MEDICAL

1. Which of the following therapies has been demonstrated to improve survival and hospital discharge with favorable neurologic outcomes in out of hospital cardiac arrest?
A. Amiodarone
B. Epinephrine
C. Hypothermia
D. Time to initial defibrillation < 10 min
E. Vasopressin

Hypothermia has been confirmed as a benefit following out of hospital arrest in studies. These trials showed that rapidly cooling to 32-34⁰C and maintaining these temperatures for 12-24 hours decreased in-hospital mortality and patients were 40-85% more likely to have good neurologic outcomes upon hospital discharge. Medications listed here have never demonstrated any effects on neurologic outcomes and only defibrillation within 5 minutes has the greatest likelihood for good neurologic outcomes.

2. A 19-year-old female presents with complaints of DOE and mild fatigue. She has no significant medical history, does not use tobacco and takes no regular medications. On exam, her lungs are clear and cardiac exam reveals a II/VI systolic murmur at the 2nd left intercostal space, which varies with inspiration. What is the most likely diagnosis for this patient?
A. Atrial septal defect
B. Pulmonary stenosis
C. Bicuspid aortic valve
D. Ventricular septal defect
E. Aortic regurgitation

This patient presents with a systolic murmur that varies with respiration. This makes it likely that the etiology is right sided, and given the location, pulmonary stenosis is more likely than tricuspid regurgitation. These right sided murmurs vary with respiration because filling of the right heart is influenced by changes in thoracic pressure.

3. A 31-year-old man presents with repetitive generalized motor convulsions that continue for 35 minutes until 2 mg of lorazepam are administered intravenously. Which of the following is best to administer next?
A. Phenytoin
B. Carbamazepine
C. Pentobarbital
D. Ethosuximide
E. Diazepam

Administration if IV lorazepam should be followed by the administration of phenytoin (or fosphenytoin) to control status epilepticus because the duration of action of lorazepam is limited. Carbamazepine is an effective anticonvulsant, but it cannot be given IV or IM. IV pentobarbital can be used but because the patient is not currently convulsing, induction of barbiturate coma is not indicated. Ethosuximide is indicated for the treatment of absence but not generalized tonic-clonic seizures. Rectal diazepam is used to abort seizures temporarily, especially in children.

4. Doxycycline FDA indications include treatment of which of the following conditions?
A. Rocky Mountain spotted fever
B. Anthrax
C. Malaria
D. A&B
E. All the above

A&B. Doxycycline has many FDA approved indications including rickettsial infections including Rocky Mountain spotted fever, trachoma, anthrax, and many specific bacterial infections including respiratory tract infections caused by Mycoplasma pneumonia, plague due to Yersinia pest

5. What is the most common clinical feature of Lyme Carditis?
A. Myopericarditis
B. AV conduction block
C. Cardiomyopathy
D. Heart failure
E. Tachycardia

While Lyme Carditis is rare, it can occur weeks after early disseminated Lyme disease. The most common clinical feature of Lyme Carditis is atrioventricular conduction blocks. Most of the time the AV block is short lived, but patients may require hospitalization and IV antibiotics if the PR interval is > 300 milliseconds.

6. All of the following are contraindications of hydralazine EXCEPT?
A. Dissecting aortic aneurysm
B. Severe mitral regurgitation
C. Severe mitral stenosis
D. All of the following are contraindications
E. None of the following are contraindications

Contraindications for hydralazine include dissecting aortic aneurysm and rheumatic heart disease (also known as mitral stenosis).  Severe coronary artery disease is a possible contraindication. Because hydralazine decreases systemic vascular resistance (afterload), it improves forward heart flow and therefore can be an indication for severe mitral regurgitation.

