Question: A 55-year-old man presents to his primary care physician with ear pain. The patient states he has had worsening ear pain for the past 2 days. He describes his pain as 9/10. The patient has a past medical history of diabetes, obesity, and hypertension. His current medications include insulin, metformin, lisinopril, aspirin, and atorvastatin. His temperature is 100.5°F (38.1°C), blood pressure is 177/99 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam reveals a purulent drainage from the ear canal. Manipulation of the ear causes severe pain. Which of the following is the most likely infectious agent?

Answer: Pseudomonas aeruginosa

A. Haemophilus influenzae

B. Moraxella catarrhalis

C. Pseudomonas aeruginosa

D. Staphylococcus aureus


Question:
A 19-year-old male college student with no significant medical history presents to the emergency department with altered mental status. His girlfriend said that he drank multiple shots of vodka and gin throughout the weekend and was found slumped on the couch with some vomit on his shirt. He is afebrile, with a blood pressure of 128/60 mmHg, pulse of 100/min, respirations at 25/min, and SpO2 of 95% on room air. His pupils are equal and reactive to light bilaterally. He exhibits no tremors or myoclonus. The remainder of the physical exam is unremarkable. His basic metabolic panel is displayed below:

Serum:
Na+: 138 mEq/L
Cl-: 90 mEq/L
K+: 4.0 mEq/L
HCO3-: 20 mEq/L
BUN: 30 mg/dL
Glucose: 100 mg/dL
Creatinine: 0.8 mg/dL

An arterial blood gas reveals the following:

pH: 7.32
pCO2: 34 mmHg
pO2: 89 mmHg

The girlfriend is concerned that the patient's breathing appears uncomfortable. How do you respond?

Answer: His breathing suggests that he needs some fluids

A. His breathing is concerning for hepatic encephalopathy

B. His breathing suggests that he needs some fluids

C. His breathing suggests that he has major depression disorder

D. You are not his healthcare proxy and I cannot speak to you


Question: A 56-year-old man presents to his primary care provider for a check-up. His past medical history is significant for type 2 diabetes mellitus for 20 years and insomnia.  He takes metformin and insulin NPH. Both of his parents died in a car accident several years ago. He smokes a half of a pack of cigarettes every day and drinks 1-2 beers a day and more on the weekends. Today, his blood pressure is 130/80 mm Hg, pulse is 76/min, respiratory rate is 18/min, and temperature is 36.5°C (97.7°F). On physical exam, he appears obese. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. A foot exam is performed and is unremarkable. A urinalysis reveals  glucose (++), and protein (+++). Which of the following explains these findings?

Answer: Glomerular hyperfiltration

A. Glomerular hyperfiltration

B. Renal artery stenosis

C. Subendothelial immune-complex deposits

D. Interstitial atrophy


Question: A 64-year-old man comes to the physician because of a 1-month history of progressively worsening back pain that wakes him up at night. He also reports symptoms of urinary urgency and a weak urine stream. He has no history of serious illness and takes no medications. Rectal examination shows an enlarged and hardened prostate with a nodular surface. After further evaluation and confirmation of the diagnosis, he is started on a new drug. Initially, there is an increase in serum testosterone and dihydrotestosterone levels, followed by a sustained decrease in both serum hormone levels. Treatment with which of the following drugs was most likely initiated in this patient?

Answer: Leuprolide

A. Leuprolide

B. Finasteride

C. Ketoconazole

D. Cyproterone acetate


Question: A 46-year-old man presents to a physician three days after arriving in Morocco. He endorses acute onset of painless, profuse watery diarrhea that appears white and cloudy. The patient denies bloody stool, vomiting, or subjective fevers. Vital signs are T 98.6, HR 120, RR 17, and BP 85/50. On physical exam, the patient has dry mouth, decreased skin turgor, and cold clammy skin. His peripheral pulse is rapid and thready. The toxin responsible for this clinical presentation has a mechanism of action that is most similar to which other toxin?

Answer: Edema toxin

A. Diphtheria toxin

B. Exotoxin A

C. Edema toxin

D. Shiga-like toxin


Question: A 25-year-old woman presents to the urgent care center with a one month history of intermittent chest pain that occurs about 2-3 times per week in the early mornings. She does not smoke and has never suffered from chest pain before. She has no family history of early MI. A 12 lead ECG does not show any abnormalities. Creatine kinase and troponin I enzymes are within normal limits. What test will most likely be positive?

Answer: Ergonovine

A. Ergonovine

B. Immediately repeat ECG

C. Exercise stress test

D. Kehr's sign


Question: A 28-year-old man is scheduled for skin grafting of the right leg. Four weeks earlier, he underwent open reduction and internal fixation of an open right tibial fracture. The postoperative period at that time was complicated by necrosis of the overlying skin. In the operating room, he is placed on continuous hemodynamic monitoring and anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace. Thirty minutes later, he has severe shortness of breath and lightheadedness and loses consciousness. His temperature is 37.1°C (98.8°F), pulse is 38/min, respirations are 24/min, and palpable systolic blood pressure is 58 mmHg. The skin is diaphoretic and flushed. He withdraws the upper extremities to painful stimuli above the navel. The lungs are clear to auscultation. Heart sounds are not audible. Which of the following is the most likely underlying cause of this patient's symptoms?

Answer: Loss of sympathetic vascular tone

A. Loss of sympathetic vascular tone

B. Obstructive thrombus in the pulmonary artery

C. Intravascular volume depletion

D. Type I hypersensitivity reaction


Question: A 42-year-old man with no significant medical history presents to the emergency department with complaints of headache, nausea, and dizziness. He states that he was at home working on his car when he started to feel dizzy and experienced a headache. This progressed to him feeling nauseous. The patient states he went inside and drank some water and felt better; however, when he started working on his car again his symptoms returned. Upon presentation, he states his symptoms have mostly improved except for a persistent headache. His temperature is 98.1°F (36.7°C), blood pressure is 125/84 mmHg, pulse is 87/min, respirations are 18/min, and oxygen saturation is 98% on room air. Neurologic exam is unremarkable. Which of the following is the best next step in management?

Answer: 100% oxygen

A. 100% oxygen

B. CT

C. Hydroxocobalamin

D. Ibuprofen and acetaminophen


Question: A 19-year-old woman comes to the physician because of severe headaches for the past 3 months. The headaches are pulsating in nature and she describes the pain as 8 out of 10 in intensity. She has visited the emergency department for headaches twice in the past month; during both visits, her blood pressure was elevated. She has polycystic ovarian disease. Her medications include metformin and an oral contraceptive pill. She is 162 cm (5 ft 4 in) tall and weighs 86 kg (190 lb); BMI is 32.8 kg/m2. Her temperature is 37°C (98.6°F), pulse is 99/min, and blood pressure is 168/98 mm Hg. Examination shows hirsutism. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. An abdominal bruit is heard on the left side. Neurologic examination shows no focal findings. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. Plasma free metanephrines are within the reference range. An abdominal ultrasound shows an increased peak systolic velocity in the distal portion of the left renal artery. A contrast-enhanced CT scan of the abdomen shows alternating stenosis and dilation in an 8-mm distal segment of the left renal artery with approximately 75% reduction in the diameter of the vessel. A CT scan of the brain shows no abnormalities. Which of the following is the most appropriate next step in management?

Answer: Ramipril and percutaneous transluminal angioplasty without stent placement

A. Combination therapy with captopril and valsartan

B. Percutaneous transluminal angioplasty without stent placement

C. Ramipril and percutaneous transluminal angioplasty without stent placement

D. Enalapril and aortorenal bypass with a vein graft


Question: A 28-year-old male is found to have 93% HbA, 2% HbF, and 5% HbA2 on hemoglobin electrophoresis. Which of the following is the most likely diagnosis?

Answer: Beta-thalassemia minor

A. Alpha thalassemia major with Hb Bart's

B. Beta-thalassemia minor

C. Beta-thalassemia major

D. Diabetes mellitus


Question: A 76-year-old female is brought to the emergency department for altered mental status. She is accompanied by a nurse from her nursing home. The nurse says that usually the patient is interactive even though she is sometimes forgetful. In the last two days, the patient has been increasingly lethargic and doesn’t respond to the staff’s questions. She also has not been able to get up and use the restroom so the staff has had to change multiple soiled sheets. Her temperature is 102.1°F (38.9°C), blood pressure is 100/74 mmHg, pulse is 120/min, and respirations are 24/min. The patient is combative on arrival but can be subdued with reorientation by the care team. She is not oriented to person, place, or time. Urinalysis shows positive leukocyte esterase and nitrites. Urine culture grows >100,000 CFU of E. coli. The physician team would like to consent this patient for a Foley catheter. Which of the following is the best assessment of the patient’s capacity to make healthcare decisions?

Answer: Capacity cannot be determined at this time

A. The patient does not have capacity to make decisions

B. The patient does have capacity to make decisions

C. The hospital ethics board should be consulted

D. Capacity cannot be determined at this time


Question: A 19-year-old woman is brought to the emergency department by ambulance 1 hour after a motor vehicle accident. She has no history of serious illness. She is on mechanical ventilation without any sedation. Her vital signs are within a normal range. Her Glasgow Coma Scale (GCS) is 3. Examination by the attending trauma surgeon and neurologist shows brain death. Laboratory studies show no abnormalities. A search on the state donor registry shows that she has registered as an organ donor. Her father is shocked at the suggestion of organ donation and says that “life is still circulating in her body because it is warm, and she has a normal heartbeat!” While the physician empathizes with the family, which of the following is the most appropriate response?

Answer: “Brain death is considered legal death just as if her heart was not beating.”

A. “Only after your consent will her organs be removed.”

B. “Brain death is considered legal death just as if her heart was not beating.”

C. “She is very unlikely to recover.”

D. “She will be dead once she is disconnected from advanced life-support.”


Question: A 58-year-old male has had long-term involvement in the world of organized crime. He very recently retired from his post within this organization. This former mafia boss has now suddenly started making large contributions to several local charities. Which of the following ego defenses best characterizes this gentleman's behavior?

Answer: Altruism

A. Altruism

B. Displacement

C. Sublimation

D. Atonement


Question: A 45-year-old man presents with a chronic productive cough that he has had for the past few years. He admits to having smoked 1 pack of cigarettes a day for the past 25 years. A chest radiograph reveals an enlarged heart. The patient's pulmonary function tests would be similar to that seen in a patient with:

Answer: Emphysema

A. Asymptomatic asthma

B. Silicosis

C. Emphysema

D. Coal worker's pneumonitis


Question: A 69-year-old gentleman presents to his primary care physician for a general checkup. He states that overall he is doing well. Ever since he retired, he has been working on projects at home, and taking time to exercise every day. He eats a balanced diet, and has been spending time with his wife every evening. Despite this, the patient claims that he feels less well rested when he awakes in the morning. The patient states that he used to sleep nine hours a night in his youth and felt excellent. Now he sleeps seven hours a night and doesn’t feel as well rested as he used to. The patient’s wife states that he seems to sleep peacefully. On physical exam the patient’s neurological exam is within normal limits. The patient is muscular and has a healthy weight and has a pleasant demeanor. He denies feeling fatigued or tired currently. Which of the following physiological changes is most likely in this patient?

