Question: A group of investigators is studying hemodynamic regulatory mechanisms in a human volunteer subject. The volunteer is administered a stimulant drug, and a sudden increase in blood pressure is observed. It is hypothesized that the increase in blood pressure causes stretching of the atria. Increased atrial stretch would most likely lead to which of the following changes?

Answer: Decreased reabsorption of sodium

A. Vasodilation and decreased platelet aggregation

B. Decreased reabsorption of sodium

C. Increased reabsorption of solute-free water

D. Vasoconstriction and stimulation of thirst


Question: A 26-month-old boy is presented to the outpatient clinic by his parents complaining of a productive cough for the last 5 days. His mother reports a history of recurrent chest infections during the past year. He also has a history of chronic bloody diarrhea and pronounced bleeding after his circumcision. The vital signs are as follows: blood pressure 100/60 mm Hg, pulse 100/min, temperature 38.0°C (100.4°F), and respiratory rate 27/min. On examination, there are purpuric eruptions over the extremities as well as eczematous patches on the flexural surfaces of his elbows and knees. Chest auscultation reveals crepitus over the base of the right lung. Chest radiography is suggestive of consolidation in the right lower lobe. Blood test results show anemia, thrombocytopenia with small platelets, and leukopenia. With a suspicion of a congenital immunodeficiency, flow cytometry is ordered which reveals a Wiskott-Aldrich syndrome protein (WASP) mutation. Which of the following would be the definitive treatment of this patient’s condition?

Answer: Early hematopoietic stem cell transplantation (HSCT)

A. Early hematopoietic stem cell transplantation (HSCT)

B. Intravenous immunoglobulin (IVIG)

C. Rituximab

D. Chemotherapy


Question: Four hours after undergoing an open emergency surgery under general anesthesia for a bleeding abdominal aortic aneurysm, a 55-year-old man is unable to move both his legs. During the surgery, he had prolonged hypotension, which was corrected with IV fluids and vasopressors. He has a history of hypertension and hyperlipidemia. He has smoked one pack of cigarettes daily for 35 years. Prior to admission, his medications were hydrochlorothiazide and atorvastatin. The patient is conscious and oriented to place and person. His temperature is 37.7°C (99°F), pulse is 74/min, and blood pressure is 100/70 mm Hg. Examination shows muscle strength of 1/5 in the lower extremities. Further evaluation of this patient is most likely to show which of the following?

Answer:
Normal proprioception in the extremities
"

A. Babinski's sign present bilaterally

B. Normal bulbocavernosus reflex

C. Bilaterally increased knee and ankle jerk

D.
Normal proprioception in the extremities
"


Question: A 30-year-old woman seeks evaluation at a local walk-in clinic with a week-long history of lightheadedness and palpitations. She also complains of fatigability and shortness of breath of the same duration. The past medical history is significant for menarche at 9 years of age, heavy menstrual bleeding for the past several years and abdominal pain that worsens during menses. She stopped trying to conceive a child after 2 spontaneous abortions in the past 4 years and has been on iron oral supplementation for the last 2 years. She adds that she feels a dull pressure-like discomfort in her pelvis and constipation. The physical examination is significant for pale mucous membranes and a grade 2/6 ejection systolic murmur in the area of the pulmonic valve. Pelvic examination reveals an enlarged, mobile uterus with an irregular contour. The hemoglobin level is 10 g/dL and the hematocrit is 27%. Based on these findings, which of the following is the most likely diagnosis?

Answer: Uterine leiomyoma

A. Uterine leiomyoma

B. Endometrial hyperplasia

C. Endometrial carcinoma

D. Endometrial polyp


Question: A study is conducted in a town with a population of 225,000, where the people are followed-up for the development of emphysema. A total of 1,000 smokers are selected and followed-up, out of which 200 actually develop the disease. A control group of 1,000 non-smokers is formed, out of which 20 develop emphysema. The prevalence of smoking in the general population is 40%. The researcher calculates all possible risk estimates, including the odds ratio. What percentage of the risk of developing emphysema can be attributed to smoking?

Answer: 18%

A. 40%

B. 20%

C. 10%

D. 18%


Question: A medical student is performing clinical research by analyzing the aggregated data of all patients from a national database. In performing the study, she uses all the data collected from patients who had an appendectomy and analyzes the risk factors that are associated with readmission after discharge. She first excludes some of the data based on previously determined exclusion criteria and then performs analysis on the rest. She performs a multiple regression on all variables and finds that one of the risk factors demonstrates a < 5% probability of being the same between groups. She takes this result and presents it to faculty; however, they respond that the finding is meaningless. Which of the following faults to this study most likely explains why the result was considered meaningless?

Answer: Failure to consider clinical significance versus statistical significance

A. Data should not have been aggregated

B. Failure to consider clinical significance versus statistical significance

C. Single rather than multiple regression should have been performed

D. Usage of the wrong threshold for significance


Question: A 60-year-old man presents to the emergency department with ‘discomfort’ in his chest and a ‘squeezing’ sensation in his neck. The symptoms started 45 minutes ago while he was washing the dishes. He also complains of nausea. He has been a regular smoker for 45 years, averaging a pack of cigarettes each day. He also drinks heavily on weekends. His medical history is significant for a stroke 3 months ago, but the patient admits he has not been taking his medications. Vital signs show: pulse 62/min, respiratory rate 20/min, blood pressure 176/94 mm Hg, and temperature 36.9°C (98.4°F). Physical examination reveals a visibly distressed man who is sweating profusely. The chest is clear to auscultation and a 4th heart sound can be heard. Aspirin was administered upon arrival. His ECG is shown in the picture. Which of the following features is a contraindication for thrombolytic therapy in this patient?

Answer: Stroke 3 months ago

A. Aspirin administration

B. Elevated blood pressure

C. History of smoking

D. Stroke 3 months ago


Question:
A 3-year-old girl is brought by her parents to the office for bloody diarrhea and a seizure. The parents say she started having fever, abdominal pain, and diarrhea about 3 days ago, but the bloody diarrhea started 12 hours ago. The seizure was the last symptom to appear 3 hours ago, and it consisted of repetitive movement of arms and legs with loss of consciousness. Her 4-year-old brother had a similar case with bloody diarrhea 2 weeks ago. Her vital signs include: blood pressure is 130/85 mm Hg, her respiratory rate is 25/min, her heart rate is 120/min, and her temperature is 39.2°C (102.6°F). On physical examination, she looks pale and sleepy, the cardiopulmonary auscultation is normal, the abdomen is painful on palpation, and the skin assessment reveals the presence of disseminated pinpoint petechiae. The urinalysis show hematuria. The Coombs test is negative. The complete blood count results are as follows:
Hemoglobin 7 g/dL
Hematocrit 25 %
Leukocyte count 17,000/mm3
Neutrophils 70%
Bands 2%
Eosinophils 1%
Basophils 0%
Lymphocytes 22%
Monocytes 5%
Platelet count 7,000/mm3
Her coagulation tests are as follows:
Partial thromboplastin time (activated) 30 seconds
Prothrombin time 12 seconds
Reticulocyte count 1 %
Thrombin time < 2 seconds deviation from control
What is the most likely diagnosis?

Answer: Hemolytic-uremic syndrome

A. Disseminated intravascular coagulation

B. Henoch-Schonlein purpura

C. Systemic vasculitis

D. Hemolytic-uremic syndrome


Question: A 68-year-old woman presents to the emergency room with productive cough and fever. She has a chronic cough that has been getting progressively worse over the last 2 weeks. Last night she developed a fever and vomited. She smoked one pack of cigarettes per day for 40 years and recently quit. Her past medical history includes COPD and her medications include ipratropium and fluticasone. On physical exam her temperature is 102.2°F (39°C), blood pressure is 131/78 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 95% on room air. She has decreased breath sounds bilaterally with diffuse crackles. You obtain a sputum sample and identify an organism that grows selectively on medium containing factors V and X. Which of the following organisms is the most likely cause of this patient's symptoms?

Answer: Haemophilus influenzae

A. Haemophilus influenzae

B. Streptococcus pneumoniae

C. Mycoplasma pneumoniae

D. Fusobacterium species


Question: A 36-year-old man comes to the physician because of progressive fatigue and night sweats for 2 months. During this time, he has also had a 10-kg (22-lb) weight loss. Physical examination shows painless swelling of the cervical, axillary, and inguinal lymph nodes. Examination of the abdomen shows hepatosplenomegaly. Histologic examination of a lymph node biopsy specimen shows Reed-Sternberg cells. A diagnosis of Hodgkin lymphoma is made. The patient is started on a chemotherapeutic regimen that includes bleomycin. The mechanism of action of this drug is most similar to that of which of the following?

Answer: Metronidazole

A. Trimethoprim

B. Sulfamethoxazole

C. Metronidazole

D. Chloramphenicol


Question: An 7-year-old girl is brought to the pediatrician by her concerned mother, because she is "more physically matured" than the rest of the girls in her class. On physical exam, she is noted to have breast development and pubic hair. On gonadotropin reseasing hormone (GnRH) stimulation, she has an increase in leutienizing hormone (LH) levels. Thyroid function tests and an MRI of the head are both within normal limits. Which of the following is the most appropriate treatment for this condition?

Answer: Leuprolide

A. Leuprolide

B. Finasteride

C. Octreotide

D. Anastrozole


Question:
A 45-year-old woman presents to the emergency department with hematemesis. Her son said that the patient had complained of gnawing abdominal pain that worsened before and improved after meals for the past 3 weeks. She frequently travels for work and is often stressed. She drinks alcohol socially and does not smoke tobacco or marijuana. She has not had anything to eat or drink for the past 24 hours due to the pain, but coughed up "several cup of" frank red blood before arrival. Her temperature is 98°F (37°C), blood pressure is 80/50 mmHg, pulse is 140/min, respirations are 23/min, and oxygen saturation is 96% on room air. Gastric ultrasound reveals high gastric residual volume. The patient is empirically started on 3 units of uncrossmatched O-negative blood transfusion and pantoprazole. The patient's initial laboratory data return in the meantime:

Hemoglobin: 5 g/dL
Hematocrit: 18 %
Leukocyte count: 8,000/mm^3 with normal differential
Platelet count: 400,000/mm^3

Serum:
Na+: 140 mEq/L
Cl-: 115 mEq/L
K+: 3.2 mEq/L
HCO3-: 26 mEq/L
BUN: 60 mg/dL
Glucose: 104 mg/dL
Creatinine: 1.1 mg/dL

Blood type: AB
Rhesus status: negative

After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours. The patient now complains of feeling hot with intermittent shivering. She denies any other symptoms. Her temperature is 101°F (38.3°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air. Her lungs are clear to auscultation bilaterally, and no accessory respiratory muscle use is observed. No rash is seen. What is the most likely diagnosis?