7. Which condition is most likely to be associated with decreased BNP levels?
A. Morbid obesity
B. Congestive heart failure
C. Chronic kidney disease
D. Severe pulmonary hypertension
E. Sepsis

BNP levels can be increased with CHF, Chronic Kidney Disease, Sepsis, Severe Pulmonary Hypertension, Coronary Heart Disease and Valvular Heart Disease.  Patients with obesity can actually have low BNP levels.

8. Which of the following is least likely to be associated with mitral regurgitation?
A. Holosystolic murmur
B. Atrial fibrillation
C. Myxomatous changes in developed countries
D. Possible S3 gallop
E. Murmur becomes louder with standing maneuver

All of the above can be associated with mitral regurgitation except that the murmur becomes louder with standing maneuver. An increase in cardiac volume normally makes a mitral regurgitation murmur louder.  Maneuvers that will increase the cardiac volume for a short period of time includes raising the legs and squatting down.  Standing will decrease the cardiac volume for a short period (and decrease the murmur intensity) as more volume then goes to the lower extremities.

9. All the following are gout risk factors EXCEPT?
A. Thiazide diuretics
B. Niacin
C. Dairy products
D. A&B
E. All the above

Risk factors for gout include (A&B) thiazide diurectics, niacin and seafood. Protective factors for gout include: coffee, dairy products and low BMI.

10. Which of the following is the FDA approved colchicine dosage for an acute gout flare up?
A. One tablet at onset and daily x 3 days
B. One tablet bid x 3 days
C. Two tablets bid x 3 days
D. Two tablets at onset and one tablet one hour later
E. Two tablets at onset and daily x 3 days

FDA indications for colchicine include taking two tablets at onset and one tablet one hour later. The maximum dose in one hour is 1.8mg.

11. Which of the following is/are FDA approved indication(s) for sumatriptan?
A. Migraine headache with aura
B. Cluster headache
C. Basilar & hemiplegic migraine
D. A&B
E. All the above

Migraine headache (with and without aura) and cluster headaches (A&B) are indications for sumatriptan. Basilar and hemiplegic migraine are contraindications.

12. Which condition is most likely to be associated with increased deep tendon reflexes?
A. Alcoholism
B. Upper motor lesions
C. Diabetes mellitus
D. Vitamin deficiencies
E. Lead poisoning

Of the choices, only upper motor lesions can increase deep tendon reflexes. Deep tendon reflexes are decreased with: peripheral neuropathy (most common cause), diabetes mellitus, alcoholism, amyloidosis, uremia, vitamin deficiencies (pellagra, beriberi), pernicious anemia, and toxins (lead, arsenic, isoniazid).

13. Which of the following immunizations should be avoided if the patient has an egg allergy?
A. Varicella
B. Measles, Mumps, Rubella
C. Haemophilus influenzae
D. Influenza
E. Meningococcal

Influenza vaccination should NOT be given if patients have an egg allergy.  Measles, Mumps, & Rubella (MMR), varicalla, and polio vaccines should be avoided if patient has a neomycin allergy.

14. All of the following immunizations are recommended to be given at the 2, 4, and 6 months age EXCEPT?
A. DTaP
B. Haemophilus influenzae
C. Measles, Mumps, Rubella
D. Polio
E. All the above can be given at 2, 4, and 6 months

Measles, Mumps, & Rubella (MMR) vaccine should NOT be given at the 2, 4, and 6 months but rather at one year (12-15 months) and repeated at 4-6 years. The following vaccines can be given at 2, 4, and 6 months:

  • DTAP: 5 doses with last 2 at 15-18 months and 4-6 years
  • Haemophilus influenzae B: 4 doses with last dose at 12-15 months
  • Pneumococcal: 4 doses with last dose at 12-15 months
  • Polio: 4 doses with last dose at 4-6 years
  • Rotavirus: 2 or 3 doses at 2, 4, and/or 6 months

15. A 56-year-old woman has an elevated serum calcium level of 12.2 mg/dL. She has no history of any illness or treatment associated with hypercalcemia. Which of the following studies would be most helpful in making a diagnosis of primary hyperparathyroidism?
A. 24 hr urine calcium excretion
B. Serum ionized calcium
C. Serum intact parathyroid hormone (PTH)
D. Computed tomography of the neck
E. Serum phosphate

