Question: A 58-year-old man with chronic obstructive pulmonary disease and hypertension comes to the physician because of shortness of breath 3 days after starting propranolol. His temperature is 36.7°C (98.1°F), pulse is 64/min, respirations are 20/min, and blood pressure is 138/88 mm Hg. Auscultation of the lungs shows diffuse expiratory wheezes. In addition to discontinuing the propranolol, which of the following drugs should be administered?

Answer: Albuterol

A. Albuterol

B. Prednisone

C. Tiotropium bromide

D. Theophylline


Question: A 6-year-old boy is admitted with a one-week history of diarrhea, which was sometimes bloody and originally began after a birthday party. He has become lethargic and has not been eating or drinking. His vital signs are as follows: T 38.5 C, HR 135, BP 82/54. Physical examination is significant for petechiae on his legs and diffuse abdominal tenderness to palpation. Lab-work shows BUN 72 mg/dL, creatinine 8.1 mg/dL, and platelet count < 10,000. PT and PTT are within normal limits. Which of the following would be expected on a peripheral blood smear?

Answer: Fragmented red blood cells

A. Rouleaux formation

B. Fragmented red blood cells

C. Spur cells

D. Giant platelets


Question: A microbiology student is studying the different types of cell surface markers on immune cells. He is interested in the human major histocompatibility complex (MHC) and human leukocyte antigens (HLAs). While studying, he learns that both class I and class II MHC molecules are expressed on specific types of cells. Currently, he is studying the HLA-DP, HLA-DQ, HLA-DRα, and HLA-DRβ genes. Which of the following cells express molecules encoded by these genes?

Answer: Thymic epithelial cells

A. Eosinophils

B. Mesenchymal cells

C. Platelets

D. Thymic epithelial cells


Question:
A 10-year study of 1,000 residents in a small US town is conducted to determine the risk of developing lung cancer. The study assesses each subject with a comprehensive physical exam and chest X-ray at 3-time points: at baseline, at the 5-year point, and at the conclusion of the study. At each time point, the total number of cases of lung cancer in the population is recorded. The data gathered from the study are given in the table below:
Time point Total cases of lung cancer
t = 0 years 100
t = 5 years 500
t = 10 years 600
Which of the following is the incidence of lung cancer per 1,000 people per year?

Answer: 87

A. 104

B. 0.6

C. 87

D. 125


Question: A 7-year-old boy suffers from generalized edema. Urine protein excretion is 5.2 g over 24 hours, and serum analysis reveals hyperlipidemia. The patient responds to treatment with prednisone, and, 8 weeks later, his urine does not contain measurable protein. If a kidney biopsy had been performed while the patient’s condition was pathologic, which of the following would you expect to find upon glomerular electron microscopy?

Answer: Effacement of podocyte foot processes

A. Effacement of podocyte foot processes

B. Subepithelial ‘spike and dome’ deposits

C. Subepithelial humps

D. Subendothelial thickening


Question: A previously healthy 3-month-old girl is brought to the emergency department because her lips turned blue while passing stools 20 minutes ago. She has not stopped crying since then. She was born at 38 weeks' gestation. She is at the 50th percentile for length and below the 30th percentile for weight. She is alert and agitated. Her temperature is 36.6°C (98°F), pulse is 180/min, respirations are 50/min, and blood pressure is 70/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 70%, which increases to 81% on administration of 100% oxygen. Physical examination shows perioral cyanosis and retractions of the lower ribs with respiration. Cardiac examination shows a harsh grade 2/6 systolic crescendo-decrescendo murmur at the left upper sternal border. Which of the following would most likely improve this patient's symptoms?

Answer: Knee-chest positioning

A. Knee-chest positioning

B. Supine positioning

C. Lower limb elevation

D. Prone positioning


Question:
An 8-year-old girl of Asian descent is brought to the physician because of fatigue. She is not able to keep up with the rest of her classmates in gym class because she tires easily. Physical examination shows pale conjunctivae. Laboratory studies show:
Hemoglobin 11.0 g/dL
Mean corpuscular volume 74 μm3
Red cell distribution width 14 (N=13-15)
Serum ferritin 77 ng/mL
Peripheral blood smear shows small, pale red blood cells. Hemoglobin electrophoresis is normal. Which of the following best describes the pathogenesis of the disease process in this patient?"

Answer: Cis deletion of α-globin genes

A. Decreased production of β-globin proteins

B. Amino acid substitution in the β-globin protein

C. Cis deletion of α-globin genes

D. Acquired inhibition of heme synthesis


Question:
A 52-year-old postmenopausal woman comes to the physician with a 6-month history of difficulty biting down and chewing that is becoming progressively worse. She has been taking acetaminophen for headaches and nonspecific pain in her hips and back. She also complains that her hearing has been deteriorating as she gets older. Vital signs are within normal limits. Examination shows a mildly tender, 1-cm, bony, immobile swelling in the left side of her forehead. Intraoral examination shows bilateral expansion of the maxillary alveolus and malocclusion. Audiometry shows bilateral mixed conductive and sensorineural hearing loss. Laboratory studies show:
Hemoglobin 14.6 g/dL
Leukocyte count 9,000/mm3
Platelet count 256,000/mm3
Serum
Alkaline phosphatase 1100 U/L
Vitamin D 40 ng/ml (N = 20–100 ng/mL)
Calcium 9.5 mg/dL
Parathyroid hormone 300 pg/mL
A plain x-ray of the skull is shown. Which of the following is the most appropriate next step in management?"

Answer: Intravenous zoledronate

A. Hematopoietic cell transplantation

B. Transsphenoidal hypophysectomy

C. Intravenous zoledronate

D. Estrogen replacement therapy


Question:
A 66-year-old man is brought to the emergency department because of worsening shortness of breath and progressive swelling of his legs for 1 week. He has hypertension and hyperlipidemia. Current medications include amlodipine and pravastatin. His temperature is 37.5°C (99°F), pulse is 95/min, respirations are 12/min, and blood pressure is 113/70 mm Hg. Pulmonary examination shows bilateral coarse crackles. An S3 gallop is heard on auscultation. There is jugular venous distension and pitting edema of both ankles. He is admitted to the hospital and treatment with intravenous bumetanide is initiated. Serum studies obtained 5 days after admission show:
Na+ 138 mEq/L
Cl− 101 mEq/L
Mg2+ 1.3 mEq/L
Urea nitrogen 42 mg/dL
Creatinine 1.8 mg/dL
Arterial blood gas analysis on room air:
pH 7.51
PCO2 52 mm Hg
PO2 60 mm Hg
HCO3- 33 mmol/L
Further evaluation of this patient is most likely to show which of the following findings?"

