1. A 58 year old man complains of pain in his calf and

posterior aspect of the thigh, which is brought on after walking

one block vigorously and resolves with rest. This symptom

constellation may be associated with:

A. impotence

B. high risk for significant coronary disease,

C. a bruit in the femoral area on physical examination.

D. All of the above

E. None of the above

2. A 20 year old man is noted to have delayed carotid

upstrokes and a harsh systolic crescendo-decrescendo

murmur. This patient might be expected to have all of the

following EXCEPT:

A. PMI at the 6th intercostal space and midaxillary line

B. an audible S4

C. an ejection sound

D. pulsus paradoxicus

E. radiation of the murmur to the carotids

3. Which of the following is LEAST likely to be associated

with an "innocent" flow murmur;

A) A patient with Hyperthyroidism

B) A patient who uses IV drugs

C) A Pregnant patient

D) A patient with a severe Anemia

E) A patient with a high fever

4. All of the following can be associated with an "innocent"

flow murmur EXCEPT;

A) Ejection sound is usually audible on left lateral

decubitus position

B) Usually decreases or disappears on sitting

C) Located 2nd to 4th left interspaces between left sternal

border and apex

D) Murmur remains localized with an intensity of 1-2/6

E) Second heart sound splits on inspiration

5. An opening snap in the mitral area may be better heard;

A. Using the diaphragm of the stethoscope

B. Sitting the patient forward and listening while thepatient is inhaling

C. Both of the above

D. Neither of the Above

QUESTIONS 6-11 CONCERN THE SAME PATIENT

6) While covering another physician at a clinic, a nurse stops

you to tell you about a patient that has come without an

appointment complaining of a severe headache. She tells you that

this patient comes to the clinic at least once a week always

complaining of something different. You review her chart which is

quite thick and includes numerous laboratory studies and x-ray

reports. The patient is a 45 year old elementary school teacher.

On entering the room, you notice the patient has been crying. The

MOST appropriate INITIAL response from you would be;

A) "Tell me about the headache"

B) "How long have you been depressed?"

C) Give her a box of tissues and ask "How can I help you?"

D) Give her a box of tissues but avoid any direct eye

contact so as not to embarrass her

E) "I will get the nurse to give you something for your

headache and then I will come back when you are a little calmer"

7) The patient tells you that the headache began that morning,

it is quite severe, and it is associated with nausea and

vomiting. The MOST appropriate next response from you would be;

A) Have you ever had this before?

B) Do you have a family history of headaches?

C) Have you been in contact with someone with meningitis?

D) Can you describe the headache for me?

E) Have you ever seen a neurologist for this?

8) As you continue to interview the patient you get the, following information: The headaches started shortly after amajor financial stress in her life, she drinks about a 6 pk of beer a week, she smokes 1 pack of cigarettes a day for 20 years. Her husband has coronary heart disease and may need bypass surgery, her sister was diagnosed as having migraine headaches,she has dysuria once every 3-4 months. As you are writing up herstory, which of the following would be MOST appropriate forCHIEF COMPLAINT:

A) Headache

B) Migraine Headache

C) Rule out Meningitis

D) Depression

E) Alcohol abuse

9) Of the following, which information is LEAST related to the

STORY OF PRESENT ILLNESS;

A) Husband needs bypass surgery

B) Alcohol history

C) History of Dysuria

D) Financial problems

E) Family history of headaches

10) After completing a detailed history of her chief complaint,

you believe she is depressed. Which of the following is helpful

in distinguishing between a serious medical illness and

depression;

A) Fatigue

B) Loss of Appetite

C) Loss of Weight

D) All of the Above

E) None of the above

11) You perform a focused neurologic examination on the patient.

which of the following neurologic signs is/are indicative of a

disease process;

A) Rinne test; Air conduction is better than bone

conduction.

B) Occasional beats of nystagmus are visible on extreme

lateral gaze in both directions.

C) Sustained clonus is demonstrated on testing both

Achilles reflexes

D) Depressed deep tendon reflexes in all extremities

E) All of the above

MATCH THE FOLLOWING NEUROLOGIC SIGNS WITH THE APPROPRIATE

ABNORMALITY;

12) On asked to say "ahh", the uvula is rises to the left.