Answer: Febrile nonhemolytic reaction

A. Febrile hemolytic reaction

B. Febrile nonhemolytic reaction

C. Transfusion related bacterial contamination

D. Transfusion related acute lung injury


Question: A 66-year-old man comes to the physician because of a 3-week history of shortness of breath with exertion. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications include aspirin, losartan, simvastatin, and insulin. His temperature is 37.1°C (98.8°F), pulse is 74/min, and blood pressure is 150/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Cardiac examination is shown. Further evaluation of this patient is most likely to show which of the following?

Answer: Elevated serum brain natriuretic peptide levels

A. Earlier onset of abnormal cardiac sound with standing

B. Elevated serum brain natriuretic peptide levels

C. Left-to-right shunt through the atrial septum

D. Bounding pulses of peripheral arteries


Question: A 27-year-old gravida 2, para 2 woman presents to her OB/GYN’s office concerned that she may be pregnant. She and her husband use condoms for contraception. The night before, the condom broke during intercourse. She has 2 children under the age of 3 and does not want another child at this time. She says she cannot take “the pill” because she had a blood clot in her leg after her last cesarean section successfully treated with 6 months of anticoagulation. She smokes cigarettes and drinks alcohol regularly. Which of the following would be the most appropriate recommendation for this patient?

Answer: Recommend copper IUD

A. Reassure her that she is likely not pregnant

B. Refer her to an abortion clinic

C. Recommend etonogestrel implant

D. Recommend copper IUD


Question:
A 25-year-old Ashkenazi Jewish man presents to his primary care physician for a follow-up visit. One week ago, he presented with a chief complaint of priapism while engaging in intercourse with two of his partners. During that visit, it was determined that his blood pressure was 175/100 mmHg. He returns this week to have his vitals rechecked. His temperature is 99.5°F (37.5°C), pulse is 80/min, blood pressure is 182/100 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air. Bloodwork is drawn and is shown below.

Serum:
Na+: 139 mEq/L
K+: 3.7 mEq/L
Cl-: 100 mEq/L
HCO3-: 28 mEq/L
Urea nitrogen: 9 mg/dL
Glucose: 122 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: 9.8 mg/dL
Mg2+: 1.7 mg/dL

After a physical exam is performed, which of the following is the best initial step in management for this patient's underlying condition?

Answer: Duplex ultrasound

A. Begin lifestyle modification and weight loss program

B. Begin lifestyle modification, weight loss program, and hydrochlorothiazide

C. 24-hour urinary cortisol

D. Duplex ultrasound


Question:
A 63-year-old man is brought to the emergency department after having 8–9 episodes of red watery stool. He has no abdominal pain or fever. He underwent an angioplasty 4 years ago and received 2 stents in his left main coronary artery. He has hypertension, hypercholesterolemia, coronary artery disease, and chronic constipation. Current medications include aspirin, metoprolol, and simvastatin. He drinks one beer daily. He is in distress. His temperature is 37.3°C (99.1°F), pulse is 110/min, respirations are 14/min, and blood pressure is 86/58 mm Hg. Examination shows pale conjunctivae. The abdomen is soft and nontender. Bowel sounds are increased. The lungs are clear to auscultation. Cardiac examination shows an S4 gallop. Rectal examination shows frank blood. Laboratory studies show:
Hemoglobin 9.8 g/dL
Leukocyte count 7,800/mm3
Platelet count 280,000/mm3
Prothrombin time 14 seconds (INR=0.9)
Serum
Na+ 135 mEq/L
K+ 4.1 mEq/L
Cl- 101 mEq/L
Urea nitrogen 16 mg/dL
Glucose 96 mg/dL
Creatinine 0.7 mg/dL
Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered. A nasogastric tube is inserted. Aspiration shows clear gastric content containing bile. Directly afterwards, his pulse is 133/min and blood pressure is 80/54 mm Hg. Which of the following is the most appropriate next step in management?"

Answer: Angiography

A. Angiography

B. Laparotomy

C. Esophagogastroduodenoscopy

D. Enteroscopy


Question: A 15-month-old boy with Down syndrome is brought to the physician for a well-child examination. The mother is concerned about giving the child any more vaccinations, as she reports he had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12-months of age. He has had a runny nose for 2 days. He has a seizure disorder with a seizure lasting 1–2 minutes a few times a week that has not been controlled by medications. He was treated for intussusception at 6 months of age. His father was diagnosed with HIV 2 years ago. His medications include phenytoin, levetiracetam, and vitamin supplements. He is allergic to amoxicillin and has previously developed localized urticaria after consumption of eggs. His immunizations are up-to-date. Vital signs are within normal limits. Examination shows low-set ears, hypertelorism, and a flat head. The remainder of the examination shows no abnormalities. Which of the following is a relative contraindication for administering one or more routine vaccinations in this patient at this time?

Answer:
Uncontrolled seizure disorder
"

A. Egg protein allergy

B. Fever of 38.7°C (101.7°F) after previous vaccination

C. Current upper respiratory tract infection

D.
Uncontrolled seizure disorder
"


Question: A 1-year-old boy is brought to his pediatrician’s office due to regression of development. She has observed that he is not progressing as he did during the 1st year of his life. There seems to be a regression in some behavioral and other milestones. She is also concerned about his facial development. On examination, the vital signs are normal. He has coarse facial features with a bulging frontal bone. Additionally, his lips are enlarged and corneal clouding is observed. Urine studies show an increase in dermatan sulfate. Which of the following genetic conditions is most likely related to these clinical features?

Answer: Hurler syndrome

A. Morquio syndrome

B. Tay-Sachs disease

C. Hurler syndrome

D. Fabry disease


Question: A 6-year-old African American girl is brought to the physician by her mother because she has recently developed axillary and pubic hair. She also has multiple pustules on her forehead and has had oily skin for 3 months. Her mother reports that she recently bought some deodorant for the girl because of her body odor. Her mother has hypothyroidism. She is at the 95th percentile for height and the 99th percentile for weight and BMI. Her vital signs are within normal limits. She has no palpable glandular breast tissue. There is coarse hair under both axilla and sparse dark hair on the mons pubis and along the labia majora. Which of the following is the most likely explanation for this patient's examination findings?

Answer: High levels of insulin

A. High levels of insulin

B. Adrenal enzyme deficiency

C. Pituitary tumor

D. Ovarian cyst


Question: A 45-year-old woman comes to the physician for a health maintenance examination. Her father has a history of type 2 diabetes mellitus. She has gained 18-kg (40-lb) since the birth of her son 6 years ago. Her BMI is 31 kg/m2. Physical examination shows hyperpigmented plaques in the axillae and posterior neck. Laboratory studies show a hemoglobin A1c of 6.4% and an elevated serum insulin level. Which of the following factors is most likely involved in the pathogenesis of this patient's condition?

Answer: Increased levels of serum fatty acids

A. Increased serum levels of glucagon-like peptide-1

B. Increased levels of serum fatty acids

C. Decreased levels of serum cortisol

D. Positive HLA-DR4 serotype


Question: An 89-year-old woman presents with worsening dyspnea on exertion and generalized fatigue. She has fainted once. Exam reveals a crescendo-decrescendo systolic ejection murmur that radiates to the carotids. What pathological step preceded calcification in her condition?

Answer: Cellular injury and necrosis

A. Commissural fibrosis

B. Congenital bicuspid valve

C. Fibrillin-1 deficiency

D. Cellular injury and necrosis


Question: A 22-year-old man presents to the emergency department for chest pain. He says that the chest pain began a few hours prior to presentation and is associated with nausea, abdominal discomfort, and sweating. He has experienced similar symptoms multiple times in the past, which brings him great concern because he believes he may be having a heart attack. This concern has persisted for 2 months. This has caused him to avoid taking long train rides or driving on divided highways. Approximately 7 months ago his parents divorced. Medical history is significant for obesity. He denies any medications or illicit drug use. Physical examination is unremarkable. An electrocardiogram demonstrates sinus tachycardia with a pulse of 110/min. Which of the following is most likely the diagnosis?

Answer: Panic disorder

A. Adjustment disorder

B. Illness anxiety disorder

C. Panic disorder

D. Specific phobia


Question: An investigator is developing a new vaccine. Eukaryote ribosomes are utilized to create a novel protein. After the aminoacyl-tRNA binds to the A site, which of the following is the next step in protein formation?

Answer: Catalysis of peptide bond

A. Catalysis of peptide bond

B. Recognition of UAG codon by release factor

C. Assembly of 40s subunit with tRNA

D. Advancement of ribosome in 3' direction


Question: A 70-year-old Caucasian woman presents with a 2-week history of blood-tinged sputum. Her past medical history is significant for peptic ulcer disease for which she underwent triple-drug therapy. She is a lifetime non-smoker and worked as a teacher before retiring at the age of 60 years. A review of systems is significant for a weight loss of 6.8 kg (15 lb) over the last 5 months. Her vitals include: blood pressure 135/85 mm Hg, temperature 37.7°C (99.9°F), pulse 95/min, and respiratory rate 18/min. Physical examination is unremarkable. A contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung. A CT-guided biopsy is performed and reveals malignant tissue architecture and gland formation with a significant amount of mucus. Which of the following is the most significant risk factor for this patient’s most likely diagnosis?

Answer: Sex

A. Medications

B. Occupational history

C. Race

D. Sex


Question: Four days after admission to the hospital for community-acquired pneumonia, a 68-year-old woman has abdominal pain and multiple episodes of loose stools. They are watery, foul-smelling, and occasionally streaked with blood. She has approximately 6 episodes daily. She feels tired. She is currently being treated with intravenous ceftriaxone and oral azithromycin. She underwent a laparoscopic cholecystectomy 5 years ago. She returned from a trip to Bolivia 4 weeks ago. Her temperature is 37.5°C (99.5°F), pulse is 98/min, and blood pressure is 138/80 mm Hg. Bronchial breath sounds are heard over her right lung. Abdominal examination shows mild diffuse tenderness throughout the lower quadrants. The abdomen is not distended. The remainder of her examination shows no abnormalities. Her hemoglobin concentration is 12 g/dL, leukocyte count is 14,100/mm3, and erythrocyte sedimentation rate is 37 mm/h. Which of the following is the most appropriate next step in management?

Answer: Enzyme immunoassay for glutamate dehydrogenase antigen

A. Stool for ova and parasites

B. Fecal lactoferrin

C. Enzyme immunoassay for glutamate dehydrogenase antigen

D. Stool acidity test


Question: An otherwise healthy 52-year-old man comes to the physician because of a 2-month history of palpitations. He says that he can feel his heart beat in his chest all the time. For the past 3 weeks, he has shortness of breath on exertion. He has not had chest pain, orthopnea, or nocturnal dyspnea. He emigrated from Nepal at the age of 25 years. He does not take any medications. His temperature is 36.5°C (97.7°F), pulse is 103/min, and blood pressure is 138/56 mm Hg. The lungs are clear to auscultation. Cardiac examination is shown. Which of the following is the most likely diagnosis?

