Question: A 31-year-old man comes to the physician for evaluation of chronic cough, sinus pain, and nasal discharge. He has a history of frequent upper respiratory infections and recurrent sinusitis since childhood. He is also concerned about fertility, as he and his wife have been trying to conceive for 5 years unsuccessfully. Pulmonary examination shows crackles and wheezing throughout both lung fields. A CT scan of the chest is shown. The most likely cause of this patient's condition is a defect in which of the following molecular structures?

Answer: Dynein arm

A. IL-2R gamma chain

B. NADPH oxidase

C. CFTR protein

D. Dynein arm


Question: A 3-year-old boy is brought to the emergency department because of abdominal pain and watery diarrhea for the past 3 days. This morning he also had nausea and his stool had a red tint. Four days ago, he and his parents returned home from a vacation, during which they visited a petting zoo and consumed many new foods. He lives with his family and they have cats and dogs at home. The patient attends daycare. His immunizations are up-to-date. His temperature is 38°C (100.4°F), pulse is 140/min, and blood pressure is 80/45 mm Hg. Examination shows dry mucus membranes. The abdomen is soft, and there is tenderness to palpation of the right lower quadrant with rebound. Stool culture grows Yersinia enterocolitica. Which of the following is most likely to have prevented this patient's condition?

Answer: Avoiding the consumption of undercooked pork

A. Hand-washing at daycare

B. Avoiding the consumption of undercooked pork

C. Avoiding the consumption of deli meats

D. Avoiding the consumption of unwashed vegetables


Question: A 61-year-old woman dies unexpectedly. She had not seen a physician in 10 years. Examination of the heart during autopsy shows hypertrophy of the left ventricular wall and enlargement of the left ventricular chamber. Microscopic examination shows lengthening of individual muscle fibers due to duplication of sarcomeres in series. Which of the following is the most likely underlying cause of these findings?

Answer: Increased left ventricular end diastolic volume

A. Increased pulmonary arterial pressure

B. Decreased left ventricular contractility

C. Decreased left ventricular compliance

D. Increased left ventricular end diastolic volume


Question:
A 57-year-old man with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and obstructive sleep apnea presents to your office for routine screening. He reports compliance with his medications but admits to difficulty maintaining the diet and exercise routines discussed during his last visit. He does not have any other complaints. He drinks 3-4 beers on the weekends and does not smoke cigarettes. His current medications include metformin, atorvastatin, and hydrochlorothiazide. On physical examination, his temperature is 99°F (37.2°C), blood pressure is 130/85 mmHg, pulse is 85/min, and respirations are 18/min. Laboratory results are shown below:

Serum:
Na+: 138 mEq/L
Cl-: 100 mEq/L
K+: 3.9 mEq/L
HCO3-: 23 mEq/L
BUN: 13 mg/dL
Glucose: 160 mg/dL

You decide to start the patient on a medication that triggers insulin release. What is the mechanism of action of this drug?

Answer: Close potassium channels

A. Close potassium channels

B. Increase insulin sensitivity

C. Delay gastric emptying

D. Increase ATP generation


Question: A 28-year-old woman presents to the emergency department with fever and abdominal pain for the past several days. She says she feels like she has a slight fever. She denies nausea or vomiting. Physical examination shows pain in the right upper quadrant to deep palpation with rebound tenderness and guarding. A laparoscopy is performed which shows string-like, fibrous scar tissue in the perihepatic recesses. Which of the following is the most likely organism responsible for the patient's condition?

Answer: Neisseria gonorrhoeae

A. Giardia lamblia

B. Gardnerella vaginalis

C. Trichomonas vaginalis

D. Neisseria gonorrhoeae


Question: A 30-year-old woman comes to the emergency department because of a 1-day history of sharp chest pain radiating to the left shoulder. The pain worsens when she coughs, breathes deeply, or lies down. She has had a mild fever and a cough for the past 2 days. She takes ibuprofen for hip and knee pain, which started 4 months ago. Examination shows a symmetric, erythematous rash on her nose and cheeks, and erythematous patches with scaling and plugged follicles over her hands. Cardiovascular evaluation of this patient is most likely to show which of the following findings?

Answer: Triphasic scratchy heart sound of varying intensity

A. Increased distension of jugular veins during inspiration

B. 18 mm Hg decrease in systolic blood pressure during inspiration

C. Triphasic scratchy heart sound of varying intensity

D. Holosystolic blowing murmur heard best at the apex


Question: A 22-year-old man comes to the physician because he has been increasingly worried and stressed in recent weeks. He started a marketing job three months ago, which involves traveling between Washington and California several times a year. Two months ago, he was supposed to fly to Seattle, but he experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane, causing him great embarrassment. He had never been on a plane before; his parents died in a plane crash when he was younger. A week ago, he called in sick when he was supposed to go on a business trip. He worries that he will lose his job. He is otherwise well and has no history of serious illness. He takes no medications. His temperature is 37.2°C (99°F), pulse is 85/min, respirations are 12/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, he is alert and cooperative. His speech is normal and his thought process is organized. His memory, attention, and concentration are intact. Which of the following is the most appropriate next step in management of this patient's symptoms?

Answer: Cognitive behavioral therapy

A. Oral paroxetine

B. Oral alprazolam

C. Observation

D. Cognitive behavioral therapy


Question: A 52-year-old man presents to the office complaining of a 2-week history of fatigue, progressively worsening shortness of breath, and swelling of his lower legs and feet. His past medical history is only significant for slightly elevated blood pressure. The patient denies tobacco use although he does admit to drinking 8-10 beers, daily, for the past 10 years. He takes a low dose of aspirin daily, ever since he had an anterior myocardial infarction 2 years ago. The patient works as a financial consultant and frequently travels for work. The current temperature is 36.8°C (98.3°F), the pulse rate is 68/min, the blood pressure is 152/84 mm Hg, and the respiratory rate is 16/min. His weight is 102 kg (224 lb) and height 180 cm (5 ft 9 in). Echocardiography demonstrates an ejection fraction of 35% and a thin left ventricular wall. What is the appropriate medication for this patient’s condition?

Answer: Spironolactone

A. Nifedipine

B. Procainamide

C. Ibuprofen

D. Spironolactone


Question: A 70-year-old man comes to the physician for a follow-up evaluation. Eight months ago, he presented with a 6-month history of increased urinary frequency, difficulty to initiate urination, and straining to maintain the urinary stream. Digital rectal examination showed symmetrically enlarged, nontender prostate with rubbery texture. Laboratory studies showed a prostate-specific antigen (PSA) level of 2 ng/mL. Abdominal ultrasound showed a post-void residual urine volume of 250 ml and bladder wall thickening. The patient received appropriate treatment. His vital signs are within normal limits. Laboratory studies now show a PSA level of 1 ng/mL. Which of the following medications was most likely used to treat this patient's symptoms?

Answer: Dutasteride

A. Oxybutynin

B. Dutasteride

C. Terazosin

D. Tadalafil


Question: A 53-year-old man presents to the office complaining of persistent abdominal pain. He states that he has gained 4.5 kg (10.0 lb) because the pain is only relieved by eating. The patient also admits that he has had numerous loose, foul-smelling stools over the last few weeks with associated nausea. He has taken some over the counter antacids without relief or change in symptoms. His blood pressure is 132/76 mm Hg, respiratory rate is 14/min, and heart rate is 75/min. Physical examination reveals mild tenderness to palpation of the upper abdomen. Which of the following is the most likely diagnosis?

Answer: Zollinger-Ellison syndrome

A. H. pylori infection

B. Intestinal type gastric adenocarcinoma

C. NSAID induced peptic ulcer disease

D. Zollinger-Ellison syndrome


Question: A 68-year-old man with advanced dementia is brought to the preoperative unit prior to an elective cholecystectomy for biliary colic. He says he does not want the surgery anymore. He begins yelling at unit staff and requests to leave. His designated medical power of attorney, who had previously signed the surgery consent forms, is present. Which of the following is the most appropriate next step in management?

Answer: Ask the patient about his concerns and try to address them

A. Cancel the surgery and allow the patient to leave

B. Ask the patient about his concerns and try to address them

C. Call family members and schedule a family meeting

D. Perform cognitive screening evaluation


Question: A 67-year-old man presents to his physician’s office with a progressive cough. It has been increasing in intensity over the past week. He has also been noticing an increase in the amount of sputum he usually produces, which is thick and yellow. He also complains of increased difficulty in breathing, more so than he previously experienced. He was diagnosed with chronic obstructive lung disease (COPD) about 3 years ago and has been on treatment for it since then. He doesn’t report any fever, chills, or night sweats. He has observed a foul smell to his sputum. His blood pressure is 100/65 mm Hg, the respirations are 23/min and the pulse is about 110/min. Currently, his FEV1 is around 48% of the normal predicted value. He is currently receiving a yearly influenza shot and has taken the pneumococcal vaccination at the time of his diagnosis. In spite of this, he has had acute exacerbations of his symptoms 4 times over the last year. His last episode was 2 months ago, for which he was treated with a short course of antibiotics. He is also currently receiving treatment for diabetes. Which of the following pathogens should be considered before initiating treatment for the current episode?

Answer: P. aeruginosa

A. S. pneumonia

B. H. influenzae

C. P. aeruginosa

D. Syncytial virus


Question: A 27-year-old man who was involved in a motor vehicle collision is brought into the emergency room with a fractured skull. The paramedics report that the patient was conscious and lucid on the way to the hospital but now is unresponsive. His vitals are a blood pressure of 122/78 mm Hg, temperature of 37.0°C (98.6°F), pulse rate of 88/min, and respiratory rate of 14/min. A noncontrast CT scan of the head shows an epidural hematoma. Which of the following structures is involved in the development of an epidural hematoma?

Answer: Middle meningeal artery

A. Middle meningeal artery

B. Bridging cortical veins

C. Arteriovenous malformation

D. Lenticulostriate vessels


Question: A 54-year-old woman presents to the emergency department due to recent onset of a high fever, accompanied by severe headache and neck stiffness. Her past medical history is significant for rapidly progressive glomerulonephritis. She is currently on immunosuppressants after a kidney transplant performed 6 months ago. On presentation, her temperature is 102.2°F (39°C), blood pressure is 112/71 mmHg, pulse is 107/min, and respirations are 22/min. Physical exam reveals severe pain with neck flexion and reciprocal knee flexion. Laboratory tests reveal a gram-positive organism with endotoxin. Which of the following characteristics is true of the most likely cause of this patient's disorder?

Answer: Tumbling motility in broth

A. Anaerobic spore forming rods

B. Catalase-negative

C. Coagulase-positive

D. Tumbling motility in broth


Question: A 2-year-old boy is brought to see the pediatrician by his mother due to a “bad” cough. The mother reports that he has been coughing so hard that he threw up on several occasions. He is adopted and the mother does not know his vaccination history. He has no known allergies. His temperature is 38.5°C (100.5°F), pulse is 120/min, respirations are 33/min, blood pressure is 101/54 mm Hg, and oxygen saturation is 96% on room air. The boy looks unwell with mild difficulty breathing and a nonproductive cough multiple times followed by a “whoop” sound during the inhalation. He has scattered petechiae on his face. A nasopharyngeal swab is sent for culture and PCR. Which of the following antibiotics is recommended for this patient?

