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 TM
Medicine
PreTest Self-Assessment and Review
 Notice

Medicine is an ever-changing science. As new research and clinical experience

broaden our knowledge, changes in treatment and drug therapy are required. The
authors and the publisher of this work have checked with sources believed to be
reliable in their efforts to provide information that is complete and generally in
accord with the standards accepted at the time of publication. However, in view of
the possibility of human error or changes in medical sciences, neither the authors
nor the publisher nor any other party who has been involved in the preparation or
publication of this work warrants that the information contained herein is in every
respect accurate or complete, and they disclaim all responsibility for any errors or
omissions or for the results obtained from use of the information contained in this
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uct information sheet included in the package of each drug they plan to administer
to be certain that the information contained in this work is accurate and that
changes have not been made in the recommended dose or in the contraindications
for administration. This recommendation is of particular importance in connection
with new or infrequently used drugs.
 TM
Medicine
PreTest Self-Assessment and Review
Twelfth Edition

Robert S. Urban, MD
Associate Professor
Department of Internal Medicine
Texas Tech University Health Sciences Center
School of Medicine
Amarillo, Texas

J. Rush Pierce, Jr., MD, MPH

Associate Professor
Department of Internal Medicine
Texas Tech University Health Sciences Center
School of Medicine
Amarillo, Texas

Marjorie R. Jenkins, MD
Associate Professor
Department of Internal Medicine
Executive Director, Laura W. Bush Institute for Women’s Health
Texas Tech University Health Sciences Center
School of Medicine
Amarillo, Texas

Steven L. Berk, MD
Dean and Professor of Medicine
Texas Tech University Health Sciences Center
School of Medicine
Lubbock, Texas

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 Contributors
Todd Bell, MD
Assistant Professor, Internal Medicine
Texas Tech University School of Medicine, Amarillo
Hospital-Based Medicine, Cardiology

Harvey Richey, DO
Assistant Professor, Internal Medicine
Texas Tech University School of Medicine, Amarillo
Pulmonary Medicine

Joanna Wilson, DO
Assistant Professor, Internal Medicine
Chief, Division of Women’s Health and Gender-Based Medicine
Texas Tech University School of Medicine, Amarillo
Women’s Health

v
 Student Reviewers
Miranda Boucher
Texas Tech University School of Medicine
Class of 2008

Anne Doughtie
Texas Tech University School of Medicine
Class of 2009

Edward Gould
SUNY Upstate Medical University
Class of 2009

Joshua Lynch
Lake Erie College of Osteopathic Medicine
Class of 2008

Reza Samad
SUNY Upstate Medical University
Class of 2009

Jay Yuan
Stony Brook University School of Medicine
Class of 2008

vi
 Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

Infectious Disease
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Hospital-Based Medicine
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Rheumatology
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Pulmonary Disease
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Cardiology
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

Endocrinology and Metabolic Disease

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Gastroenterology
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

vii
viii Contents

Nephrology
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Hematology and Oncology

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Neurology
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Dermatology
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

General Medicine and Prevention

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349

Allergy and Immunology

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368

Geriatrics
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382

Women’s Health
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
 Introduction
Medicine: PreTest Self-Assessment and Review, Twelfth Edition, is intended to
provide medical students, as well as house officers and physicians, with a
convenient tool for assessing and improving their knowledge of medicine.
The 500 questions in this book are similar in format and complexity to
those included in Step 2 of the United States Medical Licensing Examina-
tion (USMLE). They may also be a useful study tool for Step 3.
For multiple-choice questions, the one best response to each question
should be selected. For matching sets, a group of questions will be pre-
ceded by a list of lettered options. For each question in the matching set,
select one lettered option that is most closely associated with the question.
Each question in this book has a corresponding answer, a reference to a
text that provides background to the answer, and a short discussion of var-
ious issues raised by the question and its answer. A listing of references for
the entire book follows the last chapter.
To simulate the time constraints imposed by the qualifying examina-
tions for which this book is intended as a practice guide, the student or
physician should allot about one minute for each question. After answering
all questions in a chapter, as much time as necessary should be spent in
reviewing the explanations for each question at the end of the chapter.
Attention should be given to all explanations, even if the examinee
answered the question correctly. Those seeking more information on a sub-
ject should refer to the reference materials listed or to other standard texts
in medicine.

ix
 Acknowledgments
We would like to offer special thanks to:

Joan Urban, David Urban,

Elizabeth Urban, Catherine Urban.