Answer: Aortic valve regurgitation

A. Pulmonary valve stenosis

B. Aortic valve regurgitation

C. Tricuspid valve regurgitation

D. Mitral valve prolapse


Question: A 55-year-old male presents to the emergency department after he was seen having a seizure. On presentation he is comatose and very jaundiced despite having no previous medical history and dies shortly thereafter. Over the next several hours 5 more patients present to the ER with severe diarrhea, abdominal pain, and bleeding abnormalities. They all recently returned from a several day camping trip where they slept in the woods and cooked with ingredients they were able to find in the wild. The original patient was also part of this camping trip. Postmortem analysis reveals massive hepatic necrosis. Which of the following activities was most likely inhibited by the cause of this patient's presentation?

Answer: Transcription of mRNA

A. Transcription of mRNA

B. Transcription of rRNA

C. Transcription of tRNA

D. Translation of mRNA


Question: A 46-year-old woman is brought to the emergency department for respiratory depression. Routine urine toxicology screening is positive for alcohol, fentanyl, and benzodiazepines. Blood glucose is 80 mg/dL. Naloxone, flumazenil, and lactated Ringer's solution are administered intravenously. Two hours later, the woman has a tonic-clonic seizure lasting for one minute. Her pulse is 100/min, blood pressure is 145/90 mm Hg, and respiratory rate is 24/min. Pulse oximetry on room air shows an oxygen saturation of 98%. The patient appears drowsy and diaphoretic. She is not oriented to place or time but responds to her name. Examination shows a hematoma on her left temple. Neurological examination shows stiff extremities and a tremor in both hands. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of this patient's seizure?

Answer: Benzodiazepine withdrawal

A. Hypoglycemia

B. Benzodiazepine withdrawal

C. Alcohol withdrawal

D. Subdural hemorrhage


Question: A 22-year-old man comes to the emergency department because of sudden onset of facial swelling, abdominal pain, and nausea 1 hour after eating some trail mix. He does not have shortness of breath or hoarseness. He has never had a similar episode before. He has asthma treated with an albuterol inhaler, which he uses less than once a month. His pulse is 90/min, respirations are 25/min, and blood pressure is 125/80 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows perioral swelling and scattered urticaria over the face and the fingers of his right hand. There is no swelling of the oropharynx and no audible stridor. The lungs are clear to auscultation bilaterally. Treatment with intravenous diphenhydramine is begun. Shortly after, the abdominal pain and nausea have resolved, the swelling has improved, and the rash has started to fade. Which of the following is the most appropriate next step in management?

Answer: Prescribe epinephrine autoinjector

A. Recommend avoidance of peanuts

B. Perform patch test

C. Prescribe epinephrine autoinjector

D. Administer oral prednisone


Question: A 2-year-old boy is referred by his primary care physician to a geneticist because of prolonged and recurrent infections. Specifically, he has had an abnormally large number of upper respiratory and gastrointestinal infections over the last year. He was born with a defect in the cardiac septum that was repaired right after birth and has remained asymptomatic since then. On evaluation, the patient appears to have hyperactive reflexes and his arm twitches upon blood pressure measurement. The regions of this patient's lymph nodes that is likely abnormal also contains which of the following?

Answer: High endothelial venules

A. Efferent sinuses

B. High endothelial venules

C. Plasma cell cords

D. Primary follicles


Question:
A 45-year-old woman presents with a 2-year history of fatigue, paresthesia, diarrhea, and abdominal pain. She says she experiences 2–3 episodes of non-bloody diarrhea per month associated with crampy abdominal pain. She also has the bilateral tingling sensation of her upper and lower limbs in a glove and stocking pattern which is sometimes associated with the burning sensation of her hands and legs. Past medical history is unremarkable. The patient denies smoking, alcohol consumption, illicit drug use. Her vital signs include: blood pressure 100/60 mm Hg without postural changes, heart rate 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉). Laboratory findings are significant for the following:
Hgb 7.2 gm/dL
MCV 110 fL
RBC 3.6 X109/L
Platelets 10,000/mm3
Total count  4,200/mm3
Reticulocyte 0.8%
A peripheral blood smear demonstrates hypersegmented neutrophils. Anti-intrinsic factor and anti-tissue transglutaminase antibodies were negative. An upper GI series with small bowel follow-through is performed which shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string. Which of the following is the most likely diagnosis in this patient?

Answer: Crohn's disease

A. Celiac disease

B. Crohn's disease

C. Bacterial overgrowth

D. Hypothyroidism


Question: A 15-month-old boy is brought to his pediatrician by his mother with a swollen and painful right elbow. She reports that he stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground. The mother reports that he did not appear to be in a great deal of pain after the fall, and that she noted the swelling of the joint a few hours after the fall. He recently started walking approximately 2 weeks ago. He does not have any known medical issues, and he is not currently on medication. The mother's pregnancy was without complications and the boy was delivered vaginally without complications at 40 weeks. Aspiration of the right elbow joint reveals frank blood. Which of the following should be included in the work-up of this patient?

Answer: Prothrombin time/partial thromboplastin time

A. Peripheral blood smear

B. Creatinine level and percutaneous kidney biopsy

C. Prothrombin time/partial thromboplastin time

D. 24 hour urine collection for porphyrin levels


Question: A 45-year-old male comes into your office one week after he was tackled playing football with his friends. The patient states that the medial aspect of his knee collided with another player's knee. Since then, he has been taking ibuprofen for knee pain. On exam, the patient's right knee appears larger than his left knee with a small effusion. The patient has intact sensation and strength in both lower extremities. The patient's right knee has no laxity on valgus stress test, but is very lax on varus stress test. Lachman's test and posterior drawer test both have firm endpoints without laxity. McMurray's test is positive and the patient states he feels catching and locking during the test. Which of the following structures has this patient injured in addition to the meniscus?

Answer: Lateral collateral ligament

A. Anterior cruciate ligament

B. Posterior cruciate ligament

C. Medial collateral ligament

D. Lateral collateral ligament


Question: A 19-month-old girl is brought for a well-child examination. She was born at term and has been healthy. On physical examination, the child is alert and active. Her temperature is 37.3 °C (99.1 °F), pulse is 102/min, respirations are 24/min, and blood pressure is 102/54 mm Hg. She is at the 75th percentile for height and 80th percentile for weight. Cardiac examination shows a normal S1 and a split S2 during inspiration. A grade 2/6 soft mid-systolic murmur is heard maximally at the lower left sternal border. A contrast echocardiogram is performed and reveals a mild transient right-to-left interatrial shunt that becomes apparent when the child coughs. Which of the following is the most appropriate next step in management?

Answer: No intervention

A. No intervention

B. Aspirin therapy

C. Surgical closure

D. Regular echocardiographies


Question: A 6-year-old girl is brought to the emergency department because of right knee pain for the past 3 days. During this period, the girl has refused to walk. Her mother reports that her symptoms began after she fell down while playing. Three weeks ago, the patient had a sore throat and was treated with penicillin V. Her father has hemophilia A and has had repeated episodes of joint pain and swelling following minor injury. The patient's immunizations are up-to-date. Her temperature is 38.1°C (100.6°F), pulse is 120/min, and respirations are 21/min. The right knee joint is warm and erythematous. The girl starts to cry as soon as the physician tries to flex the knee joint. Further evaluation of this patient is likely to show which of the following findings?

Answer: Gram-positive cocci in synovial fluid

A. Gram-positive cocci in synovial fluid

B. Prolonged prothrombin time

C. Increased antistreptolysin O titers

D. Rhomboid crystals in synovial fluid


Question: A 35-year-old man attempted to climb Mount Everest. At an altitude of 7,000 meters, he became short of breath and developed a dusky blue tinge around his face and lips. A physician in the climbing party performs a rudimentary physical exam which reveals a respiratory rate of 30/min, blood pressure of 130/90 mm Hg, heart rate of 108/min, and temperature of 36.4°C (97.5°F), with few basal crackles on the right side of chest. No jugular venous distension or dependent edema is noted. With this information, the mountain climber is sent down the mountain for further evaluation. Investigation reveals a normal chest X-ray with a normal heart size. What is the most likely cause of this patient’s condition?

Answer: Hypoxemic hypoxia

A. Diffusion defect

B. Anemic hypoxia

C. Ischemic hypoxia

D. Hypoxemic hypoxia


Question: A 28-year-old man who was involved in a motorcycle accident presents to the nearest trauma center to get his wounds treated. After the initial evaluation and resuscitation by the emergency trauma team, a CT scan shows a skull base fracture. Which of the following clinical features can be seen as a long-term complication of posterior pituitary dysfunction?

Answer: Polydipsia

A. Erectile dysfunction

B. Decreased lean body mass

C. Polydipsia

D. Cold intolerance


Question: A 19-year-old woman comes to the physician for a follow-up examination. She has a history of type 1 diabetes mellitus and is compliant with her medications. After reviewing the patient's recent blood sugar levels, the physician changes the patient's antidiabetic regimen by changing the dosage of an insulin that does not produce an observable peak in serum insulin concentration. The dosage of which of the following types of insulin was most likely changed in this patient's medication regimen?

Answer: Insulin glargine

A. Insulin glargine

B. Insulin glulisine

C. Regular insulin

D. Insulin lispro


Question: A 31-year-old woman visits her local walk-in clinic for 2 days of dysuria, increased voiding frequency, urgency, and intense suprapubic pain. She just came back a day ago from a short honeymoon trip to Prague. On physical examination, the patient is found with exquisite suprapubic pain. Costovertebral tenderness is absent and pelvic examination is normal. Her vital signs are: temperature 36.5°C (97.7°F), heart rate 78/min, respiratory rate 15/min. Which of the following organisms would be most likely isolated in this patient?

Answer: Staphylococcus saprophyticus

A. Streptococcus agalactiae

B. Enterococcus faecalis

C. Klebsiella pneumoniae

D. Staphylococcus saprophyticus


Question: A 14-year-old boy is brought to the physician by his mother because of a 1-week history of fever, fatigue, and throat pain. He appears lethargic. His temperature is 38.5°C (101.3°F). Physical examination shows bilateral cervical lymphadenopathy. Oral examination shows the findings in the photograph. A peripheral blood smear shows lymphocytosis with atypical lymphocytes. A heterophile antibody test is positive. Which of the following is the most appropriate recommendation by the physician?

Answer: Avoid contact sports

A. Start antiretroviral therapy

B. Schedule bone marrow biopsy

C. Avoid contact sports

D. Avoid crowded places


Question: A 62-year-old carpenter presents to your clinic complaining of worsening joint pain in her hands. She states that the pain is present in all of her fingers, but is worse in the right hand and that it gets better when she has a few days off from work. She notes no paresthesias, fever, or fatigue. On examination, the patient is afebrile and all vital signs are stable. She has hard, non-tender lesions overlying the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand and all 5 digits on this hand have a decreased range of motion. An X-ray of her hands is shown. What is the most likely pathogenesis leading to the X-ray findings?

