Medicine Test 1 — Questions and Answers
Question 1: A 22-year-old woman with a 10-year history of asthma comes to the physician because she has had to increase her use of her albuterol inhaler during the past 6 weeks. Her asthma was previously well controlled with inhaled glucocorticoids. She has a 2-year history of generalized anxiety disorder controlled with fluoxetine and a 5-year history of migraines. The migraines were well controlled with sumatriptan until 4 months ago when she began to have headaches twice weekly; propranolol was added to her regimen at that time. She has been taking an oral contraceptive for the past year. She says she has been under increased stress at graduate school and in her personal life during the past 3 months; during this period, she has been drinking an average of four cups of coffee daily (compared with her usual one cup daily). She does not drink alcohol or use illicit drugs. She appears mildly anxious but is not in respiratory distress. Scattered end-expiratory wheezes are heard. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of the exacerbation of this patient’s asthma?
- Fluoxetine therapy
- Increased caffeine intake
- Oral contraceptive therapy
- Propranolol therapy (Correct answer)
- Sumatriptan therapy
Correct answer: Propranolol therapy
Propranolol is a non-selective beta-blocker, meaning it blocks both beta-1 and beta-2 adrenergic receptors. Beta-2 receptors are abundant in the bronchial smooth muscle, and their blockade by propranolol can lead to bronchoconstriction. This effect directly counteracts the bronchodilatory action of albuterol and can significantly exacerbate asthma symptoms, making it a contraindicated medication for most asthmatic patients.
Question 2: A 28-year-old woman has palpitations that occur approximately once a week, last 1-5 minutes, and consist of rapid, regular heart pounding. The episodes start and stop suddenly and have not been associated with chest discomfort or dyspnea. There is no history of heart problems. She drinks two to three cups of coffee daily. She rarely drinks alcohol and does not smoke. Her pulse is 96/min and regular, and blood pressure is 120/88 mm Hg. A stare and lid lag are noted. The thyroid gland is firm and 1.5 times larger than normal. There is a midsystolic click at the apex and a grade 2/6, early systolic murmur at the upper left sternal border. An ECG is normal except for evidence of sinus tachycardia. Which of the following is the most appropriate next step in diagnosis?
- Ambulatory ECG monitoring
- Measurement of urine catecholamine concentration
- Measurement of serum thyroid-stimulating hormone concentration (Correct answer)
- MUGA scan
- Echocardiography
Correct answer: Measurement of serum thyroid-stimulating hormone concentration
The patient's symptoms, including palpitations, tachycardia, stare, lid lag, and an enlarged, firm thyroid gland, are highly suggestive of hyperthyroidism. Thyroid hormones increase metabolic rate and cardiac excitability. Measuring serum thyroid-stimulating hormone (TSH) concentration is the most appropriate initial diagnostic step, as it is the most sensitive and specific test for screening primary thyroid dysfunction.
Question 3: A study is conducted to assess the benefits of a new drug to reduce the recurrence of colonic polyps. The results show a number needed to treat (NNT) of 16. Which of the following is the most accurate interpretation of this result?
- For every 16 patients treated, 1 would benefit from the new drug (Correct answer)
- For every 100 patients treated, 16 would benefit from the new drug
- The new drug is 1.6 times more beneficial than a placebo
- 93% of patients taking the new drug would benefit from it
- 84% of patients taking the new drug would not have any benefit from it
Correct answer: For every 16 patients treated, 1 would benefit from the new drug
The Number Needed to Treat (NNT) is a crucial epidemiological measure that quantifies the effectiveness of a medical intervention. It represents the average number of patients who need to be treated with a specific intervention for one additional patient to experience a beneficial outcome, compared to a control group. Therefore, an NNT of 16 means that for every 16 patients treated with the new drug, one patient will benefit.