Diane Pierce, Read Pierce, Rebecca Pierce Martin,

Cason Pierce, and Susanna Pierce.

Stephen Jenkins, Katharine Jenkins,

Matthew Jenkins, Rebecca Jenkins.

Shirley Berk, Jeremy Berk, Justin Berk.

Cris Sheffield and Julie Schaef, for secretarial assistance.

To the medical students, residents, faculty, and staff

of Texas Tech University School of Medicine—
in pursuit of excellence.

x
 Infectious Disease
Questions

1. A 30-year-old male patient complains of fever and sore throat for several
days. The patient presents to you today with additional complaints of hoarse-
ness, difficulty breathing, and drooling. On examination, the patient is febrile
and has inspiratory stridor. Which of the following is the best course of action?
a. Begin outpatient treatment with ampicillin.
b. Culture throat for β-hemolytic streptococci.
c. Admit to intensive care unit and obtain otolaryngology consultation.
d. Schedule for chest x-ray.
e. Obtain Epstein-Barr serology.

2. A 70-year-old patient with long-standing type 2 diabetes mellitus presents

with complaints of pain in the left ear with purulent drainage. On physical
examination, the patient is afebrile. The pinna of the left ear is tender, and
the external auditory canal is swollen and edematous. The white blood cell
count is normal. Which of the following organisms is most likely to grow from
the purulent drainage?
a. Pseudomonas aeruginosa
b. Streptococcus pneumoniae
c. Candida albicans
d. Haemophilus influenzae
e. Moraxella catarrhalis

1
2 Medicine

3. A 25-year-old male student presents with the chief complaint of rash.

He denies headache, fever, or myalgia. A slightly pruritic maculopapular rash
is noted over the abdomen, trunk, palms of the hands, and soles of the feet.
Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic,
flat, wartlike lesions are noted around the anal area. Laboratory studies show
the following:
Hct: 40%
Hgb: 14 g/dL
WBC: 13,000/μL
Diff: 50% segmented neutrophils, 50% lymphocytes
Which of the following is the most useful laboratory test in this patient?
a. Weil-Felix titer
b. Venereal Disease Research Laboratory (VDRL) test
c. Chlamydia titer
d. Blood cultures
e. Biopsy of perianal lesions

4. A 35-year-old previously healthy male develops cough with purulent

sputum over several days. On presentation to the emergency room, he is
lethargic. Temperature is 39°C, pulse 110, and blood pressure 100/70. He has
rales and dullness to percussion at the left base. There is no rash. Flexion
of the patient’s neck when supine results in spontaneous flexion of hip and
knee. Neurologic examination is otherwise normal. There is no papilledema.
A lumbar puncture is performed in the emergency room. The cerebrospinal
fluid (CSF) shows 8000 leukocytes/μL, 90% of which are polys. Glucose is
30 mg/dL with a peripheral glucose of 80 mg/dL. CSF protein is elevated to
200 mg/dL. A CSF Gram stain shows gram-positive diplococci. Which of
the following is the correct treatment option?
a. Begin acyclovir for herpes simplex encephalitis.
b. Obtain emergency MRI scan before beginning treatment.
c. Begin ceftriaxone and vancomycin for pneumococcal meningitis.
d. Begin ceftriaxone, vancomycin, and ampicillin to cover both pneumococci and
Listeria.
e. Begin high-dose penicillin for meningococcal meningitis.
 Infectious Disease 3

5. A 20-year-old female college student presents with a 5-day history of

cough, low-grade fever (temperature 37.8°C [100°F]), sore throat, and coryza.
On examination, there is mild conjunctivitis and pharyngitis. Tympanic
membranes are inflamed, and one bullous lesion is seen. Chest examination
shows a few basilar rales. Sputum Gram stain shows white blood cells with-
out organisms. Laboratory findings are as follows:
Hct: 31
WBC: 12,000/μL
Lymphocytes: 50%
Mean corpuscular volume (MCV): 94 nL
Reticulocytes: 9% of red cells
CXR: bilateral patchy lower lobe infiltrates
Which of the following is the best method for confirmation of the diagnosis?
a. High titers of antibody to adenovirus
b. High titers of IgM cold agglutinins or complement fixation test
c. Methenamine silver stain
d. Blood culture
e. Culture of sputum on chocolate media