Answer: Repetitive movement injury

A. Repetitive movement injury

B. Overgrowth of a gram-positive bacteria

C. Deposition of monosodium urate crystals

D. Production of rheumatoid factor and other autoantibodies


Question: A 7-year-old girl presents to the emergency department with a bloody nose that spontaneously started bleeding 20 minutes ago. On physical examination, she appears well and has no lymphadenopathy. Her heart has a regular rate and rhythm, her lungs are clear to auscultation bilaterally, and her abdomen is soft without hepatosplenomegaly, but she does have petechiae over her lower extremities. A complete blood count is obtained and reveals a leukocyte count of 11,300 cells/mcL, hemoglobin 12.1 g/dL, hematocrit 36%, and platelets 15,000/mcL. A peripheral smear shows a few morphologically normal platelets. Her mother reports that she had a viral infection 2 weeks ago but has been otherwise healthy. Which of the following is the next best step?

Answer: Start intravenous immunoglobulin

A. Start intravenous immunoglobulin

B. Perform a splenectomy

C. Perform a bone marrow aspiration

D. Observation


Question: A 2-year-old boy is brought to the physician by his parents because their son frequently avoids eye contact and has no friends in daycare. He was born at term and has been healthy except for an episode of otitis media 6 months ago. His immunizations are up-to-date. He is at the 95th percentile for height, 20th percentile for weight, and 95th percentile for head circumference. Vital signs are within normal limits. Examination shows elongated facial features and large ears. The patient is shy and does not speak or follow instructions. He continually opens and closes his mother's purse and does not maintain eye contact. Which of the following is the most likely cause of this patient's presentation?

Answer: CGG trinucleotide repeat expansion on X-chromosome

A. CGG trinucleotide repeat expansion on X-chromosome

B. Deletion of the long arm on chromosome 7

C. Genomic imprinting on chromosome 15

D. An additional X chromosome


Question:
A 78-year-old man is admitted to hospital for treatment of a severe attack of pneumonia he has been experiencing for the past three days. A week earlier, he had been feeling well until he developed what he describes as a mild cold. Over the next few days, he began to have difficulty breathing and developed a productive cough and fever. As his condition worsened despite antibiotic therapy at home, he was admitted for intravenous antibiotics and observation. He has a 50-pack-year history of smoking and has been diagnosed with chronic obstructive pulmonary disease (COPD). Prior to admission, the man was taking inhaled formoterol, budesonide, and oxygen at home. He has been drinking 3 alcoholic drinks daily for the last 60 years and smoked marijuana during his 20s. His lab results from 1 week ago and from his day of admission to hospital are as follows:
7 days ago
On admission to hospital
Serum glucose (random)  130 mg/dL
Serum electrolytes
Sodium 142 mEq/L
Potassium 3.9 mEq/L
Chloride 101 mEq/L
Serum creatinine 0.8 mg/dL
Blood urea nitrogen 9 mg/dL
Cholesterol, total 170 mg/dL
HDL-cholesterol 42 mg/dL
LDL-cholesterol 110 mg/dL
Triglycerides 130 mg/dL
Serum glucose (random)  100 mg/dL
Serum electrolytes
Sodium 140 mEq/L
Potassium 4.0 mEq/L
Chloride 100 mEq/L
Serum creatinine 0.9 mg/dL
Blood urea nitrogen 11 mg/dL
Cholesterol, total 130 mg/dL
HDL-cholesterol 30 mg/dL
LDL-cholesterol 80 mg/dL
Triglycerides 180 mg/dL
What best explains the change in this patient’s lipid profile over this time period?

Answer: Physiological response

A. COPD exacerbation

B. Drug side effect

C. Physiological response

D. Undiagnosed dyslipidemia


Question: A 42-year-old woman comes to the physician because of a 4-week history of progressive difficulty swallowing solid foods. The patient reports feeling like food gets stuck in her throat, and that she has to drink a lot of water to swallow her meals. Over the past 3 months, she has had progressive fatigue and occasional dyspnea while performing her daily activities. Her pulse is 104/min, respirations are 19/min, and blood pressure is 110/70 mm Hg. Physical examination shows conjunctival pallor, erythema around the corners of the mouth, and dry, scaly lips. Her fingernails appear spoon-shaped and brittle. Auscultation of the heart shows a grade 1/6 systolic murmur best heard at the second left intercostal space. Esophagogastroduodenoscopy shows thin membranes that are protruding into the upper third of the esophagus. Further evaluation of the patient is most likely to show which of the following?

Answer: Craving for non-nutritive substances

A. Altered sense of smell

B. Intolerance to cold temperatures

C. Thickening of the skin

D. Craving for non-nutritive substances


Question: A 27-year-old nullipara makes an appointment with her gynecologist to discuss the results of her cervical cancer screening. She is not vaccinated against HPV and has a single sexual partner. She and her partner are planning pregnancy, so she recently discontinued oral contraception and began to take folate and iron supplements. She has no history of gynecologic diseases. Her first Pap smear showed atypical squamous cells of undetermined significance, but 2 subsequent Pap smears had normal results. The most recent Pap smear was reported as a high-grade squamous intraepithelial lesion. Colposcopy was performed at the next visit and a biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone. The pathologic assessment shows CIN 3. Which of the following statements regarding the management of this patient is correct?

Answer: Close follow-up with cytology and colposcopy may be considered in this patient.

A. The annual rate of progression of CIN 3 to cancer is > 10%, so the patient should be treated as soon as possible.

B. Close follow-up with cytology and colposcopy may be considered in this patient.

C. Additional HPV testing would be useful to guide the therapy.

D. Pregnancy is not recommended in women with high-grade cervical lesions, so treatment is reasonable.


Question: A 47-year-old woman comes to the physician because of a 3-month history of recurrent episodes of nausea and feeling like the room is spinning. Each episode lasts less than a minute and usually occurs when she gets out of bed in the morning or suddenly turns her head. She has not vomited and does not have headaches. She is asymptomatic between episodes. Which of the following findings most closely correlates with this patient's symptoms?

Answer: Nystagmus

A. Intention tremor

B. Nystagmus

C. Abnormal Rinne test

D. Orthostatic hypotension


Question: A 56-year-old man is brought to the emergency department by his wife because of increasing confusion and lethargy for the past 12 hours. He is oriented only to person. His temperature is 37.3°C (99.1°F), pulse is 109/min, respirations are 18/min, and blood pressure is 108/67 mm Hg. Examination shows abdominal distention and several erythematous, lacy lesions on the chest that blanch with pressure. His hands make a flapping motion when they are dorsiflexed. Which of the following is the most likely precipitating factor for this patient's symptoms?

Answer: Presence of hemoglobin in the intestine

A. Elevated systemic vascular resistance

B. Destruction of gut anaerobes

C. Presence of hemoglobin in the intestine

D. Low protein consumption


Question: A 63-year-old man comes to the physician because of a 4-hour history of severe pain in the right knee. His temperature is 38.0°C (100.1°F). Examination shows erythema, edema, and warmth of the right knee; range of motion is limited by pain. Arthrocentesis of the knee joint yields cloudy fluid with a leukocyte count of 24,000/mm3 (74% segmented neutrophils). Polarized light microscopy shows needle-shaped, negatively birefringent crystals. Five hours after treatment with a drug is begun, he develops abdominal cramp, diarrhea, and vomiting. The patient was most likely treated with a drug that predominantly acts on which of the following parts of the cell?

Answer: Cytoskeleton

A. Cell wall

B. Cytosolic enzyme

C. Nucleus

D. Cytoskeleton


Question: A 1-year-old boy presents to the emergency department for several days of irritability and poor feeding. His parents are very concerned that he has been acting differently. The patient has an unremarkable past medical history and has been followed by a pediatrician. His temperature is 102°F (38.9°C), blood pressure is 57/38 mmHg, pulse is 170/min, respirations are 35/min, and oxygen saturation is 99% on room air. During the exam the infant is irritable and is crying. Musculoskeletal exam reveals that the patient's knee can not be extended while the patient's hip is in a flexed position without significant patient irritation. Fundoscopy is within normal limits. Abdominal, cardiac, and pulmonary exam are within normal limits. Which of the following is the next best step in management?

Answer: Lumbar puncture

A. Blood and urine cultures

B. Lumbar puncture

C. Vancomycin and ceftriaxone

D. Vancomycin, ceftriaxone, and prednisone


Question: A 74-year-old man comes to the physician because of a 2-month history of shortness of breath and leg swelling. He has trouble climbing one flight of stairs due to dyspnea. He has hypertension and was diagnosed with multiple myeloma 6 months ago. Current medications include hydrochlorothiazide. Cardiopulmonary examination shows jugular venous distention, bibasilar crackles, and pitting edema in the lower extremities. Transthoracic echocardiography shows a thickened myocardium with elevated diastolic filling pressures. Which of the following is the most likely underlying mechanism of this patient's cardiomyopathy?

Answer: Amyloid deposition

A. Chronic vasoconstriction

B. Myosin gene mutation

C. Amyloid deposition

D. Chronic hypercalcemia


Question: A 47-year-old man is brought to the emergency department 30 minutes after he was involved in a motor vehicle collision. On arrival, he is unconscious and unresponsive to painful stimuli. His pulse is 120/min, respirations are 10/min, and his blood pressure is 88/60 mm Hg. Infusion of 0.9% saline is begun, and intubation is attempted without success. Pulse oximetry on 20 L/min of oxygen via bag mask shows an oxygen saturation of 78%. The next appropriate step in the management of this patient involves passing a tube through an incision through which of the following structures?

Answer: Investing layer of deep cervical fascia

A. Investing layer of deep cervical fascia

B. Annular ligament

C. Cricotracheal ligament

D. Prevertebral layer of deep cervical fascia


Question: Parents bring an 11-month-old baby to the clinic because the baby has a fever of 39.0°C (102.2°F). The baby is irritated and crying constantly. She is up to date on immunizations. A complete physical examination reveals no significant findings, and all laboratory tests are negative. Five days after resolution of her fever, she develops a transient maculopapular rash. What is the most likely diagnosis?

Answer: Roseola

A. Roseola

B. Erythema infectiosum

C. Rubella

D. Kawasaki disease


Question: A 67-year-old man is brought to his primary care practitioner by his daughter who has noticed a ‘pill-rolling’ tremor in his right hand, along with a progressively slow, shuffling gait. The patient’s daughter says that these symptoms gradually started 2 weeks ago and have progressively worsened. His past medical history is significant for hypertension, which is well-controlled with losartan. He does not take any other medications. Physical examination reveals a slow shuffling gait, difficulty initiating movements, a resting tremor in his right hand that decreases in intensity with voluntary movement, and cogwheel-like rigidity in the right arm. The primary care practitioner decides to prescribe levodopa and carbidopa. Which of the following statements would best explain the mechanism of action of these drugs?