Question 4: A previously healthy 57-year-old woman comes to the physician 1 week after noticing a lump under her right arm. She is concerned that it is breast cancer because both her mother and maternal aunt died of breast cancer. She does not smoke, drink alcohol, or use illicit drugs. She has avoided the sun for the past 10 years. She notes that her skin has never tanned but always burned and freckled when exposed to the sun. She exercises daily on a stationary bicycle and eats a well-balanced diet. Her temperature is 37°C (98.6°F), pulse is 82/min and regular, respirations are 14/min, and blood pressure is 130/74 mm Hg. There are numerous freckles over the entire body. Examination of the right breast shows a 0.6-cm, flat, brown lesion; the lesion is mottled with deep purple and black areas and has an irregular border. There are no breast masses, dimpling, peau d’orange, or nipple discharge. The patient says that the lesion has been present for 1 year, but she has never had it examined. There is a firm, nontender mass in the right axilla. Examination shows no other abnormalities. Which of the following is the most likely diagnosis?
- Basal cell carcinoma
- Fibrocystic changes of the breast
- Mastitis
- Melanoma (Correct answer)
- Pigmented nevus
- Port-wine stain
- Squamous cell carcinoma
- Superficial breast carcinoma
Correct answer: Melanoma
The described lesion—a flat, brown lesion mottled with deep purple and black areas, irregular borders, and a size of 0.6 cm—fits the ABCDE criteria for melanoma (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving). The presence of a firm, non-tender mass in the axilla strongly suggests metastatic spread to regional lymph nodes, further supporting the diagnosis of melanoma, a highly aggressive skin cancer.
Question 5: Two days after receiving 3 units of packed red blood cells for postpartum hemorrhage, a 24-year-old woman has fatigue and slight jaundice. Laboratory studies show: Hemoglobin 8.8 g/dL Hematocrit 28% Serum total bilirubin 5 mg/dL Liver tests are otherwise within normal limits. Which of the following is the most appropriate next step in diagnosis?
- Cytomegalovirus antibody titer
- Direct and indirect antiglobulin (Coombs) tests (Correct answer)
- Monospot test
- Serology for hepatitis B markers
- Ultrasonography of the gallbladder
Correct answer: Direct and indirect antiglobulin (Coombs) tests
The patient's symptoms of fatigue, jaundice, anemia, and elevated bilirubin developing a few days after a blood transfusion are highly suggestive of a delayed hemolytic transfusion reaction. This reaction occurs when the recipient's antibodies, often formed from prior exposure, react with antigens on the transfused red blood cells, leading to their destruction. Direct and indirect antiglobulin (Coombs) tests are essential to detect these antibodies and confirm immune-mediated hemolysis.
Question 6: A 30-year-old man has had nausea, vomiting, and severe colicky right flank pain radiating into the thigh for 4 hours. He is afebrile. There is right costovertebral angle tenderness. Urinalysis shows RBCs too numerous to count and no bacteria. Which of the following is the most likely diagnosis?
- Acute glomerulonephritis
- Bacterial cystitis
- Benign prostatic hyperplasia
- Bladder carcinoma
- Renal cell carcinoma
- Urinary tract tuberculosis
- Urolithiasis (Correct answer)
Correct answer: Urolithiasis
The patient's presentation of sudden-onset, severe, colicky right flank pain radiating into the thigh, accompanied by right costovertebral angle tenderness and hematuria (RBCs in urine) without signs of infection (afebrile, no bacteria), is classic for urolithiasis (kidney stones). The pain is caused by the obstruction of the ureter by the stone, leading to distension and spasm.
Question 7: A 66-year-old woman comes to the emergency department 1 hour after the sudden onset of retrosternal chest discomfort accompanied by nausea and diaphoresis. She has hypotension, jugular venous distention, and a murmur of tricuspid regurgitation. An ECG shows ST-segment elevation in the right precordial leads. Which of the following is the most likely diagnosis?
- Constrictive pericarditis
- Dissecting aortic aneurysm
- Pericardial tamponade
- Pulmonary emboli
- Right ventricular infarction (Correct answer)
Correct answer: Right ventricular infarction
The combination of retrosternal chest discomfort, hypotension, jugular venous distention, and ST-segment elevation in the right precordial leads (suggesting right ventricular involvement) is pathognomonic for right ventricular infarction. The right ventricle is highly preload-dependent, and its infarction leads to impaired pumping, causing systemic venous congestion (elevated JVD) and reduced cardiac output (hypotension).