13) When asked to stick out the tongue, there is deviation to the

right with atrophy of that half of the tongue.

14) When asked to smile, there is flattening of the nasolabial

fold on the right.

15) When asked to turn head tothe right against resistance, there

is decreased definition of the sternocleidomastoid muscles on

that side.

16) When asked to follow a finger with the eyes until it touches

T me nose of the patient, there is constriction of the pupils

A) Glossopharyngeal and Vagus nerve deficit

B) Bells palsy (VII)

C) XII nerve palsy

D) XI nerve palsy

E) Normal finding

QUESTIONS 17 AND 18 ARE REGARDING CEREBELLAR TESTS

17) Which of the following are tests of cerebellar function?

A) Finger to nose

B) Babinski sign

C) Both of the Above

D) Neither of the Above

18) Which of the following are tests of cerebellar function?

A) Rapid alternating movements

B) Gait

C) Both of the Above

D) Neither of the Above

19) All of the following are true with regards to examination of

the oral cavity EXCEPT:

A) Unilateral fasciculation of the tongue is indicative of

Hypoglossal nerve deficit

B) Cancers frequently affect the lateral surfaces of the

tongue

C)Leukoplakia in a smoker is a normal finding and does not

require follow-up

D) Poor dental hygiene may be a risk for pulmonary

infections

E) Erosion of the enamel on the buccal side of the teeth

may indicate reflux esophagitis

20) On examination of the head/neck, all of the following

findings are considered normal variants EXCEPT;

A)Torus (or Tori)

B) Tophus (or Tophi)

C) Light Reflex of tympanic membrane

D) Red Reflex of fundus

E) "Cheesy debris" in tonsillar crypts

21) A 28 year old woman who moved to Houston 3 years ago presents

for complaints of "sinus problems". She brings with her a set of

recent sinus X-rays demonstrating opacification of both maxillary

sinuses. On examination, she is uncomfortable and has an oral

temperature of 101° F. From this information, you would expect to

find all of the following EXCEPT;

A) purulent nasal discharge

B) throbbing occipital headache

C) tenderness to digital pressure over sinuses

D) inability to transilluminate sinuses

E) Translucent tympanic membrane

22) All of the following are true with regards to examination of

the ears EXCEPT;

A) In a child, the auricle should be pulled gently downward

for best visualization.

B) Foreign bodies are a common cause of ear complaints in a

child.

C) External otitis (swimmer's ear) is characterized by

intense pain on manipulation of the auricle.

D) Otitis media is characterizedby intense pain on

manipulation of the auricle.

E) All of the above

23) A 23 year old woman presents to you with concern about a lump

in her neck. Her mother has thyroid disease. Which of the

following is TRUE with reference-to the thyroid exam;

A) It is best palpated standing behind the patient and

having her swallow.

B) It is difficult to distinguish between thyroid and lymph

nodes on exam as both move together on swallowing.

C) Both of the above

D) Neither of the above

24) A 70 year old man presents with acute onset of hemiparesis.

On a detailed neurologic examination you notice an abnormality of

visual fields. Using a red match head and testing each of the

patient's eyes separately, you notice that the left visual field

of each eye is restricted when compared to your own. This defect

is BEST described as;

A) a scotoma

B) Bitemporal hemianopsia

C) Homonymous hemianopsia

D) Amaurosis

E) None of the above

25) A 16 year old girl presents with a painful eruption on her

right arm. Your colleague describes it to you on the telephone as

being grouped vesicles on an erythematous base. Of the following,

the BEST descriptive term for this lesion is;

A) purpuric

B) herpetiform

C) serpiginous

D) verrucous

E) papulosquamous

26) A 30 year old woman presents with a "mole" on her back. Which

of the following features is LEAST suggestive of a malignant

melanoma;

A) The lesion is located on non-sunexposed skin

B) The lesion is 8 mm in diameter

C) The lesion is primarily black, with some variation of Color

D) The border of the lesion is slightly notched andirregular

E) The lesion was present at birth.