Answer: Erythromycin

A. Ceftriaxone

B. Cefotaxime

C. Erythromycin

D. Ampicillin


Question: A 19-year-old man returns from travel in South America. He presents complaining of profuse, watery diarrhea. You suspect the causative organism to be Enterotoxigenic E. coli. What is the mechanism by which this organism causes diarrhea?

Answer: Stimulates adenylate cyclase (increasing cAMP)

A. Blocks the release of inhibitory neurotransmitters GABA and glycine

B. Blocks the presynaptic release of acetylcholine at the neuromuscular junction

C. Stimulates release of cytokines

D. Stimulates adenylate cyclase (increasing cAMP)


Question: A 38-year-old man presents to the clinic for complaints of abdominal pain and diarrhea. He reports a long-standing history of the symptoms except for the time when he attempted a carbohydrate-free diet 5 years ago. The pain is described as stabbing, diffuse, 8/10, and is especially worse following food intake. Recently, he noticed some numbness and tingling of his feet but denies any bloody stool, nausea, vomiting, fevers, weight loss, or focal neurological deficits. What histopathological findings would you expect to find in this patient?

Answer: Blunting of the intestinal villi at the ileum

A. Blunting of the intestinal villi at the ileum

B. Crypt abscesses at the descending colon

C. Noncaseating granulomas at the ileum

D. Normal gastric mucosa at the jejunum


Question: A 25-year-old male presents for a new primary-care visit. He has never been seen by a physician and reports that he has been in good health. You note a very tall, very thin male whose arm span is greater than his height. The patient reports that his father had a similar build but passed away suddenly in his 40s. You suspect a genetic disorder characterized by a defect in fibrillin-1. What is the histopathology of the most common large-artery complication of this disease?

Answer: Cystic medial degeneration

A. Focal granulomatous inflammation with mural lymphocytes, macrophages, giant cells

B. Predominant neutrophilic infiltration with fibrinoid necrosis

C. Fibrinoid necrosis of blood vessel walls, endothelial swelling, and neutrophilic infiltrate in skin lesions

D. Cystic medial degeneration


Question: A group of investigators is evaluating the efficacy of intranasal ketamine in decreasing acute suicidality in teenagers admitted to inpatient psychiatric units. They conducted a pilot study in which 15 participants were randomized to receive intranasal ketamine while 15 participants were randomized to receive placebo. The investigators ultimately found no statistically significant difference in suicidality after 30 days of follow up with the level of significance fixed at 5%. They suspect inadequate statistical power. Assuming the investigators intend to keep the level of significance at 5%, which of the following changes would be most effective to increase the statistical power?

Answer: Decrease the type II error rate

A. Decrease the sample size

B. Decrease the type II error rate

C. Increase beta

D. Increase the type I error rate


Question: A 56-year-old man presents with severe back pain for the past hour. He says the pain started about 1 hour ago and has not improved. The patient describes the pain as sharp, 10/10, and located between his scapula. Past medical history is significant for hypertension, which he is noncompliant with medication. His vital signs are a blood pressure of 180/95 mm Hg and a pulse of 108/min. On physical examination, there is a loss of pain and temperature sensation in the lower trunk and extremities bilaterally. Strength is 4 out of 5 in all muscle groups in the lower extremities bilaterally. A contrast CT of the chest reveals findings consistent with a type B aortic dissection. Which of the following etiologies is the most likely cause of this patient’s neurologic findings?

Answer: Anterior cord syndrome

A. Brown-Séquard syndrome

B. Spinal cord compression

C. Anterior cord syndrome

D. Spinal epidural hematoma


Question: A 7-year-old girl is brought to the physician by her mother because of a 6-month history of worsening fatigue and frequent upper respiratory tract infections. She is at the 2nd percentile for height and 10th percentile for weight. Physical examination shows pallor, diffuse hyperpigmented macules, absence of the radial bones, and hypoplastic thumbs. Her hemoglobin concentration of 8.7 g/dL, leukocyte count is 2,500/mm3, and platelet count is 30,000/mm3. This patient's condition is most likely caused by a defect in a gene encoding a protein that is normally involved in which of the following processes?

Answer: DNA interstrand crosslink repair

A. Hydrolysis of glucocerebroside

B. DNA interstrand crosslink repair

C. Maturation of erythroid progenitor cells

D. Ras signal transduction pathway


Question:
A 36-year-old woman is brought to the emergency department because of loss of consciousness. Her husband says that she complained of vomiting and dizziness for 2 days, but did not seek medical care. She has a history of acral vitiligo. Her blood pressure is 90/60 mm Hg, temperature is 35.9°C (96.6°F), and pulse is 90/min. On physical examination, she is obtunded, skin turgor is reduced, and her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks. Lab results are shown:
Random plasma glucose 40 mg/dL
Serum osmolarity 275 mOsm/kg H₂O
Serum sodium 130 mEq/L
Serum potassium 6 mEq/L
Urine sodium level 30 mEq/L
ECG shows normal sinus rhythm without ST-T wave changes. Dextrose 5% is given and random plasma glucose becomes 60 mg/dL, but her blood pressure is still the same. Which of the following is the best next step in the management of this patient condition?

Answer: Normal saline and intravenous dexamethasone

A. Intravenous calcium gluconate

B. ACTH stimulation test

C. Oral dehydroepiandrosterone (DHEA)

D. Normal saline and intravenous dexamethasone


Question: A 4-year-old girl is seen by her pediatrician for developmental delay. One year prior, the patient was able to ride a tricycle, stack 3 blocks, and speak in short sentences. Now, she is unable to feed herself and has recently started to point to objects she wants rather than asking. Physical exam reveals a well nourished child sitting in a stroller wringing her hands. Vital signs are normal. The patient's mother reports that her 7-year-old son is doing well, and that they have no family history of mental retardation or other cognitive disorders. What is the most likely diagnosis?

Answer: Rett syndrome

A. Angelman syndrome

B. Rett syndrome

C. Prader-Willi syndrome

D. McCune-Albright syndrome


Question: A 49-year-old woman visits the emergency department with the acute onset of severe shortness of breath. She also reports right-sided calf pain that developed after a 22-hour flight from Beijing to Los Angeles, and that, several hours after she felt pain in her calf, she began to have trouble breathing. Currently, her shortness of breath is so severe that she is unable to speak clearly or quickly, but she manages to deny any recent surgery or history of recent bleeding. The vital signs include: blood pressure 111/69 mm Hg, pulse 142/min, and respiratory rate 33/min. On observation, she is using accessory muscles to breathe. On auscultation, her lungs are clear and her heart rate is rapid but regular. Her right calf is swollen, warm, and tender. The arterial blood gas test result reveals a pH of 7.5, partial pressure of carbon dioxide (PCO2) 22 mm Hg, and a partial pressure of oxygen (PaO2) 47 mm Hg on 6 L of oxygen by nasal cannula. Which of the following is the most appropriate next step in the management of this patient?

Answer: Streptokinase

A. Unfractionated heparin

B. Streptokinase

C. Low molecular-weight heparin

D. Embolectomy


Question: A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor. She has had no prenatal care. Her three children were delivered by lower segment transverse cesarean section. The patient appears in acute distress. Her pulse is 98/min, respirations are 15/min, and blood pressure is 130/80 mm Hg. The abdomen is nontender and contractions are felt. The fetus is in a cephalic presentation. The fetal heart rate is reactive with no decelerations. One hour following vaginal delivery, the placenta is not delivered. Manual separation of the placenta leads to profuse vaginal bleeding. A firm, nontender uterine fundus is palpated at the level of the umbilicus. Which of the following is the most likely diagnosis?

Answer: Placenta accreta

A. Uterine rupture

B. Placenta previa

C. Placenta accreta

D.
Abruptio placentae
"


Question: A 40-year-old man is brought to the clinic by his wife with a complaint of behavioral changes for the past few months. He is irritable and gets angry with trivial matters. He sometimes screams in the middle of the night and remains restless. His wife has recently noticed that he is forgetting things and repeats the same question multiple times. For the past few weeks, he is also having abnormal movements of his body, more prominent in the arms and hands. The past medical history is unremarkable. His father died at the age of 28 years old in a road traffic accident. His grandmother had similar symptoms after her retirement. He does not smoke, drinks alcohol, or uses illicit drugs. The physical examination reveals a restless ill-groomed man. He is having intermittent involuntary dance-like movements. The slit-lamp ophthalmic examination is normal. His mini-mental state examination (MMSE) score is 22/30. The complete blood count, basic metabolic profile, thyroid profile, liver profile, serum vitamin B12, and ceruloplasmin levels are within normal range. An MRI of the brain will reveal an atrophy of which of the following structure?

Answer: Caudate nucleus

A. Caudate nucleus

B. Cerebellum

C. Diffuse cortex

D. Frontal and temporal lobes


Question: A researcher is studying the association between hemoglobin levels and BMI. He divides volunteers who wish to participate into 2 groups based on their BMI, a normal weight group and an overweight group. He then measures the hemoglobin level of all of the volunteers. His null hypothesis is that there is no association between hemoglobin levels and body weight. The mean hemoglobin level for the normal weight group is 13.4 g/dL and 13.8 g/dL for the overweight group. He obtains a mean difference of 0.4 g/dL between the 2 groups. He does an unpaired t-test and gets a p-value of 0.10. Which of the following statements best describes the study?

Answer: If the null hypothesis is true, there is a 10% probability to get this difference of 0.4 g/dL or higher due to chance.

A. If the null hypothesis is not true, 10% or more of the volunteers would not show any association between hemoglobin level and weight.

B. If the null hypothesis is not true, there is still a 10% probability to not get this difference of 0.4 g/dL or higher due to chance.

C. If the null hypothesis is true, there is still a 10% probability of not getting this difference of 0.4 g/dL or higher due to chance.

D. If the null hypothesis is true, there is a 10% probability to get this difference of 0.4 g/dL or higher due to chance.


Question: A 51-year-old female with a history of papillary thyroid carcinoma who is two weeks status-post thyroidectomy presents to her surgeon complaining of difficulty with her voice. Following the operation, she developed immediate hoarseness and difficulty speaking. The hoarseness has not improved since the operation. Her past medical history is notable for hypertension and obesity. Her temperature is 99°F (37.2°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 16/min. Physical examination reveals a healing surgical scar without evidence of infection or dehiscence. Which of the following embryologic structures most likely gave rise to the structure that was damaged in this patient?