Question 8: A 20-year-old African American woman comes to the physician because of a 6-month history of diffuse joint pain, especially in her hips and knees. During this period, she occasionally has had a rash on her nose and cheeks. She has no history of serious illness and takes no medications. Her temperature is 38.1°C (100.5°F). Examination shows warmth and swelling of the knees. Laboratory studies show: Hemoglobin 10.5 g/dL Erythrocyte sedimentation rate 40 mm/h Serum Urea nitrogen 30 mg/dL Creatinine 1.8 mg/dL Which of the following is the most likely diagnosis?
- Ankylosing spondylitis
- Gouty arthritis
- Psoriatic arthritis
- Reactive arthritis
- Septic arthritis
- Systemic lupus erythematosus (Correct answer)
- Rheumatoid arthritis
Correct answer: Systemic lupus erythematosus
This patient's constellation of symptoms, including diffuse joint pain (polyarthralgia/arthritis), a malar rash (rash on nose and cheeks), fever, anemia, elevated erythrocyte sedimentation rate (ESR), and evidence of renal involvement (elevated BUN and creatinine), is highly characteristic of systemic lupus erythematosus (SLE). SLE is a chronic autoimmune disease that can affect multiple organ systems.
Question 9: A 37-year-old man with type 1 diabetes mellitus comes to the physician for a routine examination. His only medication is insulin. His pulse is 72/min, respirations are 12/min, and blood pressure is 138/88 mm Hg. Funduscopic examination shows microaneurysms and hemorrhages. Sensation to vibration and light touch is decreased over the lower extremities. His serum creatinine concentration is 1.6 mg/dL. A 24-hour urine collection shows 550 mg of protein. Treatment with which of the following is most likely to slow progression of this patient’s renal disease?
- Atenolol
- Clonidine
- Hydralazine
- Hydrochlorothiazide
- Lisinopril (Correct answer)
Correct answer: Lisinopril
The patient has evidence of diabetic nephropathy, characterized by proteinuria and elevated serum creatinine. Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, are the cornerstone of treatment for diabetic nephropathy. They reduce intraglomerular pressure by dilating the efferent renal arteriole, thereby decreasing proteinuria and significantly slowing the progression of renal disease.
Question 10: A 50-year-old man is admitted to the hospital within 2 hours of the onset of nausea, vomiting, and acute crushing pain in the left anterior chest. He has a family history of early coronary artery disease. The pain does not subside with the administration of nitroglycerin, sublingually. An ECG shows ST-segment elevation in leads aVL and V2 through V4 . Which of the following is the most appropriate management to decrease myocardial damage and mortality?
- Administration of digitalis
- Administration of lidocaine
- Administration of quinidine
- Coronary artery bypass grafting within 1 week
- Thrombolytic therapy (Correct answer)
Correct answer: Thrombolytic therapy
The patient is experiencing an acute ST-segment elevation myocardial infarction (STEMI), indicated by the crushing chest pain, nausea, vomiting, and ST-segment elevation in multiple anterior leads. The most critical intervention to minimize myocardial damage and mortality in STEMI is prompt reperfusion therapy. Thrombolytic therapy, by dissolving the clot occluding the coronary artery, restores blood flow to the ischemic myocardium.
Question 11: A previously healthy 67-year-old woman comes to the physician with her husband because of a 4-month history of a resting tremor of her right arm. Her husband reports that her movements have been slower and that she appears less stable while walking. Examination shows increased muscle tone in the upper extremities that is greater on the right than on the left. There is decreased right arm swing. Her gait is slow and shuffling. Which of the following is the most likely explanation for this patient’s symptoms?
- Bilateral frontal lobe degeneration
- Decreased dopaminergic input to the striatum (Correct answer)
- Decreased serotonergic activity in the brain stem
- Excessive output of oxytocin
- Excessive thalamic output of norepinephrine
Correct answer: Decreased dopaminergic input to the striatum
The patient's symptoms—resting tremor, slowed movements (bradykinesia), unstable gait (postural instability), increased muscle tone (rigidity), and decreased arm swing—are classic manifestations of Parkinson's disease. This neurodegenerative disorder is primarily caused by the progressive loss of dopaminergic neurons in the substantia nigra pars compacta, leading to a significant reduction in dopamine input to the striatum and subsequent disruption of basal ganglia function.