Answer: Elevated serum aldosterone

A. Elevated serum aldosterone

B. Decreased urine chloride

C. Decreased serum renin

D. Elevated serum potassium


Question: A 16-year-old boy is brought to the emergency department by his parents after collapsing at home. He was resting at home after an uneventful dental procedure that involved the extraction of several teeth. He became drowsy and then unconscious and was unrousable. At the hospital, his temperature is 37.0° C (98.6° F), respiratory rate is 15/min, pulse rate is 67/min, and blood pressure is 122/98 mm Hg. Oxygen saturation is 85% on room air. The patient is deeply cyanosed despite a good respiratory effort and a clear airway. His lungs are clear to auscultation, bilaterally. Even though an endotracheal tube is introduced and assisted ventilation is induced, his condition does not improve. A review of dental records reveals the details of the procedure where the local anesthetic pilocarpine was administered. What is the most likely cause of this patient’s condition?

Answer: Methemoglobinemia

A. Cyanide poisoning

B. Methemoglobinemia

C. Sulfhemoglobinemia

D. Carbon monoxide poisoning


Question:
Please refer to the summary above to answer this question
Which of the following is the most likely underlying cause of this patient's upper extremity symptoms?"
"Patient Information
Age: 1 day
Sex: F
Ethnicity: Hispanic
Site of Care: office
History
Reason for Visit/Chief Concern: brought in by her parents because “her arm looks funny”
History of Present Illness:
mother had no prenatal care
labor was spontaneous with rupture of membranes yielding fluid with dark green streaks
the infant was delivered vaginally 1 day ago at home at approximately 39 weeks' gestation
the delivery was complicated by shoulder dystocia, which was managed with suprapubic pressure and the McRoberts maneuver
father reports that the infant's right arm “just hangs by the side” and that she never bends her right elbow
the infant is breastfeeding, stooling, and voiding without complication
Past Medical History:
none
Family History:
mother has type 2 diabetes mellitus
Medications:
none
Immunizations:
has not received any routine vaccinations
Allergies:
no known drug allergies
Social History:
the infant lives with her mother, father, and paternal grandmother
no one in the residence smokes
Physical Examination
Temp Pulse Resp BP O2 Sat Ht Wt Head circumference
37.1°C
(98.8°F)
154/min 45/min 87/49 mm Hg
99%
50 cm
(20 in; 69th percentile)
4,400 g
(9 lb 11 oz; 99th percentile)
35 cm
(13.8 in; 82nd percentile)
Appearance: well-appearing; crying during the examination
HEENT: red reflex is seen bilaterally; there is a fluctuant area over the left parietal bone that crosses suture lines
Pulmonary: clear to auscultation
Cardiac: regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops
Abdominal: no tenderness, masses, or hepatosplenomegaly; bowel sounds normal; umbilical stump is intact and clamped
Extremities: hips are stable bilaterally
Musculoskeletal: clavicles are intact bilaterally; the right upper extremity hangs limply from the shoulder in full extension, adduction, and fixed internal rotation; the hand is pronated, and the wrist and fingers are flexed
Skin: dry, warm; no jaundice
Neurologic: normal suck and grasp reflexes; the Moro reflex is normal in the left upper extremity and absent in the right upper extremity; deep tendon reflexes are 2+ bilaterally"

Answer: Damage to the upper trunk of the brachial plexus

A. Injury to the median nerve

B. Damage to the upper trunk of the brachial plexus

C. Damage to the lower trunk of the brachial plexus

D. Aspiration of meconium


Question: A 34-year-old man presents with severe left inguinal pain and swelling since last night. He has just returned from a summer trip to the southwestern United States where he spent most of his time working with homeless and unemployed people in an area that straddles New Mexico and Utah. Upon further inquiry, he denies any contact with wild or domestic animals including pets, but he does remember occasionally seeing mice in his motel room and found their droppings on the floor. On physical exam his temperature is 38.5°C (101.3°F), pulse is 95/min, respiration rate is 18/min, and blood pressure is 130/85 mm Hg. The left inguinal area is swollen. There is no skin erythema and it is not warm to palpation. There are several enlarged and soft lymph nodes with a hard underlying core. The area is very tender and surrounded by edema. A localized rash is found in the ipsilateral inner thigh above the knee (see image). Examination of the heart, lungs, abdomen, and other limbs shows no abnormalities. Which of the following pathogens is the most likely cause of this patient’s condition?

Answer: Yersinia pestis

A. Hantavirus

B. Rhabdovirus

C. Borrelia burgdorferi

D. Yersinia pestis


Question: A 10-year-old unvaccinated girl presents to her pediatrician with a rash. Her mother reports that she has had a fever, “red eyes,” sore throat, and rash on her face for the last day. On physical examination, the girl appears sick but not toxic, and has nonpurulent conjunctivitis and an erythematous posterior pharynx without exudate or tonsillar hypertrophy. She has lymphadenopathy bilaterally. Her heart has a regular rate without murmurs, her lungs are clear to auscultation bilaterally, and her abdomen is soft without hepatosplenomegaly. She has red cheeks with circumoral pallor and no other skin findings. Which of the following is the most appropriate advice for this patient’s mother?

Answer: She will likely develop a maculopapular truncal rash in a few days that will fade to become a lacy rash.

A. This infection could have been prevented with a vaccine.

B. Her symptoms were caused by human herpesvirus type 6 (HHV-6) or human herpesvirus type 7 (HHV-7).

C. She will likely develop a maculopapular truncal rash in a few days that will fade to become a lacy rash.

D. She should be started on oral valacyclovir.


Question: A 42-year-old woman presents to the clinic for worsening fatigue and difficulty breathing for the last 6 months. Previously, she could routinely walk 3 miles after dinner, but now she can no longer walk more than 2 blocks without being short of breath. She also reports being tired soon after starting any type of physical activity. On further questioning, she recalls having on and off fevers, occasional night sweats, and losing 5 kg (11 lb) over the last 6 months. Her past medical history reveals 2 cesarean deliveries in her twenties and a hospitalization for acute appendicitis in her teens. She currently takes no medications and also denies smoking and recreational drug use. She drinks half a glass of wine with her evening meals. Her vitals include a respiratory rate of 14/min, a pulse rate of 87/min, a blood pressure of 110/89 mm Hg, and a temperature of 36.7°C (98.0°F). Physical examination is normal. A chest X-ray shows bilateral hilar lymphadenopathy. Which of the following changes in forced expiratory volume (FEV1) and forced vital capacity (FVC) are expected if she takes a pulmonary function test?