Answer: Decreased melatonin

A. Decreased orexin

B. Decreased melatonin

C. Increased dopamine

D. Increased acetylcholine


Question: A 7-year-old boy with sickle cell disease is brought into the clinic by his mother for knee and hip pain. The child has been admitted several times in the past for pain crises managed with fluids and hydromorphone. He started complaining of worsening hip pain over the last several days and now walks with a limp. His temperature is 97.9°F (36.6°C), blood pressure is 84/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 99% on room air. On physical exam, the hip appears normal and is cool to the touch. There is decreased range of motion at the hip and pain with ambulation. Which of the following is the most appropriate next step in management?

Answer: Radiograph

A. CT

B. Ibuprofen and acetaminophen

C. MRI

D. Radiograph


Question: A 65-year-old asian man presents to his primary care physician because of abdominal distension, right upper quadrant (RUQ) abdominal pain, decreased appetite, and weight loss for several weeks. He denies smoking or excess alcohol intake. His temperature is 37.1°C (98.7°F), blood pressure is 120/80 mm Hg, and pulse is 85/min. Physical examination reveals a cachectic man with jaundice, palmar erythema, ascites, and a palpable mass in the RUQ. Abdominal ultrasound shows a 3 cm hypoechoic mass in the right lobe of the liver. Alpha fetoprotein (AFP) is 500 μg/L. Which of the following is a risk factor for this patient condition?

Answer: Chronic hepatitis C infection

A. Exposure to nitrosamines

B. Cyclophosphamide use

C. Clonorchis sinensis infection

D. Chronic hepatitis C infection


Question: A 71-year-old man from Puerto Rico presents to the emergency department with a 2-week history of abdominal pain. He does not speak much English so his family explains that he has been complaining of intermittent pain that is not associated with any particular actions. Furthermore, his family is concerned because he has been having weight loss and blood in his stool for 3 months. The physician explains that there is a concern for colon cancer and that a colonoscopy is required to evaluate his condition further. The family is afraid that the news will upset the patient so they ask that they be allowed to make healthcare decisions on the patient's behalf. They explain that this is the way that their culture handles medical decisions. What should the physician do in this situation?

Answer: Call for a Spanish-speaking interpreter to speak with the patient

A. Ask the family to translate the plan for the patient and ask for questions

B. Call for a Spanish-speaking interpreter to speak with the patient

C. Respect the family's cultural wishes and not discuss the plan with the patient

D. Speak directly with the patient in English to ascertain their wishes


Question: A 45-year-old man presents to a physician with recurrent episodes of palpitations over the last 3 months. The episodes are self-limiting but cause significant distress and discomfort to the patient. After a detailed electrophysiological workup, the physician concludes that the symptoms occur mainly due to abnormal function of the cardiac ion channels, which primarily produce the plateau phase of the action potential in cardiac myocytes in healthy patients. Which of the following ion channels is dysfunctional in this patient?

Answer: L-type voltage-gated calcium channels

A. Fast sodium channels

B. L-type voltage-gated calcium channels

C. T-type voltage-gated calcium channels

D. Inward rectifier IK1 channels


Question: A 23-year-old man comes to the physician because of severe daytime sleepiness and random episodes of falling asleep during the day for short periods of time. When he wakes up from these episodes, he feels refreshed. He sleeps 6–7 hours at night. He reports that sometimes he is unable to move for a few minutes when he first wakes up in the morning. Last week, he suddenly “lost control” of his legs and neck for about 30 seconds after his classmate had told him a joke. An analysis of this patient's cerebral spinal fluid is most likely to show which of the following findings?

Answer: Decreased orexin-A

A. Decreased orexin-A

B. Increased neuron-specific enolase

C. Increased 14-3-3 protein

D. Anti-ganglioside antibodies


Question: A 73-year-old man is brought to the emergency department 30 minutes after he lost consciousness for 5 minutes while watching a game of summer league football in a seat from the stands in the afternoon. On arrival, he is lethargic and oriented only to person. Three weeks ago, he was treated for hepatitis A. He has type 2 diabetes mellitus and hypothyroidism. Current medications include metformin and levothyroxine. His temperature is 41.5 °C (106.7 °F), pulse is 106/min, respirations are 26/min, and blood pressure is 128/70 mm Hg. Examination shows hot, dry skin. The pupils are equal and reactive to light. Neurologic examination shows no focal findings. Fundoscopy shows proliferative diabetic retinopathy. Cardiopulmonary examination shows no abnormalities. His abdomen is soft and nontender. There is no costovertebral angle tenderness. His serum glucose concentration is 160 mg/dL. An ECG shows a normal sinus rhythm. Which of the following is the most likely underlying cause of this patient's symptoms?

Answer: Inadequate hypothalamic response

A. Inadequate hypothalamic response

B. Metabolic acidosis with ketosis

C. Elevation of serum thyroxine levels

D. Central dopamine receptor blockade


Question: A 3-year-old boy is brought to the physician for a well-child examination. He feels well. He was born at 38 weeks' gestation and weighed 2766 g (6 lb 2 oz). He now weighs 14 kg (31 lbs). There is no personal or family history of serious illness. His immunizations are up-to-date. He is at 60th percentile for height and 55th percentile for weight. Vital signs are within normal limits. The lungs are clear to auscultation. A grade 3/6 systolic ejection murmur is heard along the upper left sternal border. S2 is widely split and does not vary with respiration. There is a grade 2/6 mid-diastolic murmur along the lower left sternal border. The abdomen is soft and nontender; there is no organomegaly. Which of the following is the most likely diagnosis?

Answer: Atrial septal defect

A. Patent ductus arteriosus

B. Benign heart murmur

C. Atrial septal defect

D. Pulmonary valve stenosis


Question: A 30-year-old man presents to the emergency department after being attacked by 2 men a few minutes ago. He was suddenly approached by 2 men holding knives while he was walking on the street nearby. While trying to escape, he was stabbed once in the neck. He is complaining of difficulty breathing and chest pain. He is in apparent distress. His temperature is 36.8°C (98.2°F), the blood pressure is 100/60 mm Hg, the pulse is 110/min, the respirations are 28/min, and the SaO2 is 85% on 4 L oxygen by nasal cannula. Examination of the neck reveals a deep penetrating injury on the right side and distended neck veins. The respiratory exam shows severe tenderness in the right chest, decreased inspiration in the right lung, and tracheal deviation to the left. What is the next best step in the management of this patient?

Answer: Needle thoracostomy

A. Pericardiocentesis

B. Intravenous fluids

C. Dobutamine

D. Needle thoracostomy


Question: An 8-month-old male presents to your office with a 5-day history of blood in his stool. Abdominal pain is notably absent on history obtained from his parents. Past medical history and physical exam findings are not remarkable. Laboratory findings are significant for mild iron deficiency. Which of the following is characteristic of this patient’s diagnosis?

Answer: Diagnostic studies localize ectopic gastric tissue.

A. It may affect neonates but is more common in adolescents.

B. It is rare, affecting less than 1% of the population.

C. Both males and females are equally affected.

D. Diagnostic studies localize ectopic gastric tissue.


Question: A 19-year-old man is brought to a psychiatrist by his mother. The patient’s mother has become increasingly concerned about him since his high school graduation. Although she says that he had been an excellent student in high school, his grades have begun slipping in his second year in college, and he no longer socializes with friends. When she asked him why he no longer talks to his friends, she states that he told her, “They already know where I am. They can see me. They watch me from my bedroom window, so they already know what I’m doing. We don’t need to talk.” She found this to be bizarre, as nearly all of his friends live hours away. The patient states that he feels fine and doesn’t understand why everyone thinks he is crazy. The psychiatrist notices reduced spontaneous movements while the patient is speaking and that he speaks in a monotone with a voice that is soft in volume. He also appears suspicious and defensive, asking the psychiatrist “why are you asking me that?” after each evaluative question. His mood is generally flat with little reactivity or engagement during the course of his interview, but he denies any symptoms of depression or psychosis. No significant past medical history. Family history is not available as he was adopted. Which of the following is the most likely diagnosis in this patient?

Answer: Schizophrenia

A. Paranoid personality disorder

B. Schizophrenia

C. Drug abuse

D. Brain tumor


Question: A 26-year-old woman comes to the physician because of progressively worsening episodic pelvic pain for 2 years. The pain starts a few days before her menstrual period and lasts about 10 days. She has tried taking ibuprofen, but her symptoms do not improve. Menses have occurred at regular 29-day intervals since menarche at the age of 11 years and last for 5–7 days. The first day of her last menstrual period was 2 weeks ago. She is sexually active with her boyfriend and has noticed that intercourse is often painful; they use condoms inconsistently. Vital signs are within normal limits. Pelvic examination shows a normal vagina and cervix. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses. Urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

Answer: Prescribe estrogen-progestin contraceptives

A. Perform MRI of the pelvis

B. Prescribe gonadotropin-releasing hormone agonists

C. Prescribe androgenic steroids

D. Prescribe estrogen-progestin contraceptives


Question: A research group has developed a new screening test for HIV that can detect infection 2 weeks earlier than the current gold standard. A rigorous clinical study of this new screening test involving n subjects yields a false-positive probability α, and a false-negative probability, β. Which of the following will most likely reduce the type II error of this screening test?

Answer: Increasing α

A. Decreasing n

B. Increasing α

C. Increasing the specificity of the test

D. Decreasing the sensitivity of the test


Question: A 70-year-old female underwent a right total knee arthroplasty without complication. She was discharged to a rehab facility on post-operative day 3. Two days after her discharge from the hospital, she began experiencing pain and swelling of the right leg. Doppler ultrasound imaging at this time revealed a deep venous thrombosis in the right popliteal and tibial veins. The patient was re-admitted and started on an unfractionated heparin infusion. Five days later, doppler ultrasonography of the lower extremities revealed extension of the clot in the right lower extremity to include the common femoral, superficial femoral, popliteal, tibial, and saphenous veins. In addition, a thrombus was noted in the left common femoral vein as well. CBC showed a decrease in platelet count from 195,000/uL on admission to 83,000/uL. Which of the following is the pathophysiology of this patient's presentation?

Answer: Formation of antibodies to heparin-platelet factor-4 complex

A. Excessive irreversible inactivation of the cyclo-oxygenase enzyme

B. Formation of antibodies to heparin-platelet factor-4 complex

C. Deposition of immune complex nuclear antigens in kidneys

D. Inherited mutation in clotting factor V, which cannot be degraded by activated protein C


Question: Three days after surgical repair of a distal right radius fracture, a 62-year-old man develops severe wound pain and fever. His temperature is 39.1°C (102.4°F). Physical examination shows erythema and edema of the right arm that extends up to the elbow. Yellow pus drains from the surgical wound. Cultures from the wound fluid grow gram-positive bacteria in grape-like clusters that are resistant to nafcillin. While treating the patient's condition, the hospital also wants to eradicate the causal pathogen in asymptomatic carriers. Which of the following measures would be most effective?