Answer: Increased dopamine synthesis

A. Inhibition of the enzyme monoamine oxidase (MAO) B

B. Blockade of muscarinic receptors

C. Inhibition of dopamine reuptake

D. Increased dopamine synthesis


Question: A 79-year-old man with a long-standing history of hypertension and diabetes presents to the emergency department with sudden-onset of loss of motor function on the left side of his body. Neurologic exam shows normal sensation throughout the body. MRI of the brain is obtained and shows a small sub-cortical infarct involving a perforating vessel. Which of the following is the most likely underlying pathogenesis?

Answer: Lipohyalinosis of small vessels

A. Embolism originating from the left atrium

B. Berry aneurysm

C. Lipohyalinosis of small vessels

D. Fibromuscular dysplasia


Question: A cardiology specialist working in the university hospital center noticed that a large number of his patients who had myocardial infarctions also had some sort of malignancy in their medical history. In order to determine whether a relationship existed between myocardial infarction and malignant processes, he decided to pursue a case-control study. His selected cases consisted of a sample of patients hospitalized in an internal ward with a history of a myocardial infarction, while control cases were patients on the same ward without a history of a myocardial infarction. Their charts and medical documentation were then reviewed for a history of any type of malignancy. The results of the study led the cardiologist to conclude that, for patients with malignancy, the odds of having a myocardial infarction were 3.2 times higher when compared to patients without malignancy. If the cardiologist was aware of Berkson’s bias (also known as the admission rate bias), he could minimize it by which of the following?

Answer: Recruiting the controls from different wards to increase disease variability

A. Including the diagnoses negatively related to the risk factor being studied

B. Excluding controls that present a probability of hospital admission similar to cases

C. Recruiting the controls from different wards to increase disease variability

D. Excluding those patients with preferential recollection of exposures


Question: A 27-year-old woman presents to her primary care physician’s office with fatigue, headaches, and concentration difficulties. Her symptoms began approximately 7 months prior to presentation. Throughout this time, she reports problems with initiating and remaining asleep, has noticed periods of muscle soreness, and has feelings of restlessness. She states that she is very concerned about whether she will be able to pay her monthly expenses and if her parents are satisfied with her career choices. She is also worried about how her colleagues and supervisor think of her performance at work. She denies any significant past medical history besides occasional palpitations. She takes a daily multivitamin. Family history is significant for panic disorder in her mother. She currently lives alone and at times socializes with friends. She occasionally drinks alcohol during social gatherings, does not smoke, and denies any illicit drug use. Her temperature is 99°F (37.2 °C), blood pressure is 110/75, pulse is 101/min, and respirations are 18/min. Physical examination is unremarkable. Which of the following is the most appropriate pharmacologic treatment for this patient?

Answer: Buspirone

A. Buspirone

B. Mirtazapine

C. Olanzapine

D. Trazodone


Question:
A 73-year-old man comes in to the emergency department because of nausea and severe pain in his upper abdomen and right shoulder blade for the past day. He was able to eat a little for breakfast but vomited up the meal a couple of hours later. He has type 2 diabetes mellitus treated with metformin. He has smoked half a pack of cigarettes daily for 40 years and drinks 4 beers every week. He appears acutely distressed. His temperature is 38.8°C (102°F), pulse is 124/min, and blood pressure is 92/68 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. The abdomen is soft and there is tenderness to palpation of the right upper quadrant with soft crepitus. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 14.3 g/dL
Leukocyte count 18,100/mm3
Platelet count 216,000/mm3
Serum
Aspartate aminotransferase (AST, SGOT) 41 U/L
Alanine aminotransferase (ALT, SGPT) 19 U/L
Alkaline phosphatase 110 U/L
Total bilirubin 0.9 mg/dL
Direct bilirubin 0.2 mg/dL
Albumin 4.1 g/dL
Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen. Which of the following is the most likely diagnosis?"

Answer: Emphysematous cholecystitis

A. Chronic pancreatitis with pseudocyst rupture

B. Emphysematous cholecystitis

C. Gallstone ileus

D. Primary sclerosing cholangitis


Question: A 26-year-old man presented with a headache and fatigue for the past few months. On presentation to the clinic, the blood pressure is 190/110 mm Hg; the femoral pulse is reduced compared to the radial pulse, and an ejection click is heard. There was no murmur. Which of the following is associated with his condition?

Answer: Coarctation of the aorta

A. Ventricular septal defect (VSD)

B. Wolff-Parkinson-White syndrome

C. Coarctation of the aorta

D. Atrial septal defect (ASD)


Question: A 57-year-old man with a history of diabetes and stage 3 chronic kidney disease is admitted to the hospital for elective coronary angiography. The senior resident admitting the patient to the ward is concerned about his chronic renal impairment and the scheduled angiography, which will require the use of intravenous contrast. Which of the following strategies is most likely to decrease the likelihood that the procedure will exacerbate the patient’s renal failure?

Answer: Use non-iodinated contrast medium

A. Intravenous mannitol before and during the procedure

B. Intravenous N-acetyl cysteine before and during the procedure

C. Use non-iodinated contrast medium

D. Forced diuresis with furosemide


Question: A 17-year-old girl is brought in a wheelchair because of gradually progressive difficulty in walking, incoordination, and frequent falls. Her symptoms started at 9 years old with clumsiness while walking. She later experienced difficulties with coordination, which later involved her arms and trunk. She was born at term with normal developmental milestones. The physical examination reveals severely ataxic gait, nystagmus, absent deep tendon reflexes, and loss of vibration and proprioception. Presuming it is an inherited condition, what is the most likely genetic pathophysiology of this disorder?

Answer: GAA trinucleotide repeats

A. GAA trinucleotide repeats

B. Mitochondrial DNA mutation

C. NOTCH3 mutation

D. PMP22 gene duplication


Question: A previously healthy 51-year-old man is brought to the emergency department because of confusion for 2 hours. His wife reports that he fell and hit his head while changing a ceiling light the previous evening. On arrival, he is unconscious. His temperature is 37.1°C (98.8°F), pulse is 54/min, respirations are 8/min and irregular, and blood pressure is 198/106 mm Hg. The right pupil is dilated and fixed; the left pupil is round and reactive to light. There is extension of the extremities to painful stimuli. He is intubated and mechanically ventilated. A mannitol infusion is begun. A noncontrast CT scan of the brain shows herniation of the right medial temporal lobe. Which of the following is the most likely additional finding in this patient?

Answer: Right-sided hemiplegia

A. Right-sided hemiplegia

B. Left-side facial nerve palsy

C. Bilateral spasticity

D. Multifocal myoclonus


Question: A 1-year-old female presents to the emergency department with 2 days of fever up to 103ºF. During the course of her work-up, a urine culture reveals gram negative rods and a urinary tract infection (UTI) is diagnosed. She is placed on ceftriaxone and quickly defervesces. Follow-up of the urine culture reveals the causal bacteria was E. coli, without any concerning resistance patterns and was susceptible to ceftriaxone. This is her first UTI and there is no family history of renal abnormalities or vesicourethral reflux. In addition to her current therapy, what additional steps should be taken during the management of this child's UTI?

Answer: Renal bladder ultrasound

A. Prophylactic antibiotic therapy to prevent future UTIs

B. Voiding cystourethrogram

C. Renal bladder ultrasound

D. Repeat urine culture


Question: A 22-year-old woman presents to her primary care physician because she has been having severe pruritus on her left leg. She says the symptoms started 1 week ago after she went on a hiking trip with her friends. She wore shorts during the hike and felt as if something brushed her skin on the front of her leg just below the knee. She has no past medical history and no family history of autoimmune diseases. On physical exam, she has red pruritic papules and vesicles on her left leg. Which of the following mechanisms was most likely involved in the development of this patient's symptoms?

Answer: Cytotoxicity due to T-cells

A. Activation of cell surface receptors by antibodies

B. Cross-linking of IgE antibodies

C. Cytotoxicity due to T-cells

D. Immune complex deposition


Question: An adopted 7-year-old boy is brought to a pediatrician with a history of progressive muscular weakness, intellectual impairment, and speech problems. The adoptive parents say that the patient was normal at birth, but as he grew older, his muscular weakness increased. Physical examination reveals the wasting of muscles of the dorsal forearm and the anterior compartment of the lower legs. Thenar and hypothenar eminences are also flattened. However, deep tendon reflexes are 2+ bilaterally. His face has an atypical appearance with thin cheeks and temporal wasting. When he was asked to make a tight fist and open his hands quickly, he could not open them immediately, and relaxation of the contracted muscles was very slow. The pediatrician suspects genetic muscular dystrophy. Which of the following is the trinucleotide repeat linked to this patient’s most likely condition?

Answer: CTG

A. CTG

B. CGG

C. GAA

D. CGT


Question: A 36-year-old woman presents to her primary care physician for her yearly physical exam. She says that she has been experiencing some mild shortness of breath, but otherwise has no medical complaints. Her past medical history is significant for allergies and asthma as a child, but she is not currently taking any medications or supplements. She does not smoke and drinks about 2 glasses of wine per week as a social activity. On physical exam she is asked to take deep breaths during cardiac auscultation. The physician notices that the splitting of S2 decreases during inspiration. Which of the following is most consistent with this physical exam finding?

Answer: Left bundle branch block

A. Asthma recurrence

B. Atrial septal defect

C. Left bundle branch block

D. Pulmonary stenosis


Question: A 47-year-old woman presents to the emergency department with calf pain and swelling that has persisted for the past 24 hours. She recently had an elective cholecystectomy performed 3 days ago that was complicated intraoperatively by bleeding requiring a transfusion of 1 unit of packed red blood cells. The patient is otherwise healthy, and her vitals are within normal limits. Physical exam is notable for an enlarged and tender right calf. Ultrasound with doppler reveals non-compressible veins of the affected leg. Which of the following is appropriate initial management of this patient?

Answer: Heparin

A. CT angiogram of the chest

B. Heparin

C. Inferior vena cava filter

D. Warfarin


Question: A 24-year-old primigravida is admitted to the hospital at 36 weeks gestation with a headache and blurred vision. The vital signs are as follows: blood pressure, 170/95 mm Hg; heart rate, 88/min; respiratory rate, 15/min; and temperature, 36.6℃ (97.9℉). The physical examination is significant for pitting edema of the lower extremity. Meningeal signs are negative. The ophthalmoscopic exam shows vascular narrowing and a cotton-like fundal exudate. The dipstick test shows 1+ proteinuria. While the blood is being drawn, the patient has a generalized tonic-clonic seizure. Which of the following options describe the most likely mechanism underlying the patient’s seizure?