Answer: FEV1: decrease and FVC: decreased

A. FEV1: decrease and FVC: decreased

B. FEV1: decreased and FVC: no change

C. FEV1: decreased and FVC: increased

D. FEV1: no change and FVC: no change


Question: A 42-year-old woman is brought to the emergency department because of a severe, throbbing, occipital headache for 2 hours. She also reports nausea, photophobia, and chest tightness. The symptoms developed shortly after she had a snack consisting of salami and some dried fruits at a wine tasting event. The patient has recurrent migraine headaches and depression, for which she takes medication daily. She is mildly distressed, diaphoretic, and her face is flushed. Her temperature is 37.2°C (98.9 F), pulse is 88/min, respirations are 19/min, and blood pressure is 190/128 mmHg. Deep-tendon reflexes are 2+ bilaterally. This patient's symptoms are most likely caused by a side effect of which of the following medications?

Answer: Tranylcypromine

A. Tranylcypromine

B. Almotriptan

C. Topiramate

D. Doxepin


Question: A 70-year-old man is brought to the emergency department because of severe back pain that began when he was lifting a box 1 hour ago. He also has a 2-year history of increasingly severe right hip pain. Physical examination shows tenderness to palpation of the lower spine as well as erythema of the skin over the right hip. Neurologic examination shows decreased hearing in the left ear; the Weber test localizes to the left side. Serum studies show an alkaline phosphatase concentration of 410 U/L, calcium concentration of 9.5 mg/dL, and parathyroid hormone level of 322 pg/mL. An x-ray of the spine shows a fracture of the L4 vertebra. Which of the following is the most likely diagnosis?

Answer: Osteitis deformans

A. Osteoporosis

B. Osteomalacia

C. Osteitis deformans

D. Osteonecrosis


Question: A study investigating the use of adalimumab for the relief of peripheral arthropathy in patients with psoriatic arthritis was conducted. The study utilizes a crossover design in which half of the study participants are given adalimumab for a month while the other half takes placebo. After a 2 week washout period in which no one takes any adalimumab, the group that was originally on adalimumab is given placebo for a month while the group that was originally taking placebo is given adalimumab for a month. Pain in all affected joints is assessed clinically by follow-up visits every two weeks for the duration of the study. Which of the following is true about cross-over study designs?

Answer: 1 and 2

A. Crossover studies avoid the ethical issue of not giving all participants access to a novel therapeutic agent

B. Crossover studies minimize the effects of differences between participants

C. The purpose of the washout period is to increase the length of the study to gather more data

D. 1 and 2


Question: A 64-year-old woman presented to the community health clinic complaining of nausea, bloating, pain in both knees, and a burning sensation in her feet. She has recently immigrated to the United States and was previously diagnosed with diabetes mellitus, hypertension, and osteoarthritis but no medical records are currently available. She has stopped taking her medication since immigrating; however, she does recall being on insulin but cannot recall the dosage or the specific type. She has a blood pressure of 172/120 mm Hg, heart rate of 95/min, respiratory rate of 15/min, and temperature of 37.0°C (98.6°F). Her random serum glucose is 364 mg/dL. She is started on atorvastatin, amlodipine, ramipril, aspirin, duloxetine, metoclopramide, acetaminophen, and insulin detemir. Three weeks later, she presents with generalized weakness, walking difficulty, and hand tremors. Physical examination reveals bilateral hand tremors, cogwheel rigidity, and bradykinesia. She is walking with small narrow steps and reduced arm swing. Today her random serum glucose is 150 mg/dL. Her symptoms are presumed to be caused by a drug. Which medication is likely responsible for these symptoms?

Answer: Metoclopramide

A. Atorvastatin

B. Metoclopramide

C. Ramipril

D. Acetaminophen


Question: A 51-year-old man presents to the emergency room after being the victim of a robbery and assault. He was walking down an alley when he was approached by a stranger with a knife. Upon resisting, the stranger stabbed the patient’s right distal forearm before stealing his wallet and evading the scene. The patient was able to call an ambulance and has remained conscious despite mild bleeding from the injury site. He reports severe pain in his forearm and an inability to move his 2nd and 3rd fingers. He has no medical conditions and takes no medications. He is allergic to penicillin and ibuprofen. On exam, the patient is able to flex the proximal interphalangeal (PIP) joints of his 2nd through 5th fingers. When the PIP joints of his 2nd through 5th fingers are restrained by the examiner, flexion is noted at the DIP joints of the 4th and 5th fingers but not the 2nd and 3rd digits. Thumb flexion at the metacarpophalangeal (MCP) joint and interphalangeal (IP) joint is preserved. Sensation is intact over the palmar and dorsal aspects of the radial and ulnar hand. This patient most likely has an injury to which of the following muscle tendons?

Answer: Flexor digitorum profundus

A. Flexor digitorum longus

B. Flexor digitorum profundus

C. Flexor digitorum superficialis

D. Flexor pollicis longus


Question: Researchers develop a drug X that acts on the loop of Henle but discover that it does not reach its intended site of action within the nephron. It is freely filtered but rapidly disappears from the proximal tubule. They modify several of the chemical properties of drug X to produce drug Y, which cannot be reabsorbed from the proximal tubule. Which of the following natural substances are most similar to the concentration profiles of drug X and drug Y in the proximal tubule?

Answer: Drug X: glucose; Drug Y: creatinine

A. Drug X: creatinine; Drug Y: glucose

B. Drug X: glucose; Drug Y: creatinine

C. Drug X: glucose; Drug Y: potassium

D. Drug X: potassium; Drug Y: creatinine


Question: A 66-year-old woman comes to the emergency department because of fever and difficulty swallowing for 5 hours. She appears anxious. Her temperature is 39.1°C (102.4°F). Physical examination shows an extended neck and excessive drooling. Her voice is muffled and there is inspiratory stridor. There is tender bilateral cervical lymphadenopathy and pain upon palpation of the hyoid. Laboratory studies show a leukocyte count of 18,800/mm3 with 85% neutrophils. Which of the following is the most likely causal organism?

Answer: Haemophilus influenzae type b

A. Haemophilus influenzae type b

B. Streptococcus pyogenes

C. Corynebacterium diphtheriae

D.
Parainfluenza virus
"


Question: A 65-year-old man with a history of coronary artery disease presents to your office complaining of ongoing chest pain with exertion. The patient has had a recent cardiac work-up that showed no areas of acute ischemia. At the last visit, the patient was prescribed sublingual nitroglycerin for symptom relief of stable angina. On further questioning, the patient states that he has been swallowing the tablet whole instead of allowing it to dissolve because he “does not like the taste”. What is the cause of the persistent symptoms?