Question 12: A 47-year-old man comes to the physician because of a 4-week history of increased thirst and urination. He has had a 23-kg (50-lb) weight gain during the past 2 years. He has no history of serious illness and takes no medications. His mother and maternal grandfather have type 2 diabetes mellitus. The patient does not smoke and drinks one beer every night. He is 175 cm (5 ft 9 in) tall and now weighs 104 kg (230 lb); BMI is 34 kg/m2 . His pulse is 90/min, and blood pressure is 150/88 mm Hg. The remainder of the examination shows no abnormalities. His serum glucose concentration is 330 mg/dL. Which of the following is the most likely underlying cause of this patient’s increased serum glucose concentration?
- Autoimmune destruction of islet cells
- Chronic pancreatitis
- Exogenous production of corticosteroids
- Insulin resistance (Correct answer)
- Pancreatic cancer
Correct answer: Insulin resistance
This patient presents with classic features of type 2 diabetes mellitus, including significant weight gain leading to obesity (BMI 34), hypertension, and marked hyperglycemia (serum glucose 330 mg/dL). His family history of type 2 diabetes further supports this diagnosis. The underlying cause of type 2 diabetes is primarily insulin resistance, where target cells fail to respond adequately to insulin, leading to compensatory hyperinsulinemia and eventual pancreatic beta-cell exhaustion.
Question 13: A previously healthy 39-year-old woman is brought to the physician because of a tingling sensation in her fingers and toes for 2 days and rapidly progressive weakness of her legs. She had an upper respiratory tract infection 2 weeks ago. She was unable to get up from bed this morning. Examination shows weakness of all four extremities, distal greater than proximal. Deep tendon reflexes are absent. Sensation is mildly decreased over the feet. Which of the following is the most likely diagnosis?
- Guillain-Barré syndrome (Correct answer)
- Multiple sclerosis
- Myasthenia gravis
- Poliomyelitis
- Tick paralysis
Correct answer: Guillain-Barré syndrome
This patient's presentation of rapidly progressive, ascending weakness (legs first, then all four extremities, distal greater than proximal), accompanied by tingling sensations and absent deep tendon reflexes, is highly characteristic of Guillain-Barré syndrome (GBS). The preceding upper respiratory tract infection 2 weeks prior is a common trigger for this acute demyelinating polyneuropathy, where the immune system attacks peripheral nerves.
Question 14: A previously healthy 77-year-old woman who resides in a skilled nursing care facility is brought to the emergency department 6 hours after the onset of acute midback pain that began while lifting a box. The pain does not radiate, and she has no other symptoms. She continues to carry out her daily activities. She appears to be in mild distress. She is 157 cm (5 ft 2 in) tall and weighs 47 kg (104 lb); BMI is 19 kg/m2 . Examination shows mild tenderness over T11. There is no tremor. Serum studies show a calcium concentration of 9.1 mg/dL, a urea nitrogen concentration of 12 mg/dL, and a creatinine concentration of 0.5 mg/dL. An x-ray of the dorsal and lumbar spine shows an anterior wedge fracture of T11. In addition to treating the pain, supplementation with which of the following is most likely to improve this patient’s underlying condition?
- 25-Hydroxycholecalciferol (Correct answer)
- Levothyroxine
- Selenium
- Vitamin C
- Vitamin E
Correct answer: 25-Hydroxycholecalciferol
This elderly, frail woman (BMI 19) experienced an acute vertebral wedge fracture after minimal trauma (lifting a box), which is a classic fragility fracture indicative of osteoporosis. While pain management is important, addressing the underlying bone weakness is crucial. Supplementation with 25-hydroxycholecalciferol (Vitamin D) is essential for calcium absorption and bone mineralization, making it a cornerstone of osteoporosis treatment and prevention, especially in the elderly who are often deficient.