An elevated level of serum intact PTH, in the absence of renal failure or other cause of secondary hyperparathyroidism, is strong evidence for primary hyperparathyroidism. A high normal PTH is also compatible with primary hyperparathyroidism because the PTH should be suppressed due to the hypercalcemia and is, therefore, inappropriately elevated. In hypercalcemia due to other causes (e.g., with cancer, sarcoidosis, or excessive vitamin D intake), the PTH level is suppressed by the hypercalcemia and is low (or normal).

PHARMACOLOGY

1. Most antiarrhythmic drugs can be categorized into four main classes. Which of the following is considered a class II antiarrhythmic medication?
A. Quinidine
B. Lidocaine
C. Procainamide
D. Phenytoin
E. Propranolol

Propranolol is a beta blocker and beta blockers are considered class II antiarrhythmics.

2. A 71-year-old male moves to your state and transfers as a new patient. He has been successfully treated for exercise-induced angina for the past 6 years. About 3 days ago he notes being woken up in the middle of night with chest pain. Which of the following medications would be useful in preventing this patient’s nocturnal angina?
A. Amyl nitrate
B. Esmolol
C. Nitroglycerin (sublingual)
D. Nitroglycerin (transdermal)
E. Hydralazine

Transdermal nitroglycerin can sustain blood levels for as long as 24 hours but because tolerance can occur, it is recommended that the patch be removed after 10 to 12 hours to allow recovery of sensitivity. Esmolol (IV), amyl nitrite, and sublingual nitroglycerin all have short durations of actions. Hydralazine could possibly precipitate an anginal attack.

3. A 68-year-old man recently had a myocardial infarction. Which of the following medications would be the most appropriate prophylactic antiarrhythmic therapy for this patient?
A. Procainamide
B. Lidocaine
C. Metoprolol
D. Verapamil
E. Quinidine

Numerous studies show that Beta blockers such as Metoprolol help prevent cardiac arrhythmias that occur related to myocardial infarctions. None of the other medications listed have been proven to be more effective.

4. Which one of the following antihypertensive drugs can precipitate a hypertensive crisis following abrupt cessation of therapy?
A. Clonidine
B. Enalapril
C. Diltiazem
D. Losartan
E. Hydrochlorothiazide

Increased sympathetic nervous system activity occurs if clonidine is abruptly stopped after prolonged administration causing uncontrolled elevation in blood pressure. Patients should be slowly weaned from clonidine while other antihypertensive medications are initiated.

5. Patients with heart failure often have compensatory increases in heart rate and renin release. Which of the following medications can help prevent this?
A. Digoxin
B. Enalapril
C. Dopamine
D. Metoprolol
E. Dobutamine

Heart failure usually causes a decrease in cardiac output and the body will naturally try to compensate by sympathetic stimulation. Beta blockers such as metoprolol prevent this increased heart rate and renin release. Enalapril is an ACE-inhibitor that will actually increase renin release. Digoxin slows the heart rate because of its vagomimetic effects, but does not affect renin release. Dopamine and Dobutamine are positive inotropic medications and neither decreases heart rate or affects renin release.

6. Which medication causes a decrease in liver triacyglycerol synthesis by limiting available free fatty acids needed as building blocks?
A. Fenofibrate
B. Niacin
C. Cholestyramine
D. Gemfibrozil
E. Atorvastatin

The primary producer of circulating free fatty acids is lipolysis in adipose tissue. The liver normally utilizes these free fatty acids as a major precursor for triacylglycerol synthesis. Niacin strongly inhibits adipose lipolysis and hence decreases the free fatty acids needed in liver triacylglycerol synthesis and VLDL production.