Answer: Sixth branchial arch

A. First branchial arch

B. Second branchial arch

C. Fourth branchial arch

D. Sixth branchial arch


Question: Six days after admission to the hospital for treatment of infective endocarditis, a 64-year-old woman develops persistent ringing in both ears, lightheadedness, and nausea. When she turns her head, she sees the light on the ceiling swinging from side to side. She has congestive heart disease, hypertension, and coronary artery disease. She was treated for a cerebrovascular accident 7 years ago and has no residual deficits. Current medications include intravenous vancomycin and gentamicin, as well as oral aspirin, atenolol, furosemide, and lisinopril. Her vital signs are within normal limits. Cardiac examination shows a grade 3/6 holosystolic murmur along the left lower sternal border. While the patient fixates on a target, administration of brisk, horizontal head rotations to both sides results in corrective saccades to refixate back to the target. She has an unsteady gait. Muscle strength and sensation are normal. Which of the following is the most likely cause of this patient's current symptoms?

Answer: Medication toxicity

A. Decreased endolymph resorption

B. Suppurative labyrinthitis

C. Medication toxicity

D. Delirium


Question: A patient with congestive heart failure with viral myocarditis due to coxsackievirus infection presents to a local hospital for treatment and then returns home. Which of the following cardiac conditions are the most likely long-term consequence of the patient’s clinical presentation and hospitalization?

Answer: Dilated cardiomyopathy

A. Concentric hypertrophy

B. Dilated cardiomyopathy

C. Endarteritis obliterans

D. Hypertrophic cardiomyopathy


Question: A 5-year-old male presents to the pediatrician with his mother for a well child visit. His mother has no complaints. The patient is doing well in preschool and appears to be ready for kindergarten. He can begin to sound out letters and write out his first name. He has many friends at school and enjoys playing with his older siblings. The patient’s past medical history is notable for birth weight in the 99th percentile and unexplained hypoglycemia in the first week of life. The patient’s mother denies any family history of genetic syndromes or malignancy. The patient’s height and weight are in the 99th percentile. On physical exam, the patient has an enlarged tongue with no other dysmorphic features. He also has the physical exam findings seen in Figures A and B. This patient should be screened for abnormalities in which of the following organs?

Answer: Kidneys

A. Adrenal glands

B. Bone

C. Eyes

D. Kidneys


Question: A first-year medical student undergoes a surgical procedure involving a midline laporotomy incision. The patient presents back to the surgeon approximately 3 months later and asks the surgeon: "What type of tissue is causing the scar to form on my abdomen?" The physician promptly answers:

Answer: Type 1 collagen

A. Keratin

B. Type 1 collagen

C. Type 2 collagen

D. Type 4 collagen


Question: A 40-year-old female complains of muscle weakness. Her blood pressure is 180/140 mm Hg, and serum potassium is 3.2 mEq/L. Plasma renin levels are abnormally low. A CT scan of her abdomen reveals a 3 cm lesion in her right adrenal gland. The patient’s lesion is likely composed of functional cells from which of the following regions:

Answer: Zona glomerulosa

A. Zona glomerulosa

B. Zona fasciculata

C. Adrenal medulla

D. Posterior pituitary


Question: A 75-year-old woman is brought to the physician by her daughter because of a 1-month history of fatigue and a 3.5-kg (7-lb) weight loss. The patient has a history of hypertension, hyperlipidemia, and Alzheimer's dementia. She lives with her daughter and requires assistance with all of her banking and meal preparation. Her daughter has hypothyroidism but there is no other history of serious illness in the family. She does not remember the names of her medications but says she takes them every day. Her pulse is 114/min and blood pressure is 148/101 mm Hg. Physical examination shows warm skin and a tremor. The thyroid gland is not palpable. The serum thyroid stimulating hormone level is undetectable. Histological examination of a thyroid biopsy shows follicular atrophy. Which of the following is the most likely underlying cause of this patient's symptoms?

Answer: Exogenous levothyroxine use

A. Graves disease

B. Exogenous levothyroxine use

C. Granulomatous thyroiditis

D. Iodine exposure


Question: A 42-year-old man is brought to the emergency department by EMS from the scene of an automobile accident, where he appeared to be an unrestrained passenger. The patient is confused and unable to answer questions. His temperature is 98.6°F (37°C), pulse is 120/min, blood pressure is 75/44 mmHg, and respiratory rate is 22/min. On physical exam, there is bruising over his sternum and left chest, with tenderness to palpation. Cardiac auscultation reveals normal heart sounds with no murmurs, rubs, or gallops. He has marked jugular venous distention and bibasilar crackles on pulmonary auscultation with equal air entry bilaterally. Abdominal and cranial nerve exams are within normal limits. His extremities are cool with prolonged capillary refill, and he is diaphoretic. The patient is admitted to the intensive care unit and hemodynamic monitoring is established, which reveals a pulmonary capillary wedge pressure (PCWP) of 22 mmHg (normal range 8-12 mmHg), central venous pressure (CVP) of 12 cmH2O (normal range 4-12 cmH2O), cardiac output (CO) of 2.2 L/min (normal range 4-8 L/min), and systemic vascular resistance (SVR) of 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5). Which of the following types of shock best describes this patient's condition?

Answer: Cardiogenic

A. Cardiogenic

B. Anaphylactic

C. Neurogenic

D. Obstructive


Question: A 23-year-old man comes to the emergency department complaining of 10/10 abdominal pain. He describes the pain as sharp, stabbing, intermittent, and concentrated at the left lower quadrant. It started about 3 hours ago with no obvious precipitating factor. He reports multiple similar episodes in the past but they have all resolved within 1 hour or so. He denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes but endorses “red-colored urine” for the past day. He just returned from an extensive hiking trip in Colorado. A radiograph of the abdomen was unremarkable. What is the most likely explanation for this patient’s presentation?

Answer: Hereditary defect of amino acid transporter in the kidney

A. Hereditary defect of amino acid transporter in the kidney

B. Infection with urease positive bacteria

C. Presence of antibodies to the glomerular basement membrane

D. Thinning and splitting of the glomerular basement membrane


Question: A 33-year-old African American woman presents to the emergency department due to diffuse pain and fatigue. The woman states that she feels like her bones and muscles diffusely hurt. She also has experienced some abdominal pain as well and states that she has trouble focusing. The patient has a past medical history of sickle cell disease for which she takes hydroxyurea. Her temperature is 98.1°F (36.7°C), blood pressure is 119/59 mmHg, pulse is 130/min, respirations are 16/min, and oxygen saturation is 98% on room air. Laboratory values are ordered and are currently pending. Which of the following is a side-effect of definitive treatment for this patient?

Answer: Tetany

A. Dilute urine

B. Peaked T-waves on ECG

C. QT shortening on ECG

D. Tetany


Question: A 40-year-old man with psoriatic arthritis comes to the physician because of progressively worsening pain and stiffness in both of his hands and feet for the past 3 weeks. His psoriatic arthritis had been well-controlled with adalimumab for several years prior to this. His only other medication is omeprazole. Physical examination shows scaly plaques on both elbows and limited range of motion of most of the larger joints. Which of the following is the most likely underlying mechanism of the recurrence of this patient's symptoms?

Answer: Formation of antidrug antibodies

A. Suppression of the bone marrow

B. Decreased ionization by the glomeruli

C. Formation of antidrug antibodies

D. Increased acetylation by the liver


Question: A 35-year-old African American female presents to the emergency department with a three day history of cough, chest pain, and fever. Upon presenting to the emergency department, her temperature is 101.4 °F (38.5 °C), blood pressure is 110/80 mmHg, pulse is 95/min, and respirations are 24/min. Lung auscultation reveals crackles over the left lung base. Chest radiograph reveals a dense consolidation in the left lower lung. The patient undergoes lab tests in the emergency department that demonstrate an elevated level of C-reactive protein. This abnormal lab finding was most likely caused by increased activity of which of the following mediators?

Answer: IL-6

A. IL-12

B. IL-8

C. IL-6

D. IL-2


Question: A 50-year-old man comes to the physician after a fall on a flight of stairs earlier that day. He slipped, causing him to fall and hit the handrail with the lateral part of his chest. He has no shortness of breath. He returned from a 10-day trip to South Africa 4 weeks ago. He smoked one pack of cigarettes daily for 10 years but stopped 18 years ago. He drinks 1–2 beers a week. His temperature is 37.1°C (98.8°F), pulse is 78/min, and blood pressure is 126/72 mm Hg. Examination shows normal breath sounds bilaterally. The left lateral chest wall is tender to palpation. An x-ray of the chest shows no fracture; there is a 5-mm lesion in the right upper lung field. There are no previous x-rays of the patient available. Which of the following is the most appropriate next step in management?

Answer: CT scan of the chest

A. Follow-up x-ray of the chest in 12 months

B. Positron emission tomography

C. CT scan of the chest

D. Reassurance


Question:
A 62-year-old woman presents to a clinic with complaints of a worsening rash on her back, fevers with chills, and rigor for 2 days. She denies any headaches, nausea, or vomiting. She is currently on chemotherapy for multiple myeloma, which was diagnosed last year. On examination, there were multiple punched-out ulcers covered in crusts surrounded by raised, violaceous margins on her back. Some of the lesions have black necrotic centers. The vital signs include: temperature 38.8°C (102.0°F), respirations 24/min, pulse 110/min, and blood pressure 100/90 mm Hg. Laboratory studies show:
Hemoglobin 8.4 g/dL
White blood cell (WBC) count  1,500/mm3
Platelets 300,000/mm3
Which of the following organisms is most likely responsible for this patient’s condition?

Answer: Pseudomonas aeruginosa

A. Pseudomonas aeruginosa

B. Streptococcus pneumoniae

C. Haemophilus influenzae

D. Streptococcus pyogenes


Question: An 8-year-old boy developed nausea, abdominal pain, and watery diarrhea 6 hours after consuming homemade mushroom soup. The boy is rushed to the emergency department. He is severely dehydrated and his blood pressure is 60/40 mm Hg. He is managed with intravenous fluids and other supportive treatment. The mushrooms in the soup had been picked from his family's backyard, and samples of mushrooms were sent to the lab for analysis. The lab reports confirmed that the mushrooms contained some kind of toxin. Which of the following enzymes is most likely inhibited by this toxin?

Answer: RNA polymerase II

A. DNA gyrase

B. RNA polymerase II

C. RNA polymerase I

D. RNA polymerase III


Question:
A 6-year-old girl is brought to the physician because of generalized fatigue and dark urine for 4 days. Four weeks ago, she was treated with cephalexin for a skin infection. Her temperature is 37°C (98.6°F) and blood pressure is 132/89 mm Hg. Physical examination shows 1+ pretibial edema bilaterally. Her serum creatinine is 1.7 mg/dL. Urine studies show:
Blood 2+
Protein 2+
RBC 12–14/hpf with dysmorphic features
RBC casts numerous
Which of the following is the most likely cause of these findings?"

