First Aid Q&A for the USMLE Step 2 CK, 2e (First Aid USMLE) [McGraw-Hill Medical] [2009]

FIRST AID

™

Q&A FOR THE
USMLE
STEP 2 CK

Second Edition
SENIOR EDITORS

EDITORS

TAO LE, MD, MHS

HERMAN SINGH BAGGA, MD

Assistant Clinical Professor
Chief, Section of Allergy and Clinical Immunology
Department of Medicine
University of Louisville

Resident
Department of Urology
University of California, San Francisco Medical Center

KRISTEN VIERREGGER, MD

Resident
Department of Dermatology

Mayo Clinic

Resident
Department of Pathology
University of California, Irvine Medical Center

THOMAS L.H. HOCKER, MD

CHRISTOPHER R. KINSELLA, JR., MD
Research Fellow
University of Pittsburgh Medical Center

MATTHEW O'ROURKE, MD
Resident
Morgan Stanley Children's Hospital of New York–
Presbyterian
Columbia University Medical Center

JOHN RHYNER, MD
Resident
Department of Internal Medicine
University of Michigan Medical Center

SADE CLARKE UDOETUK, MD
Resident
Department of Psychiatry
Baylor College of Medicine

New York / Chicago / San Francisco / Lisbon / London / Madrid / Mexico City
Milan / New Delhi / San Juan / Seoul / Singapore / Sydney / Toronto

Copyright © 2010, 2008 by Tao Le. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.
ISBN: 978-0-07-162930-0
MHID: 0-07-162930-0
The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-162571-5, MHID: 0-07-162571-2.
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an
editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they
have been printed with initial caps.
McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. To contact a
representative please e-mail us at
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 work. Readers are
encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product 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.
TERMS OF USE
This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use of this work is subject to
these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse
engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGrawHill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may
be terminated if you fail to comply with these terms.
THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED
THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT
NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not
warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill
nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom.

McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable
for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised
of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or
otherwise.


D E D I C AT I O N
To the contributors to this and future editions, who took time to share their
knowledge, insight, and humor for the benefit of residents and clinicians.
and
To our families, friends, and loved ones, who supported us in the task of
assembling this guide.


This page intentionally left blank


CONTENTS

Authors

vii

Faculty Reviewers

ix

Preface

xi

Acknowledgments

xiii

How to Contribute

xv

S EC T IO N I

O R G A N SYST E M S

1

Chapter 1

Cardiovascular

Chapter 2

Dermatology

47

Chapter 3

Endocrinology

57

Chapter 4

Epidemiology and Preventive Medicine

91

Chapter 5

Ethics and Legal Issues

117

Chapter 6

Gastrointestinal

127

Chapter 7

Hematology/Oncology

167

Chapter 8

Infectious Disease

211

Chapter 9

Musculoskeletal

261

Chapter 10

Neurology

285

Chapter 11

Obstetrics

321

Chapter 12

Gynecology

351

Chapter 13

Psychiatry

375

Chapter 14

Pulmonary

409

Chapter 15

Renal/Genitourinary

441

S EC T IO N I I

F U LL-LE N G T H E X A M I NAT I O N S

3

471

Test Block 1

473

Test Block 2

507

Test Block 3

539

v


Test Block 4

573

Test Block 5

607

Test Block 6

641

Test Block 7

675

Test Block 8

709

About the Authors

743

vi


AUTHORS
CYNTHIA ADAMS, MD

LAURA MEINTS

Resident
Boston Combined Residency Program in Pediatrics
Children's Hospital Boston

Vanderbilt University School of Medicine
Class of 2009

CLARISSA BARNES, MD
Resident
Department of Internal Medicine
Johns Hopkins University School of Medicine

RACHEL BORTNICK, MPHIL
Medical Scientist Training Program
Harvard Medical School

CHRISTOPHER CHAPMAN, MD
Resident
Department of Internal Medicine
University of Chicago Medical Center

LIA CLATTENBURG, MD, MPH

Resident
Department of Internal Medicine
Union Memorial Hospital
Baltimore, Md.