6. A 22-year-old male, recently incarcerated and now homeless, has received

one week of clarithromycin for low-grade fever and left upper-lobe pneu-
monia. He has not improved on antibiotics, with persistent cough productive
of purulent sputum and flecks of blood. Repeat chest x-ray suggests a small
cavity in the left upper lobe. Which of the following statements is correct?
a. The patient has anaerobic infection and needs outpatient clindamycin therapy.
b. The patient requires sputum smear and culture for acid fast bacilli.
c. The patient requires glove and gown contact precautions.
d. Isoniazid prophylaxis should be started if PPD is positive.
e. Drug resistant pneumococci may be causing this infection.
4 Medicine

7. A 19-year-old male presents with a 1-week history of malaise and anorexia

followed by fever and sore throat. On physical examination, the throat is
inflamed without exudate. There are a few palatal petechiae. Cervical adeno-
pathy is present. The liver span is 12 cm and the spleen is palpable.
Throat culture: negative for group A streptococci
Hgb: 12.5, Hct: 38%
Reticulocytes: 4%
WBC: 14, 000/μL
Segmented: 30%
Lymphocytes: 60%
Monocytes: 10%
Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2)
Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220)
Aspartate aminotransferase (AST): 40 U/L (normal 8 to 20 U/L)
Alanine aminotransferase (ALT): 35 U/L (normal 8 to 20 U/L)
Alkaline phosphatase: 40 IU/L (normal 35 to 125)
Which of the following is the most important initial test combination to order?
a. Liver biopsy and hepatitis antibody
b. Streptococcal screen and antistreptolysin O (ASO) titer
c. Peripheral blood smear and heterophile antibody
d. Toxoplasma IgG and stool sample
e. Lymph node biopsy and cytomegalovirus serology

8. A 30-year-old male presents with right upper quadrant pain. He has been
well except for an episode of diarrhea that occurred 4 months ago, just after
he returned from a missionary trip to Mexico. He has lost 7 pounds. He is
not having diarrhea. His blood pressure is 140/70, pulse 80, and temperature
37.5°C (99.5°F). On physical examination there is right upper-quadrant ten-
derness without rebound. There is some radiation of the pain to the shoulder.
The liver is percussed at 14 cm. There is no lower-quadrant tenderness. Bowel
sounds are normal and active. Which of the following is the most appropriate
next step in evaluation of the patient?
a. Serology and ultrasound
b. Stool for ova and parasite
c. Blood cultures
d. Diagnostic aspirate
e. Empiric broad-spectrum antibiotic therapy
 Infectious Disease 5

9. An 80-year-old male complains of a 3-day history of a painful rash exten-

ding over the left half of his forehead and down to his left eyelid. There are
weeping vesicular lesions on physical examination. Which of the following is
the most likely diagnosis?
a. Impetigo
b. Adult chickenpox
c. Herpes zoster
d. Coxsackie A virus
e. Herpes simplex

10. A 28-year-old female presents to her internist with a 2-day history of

low-grade fever and lower abdominal pain. She denies nausea, vomiting, or
diarrhea. On physical examination, there is temperature of 38.3°C (100.9°F)
and bilateral lower quadrant tenderness, without point or rebound tenderness.
Bowel sounds are normal. On pelvic examination, an exudate is present and
there is tenderness on motion of the cervix. Her white blood cell count is
15,000/μL and urinalysis shows no red or white blood cells. Serum β-hCG is
undetectable. Which of the following is the best next step in management?
a. Treatment with ceftriaxone and doxycycline
b. Endometrial biopsy
c. Surgical exploration
d. Dilation and curettage
e. Aztreonam

11. A 35-year-old male complains of inability to close his right eye. Exam-
ination shows facial nerve weakness of the upper and lower halves of the
face. There are no other cranial nerve abnormalities, and the rest of the neuro-
logical examination is normal. Examination of the heart, chest, abdomen,
and skin show no additional abnormalities. There is no lymphadenopathy.
About one month ago the patient was seen by a dermatologist for a bull’s-eye
skin rash. The patient lives in upstate New York and returned from a camping
trip a few weeks before noting the rash. Which of the following is the most
likely diagnosis?
a. Sarcoidosis
b. Idiopathic Bell palsy
c. Lyme disease
d. Syphilis
e. Lacunar infarct
6 Medicine