7. A 23-year-old college male comes to your clinic because he and his friends are going mountain climbing in the Andes next week. He heard there is a medication you can take to help prevent acute mountain sickness. Which of the following would you prescribe?
A. Anticholinergic
B. Thiazide diuretic
C. Loop diuretic
D. Carbonic anhydrase inhibitor
E. Beta blocker

Acetazolamine is a carbonic anhydrase inhibitor that can be used prophylactically before an ascent above 10,000 feet. This treatment helps prevent nausea and cerebral and pulmonary complications associated with acute mountain sickness.

8. Which of the following is/are long-acting B2-agonist(s)?
A. Salmeterol
B. Formoterol
C. Omalizumab
D. A&B
E. All the above

A&B, both Salmeterol and Formoterol are long long-acting B2-agonists. Omalizumab is a recombinant DNA-derived monoclonal antibody that selectively binds to human immunoglobulin E (IgE), and may be used to treat moderate to severe allergic asthma in patiients who are poorly controlled with conventional therapy.

9. Which of the following adverse effects is most specific to the biguanide diabetic drug metformin?
A. Hypoglycemia
B. Somnolence
C. Nausea
D. Lactic acidosis
E. All the above

Lactic Acidosis is the most dangerous adverse effect of metformin administration with death resulting in approximately 50 percent of individuals who develop lactic acidosis while on this drug. Metformin does not induce insulin production; thus, administration does not result in hypoglycemic events. Some nausea, vomiting, and diarrhea may develop but is usually not severe AND N/V/D is not specific to metformin. Metformin does not induce sleepiness.

10. Serious adverse effects of oral contraceptives include:
A. Thromboembolic complications
B. Stroke
C. Early or mid-cycle bleeding
D. A&B
E. All the above

Serious adverse effects of oral contraceptives include A&B, thromboembolic complications (DVT), stroke, and myocardial infarction. These risks are increased in women who smoke. Early or mid-cycle bleeding are effects of estrogen deficiency.

11. Which of the following is the most likely side effect of first-generation over-the-counter antihistamines in infants and children?
A. Reye’s syndrome
B. Cholinergic effects
C. Paradoxical CNS stimulation
D. Nausea
E. Diarrhea

Typically, first generation OTC antihistamines have a sedating effect because of passage into the CNS. However, in some individuals, especially infants and children, paradoxical CNS stimulation occurs and is manifested by excitement, euphoria, restlessness, and confusion. For this reason, use of first-generation OTC antihistamines has declined, and second-generation product usage has increased. Reye’s syndrome is a systemic response to a virus. First generation OTC antihistamines do not exhibit a cholinergic effect and do not commonly cause nausea or diarrhea.

12. Which of the following is the most serious adverse effect of tricyclic antidepressant (TCA) overdose?
A. Seizures
B. Hyperpyrexia
C. Metabolic acidosis
D. Cardiac arrhythmias
E. Pulmonary Fibrosis

Excessive ingestion of TCAs result in life-threatening cardiac arrhythmias with wide QRS complex tachycardia. TCA overdose can induce seiures, but they are typically not life-threatening. TCAs do not cause an elevation in body temperature, metabolic acidosis or pulmonary fibrosis.

13. Which electrolyte abnormality is most associated with prolonged use of a proton pump inhibitor?
A. Hyponatremia
B. Hypocalcemia
C. Hypokalemia
D. Hypomagnesemia
E. Hypophosphatemia

Hypomagnesemia. Prolonged use of a proton pump inhibitor (PPI) can lead to hypomagnesemia as noted by the FDA. While most patients who take PPIs for a long time do not develop hypomagnesemia, about 30 cases of severe hypomagnesemia have been reported in long-term PPI users. When the PPI was stopped, serum magnesium levels returned to normal in less than 2 weeks. The exact mechanism is unknown. Patients also taking other drugs that cause hypomagnesemia, such as diuretics and digoxin, may be at increased risk.

