelets 212; MCV 88 fL; Na+ 144; K+ 4.8; Cl­ 101; HCO3­ 26; BUN 14; Creatinine 1.0; Glucose 101; LDH 410 U/L; Haptoglobin 8 mg/dL. Which of the following is the most appropriate next step in management of this patient? A . Quantitative IgM for hepatitis A virus B . Begin darbopoietin injections C . Begin methylprednisolone D . Discontinue trimethoprim/sulfamethoxazole E . Immediate transfusion of packed red blood cells Previous Question Next Question Question 19 Select the single best answer to the numbered question. A 65 year old female with diabetes is found on routine screening to have a total serum cholesterol concentration of 198 mg/dL, with a serum HDL cholesterol of 58 mg/dL and serum LDL cholesterol of 128 mg/dL. Triglycerides are 78 mg/dL, and last hemoglobin A1c is 6.5%. The patient has no known history of coronary artery disease, does not smoke, and exercises daily. Current medications include rosuvastatin, fosinopril, glyburide, and metoprolol. Blood pressure is 129/78. Urinalysis shows no protein. Which of the following is the best management plan and treatment goal for this patient?