QUESTIONS 27-29 REFER TO THE SAME PATIENT

27) On further examination of the above individual you notice

that the PMI (point of maximal impulse) is in the 6th Left

intercostal space at the mid-axillary line, there is an audible

53 at the base, and a blowing decrescendo diastolic murmur heard

best along the sternal border. The MOST likely cardiac

abnormality in this patient is;

A) Aortic Stenosis

B) Aortic Insufficiency

C) Mitral Stenosis

D) Mitral Insufficiency

E) Ventricular Septal defect

28) Regarding the above patient, which of the following signs

would you expect him to exhibit;

A) Waterhammer pulse (also known as Corrigan's or

Collapsing pulse)

B) Pulsus Tardus and Parvus (or plateau pulse)

C) Pulsus paradoxus

D) Pulsus alternans

E) Bigeminal pulse

29) A 68 year old man is admitted with chest pain and a

presumptive diagnosis of dissecting aortic aneurysm is made from

the history, examination, and review of the Chest X-ray (widened

mediastinum). Of the following, which finding is NOT CONSISTENT

with this diagnosis;

A) History of hypertension

B) Chest pain that worsens with exertion

C) Chest pain that is "tearing" in quality

D) Unilateral carotid bruit

E) Blood pressure 180/100 in the right arm and 110/70 in

the left arm

30) A 16 year old boy is found to be hypertensive at the time of

a routine physical examination for school. Neither of his parents

are hypertensive. He complains of cramps in his calves on running

one mile in physical education class. On examination his BP is

160/110 in both arms. There is a marked diminution in pulse

volume in both femoral arteries. The MOST likely cause of this

patient's hypertension is;

A) Essential hypertension

B) Pheochromocytoma

C) Patent Ductus Arteriosus

D) Coarctation of the Aorta

E) Dissecting aortic aneurysm

31) A 74 year old man is thought to have parkinsonism based on a

"pill rolling" tremor. Which of the following gaits would you

most LIKELY observe in this gentleman;

A) The gait is broad based and the patient may stagger or

lurch irregularly.

B) The patient may have difficulty getting started, then he

may take short shuffling steps because of rigidity.

C) Bilateral foot drop causes the patient to lift his feet

high, bending at the knees.

D) There is circumduction of the leg with the knee stiff,

often with scraping of the outside of the foot.

E) The patient may take short uneven high steps in a

jerking fashion. Romberg test is positive.

32) To test for accommodation:

A) Use a swinging flashlight

B) Have the patient look across the room and then suddenly

fix on an object held 6 inches from his/her nose

C) Both of the Above

D) Neither of the Above

33) All of the following statements about testing the integrity

of the Trigeminal nerve (V) are true EXCEPT;

A) In testing sensation, always compare the top half of

each side of the face with the bottom half.

B) In testing the corneal reflex, brush a wisp of cotton

across the cornea while the patient looks away. Look for blinking

on both sides.

C) In testing the masseter and temporalis muscles, have the

patient clench his teeth.

D) The jaw jerk is elicited by having the patient partially

open the mouth with the jaw relaxed, and tap on your finger which

is resting on the patient's chin.

E) A unilateral lesion to the trigeminal nerve will cause

the jaw to deviate to the side of the weak muscles when the

patient opens and closes his mouth.

34) To obtain an adequate examination of the heart, all of the

following are appropriate EXCEPT;

A) Having the patient sit forward to listen for aortic

murmurs

B) Having the patient lie on their left side to listen for

mitral murmurs

C) Using the bell of the stethoscope to listen for low

frequency sounds

D) Having the patient sit up or stand up to listen for

changes in murmurs

E) Listening to the heart through a hospital gown or

brassiere to comply with the modesty of the patient

35) A 58 year old man presents with low back pain after helping

someone move a refrigerator at work. All of the following

techniques would be helpful in determining the source of the pain

EXCEPT;

A) One should palpate the paraspinous muscles looking for

spasm and local tenderness.

B) One should look for protective splinting by observing

the mobility of the spine to flexion, extension, and rotation.

C) One should have the patient in a supine position and

passively flex the straightened leg at the hip up to 90 degrees

watching for pain or involuntary spasm.

D) Have the patient bend over and touch his toes looking

for any early flexion at the hips.

E)One should passively flex the neck with the patient lying

supine and look for nuchal rigidity or flexion of the knees

(Brudzinski's sign).