Answer: First pass metabolism of nitroglycerin

A. Nitroglycerin tolerance

B. Unstable angina

C. First pass metabolism of nitroglycerin

D. Concomitant use of sildenafil


Question: A 5-year-old boy is brought to the physician by his mother because of a 3-day history of low-grade fever and sore throat. This morning, she noticed a rash on his buttocks, hands, and feet. He does not have pruritus. His temperature is 38.3°C (100.9°F), pulse is 99/min, and blood pressure is 123/78 mm Hg. Physical examination shows oral vesicles. A photograph of the rash on the feet is shown. Which of the following is the most likely pathogen?

Answer: Coxsackie A virus

A. Herpes simplex virus 1

B. Coxsackie A virus

C. Parvovirus B19

D. Epstein-Barr virus


Question: An 8-year-old African-American male is found to have a holosystolic, harsh-sounding murmur upon physical examination. The murmur is best appreciated at the left sternal border, and is found to be louder when the patient squats. Which of the following is the most likely diagnosis?

Answer: Ventricular septal defect

A. Ventricular septal defect

B. Patent ductus arteriosus

C. Atrial septal defect

D. Tricuspid atresia


Question: A 29-year-old G1P0 woman at 32 weeks of gestation comes to the emergency department complaining of vaginal bleeding for the past hour. She noticed some blood on the toilet paper when she went to the bathroom an hour ago, but now she is bleeding through her underwear. She denies any trauma, pain, abnormal discharge or odor, fever, or recent infections. The patient mentioned that that during her last ultrasound, the doctor told her that, “there’s an abnormality but not to worry,” but she can’t remember the name of the condition. Her temperature is 100.1°F (37.8°C), blood pressure is 120/70 mmHg, pulse is 86/min, and respirations are 15/min . A fetal heart tracing is obtained and shows a fetal heart rate of 130-140, long-term variability, and appropriate accelerations. What is the most likely explanation for this patient’s presentation?

Answer: Attachment of the placenta to the lower placental segment over the internal os

A. Abnormal placental spiral artery development

B. Attachment of the placenta to the lower placental segment over the internal os

C. Cystic swelling of chorionic villi and trophoblast proliferation

D. Fetal vessels in close proximity to the cervical os


Question:
A 55-year-old woman comes to the office complaining of a dry mouth for the past few months. She has to drink water more frequently, as she finds it difficult to chew and swallow solid foods. She has to wake up 3–5 times each night to drink due to intense thirst. She also complains of a foreign body sensation in both the eyes for the past month. She has had no joint pain, fever, weight loss, or urinary or bowel changes. She does not smoke cigarettes but drinks alcohol socially. Her mother has rheumatoid arthritis for which she takes methotrexate, and her father died of prostatic carcinoma 7 years ago. Her temperature is 36.7°C (98°F), blood pressure is 130/75 mm Hg, pulse is 80/min, respirations are 14/min, and BMI is 28 kg/m2. On examination, the eyes and oral cavity appear dry, and dental caries are present. No lymphadenopathy is noted. Cardiopulmonary and abdominal examinations are negative. Laboratory results are shown below:
Complete blood count:
Hemoglobin 10 g/dL
Leukocytes   13,500/mm3
Platelets 170,000/mm3
ESR 65 mm/hr
   Antinuclear antibody Positive
Rheumatoid factor Positive
Anti dsDNA Negative
Anti Ro Positive
Anti-CCP Negative
Anti Jo 1   Negative
Which of the following is the most likely diagnosis?

Answer: Primary Sjogren’s syndrome

A. Rheumatoid arthritis

B. Systemic lupus erythematosus

C. Primary Sjogren’s syndrome

D. Polymyositis


Question:
A 42-year-old woman presents to the physician with chronic abdominal pain. She was initially diagnosed with an ulcer in the 2nd part of the duodenum and severe esophagitis 6 years ago. Despite confirmed H. pylori eradication and long-term therapy with pantoprazole, she has had frequent recurrences of duodenal and gastric ulcers. The medical history is otherwise unremarkable. She is a 10 pack-year smoker and consumes alcohol regularly. Her father had severe gastric ulcer disease. The vital signs are within normal limits. The body mass index is 19 kg/m2. Mild epigastric tenderness is noted on deep palpation of the epigastrium. The laboratory studies show the following:
Laboratory test
Hemoglobin 10 g/dL
Mean corpuscular volume 75 μm3
Leukocyte count 7500/mm3 with a normal differential
Serum
Na+ 145 mEq/L
K+ 4.5 mEq/L
Ca+ 9.5 mg/dL
Phosphorus 4 mg/dL
Urea nitrogen 18 mg/dL
Creatinine 1.0 mg/dL
Which of the following is the most likely underlying cause of this patient’s condition?

Answer: Gastrin-secreting tumor

A. Chronic alcohol consumption

B. Gastrin-secreting tumor

C. Primary hyperparathyroidism

D. Tobacco use


Question: A 33-year-old woman comes to the emergency department for severe abdominal pain for the past hour. The pain is 10/10, stabbing, and concentrated around the epigastric region with radiation to the back. She had 2 episodes of emesis and complains of nausea. She has had multiple similar episodes over the past 3 months which are not correlated with oral intake. She denies fever, weight changes, headaches, palpitations, bowel changes, or chest pain, but endorses nausea and stool that is hard to flush. Her medical history is significant for diabetes that is controlled with metformin. Her surgical history is significant for an elective cesarean section 5 years ago. She is currently sexually active with contraceptive use. What imaging finding would you expect in this patient?

Answer: Multiple pancreatic calcifications on CT

A. Gallbladder thickening and presence of cholelithiasis on ultrasound

B. Increase in appendicular diameter and fat stranding on computer tomography (CT)

C. Lack of an intrauterine pregnancy on ultrasound

D. Multiple pancreatic calcifications on CT


Question: A 37-year-old female presents to her primary care provider for a normal follow-up visit. Her past medical history is notable for poorly controlled type II diabetes mellitus despite good treatment adherence to oral medications. She has been trialed on metformin and glyburide but stopped them due to rapid weight gain, respectively. She was started on a new oral diabetes medication three months ago. Since starting the new medication, she has noticed slowly progressive swelling in her lower extremities. Her temperature is 99.2°F (37.3°C), blood pressure is 120/75 mmHg, pulse is 105/min, and respirations are 22/min. She has gained 10 pounds since her last visit. Physical examination reveals 1+ pitting edema in the bilateral legs. A hemoglobin A1c lab test is drawn. This patient’s symptoms are most likely attributable to which of the following medications?