Question 15: A 52-year-old woman comes to the physician because of a 3-month history of diarrhea and intermittent abdominal pain that radiates to her back. The pain is exacerbated by eating. She describes her stools as greasy, foul-smelling, and difficult to flush. She has had a 4.5-kg (10-lb) weight loss during the past 4 months. She has a history of chronic alcohol abuse. Examination shows mild epigastric tenderness. An x-ray of the abdomen shows calcifications in the epigastrium. Which of the following is the most likely diagnosis?
- Bacterial overgrowth
- Celiac disease
- Lactose intolerance
- Malabsorption of bile salts
- Pancreatic insufficiency (Correct answer)
Correct answer: Pancreatic insufficiency
The patient's history of chronic alcohol abuse, recurrent abdominal pain radiating to the back, and characteristic greasy, foul-smelling stools (steatorrhea) strongly suggest chronic pancreatitis. The abdominal x-ray showing epigastric calcifications is pathognomonic for chronic pancreatitis. This condition leads to pancreatic insufficiency, where the exocrine pancreas fails to produce sufficient digestive enzymes, resulting in malabsorption of fats and subsequent steatorrhea and weight loss.
Question 16: A 67-year-old woman comes to the physician because of an 8-month history of progressive shortness of breath. The shortness of breath initially occurred only with walking long distances but now occurs after walking ÂĽ mile to her mailbox. She also has a daily morning cough productive of whitish tan sputum. She has had no chest pain, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. She has smoked one pack of cigarettes daily for 52 years. Her pulse is 88/min, respirations are 20/min, and blood pressure is 144/90 mm Hg. Examination shows a barrel-shaped chest. Breath sounds are decreased, and faint expiratory wheezes are heard in all lung fields. There is no peripheral edema. An x-ray of the chest shows no abnormalities except for hyperinflation. Which of the following is the most likely diagnosis?
- Angina pectoris
- Asthma
- Chronic obstructive pulmonary disease (Correct answer)
- Chronic pulmonary embolism
- Congestive heart failure
- Panic disorder
Correct answer: Chronic obstructive pulmonary disease
This patient's extensive smoking history (52 pack-years), progressive shortness of breath, chronic productive cough, barrel-shaped chest, decreased breath sounds, expiratory wheezes, and hyperinflation on chest x-ray are all classic signs and symptoms of chronic obstructive pulmonary disease (COPD). COPD is a progressive lung disease primarily caused by long-term exposure to irritants, most commonly cigarette smoke, leading to airflow limitation and emphysema/chronic bronchitis.
Question 17: A 22-year-old woman comes to the physician because of a 10-day history of pain in multiple joints. She first had pain in her right elbow, and then her right shoulder, and now has pain, redness, and swelling in her left knee that began 2 days ago. She currently has no pain in the right shoulder and elbow. There is no history of trauma. She is sexually active, and she and her partner use condoms for contraception inconsistently. Examination of the left knee shows warmth, erythema, tenderness, and soft-tissue swelling. Range of motion of the knee is limited to 10 degrees of flexion. The remainder of the examination, including pelvic examination, shows no abnormalities. Arthrocentesis of the knee joint yields 10 mL of cloudy fluid with a leukocyte count of 18,300/mm3 (97% segmented neutrophils). Microscopic examination of the leukocytes within the joint fluid is most likely to show which of the following?
- Acid-fast bacteria
- Cuboidal positively birefringent crystals
- Gram-negative diplococci
- Gram-positive cocci in clusters (Correct answer)
- Needle-shaped negatively birefringent crystals
Correct answer: Gram-positive cocci in clusters
The patient's migratory polyarthralgia followed by acute monoarthritis in a young, sexually active woman with inconsistent condom use strongly suggests disseminated gonococcal infection. However, the question asks for the *most likely* microscopic finding in the joint fluid. While Neisseria gonorrhoeae (gram-negative diplococci) is a strong clinical suspicion, Staphylococcus aureus (gram-positive cocci in clusters) remains the most common cause of septic arthritis overall, even in this demographic. Therefore, gram-positive cocci in clusters are the most likely finding on Gram stain of the synovial fluid.