Answer: Granular subepithelial immune complex deposition

A. Granular subepithelial immune complex deposition

B. Systemic amyloid protein aggregation

C. Anti-type IV collagen antibody formation

D. DNA-anti-DNA antibody immune complex formation


Question: A 7-year-old girl is brought to the physician by her mother for a 6-month history of irritability. She has no history of significant illness and is up-to-date on her immunizations. She appears markedly lethargic. Her vital signs are within normal limits. Physical examination shows subconjunctival pallor. Her hemoglobin concentration is 9.2 g/dL and mean corpuscular volume is 76 μm3. A photomicrograph of a wet stool mount is shown. Which of the following infectious agents is the most likely cause of these findings?

Answer: Necator americanus

A. Necator americanus

B. Enterobius vermicularis

C. Trichuris trichiura

D. Taenia solium


Question: A 15-year-old girl is brought to the physician by her mother because of a 3-day history of lower abdominal pain. Over the past 9 months, she has had multiple similar episodes of abdominal pain, each lasting for 4–5 days. Menarche has not yet occurred. Examination shows suprapubic tenderness to palpation. Pubic hair and breast development are Tanner stage 4. Pelvic examination shows bulging, bluish tissue 1 cm inside the vaginal introitus. Which of the following is the most likely diagnosis?

Answer: Imperforate hymen

A. Labial adhesions

B. Androgen insensitivity

C. Endometriosis

D. Imperforate hymen


Question: A 6-year-old boy presents with high fever, sore throat, and cough for the past day. The patient’s mother also says he is complaining of generalized muscle aches and chills. Past medical history is significant for childhood asthma, managed with inhaled mometasone furoate. The patient’s temperature is 39.1°C (102.3°F), pulse is 120/min, and respiratory rate is 20/min. On physical examination, his oropharynx is erythematous with mild swelling of the pharyngeal tonsils. Chest auscultation reveals crepitus over the lung bases bilaterally. There are no signs of respiratory distress. Rapid diagnostic testing for influenza B infection in this patient is positive. In addition to symptomatic treatment, which of the following antiviral drugs would most likely benefit this patient?

Answer: Oseltamivir

A. Amantadine

B. Ribavirin

C. Rimantadine

D. Oseltamivir


Question: A 38-year-old woman presents to the emergency department with nausea and progressive right upper quadrant abdominal pain for the past day. For the past year, she has had occasional pain in her right upper quadrant which is often relieved on its own after a few hours. She was recently diagnosed with multiple gallstones for which she underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago. Past medical history is otherwise unremarkable. On physical examination, there is tenderness over the epigastrium with no guarding or rebound. Vital signs include blood pressure 110/68 mm Hg, pulse 98/min, temperature 36.2°C (97.2°F), and respiratory rate 11/min. Laboratory tests are pending. An imaging study of the abdomen confirms the most likely diagnosis. Which of the following is most likely to be below the normal range in her blood due to her current condition?

Answer: Calcium

A. Trypsinogen

B. C-reactive protein

C. Glucose

D. Calcium


Question: A 42-year-old woman comes to the emergency department because of hematuria and pain in both flanks. She has a history of recurrent urinary tract infections. She also complains of swelling of both feet and facial puffiness. She has passed urinary stones twice before. Her mother also has a history of urinary stone and underwent a kidney transplant. Her temperature is 38.0°C (100.4°F), pulse is 110/min, and blood pressure is 150/98 mm Hg. Abdominal examination shows palpable, bilateral flank masses. Results of a complete blood count are within the reference range. Her serum creatinine concentration is 2.7 mg/dL. Which of the following additional findings is most likely to be seen in this patient?

Answer: Multiple hepatic cysts

A. Osteolytic bone lesions

B. Multiple hepatic cysts

C. Mitral valve stenosis

D. Popliteal aneurysm


Question: A 51-year-old man with a past medical history of peptic ulcer disease currently treated via outpatient triple therapy presents to the urgent care center complaining of acute abdominal pain which began suddenly less than 2 hours ago. The physical examination shows his abdomen to be mildly distended, diffusely tender to palpation, and positive for rebound tenderness. Physical exam is unremarkable. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 96/54 mm Hg, heart rate 112/min, and respiratory rate 19/min. Given the following options, what is the next best step in patient management?

Answer: CT abdomen and pelvis

A. Abdominal radiographs

B. CT abdomen and pelvis

C. H. pylori testing

D. Serum gastrin level


Question: A 10-month-old boy is brought to the physician because of fever and a cough for 3 days. He was treated for otitis media 3 and 4 months ago. He was also treated for pneumococcal pneumonia and H. influenzae meningitis this past month. He was delivered at term. Pregnancy and neonatal period were uncomplicated. He was breast-fed until 6 months of age. He has a maternal uncle who died of recurrent respiratory tract infections at 28 years of age. He is at the 20th percentile for height and the 10th percentile for weight. His temperature is 39°C (102.2°F), pulse is 122/min, and respirations are 44/min. Examination shows crackles at the left lung base. Palatine tonsils are absent. An x-ray shows an infiltrate in the left lower lung lobe. Flow cytometry shows absence of B-cells. Which of the following is mostly responsible for this patient's late onset of symptoms?

Answer: Maternal IgG decreases by 6 months

A. Reduced T-cell receptor excision circles by 6 months

B. Involution of the thymus begins at 6 months

C. Splenic dysfunction occurs by 6 months

D. Maternal IgG decreases by 6 months


Question: A 55-year-old right-handed woman is being evaluated for a long history of numbness and tingling in both of her hands, particularly in the third digits, that is worse at night. She works as a medical office assistant in a local travel medicine clinic. Her past medical history is significant for hypothyroidism, managed medically with thyroxine. Physical examination showed thenar eminence atrophy, decreased sensation in the 3 first digits of both hands that extends proximally, and weakness on thumb abduction and thumb opposition; deep tendon reflexes are normal. Phalen and Tinel tests are positive. Which of the following is the most inclusive list of spinal roots that contribute to the affected nerve in this patient?

Answer: C5, C6, C7, C8, T1

A. C4, C5

B. C6, C7, C8

C. C3, C4, C5

D. C5, C6, C7, C8, T1


Question: A 7-year-old girl is referred to a pediatric cardiologist after a heart murmur was auscultated during a routine school health examination. The patient has not experienced any symptoms of shortness of breath, fatigue, chest pain, or palpitations. She is healthy, does not have any significant medical history, and had an uneventful birth without any complications. Her vital signs are as follows: T 37.2 C, HR 92, BP 104/62, RR 24, SpO2 99%. Physical examination is significant for a midsystolic ejection murmur heard best at the 2nd intercostal space near the left sternal border, a loud S1 heart sound, a widely fixed split S2 heart sound, and no evidence of cyanosis or clubbing. An echocardiogram is conducted and reveals a left-to-right shunt across the interatrial septum. Surgical correction of this patient's condition will most likely prevent which of the following from developing later in life?

Answer: Pulmonary hypertension

A. Arteriovenous fistula

B. Pulmonary stenosis

C. Pulmonary hypertension

D. Aortic root dilation


Question:
A 21-year-old man is brought to the emergency department by the police because of altered mental status. The police found him covering his ears and shouting near a highway rest area. Upon questioning, he was unable to look directly at the police and answer coherently. On the way to the hospital, he reported feeling nauseous and vomited twice. His temperature is 38.2°C (100.8°F), pulse is 100/min, respirations are 28/min, and blood pressure is 110/77 mm Hg. He is admitted to the hospital for evaluation. Three hours after admission, he has a tonic-clonic seizure. Laboratory studies show:
Serum
Na+ 140 mEq/L
Cl- 102 mEq/L
Arterial blood gas analysis on room air:
On admission Three hours later
pH 7.47 7.39
PaCO2 24 mm Hg 31 mm Hg
PO2 84 mm Hg 82 mm Hg
HCO3- 20 mEq/L 18 mEq/L
Which of the following is the most likely explanation of the patient's laboratory findings?"

Answer: Salicylate toxicity

A. Salicylate toxicity

B. Diabetic ketoacidosis

C. Recurrent vomiting

D. Adrenal insufficiency


Question:
A 58-year-old man makes an appointment with his nephrologist because he has been feeling weak and increasingly fatigued over the last month. Specifically, he has not been able to do activities of daily living independently because he feels short of breath after several minutes of activity. His past medical history is significant for rapidly progressive glomerulonephritis that led to kidney failure. He has been on hemodialysis for the last 6 months and has been compliant with attending every dialysis session. Physical exam reveals conjunctival pallor. Laboratory tests are obtained and results are shown below:

Hemoglobin: 8.9 g/dL (normal: 13.5-17.5 g/dL)
Platelet count: 198,000/mm^3 (normal: 150,000-400,000/mm^3)
Mean corpuscular volume: 87 µm^3 (normal: 80-100 µm^3)
Reticulocyte count: 0.1% (normal: 0.5-1.5%)

Based on these findings, the patient is given appropriate treatment to address his symptoms. Which of the following is the most likely mechanism of action for this treatment?

Answer: Activation of receptors on erythroid progenitor cells

A. Activation of receptors on erythroid progenitor cells

B. Chelation of heavy metals

C. Provision of finished blood products

D. Removal of red blood cell clearing organ


Question: A 33-year-old African American woman comes to the physician because of a 4-month history of progressive fatigue, shortness of breath, constipation, and a nonproductive cough. She returned from a trip to Nigeria 6 months ago. Physical examination is unremarkable. Serum calcium concentration is 11.7 mg/dL. An x-ray of the chest shows bilateral hilar lymphadenopathy with coarse, nodular opacities in both lower lobes. A photomicrograph of a biopsy specimen of the affected area of the lungs is shown. Which of the following best describes the pathogenesis of this patient's histopathological findings?

Answer: TNF-α secretion by CD4+ T cells

A. MHC I binding to CD8+ T cells

B. Antigen binding to IgM

C. TNF-α secretion by CD4+ T cells

D. IL-5 secretion by Th2 cells


Question: A 15-day-old female newborn is brought to the physician for evaluation of red eyes with discharge for 3 days. She was born at 37 weeks' gestation to a 26-year-old woman. Pregnancy and delivery were uncomplicated. The mother received irregular prenatal care during the 3rd trimester of pregnancy. Examination of the newborn shows watery discharge in both eyes and mild eyelid swelling. Which of the following is the most likely cause of this patient's presentation?

Answer: Chlamydia trachomatis

A. Staphylococcus aureus

B. Chlamydia trachomatis

C. Neisseria gonorrhoeae

D. Herpes simplex virus 2


Question: An investigator is studying central nervous system neurotransmitters in mice. He injects the spinal cord with a protease that cleaves SNARE proteins, thereby blocking the release of neurotransmitters from the Renshaw cells in the spinal cord. Which of the following consequences would be expected?