GILLIAN DIERCKS
Columbia University College of Physicians and Surgeons
Class of 2009

VAHID ENTEZARI, MD
Postdoctoral Research Fellow
Orthopedic Biomechanics Laboratory
Beth Israel Deaconess Medical Center

JOHNATHAN ETHRIDGE
Johns Hopkins University School of Medicine
Class of 2009

ROBERT MICHELETTI, MD
Resident
Departments of Internal Medicine and Dermatology
Hospital of the University of Pennsylvania

DANIEL L. MILLER
Johns Hopkins University School of Medicine
Class of 2009
Johns Hopkins Bloomberg School of Public Health
Class of 2009

DEEPIKA NEMANI

University of Pennsylvania School of Medicine
Class of 2009

TIMOTHY NIESSEN
Johns Hopkins University School of Medicine
Class of 2009
Johns Hopkins Bloomberg School of Public Health
Class of 2009

HOWARD O'ROURKE, MD
Resident
Department of Diagnostic Radiology
University of Pittsburgh Medical Center

NISHANT PATEL
Johns Hopkins University School of Medicine
Class of 2009

ROHITH PIYARATNA, MD

ERICA Y. FAN

Resident
Department of Anesthesiology
Stanford University Medical Center

St. Louis University School of Medicine
Class of 2009

ANTHONY PRINCE, MD

CARL ERIK FISHER

Resident
Department of Otolaryngology
Mount Sinai Medical Center

Columbia University College of Physicians and Surgeons
Class of 2009

SATTAR GOJRATY, MD

FIORELLA SAPONARA, MD

Resident
Department of Internal Medicine
Hospital of the University of Pennsylvania

Resident
Transitional Program
Maimonides Medical Center
New York City

NILAY KAVATHIA, MD

ASHA JAYENDRAKUMAR SHAH, MD

Resident
Department of Internal Medicine
Thomas Jefferson University Hospital

Intern
Department of Internal Medicine
Emory University School of Medicine

vii


MONICA E. SHUKLA

BRANT W. ULLERY, MD

Vanderbilt University School of Medicine
Class of 2009

Resident
Department of Surgery
Hospital of the University of Pennsylvania

MEGHAN SISE
Columbia University College of Physicians and Surgeons
Class of 2009

D'MITRI SOFIANOS, MD
Resident
Department of Orthopedic Surgery
University of Utah Medical Center

ANNA E. TEETER
Duke University School of Medicine

Class of 2009

JOSHUA D. UDOETUK, MD

KELLY VRANAS, MD
Resident
Department of Internal Medicine
Hospital of the University of Pennsylvania

DAVID WEI
Columbia University College of Physicians and Surgeons
Class of 2009

ZACHARY ZAVODNI
Duke University School of Medicine
Class of 2009

Transitional Intern
University of Texas-Houston Medical School

ASSOCIATE AUTHORS
MARINA FRIMER, MD

SUNIL SHETH

Resident
Department of Obstetrics and Gynecology and Women's Health
Albert Einstein College of Medicine

Harvard Medical School

Class of 2009

MARK J. MANN, MD
Resident
Department of Urology
State University of New York Upstate Medical University
Syracuse, N.Y.

PARIN J. PATEL, MD
Resident
Department of Internal Medicine
Hospital of the University of Pennsylvania

viiiviii

LEANNE STANLEY
Duke University School of Medicine
Class of 2009

TIAN ZHANG
Harvard Medical School
Class of 2009


FACULTY REVIEWERS
JONATHAN W. BRESS, MD

KERILYN MORGAN, MD

Nephrologist

Philadelphia Hypertension & Nephrology Consultants

RACHEL CHONG, MD

Associate Program Director
Department of Internal Medicine
Banner Good Samaritan Medical Center
Phoenix, Ariz.

Endocrinologist
Lakeridge Health Corporation

RINI BANERJEE RATAN, MD

PETER DANYI, MD, MPH, MBA

Assistant Clinical Professor
Department of Obstetrics and Gynecology
Columbia University College of Physicians & Surgeons

Instructor, Hospitalist Program
Division of General Internal Medicine
Johns Hopkins University School of Medicine

ROBIN GIRDHAR, MD
Vice Chairperson and Director of Quality Assurance
Division of Cardiology
Shadyside Hospital
University of Pittsburgh School of Medicine

ANDREW J. LENNEMAN, MD
Clinical Fellow
Cardiovascular Medicine Division
Vanderbilt University School of Medicine

ESTER C. LITTLE, MD
Associate Director
Banner Liver Disease Center
Clinical Assistant Professor of Medicine
University of Arizona College of Medicine