Answer: Mupirocin nasal ointment

A. Permethrin hair wash

B. Colistin nebulized aerosol

C. Chlorhexidine hand disinfection

D. Mupirocin nasal ointment


Question: A research group from Europe is investigating a potential link between certain lifestyle risk factors and the development of potentially fatal renal disease. They designed a cohort study that included 68 individuals: 34 exposed and 34 unexposed to given risk factors, who were followed up for 4 years in total. During this time, the renal disease of interest was seen in 6 individuals among the exposed group and 6 individuals among the unexposed group; thus, the risk ratio (RR) of the disease development (exposed vs. unexposed) was 1. During the initial 2 years, there was 1 death in the exposed group, and another death in the unexposed group. A survey administered for the last 2 years of the study showed that the prevalence ratio of disease between exposed and unexposed individuals was in fact 0.5 (at 2 years of follow-up there was only 1 case of the disease in the 34 exposed individuals, with a resulting prevalence of 2.94%; and only 2 cases of the disease in the 34 unexposed individuals, with a resulting prevalence of 5.88%), a value that deviates from the true RR (i.e. 1). For this reason (and to accurately answer the research question), the risk of the disease should be estimated in terms of which of the following?

Answer: Incidence

A. Incidence

B. Prevalence

C. Mortality

D. Survival rates


Question: A 55-year-old male with fever, fatigue, generalized weakness, and bleeding gums for the past 3 weeks presents to his family physician. On exam, he has bilateral submandibular lymphadenopathy and hepatosplenomegaly. CBC demonstrates decreased RBCs and mature WBCs. The patient is referred to an oncologist, and a bone marrow aspiration is performed, demonstrating >20% myeloblasts with Auer rods that are myeloperoxidase positive. What is the most likely chromosomal translocation that is responsible for this patient's clinical presentation and lab results?

Answer: 15;17

A. 15;17

B. 14;18

C. 11;14

D. 8;14


Question: A 59-year-old man with Parkinson disease is brought to the emergency department 1 hour after he had a syncopal episode. Over the past two weeks, the patient has felt light-headed upon standing and has noticed that his legs have been swollen. He was started on a medication for early symptoms of Parkinson disease one month ago. Vital signs show blood pressure 114/70 mm Hg when supine and 92/38 mm Hg upon standing. Examination of the lower extremities shows a lacy, purple rash and 2+ pitting edema. Neurologic examination shows an ataxic gait. The physician decreases the dose of medication. The patient is most likely experiencing adverse effects caused by a drug that works through which of the following mechanisms of action?

Answer: Increased dopamine release from central neurons

A. Increased dopamine release from central neurons

B. Inhibition of acetylcholine activity in the basal ganglia

C. Selective inhibition of monoamine oxidase type B

D. Inhibition of central methylation of dopamine


Question: A 50-year-old woman presents to her primary care physician for muscle weakness. Her symptoms have progressively worsened over the course of several months, where she has experienced difficulty getting up from a chair, climbing the stairs, and placing her groceries on the top shelves of her kitchen. She also reports feeling tired lately and is unsure when this began. Physical examination is notable for muscle weakness in the deltoids and hip flexors with 2+ biceps, triceps, patellar, and ankle tendon reflexes. Laboratory testing demonstrates a creatine kinase level of 4,200 U/L (normal is 10-70 U/L), lactate dehydrogenase level of 150 U/L (normal is 45-90 U/L), and thyroid-stimulating hormone level of 1.5 µU/mL (normal is 0.5-5.0 µU/mL). Which of the following is the best initial treatment for this patient?

Answer: Prednisone

A. Azathioprine

B. Intravenous immunoglobulin

C. Prednisone

D. Thyroxine


Question:
A 22-year-old woman comes to the physician because of a 5-kg (11-lb) weight gain and hair loss over the past 4 months. Menarche occurred at the age of 12 years and menses occurred at irregular intervals until she stopped having periods 2 months ago. She is 165 cm (5 ft 5 in) tall and weighs 82 kg (180 lb); BMI is 30 kg/m2. Physical examination shows a receding hairline and hair loss over the vertex of the head. Serum studies show:
Thyroid-stimulating hormone 2 μU/mL
Luteinizing hormone 32 mIU/mL
Prolactin 11 ng/mL
Urine pregnancy test is negative. Withdrawal bleeding occurs after a progestin challenge test. The most likely cause of amenorrhea in this patient is an increase in production of which of the following hormones?"

Answer: Estrogen in adipose tissue

A. Progesterone in corpus luteum

B. Estrogen in adipose tissue

C. Follicle stimulating hormone in the adenohypophysis

D. Dopamine in the hypothalamus


Question: A 70-year-old man with chronic myopia comes to the physician because of a 4-month history of difficulty seeing distant objects, especially at night, despite wearing glasses. Examination shows bilateral narrowing of peripheral visual fields, cupping of the optic discs, and elevated intraocular pressure. Gonioscopy shows no abnormalities. He is prescribed a drug. At a follow-up examination several months later, intraocular pressure is normal, but darkening of the iris and an increase in the length of the eyelashes is observed. Which of the following drugs was most likely prescribed?

Answer: Latanoprost

A. Timolol

B. Acetazolamide

C. Apraclonidine

D. Latanoprost


Question:
A 3-week-old female presents with her parents to her pediatrician for a routine visit. The parents report that the child is sleeping in regular two-hour intervals and feeding and stooling well. They are concerned because they have on occasion noticed a “swelling of the belly button.” Cord separation occurred at seven days of age. The parents report that the swelling seems to come and go but is never larger than the size of a blueberry. They deny any drainage from the swelling. On physical exam, the child is in no acute distress and appears developmentally appropriate for her age. Her abdomen is soft and non-tender with a soft, 1 cm bulge at the umbilicus. The bulge increases in size when the child cries and can be easily reduced inside the umbilical ring without apparent pain.

Which of the following is the best next step in management?

Answer: Expectant management

A. Expectant management

B. Histopathologic evaluation

C. Elective surgical management

D. Immediate surgical management


Question: A 25-year-old man presents to the emergency department after a motor vehicle collision. He is currently complaining of chest pain and shortness of breath and seems rather confused. His temperature is 97.7°F (36.5°C), blood pressure is 94/54 mmHg, pulse is 170/min, respirations are 12/min, and oxygen saturation is 90% on room air. A 14-gauge needle is placed in the 2nd intercostal space on the patient’s left, and his blood pressure increases to 104/74 mmHg and his pulse decreases to 100/min. Which of the following is the best next intervention for this patient?

Answer: Tube thoracostomy

A. Chest radiograph

B. Pericardiocentesis

C. Thoracotomy

D. Tube thoracostomy


Question: A 13-year-old girl presents with a rash on her left hand and forearm. She went hiking with friends the day before yesterday and awoke this morning to find her hand and forearm red and itchy. She denies any swelling of the face or throat, difficulty breathing, dizziness, or palpitations. She has no significant past medical history or known allergies. She is afebrile and her vital signs are within normal limits. On physical examination, there are multiple erythematous papules and fluid-filled vesicles in a linear pattern on her left hand and forearm as shown in the exhibit (see image). Which of the following is the best course of treatment for this patient?

Answer: Topical clobetasol

A. Oral prednisone

B. Topical clobetasol

C. Phototherapy

D. Azathioprine


Question: A 12-year-old boy is brought to the physician for multiple bruises. He has fallen multiple times over the past 4 months and has difficulty walking without assistance. His speech is slow and difficult to understand. Neurological examination shows bilateral nystagmus, decreased muscle strength, 1+ reflexes bilaterally, and a wide-based gait with irregular and uneven steps. His proprioception and vibration senses are absent. The remainder of the examination shows kyphoscoliosis and foot inversion with hammer toes. This patient is most likely to die from which of the following complications?

Answer: Heart failure

A. Renal cell carcinoma

B. Heart failure

C. Posterior fossa tumors

D.
Aspiration pneumonia
"


Question: A 28-year-old nulligravid woman comes to the physician for a routine health maintenance examination. Upon questioning, she reports that she and her husband have been trying to conceive for more than 1 year; they have unprotected sexual intercourse 3–4 times per week. Recently, she has not been enjoying sexual intercourse with her husband because of painful penetration. She also reports episodic back and pelvic pain over the past 6 months that lasts for 2–3 days; she has missed several days of work each month because of the pain. Menarche was at the age of 13 years, and menses occur at 26–28 day intervals. Pelvic examination shows a normal-appearing vulva and vagina. There is rectovaginal tenderness. Ultrasonography of the pelvis shows a retroverted normal-sized uterus. Further evaluation is most likely to show which of the following findings?

Answer: Reddish-black peritoneal lesions on laparoscopy

A. Endometrial tisssue within the myometrium on biopsy

B. Multiple bilateral ovarian cysts on ultrasonography

C. Reddish-black peritoneal lesions on laparoscopy

D. Concentric, solid myometrial tumors on MRI


Question: A 2-year-old Caucasian male presents with recurrent diaper rash and oral thrush. He has also experienced recurrent episodes of otitis media from repeat Streptoccous pneumoniae. He notably has reduced T and B cell counts. What disease is the child suffering from?

Answer: Severe combined immunodeficiency

A. X-linked agammaglobulinemia

B. Isolated IgA deficiency

C. Severe combined immunodeficiency

D. DiGeorge syndrome


Question: A 42-year-old primigravida woman presents to her gynecologist for a routine prenatal visit at 11 weeks of gestation. Her pregnancy has been uneventful so far. She denies smoking, using alcohol, or any illicit drugs. Past medical history is significant for Hashimoto’s thyroiditis which is well-controlled with levothyroxine. Her blood pressure is 110/70 mm Hg, a heart rate of 95/min, a respiratory rate of 20/min, and a temperature of 36.4°C (97.5°F). Physical examination is unremarkable. A transvaginal ultrasound reveals increased nuchal translucency. Laboratory studies show decreased levels of PAPP-A and increased levels of β-hCG. If the pregnancy is continued to term, the child is at an increased risk of developing which of the following conditions?

Answer: Alzheimer’s disease

A. Vaginal adenosis

B. Huntington disease

C. Alzheimer’s disease

D. Ebstein anomaly


Question: An 18-month-old boy is brought to the emergency department by his babysitter because of lethargy and fever for 3 hours. He has not fully recovered from a middle ear infection that started a few days ago. The parents cannot be reached for further information. His temperature is 39.1°C (102.3°F). Physical examination shows nuchal rigidity. A pathogen is isolated from the patient's cerebrospinal fluid that does not grow on regular blood agar plate but produces colonies when cocultured with Staphylococcus aureus. Vaccination against the causal pathogen of this patient's current disease is most likely to also prevent which of the following conditions?