Answer: Spastic paralysis

A. Disinhibited behavior

B. Hydrophobia

C. Positive Kernig sign

D. Spastic paralysis


Question: A 32-year-old G2P2 at 33 weeks and 4 days of gestation presents to the emergency room with low-grade fever, mild low back pain, and dysuria for 1 day. She has a history of urinary tract infections, including one during this current pregnancy that was treated successfully with cephalexin. On examination, she is nontoxic but mildly uncomfortable; she has CVA tenderness on her right side. Her urinalysis is positive for leukocyte esterase and nitrites, and she is admitted to the hospital for IV antibiotics with ceftriaxone. Her present condition places her at increased risk for which of the following:

Answer: Preterm labor

A. Low birth weight

B. Pre-eclampsia

C. Postpartum hemorrhage

D. Preterm labor


Question: A 16-year-old African-American boy is brought to the physician because of a 2-month history of progressive right shoulder pain. He has had many episodes of joint and bone pain in the past, and as a child, had recurrent painful swelling of his hands and feet. His brother had a stroke at 6 years of age and now has an intellectual disability. The patient is at the 60th percentile for height and 55th percentile for weight. His vital signs are within normal limits. Physical examination shows tenderness of the right anterior humerus without noticeable swelling or skin changes. Active and passive range of motion of the right shoulder is decreased and there is pain with movement. The leukocyte count is 4600/mm3. An x-ray of the right shoulder shows subchondral lucency of the humeral head with sclerosis and joint space narrowing. Which of the following is the most likely explanation for this patient's symptoms?

Answer: Infarction of the bone trabeculae

A. Infection of the dermis and subcutaneous tissue

B. Infection of the bone

C. Infarction of the bone trabeculae

D. Loss of bone mineral density


Question: A 50-year-old woman comes to the emergency department after waking up with facial swelling and with difficulties swallowing. She was recently diagnosed with hypertension and started on an antihypertensive drug. She follows a strict vegetarian diet. Her pulse is 110/min and blood pressure is 135/85 mm Hg. Physical examination shows marked edematous swelling of the face, lips, and tongue. There is no rash. Serum C4 levels are within the reference range. Which of the following is the most likely cause of this patient's symptoms?

Answer: Impaired breakdown of kinins

A. Deficiency of C1 esterase inhibitor

B. Scombroid poisoning

C. Nonimmunologic release of histamine

D. Impaired breakdown of kinins


Question:
An 82-year-old man presents to the primary care physician with complaints of urinary leakage over the last 2 months. The leakage occurred without any additional symptoms. He has a history of prostatic hyperplasia. The vital signs include: blood pressure 140/90 mm Hg, heart rate 84/min, respiratory rate 18/min, and temperature 36.6°C (98.0°F). Physical examination reveals a palpable and distended bladder. Urinalysis reveals:
Color Yellow
Clarity/turbidity Clear
pH 5.5
Specific gravity 1.015
Nitrites Negative
Leukocyte esterase Negative
Which of the following is the best initial management for this patient?

Answer: Bladder catheterization

A. Anticholinergics

B. Surgery

C. Bladder catheterization

D. Pelvic floor muscle training


Question: A 25-year-old female presents to her geneticist due to the fear that she may have inherited her father's disease. He was diagnosed at the age of 41 when his symptoms of chorea, coordination problems, and cognitive decline begin to occur. He was diagnosed with a disease resulting from the expansion of CAG repeats on chromosome 4 and later developed severe dementia and died at the age of 56. The daughter was found to have double the amount of CAG repeats and was told by the geneticist that she may have an earlier onset with increased severity of disease. What phenomenon describes this?

Answer: Anticipation

A. Variable expression

B. Incomplete penetrance

C. Anticipation

D. Heteroplasmy


Question: A 25-year-old man presents to the emergency department after being rescued from a house fire 30 minutes ago. He is conscious and in distress. On examination, he is noted to have 1st-degree burns involving 54% of his total body surface area. He has type 1 diabetes and takes insulin every day. He is admitted to the burn unit and treated appropriately. Ten days after admission, the physician notices blue-green pus oozing from the burn wounds. He is afebrile with a pulse of 90/min and a blood pressure of 130/80 mm Hg. A sample exudate is collected with a sterile swab and sent to the laboratory for culture, which yields the growth of aerobic gram-negative rods. Which of the following antibiotics will be most effective in treating this patient’s condition?

Answer: Piperacillin with gentamicin

A. Azithromycin with rifampin

B. Piperacillin with gentamicin

C. Piperacillin

D. Ticarcillin


Question: A 67-year-old man with a past medical history of obesity and diabetes presents to the emergency department with fatigue. The patient has become more confused over the past several days and has been urinating profusely. His temperature is 99.0°F (37.2°C), blood pressure is 120/68 mmHg, pulse is 160/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam is notable for a confused man with dry mucous membranes. He is unable to answer simple questions and is moving all extremities spontaneously. Which of the following is also likely to be found in this patient?

Answer: Blurred vision

A. Blurred vision

B. Meningeal symptoms

C. Seizures

D. Tremulousness


Question: A 42-year-old man presents with acute onset jaundice. Past medical history is significant for COPD diagnosed 4 years ago, managed medically, and admission for acute pancreatitis 6 months ago. The patient denies any history of smoking, alcohol use or recreational drugs. Which of the following is the most likely etiology of liver damage in this patient?

Answer: α1-antitrypsin (AAT) deficiency

A. α1-antitrypsin (AAT) deficiency

B. Glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency)

C. Dubin–Johnson syndrome

D. Hepatitis C


Question: An 8-year-old girl presents to the emergency department with respiratory distress, facial edema, and a skin rash after eating a buffet dinner with her family. Her parents say they were eating at a seafood buffet when, all of a sudden, the patient began to cough and feel short of breath. They say nothing like this has ever happened before. The patient has a history of seasonal allergies for which she occasionally takes cetirizine. Her blood pressure is 80/52 mm Hg; heart rate, 122/min; and respiratory rate, 22/min. On physical examination, the patient has severe edema over her face and audible stridor. Of the following options, which is the most appropriate next step in the management of this patient?

Answer: Intramuscular epinephrine

A. Intramuscular epinephrine

B. Intravenous epinephrine

C. Extra-strength topical diphenhydramine

D. Inhaled sodium cromolyn


Question: A 33-year-old man presents to his physician complaining of a small mass he noticed in his scrotum about 1 month ago. The mass feels loosely attached to the right testicle and is firm, and not painful. He has no history of a serious illness and takes no medications. He is married with 2 children. His vital signs are within normal limits. Examination shows a 1-cm spherical mass in the superior part of the right testis that has a smooth border. It transilluminates with a flashlight. The mass does not enlarge when the patient coughs or bears down. Scrotal ultrasonography shows an extratesticular hypoechoic mass near the epididymal head of the right testicle with posterior acoustic enhancement and without internal shadows. Which of the following is the most appropriate next step in management?

Answer: No therapy at this time

A. Ligation of processus vaginalis

B. Microsurgical varicocelectomy

C. Orchiectomy

D. No therapy at this time


Question: A 51-year-old asymptomatic woman undergoes colposcopy due to a high-grade intraepithelial lesion based on a Pap smear. Colposcopy shows a visible lesion 2 cm in diameter located on the posterior cervical lip and confined to the cervix with sharp borders, a coarse mosaic pattern after application of acetic acid, and contact bleeding. The histologic evaluation of the biopsy shows glandular epithelial cells with nuclear hyperchromasia and enlargement, increased mitoses, a fusion of glands, and stromal infiltration to 8 mm. The chest X-ray and abdominal ultrasound are negative for any additional findings. Which of the following interventions is a proper management strategy for the presented patient?

Answer: Modified radical (Wertheim) hysterectomy

A. Loop electrosurgical excision procedure (LEEP)

B. Modified radical (Wertheim) hysterectomy

C. Platinum-based chemotherapy

D. Simple hysterectomy with bilateral salpingo-oophorectomy


Question: A 65-year-old man presents to the Emergency Department complaining of substernal chest pain. An acute coronary event is suspected and a coronary catheterization procedure reveals an atherosclerotic plaque in the patient's left anterior descending artery. In the formation of an atherosclerotic plaque, which of the following pairings is correct?

Answer: Smooth muscle cells (SMC) -- extracellular matrix (ECM) deposition

A. Fibroblasts -- foam cells

B. Smooth muscle cells (SMC) -- extracellular matrix (ECM) deposition

C. Endothelial cells -- downregulation of VCAM-1

D. LDL chemical reduction -- endothelial dysfunction


Question: A 15-year-old boy is brought to the physician by his mother because of a 2-month history of pain in his left hip. The pain started suddenly and has worsened over the past 2 weeks. The pain radiates down the thigh and is aggravated by movement. He had a fall while cycling around a month ago. He had a urinary tract infection 3 months ago that resolved with trimethoprim/sulfamethoxazole. There is no family history of serious illness. His immunizations are up-to-date. He is 165 cm (5 ft 5 in) tall and weighs 85 kg (187 lb); BMI is 31.2 kg/m2. His temperature is 37.5°C (99.5°F), pulse is 65/min, and blood pressure is 104/70 mm Hg. Examination shows an antalgic gait. The left groin is tender to palpation and internal rotation is limited due to pain. Flexing the hip causes external rotation and abduction. His leukocyte count is 9,800/mm3 and erythrocyte sedimentation rate is 12 mm/h. An x-ray of the pelvis is shown. Which of the following is the most appropriate next step in management?

Answer: Surgical pinning of femoral head

A. Long leg cast

B. Surgical pinning of femoral head

C. Intra-articular lidocaine

D. Proximal femoral osteotomy


Question: A 58-year-old man is hospitalized and treated with clindamycin for a pulmonary abscess. During his hospital stay he develops abdominal pain and bloody diarrhea, and has a WBC of 14,000; serum creatinine is 0.9 mg/dL. On teaching rounds, you learn that the responsible pathogen produces a multi-unit toxin that binds to the colonic mucosa, causing actin depolymerization that results in cell death and mucosal necrosis. What is the preferred treatment for this condition?

Answer: Metronidazole

A. Metronidazole

B. Penicillin G

C. Tetracycline

D. Erythromycin


Question: A 61-year-old Caucasian woman presents to her physician for a routine checkup. She has primary hypertension and rheumatoid arthritis. She currently does not report any relevant symptoms, such as weight change, increased or decreased appetite, sleep or mood problems, gastrointestinal symptoms, fever, or night sweats. Her medications include valsartan 160 mg, hydrochlorothiazide 25 mg daily, and methylprednisolone 28 mg every other day. According to her diary, her blood pressure varies from 130/80 to 120/60 mm Hg. In the past year, she had humeral and tibial fractures from a self-height fall and stepping over a fence, respectively, that occurred 6 months apart. She is in menopause and is not on hormone replacement therapy. Currently, she does not smoke but has a 10-pack-year history of smoking. She consumes alcohol occasionally. She weighs 56 kg (123.5 lb), and her height is 169 cm (5 ft 7 in). She does not report a family history of any cancer. Her father died after a myocardial infarction at the age of 63. She performs daily household activities but is not engaged in either aerobic or strength training. She mainly consumes vegetables, cereals, and dairy products. Her blood pressure is 125/80 mm Hg, heart rate is 67/min, respiratory rate is 14/min, and temperature is 36.5°C (97.7°F). Her physical examination is unremarkable. Which result would you expect to find on her screening tests?