Answer: Pioglitazone

A. Glipizide

B. Exenatide

C. Pioglitazone

D. Acarbose


Question: A 21-year-old woman comes to the physician for a follow-up examination. Four months ago, she underwent posterior arthrodesis for thoracolumbar scoliosis. She has recovered well from the surgery but noticed difficulties combing her hair with her right hand. A photograph of the patient's back is shown. The nerve that was most likely injured in the surgery originates from which of the following spinal roots?

Answer: C5–C7

A. C6-C8

B. C1-C3

C. T2-T5

D. C5–C7


Question: A 45-year-old female is brought by ambulance to your emergency room after complaining of shortness of breath along with profuse sweating at a company social function. Her vitals were notable for elevated blood pressure with a normal exam and a stable electrocardiogram. She has been seeing a psychiatrist recently for her depression and was prescribed phenelzine after failing treatment with a first-line antidepressant therapy. What must she have been exposed to at the party that led to such a dramatic side effect?

Answer: Tyramine

A. Norepinephrine

B. Tyramine

C. Gluten

D. Dopamine


Question: A 3-day-old female infant is brought by her mother to the pediatrician’s office. The patient’s mother says she has been noticing bruising on her child’s arms and some blood in her diapers. The infant was born at home after the mother received normal prenatal care. The patient has been exclusively breastfed since birth and is gaining weight appropriately. On exam, multiple ecchymoses are noted throughout the patient’s torso and extremities. The patient is lethargic with a large, full anterior fontanelle. On examination of the diaper, some dried blood mixed with a small amount of stool is noted. Which of the following would most likely be expected for this patient's prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time?

Answer: PT increased, aPTT normal, bleeding time normal

A. PT normal, aPTT normal, bleeding time normal

B. PT increased, aPTT normal, bleeding time normal

C. PT normal, aPTT normal, bleeding time increased

D. PT normal, aPTT increased, bleeding time normal


Question: A 53-year-old woman comes to see her primary care physician because she has had fever and malaise for two days. She was in her usual state of health until three days ago when she began to feel tired in the evening and decided to go to bed early. The next day she developed a fever, productive cough, chills, and malaise. She is otherwise healthy with no chronic conditions and lives by herself with two cats. She smokes one pack of cigarettes per day and drinks alcohol socially. On physical exam, she is found to have increased dullness to percussion at the lung bases and blood work is obtained showing elevated levels of C-reactive protein and hepcidin. The signal responsible for the elevated levels of these proteins was most likely secreted by which of the following cells?

Answer: Macrophages

A. Macrophages

B. Neutrophils

C. Regulatory T-cells

D. Type 2 helper T-cells


Question: Three weeks after undergoing transurethral prostate resection for benign prostatic hyperplasia, a 70-year-old man has fever, malaise, and pain in his extremities. Physical examination shows subungal petechiae and tender red papules on his fingers and toes. A new holosystolic murmur is heard on chest auscultation. A photomicrograph of a Gram stain of an isolate from blood culture is shown. The organism does not cause hemolysis on blood agar. Addition of pyrrolidonyl-β-naphthylamide gives the bacterial colonies a cherry red color. Which of the following is the most likely causal organism?

Answer: Enterococcus faecalis

A. Enterococcus faecalis

B. Streptococcus gallolyticus

C. Cardiobacterium hominis

D. Staphylococcus epidermidis


Question: An 85-year-old woman is brought to her primary care provider by her son for a checkup. She is feeling well with no major complaints. Her son is concerned that she has been bruising much more easily over the last week or two. Past medical history is significant for hypertension, hyperlipidemia, and a urinary tract infection that was successfully treated with an extended course of oral cephalexin 3 weeks ago. Family history is noncontributory. Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 125/85 mm Hg, and temperature is 36.7°C (98.1°F). On physical exam, her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. She has some poorly demarcated purple-yellow bruising and areas of dark purple bruising as well. Further analysis reveals a prolonged PT that corrects with mixing, normal liver function tests, and a stool test that is guaiac positive. The physician administers an injection that should improve her condition and recommends further testing and a follow-up exam. What is the mechanism of action of the medication received by the patient?

Answer: γ-carboxylation of liver enzymes

A. γ-carboxylation of pancreatic enzymes

B. Protein C deficiency

C. Activation of 7-dehydrocholesterol by UV light

D. γ-carboxylation of liver enzymes


Question: A 35-year-old man presents with loose stools and left lower quadrant abdominal pain. He says he passes 8–10 loose stools per day. The volume of each bowel movement is small and appears mucoid with occasional blood. The patient reports a 20-pack-year smoking history. He also says he recently traveled abroad about 3 weeks ago to Egypt. The vital signs include: blood pressure 120/76 mm Hg, pulse 74/min, and temperature 36.5°C (97.8°F). On physical examination, mild to moderate tenderness to palpation in the left lower quadrant with no rebound or guarding is present. Rectal examination shows the presence of perianal skin ulcers. Which of the following is the most likely diagnosis in this patient?

Answer: Amebiasis

A. Amebiasis

B. Crohn’s disease

C. Salmonellosis

D. Diverticulosis


Question: Hepatocyte nuclear factor 4 alpha (HNF4a) is a transcription factor that is found in the liver, pancreas, kidney, and intestines. The gene is composed of 11 exons and depending on the tissue there are different isoforms of the protein being expressed. Which of the following is responsible for producing the different isoforms of HNF4a?

Answer: Alternative splicing

A. Addition of 7-methylguanosine cap

B. Addition of polyadenylated (poly-A) tail

C. Alternative splicing

D. DNA methylation


Question:
A 50-year-old man presents for a routine examination. Past medical history is significant for cirrhosis secondary to hepatitis C virus (HCV) infection diagnosed 4 years ago and complicated by ascites. Current medications include furosemide 40 mg orally daily. Physical examination is unremarkable. Laboratory findings are significant for the following:
Laboratory test
Aspartate Aminotransferase (AST) 80 U/L
Alanine Aminotransferase (ALT) 50 U/L
Total bilirubin 2.5 mg/dL
Direct bilirubin 1.8 mg/dL
Alkaline phosphatase (ALP) 140 U/L
International normalized ratido (INR) 1.9
Serum creatinine 1 mg/dL
Urinalysis
Sodium 200 mmol/24h
Potassium 60 mmol/24h
Protein Nil
RBCs Nil
RBC casts Nil
WBCs Nil
Urea 13 g/24h
Creatinine 6 mmol/24h
  Abdominal and renal ultrasound reveals no interval change over the past 6 months. Moderate ascites is present. Upper GI endoscopy reveals esophageal varices with a hepatic venous pressure gradient measuring 14 mm Hg. Diagnostic paracentesis is performed and yields a clear liquid with an absolute polymorphonuclear neutrophil (PMN) count of 75 cells/mm3. Which of the following is the most likely etiology of this patient’s condition?