QUESTIONS 36-41 RELATE TO THE SAME PATIENT

36) A 68 year old man who has been a heavy smoker for many years

presents to the clinic with dyspnea on exertion and a productive

cough with green sputum. He first noticed the dyspnea about 1

year ago when he had difficulty climbing 2 flights of stairs.

This has progressed such that yesterday he had difficulty walking

across the room and today he is short of breath with minimal

exertion. All of the following are consistent with the diagnosis

of chronic bronchitis EXCEPT;

A) He has had a chronic cough for many years with about 1/2

cup of white sputum production daily.

B) He has a history of deep venous thrombosis.

C) Occasionally his chest feels tight and he feels like he

is wheezing.

D) A physician noted clubbing of his nails.

E) He had hemoptysis last year during an upper respiratory

infection.

37) On examining the chest of the above patient you notice faint

breath sounds, bilateral wheezing, but no crackles. A chest X-

ray reveals hyperexpanded and hyperlucent lung fields, flat

diaphragms, increased anterior-posterior diameter, and no areas

of increased density. Which of the following statements is/are

consistent with these findings;

A) The wheezing is indicative of bronchospasm.

B) The chest will be dull to percussion.

C) Whispered pectoriloquy will be present.

D) Egophony will be present.

E) All of the above.

38) The cardiac exam of the above patient reveals the following;

mild sternal lift, distant heart sounds, loud P2 and an S4. These

findings are MOST consistent with;

A) Atrial fibrillation.

B) Left ventricular failure.

C) Myocardial infarction.

D) Pulmonary stenosis.

E) Pulmonary hypertension.

39) Completing the examination of the above patient you note a

distended abdomen and severe peripheral edema (4+) from the feet

up to the sacrum as well as scrotal edema. All of the following

statements are true about detecting the presence of ascites

EXCEPT;

A) A protuberant abdomen with bulging flanks suggests the

possibility of ascitic fluid.

B) After mapping the borders of tympany and dullness by

percussion with the patient lying on his back, ask the patient to

turn onto one side and percuss and mark the borders again. In a

person with ascites, the borders between tympany and dullness

will change or "shift".

C) With the patient supine, tap your fingers sharply

against one flank and feel for a fluid wave on the opposite

flank. This maneuver may require an assistant.

D) The physical diagnosis tests for the presence of ascites

are quite sensitive and correlate well with the amount of ascitic

fluid present, even in obese patient.

E) The ability to ballotte the liver by making a brief

jabbing movement directly toward the anticipated structure and

feeling for it to "bounce" off your fingers, is confirmatory for

the presence of ascitic fluid.

40) Based on the information given for the above patient, theMOST likely cause(s) of ascites in THIS patient is/are;

A) Cirrhosis

B) Cor pulmonale

C) Both of the above

D) Neither of the above

41) A 42 year old man was diagnosed by endoscopy last year with a

duodenal ulcer. He now returns to clinic saying that he is having

the same symptoms again. All of the following is consistent with

active duodenal ulcer disease EXCEPT;

A) He had several episodes of hematochezia

B) He had several episodes of hematemesis

C) He said that his stool became black and tarry

D) Location of pain is primarily epigastric

E) Pain is relieved by antacids

42) A 48 year old woman with severe abdominal pain, was found to

have gallstones on ultrasound examination. This pain was MOST

likely;

A) Burning in quality

B) Steady aching, lasting hours

C) Localized to the periumbilical area

D) Relieved by meals

E) Associated with bloody stools

43) A 20 year old college student presents with 2 hours of severe

abdominal pain and fever. He is concerned he has acute

appendicitis. The following findings are consistent with this

diagnosis;

A) The initial pain starts in the periumbilical area and

then shifts to the right lower quadrant.

B) The pain is worsened by coughing.

C) Both of the Above

D) Neither of the Above

44) A 50 year old woman presents because she says that her skin

Es turning yellow. On examination, her sclera are icteric. All of

the following are consistent with your exam-.EXCEPT;

A) She eats a lot of carrots

B) Her urine is like coca-cola or dark tea

C) Her stools are light colored-or gray

D) Her skin itches

E) She feels very fatigued

45) A 38 year old man is found to have. the following findings on

physical examination; muscle wasting, spider angiomata, palmar