Answer: Failure of cerebral vasoregulation

A. Increase in the extracellular sodium concentration

B. Failure of cerebral vasoregulation

C. Inhibition of brain GABA-signaling

D. Increased activation of NMDA receptors


Question: A 12-month-old girl is brought in by her mother to the pediatrician for the first time since her 6-month checkup. The mother states that her daughter had been doing fine, but the parents are now concerned that their daughter is still not able to stand up or speak. On exam, the patient has a temperature of 98.5°F (36.9°C), pulse is 96/min, respirations are 20/min, and blood pressure is 100/80 mmHg. The child appears to have difficulty supporting herself while sitting. The patient has no other abnormal physical findings. She plays by herself and is making babbling noises but does not respond to her own name. She appears to have some purposeless motions. A previous clinic note documents typical development at her 6-month visit and mentioned that the patient was sitting unsupported at that time. Which of the following is the most likely diagnosis?

Answer: Rett syndrome

A. Language disorder

B. Rett syndrome

C. Fragile X syndrome

D. Trisomy 21


Question: A 55-year-old man comes to the emergency department because of cramps and left-sided flank pain, nausea, and urinary frequency for 3 hours. He has no history of serious illness and takes no medications. He drinks 2–3 alcoholic beverages daily. His temperature is 37.2°C (99.0°F), pulse is 107/min, and blood pressure is 145/80 mm Hg. Examination of the back shows left costovertebral angle tenderness. An x-ray of the abdomen shows no abnormalities. Abdominal ultrasound shows a 4-mm stone in the distal left ureter and a scatter of small stones in the left renal pelvis. Urinalysis shows RBCs and needle-shaped crystals, but no WBCs. Pain medication and intravenous fluids are administered. In addition to adequate hydration, the patient is most likely to benefit from which of the following?

Answer: Potassium citrate

A. Probenecid

B. Potassium citrate

C. High-protein diet

D. Hydrochlorothiazide


Question: A 4-year-old boy is brought to the physician because of a 1-month history of generalized fatigue. During the past week, he has also had fever and severe leg pain that keeps him awake at night. Examination shows cervical and axillary lymphadenopathy. His liver is palpated 4 cm below the right costal margin and the spleen is palpated 3 cm below the left costal margin. His hemoglobin concentration is 10.2 g/dL, leukocyte count is 64,500/mm3, and platelet count is 29,000/mm3. A bone marrow aspirate predominantly shows immature cells that stain positive for CD10, CD19, and TdT. Which of the following is the most likely diagnosis?

Answer: Acute lymphoblastic leukemia

A. Idiopathic thrombocytopenic purpura

B. Acute myeloid leukemia

C. Acute lymphoblastic leukemia

D. Hodgkin lymphoma


Question: A 41-year-old man comes to the physician because of a 10-day history of generalized weakness. He has also had headaches and night sweats and is a known user of illicit intravenous drugs. His temperature is 39.1°C (102.4°F), pulse is 110/min, respirations are 17/min, and blood pressure is 127/78 mm Hg. There are several track marks on his forearms. A holosystolic murmur that increases on inspiration is heard along the left sternal border. Laboratory studies show a leukocyte count of 13,900/mm3 and an erythrocyte sedimentation rate of 58 mm/h. Which of the following is the most likely consequence of this patient's condition?

Answer: Pulmonary embolism

A. Hematuria

B. Rupture of nail-bed capillaries

C. Pulmonary embolism

D. Painful nodules on pads of the fingers


Question: A 17-year-old girl presents to the emergency department with a painful rash on her head. She says that she started noticing a rash 2 weeks ago that has gotten worse over time. In addition, she says that she has been very thirsty over the same time period and often needs to urgently use the restroom during the day, which has been disrupting her ability to pay attention in school. Otherwise she says that she has some headaches, but attributes this to migraines that run in her family. She does not take any medications, doesn't smoke, and drinks socially with her friends. On physical exam, a disfiguring red scalp rash is observed and radiographs reveal lytic appearing skull lesions. Further examination and testing would most likely reveal which of the following findings in this patient?

Answer: Granules with tennis racket shape on electron microscopy

A. Anti-nuclear antibodies on serology

B. Granules with tennis racket shape on electron microscopy

C. HLA-B27 gene variant on genetic testing

D. Noncaseating granulomas with multinucleated giant cells on histology


Question: A 57-year-old man presents to the emergency department with a change in his mental status. His wife noticed he was particularly somnolent this evening which prompted her to bring him in. The patient has a past medical history of congestive heart failure, diabetes, and hypertension. His temperature is 99.5°F (37.5°C), blood pressure is 97/58 mmHg, pulse is 40/min, respirations are 17/min, and oxygen saturation is 95% on room air. A fingerstick blood glucose is notable for a value of 47 mg/dL. Which of the following is the best treatment for this patient?

Answer: Glucagon

A. Calcium chloride

B. Dextrose

C. Glucagon

D. Transcutaneous pacing


Question: A 16-year-old boy comes to his primary care clinic for a sports physical. He states that he wants to try out for his high school’s football team this year. He's "trying to get in better shape.” The patient has no complaints except for occasional headaches when he is stressed about exams. The patient also mentions that he is embarrassed of his “small penis” and asks if there is something he can take for that. The patient’s temperature is 98°F (36.7°C), blood pressure is 118/76 mmHg, and pulse is 79/min. On physical examination, the patient is obese and has no visible facial hair. His testes are less than 20 mL in volume, and his phallus measures less than 8 cm. Initial labs show testosterone levels of 95 ng/dL and a low follicle stimulating hormone/luteinizing hormone ratio. Which of the following is the next best diagnostic step?

Answer: Thyroid-stimulating hormone and prolactin levels

A. Adrenocorticotrophic hormone stimulation test

B. Semen analysis

C. Spectral karyotype

D. Thyroid-stimulating hormone and prolactin levels


Question: A 72-year-old man presents to the hospital with retrosternal chest pain and shortness of breath. The pain started 5 hours prior to arrival and has not changed after sublingual nitroglycerin intake. The patient has a history of long-standing persistent atrial fibrillation but had not been taking anticoagulants at the time of presentation. He had also been diagnosed with iron-deficiency anemia 3 months before admission and is taking 120 mg of elemental iron daily. He has no history of ischemic heart disease. Clinical investigation confirms inferior ST-elevation myocardial infarction with occlusion of the right coronary artery. The patient is managed with percutaneous coronary intervention (PCI). Six hours after the PCI, the patient develops cardiogenic shock; 8 hours after presentation, he dies, despite intensive care management. The autopsy reveals widespread inferior-posterior myocardial infarction and thrombotic occlusion of the left circumflex artery. The microscopic image depicts a macroscopically intact myocardium. Which of the following statements regarding this patient’s myocardial tissue is true?

Answer: This slide shows changes in the myocardial tissue that result from lipid peroxidation during the patient's lifetime.

A. This slide shows changes in the myocardial tissue that result from lipid peroxidation during the patient's lifetime.

B. The changes shown on this slide are a result of iron overload.

C. The slide shows cardiac steatosis.

D. The microscopic image reveals cardiac tissue hypertrophy.


Question: A 3-year-old boy is brought in by his parents for placement of a tracheostomy tube in order to allow for better ventilator support of his breathing. At birth, he was flaccid with a poor sucking reflex. Since then, his weakness has progressively worsened such that he is unable to sit, eat, or breathe independently. Family history reveals that his grandfather was affected by a degenerative disorder at age 50, and his father had the same degenerative disorder at age 30. Examination is significant for tongue fasciculations and absent deep tendon reflexes. Which of the following forms of inheritance is associated with the most likely cause of this patient's disorder?

Answer: Autosomal recessive on chromosome 5

A. Autosomal dominant on chromosome 19

B. Autosomal recessive on chromosome 5

C. Autosomal recessive on chromosome 9

D. X-linked dominant


Question: A 73-year-old man is brought to the emergency department 30 minutes after the sudden onset of right-sided body weakness. His wife reports that he does not seem to understand simple questions. He has type 2 diabetes mellitus and has smoked 1 pack of cigarettes daily for 45 years. The patient speaks fluently, but he answers questions with nonsensical phrases and cannot repeat single words. Which of the following is the most likely diagnosis?

Answer: Wernicke aphasia

A. Conduction aphasia

B. Global aphasia

C. Wernicke aphasia

D. Transcortical sensory aphasia


Question: A 23-year-old woman comes to physician for an annual health maintenance examination. She feels well. She is 155 cm (5 ft 1 in) tall and weighs 79 kg (174 lb); BMI is 33 kg/m2. Examination shows a skin rash over both axillae. A photograph of her left axilla is shown. This patient's skin finding is most likely associated with which of the following conditions?

Answer: Polycystic ovarian syndrome

A. Niacin deficiency

B. Primary adrenal insufficiency

C. Polycystic ovarian syndrome

D. Hashimoto thyroiditis


Question: A 72-year-old female is brought in by ambulance after being found down in her home. Her daughter discovered her after returning from work and does not know how long she has been down. Physical exam reveals right sided paralysis with a positive babinski sign. She is also found to produce strained stuttering speech with no perceivable meaning. She is unable to follow any instructions and cannot repeat speech. An MRI is obtained showing a left MCA infarct. Damage to which of the following structures is most likely to be responsible for her language deficits?

Answer: Arcuate fasciculus + Inferior frontal gyrus + superior temporal gyrus

A. Arcuate fasciculus

B. Inferior frontal gyrus

C. Inferior frontal gyrus + superior temporal gyrus

D. Arcuate fasciculus + Inferior frontal gyrus + superior temporal gyrus


Question: A 66-year-old male with a history of diabetes and knee osteoarthritis presents to his primary care provider in July complaining of headaches and blurry vision. He reports a 6-month history of occasional dull diffuse headaches and blurry vision. He notes that the episodes have increased in severity since the weather got warmer and that he occasionally feels extremely itchy when he spends time outdoors. The patient lives in southern Arizona. Moreover, he has felt chronically fatigued and has lost 10 pounds without dieting or changing his appetite. He currently takes metformin and his most recent hemoglobin A1c was 6.5%. Physical examination reveals multiple bruises on the bilateral upper and lower extremities and hepatosplenomegaly. Fundoscopic examination demonstrates enlarged retinal veins. Multiple laboratory tests are pending. At steady state, which of the following sets of findings is most likely in this patient?

Answer: Increased plasma volume, increased RBC mass, decreased EPO, normal SaO2

A. Increased plasma volume, increased RBC mass, decreased EPO, normal SaO2

B. Normal plasma volume, increased RBC mass, increased EPO, normal SaO2

C. Decreased plasma volume, normal RBC mass, normal EPO, normal SaO2

D. Increased plasma volume, decreased RBC mass, decreased EPO, normal SaO2


Question: A 25-year-old woman is brought to the emergency department for the evaluation of severe abdominal pain for the last hour. Abdominal ultrasound shows a non-compressible and enlarged appendix. The patient is diagnosed with acute appendicitis. While obtaining informed consent from the patient for appendectomy, the patient reports that she does not want to undergo surgery because she does not trust doctors. She states that all doctors are “bad” and all they think about is money. She adds that she thinks that nurses are “angels” and that they should take care of her instead of the “arrogant” doctors. This patient's behavior is characteristic of a condition that is most typically associated with which of the following?