MARCUS A. MCFERREN, MD, PHD
Department of Dermatology
Yale-New Haven Hospital

ELIZABETH SASTRE, MD
Assistant Professor
Vanderbilt University Medical Center
Attending Physician
Medical Service, Primary Care
Tennessee Valley Healthcare Veteran’s Administration Hospital

JERRY D. SMILACK, MD
Emeritus Associate Professor of Medicine
Mayo College of Medicine
Retired Consultant
Department of Internal Medicine
Mayo Clinic

MYRA J. WICK, MD, PHD

Department of Medical Genetics
Mayo Clinic

APRIL ZHU, MD
The Permanente Medical Group
Santa Clara, Calif.

ix


This page intentionally left blank


PREFACE

With First Aid Q&A for the USMLE Step 2 CK, we continue our commitment to providing students with the most useful and up-to-date preparation
guides for the USMLE Step 2 CK. This addition to the First Aid series represents an outstanding effort by a talented group of authors and includes the following:
Ⅲ
Ⅲ
Ⅲ
Ⅲ
Ⅲ
Ⅲ

1,000 high-yield USMLE-style questions based on the top-rated
USMLERx Qmax Step 2 CK Test Bank (www.usmlerx.com)
Concise yet complete explanations to correct and incorrect answers
Organized as a perfect complement to First Aid for the USMLE Step 2 CK
Eight full-length test blocks simulate the actual exam experience
High-yield images, diagrams, and tables complement the questions and

answers
Timely updates and corrections at www.firstaidteam.com

We invite you to share your thoughts and ideas to help us improve First Aid
Q&A for the USMLE Step 2 CK. See How to Contribute, p. xv.
Louisville
Irvine

Tao Le
Kristen Vierregger

xi


This page intentionally left blank


ACKNOWLEDGMENTS

This has been a collaborative project from the start. We gratefully acknowledge the thoughtful comments and advice of the medical students, residents,
international medical graduates, and faculty who have supported the authors
in the development of First Aid Q&A for the USMLE Step 2 CK.
Additional thanks to Neil Busis and Hey Chong for their review of the manuscript.
For support and encouragement throughout the process, we are grateful to
Thao Pham, Selina Franklin, Louise Petersen, Jonathan Kirsch, and Vikas
Bhushan. Thanks to our publisher, McGraw-Hill, for the valuable assistance
of their staff. For enthusiasm, support, and commitment to this challenging
project, thanks to our editor, Catherine Johnson. For outstanding editorial
work, we thank Steve Freedkin, Isabel Nogueira, and Emma D. Underdown.
A special thanks to Rainbow Graphics for remarkable production work.

For contributions, corrections, and surveys we thank Juan F. Alvarez, M.R.
Brenz, Ericka Li Fuentes, Katherine Kline, Solomon Onyenkachukwu, Matthew Swenson, and Jennifer Turley.
Louisville
Irvine

Tao Le
Kristen Vierregger

xiii


This page intentionally left blank


HOW TO CONTRIBUTE

To continue to produce a high-yield review source for the USMLE Step 2 CK exam, we invite you to
submit any suggestions or corrections. We also offer paid internships in medical education and publishing ranging from three months to one year (see below). Please send us your suggestions for
Ⅲ
Ⅲ
Ⅲ

Corrections or enhancements to existing questions and explanations
New high-yield questions
Low-yield questions to remove

For each entry incorporated into the next edition, you will receive a $10 gift certificate, as well as personal acknowledgment in the next edition. Diagrams, tables, partial entries, updates, corrections, and
study hints are also appreciated, and significant contributions will be compensated at the discretion of
the authors.
The preferred way to submit entries, suggestions, or corrections is via our blog at:

www.firstaidteam.com
Otherwise, please send entries, neatly written or typed or on disk (Microsoft Word), to:
First Aid Q&A for the USMLE Step 2 CK , Second Edition
914 North Dixie Avenue, Suite 100
Elizabethtown, KY 42701
All entries become property of the authors and are subject to editing and reviewing. Please verify all data
and spellings carefully. In the event that similar or duplicate entries are received, only the first entry received will be used. Include a reference to a standard textbook to facilitate verification of the fact. Please
follow the style, punctuation, and format of this edition if possible.