Answer: Epiglottitis

A. Bacterial rhinosinusitis

B. Epiglottitis

C. Chancroid

D. Impetigo


Question: A 20-month-old boy is brought to the physician for the evaluation of intellectual and behavioral abnormalities and abnormal movements of his extremities. His mother reports that he often hits his head and limbs against furniture. He is unable to walk without support and speaks in unclear 2-word phrases. Examination shows multiple bruises on the forehead and several healing wounds over the fingers. There is increased muscle tone in all extremities. Laboratory studies show an increased serum uric acid concentration. The serum concentration of which of the following substances is most likely to also be increased in this patient?

Answer: Phosphoribosyl pyrophosphate

A. Phenylalanine

B. Deoxyadenosine trisphosphate

C. Phosphoribosyl pyrophosphate

D. Cytosine monophosphate


Question: A 24-year-old man presents to the office for a physical exam and drug screening requested by his parole officer. He has a history of multiple run-ins with the law, including theft, destruction of property, and assault and battery. Patient confesses that he has always been the 'problem child' in his home and always got into trouble with authority figures. Past medical records reveal testimonies from his mother describing episodes of physically aggressive behavior in school starting at before 12. Although a single parent, his mother states there were no stressful changes or issues at home. Today's urine toxicology screens are negative. Which of the following is most likely this patient’s diagnosis?

Answer: Antisocial personality disorder

A. Substance use-related aggression

B. Conduct disorder

C. Antisocial personality disorder

D. Borderline personality disorder


Question: A 47-year old woman is referred to a nephrologist due to hematuria over the last week and lower extremity edema. She first noticed her feet and legs would swell in the mornings about 2 weeks ago. Her past medical history is significant for systemic lupus erythematosus for the past 24 years. This causes her mild joint and muscle pain on most day and she manages her symptoms with ibuprofen and acetaminophen. Today, her heart rate is 90/min, the respiratory rate is 17/min, the blood pressure is 140/90 mm Hg, and the temperature is 37.1°C (98.8°F). Urine analysis shows 6-10 dysmorphic RBCs per high powered field and occasional cellular casts. Serum creatinine is 2.4 mg/dL and a 24 hour urine collection reveals 550mg of excreted protein. A kidney biopsy shows findings consistent with diffuse proliferative glomerulonephritis. Which of the following is the best initial therapy for this patient?

Answer: Cyclophosphamide and prednisolone

A. Methotrexate and folic acid

B. Intravenous immunoglobulin

C. Plasmapheresis

D. Cyclophosphamide and prednisolone


Question: A 6-year-old girl presents to your clinic two weeks after receiving a routine immunization in preparation for a trip overseas. Periorbital edema is present on exam, and 24 hour urine collection shows excretion of 4.3 grams of protein/day. Which pathological change would likely be seen on microscopy?

Answer: Podocyte effacement on electron microscopy

A. Linear IgG deposition on light microscopy

B. IgA-immune complexes in the mesangium on electron microscopy

C. Subepithelial deposits with “spike and dome” appearance on electron microscopy

D. Podocyte effacement on electron microscopy


Question:
A 9-year-old girl is brought to the physician by her father for evaluation of intermittent muscle cramps for the past year and short stature. She has had recurrent upper respiratory tract infections since infancy. She is at the 5th percentile for weight and 10th percentile for height. Physical examination shows nasal polyps and dry skin. An x-ray of the right wrist shows osteopenia with epiphyseal widening. Which of the following sets of laboratory findings is most likely in this patient's serum?
 $$$ Calcium %%% Phosphorus %%% Parathyroid hormone %%% Calcitriol $$$

D. Normal ↓ ↑ ↓


Question: A 24-year-old medical student presents to urgent care with cough and rhinorrhea. He has been learning about HIV and immunosuppression in medical school, and he is worried that he is seriously ill. He has no significant medical history, and he is sexually active with his girlfriend. He consumes alcohol on weekends but does not use tobacco or other recreational drugs. He candidly reports that, in microbiology lab, he cultured his own sputum on Sabouraud agar, and Candida grew on the agar. Examination of the oropharynx does not show any abnormalities. You perform a nasal viral swab, which confirms that he has a rhinovirus infection. Which of the following is the most likely explanation for his positive Candida culture?

Answer: Benign Candida colonization

A. HIV virus infection

B. Xerostomia

C. Surreptitious drug use

D. Benign Candida colonization


Question: A 57-year-old woman comes to her physician with a persistent cough. She has observed an increase in the frequency of her cough over the past few months and also the production of yellowish sputum on several occasions. She says that sputum production is greater in the morning compared to the rest of the day. She has been a chain smoker for about 35 years now, smoking close to 3 packs a day. She has never had the will to quit. Over the last 2 years, she has had this cough and doesn't recall being free of it for 3 months at a stretch. On examination, there is a slight expiratory wheeze in the lower lung fields. Her respiratory rate is 18/min, pulse is 85/min, and blood pressure is 110/70 mm Hg. Her forced expiratory volume in the first second is 83% at this time. Her FEV1/FVC post-bronchodilator ratio is 0.65. Based on these findings, her physician recommends that she quit smoking. She is also advised to take pneumococcal and influenza vaccinations over the next few months. Which of the following medications would be most appropriate to assist the patient with her symptoms at this time?

Answer: Albuterol

A. Albuterol

B. Fluticasone

C. Doxycycline

D. Prednisone


Question: A 56-year-old woman presents to her primary care physician for dizziness. She says that her symptoms began approximately 1 month prior to presentation and are associated with nausea and ringing of the ears. She describes her dizziness as a spinning sensation that has a start and end and lasts approximately 25 minutes. This dizziness is severe enough that she cannot walk or stand. Her symptoms are fluctuating, and she denies any tunnel vision or feelings of fainting. However, she has abruptly fallen to the ground in the past and denied losing consciousness. Medical history is significant for a migraine with aura treated with zolmitriptan, type 2 diabetes managed with metformin, and hypertension managed with lisinopril. Her blood pressure is 125/75 mmHg, pulse is 88/min, and respirations are 16/min. On physical exam, when words are whispered into her right ear, she is unable to repeat the whispered words aloud; however, this is normal in the left ear. Air conduction is greater than bone conduction with Rinne testing, and the sound of the tuning fork is loudest in the left ear on Weber testing. Which of the following is most likely the diagnosis?

Answer: Meniere disease

A. Benign paroxysmal positional vertigo

B. Meniere disease

C. Migraine

D. Transient ischemic attack


Question: A 3086-g (6-lb) male newborn is delivered at 39 weeks' gestation to a 29-year-old woman. Initial examination shows micrognathia, a broad nasal bridge, short philtrum, and a cleft palate. Intermittent muscle spasms are seen predominantly in the hands and feet. A harsh systolic murmur is heard over the lower left sternal border. Which of the following is the most likely cause of this infant’s symptoms?

Answer: Deletion in chromosome 22

A. Deletion in chromosome 7

B. Deletion in chromosome 22

C. Nondisjunction of chromosome 21

D. Nondisjunction of chromosome 13


Question:
A 37-year-old woman comes to the emergency department because her eyes have had a yellow discoloration and she has had dark urine for the past 3 days. She has also had fever, itching, and severe fatigue. She reports having symptoms of the stomach flu a week ago, which resolved with over-the-counter medication. She does not have diarrhea but says her stools are whitish in appearance. She has no personal history of serious illness. She does not smoke and drinks an average of 2 beers on weekends. She does not use illicit drugs. She has been sexually active with the same partner for 12 years and uses condoms consistently. She works as a flight attendant for an international airline. She appears ill. Her temperature is 39.3°C (102.7°F), pulse is 64/min, and blood pressure is 132/82 mm Hg. Examination shows scleral icterus, excoriation marks over her extremities, and parched lips. The liver is tender on palpation; there is no splenomegaly. Cardiopulmonary examination is normal. Laboratory studies show:
Hemoglobin 11.6 g/dL
Leukocyte count 10,300/mm3
Platelet count 256,000/mm3
ESR 19 mm/hr
Prothrombin time 13 seconds
Serum
Urea nitrogen 28 mg/dL
Glucose 89 mg/dL
Creatinine 0.7 mg/dL
Bilirubin
Total 8 mg/dL
Direct 4 mg/dL
ALP 80 U/L
AST 312 U/L
ALT 569 U/L
An ultrasound of the abdomen shows no abnormalities. Serum studies are most likely to show which of the following findings?"

Answer: Anti-HAV IgM

A. Anti-mitochondrial antibodies

B. Perinuclear anti-neutrophil cytoplasmic antibodies

C. Anti-HAV IgM

D. Anti-HEV IgG


Question: A 27-year-old man presents with diarrhea, fatigue and weight loss. He says he has been having occasional loose stools and abdominal pain for the past month, but he did not seek any medical attention because of work deadlines. He says the diarrhea is associated with cramping lower abdominal pain and an urgency to defecate. His stool is loose, occasionally blood-tinged, and contains mucus. He also says he feels fatigued and has lost 11 kg (24 lb) over the last 2 months. The patient denies any fever, sick contacts, or a history of recent travel. No significant past medical history. Family history is significant for colon cancer in his father, who died at the age of 50. On physical examination, the patient has generalized pallor. Abdominal exam reveals mild tenderness to palpation in the left lower quadrant. Laboratory investigations reveal microcytic anemia with an elevated ESR. A colonoscopy with biopsy is performed, which shows inflammation of the sigmoid colon and rectum. Biopsy shows a predominantly lymphoid infiltration of the mucosa and submucosa with multiple crypt abscesses. No evidence of granulomatous disease. What is the mechanism of action of the drug which typically induces remission of this patient’s most likely condition?

Answer: Inhibition of prostaglandins and inflammatory cytokines

A. Inhibition of prostaglandins and inflammatory cytokines

B. Antibody against tumor necrosis factor

C. Inhibition of cellular metabolism

D. Suppression of polymorphonuclear cell migration


Question:
A 61-year-old woman presents to your office complaining of mild fatigue and weight loss over the past 6 months. She states she has felt generally unwell and has had decreased appetite during this time frame. Her temperature is 98.1°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 88/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam reveals splenomegaly and a nontender abdomen. A complete blood count with differential shows the following:

Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 166,500/mm^3
Segmented neutrophils 92%
Leukocyte alkaline phosphatase: Low
Platelet count: 92,000/mm^3

A bone marrow biopsy is performed demonstrating infiltration with a large number of normal-appearing neutrophils. Which of the following translocations is likely to be seen in this patient?

Answer: t(9;22)

A. t(8;14)

B. t(9;22)

C. t(12;21)

D. t(15;17)


Question:
A 44-year-old homeless man is brought to the emergency department after he was arrested when found intoxicated in someone's garage. The patient is acutely altered and is covered in urine, stool, and vomit. His temperature is 97.6°F (36.4°C), blood pressure is 104/64 mmHg, pulse is 130/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is aroused with pain and begins answering basic questions. He states his vision is blurry and he can't see anything. Laboratory values are ordered as seen below.