Answer: Self-injurious behavior

A. Repeated performance of certain routines

B. Substance use disorder

C. Fear of social situations

D. Self-injurious behavior


Question: A 20-year-old woman presents with persistent sadness for the last 2 months. She says that she is always feeling tired and nothing seems to cheer her up. Although previously a top student at her college, she did not register for classes this term, because she does not feel like going to school anymore. She says her friends complain that she does not want to ‘hang out’ with them anymore. She is sleeping more than usual and often does not want to leave the bed in the morning. The patient denies any suicidal ideation or preoccupation with death. Her past medical history is unremarkable. She currently takes a daily multivitamin. The vital signs include pulse 64/min, respiratory rate 12/min, blood pressure 110/70 mm Hg, and temperature 36.9°C (98.5°F). Her body mass index (BMI) is 17.5 kg/m2. On physical examination, the patient is pale. Mucous membranes and oral cavity are dry with poor dentition. Multiple calluses are present on the knuckles of her left hand. Which of the following medications is the best course of treatment in this patient?

Answer: Mirtazapine

A. Mirtazapine

B. Lorazepam

C. Bupropion

D. Amitriptyline


Question: A 31-year-old man presents to the clinic with complaints of sudden onset of fever, headache, chills, and a painful “bump” in his right groin. He recently spent three months working as a park ranger in New Mexico. His physical exam is notable for an enlarged lymph node in the inguinal region that is extremely tender to palpation. The patient is promptly treated with antibiotics, and his case is reported to the Centers for Disease Control and Prevention. Which of the following was the most likely vector that transmitted the disease to this for patient?

Answer: Flea

A. Armadillo

B. Flea

C. Rat

D. Tick


Question: As the only full-time inpatient endocrinologist at your hospital, you have been tasked with deciding which blood glucose measuring device to use on the wards. A medical device representative presents you with the data in Image A. All readings were performed on the same individual whose blood glucose was known to be 125 mg/dL at the time. Which of the devices has the best precision?

Answer: Device D

A. Device B

B. Device C

C. Device D

D. Not enough information provided


Question: A 21-year-old male comes to the physician’s office with complaints of fatigue. The patient is a college intramural athlete and has noticed that during hard workouts with his team, he gets severe muscle pain and weakness to the point where he has to stop and rest. Usually he is able to recover and the cramps subside after rest. After strenuous workouts he has also noticed that his urine is dark. On exam, the patient has no acute symptoms and appears to be sitting comfortably with a completely normal exam. The patient does not have any tenderness to palpation of his muscles. Which of the following enzymes is most likely defective in this patient?

Answer: Glycogen phosphorylase

A. Glucose-6-phosphatase

B. Debranching enzyme

C. Glycogen phosphorylase

D. Acid maltase


Question: A 78-year-old man comes to the physician because of a 3-week history of dyspnea, chest pain, dry cough, painful swallowing, and a feeling of fullness in his head. The symptoms were initially mild but have progressively worsened. He has a history of gastroesophageal reflux disease treated with esomeprazole. He does not smoke cigarettes. His pulse is 99/min and blood pressure is 95/66 mm Hg. Examination shows swelling and redness of the face and neck. There is distention of the superficial veins of his neck and upper thorax. Plain radiographs of the chest show a widened mediastinum and unremarkable lung fields. Which of the following is the most likely underlying cause of this patient's symptoms?

Answer: Mediastinal lymphoma

A. Pancoast tumor

B. Constrictive pericarditis

C. Descending aortic aneurysm

D. Mediastinal lymphoma


Question: A 52-year-old man is brought to the emergency department 30 minutes after his farmhand found him on the ground sweating profusely. On arrival, he is lethargic and unable to provide any history. His temperature is 37.5°C (99.5°F), pulse is 42/min, and blood pressure is 95/60 mm Hg. Physical examination shows diaphoresis and excessive salivation. The pupils are constricted. There is scattered expiratory wheezing throughout both lung fields. His clothes are soaked with vomit, urine, and feces. A drug with which of the following mechanisms of action is most appropriate for this patient?

Answer: Muscarinic acetylcholine receptor antagonism

A. Non-selective α adrenergic receptor antagonism

B. β2 adrenergic receptor agonism

C. Muscarinic acetylcholine receptor antagonism

D. Nicotinic acetylcholine receptor agonism


Question: A 40-year-old woman is admitted to the hospital about four hours after her husband discovered that she ingested a bottle of acetaminophen in an attempted suicide. The patient denies any symptoms at this time. Vital signs include a blood pressure of 115/80 mmHg and pulse of 85/min. Physical exam is unremarkable. AST and ALT levels are approximately 2500 U/L. APAP level is 160 mcg/mL, and INR is 1.7. The patient refuses N-acetyl-cysteine (NAC) treatment. What is the best next step in management?

Answer: Involve the patient's husband to guide medical care

A. Administer NAC

B. Cancel the NAC order

C. Involve the patient's husband to guide medical care

D. Force the patient to accept NAC


Question: An 11-month-old baby boy is brought to the emergency room by his parents for vomiting. His mom reports that he has had a cold for the past week with a runny nose and low-grade fevers. However, his condition worsened today when he began coughing and struggling to breathe. During one of his coughing spells he threw up his milk as well. The parents deny any sick contacts, changes in diet, or bowel changes but endorse fatigue and decreased appetite. A physical examination demonstrates a healthy-looking baby with an intense cough and significant inspiratory stridor. What is the pathophysiology of this patient’s condition?

Answer: Toxin that inactivates Gi protein

A. Generation of reactive oxygen species

B. Production of IgA proteases

C. Toxin that inactivates Gi protein

D. Toxin that permanently activates Gs protein


Question: A 56-year-old male undergoes a pancreaticoduodenectomy for resection of a tumor of the head of the pancreas. His medical history is otherwise insignificant except for a series of minor respiratory and gastrointestinal infections since childhood that were effectively treated with antibiotics. Before today, he has not had any prior surgeries or required a blood transfusion. In the post anesthesia care unit, his hemoglobin is measured and found to be 5.2 g/dL. A transfusion of 2 units of packed red blood cells is ordered. Minutes after the transfusion is initiated, the patient reports severe itching, nausea, and shortness of breath. His vital signs show a drop in blood pressure from 138/88 to 92/47 and an increase in heart rate from 94 to 118. The patient's nurse stops the transfusion immediately. Which of the following underlying conditions most likely predisposed this patient to develop this reaction?

Answer: Selective IgA deficiency

A. Severe combined immunodeficiency disorder

B. Bruton's agammaglobulilnemia

C. Wiskott-Aldrich syndrome

D. Selective IgA deficiency


Question: A 5-year-old girl is brought to the emergency department after sustaining an atraumatic tibial fracture while playing with her friends. This patient has a history of fractures in her upper and lower extremities. Children's services have investigated the family several times in the past and found no abuse. She was born at 39 weeks gestation via spontaneous vaginal delivery which resulted in several mild fractures. She is up to date on all vaccines and is meeting all developmental milestones. The mother has a brother with a similar history that is still living. Her vital signs show a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F). Physical exam reveals a regular heart rate, and her lungs are clear to auscultation bilaterally. The sclera of both eyes are blue. Additionally, her teeth are brown and distorted. Her leg is swollen, erythematous, and tender to palpation. An X-ray reveals a tibia fracture, while multiple fractures at various stages of healing are also seen on her arms. The physician suspects this is a genetic condition. Which of the inheritance patterns can be attributed to the girl’s condition?

Answer: Locus heterogeneity

A. Pleiotropy

B. Anticipation

C. Locus heterogeneity

D. De novo mutation


Question: A 72-year-old woman presents to her primary care physician because she is coughing pink sputum and has difficulty breathing. She says that she was feeling pretty good until she traveled to her grandson's wedding last week. Since then she has had increasing difficulty sleeping and walking due to her shortness of breath. Physical exam reveals swollen ankles, basilar crackles bilaterally, and a murmur best heard in the left lateral decubitus position. She is already taking several medications for this condition; however, given the recent worsening of symptoms she is started on an additional medication. Which of the following is the most likely mechanism of action for the medication that was started in this patient?

Answer: Inhibition of Na-K-Cl cotransporter

A. Competitive inhibition of hormonal signaling

B. Decrease in adenylyl cyclase activity

C. Inhibition of Na-Cl symporter

D. Inhibition of Na-K-Cl cotransporter


Question: A 37-year-old woman is brought to the emergency department for acute abdominal pain for the past 2 hours. She reports that the pain is constant, 10/10, and is diffusely spread across her stomach. She reports nausea and 1 episode of vomiting 1 hour ago, painless bloody urine, and paresthesias in her hands bilaterally. The patient claims similar episodes in the past following the use of alcohol, though with milder pain. Her past medical history is significant for pelvic inflammatory disease that was adequately treated 5 years ago. She is currently sexually active with her husband without contraceptive use. Her temperature is 98.6°F (37°C), blood pressure is 148/98 mmHg, pulse is 103/min, respirations are 18/min, and oxygen saturation is 99% on room air. A physical examination demonstrates a patient in acute distress with diffuse abdominal tenderness and decreased sensation of the hands bilaterally. What is the most likely explanation for this patient’s symptoms?

Answer: Mutation of the porphobilinogen deaminase enzyme

A. Implantation of the embryo outside of the uterus

B. Inflammation of the appendix

C. Mutation of the porphobilinogen deaminase enzyme

D. Obstruction of the cystic duct and subsequent inflammation of the gallbladder


Question: A medical research study is being conducted to evaluate the specificity of a novel blood test for rheumatoid arthritis. Of the 300 patients enrolled, half are diagnosed with RA. The remaining patients are age-matched controls. In the subgroup of patients with RA, 125 are found positive for the novel blood test. In the control group, 45 are found positive. Which of the following represents the overall specificity of this novel test?

Answer: 105 / (105 + 45)

A. 105 / (105 + 25)

B. 125 / (125 + 105)

C. 105 / (105 + 45)

D. 125 / (125 + 25)


Question: A 58-year-old man comes to the emergency department because of multiple episodes of coughing up blood over the past 2 hours. He says that he has coughed up approximately half a cup of bright-red blood each time. He has had progressively worsening shortness of breath on exertion and a productive cough with occasionally blood-tinged sputum for the past 6 months. He has a history of hypertension and chronic obstructive pulmonary disease. He has worked in a car manufacturing company for over 20 years. He drinks 2 to 3 beers every evening. He has smoked 1 pack of cigarettes daily for the past 30 years. His medications include amlodipine, tiotropium, and an albuterol inhaler as needed. His temperature is 37.2 °C (99.0 °F), blood pressure is 102/68 mm Hg, pulse is 108/min, and respirations are 22/min. Pulse oximetry on room air shows an oxygen saturation of 89%. He appears anxious and cachectic. Examination of the lung shows decreased breath sounds bilaterally. There is no cervical or axillary lymphadenopathy. His hemoglobin is 11.5 g/dL, leukocyte count is 8,800/mm3, and a platelet count is 160,000/mm3. His coagulation parameters are within normal limits. Serum studies and urine analysis show no abnormalities. He is intubated and mechanically ventilated, and infusion of 0.9% saline is begun. An x-ray of the chest shows hyperinflation of the lung fields and a 2-cm nodule in the right lower lobe. In addition to placing the patient in the right lateral decubitus position, which of the following is the most appropriate next step in management?