Question 18: A 47-year-old woman comes to the physician for a routine health maintenance examination. She feels well and has no history of serious illness. Her mother, brother, and sister have hypertension. The patient’s pulse is 84/min, and blood pressure is 138/85 mm Hg. Examination shows no other abnormalities. The most appropriate recommendation is decreased intake of which of the following?
- Calcium
- Carbohydrates
- Potassium
- Protein
- Sodium (Correct answer)
Correct answer: Sodium
This patient has elevated blood pressure (138/85 mm Hg), which is considered elevated blood pressure or pre-hypertension, and a family history of hypertension. Dietary sodium restriction is a primary and highly effective lifestyle modification recommended for preventing and managing hypertension. Reducing sodium intake helps lower blood pressure and is a crucial first step in patients with elevated readings or a family history of the condition.
Question 19: A 32-year-old man comes to the physician because of a 12-day history of abdominal cramps and bloating, diarrhea, and flatulence. He says that he started a new exercise program 2 weeks ago and has been consuming a high quantity of yogurt bars, peanut butter, and protein- and calorie-enriched milk shakes to “bulk up.” He has no history of serious illness and takes no medications. His temperature is 37°C (98.6°F). The abdomen is distended, nontender, and tympanitic to percussion. Bowel sounds are increased. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of this patient’s symptoms?
- Allergy to peanuts
- Fungal overgrowth in the small bowel
- Incarcerated hernia
- Irritable bowel syndrome
- Lactase deficiency (Correct answer)
Correct answer: Lactase deficiency
The patient's symptoms of abdominal cramps, bloating, diarrhea, and flatulence, which began after increasing his consumption of dairy-containing products like yogurt bars and milkshakes, are highly suggestive of lactase deficiency (lactose intolerance). This condition results from the inability to digest lactose, leading to its fermentation by gut bacteria and the production of gas and osmotic diarrhea.
Question 20: A 22-year-old college student comes to student health services because of a 7-day history of low-grade fever, sore throat, fatigue, and general malaise. One month ago, she had a painless vulvar ulcer that resolved spontaneously; she has been otherwise healthy. Her last menstrual period was 3 weeks ago; she uses tampons regularly. She is sexually active and has had three partners since the age of 15 years; she uses an oral contraceptive. Her temperature is 38°C (100.4°F), pulse is 100/min, and blood pressure is 110/60 mm Hg. Examination shows a rash over the palms and soles and mild cervical lymphadenopathy. Pelvic examination shows no abnormalities. Which of the following is the most appropriate pharmacotherapy?
- Acyclovir
- Dexamethasone
- Interferon
- Penicillin (Correct answer)
- Zidovudine (AZT)
Correct answer: Penicillin
This patient's clinical presentation, including a history of a painless vulvar ulcer that resolved spontaneously (primary syphilis chancre), followed by systemic symptoms (fever, sore throat, fatigue) and a rash on the palms and soles, is classic for secondary syphilis. Penicillin is the drug of choice for treating all stages of syphilis, effectively eradicating the causative spirochete, Treponema pallidum.
Medicine Test 1
A 22-year-old woman with a 10-year history of asthma comes to the physician because she has had to increase her use of her albuterol inhaler during the past 6 weeks.
Her asthma was previously well controlled with inhaled glucocorticoids.
She has a 2-year history of generalized anxiety disorder controlled with fluoxetine and a 5-year history of migraines.
The migraines were well controlled with sumatriptan until 4 months ago when she began to have headaches twice weekly; propranolol was added to her regimen at that time.
She has been taking an oral contraceptive for the past year.
She says she has been under increased stress at graduate school and in her personal life during the past 3 months; during this period, she has been drinking an average of four cups of coffee daily (compared with her usual one cup daily).
She does not drink alcohol or use illicit drugs.
She appears mildly anxious but is not in respiratory distress.
Scattered end-expiratory wheezes are heard.
The remainder of the examination shows no abnormalities.
Which of the following is the most likely cause of the exacerbation of this patient’s asthma?