Serum:
Na+: 141 mEq/L
Cl-: 102 mEq/L
K+: 4.4 mEq/L
HCO3-: 14 mEq/L
BUN: 25 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.4 mg/dL
Ca2+: 10.2 mg/dL

Which of the following is the most appropriate initial treatment of this patient?

Answer: Inhibition of alcohol dehydrogenase

A. Glutathione formation

B. Inhibition of alcohol dehydrogenase

C. Muscarinic antagonism

D. Removal via dialysis


Question: A 32-year-old construction worker is brought to the Emergency Department after a block of concrete crushed his right leg. His coworkers tried to remove the block, but it was not possible until firemen arrived on the scene 30 minutes after the incident. His personal medical history is unremarkable. Upon admission his vitals were stable. On physical examination the man is unconscious. His right leg is deformed with lacerations and hematomas. There are at least two fractures and several areas of the muscle appear pulpified. Distal right pulses are absent. An X-ray of the right leg reveals several displaced fractures of the tibia and fibula. Blood samples and a urine specimens are sent to the lab for analysis. Which of the following laboratory abnormalities would you expect to find in this patient?

Answer: Fractional excretion of sodium (FeNa+) > 2%

A. Fractional excretion of sodium (FeNa+) > 2%

B. Urine osmolality > 500 mOsmol/kg

C. Red-tinted plasma

D. Elevated haptoglobin


Question: A 42-year-old primigravida woman goes into labor at 37 weeks. After several hours of labor, a boy is born with multiple physical abnormalities including cleft palate, micrognathia, and low-set ears. Imaging reveals an absence of the thymic shadow. Which of the following is the most likely cause of the patient’s condition?

Answer: Microdeletion of the long arm of chromosome 22

A. Microdeletion of the long arm of chromosome 22

B. Microdeletion of the long arm of chromosome 7

C. Microdeletion of the short arm of chromosome 5

D. Adenosine deaminase deficiency


Question: A 20-year-old woman presents following a seizure 2 hours ago. The patient's roommate describes seeing the patient suddenly 'freeze', collapse, and start having jerky movements involving her entire body. The patient says she can not recall the episode but does remember 'seeing stars' before losing consciousness. She remembers being confused about where she was soon after the seizure and had urinated in her clothes when she regained consciousness. A persistent headache has troubled her since the seizure for which she took acetaminophen before coming to the hospital. Her past medical history is unremarkable. She denies alcohol and drug use. The physician starts her on an antiepileptic drug that acts in the motor cortex by blocking repeated activation of voltage-gated sodium channels and is also used in status epilepticus. When this drug is used long-term, which of the following complications can develop?

Answer: Drug-induced SLE

A. Drug dependence

B. Drug-induced SLE

C. Renal failure

D. Liver failure


Question: A 68-year-old man presents to his primary care physician for pain in his feet. The patient states that it is very painful for him to walk around, and he has significant pain in his right and left toes. The patient has a past medical history of obesity, type II diabetes mellitus, anxiety, depression, COPD, and a 30 pack-year smoking history. The patient’s current medications include lisinopril, hydrochlorothiazide, insulin, metformin, fluoxetine, clonazepam, albuterol, home oxygen, varenicline, and fish oil and he is compliant with all medications. On physical exam, the patient’s toes appear pale and dirty. When inspecting his toes, shallow wounds with a pale base devoid of granulation tissue can be appreciated. The patient has decreased pinprick sensation in his lower extremities bilaterally. Pulmonary exam is notable for a prolonged expiratory phase. Which of the following findings is most likely to be found in this patient?

Answer: Calf pain after walking moderate distance

A. Bipedal edema

B. Increased reflexes of the lower extremities

C. Loss of vibration sensation in the lower extremities

D. Calf pain after walking moderate distance


Question: A 16-year-old man is brought to the emergency department for left arm pain. Per the patient, he was playing at his high-school football game when a member of the opposing team tackled him from behind, which resulted in him landing on his left arm. He felt a “popping” sensation and immediate, sharp pain at his left shoulder. The patient is in mild distress and holds his arm against his abdomen. Physical examination demonstrates limited abduction secondary to pain and reduced muscle tone over the shoulder. What additional finding would you expect from this patient?

Answer: Loss of sensation over the lateral arm

A. Loss of sensation over the dorsal hand

B. Loss of sensation over the lateral 3 1/2 fingers

C. Loss of sensation over the lateral arm

D. Loss of sensation over the lateral forearm


Question: A 68-year-old woman is brought to the emergency room because of pain in her right shoulder after falling down the stairs in her apartment. She has a history of postmenopausal osteoporosis. Her current medications are alendronate, vitamin D, and calcium supplementation. Physical examination shows shortening of the right arm as well as tenderness and swelling over the right shoulder. The range of motion of the right arm is limited by pain. An x-ray of the right shoulder shows a fracture of the surgical neck of the humerus. Which of the following movements is most likely to be impaired in this patient?

Answer: Arm abduction

A. Wrist extension

B. Elbow flexion

C. Arm abduction

D. Thumb adduction


Question:
A hematologist has found a historical hemocytometer used during the 1960s. Out of curiosity, he decides to obtain platelet counts from his brother, who has idiopathic thrombocytopenic purpura (ITP), with both the historical hemocytometer and a modern automated CBC analyzer. The platelet counts of repeated measurements are shown in ascending order:
Historical hemocytometer 55,000 57,000 62,000 76,000 77,000 82,000 92,000 Mean: 72,000
Modern automated CBC analyzer 71,000 71,000 72,000 72,000 73,000 74,000 74,000 Mean: 72,000
If the measurements on a modern automated CBC analyzer are considered accurate, which of the following conclusions can be drawn about the historical hemocytometer?"

Answer: Test lacks precision

A. Test lacks accuracy

B. Test lacks validity

C. Test lacks specificity

D. Test lacks precision


Question: A 9-year-old female child whose family recently emigrated from Afghanistan presents to the county hospital with difficulty swallowing and generalized muscle rigidity. Her parents note that although she is in severe pain she always appears to be smiling. After getting a detailed history from the parents, the residents comes to the conclusion that the child's clinical presentation is due to a lack of immunizations and a deep wound on her knee resulting from a fall six days ago. Which of the following is the mechanism of action of the toxin causing this child's symptoms?

Answer: Preventing release of GABA by cleaving of synaptobrevin 2

A. Inhibiting protein synthesis via ADP-ribosylation of elongation factor 2

B. Overactivating adenylate cyclase by ADP-ribosylation of the Gs alpha subunit

C. Overactivating adenylate cyclase by disabling the Gi subunit

D. Preventing release of GABA by cleaving of synaptobrevin 2


Question: A 49-year-old obese man presents to the emergency department with a fever and a cough productive of bloody sputum. He has also been waking up at night frequently, which he attributes to sweating while asleep. He is also proud of recently losing some weight but denies actively trying to do so. He says that he has had these symptoms intermittently for the last several years but has not consistently sought treatment because his housing has been transient with periods of homelessness. He is started on a course of therapy and leaves against medical advice before his physician is able to explain the medications. He returns two days later because he is concerned that his eyes are bleeding. The area of the lung most likely affected by this patient's condition has which of the following characteristics?

Answer: Low perfusion, low ventilation, high V/Q ratio

A. High perfusion, high ventilation, high V/Q ratio

B. High perfusion, high ventilation, low V/Q ratio

C. Low perfusion, low ventilation, high V/Q ratio

D. Low perfusion, low ventilation, low V/Q ratio


Question:
A 66-year-old male presents to clinic for a blood glucose level of 169 mg/dL taken at a local pharmacy. He is a farmer in rural Alabama and has not seen a doctor for decades. He wants to be in excellent shape prior to his trip to visit his daughter at college. His past medical history and family history are unknown, and he does not take any medications. His diet consists of pork products and he does not smoke. His temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 169/90 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air. The patient is started on metformin, lisinopril, and a guided exercise program. Lab results are below:

Serum:
Na+: 145 mEq/L
Cl-: 100 mEq/L
K+: 4.9 mEq/L
HCO3-: 24 mEq/L
BUN: 18 mg/dL
Glucose: 211 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: 10.0 mg/dL

He returns from his trip, complaining of cough. He denies any other symptoms. His temperature is 99.5°F (37.5°C), pulse is 101/min, blood pressure is 160/85 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air. Repeat lab results are below:

Serum:
Na+: 145 mEq/L
Cl-: 100 mEq/L
K+: 5.3 mEq/L
HCO3-: 24 mEq/L
BUN: 22 mg/dL
Glucose: 169 mg/dL
Creatinine: 1.2 mg/dL
Ca2+: 10.1 mg/dL

What is the next best step in management?

Answer: Switch blood pressure medication to losartan

A. Switch blood pressure medication to losartan

B. Switch blood pressure medication to hydrochlorothiazide

C. Azithromycin

D. Loratadine


Question: A 25-year-old woman presents to her primary care physician for her annual physical exam. Her prior medical history is significant for seasonal allergies and a broken arm at age 12 that was treated in a long arm cast. She has not had any major illnesses in the previous year and does not currently have any major complaints. On physical exam her blood pressure is found to be 152/95 mmHg. Laboratory findings reveal elevated levels of renin and aldosterone. Given her elevated blood pressure, she is prescribed captopril; however, 1 week later she presents to the emergency department with hypertensive urgency. At that point captopril is immediately stopped. Which of the following is the most likely cause of this patient's disorder?

Answer: Bilateral fibromuscular dysplasia

A. Bilateral fibromuscular dysplasia

B. Conn syndrome

C. Renin secreting tumor

D. Unilateral fibromuscular dysplasia


Question: An investigator is analyzing the serum calcium and parathyroid hormone levels of 100 patients. A scatter plot of the findings is shown. Which of the following is a possible explanation for the group marked with the letter E?

Answer: Lymphoma

A. Lymphoma

B. End-stage kidney disease

C. Thyroidectomy

D. Multiple endocrine neoplasia


Question: A 56-year-old male is admitted to the emergency department with sudden onset of pain, left-sided scrotal swelling, and nausea. The patient states that the symptoms started three hours ago after he lifted up a heavy pack. He says that the swelling had been intermittently present for several years already and was most prominent when physically straining or coughing, but it had never been painful. Past medical history is unremarkable. Patient reports a 26-pack-year history of smoking. Vital signs are as follows: blood pressure 150/90 mm Hg, heart rate 85/min, respiratory rate 14/min, and temperature 37.8℃ (100℉). BMI is 32.9 kg/m2. Patient’s respiratory and cardiovascular exams are within normal limits. The abdomen is moderately distended. There is a tender erythematous scrotal swelling on the left, which cannot be manually reduced. Which of the following tests should be performed to confirm the diagnosis in this patient?