I N T E R N S H I P O P P O RT U N I T I E S

The First Aid Team is pleased to offer part-time and full-time paid internships in medical education and
publishing to motivated medical students and physicians. Internships may range from three months (e.g., a
summer) up to a full year. Participants will have an opportunity to author, edit, and earn academic credit on
a wide variety of projects, including the popular First Aid and USMLERx series. Writing/editing experience, familiarity with Microsoft Word, and Internet access are desired. For more information, submit a résumé or a short description of your experience along with a cover letter to fi

xv


This page intentionally left blank


SECTION I

Organ Systems

᭤ Cardiovascular
᭤ Dermatology
᭤ Endocrinology
᭤ Epidemiology and

Preventive Medicine
᭤ Ethics and Legal Issues
᭤ Gastrointestinal
᭤ Hematology/Oncology
᭤ Infectious Disease
᭤ Musculoskeletal
᭤ Neurology
᭤ Obstetrics
᭤ Gynecology
᭤ Psychiatry
᭤ Pulmonary
᭤ Renal/Genitourinary

1


This page intentionally left blank


CHAPTER 1

Cardiovascular

3


HIGH-YIELD SYSTEMS
Cardiovascular

4

Section I: Organ Systems • Questions

Q U E ST I O N S

1. A 66-year-old retired carpenter presents with
chronic shortness of breath upon exertion. He
has smoked one pack of cigarettes per day for
the past 5 years and drinks alcohol regularly.
Physical examination reveals a displaced point
of maximal impulse and hepatosplenomegaly.
His medications include pantoprazole for gastroesophageal reflux and sertraline for depression. Echocardiogram reveals an ejection fraction of 30% and dilated left and right ventricles.
Laboratory tests show:
Na+: 129 mEq/L
K+: 5.2 mEq/L
Cl−: 101 mEq/L
Blood urea nitrogen: 45 mg/dL
Creatinine: 1.3 mg/dL
Glucose: 134 mg/dL
Aspartate aminotransferase: 220 U/L
Alanine aminotransferase: 140 U/L
Alkaline phosphatase: 280 U/L
Which of the following is the most likely cause
of his cardiac findings?
(A) Borrelia burgdorferi
(B) Cigarette smoking
(C) Coxsackie B virus
(D) Ethanol
(E) Pantoprazole toxicity
(F) Trypanosoma cruzi

2. A 52-year-old man presents to his primary care
physician’s office for routine care. He has hypertension, hypercholesterolemia, and type 2
diabetes mellitus, and has smoked one pack of
cigarettes per day for the past 30 years. Medications include hydrochlorothiazide, atorvastatin,
and glipizide. There is a family history of myocardial infarction in the maternal grandfather
at age 60. The patient has undergone screening for colon and prostate cancer. Physical examination reveals a pleasant, obese man who is
175 cm (5′ 9″) tall and weighs 108 kg (238 lb).
His blood pressure is 155/81 mm Hg, heart rate
is 78/min, respiratory rate is 14/min, and temperature is 36.8°C (98.3°F). What one action
would most reduce the patient’s stroke risk?

(A) Blood glucose reduction
(B) Blood pressure reduction
(C) Serum cholesterol reduction
(D) Smoking cessation
(E) Weight loss
3. A 36-year-old man presents to the clinic with
complaints of a genital sore. The patient is a
sexually active heterosexual involved with
three partners and practices unprotected intercourse. Fours days ago he noted a painless sore
on his penis. He is afebrile, with a heart rate of
80/min and blood pressure of 120/77 mm Hg.
Physical examination reveals a solitary ulcerated lesion located on the lateral aspect of his
penis. The lesion is nontender and associated
with bilateral inguinal lymphadenopathy. Physical examination is otherwise normal. If left
untreated, this man is at increased risk for
which of the following?
(A) Ascending aortic aneurysm
(B) Coronary artery aneurysm
(C) Endocarditis

(D) Mitral valve stenosis
(E) Rupture of ventricular free wall
4. An 81-year-old man is hospitalized for acute
onset of shortness of breath and lower extremity edema. Although he lives by himself, it is
very difficult for him to move around his apartment without experiencing fatigue. He has not
seen his physician in years but was told in the
past that he had high blood pressure. On physical examination his jugular venous pulse is palpated 9 cm above his sternal notch, inspiratory
crackles are heard at his lung bases, and there
is 3+ lower extremity edema. Which of the following will confirm the most likely diagnosis?
(A) Cardiac angiography
(B) Echocardiography
(C) Electrocardiogram
(D) Endomyocardial biopsy
(E) Pulmonary function tests
(F) X-ray of the chest