14. Which of the following is often associated with hypomagnesemia?
A. Hypocalcemia
B. Hypokalemia
C. Weakness
D. All the above
E. None of the above

All the above. Hypomagnesemia is often accompanied by hypocalcemia and hypokalemia. Patients with hypomagnesemia may also have muscle weakness, tremor, muscle cramps, carpopedal spasm, tetany, seizures, and cardiac conduction disturbances and arrhythmias.

15. A 63-year-old, 73 kg white male just underwent a total left knee replacement and is taking IV acetaminophen 650 mg q 4hr and morphine as needed for post-operative pain. What is a possible risk of IV acetaminophen?
A. Hepatoxicity because the dosage of acetaminophen is higher than recommended
B. Hepatoxicity because morphine increases serum concentrations of acetaminophen
C. Acetaminophen may mask a post-operative fever that could be a sign of infection
D. Acetaminophen could have an additive effect on respiratory depression due to morphine
E. None of the above

Acetaminophen may mask a post-operative fever that could be a sign of infection due to its antipyretic effects. IV acetaminophen does not affect respiratory depression and has not been associated with hepatotoxicity, but overdose can cause serious or fatal hepatic injury. IV analgesic adult dosage is 1000mg q6h or 650 mg q4hr (max: 4,000 mg/d). Given in conjunction with an opiod for moderate to severe pain, it has been shown to have an opiod-sparing effect.

SURGICAL

1. During a workup for infertility, a 35-year-old man is noted to have a painless solid tumor in the anterior aspect of his left testis. What is the most likely diagnosis?
A. Testicular torsion
B. Cyst of the epididymis
C. Epididymo-orchitis
D. Lipoma of the cord
E. Testicular cancer

Painless solid tumors in the testes are testicular cancer until proven otherwise. Nonhematogenous testicular tumors are divided into 2 categories – germ cell tumors (seminoma, nonseminoma [embryonal, choriocarcinoma, teratoma, teratocarcinoma, yolk sac tumors]) and nongerm cell tumors (Leydig cell or Sertoli cell). There is no mass within the testis with torsion. Epididymitis presents with a painful tender testis

2. A 44-year-old male comes to the clinic because his face is slightly swollen and he has some mild shortness of breath. He works in a factory and has never smoked. On examination, vital signs are normal, and pupils are equal and reactive to light. Dilated veins are noted around the shoulders, upper chest, and face. An x-ray of the chest reveals an opacity in the superior mediastinum. What is the most likely diagnosis?
A. Thymoma
B. Neurogenic tumor
C. Lymphoma
D. Teratodermoid tumor
E. Pheochromocytoma

The most common cause of primary mediastinal tumor is a neurogenic tumor (20-25%), and 10% are malignant (more likely in children). They usually arise from an intercostal nerve or sympathetic ganglion. Varieties of neurogenic tumors include schwannoma, neurofibroma, ganglioneuroma, and neuroblastoma. Next in frequency (of primary mediastinal tumors) are thymoma, congenital cysts, and lymphoma.

3. During surgery for a right inguinal hernia, a 70-year-old man is found to have a hernia sac that in not independent of the bowel wall. The cecum forms part of the wall of the sac. Which of the following describes this hernia?
A. Incarcerated
B. Irreducible
C. Sliding
D. Interstitial
E. None of the above

A sliding hernia refers to the peritoneum that slides along with the hernia in its passage along the cord. The viscus forms part of the wall of the sac. The peritoneum should not be removed from the bowel wall, because devascularization may occur.

4. Which is the second most common primary cardiac tumor in adults?
A. Rhabdomyomas
B. Fibromas
C. Myxomas
D. Teratomas
E. Papillary fibroelastomas

The most common primary cardiac tumor in adults is a myxoma.  The second most common primary cardiac tumor in adults is a papillary fibroelastoma.