Answer: No further tests are needed

A. Ultrasonography

B. No further tests are needed

C. Fine needle biopsy

D. Laparoscopy


Question: A 6-year-old boy presents to a pediatrician for initial evaluation. He was recently adopted from abroad and his parents want to establish care in the United States. His medical history is unclear and there are no records on any family history. On presentation, he is found to fall below the 5th percentile in height for his age with shortened 4th and 5th digits. Physical exam reveals wrist spasms when his blood pressure is taken. Radiographs reveal decreased bone mineral density and several healing fractures. Which of the following mechanisms is most likely associated with this patient's presentation?

Answer: Resistance to effects of parathyroid hormone

A. Decreased production of parathyroid hormone

B. Inadequate intake of vitamin D

C. Malabsorption of nutrients

D. Resistance to effects of parathyroid hormone


Question: A 12-year-old boy is brought to the emergency department with a 2-month history of increasing difficulty with physical activity. Specifically, he says that he gets short of breath quickly with exertion even though he used to participate in all activities without a problem. When asked, he endorses sometimes coughing up flecks of blood. His past medical history is unclear because he was recently adopted from abroad and has not yet established care. Physical exam reveals blue discoloration of his lips and fingernails as well as a holosystolic murmur best heard at the lower left sternal border. Which of the following physiologic mechanisms is primarily responsible for this patient's current presentation?

Answer: Pulmonary artery hypertension

A. Increasing size of ventricular septal defect

B. Left ventricular outflow tract obstruction

C. New atrial septal defect

D. Pulmonary artery hypertension


Question: A scientist isolates the rough endoplasmic reticulum from HeLa cells. He performs a northern blot to isolate nucleic acid sequences of interest. Which of the following molecules make up part of the structure that was separated?

Answer: Ribosomal RNA

A. RNA polymerase

B. Transfer RNA

C. Ribosomal RNA

D. Mitochondrial RNA


Question: A 14-month-old girl is brought to the pediatrician after her parents noticed her being increasingly irritable with frequent vomiting for the past 2 weeks. Parents deny any history of fever. They recently immigrated to the country and, unfortunately, the mother did not receive prenatal care during pregnancy due to a lack of health insurance. Physical examination is unremarkable except for a head circumference over 2 standard deviations larger than the mean for her age, and delay in meeting motor developmental milestones. A magnetic resonance imaging (MRI) of her brain shows an enlargement of the posterior fossa, cystic dilation of the 4th ventricle, and hypoplasia of the cerebellar vermis (see image). Which of the following is the most likely diagnosis in this patient?

Answer: Dandy-Walker malformation

A. Chiari II malformation

B. Chiari III malformation

C. Dandy-Walker malformation

D. Klippel Feil syndrome


Question: A 28-year-old woman presents with a 3-year history of recurrent headaches. She says the episodes are typically triggered by hunger, mental stress, physical exertion, and lack of sleep, although many times the trigger is not known. She describes her headaches as unilateral, severe, throbbing, and aggravated by movement. The patient says that each episode usually lasts for 6–24 hours and is often accompanied by nausea, vomiting, and intolerance to light. Which of the following brain regions, if lesioned, would most likely result in no change in this patient’s symptoms?

Answer: Red nucleus

A. Red nucleus

B. Locus coeruleus

C. Nucleus raphe magnus

D. Periaqueductal gray


Question: A 68-year-old man comes to the physician for a routine health maintenance examination. He has had increasing shortness of breath and a productive cough for the past 1 year. He can walk up a flight of stairs without stopping. He has hypertension and his only medication is amlodipine. He has a history of asthma during childhood. He smoked 1 pack of cigarettes daily for 30 years but quit 16 years ago. He used to work at a shipyard and retired 5 years ago. His pulse is 98/min, respirations are 25/min and blood pressure is 134/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields. Cardiac examination shows no murmurs, rubs, or gallops. Spirometry shows an FEV1:FVC ratio of 63% and an FEV1 of 65% of predicted. His diffusing capacity for carbon monoxide (DLCO) is 40% of predicted. Which of the following is the most likely cause of this patient's findings?

Answer: Emphysema

A. Asthma

B. Congestive heart failure

C. Emphysema

D.
Asbestosis
"


Question: A 9-year-old boy presents to his orthopedic surgeon for ongoing evaluation of his lower extremity deformities. Specifically, his hips have been dislocating over the last year despite bracing in hip-knee-ankle-foot orthoses. He is paralyzed from below the L2 nerve root and has difficulty with both bladder and bowel incontinence. He has had these abnormalities since birth due to a lower back lesion that required surgical closure during infancy. Which of the following substances was most likely elevated in his mother's serum during her pregnancy?

Answer: Alpha-fetoprotein

A. Alpha-fetoprotein

B. Beta-human chorionic growth hormone

C. Estriol

D. Sphingomyelin


Question: Polymerase chain reaction (PCR) has revolutionized the molecular biology field. PCR allows for amplification of a single piece of genetic material to produce trillions of idential copies. Which of the following is NOT necessary for PCR?

Answer: Reverse transcriptase

A. Taq polymerase

B. Reverse transcriptase

C. Primers

D. Target DNA strand


Question: An investigator is studying the efficacy of antiviral drugs in infected human cells. Harvested human cells are inoculated onto four cell culture plates. Live varicella-zoster virus (VZV) is administered to cells on two of the culture plates. One healthy and one infected cell set are set aside as controls. In comparison with the control plates, the subsequent application of a guanosine analog to the experimental cell sets induces cell death in the virally infected cells but not in the healthy cells. Which of the following is the most likely mechanism for these findings?

Answer: Phosphorylation by virally-encoded thymidine kinase

A. Secretion of interferons by virally infected cells

B. Mutation of viral DNA polymerase

C. Phosphorylation by virally-encoded thymidine kinase

D. Inhibition of RNA-dependent DNA polymerase


Question: A 13-year-old boy is brought to the physician because of pain and redness on his back for 2 days. He returned yesterday from a vacation to East Africa with his parents, where he took multiple rides on hot air balloons. His vital signs are within normal limits. Examination shows a tender, nonpruritic, erythematous rash with edema covering the extensor surface of both forearms, the shoulders, and the upper back, with small patches of skin exfoliation. The rash becomes pale when pressed and then rapidly regains color. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Answer:
Apply aloe vera-based moisturizer
"

A. Dress wound with wet gauze

B. Administer 2 liters of intravenous fluids

C. Apply topical mupirocin

D.
Apply aloe vera-based moisturizer
"


Question:
A 55-year-old man comes to the emergency department because of headache, fever, chills, shortness of breath, and abdominal pain for 1 week. He also feels tired and nauseous. He returned from a trip to Botswana 2 weeks ago. He has type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the past 30 years and drinks a glass of beer daily. His only current medication is metformin. His temperature is 39.3°C (102.8°F), pulse is 122/min, respirations are 28/min, and blood pressure is 109/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. Examination shows jaundice. A few scattered inspiratory crackles are heard in the thorax. The liver is palpated 2 cm below the right costal margin. Laboratory studies show:
Hemoglobin 9.2 g/dL
Leukocyte count 9,400/mm3
Platelet count 90,000/mm3
Serum
Na+ 137 mEq/L
Cl- 102 mEq/L
K+ 5.2 mEq/L
HCO3- 13 mEq/L
Glucose 69 mg/dL
Lactate dehydrogenase 360 U/L
Creatinine 0.9 mg/dL
Bilirubin
_ Total 4.2 mg/dL
_ Direct 0.8 mg/dL
AST 79 U/L
ALT 90 U/L
Urine
Blood 3+
Protein trace
RBC 0–1/hpf
WBC 1–2/hpf
Arterial blood gas analysis on room air shows a pH of 7.31. Which of the following is the most appropriate next step in management?"

Answer: Blood smear

A. Coombs test

B. Blood culture

C. Blood smear

D. Serology


Question: A population study was conducted to evaluate coronary artery disease in the general population. A cohort of 700 patients underwent coronary angiography to evaluate the geographic distribution of coronary arteries throughout the heart. Which of the following was the most common finding in this cohort?

Answer: Right coronary artery dominance

A. The SA node is supplied by a branch of the right coronary artery.

B. The AV node is supplied by a branch of the right coronary artery.

C. Right coronary artery dominance

D. A SA node is supplied by a branch of the left coronary artery.


Question: A 24-year-old woman comes to the physician because of intermittent episodes of stabbing facial pain for 4 months. The pain occurs over her left cheek, is 9 out of 10 in intensity, radiates towards her mouth, and lasts around half a minute before subsiding. These episodes commonly occur when she washes her face, brushes her teeth, or eats a meal. She does not have visual disturbances, weakness of her facial muscles, or hearing loss. She had a tooth extracted about 2 months ago, but the facial pain has persisted. She has hypothyroidism and vitiligo. Her mother has major depressive disorder. Current medications include levothyroxine and a herbal cream. She appears anxious. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Which of the following is the most appropriate next step in management?

Answer: Carbamazepine

A. Microvascular decompression

B. Botulinum toxin injection

C. Radiofrequency rhizotomy

D. Carbamazepine


Question: A 67-year-old man is brought to the emergency department after the sudden onset of dizziness, blurry vision, and a raspy voice. He has type 2 diabetes mellitus, hypercholesterolemia, coronary artery disease, and hypertension. He has smoked two packs of cigarettes daily for 30 years. He drinks three to four beers daily. His current medications include metformin, atenolol, lisinopril, furosemide, and aspirin. His temperature is 36.6°C (98°F), pulse is 85/min, respirations are 18/min, and blood pressure is 142/90 mm Hg. He is alert and oriented to person, place, and time. The pupil on the left is pinpoint. There is ptosis of the left eye. Horizontal nystagmus is present. The gag reflex is diminished. When he stands without support, he falls towards his left side. There is loss of pain and temperature sensation over the left face and right trunk and limbs. Occlusion of which of the following arteries is the most likely cause of this patient's symptoms?

Answer: Left posterior inferior cerebellar artery

A. Right middle cerebral artery

B. Left posterior inferior cerebellar artery

C. Right internal carotid artery

D. Left posterior cerebral artery


Question: A 67-year-old woman with a recently found hepatic carcinoma has been an inpatient for more than a week. During morning rounds, she was abnormally disoriented to time and place along with a shortened attention span. The overnight resident reports that she was coming in and out of this state for the past couple nights. The patient was known to drink often, but reported that she has not consumed alcohol in weeks leading up to her admission. She is not jaundiced and has no metabolic imbalance upon laboratory tests. What is the most likely cause of her recent mental impairment?

Answer: Delirium

A. Delirium

B. Substance abuse

C. Brain metastasis

D. Delirium tremens


Question: A 51-year-old man comes to the physician because of recurrent episodes of dizziness, tinnitus, and hearing loss on the left side for 6 weeks. These episodes last for hours at a time and are associated with the sensation that the room is spinning. He has no history of major medical illness and takes no medications. Examination shows horizontal nystagmus to the left. Weber test shows lateralization to the right ear. The Rinne test is positive bilaterally. Which of the following is the most likely cause of this patient's symptoms?