Answer: T score –2.01 on DEXA scan

A. A score of 17 on PHQ-9 test

B. T score –2.01 on DEXA scan

C. Dilation of the abdominal aorta on ultrasound examination

D. Presence of focal hyperintensities on mammography


Question: A 24-year-old man is brought to the emergency department by his sister because she has noticed that he has been behaving differently over the past 4 weeks. Today, the patient attempted to set their house on fire while yelling that he was trying to “save us all.” The patient has a history of psychotic symptoms treated with aripiprazole. His sister states that he stopped taking his medications about 3 weeks ago. He works as a dishwasher but has not been to work for several days. His vital signs are within normal limits. Mental status examination shows a blunted affect. Throughout the interview, the patient continuously stares at the ceiling and makes little eye contact with the physician. When asked about the incident today, he states that he has been hearing the voice of “the great one” who has informed him that aliens are in his neighborhood in the form of rats and cockroaches that need to be “torched to prevent the alien invasion.” He is refusing treatment and insists on going home. Which of the following is the most appropriate next step in management?

Answer: Involuntarily hospitalize the patient

A. Administer aripiprazole and follow-up after 24 hours

B. Refer the patient to a psychologist for cognitive behavioral therapy

C. Involuntarily hospitalize the patient

D. Ask the patient's sister to convince him to stay overnight


Question:
A 13-year-old girl is brought to the emergency department by her father because of a severe nosebleed. She takes no medications and has no history of serious medical illness but has had frequent nosebleeds in the past. Physical examination shows brisk bleeding from the right nare and pooled blood in the posterior pharynx. Laboratory studies show:
Hemoglobin 8 g/dL
Platelet count 195,000/mm3
Prothrombin time 12 sec
Partial thromboplastin time 49 sec
Fibrin split products negative
The bleeding time is 11 minutes. Which of the following is the most appropriate pharmacotherapy?"

Answer: Desmopressin

A. Prothrombin complex concentrate

B. Rituximab

C. Desmopressin

D. Intravenous immunoglobulin


Question: A 33-year-old man presents to the emergency department with joint pain. He states that since yesterday he has had joint pain, and today he noticed a rash. The patient does not have a significant past medical history. The patient smokes cigars, drinks 1 to 4 drinks per day, is sexually active, and uses cocaine occasionally. His temperature is 101°F (38.3°C), blood pressure is 125/65 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam reveals pustular skin lesions and an inflamed and painful right knee that is warm to the touch. Which of the following is the most appropriate treatment for the most likely diagnosis?

Answer: Cefixime and azithromycin

A. Cefixime and azithromycin

B. Ceftriaxone

C. Ceftriaxone and vancomycin

D. Piperacillin and tazobactam


Question: A 20-year-old woman presents to a physician following unprotected coitus with her boyfriend about 10 hours ago. She tells the physician that although they usually use a barrier method of contraception, but this time they did not. She does not want to become pregnant. She also mentions that she has been diagnosed with major depression and does not want to take an estrogen-containing oral contraceptive pill. After counseling, the physician prescribes an enteric-coated pill containing 1.5 mg of levonorgestrel. Which of the following is the primary mechanism of action of levonorgestrel?

Answer: Delayed ovulation through inhibition of follicular development

A. Delayed ovulation through inhibition of follicular development

B. Thickening of cervical mucus

C. Atrophy of endometrium

D. Reduction in motility of cilia in fallopian tubes


Question: A 4-year-old girl is brought to the emergency department because of colicky abdominal pain for 1 day. She has had two similar episodes in the past. Urinalysis shows red blood cells and hexagonal-shaped crystals. Urine sodium cyanide nitroprusside test is positive. Further evaluation of this patient is most likely to show which of the following findings?

Answer: Impaired intestinal ornithine reabsorption

A. Increased stool fat content

B. Inability of intercalated cells to secrete H+

C. Impaired intestinal ornithine reabsorption

D. Urease-positive bacteria in the renal pelvis


Question: A 49-year-old woman, gravida 1, para 1, comes to the physician because of shorter and less frequent menstrual periods over the past year. During this time, she has also had frequent mood swings and a 2.5-kg (5-lb) weight loss. She occasionally wakes up at night because she is too warm and sweating profusely. These episodes are followed by chills and anxiety that subside within minutes. She has no history of abnormal Pap smears. She is sexually active with her husband, who had a vasectomy 10 years prior. She is 163 cm (5 ft 3 in) tall and weighs 70 kg (154 lb); BMI is 26 kg/m2. Her temperature is 37°C (98.6°F), pulse is 103/min, respirations are 16/min, and blood pressure is 129/84 mm Hg. Abdominal and genitourinary examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Answer: Measure serum TSH concentration

A. Perform transvaginal ultrasound

B. Measure serum β-hCG concentration

C. Obtain endometrial biopsy

D. Measure serum TSH concentration


Question: An 8-year-old boy is brought by his parents to the emergency department with a tender and swollen right leg. The boy said that he was playing soccer when he accidentally kicked a metal goal post. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. A review of his medical history reveals that he had a fracture of the left tibia at 4-years-old and a fracture of the right radius 6 months ago. Neither of the two was associated with major trauma and both healed well. At the hospital, his vital signs are stable and his sclerae are white-blue. There is no muscular hypotonia. His height and weight are normal for his age and sex and the skin is normal. A tender swelling is present over his right leg and he can not put weight on that leg. The radiograph of his right leg confirms a fracture of the shaft of the tibia at the junction of its upper one-third and lower two-thirds. The clinician suspects physical abuse and orders a skeletal survey. Which of the following findings is most likely to be detected in a skeletal survey?

Answer: Wormian bones in the skull

A. A healed right scapular fracture

B. Ground-glass appearance of the cortices of the long bones

C. Widening and cupping of the metaphyses of the long bones

D. Wormian bones in the skull


Question: A previously healthy 34-year-old man comes to the physician because of loose stools for the past 4 months. On average, he has 1 episode of loose non-bloody bowel movement with abdominal cramps each day around noon. He has no diarrhea when he does not have breakfast in the morning. He also complains of excess flatus but no bowel incontinence or urgency. He has had no fever or weight loss. His symptoms are not associated with stress. He has had no overseas or mountainous trips over the past year. He takes no medications. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate initial recommendation?

Answer: Elimination of all dairy products

A. Cholestyramine

B. Elimination of all dairy products

C. Empirical therapy with metronidazole

D. Loperamide


Question: A 37-year-old male with a history of diabetes is prescribed a drug that would decrease the risk of the patient developing glomerular renal capillary damage, nodular glomerular sclerosis, and eventual nephrotic syndrome. After some time being on this medication, the patient complains of a bad cough. Which of the following physiologic changes is most likely expected after being prescribed that medication?

Answer: Decreased aldosterone, decreased GFR, increased renal plasma flow, increased bradykinin

A. Decreased aldosterone, decreased GFR, decreased renal plasma flow, increased bradykinin

B. Increased aldosterone, increased GFR, decreased renal plasma flow, increased bradykinin

C. Decreased aldosterone, decreased GFR, increased renal plasma flow, increased bradykinin

D. Increased aldosterone, increased GFR, increased renal plasma flow, increased bradykinin


Question: A 69-year-old woman presents with insomnia and altered mental status. The patient is accompanied by her husband who says her symptoms began acutely 4 days ago with no obvious trigger and have not improved. Before this point, she had been living independently with no signs of cognitive impairment. The patient’s husband says that the patient is often non-compliant with medication and eats and drinks little unless prompted. Past medical history is significant for hypertension, diabetes mellitus type 2, chronic pyelonephritis, and depression. Current medications are aspirin, metoprolol, hydrochlorothiazide, losartan, metformin, and trazodone. Vitals include: temperature 38.1℃ (100.6℉), blood pressure 130/70 mm Hg, pulse 91/min, respiratory rate 17/min, and oxygen saturation 99% on room air. On physical examination, the patient is agitated and easily distracted. Oriented x 1. She believes it is 1967, and she is at the bookstore. She talks to non-existent people and uses words inappropriately. Cardiac sounds are muffled but otherwise normal. Lungs are clear to auscultation. On abdominal examination, the tip of the urinary bladder can be palpated. Costovertebral angle tenderness is present bilaterally. Catheterization of the bladder yields cloudy, foul-smelling urine. Urinalysis is pending. Which of the following would be the best treatment for this patient’s change in mental status?

Answer: Antibiotic therapy

A. Changing trazodone to amitriptyline

B. Antibiotic therapy

C. Discontinuation of metoprolol

D. Lifelong administration of memantine


Question: A 65-year-old man presents to the physician with a concern for several lumps on his jaw. He has a history of dental caries and admits to maintaining poor oral hygiene. On physical examination, he has 3 nontender and indurated masses at the angle of his jaw that are draining thick yellow pus. Microscopy of the drained pus reveals yellow granules filled with bacteria. Which of the following medical treatments is indicated for this patient’s condition?

Answer: Penicillin

A. Amoxicillin-clavulanate

B. Dapsone and rifampin

C. Penicillin

D. Trimethoprim-sulfamethoxazole


Question:
A 23-year-old man presents with severe right lower quadrant abdominal pain for the past 2 hours. He says the pain started in the periumbilical region and has now shifted to the lower right quadrant. He describes the pain as spasmodic. Past medical history is insignificant, and the patient denies any history of smoking, alcohol, or drug use. The patient’s vital signs show: pulse 88/min, respiratory rate 18/min, blood pressure 126/84 mm Hg, and temperature 38.4°C (101.0°F). On physical examination, there is severe tenderness to palpation in the right lower quadrant with rebound and guarding. The patient is rushed to the operating room for a laparoscopic appendectomy. The following preoperative laboratory tests are obtained:
Serum glucose (random) 123 mg/dL
  Serum electrolytes
Sodium 143 mEq/L
Potassium 4.7 mEq/L
Chloride 102 mEq/L
    Serum creatinine 1.7 mg/dL
Blood urea nitrogen 32 mg/dL
    Hemoglobin (Hb%) 12.5 g/dL
Mean corpuscular volume (MCV)  80 fl
Reticulocyte count 1%
Erythrocyte count 5.1 million/mm³
Leukocyte count 14,000/mm³
Neutrophils 80%
During the induction of anesthesia, isoflurane and a second compound are administered. About 25 minutes after induction, the patient develops significant muscle rigidity and his temperature increases to 40.8°C (105.4°F). The patient’s blood pressure is now 158/94 mm Hg. Which of the following was most likely the second compound administered to this patient?