Answer: Bronchoscopy

A. Radionuclide scan

B. Upper endoscopy

C. Arteriography

D. Bronchoscopy


Question: A previously healthy 3-year-old girl is brought to the physician because she refuses to use her left arm after “tripping over a stone” that morning on the way to the supermarket while holding her mother's hand. She did not hit the ground. Development has been normal for her age. She appears anxious. Her vital signs are within normal limits. The left forearm is held close to her body in partial extension and pronation. There is no swelling or bruising of the elbow or the forearm. Palpation of the proximal radius produces pain. The child cries on attempting to passively supinate the forearm. Which of the following is the most appropriate next step for the physician?

Answer: Forced hyperpronation of the arm

A. Administer ibuprofen and ice packs

B. Forced hyperpronation of the arm

C. Notify child protective services

D.
Perform nerve conduction studies and electromyography
"


Question: A previously healthy 29-year-old woman comes to the physician because of a 3-day history of low-grade fever, muscle aches, and a rash. She has had 4 male sexual partners over the past year and uses condoms inconsistently. Examination shows a diffuse maculopapular rash that includes the palms and soles. Testing for nonspecific anticardiolipin antibodies is positive. Which of the following is the most appropriate next step in management?

Answer: Test for fluorescent treponemal antibody absorption

A. Assess for double-stranded DNA antibodies

B. Administer penicillin G

C. Analyze rash with darkfield microscopy

D. Test for fluorescent treponemal antibody absorption


Question: A 59-year-old man with New York Heart Association Class II heart failure presents to your outpatient clinic for routine follow-up. His blood pressure is 134/89 mm Hg and heart rate is 75/min. Physical examination reveals clear lung sounds bilaterally with normal S1 and S2 heart sounds. He currently takes captopril, bisoprolol, and furosemide. You would like to add on spironolactone. Of the following, which is true regarding aldosterone antagonists in patients with heart failure?

Answer: Aldosterone antagonists decrease morbidity and mortality in heart failure patients

A. Aldosterone antagonists do not require renal dosing

B. Aldosterone antagonists are indicated for patients in all stages of heart failure

C. Aldosterone antagonists decrease morbidity and mortality in heart failure patients

D. Aldosterone antagonists can cause visual disturbances


Question: A 32-year-old man comes to the physician because of a 1-week history of fever, nausea, headache, and confusion. Three weeks ago, he had an episode of a sore throat, diarrhea, and generalized lymphadenopathy. He is sexually active with a new partner that he met 2 months ago and they use condoms inconsistently. He appears ill. Physical examination shows nuchal rigidity. Further evaluation shows infection with a single-stranded, positive-sense RNA virus. The cells most likely affected in this patient’s current condition are analogous to which of the following cell types?

Answer: Langerhans cells

A. Osteoblasts

B. Mast cells

C. Schwann cells

D. Langerhans cells


Question: A 64-year-old man presents for a routine physical. He states that he has felt abnormally weak during this time and has had trouble focusing in the setting of losing 5 pounds. The patient states he has a decreased appetite and also has not had a bowel movement in the past 5 days and feels uncomfortable. On review of system, he endorses abdominal pain. His temperature is 97.5°F (36.4°C), blood pressure is 132/83 mmHg, pulse is 115/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable only for the patient being able to recall 1 of 3 objects. His cranial nerve exam is unremarkable and his gait is stable. Urinalysis is initially notable for a clear and voluminous sample with a low specific gravity. Which of the following tests is most likely abnormal in this patient?

Answer: Calcium level

A. Calcium level

B. Lead level

C. Potassium level

D. TSH level


Question:
Ten days after a motor vehicle collision, a 28-year-old man develops jaundiced skin. Upon initial presentation for his injuries, the patient was taken for an emergency laparotomy, which revealed significant internal hemorrhage from blunt abdominal trauma to the spleen. He required rapid transfusion with a total of 7 units of packed red blood cells. He has recovered well from the procedure until this morning, when he began to develop jaundiced skin and sclerae. He does not have pruritus. He has had no prior surgeries and takes no other medications. He is sexually active with one female partner. Prior to the accident, he drank 4 beers per day. His vital signs are within normal limits. Abdominal examination is limited due to pain. There are no palpable abdominal masses. There is a midline surgical scar with no erythema, purulence, or drainage. He has healing abrasions on the upper left side of his face and bruises over the anterior abdomen. CT scans show a resolving hematoma in the peritoneal cavity. Laboratory studies show:
Hemoglobin 9.7 g/dL
Hematocrit 30%
Leukocyte count 7,000/mm3
Platelet count 135,000/mm3
Serum
Total bilirubin 3.9 mg/dL
Indirect bilirubin 3.7 mg/dL
Direct bilirubin 0.2 mg/dL
Aspartate aminotransferase (AST) 60 U/L
Alanine aminotransferase (ALT) 92 U/L
Which of the following is the most likely cause of this patient's jaundice?"

Answer: Increased formation of bilirubin

A. Biliary obstruction

B. Hepatocellular injury

C. Increased formation of bilirubin

D.
Decreased hepatic uptake of unconjugated bilirubin
"


Question: A 69-year-old man comes to the physician because of a cough for the past 3 months. The cough is mostly dry, but the patient recalls a recent episode in which he coughed up mucus with dark red streaks. He has felt tired for the past few months. Over the past month, he has had poor appetite and a 5-kg (11-lb) weight loss. He also has occasional back pain, which has worsened in recent weeks. He has no recent travel history. He has smoked a pack of cigarettes daily for 30 years. He does not drink alcohol. His vitals are within normal limits. Auscultation of the lungs reveals wheezing in the lower right lung field. There is no peripheral lymphadenopathy. The liver is of normal size, and the spleen is not palpable. Laboratory studies show a hemoglobin concentration of 13.5 g/dL, serum calcium concentration of 12.3 mg/dL, and a total serum protein of 7.0 g/dL. X-rays of the chest are shown. Which of the following is the most likely diagnosis?

Answer:
Squamous cell lung carcinoma
"

A. Tuberculosis

B. Lobar pneumonia

C. Small cell lung carcinoma

D.
Squamous cell lung carcinoma
"


Question: A 37-year-old man comes to the physician because of a 3-month history of worsening painful swallowing, hoarseness, and bilateral otalgia. He has had a 10-kg (22-lb) weight loss during this period. He does not smoke or drink alcohol. Laryngoscopic examination shows an abnormal mass located on the right true vocal cord. Immunohistochemistry of the mass shows expression of HPV-16 DNA. This neoplasm most likely derived from which of the following types of epithelial tissue?

Answer: Stratified squamous epithelium with submucosal glands

A. Stratified squamous epithelium with submucosal glands

B. Simple columnar epithelium with cilia

C. Pseudostratified columnar epithelium with cilia

D. Pseudostratified columnar epithelium with cartilage


Question: An investigator is studying patients with an autosomal dominant mutation in the long arm of chromosome 10. This mutation alters the structure of CD95 receptors and impairs the binding of a ligand to this receptor. These patients are at greatest risk for which of the following complications?

Answer: Autoimmune cytopenia

A. Partial albinism

B. Autoimmune cytopenia

C. Acute myeloid leukemia

D. Diabetes mellitus


Question: An investigator is studying cardiovascular changes during exercise. He is following a 25-year-old female volunteer who is training for a marathon. Her training consists of running on a treadmill for increasing amounts of time. During her training sessions, laboratory studies show increased concentrations of adenosine and lactate in the active muscles. Which of the following is most likely a direct effect of these metabolites?

Answer: Decreased systemic vascular resistance

A. Decreased capillary pressure

B. Decreased systemic vascular resistance

C. Increased venous return

D. Increased mixed venous oxygen saturation


Question: A previously healthy 16-year-old girl is brought to the physician by her parents because of behavior changes and involuntary limb movements over the past 2 days. She also has a 2-week history of fever, headache, and fatigue. Her temperature is 38°C (100.4°F), pulse is 110/min, respirations are 20/min, and blood pressure is 102/72 mm Hg. Mental status examination shows impaired speech and a disorganized thought process. Muscle strength is 5/5 in all extremities. Urine toxicology screening is negative. Cerebrospinal fluid analysis shows a leukocyte count of 70 cells/mm3 (90% lymphocytes) and a protein concentration of 51 mg/dL. Abdominal ultrasound shows a large right adnexal mass. The patient's symptoms are most likely caused by antibodies against which of the following?

Answer: Glutamate receptors

A. Purkinje cell Yo antigens

B. GM1 ganglioside

C. Neuronal Hu antigens

D. Glutamate receptors


Question: A 7-year-old boy is brought to the physician by his mother because of low-grade fevers and a cough lasting for 2 weeks. He has vomited several times after fits of coughing. He has no history of serious illness and has not received any routine childhood vaccinations. His temperature is 38.3°C (101°F). Physical examination shows erythema of the nasal and oral mucosa. While in the exam room, he has a long series of consecutive coughs, during which he appears diaphoretic. The coughing is followed by a loud inspiratory gasp. Laboratory studies show a leukocyte count of 16,300/mm3 (67% lymphocytes). The pathogen most likely responsible for this patient's presentation contains a toxin that acts by which of the following mechanisms?

Answer: Increases intracellular cAMP

A. Increases intracellular cAMP

B. Increases intracellular cGMP

C. Inactivates host elongation factor

D. Inactivates host 60S ribosome


Question: A 21-year-old college student is rushed to the ER because of a high-grade fever that started this morning. She vomited several times last night. She is complaining of a severe, unremitting headache. Her temperature is 38.9°C (102.0°F), respiratory rate is 20/min, pulse is 112/min, and blood pressure is 105/78 mm Hg. She is highly sensitive to light. Her neck feels stiff on passive flexion, with positive Kernig’s and Brudzinski’s signs. There is a non-blanching maculopapular rash all over the body. Cerebrospinal fluid (CSF) samples are sent to the lab for analysis and she is started on intravenous fluids and antibiotics. The CSF analysis will most likely reveal which of the following?

Answer: Polymorphonuclear leukocytosis

A. Eosinophils

B. Decreased protein concentration

C. Lymphocytosis

D. Polymorphonuclear leukocytosis