Answer: Endolymphatic hydrops

A. Dislodged otoliths

B. Acoustic neuroma

C. Endolymphatic hydrops

D. Posterior inferior cerebellar artery infarction


Question: A 37-year-old farmer presents to the emergency department with acute onset of complaints of diarrhea, excessive tearing, and increased saliva production. He is concerned that he is dehydrated, as he has also been urinating with increased frequency over the past several hours. His temperature is 97.6°F (36.4°C), blood pressure is 111/64 mmHg, pulse is 60/min, respirations are 10/min, and oxygen saturation is 98% on room air. Physical exam is significant for a moderately agitated and diaphoretic man who demonstrates pinpoint pupils. Which of the following is the most appropriate next step in management?

Answer: Atropine

A. Atropine

B. Diphenhydramine

C. Naloxone

D. Physostigmine


Question:
A 54-year-old woman comes to the emergency department because of sharp chest pain and shortness of breath for 1 day. She has been coughing intermittently, which worsens the pain. She has osteoporosis, for which she takes raloxifene. Arterial blood gas analysis on room air shows:
pH 7.52
PCO2 25 mm Hg
PO2 65 mm Hg
O2 saturation 92%
Physical examination is most likely to show which of the following findings?"

Answer: Unilateral swelling of the leg

A. Unilateral swelling of the leg

B. Increased anteroposterior diameter of the thorax

C. Grouped vesicles on the right hemithorax

D. Absent left radial pulse


Question: A previously healthy 18-year-old woman comes to the emergency department because of diarrhea and abdominal cramps since the previous evening. She has had around 3–4 episodes of watery stools. She feels nauseous and has vomited twice. She recollects eating out 2 days ago. She has been on a vegan diet for 6 months. She takes no medications and has not traveled anywhere recently. Her temperature is 36.8°(98.2°F), pulse is 73/min, and blood pressure is 110/70 mm Hg. Examination shows dry mucous membranes. Abdominal examination is unremarkable. Which of the following is the most likely causal organism?

Answer: Norovirus

A. Rotavirus

B. Norovirus

C. Vibrio vulnificus

D. Bacillus cereus


Question: A 6-year-old boy is brought to the physician for a well-child examination. He has no history of major medical illness. His mother says, “Sometimes when my son forgets to flush, his urine leaves dark stains in the toilet.” She is unconcerned because her son already had dark-colored urine as a baby and he has never had any health issues. His vital signs are within normal limits. Physical examination shows no abnormalities. The patient’s condition is most likely associated with impaired formation of which of the following?

Answer: Maleylacetoacetate

A. Cystathionine

B. Methylmalonate

C. Tyrosine

D. Maleylacetoacetate


Question: A 72-year-old man presents with a recent episode of slurred speech and numbness in his left arm and left leg 2 hours ago that resolved completely within 45 minutes. He says he was having breakfast when he noticed that he had difficulty talking and the left side of his body was numb. The patient denies any past similar symptoms. Past medical history is significant for type 2 diabetes mellitus, hypertension, and ischemic heart disease. He had a coronary artery bypass graft 12 years ago and a percutaneous intervention 3 years ago. Current medications are aspirin, metformin, nitrates, and rosuvastatin. His vital signs include: blood pressure 143/97 mm Hg, pulse 80/min, oxygen saturation 98% on room air. On physical examination, the patient is alert and oriented. Higher mental functions are intact. Muscle strength is 5 out of 5l in both upper and lower limbs bilaterally. The sensation is intact. Cerebellar signs are absent and his gait is normal. Which of the following is the next best step in the management of this patient?

Answer: Admit the patient for observation and workup

A. Add clopidogrel and discharge the patient

B. Admit the patient for observation and workup

C. Discharge now and ask him to visit again when symptoms reoccur

D. Start antiepileptic drugs


Question:
A 29-year-old man is brought to the emergency department after being found unresponsive at home. The patient's roommate says that the patient had previously been feeling well. The patient and his roommate had a celebration the night before, where they drank homemade liquor. His temperature is 37°C (98.6°F), pulse is 126/min, respirations are 30/min and shallow, and blood pressure is 84/44 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. He is unresponsive to painful stimuli. The pupils are 3 mm, equal, round, and reactive to light. The lungs are clear to auscultation. Cardiac examination shows a grade 2/6 systolic murmur along the left parasternal border. Laboratory studies show:
Serum
Na+ 146 mmol/L
K+ 7.7 mmol/L
Cl- 111 mmol/L
Urea nitrogen 5.8 mmol/L
Glucose 83 mg/dL
Lactate 11.2 mmol/L
Serum osmolality 379 mosm/kg
Arterial blood gas analysis shows:
pH 6.69
pCO2 53 mm Hg
pO2 84 mm Hg
HCO3- 4.3 mmol/L
The patient is intubated and fluid resuscitation is begun. Which of the following is the most appropriate pharmacotherapy?"

Answer: Fomepizole

A. N-acetylcysteine

B. Fomepizole

C. Naloxone

D. Flumazenil


Question: A 22-year-old woman presents with an episodic history of swelling of the face, hands, and neck and a single episode of difficulty swallowing. She also has a history of frequent, severe abdominal pain. At the time of her visit, her blood pressure is 126/84 mm Hg, heart rate is 82/min, and respiratory rate is 15/min. Physical examination is unremarkable except for a swollen right hand as shown in the image below. Imaging studies are normal and do not reveal any cause of her pain. Her C1 inhibitor level is less than 6% of the reference value. Which of the following is the most likely diagnosis for this patient?

Answer: Hereditary angioedema

A. DiGeorge syndrome

B. Hereditary angioedema

C. Paroxysmal nocturnal hemoglobinuria

D. Chediak-Higashi syndrome


Question: A 60-year-old man calls his hospital and asks to speak to his physician about laboratory test reports ordered because of a 3-month history of abdominal fullness and generalized fatigue. The referral note shows that he was constipated for the previous week. His abdominal examination had shown distention, and a 7-cm, hard, irregular, nontender mass was palpable on rectal examination. His colonoscopy report reveals a low anterior circumferential rectal lesion. An MRI of the pelvis shows a rectal mass with involvement of the prostate and seminal vesicles. A brief review of the results shows that an endoscopic biopsy confirms the clinical diagnosis of advanced rectal adenocarcinoma. His serum carcinoembryonic antigen concentration is 21.0 ng/mL (N < 2.5). The physician is tasked with delivering the diagnosis to the patient. Which of the following is the most appropriate statement by the physician at this time?

Answer: """I would like to meet later today at 4:00 PM so that we have enough time to discuss the lab results. If you'd like a friend or family member to accompany you, feel free to bring them along."""

A. """Your lab reports show that you have a locally advanced rectal adenocarcinoma"""

B. """Would you like to know all the details of your diagnosis, or would you prefer I just explain to you what our options are?"""

C. """I would like to meet later today at 4:00 PM so that we have enough time to discuss the lab results. If you'd like a friend or family member to accompany you, feel free to bring them along."""

D. """You must be be curious as to why all these tests were ordered, and you may even be anxious about the results."""


Question: A 50-year-old man has a kidney transplantation for end-stage renal disease in the setting of long-standing polycystic kidney disease. His postoperative course is uncomplicated. He had smoked one pack of cigarettes daily for 20 years but quit 5 years ago. He does not drink alcohol or use illicit drugs. Current medications include basiliximab, mycophenolate mofetil, and prednisone. His vital signs are within normal limits. On physical examination, the surgical incisions appear clean and intact. Prior to discharge, administration of which of the following is most appropriate in this patient?

Answer: Trimethoprim-sulfamethoxazole

A. Azithromycin

B. Trimethoprim-sulfamethoxazole

C. Acyclovir

D. Varicella vaccine


Question:
A 28-year-old woman, gravida 1, para 0, at 32 weeks' gestation comes to the physician for a prenatal visit. She has had no prenatal care. She emigrated from China 5 years ago and cannot recall all of her vaccinations. She appears well. Physical examination shows a uterus consistent in size with a 32-week gestation. Serum studies show:
Anti-hepatitis A IgM antibody negative
Anti-hepatitis A IgG antibody positive
Hepatitis B surface antigen negative
Anti-hepatitis B surface antibody positive
Hepatitis B core antigen negative
Anti-hepatitis B core antibody negative
Which of the following is the most appropriate next step in management?"

Answer: Plan normal vaginal delivery at term

A. Plan normal vaginal delivery at term

B. Determine hepatitis B e antigen serum level

C. Administer hepatitis B vaccine to mother

D. Perform liver biopsy of mother


Question: A 58-year-old woman presents to her family physician for an annual checkup. During the visit, the patient asks her physician for help quitting smoking cigarettes. She has unsuccessfully tried quitting several times previously and has also failed prior attempts with meditation and exercise. The physician prescribes a partial agonist of the nicotinic receptor to aid the patient in cessation. Which of the following is a potential side effect of this medication?

Answer: Suicidal ideation

A. Seizure

B. Sexual dysfunction

C. Suicidal ideation

D. Tachycardia


Question: A 57-year-old man with chronic obstructive pulmonary disease comes to the emergency department because of leg swelling for 2 weeks. He has smoked 2 packs of cigarettes daily for the past twenty years. His vital signs are within normal limits. Physical examination shows jugular venous distention, hepatomegaly, and pitting edema of both lower extremities. Cardiac examination shows a regular heart rate and normal heart sounds. Auscultation of the lungs shows scattered wheezing without crackles. Left ventricular ejection fraction is 60%. Which of the following is the most likely underlying cause of this patient's condition?

Answer: Chronic hypoxic vasoconstriction

A. Left-sided systolic heart failure

B. Ventricular septal defect

C. Chronic occlusion of the pulmonary vessels

D. Chronic hypoxic vasoconstriction


Question: A young Mediterranean teen brings her 4-year-old little brother to the Emergency Room because of a high temperature. Their parents are on their way to the hospital, but, in the meantime, she provides some of the history. She explains that he has been running a fever and limping for the past week. This morning, she had trouble awakening him, and she noticed some swelling and redness around his right ankle. In terms of his past medical history, she knows he has something wrong with his blood. He had to receive extra vaccinations as an infant, and he takes an antibiotic everyday. On exam in the ED, his temperature is 102.4 deg F (39.1 deg C), blood pressure is 90/60 mmHg, pulse is 123/min, and respirations are 22/min. He is lethargic, and his exam is noteworthy for erythema and edema in an area surrounding his distal shin. What is the most likely diagnosis?