5. Which of the following describes the majority of meningiomas?
A. Benign
B. Asymptomatic
C. Schwannomas
D. A&B
E. All the above

Most meningiomas are benign (92%) and asymptomatic (D). Schwannomas are a type of nerve sheath tumor and are NOT a type of meningioma.

6. A 78-year-old man has been diagnosed with localized prostate cancer. He is not a surgical candidate, and he is refusing radiation therapy. Which of the following would prostate cancer respond best to?
A. Saw palmetto
B. Radioimmunotherapy with ibritumomab tiuxetan
C. Finasteride
D. Tamoxifen
E. Androgen blockade

Prostate cancer cells are usually responsive to testosterone withdrawal. Total androgen blockade can be accomplished by the administration of luteinizing hormone-releasing hormone antagonists and drugs that would block the biosynthetic pathway of testosterone production. Tamoxifen is an antiestrogen agent that does not have a role in the treatment of prostate cancer. Both saw palmetto and finasteride are used for BPH and do not have significant effects on prostate cancer cells.

7. Bitemporal hemianopia is most likely to occur with which tumor?
A. Glioma
B. Pituitary adenoma
C. Meningioma
D. Neurofibroma
E. Metastatic breast cancer

Bitemporal hemianopia is a symptom that can occur with pituitary adenomas, if they are large enough to push on the optic chiasm.

8. Severe mitral regurgitation in adults is defined as how much regurgitant volume?
A. ≥ 10 mL/beat
B. ≥ 30 mL/beat
C. ≥ 60 mL/beat
D. ≥ 100 mL/beat
E. ≥ 150 mL/beat

Mild mitral regurgitation is defined as < 30 mL/beat, moderate mitral regurgitation is defined as 30-59 mL/beat and severe mitral regurgitation is defined as ≥ 60 mL/beat.

9. What CSF opening pressure is diagnostic of intracranial hypertension?
A. > 20 mm H2O
B. > 50 mm H2O
C. > 100 mm H2O
D. > 250 mm H2O
E. > 400 mm H2O

In most individuals, normal opening CSF pressure is < 200 H2O. Obese patients may have pressures up to 250 mm H20. Intracranial hypertension is diagnostic when the CSF opening pressure is > 250 mm H2O.

10. What is the most commonly diagnosed primary brain tumor?
A. Meningioma
B. Glioma
C. Pituitary adenoma
D. Malignant melanoma
E. Small cell carcinoma

The most commonly diagnosed primary brain tumor is Glioma making up 54-60% of tumors. Gliomas can be either benign or malignant and include: ependymomas, astrocytomas including glioblastoma multiforme, oligodendrogliomas and mixed gliomas.

11. How proximal to the cecum is a Meckel’s diverticulum usually found?
A. 20 cm
B. 30 cm
C. 40 cm
D. 50 cm
E. 60 cm

Meckel’s diverticulum lies on the antimesenteric border of the ileum.  It is 60 cm (2 feet) from the cecum, and averages 5 cm (2 inches) in length.

12. What percentage of carcinoid tumors of the appendix will metastasize?
A. 4%
B. 24%
C. 44%
D. 64%
E. 84%

Carcinoid tumors of the appendix are relatively benign and only 4% eventually metastasize.

13. What is the most common cause of a burn?
A. Chemical burn
B. Radiation burn
C. Electrical burn
D. Thermal burn

Thermal burn is the most common cause of a burn.

14. Which infection is most likely to be associated with acute pancreatitis?
A. Salmonella
B. Mumps
C. Campylobacter
D. Clostridium
E. Respiratory syncytial virus

Infections that are associated with acute pancreatitis include mumps, cytomegalovirus, and coxsackie infection.

15. What are the three most common types of hernia to strangulate, in order of frequency from the most common to least?
A. Femoral, indirect inguinal, umbilical
B. Indirect inguinal, umbilical, femoral
C. Umbilical, femoral, indirect inguinal

(A) Femoral, indirect inguinal, umbilical