Answer: Portal hypertension

A. Hepatocellular carcinoma

B. Portal hypertension

C. Spontaneous bacterial peritonitis

D. Hepatorenal syndrome


Question: A 45-year-old man with HIV comes to the physician because of multiple lesions on his lower extremity. The lesions are increasing in size and are not painful or pruritic. He does not have lymphadenopathy. He works at a garden center. He lives in Mississippi. Medications include abacavir, dolutegravir, and lamivudine. His temperature is 37.7°C (98.8°F), pulse is 75/min, and blood pressure is 125/80 mm Hg. Examination shows multiple lesions on both heels; some are elevated. There are two similar lesions on the chest. An image of the patient's right heel is shown. His CD4+ T-lymphocyte count is 450/mm3 (normal ≥ 500/mm3). A skin biopsy shows multiple spindle-shaped cells and leukocyte infiltration. Which of the following is the most likely causal organism?

Answer: Human herpesvirus 8

A. Mycobacterium avium complex

B. Human herpesvirus 8

C. Coccidioides immitis

D. Epstein-Barr virus


Question: A 32-year-old woman presents to the office complaining of pain, numbness, and discoloration of her fingers over the past 6 months. She notices that cold temperatures worsen these symptoms, turning the tip of her fingers white and sometimes blue. Her vital signs show her temperature is 37.5°C (99.5°F), blood pressure is 124/86 mm Hg, pulse is 80/min, and respirations are 10/min. On physical examination, the patient has a pale malar rash spread across her face with tender cervical and axillary lymphadenopathy. Examination of her hands reveal tenderness and shiny sclerodactyly. Antinuclear and anti-U1 ribonucleoprotein antibodies are positive. A diagnosis of mixed connective tissue disease is confirmed. What is the next best step in management?

Answer: Echocardiogram

A. Echocardiogram

B. Arthrocentesis

C. Bone marrow transplant

D. Upper GI series


Question: A 58-year-old woman presents with difficulty moving her right shoulder. She underwent a right radical mastectomy with lymph node dissection 3 weeks ago. Her surgery went well with no complications. She has undergone some physical therapy which has not been effective. A few days ago, she started to notice brief periods of painful shoulder instability, especially while opening or closing doors. On physical examination, there is normal active and passive range of motion in the right shoulder. Strength is 5 out of 5 in all muscles of the right shoulder and upper extremity. Sensation is intact. When the patient is asked to push against the wall, her right shoulder blade moves backward (see image). Which of the following nerves is most likely injured in this patient?

Answer: Long thoracic nerve

A. Axillary nerve

B. Suprascapular nerve

C. Long thoracic nerve

D. Ulnar nerve


Question:
A 40-year-old man comes to the physician because he is concerned about the amount of breast tissue he has recently developed. His wife has noticed that he has been irritable for the past month. He was recently treated for tinea capitis. In preparation for an upcoming bodybuilding competition, he has been eating a lot of chicken breast. He drinks 2 beers everyday. He smokes marijuana 3–4 times a week but does not smoke cigarettes. He weighs 90 kg (198 lb) and is 175 cm (5 ft 8 in) tall; BMI is 30.1 kg/m2. Physical examination shows bilateral gynecomastia and small, firm testes. There is no hepatosplenomegaly or abdominal tenderness. Laboratory studies show:
Hematocrit 60%
Platelet count 400,000/mm3
Serum
Na+ 135 mEq/L
Cl- 97 mEq/L
K+ 4.5 mEq/L
HCO3- 25 mEq/L
Glucose 100 mg/dL
Which of the following is the most likely cause of his symptoms?"

Answer: Anabolic steroid use

A. Anabolic steroid use

B. Normal aging

C. Erythropoietin use

D. Marijuana use


Question: A 35-year-old woodsman from local forestry presents to a clinic for counseling regarding his contact with a wild fox that occurred 5 days ago. He says that the fox was not aggressive, allowed him to caress it, and even licked his forearm where he had an open wound. Two days ago, in the same forest, foresters shot a group of foxes who had attacked them, and the fox corpses were handed over to a local veterinary laboratory for testing. Two locals also reported they were attacked by foxes, so the patient became concerned about his exposure. At the time of presentation, the patient had no complaints. His vital signs are as follows: the blood pressure is 125/80 mmHg, the heart rate is 81/min, the respiratory rate is 14/min, and the temperature is 36.8°C (98.2°F). Physical examination reveals 2 healing lacerations, 2 × 3 cm, with a depth of 1 mm each, and multiple scratches on the flexor surface of his right arm. The patient is unaware of his immunization status. Which of the following statements is correct?

Answer: If rabies immunoglobulin is not available immediately, it can be administered within 7 days of the first vaccine dose.

A. The patient does not need immunoglobulin to be administered since he was not bitten by the animal.

B. Before initiating post-exposure prophylaxis, results of laboratory testing of the fox's corpses should be obtained.

C. There is no need to treat the patient’s wounds before administering post-exposure prophylaxis because the wounds are already healing; thus, they do not pose a threat to the patient’s health.

D. If rabies immunoglobulin is not available immediately, it can be administered within 7 days of the first vaccine dose.


Question: A 14-year-old boy presents to his primary care physician for a general check up. The patient's parents refuse to allow the boy to join the school basketball team. The patient has attended two practices, and both times during conditioning, he has fainted. Otherwise, the child is performing well in school. The patient has a past medical history of obesity, elevated fasting blood glucose, and high blood pressure. He is not currently taking any medications. The patient's parents want the patient to be cleared medically before he goes back to playing basketball again. His temperature is 99.5°F (37.5°C), blood pressure is 130/87 mmHg, pulse is 81/min, and respirations are 11/min. Physical exam is notable for an obese child who is pleasant and conversational. Pulmonary exam reveals lungs that are clear to auscultation bilaterally. Cardiovascular exam reveals a murmur heard loudest along the left sternal border. Neurological exam reveals 5/5 strength in the upper and lower extremities with 2+ reflexes. Further diagnostic exams are ordered. Which of the following is appropriate management in this patient?

Answer: Metoprolol

A. Metformin

B. Metoprolol

C. Suggest the patient exercise more before joining a competitive team

D. Clear the patient to participate in sports


Question: A 65-year-old man with chronic obstructive pulmonary disease is admitted to the hospital for the treatment of worsening shortness of breath and productive cough. Three days later, he complains of weakness in the lower limbs. His muscle strength is 4/5 at both hips but normal elsewhere. The drug that is most likely responsible for this patient's muscle weakness inhibits which of the following?