12. A 25-year-old woman complains of dysuria, frequency, and suprapubic

pain. She has not had previous symptoms of dysuria and is not on antibiotics.
She is sexually active and on birth control pills. She has no fever, vaginal
discharge or history of herpes infection. She denies back pain, nausea, or
vomiting. On physical examination she appears well and has no costovertebral
angle tenderness. A urinalysis shows 20 white blood cells per high power
field. Which of the following statements is correct?
a. A 3-day regimen of trimethoprim-sulfamethoxazole is adequate therapy.
b. Quantitative urine culture with antimicrobial sensitivity testing is mandatory.
c. Obstruction resulting from renal stone should be ruled out by ultrasound.
d. Low-dose antibiotic therapy should be prescribed while the patient remains
sexually active.
e. The etiologic agent is more likely to be sensitive to trimethoprim-sulfamethoxazole
than to fluoroquinolones.

13. A 25-year-old woman is admitted with fever and hypotension. She has a
3-day history of feeling feverish. She has no history of chronic disease, but she
uses tampons for heavy menses. She is acutely ill and, on physical examination,
found to have a diffuse erythematous rash extending to palms and soles. She is
confused. Initial blood tests are as follows:
White blood cell count: 22,000/μL
Na+: 125 mEq/L
K+: 3.0 mEq/L
Ca++: 8.0 mEq/mL
Activated partial thromboplastin time (PTT): 65 (normal 21 to 36)
Prothrombin time (PT): 12s (normal < 15s)
Aspartate aminotransferase: 240 U/L (normal < 40)
Creatinine: 3.0 mg/dL
Antinuclear antibodies: negative
Anti-DNA antibodies: negative
Serologic tests for RMSF, leptospirosis, measles: negative
Which of the following best describes the pathophysiology of the disease
process?
a. Acute bacteremia
b. Toxin-mediated inflammatory response syndrome
c. Exacerbation of connective tissue disease
d. Tick-borne rickettsial disease
e. Allergic reaction
 Infectious Disease 7

14. You are a physician in charge of patients who reside in a nursing

home. Several of the patients have developed influenza-like symptoms, and
the community is in the midst of influenza A outbreak. None of the nursing
home residents have received the influenza vaccine. Which course of action
is most appropriate?
a. Give the influenza vaccine to all residents who do not have a contraindication
to the vaccine (ie, allergy to eggs).
b. Give the influenza vaccine to all residents who do not have a contraindication
to the vaccine; also give oseltamivir for 2 weeks to all residents.
c. Give amantadine alone to all residents.
d. Give azithromycin to all residents to prevent influenza-associated pneumonia.
e. Do not give any prophylactic regimen.

15. A 60-year-old male complains of low back pain, which has intensified
over the past 3 months. He had experienced some fever at the onset of the
pain. He was treated for acute pyelonephritis about 4 months ago. Physical
examination shows tenderness over the L2-3 vertebra and paraspinal muscle
spasm. Laboratory data show an erythrocyte sedimentation rate of 80 mm/h
and elevated C-reactive protein. Which of the following statements is correct?
a. Hematogenous osteomyelitis rarely involves the vertebra in adults.
b. The most likely initial focus of infection was soft tissue.
c. Blood cultures will be positive in most patients with this process.
d. An MRI scan is both sensitive and specific in defining the process.
e. Surgery will be necessary if the patient has osteomyelitis.

16. A 30-year-old male with sickle cell anemia is admitted with cough, rusty
sputum, and a single shaking chill. Physical examination reveals increased
tactile fremitus and bronchial breath sounds in the left posterior chest. The
patient is able to expectorate a purulent sample. Which of the following best
describes the role of sputum Gram stain and culture?
a. Sputum Gram stain and culture lack the sensitivity and specificity to be of value
in this setting.
b. If the sample is a good one, sputum culture is useful in determining the antibiotic
sensitivity pattern of the organism, particularly Streptococcus pneumoniae.
c. Empirical use of antibiotics for pneumonia has made specific diagnosis unnecessary.
d. There is no characteristic Gram stain in a patient with pneumococcal pneumonia.
e. Gram-positive cocci in clusters suggest pneumococcal infection.
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