5

5. A 42-year-old man presents to the clinic for
routine evaluation. His medical history is significant for gallstones. The patient denies
smoking and drinks alcohol occasionally. His
mother had a heart attack at the age of 63
years. His blood pressure is 134/77 mm Hg.
The patient is overweight with well-healed laparoscopic cholecystectomy scars. Fasting laboratory tests show:

What is the most appropriate next step in management?
(A) A trial of lifestyle modification alone (diet,
exercise, and weight loss)
(B) A trial of lifestyle modification combined

with statin and niacin therapy
(C) A trial of lifestyle modification combined
with statin therapy
(D) Niacin therapy
(E) Statin therapy
6. Two and a half weeks after coronary artery bypass grafting, a 63-year-old man returns to the
emergency department acutely short of breath.
The patient states that he began having chest
pain and shortness of breath approximately 1
hour earlier. He has a history of hypertension,
diabetes, and two myocardial infarctions. On
examination he is hypoxic with an oxygen saturation of 86% on room air. Other vital signs
and results of a physical examination are normal. ECG shows no interval change from his
most recent ECG. CT of the chest is shown in
the image. What is the most likely etiology of
this patient’s shortness of breath?

Reproduced, with permission, from PEIR Digital Library
().

(A) Aortic dissection
(B) Exacerbation of chronic obstructive pulmonary disease
(C) Myocardial infarction
(D) Pleural effusion
(E) Pulmonary embolus
7. A 72-year-old man with coronary artery disease
and hypertension is hospitalized after suffering
a myocardial infarction 5 days ago. He suddenly complains of severe chest pain. His
blood pressure is 90/60 mm Hg and heart rate
is 65/min. Auscultation reveals no murmurs or

rubs. An ECG reveals sinus rhythm with an
acute ST-segment elevation in the anteroseptal
area. Urgent bedside echocardiography showed
anteroseptal, lateral, and apical akinesis, mild
left ventricular systolic dysfunction, and severe
pericardial effusion. Within 20 minutes he is
unconscious with undetectable pulses and
blood pressure. What is the most likely cause
of the patient’s sudden decompensation?
(A) Free wall rupture
(B) Left ventricular thrombus
(C) Mitral regurgitation
(D) Pericarditis
(E) Ventricular septal rupture

Cardiovascular

Aspartate aminotransferase: 37 U/L
Alanine aminotransferase: 28 U/L
Alkaline phosphatase: 88 U/L
Total cholesterol: 268 mg/dL
LDL cholesterol: 183 mg/dL
HDL cholesterol: 46 mg/dL
Triglycerides: 166 mg/dL

HIGH-YIELD SYSTEMS

Chapter 1: Cardiovascular • Questions

HIGH-YIELD SYSTEMS
Cardiovascular

6

Section I: Organ Systems • Questions

8. A 56-year-old woman was recently started on
medication for high blood pressure. At her next
office visit her hypertension is under good control, but she now complains of “feeling strange”
since she started the medication. On further
questioning, she reports feeling chest tightness
several times over the past 2 weeks, and has
also noticed pain in her elbows and knees. Her
blood pressure is 124/78 mm Hg (146/82 mm
Hg on last visit), heart rate is 102/min, and respiratory rate is 14/min. Her examination is notable for several erythematous plaques on the
malar distribution of the face, arms, and upper
torso. What medication was she most likely
started on during her last visit?
(A) Captopril
(B) Furosemide
(C) Hydralazine
(D) Metoprolol
(E) Verapamil
9. A 19-year-old woman was attacked while coming home from a party and is brought to the
emergency department. She recalls being
punched in the side of the head and stabbed in
the left flank. Her speech is slow and she complains of a bad headache. Her pulse is 110/
min, blood pressure is 90/50 mm Hg, and respiratory rate is 25/min. On examination she
has a stab wound at the left costal margin in

the midaxillary line. Two large-bore intravenous lines are inserted, and after infusion of
2 L of lactated Ringer’s solution her blood
pressure rises to 95/55 mm Hg. What is the
most appropriate next step in management?
(A) Abdominal ultrasound
(B) Diagnostic peritoneal lavage
(C) Exploratory laparotomy
(D) Noncontrast CT of the head
(E) Peritoneal laparoscopy
10. A 48-year-old man presents to the emergency
department complaining of crushing substernal chest pain. He is diaphoretic, anxious, and
dyspneic. His pulse is 110/min, blood pressure
is 175/112 mm Hg, respiratory rate is 30/min,
and oxygen saturation is 94%. Aspirin, oxygen,
sublingual nitroglycerin, and morphine are
given, but they do not relieve his pain. ECG
shows ST-segment elevation in leads V2 to V4.