Answer: Nuclear factor-κB

A. Adenosine receptor

B. 5-lipoxygenase

C. Myosin light-chain kinase

D. Nuclear factor-κB


Question: A 64-year-old woman is brought to the emergency department after a syncopal episode 2 hours ago while grocery shopping. She has been feeling fatigued and lightheaded for the past couple of days. She has hypertension. Current medications include carvedilol. She appears diaphoretic. She is oriented to person but not to place or time. Her blood pressure is 102/65 mm Hg. An ECG is shown. Which of the following is the most appropriate next step in management?

Answer: Placement of transcutaneous pacemaker

A. Observation

B. Administration of dopamine

C. Placement of transcutaneous pacemaker

D.
Administration of amiodarone
"


Question: A 42-year-old morbidly obese woman presents to the emergency room for evaluation of a rash that started 3 days ago. The rash appeared under the patient’s breasts as well as in the abdominal folds, and the patient describes it as being very itchy. The rash is bright red with scaling and a few scattered purulent areas of skin breakdown. The patient is afebrile and is in no apparent distress, besides being uncomfortable from the itching. What is the most likely causative agent of this rash?

Answer: A commensal yeast that is catalase-positive

A. A heavily encapsulated, urease-positive yeast

B. A gram-negative rod that produces pyocyanin

C. An acid-fast bacillus

D. A commensal yeast that is catalase-positive


Question: A 47-year-old man comes to the physician because of severe retrosternal chest pain and shortness of breath for 45 minutes. He has dyslipidemia, hypertension, and type 2 diabetes mellitus. Current medications include hydrochlorothiazide, lisinopril, metformin, and atorvastatin. He has smoked 1 pack of cigarettes daily for 20 years. He appears pale and diaphoretic. His temperature is 37°C (98.6°F), pulse is 115/min, and blood pressure is 140/70 mm Hg. Breath sounds are normal. The remainder of the examination shows no abnormalities. An ECG shows left ventricular hypertrophy with ST-segment elevation in leads I, aVL, and V1–V6. High-dose aspirin, clopidogrel, metoprolol, sublingual nitroglycerin, and unfractionated heparin are administered. As the patient awaits transport to the nearest emergency room, he collapses and becomes unresponsive. His pulse and blood pressure cannot be detected. Despite resuscitative efforts, the patient dies. Which of the following is the most likely cause of death in this patient?

Answer: Ventricular fibrillation

A. Papillary muscle rupture

B. Ventricular fibrillation

C. Septal wall rupture

D.
Pulmonary embolism
"


Question: A 4-year-old boy presents to a clinic with intermittent fevers and a rash for 6 days. According to his mother, he is also complaining of pain all over his body. She adds that the rash 1st appeared on his face within 12 hours of the onset of fever, and later spread to his trunks and limbs. The patient denies any itchiness over the rash. There is no history of a sore throat or recent use of medication for symptom relief. The temperature is 37.2°C (99.9°F) and the pulse is 88/min. On examination, there is a maculopapular rash on the face and the trunk, including the limbs, but sparing the palms and soles. The pediatrician reassures the mother that this is most likely a viral infection and will resolve spontaneously. After 7–10 days, the boy is brought back to the clinic for a follow-up visit. The areas affected by the rash appear to have a central clearing giving a lacy or reticular appearance, especially on the cheeks and it looks like someone slapped him on the cheeks. Immunoglobulin M (IgM) antibody detection by the enzyme-linked immunoassay (ELISA) will most likely detect antibodies against which of the following pathogens?

Answer: Parvovirus B19

A. Measles virus

B. Human herpesvirus 6

C. Rubella virus

D. Parvovirus B19


Question: A 25-year-old woman comes into your office with complaints of heavy bleeding. She states that her mother also has heavy bleeding during her menstrual cycle. She has had a heavy flow as long as she can remember and had her first menstrual cycle at age 12. She states during her cycle, she has to change pads every 2 hours for at least 3 days. She also states that she gets bruised easily just like her mother. She denies any past medical history other than her heavy menstrual flow and denies taking any medications. She also denies any medical history in her father and says he is "perfectly healthy." Her vitals are HR 85, T 98.8 F, RR 13, BP 125/75. Her CBC is significant for Hgb 10.5, WBC 5.8, Plts 250, Hct 33. On coagulation studies, her PT is 14 seconds and her PTT is 43 seconds. Her INR is 1.1. What is the most likely cause of this patient's menorrhagia?

Answer: Von Willebrand's disease

A. Factor V Leiden

B. Von Willebrand's disease

C. Hemophilia B

D. Antiphospholipid antibody syndrome


Question: A 30-year-old woman comes to the physician because of numbness, fatigue, and blurry vision for 1 week. The symptoms are worse after a hot shower or bath. She had an episode of right arm weakness 2 years ago that resolved without intervention. She recently returned from a hiking trip in upstate New York. Her temperature is 37.1°C (100°F) and blood pressure is 100/66 mm Hg. Physical examination shows decreased sensation to light touch in the left hand, right thigh, and right flank. Strength is normal. There is left-sided photophobia and pupillary constriction in the left eye is decreased compared to the right eye. Which of the following best describes the pathogenesis of the disease process in this patient?

Answer: Th1 cell-mediated nerve sheath damage

A. Spirochete protein cross-reactivity in the meninges

B. Osmotically-mediated Schwann cell damage

C. Th1 cell-mediated nerve sheath damage

D. Lymphocytic infiltrate of the endoneurium


Question: A 30-year-old man visits his physician with thoughts that he ‘is not real’ which occurred suddenly and have persisted for weeks. The patient states that, 3 weeks ago, he witnessed an armed robbery in which he saw a person get shot in the chest. The patient states that at the time the shot was fired, he felt as though he ‘wasn’t in the room’ and as if he was ‘floating above watching it all happen’ below him. Ever since the event, he has been having similar experiences without provocation. He states that now, seemingly out of nowhere, he will have a sudden feeling that he is ‘perceiving life as a dream’. He now seeks help to control these feelings of depersonalization. Which of the following would be the best course of treatment for this patient?

Answer: Psychotherapy

A. Amantadine

B. Butorphanol

C. Dextromethorphan

D. Psychotherapy


Question: A 9-year-old boy presents with recent onset worsening performance in school and facial lesions that look like acne. Past medical history is significant for developmental delays and infantile spasm. No current medications. On physical examination, there are facial papulonodular lesions (as shown in the image), pitting of dental enamel, and multiple hypomelanotic oval macules over the torso. Which of the following genes is most likely impaired in this patient?