Answer: Succinylcholine

A. Atracurium

B. Nitrous oxide

C. Neostigmine

D. Succinylcholine


Question: A 16-year-old boy is brought to the physician because of a 3-week history of loose stools. He has 2–3 episodes of loose stools a day that are occasionally bloody. During this period, he has also had crampy abdominal pain, generalized fatigue, and a 2-kg (5-lb) weight loss. His temperature is 37.1°C (98.8°F), pulse is 82/min, and blood pressure is 106/68 mm Hg. Examination shows mild lower abdominal tenderness to palpation. Test of the stool for ova and parasites is negative. His hemoglobin concentration is 11.8 g/dL, leukocyte count is 12,400/mm3, and erythrocyte sedimentation rate is 14 mm/h. A colonoscopy shows inflamed, friable mucosa extending just beyond the rectum that bleeds on contact with the endoscope. A biopsy confirms the diagnosis. Which of the following is the most appropriate therapy for this patient?

Answer: Mesalamine therapy

A. Gluten-free diet

B. Proctocolectomy

C. Mesalamine therapy

D.
Cyclosporine therapy
"


Question: A 26-year-old man presents with a 6-month history of headaches. Over the past 6 months, he has developed headaches that are 4/10 in intensity and occur every other day for 1–2 hours. The headaches are bilateral and feel like a ‘band is squeezing his head’. He denies photophobia, phonophobia, nausea, and vomiting. He has had no visual loss or photopsia. No significant past medical history. He is an avid weightlifter and works at a moving company, where he is constantly lifting heavy items. Additionally, he recently got his 21-year-old girlfriend and his other 23-year-old girlfriend pregnant, which he says is causing a lot of stress. Physical examination is unremarkable. Which of the following is the next best step in the management of this patient?

Answer: Ibuprofen

A. Amitriptyline

B. Magnetic resonance image (MRI) of the head

C. Ophthalmologic evaluation

D. Ibuprofen


Question: A histologic section is obtained from the central canal of the spinal cord. A special stain is used to identify a specific glial cell that makes up the lining of the central canal and ventricles in the central nervous system. Which of the following best describes the primary function that the cells highlighted in blue serve?

Answer: Production and circulation of CSF

A. Production and circulation of CSF

B. Protective membrane surrounding spinal cord

C. Conduct voluntary muscle action potentials

D. Increasing action potential conduction velocity


Question: A 58-year-old man presents to the emergency department with a 4-hour history of severe abdominal pain. He has noted brief episodes of postprandial abdominal pain for the last 2 months, but this pain is much more severe and diffuse. He also reports nausea and has had several episodes of non-bloody, non-bilious emesis since the pain started. Past medical history is notable for hyperlipidemia diagnosed 10 years ago and managed with lifestyle modifications; he has never been hospitalized. Vital signs are unremarkable. Physical examination shows dry mucous membranes and a soft, non-distended abdomen that is diffusely tender. Laboratory tests are notable for a lipase level of 3,125 U/L. CT of the abdomen shows an enlarged gallbladder and peripancreatic fluid with dilation of the pancreatic and common bile ducts. Which of the following is the best next step in the management of this patient?

Answer: Endoscopic retrograde cholangiopancreatography (ERCP)

A. Cholecystectomy

B. Colonoscopy

C. Endoscopic retrograde cholangiopancreatography (ERCP)

D. Esophagogastroduodenoscopy (EGD)


Question: A 55-year-old man presents to his primary care physician for his annual check-up. He says that he has generally been feeling well; however, he has noticed that he has had some intermittent very low grade fevers of unknown etiology. His past medical history is significant for well-controlled hypertension and diabetes. On physical exam he is found to have painless enlargement of a number of cervical and axillary lymph nodes. A biopsy of the enlarged nodes is obtained and genetic testing shows that part of chromosomes 14 and 18 are joined together. Which of the following would most likely be observed in cells with this genetic change?

Answer: Decreased release of cytochrome c

A. Decreased activation of CD95

B. Decreased activity of p53

C. Decreased release of cytochrome c

D. Increased activation of Apaf-1


Question: A 75-year-old man is brought to the emergency room because of dizziness and palpitations for the past hour. His pulse is 185/min and blood pressure is 100/52 mm Hg. An ECG shows a narrow-complex, regular tachycardia without P waves. A drug is administered that activates cardiac potassium channels and causes transient atrioventricular block. Which of the following adverse effects is most likely to occur?

Answer: Chest pain

A. Chest pain

B. Dry cough

C. Perioral paresthesia

D. Yellow vision


Question: A 70-year-old man is brought to the emergency department with painful discharge from his right ear with difficulty hearing for 3 days. His temperature is 39.5°C (103.1°F) and pulse is 120/minute. Physical examination shows mild facial asymmetry with the right corner of his mouth lagging behind the left when the patient smiles. There is severe ear pain when the right auricle is pulled superiorly. Otoscopic examination shows granulation tissue at the transition between the cartilaginous and the osseous part of the ear canal. Which of the following is most likely associated with this patient's condition?

Answer: Glucose intolerance

A. Decreased intracranial perfusion

B. Glucose intolerance

C. Pus-filled mastoid air cells

D. Positive streptococcal culture


Question: A 24-year-old female with a history of recurrent infections, bipolar disorder, and no prenatal care gives birth to a male infant. On physical exam in the delivery room, you observe a tuft of hair over the infant's lumbosacral region. Which of the following drugs was this mother most likely taking during pregnancy?

Answer: Valproate

A. Gentamicin

B. Lithium

C. Valproate

D. Folic acid


Question: A 25-year-old woman presents to the physician with the complaint of several episodes of headache in the past 4 weeks that are affecting her school performance. The episodes are getting progressively worse, and over-the-counter headache and migraine medication do not seem to help. She also mentions having to raise her head each time to look at the board when taking notes; she cannot simply glance up with just her eyes while facing her notes. She has no significant past medical or family history and was otherwise well prior to this visit. Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema. What structure is most likely to be affected by this patient's condition?

Answer: Aqueduct of Sylvius

A. Third ventricle

B. Aqueduct of Sylvius

C. Tegmentum

D. Inferior colliculi


Question: A 75-year-old woman is brought to the emergency department because of a 6-hour history of severe headache, nausea, and 1 episode of vomiting. On arrival, she is lethargic and oriented only to self. Her pulse is 50/min, respirations are 8/min and shallow, and blood pressure is 150/96 mm Hg. Examination shows medial deviation of the left globe and ecchymoses of the upper eyelids. Appropriate pharmacotherapy with an intravenous drug is initiated, and the patient's urine output subsequently increases. The patient is at greatest risk of which of the following adverse effects?

Answer: Pulmonary edema

A. Drug-induced hypersensitivity syndrome

B. Hyperuricemia

C. Tinnitus

D. Pulmonary edema


Question: A 31-year-old gravida 2 para 2 woman presents to her primary care physician for follow up. Two weeks ago, she gave birth via vaginal delivery to a 9.5 lb (4.3 kg) male infant. The delivery was complicated by a vaginal laceration that required extensive suturing once the infant was delivered. Immediately after delivery of the placenta she experienced intense shaking and chills that resolved within 1 hour. She has felt well since the delivery but admits to 6 days of malodorous smelling vaginal discharge that is tan in color. She has a history of vaginal candidiasis and is worried that it may be recurring. Her temperature is 98.8°F (37.1°C), blood pressure is 122/73 mmHg, pulse is 88/min, respirations are 16/min, and BMI is 33 kg/m^2. Speculum exam reveals a 1.5 cm dark red, velvety lesion on the posterior vaginal wall with a tan discharge. The pH of the discharge is 6.4. Which of the following is the most likely diagnosis?

Answer: Rectovaginal fistula

A. Bacterial vaginosis

B. Rectovaginal fistula

C. Vaginal melanoma

D. Vesicovaginal fistula


Question: A 50-year-old male presents to the emergency room after getting hit by a car while biking. He complains of severe pain in both thighs. His thighs appear swollen, bruised, and angulated. Radiographic imaging demonstrates bilateral femoral shaft fractures. He subsequently undergoes surgical fixation of his fractures. Initially he has an uneventful post-operative course; however, on post-op day 4 he becomes confused and develops chest pain, tachypnea, and dyspnea. A new petechial rash is seen over his chest and neck. Electrocardiogram reveals normal sinus rhythm. Which of the following is the most likely cause of this patient’s respiratory symptoms?

Answer: Occlusion of the pulmonary vessels by fat globules

A. Lobar lung consolidation

B. Aspiration of stomach contents

C. Occlusion of the pulmonary vessels by fat globules

D. Spontaneous pneumothorax


Question: A group of researchers is conducting a study to assess the validity and reliability of patient history in determining the amount and duration of drug abuse. In this study, 60 subjects with hepatitis were asked details of their history of drug abuse, such as the duration of drug abstinence, the amount and duration of drug abuse, and the treatment history. Additionally, a source close to or related to each of the study subjects (most often a spouse) was asked similar questions about the subject by a second researcher who was blinded to the subject’s drug abuse history. Results revealed that the duration of drug abstinence correlated highly between subjects and the source (Spearman’s r = 0.94, p-value < 0.001), as did the individual's score on the stimulant relapse risk scale (SRRS, Spearman’s r = 0.74, p-value < 0.001), a ranked metric of relapse risk. Which of the following statements regarding this results of this study is true?

Answer: Spearman’s correlation coefficient reveals a strong association between the SRRS scores, as assessed by the study subject and their related source.

A. If the authors had conducted a study on larger sample size, Pearson’s correlation coefficient for these data would have been calculated.

B. There is a linear relationship between the duration of drug abstinence as assessed by the subject and their close/related source.

C. Spearman’s correlation coefficient reveals a strong association between the SRRS scores, as assessed by the study subject and their related source.

D. We can conclude that 88.4% (= 0.94 x 0.94) of the variability in the duration of drug abstinence (as assessed by the study subjects) can be 'explained' by the variability in the duration of drug abstinence as assessed by their sources.


Question: A 27-year-old man comes to the emergency department for progressive weakness and numbness in his legs for 5 days. Symptoms originally started with tingling in both feet and have progressed to involve the knees and hips; he is currently unable to walk without assistance. Two weeks ago, the patient had diarrhea that subsided without antibiotics. Neurologic examination shows weakness, decreased sensation, and absent patellar reflexes in both lower extremities. Lumbar puncture shows elevated CSF protein and no white blood cells. Which of the following structures is most likely affected in this patient?