The duration of symptoms is now approximately 30 minutes. What is the most appropriate treatment for this patient at this time?
(A) Calcium channel blocker
(B) Intravenous angiotensin-converting enzyme inhibitor
(C) Intravenous β-blocker
(D) Magnesium sulfate
(E) Tissue plasminogen activator
11. A 70-year-old woman presents to the emergency department complaining of dizziness.
She is disoriented to the date and her location
and it is difficult to gather an accurate history.
Her pulse is 48/min, blood pressure is 84/60
mm Hg, and respiratory rate is 12/min. On
examination her extremities are cool and

clammy. Her capillary refill time is 5 seconds.
What is the most appropriate therapy?
(A) Adenosine
(B) Amiodarone
(C) Atropine
(D) Isoproterenol
(E) Metoprolol
12. A 77-year-old man, complaining of abdominal
pain, anorexia, and nausea and vomiting over
the past 24 hours, presents to the clinic with
his son. The son reveals that his father has also
complained of blurred vision. The patient’s vital signs are stable and his abdomen is soft, but
he appears to be somewhat confused. He is
currently taking metoprolol, digoxin, and hydrochlorothiazide for ischemic congestive
heart failure. His son says that sometimes his
father confuses his medications. The patient
also has renal insufficiency with a baseline serum creatinine of 2.6 mg/dL. The ECG reveals
a widened QRS complex and a new first-degree
heart block. Which of the following is the most
likely cause of this patient’s symptoms?
(A) Digoxin toxicity
(B) Gastroenteritis
(C) Hypocalcemia
(D) Hypovolemia secondary to thiazide diuretic overuse
(E) Myocardial infarction


(A) Borrelia burgdorferi infection
(B) Deletion mutation in dystrophin
(C) Frameshift mutation in dystrophin

(D) Trinucleotide repeat expansion
(E) X-linked emerin deficiency
14. A college sophomore is found by his roommate
to be poorly responsive and brought to the
emergency department. After resuscitation, the
man complains of a severe headache and photophobia that is accompanied by dizziness,
nausea, vomiting, and neck pain. Physical examination is noteworthy for positive Kernig’s
and Brudzinski’s signs as well as petechiae on
the trunk and mucocutaneous bleeding. Laboratory studies show:
WBC count: 17,000/mm³
Hemoglobin: 11 g/dL
Platelet count: 70,000/mm³
Bleeding time: 10 min
Prothrombin time: 17 sec
Activated partial thromboplastin time: 47 sec
Thrombin time: 18 sec

A peripheral blood smear is shown in the image. Which of the following is the most likely
diagnosis?

Reproduced, with permission, from Lichtman MA, Beutler E,
Kipps TJ, Seligsohn U, Kaushansky K, Prchal JT. Williams’
Hematology, 7th edition. New York: McGraw-Hill, 2006: Plate
III-2.

(A) Disseminated intravascular coagulation
(B) Factor V Leiden
(C) Immune thrombocytopenic purpura
(D) Protein C deficiency
(E) Thrombotic thrombocytopenic purpura

15. A 60-year-old man with coronary artery disease,
peptic ulcer disease, and gout presents to the
emergency department with a 24-hour history
of abdominal pain. The pain, which is most intense in the upper abdomen, was sudden in
onset and has become progressively more severe. Free air in the abdomen is detected on
x-ray films. The patient is in an agitated state.
His extremities are cool and capillary refill
time is 3 seconds. His blood pressure is 80/40
mm Hg and heart rate is 130/min. The neck
veins are flat and the lungs are clear to auscultation. His hemoglobin is 13.8 g/dL. A urinary
catheter is inserted and 10 mL of urine is
drained. What is the most appropriate treatment for this patient at this time?
(A) Broad-spectrum antibiotics for presumed
sepsis
(B) Infusion of isotonic fluid
(C) Infusion of norepinephrine
(D) Inotropic support with dopamine, vasopressin, or dobutamine
(E) Transfuse with 1 unit packed RBCs