Answer: Osteomyelitis

A. Dactylitis

B. Avascular necrosis

C. Osteomyelitis

D. Thrombophlebitis


Question:
A 47-year-old man comes to the emergency department complaining of weight gain and abdominal discomfort. He states that over the past month he has gained 10 lbs. This week he began experiencing mild, diffuse abdominal discomfort. He denies nausea, vomiting, constipation, or diarrhea. The patient has not seen a physician in years and takes no medications. He is a truck driver. He states that he drinks a 6-pack of beer per night. On physical examination, there is jaundice, hepatomegaly, and a positive fluid wave. An abdominal ultrasound reveals cirrhosis, portal vein dilation, and moderate ascites. He undergoes a paracentesis that relieves his symptoms. Fluid analysis is shown below:

Serum:
Albumin: 4.0 g/dL

Ascitic fluid:
Color: Yellow
Leukocyte count: 100/mm^3 with 50% neutrophils
Protein: 2.3 g/dL
Albumin: 1.9 g/dL

A culture is pending. He is discharged and instructed to follow-up with a gastroenterologist for an upper endoscopy. Upper endoscopy reveals multiple, small non-bleeding esophageal varices. Which of the following is the next best step in management of the patient’s condition?

Answer: Propranolol

A. Atenolol

B. Ceftriaxone

C. Propranolol

D. Transjugular intrahepatic portosystemic shunt


Question: An 8-month-old boy is brought to the office by his mother for recurrent infections. Over the past 2 months, the boy had multiple visits to the urgent care clinic for respiratory, ear, and skin infections. His mother is concerned about the health of her child. Currently, the child had a runny nose for the last 2 days. There is no fever but the mother adds that the boy is not eating very well. His mother denies any history of infection during her pregnancy and was tested negative for HIV. The patient’s heart rate is 90/min, respiratory rate is 14/min, and temperature is 36.7°C (98.0°F). On physical exam, there are decreased lung sounds in the left lower lobe. A chest X-ray reveals an absent thymic shadow and fails to show any lung pathology. There is no history of similar symptoms in the families of either parent. What is the most likely cause of this patient’s condition?

Answer: Adenosine deaminase deficiency

A. Adenosine deaminase deficiency

B. Hypoxanthine-guanine phosphoribosyl transferase (HGPRT) deficiency

C. HIV infection

D. Purine nucleoside phosphorylase deficiency


Question: A 4-year-old girl is brought to the physician because of a nonpruritic, painless rash on her face for 5 days. She was born at term and has been healthy since. Her 62-year-old maternal grandmother has bullous pemphigoid. Her development is adequate for her age and immunizations are up-to-date. She appears healthy and well-nourished. Her temperature is 37°C (98.6°F) and pulse is 90/min. Examination shows a nontender rash on the right side of the patient's face. An image of the patient's lower face is shown. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Answer: Topical mupirocin therapy

A. Potassium hydroxide preparation

B. Oral cephalexin therapy

C. Skin biopsy

D. Topical mupirocin therapy


Question: A 56-year-old man comes to the physician for a routine health maintenance examination. He has had mild pain in his left groin for 2 weeks. He was admitted to the hospital 1 month ago for myocardial infarction. Cardiac catheterization and angiography showed occlusion of the left anterior descending artery and he underwent placement of 2 stents. He has hypertension and hypercholesterolemia. There is no family history of serious illness. He has smoked 2 packs of cigarettes daily for 30 years. Current medications include aspirin, clopidogrel, rosuvastatin, and enalapril. His temperature is 36.7°C (98°F), pulse is 88/min, and blood pressure is 130/84 mm Hg. Examination shows a 3-cm (1.2-in), tender, pulsatile mass in the left thigh, below the inguinal ligament. There is mild erythema of the overlying skin. A loud murmur is heard on auscultation of the mass. Cardiopulmonary examination shows no abnormalities. There is no edema in the lower limbs. Femoral and pedal pulses are palpable bilaterally. Neurologic examination shows no focal findings. Which of the following is the most likely diagnosis?

Answer: Femoral artery pseudoaneurysm

A. Femoral artery dissection

B. Femoral artery pseudoaneurysm

C. Femoral artery thrombosis

D. Femoral abscess


Question: A 1-year-old girl is brought to the physician because of fever and crying while passing urine for 2 days. She was born at term and has been healthy since. Three months ago, she was treated for a urinary tract infection with oral cefixime. Her temperature is 39°C (102.2°F), pulse is 144/min, and blood pressure is 85/40 mm Hg. Physical examination shows no abnormalities. Her leukocyte count is 14,000/mm3. Urine dipstick shows leukocyte esterase and nitrites; urinalysis shows WBCs and gram-negative rods. Urine culture results are pending. Renal ultrasonography shows hydronephrosis of the left kidney. Empirical antimicrobial therapy is initiated, following which the patient's symptoms improve. Which of the following is the most appropriate next step in diagnosis?

Answer: Voiding cystourethrography

A. Intravenous pyelography

B. Dynamic renal scintigraphy

C. Urodynamic testing

D. Voiding cystourethrography


Question: A 69-year-old woman presents to her primary care physician complaining of a new-onset, left-sided, throbbing headache that has lasted for several days. She reports that the pain is worsened by eating. Which of the following is a complication of this condition if not treated promptly?

Answer: Monocular blindness

A. Skin nodules

B. Intestinal ischemia

C. Monocular blindness

D. Ischemic stroke


Question: A 32-year old woman presents to the office complaining of progressively worsening shortness of breath for 2 months. She was seen multiple times in the past for complications of systemic lupus erythematosus that include anemia, pericarditis, and chronic interstitial lung disease. As she does not have medical insurance, she does not regularly follow up with her physician and also is not compliant with her medications. She does not drink alcohol, smoke cigarettes, or take illicit drugs. Her family history is positive for colon cancer in her father. Her temperature is 36.5°C (97.8°F), the blood pressure is 106/70 mm Hg, the pulse is 84/min, and the respirations are 16/min. Severe clubbing of her fingernails is noted. Which of the following best describes the pathogenesis of this patient's nail findings?

Answer: Entrapment of megakaryocytes in the nail bed

A. Septic emboli

B. Atherosclerotic emboli

C. Entrapment of megakaryocytes in the nail bed

D. Chronic hypoxemia


Question: An otherwise healthy 27-year-old woman presents to the emergency department because of worsening headaches and nosebleeds. Her blood pressure is 185/115 mm Hg, pulse is 88/min and temperature is 36.9°C (98.4°F). She denies the use of nicotine, alcohol, or illicit drugs. Family history is irrelevant. Physical examination is only positive for abdominal bruits. She is given a calcium-channel blocker and a thiazide diuretic, but her blood pressure did not respond adequately. Aldosterone-to-renin ratio is < 20. Which of the following is the most likely cause of this patient’s condition?

Answer: Renal artery stenosis

A. Renal artery stenosis

B. Essential hypertension

C. Coarctation of the aorta

D. Primary aldosteronism


Question: A 50-year-old farmer from Jamaica presents to his physician with a wart-like lesion on his left foot. He is a plantain farmer and often farms barefoot because of the pleasant climate. Physical examination reveals warty, cutaneous nodules that resemble the florets of cauliflower. On a KOH preparation, irregular, dark brown, yeast-like bodies with septae are noted. Culture on Sabouraud agar reveals sclerotic bodies. Which of the following is the most likely diagnosis?

Answer: Chromoblastomycosis

A. Mycetoma

B. Sporotrichosis

C. Entomophthoromycoses

D. Chromoblastomycosis


Question:
A 52-year-old man comes to the physician because of a 3.6-kg (8-lb) weight loss over the past 3 months and increasing fatigue. He was diagnosed with hepatitis C 6 years ago. His father died of colon cancer. He has smoked one pack of cigarettes daily for 35 years and drinks one beer daily. He used cocaine and heroin in the past but stopped 12 years ago. He is 176 cm (5 ft 8 in) tall and weighs 71 kg (156 lb); BMI is 22.9 kg/m2. His temperature is 37.0°C (98.6°F), pulse is 79/min, and blood pressure is 115/75 mm Hg. He appears weak and lethargic. Examination shows scleral icterus and scars on both cubital fossae. There is reddening of the palms bilaterally. There are several telangiectasias over the chest and back. The abdomen is soft and nontender. The liver is firm and of nodular consistency. Laboratory studies show:
Hemoglobin 11.6 g/dL
Mean corpuscular volume 88 μm3
Leukocyte count 9,600/mm3
Platelet count 223,000/mm3
Ultrasonography of the liver shows a solitary lesion. Which of the following findings is most likely in this patient?"

Answer: Elevated α-fetoprotein

A. Positive blood cultures

B. Elevated α-fetoprotein

C. Elevated carcinoembryonic antigen

D. Spiculated lesion on chest CT


Question: A 63-year-old man comes to the physician for the evaluation of difficulty walking for the last 6 months. He reports weakness in his lower legs that improves with exercise and throughout the day. Three months ago, he started adding flax seeds to his breakfast because he is frequently constipated. He has hypertension and type 2 diabetes mellitus. He has smoked 2 packs of cigarettes daily for the last 45 years. His current medications include enalapril and metformin. Vital signs are within normal limits. Examination shows dry mucous membranes. Muscle strength in the lower extremities is decreased. Sensation to pinprick and light touch is normal. Deep tendon reflexes are 1+ bilaterally. Active muscle contraction or repeated muscle tapping increases reflex activity. Which of the following is most likely to confirm the diagnosis?

Answer: Autoantibodies against voltage-gated calcium channels

A. Demyelinating plaques on a brain MRI

B. Autoantibodies against voltage-gated calcium channels

C. Decremental response following repetitive nerve stimulation

D. Fasciculations and positive sharp waves on EMG


Question: A 5-year-old boy is brought to the emergency department by his mother because of abdominal pain. His mother says that he has not had any fever, vomiting, diarrhea, or dysuria. His last bowel movement was 3 days ago and appeared normal. The boy is restless and clutches his abdomen. His temperature is 37.2°C (99°F), blood pressure is 108/76 mm Hg, pulse is 110/min, respirations are 20/min. The abdomen appears mildly distended. On auscultation, he has hyperactive bowel sounds. The remainder of the examination shows no abnormalities. An ultrasound of the abdomen shows no abnormalities. Which of the following is the most appropriate next step in management?

Answer: Administer polyethyelene glycol

A. Administer polyethyelene glycol

B. Reassurance and observation

C. Perform a barium enema

D. Start empirical antibiotic therapy


Question: A 30-year-old woman presents to the emergency department with chest pain. She states that she was making coffee this morning when she suddenly developed sharp, 8/10, mid-sternal chest pain. The pain does not radiate and is constant. She is worried because she has a marathon next week that she has been training for. Her medical history is significant for seasonal allergies. She takes no medications except a multivitamin. Her mother has asthma. She works as a lawyer. She denies sick contacts or recent travel. She has a glass of wine with dinner but denies tobacco or recreational drug use. The patient’s initial temperature is 98°F (36.7°C), blood pressure is 122/78 mmHg, pulse is 89/min, and respirations are 14/min with an oxygen saturation of 98% on room air. A physical examination is within normal limits. Labs are pending. Which of the following is the best initial step in management?

Answer: Electrocardiogram

A. Aspirin, oxygen, nitroglycerin, and morphine

B. Computerized tomography scan

C. Electrocardiogram

D. Heparin