Answer: Schwann cells

A. Postsynaptic acetylcholine receptors

B. Muscle endomysium

C. Schwann cells

D. Cerebral white matter


Question: A 23-year-old man presents to the emergency department presenting with sudden-onset dyspnea and left-sided chest pain over the last hour. This event started when he was in class sitting for an exam. He reports that the pain is worse with inspiration and does not radiate. He says he has anxiety and takes alprazolam as needed. He smokes half a pack of cigarettes a day and drinks alcohol socially. The temperature is 36.7°C (98.0°F), the blood pressure is 130/80 mm Hg, the pulse is 82/min, and the respiratory rate is 14/min. Pulse oximetry shows 97% on room air. The patient’s weight is 63.5 kg (140 lb), height is 185 cm (6 ft 1 in), and he has a BMI of 18.5 kg/m2. A chest X-ray is taken (see exhibit). After an hour of supplemental oxygen, rest, and careful monitoring his dyspnea improves and chest pain resolves without medication. Which of the following is the most appropriate further management of this patient?

Answer: Supplemental oxygen

A. Needle thoracostomy

B. IV antibiotics

C. Supplemental oxygen

D. CT angiogram of chest


Question:
A 36-year-old male is brought to the emergency department by fire and rescue after being found down in his apartment by his wife. His wife reports that the patient had been complaining of chest pain for the last few hours but refused to go to the hospital. She went to the grocery store for about half an hour and found her husband unresponsive on the ground when she returned home. The patient’s wife reports that his past medical history is significant for a “heart murmur” and that the patient’s father died at age 32 for unknown reasons. In the trauma bay, the patient’s temperature is 98.8°F (37.1°C), blood pressure is 88/41 mmHg, pulse is 116/min, and respirations are 12/min. On physical exam, the patient has a Glascow Coma Score (GCS) of 7. He has a tall stature with long limbs and long, slender fingers. He is also noted to have a pectus deformity. On cardiac exam, the patient has a diastolic decrescendo murmur at the left third intercostal space. He has weak brachial and femoral pulses.

Which of the following is the most likely etiology of this patient’s presentation?

Answer: Spontaneous separation in the arterial wall

A. Coronary atherosclerosis

B. Spontaneous rupture of the aorta

C. Spontaneous rupture of the mitral chordae tendinae

D. Spontaneous separation in the arterial wall


Question: A 44-year-old man comes to the physician because of severe lower back pain for 1 week. He has also had fatigue, weight gain, and episodic headaches during the past 3 months. He has no history of serious illness and takes no medications. His pulse is 88/min and blood pressure is 155/102 mm Hg. Physical examination shows facial plethora and truncal obesity. The skin appears stretched, with multiple ecchymotic patches over the upper and lower extremities bilaterally. Cardiopulmonary examination shows no abnormalities. There are bilateral paravertebral muscle spasms and severe tenderness over the second lumbar vertebra. An x-ray of the lumbar spine shows decreased bone density and a compression fracture of the L2 vertebra. Further evaluation of this patient is most likely to show which of the following findings?

Answer: T-wave flattening on ECG

A. Low serum glucose levels

B. Suprasellar mass on cranial MRI

C. T-wave flattening on ECG

D. Positive Chvostek sign


Question: Two weeks after undergoing coronary artery bypass surgery for acute myocardial infarction, a 62-year-old man comes to the physician because of a 4-day history of fever, stabbing chest pain, and fatigue. Initially the pain was only present when he was lying supine, but now it is present all the time and only subsides when he is leaning forward. He has hypertension and mild mitral regurgitation. He has smoked one pack of cigarettes daily for 44 years but quit prior to surgery. Current medications include aspirin, clopidogrel, metoprolol, captopril, and atorvastatin. His temperature is 38.3°C (102°F), pulse is 84/min and regular, respirations are 16/min, and blood pressure is 132/86 mm Hg. During inspiration the blood pressure drops to 117/80 mm Hg. On physical examination there are jugular venous pulsations 4 cm above the sternal angle. Heart sounds are faint. There is 2+ edema in the lower extremities. Which of the following is the most likely cause of this patient's symptoms?

Answer: Decreased left ventricular diastolic filling

A. Increase in mean aortic pressure

B. Decreased left ventricular diastolic filling

C. Supraventricular arrhythmia

D.
Decreased right ventricular contractility
"


Question: A 28-year-old woman comes to the physician with her mother because of a 1-week history of feeling unusually energetic. The mother describes her state as “hyper” and reports that she often paces around her room. During this period, the patient has not slept. She had similar episodes 2 months and 5 months ago. The mother also states that, for the past 8 months, the patient has believed she is a famous singer and is going on a world tour next year. The patient does not have a partner and has only a few friends. She was working as a dental technician until 6 months ago, when she started to hear voices telling her to quit. She has not held a job since then. She does not use illicit drugs. Vital signs are within normal limits. Physical and neurological examinations show no abnormalities. On mental status examination, her speech is pressured, but she suddenly stops talking in the middle of sentences and does not finish them. She occasionally directs her attention to empty corners in the room, as if she were listening to someone. Which of the following is the most likely diagnosis?

Answer: Schizoaffective disorder

A. Schizoaffective disorder

B. Schizotypal personality disorder

C. Delusional disorder

D. Mood disorder with psychotic features


Question: A 4-year-old boy presents the pediatrician with his parents for a consultation after his school teacher complained about his abnormal behavior and his inability to make friends in school. They mention that the boy does not interact well with others at home, school, or daycare. On physical examination, his vital signs are stable with normal weight, height, and head circumference for his age and sex. His general examination and systemic examination, including neurologic examination, are completely normal. His recent audiologic evaluation shows normal hearing, and intellectual disability has been ruled out by a clinical psychologist. Which of the following investigations is indicated as part of his diagnostic evaluation at present?

Answer: No further testing is needed

A. Magnetic Resonance Imaging (MRI) of brain

B. Positron Emission Tomography (SPECT) Scanning of head

C. Electroencephalography

D. No further testing is needed


Question: A 57-year-old man comes to the physician because of a 5-day history of fever, joint pain, malaise, and a diffuse rash. Two months ago, he was diagnosed with latent tuberculosis and the appropriate treatment was administered. Examination shows a scaly, maculopapular rash over the chest, arms, and back. Which of the following is the most likely explanation for this patient's current condition?

Answer: Decreased acetyltransferase activity

A. Decreased acetaldehyde dehydrogenase activity

B. Decreased acetyltransferase activity

C. Decreased cytochrome p450 activity

D. Decreased glucose-6-phosphate dehydrogenase activity


Question: A 40-hour-old baby girl is being evaluated for failure to pass meconium. She is the product of a full-term vaginal delivery to a G2P2 36-year-old mother. The pregnancy was uncomplicated, and the only medication that the mother took was a prenatal vitamin. The baby has been exclusively breastfed, and she has an adequate latch. On physical examination, the newborn’s abdomen is distended and on digital rectal examination, reveals that the rectum is empty. What is the most likely additional finding?

Answer: Absence of ganglion cells in the submucosal plexus on suction biopsy of the rectum

A. Absence of ganglion cells in the submucosal plexus on suction biopsy of the rectum

B. Acid-producing mucosa visualized in a technetium scan

C. Abdominal ultrasound showing bowel-within-bowel

D. Inability to pass a 10-French catheter from the mouth into the stomach


Question: A 65-year-old man presents to the physician with a low-grade fever, fatigue, and anorexia for the past 10 days. The patient denies any chest pain, cough, or shortness of breath. He has been a smoker for the last 10 years and consumes alcohol occasionally. His past medical history is significant for colorectal carcinoma. His temperature is 38.3°C (101.0°F), the blood pressure is 130/90 mm Hg, and the pulse is 100/min. Physical examination shows reddish-brown spots under his nail bed (as shown in the exhibit) and tender erythematous fingers tips. Cardiac auscultation reveals a new holosystolic murmur best heard at the apex with no radiation. Chest X-ray, electrocardiogram, and urinalysis are normal. Which of the following is the best next step in diagnosing this patient’s condition?

Answer: Obtain blood samples for blood culture

A. Obtain anti-CCP antibody titers

B. Echocardiography

C. Obtain blood samples for blood culture

D. Reassurance and symptomatic management


Question: A 27-year-old man presents for followup 3 months after starting an antiretroviral regimen consisting of efavirenz, tenofovir, and emtricitabine. Labs drawn just prior to presentation reveal an undetectable viral load and a T-lymphocyte count of 317/mm^3. By comparison, his viral load was 6100/mL and his T-lymphocyte count was 146/mm^3 at the time of treatment initiation. He reports that he is tolerating the medications well and is not experiencing any major side effects. Which of the following treatment regimens should be recommended for this patient given the fully suppressed viral load?

Answer: Continue current regimen of efavirenz, tenofovir, and emtricitabine

A. Continue current regimen of efavirenz, tenofovir, and emtricitabine

B. Continue efavirenz and emtricitabine but discontinue tenofovir

C. Continue efavirenz and tenofovir but discontinue emtricitabine

D. Continue tenofovir and emtricitabine but discontinue efavirenz


Question: A 60-year-old male painter with severe chest pain is found to have atherosclerosis of his coronary arteries. What type of cells were most likely injured in the initial stage of his disease?

Answer: Endothelial cells

A. Myocytes

B. Neutrophils

C. Endothelial cells

D. Smooth muscle cells


Question: A 27-year-old woman, gravida 1, at 26 weeks gestation presents to the physician during a prenatal visit. She feels well. Her pregnancy has been uncomplicated. Her initial laboratory tests at 8 weeks confirmed her blood type as B-. Her partner is blood type A+. At the clinic, her temperature is 37.2°C (99.0°F), and blood pressure is 108/60 mm Hg. Pelvic examination shows a uterus consistent in size with a 24-week gestation. Fetal heartbeats are normal. A sample of blood is collected for blood type screening and verification. Regarding Rh D immunoglobulin (RhoGam) administration, the most appropriate next step is which of the following?

Answer: At 28 weeks gestation if anti-D screen is negative

A. At 28 weeks gestation if anti-D screen is negative

B. At 28 weeks gestation if anti-D screen is positive

C. Within 72 hours after birth if anti-D screen is negative

D. Rh D immunoglobulin (RhoGam) is not required in this patient regardless of test results


Question: A 32-year-old obese man visits your dermatology clinic after his barber saw a darkened area on the back of his neck. He has not seen his primary care physician in many years and does not know if he has diabetes. A rapid blood glucose test showed a normal glucose level. Otherwise, he reports recent loss of appetite with slight weight loss. What could be causing this patient’s newly-discovered dermatologic change?

Answer: Gastric adenocarcinoma

A. Gastric adenocarcinoma

B. Diabetes insipidus

C. Diabetes mellitus

D. Barrett’s esophagus


Question: A 59-year-old man comes to the physician because of a 6-month history of progressive blurry vision in both eyes. His vision has not improved with the use of reading glasses. His blood pressure is 155/98 mm Hg. Physical examination shows his visual acuity to be 20/80 in the right eye and 20/60 in the left eye. A photograph of the fundoscopic examination of the right eye is shown. Which of the following is the most likely cause of this patient's symptoms?

Answer:
Diabetic retinopathy
"

A. Idiopathic intracranial hypertension

B. Open-angle glaucoma

C. Central retinal artery occlusion

D.
Diabetic retinopathy
"