Cardiovascular

13. A 35-year-old woman presents to the clinic because of visual problems. She states that she
has always had difficulty looking up, and over
the past few years her overall vision has become blurry. Review of symptoms is notable
for several recent episodes of “near fainting.”
She takes no medication and has no other
medical history, and has not seen a physician
for 7 years. Because she was adopted as a child,
she does not know her family history, but her
son has required special tutoring at school. The

patient also remarks that her son seems to have
been dropping objects lately. Physical examination reveals bilateral ptosis. Her extraocular
movements are intact and the pupils are equal,
round, and reactive. Her corrected visual acuity is 20/100 in the right eye and 20/120 in the
left eye. The view of the fundus is obscured.
On ambulation she raises her knees and makes
a slapping sound on the floor as she walks.
ECG indicates heart block. What is the pathogenesis of this patient’s disorder?

7

HIGH-YIELD SYSTEMS

Chapter 1: Cardiovascular • Questions


HIGH-YIELD SYSTEMS
Cardiovascular

8

Section I: Organ Systems • Questions

16. A 29-year-old woman presents to the emergency department with a 3-week history of being awakened by a dull, prolonged chest pain
that occurs 3–4 times a week. She is a smoker
but has never suffered a myocardial infarction
(MI) or had chest pain before and has no family history of early MI. Results of a 12-lead
ECG are normal. Her first set of cardiac enzyme measurements (creatine kinase, creatine
kinase-MB fraction, troponin I) are negative. If
coronary angiography were taken at the time of

her chest pain, which of the following findings
is most like?
(A) Coronary artery spasm
(B) Greater than 80% stenosis in at least two
coronary arteries
(C) No abnormal findings
(D) Plaque rupture and thrombosis
17. A 42-year-old man presents to the emergency
department with a complaint of increasing
shortness of breath when walking to get his
newspaper, difficulty breathing while lying flat,
and a 4.5-kg (10-lb) weight gain over the past
month. He is afebrile, his pulse is 75/min, and
his blood pressure is 98/50 mm Hg. On examination he smells of alcohol and has 2+ pitting
edema in the lower extremities and a third
heart sound. X-ray of the chest reveals cardiomegaly. What additional findings must be present to confirm this man’s underlying diagnosis?
(A) Hepatojugular reflux and pulmonary congestion
(B) Left ventricular dilation and aortic insufficiency
(C) Left ventricular dilation and systolic dysfunction
(D) Myocardial thickening and diastolic dysfunction
(E) Pulmonary congestion and diastolic dysfunction
18. A 69-year-old man with rheumatic heart disease presents to the emergency department
complaining of a fever and weakness on his left
side. On physical examination the patient is
weak in his left upper extremity and he draws
only the right half of a clock. Shortly after his
presentation, the patient dies, and an autopsy

is performed. A gross view of the patient’s heart
is shown in the image. Which of the following

is a risk factor for the type of lesion pictured?

Reproduced, with permission, from Fauci AS, Braunwald E,
Kasper DL, Hauser SL, Longo DL, Jameson LJ, Loscalzo J,
eds. Harrison’s Online. New York: McGraw-Hill, 2008: Figure
118-1.

(A) Coronary artery disease
(B) Hypertension
(C) Mitral valve prolapse
(D) Prolonged bedrest
(E) Prosthetic valve replacement
19. A 28-year-old man with a history of intravenous
drug abuse presents to the emergency department with a 2-day history of fever, chills, and
shortness of breath. On physical examination
the patient has a new heart murmur, small retinal hemorrhages, and subungual petechiae.
Which of the following is the most likely causative organism?
(A) Group A Streptococcus
(B) Mycobacterium tuberculosis
(C) Staphylococcus aureus
(D) Staphylococcus epidermidis
(E) Streptococcus viridans
20. A boy is delivered at 37 weeks’ gestation via
spontaneous vaginal delivery. He is the product of a normal pregnancy and was delivered
without complications. Prenatally the mother
was blood type B and was rubella immune and
negative for Rh antibody, group B streptococci,
rapid plasma reagin, hepatitis B surface antigen, gonorrhea, and chlamydia. The patient
appears cyanotic. He is breathing at a rate of
60/min and his heart rate is 130/min. He has a