Answer: TSC

A. VHL

B. TSC

C. NF1

D. GNAQ


Question: A 14-year-old girl is brought to the emergency department because of occipital headache, nausea, and vomiting for the last 2 hours. She has a multi-year history of frequent left ear infections and discharge, with poor response to antimicrobial therapy. She has muffled hearing in the left ear. Her blood pressure is 134/78 mm Hg, the pulse is 83/min, the respiratory rate is 16/min, and the temperature is 36.5°C (97.7°F). She is alert and oriented. Physical examination of the left ear shows perforation of the tympanic membrane, granulation tissue, and white keratinaceous debris in the posterosuperior quadrant of the tympanic membrane. An MRI shows evidence of sigmoid sinus thrombosis on the left side and a hyperintense area in the middle ear on. Which of the following is the most likely underlying cause of this patient’s current condition?

Answer: Cholesteatoma

A. Acoustic neuroma

B. Cholesteatoma

C. Chronic serous otitis media

D. Chronic suppurative otitis media


Question: An otherwise healthy 8-year-old boy is brought to the emergency department by his mother 2 hours after the sudden onset of scrotal pain. Physical examination shows nontender testes and a tender, 5-mm, bluish nodule at the superior pole of the left testis. The patient undergoes urgent surgical exploration of the scrotum. During the operation, the nodule on the superior pole of the testis is found to be necrotic. In the process of embryologic development, this nodule forms as a result of the activity of which of the following?

Answer: Sertoli cells

A. Leydig cells

B. Estradiol

C. Luteinizing hormone

D. Sertoli cells


Question: A 23-year-old woman comes to the physician for a 6-month history of dry cough, hoarseness, and chest pain. She does not smoke and has not lost weight. Laboratory studies show no abnormalities. An x-ray of the chest shows a mass that projects across the right hilum. A CT scan of the chest is shown. Which of the following is the most likely diagnosis?

Answer: Neurofibroma

A. Rhabdomyosarcoma

B. Neurofibroma

C. Sarcoma

D. Aortic aneurysm


Question: A 4-year-old is brought into the emeregency room by his mother. The mother states that the child had a slight cough one week ago that has since worsened. The mother states the child's cough sounds like someone barking and states that he has also had mild fevers along with rhinorrhea. The patient's vitals are significant for a fever of 100.8 F, and his physical exam reveals inspiratory stridor. What is the most likely organism responsible?

Answer: Parainfluenza virus

A. Parainfluenza virus

B. Respiratory syncytial virus

C. Adenovirus

D. Ebstein barr virus


Question: A researcher interested in the relationship between vaccination and autism sends a survey to parents of children who are active patients at a large primary care practice. The survey asks several questions, including whether their children received their childhood vaccines on-time, and whether their children currently have a diagnosis of an autism spectrum disorder. Which of the following correctly identifies the study design used by the researcher?

Answer: Cross-sectional

A. Cross-sectional

B. Cohort

C. Randomized controlled trial

D. Case-control


Question: A 6-month-old boy is brought to the physician for a well-child examination. He was born at term, and pregnancy was complicated by prolonged labor. There is no family history of serious illness. He can sit upright without support and can roll over from the prone to the supine position. He cannot pull himself to stand. He can grasp his rattle and cannot transfer it from one hand to the other. He babbles. He cries if anyone apart from his parents holds him or plays with him. He touches his own reflection in the mirror. Vital signs are within normal limits. He is at 40th percentile for head circumference, 30th percentile for length and at 40th percentile for weight. Physical examination shows no abnormalities. Which of the following developmental milestones is delayed in this infant?

Answer: Fine motor

A. Fine motor

B. Social

C. Gross motor

D. Cognitive


Question: A 28-year-old woman is admitted to the hospital for treatment of a displaced fracture of the femoral neck following a high-speed motor vehicle collision. She is given pentazocine for pain relief. This drug binds to heptahelical transmembrane receptors. Which of the following is the most likely effect of this drug?

Answer: Opening of postsynaptic K+ channels

A. Release of presynaptic acetylcholine

B. Release of presynaptic norepinephrine

C. Opening of postsynaptic Na+ channels

D. Opening of postsynaptic K+ channels


Question: A 70-year-old man comes to the physician because of fatigue and intermittent epigastric pain. The symptoms began about one year ago. He describes the pain as diffuse and 3 out of 10 in intensity. Recently, he has had unusually large black stools. He appears pale. His pulse is 72/min and his blood pressure is 110/70 mm Hg. Physical examination shows epigastric tenderness. A urea breath test is positive. Upper gastrointestinal endoscopy reveals an ulcerating mass in the gastric antrum. Biopsies of the mass show diffuse infiltrates of small lymphoid cells that are positive for CD20 antigen. A CT scan of the chest and abdomen shows normal regional lymph nodes. Which of the following is the most appropriate therapy with curative intent at this time?

Answer: Amoxicillin, clarithromycin, and omeprazole

A. Rituximab, cyclophosphamide, adriamycin, and vincristine

B. Imatinib

C. External beam radiation therapy

D. Amoxicillin, clarithromycin, and omeprazole


Question:
A 42-year-old woman approaches your office complaining of a 1-year long persistent dysuria, increasing discomfort with bladder filling and voiding, and suprapubic pain. She further comments that she has been presenting with abdominal cramps, and alternating periods of diarrhea and constipation for the past 4 months. Her family medical history is negative for malignancies and hereditary disorders. Her personal history is relevant for various visits to the general practitioners for similar complaints that resulted in multiple antimicrobial treatments for urinary tract infection. At the moment, she is not taking any medication. Physical examination shows suprapubic tenderness as well as tender areas in the pelvic floor. The vital signs include: temperature 37.0°C (98.6°F), heart rate 68/min, blood pressure 120/58 mm Hg, and respiratory rate 13/min. Vaginal examination is normal. No adnexal masses are detected and no vaginal secretions are noticed.
She brings a urinalysis and a urine culture from 1 week ago that show the following:
Test Result Normal Range
Urine culture Negative < 100,000 CFU/mL to no bacterial growth in asymptomatic patients
Urinalysis Density: 1.030; Leukocyte esterase (-); Nitrites (-); pH: 6.0, Presence of 4 RBCs per high power field. Density: 1.030 - 1.060; Leukocyte esterase (-), Nitrites (-), pH: 4.5 - 8.0
What is the most appropriate step in this case?

Answer: Self-care and behavior modification

A. Self-care and behavior modification

B. Admission to the ER for intravenous antibiotic administration

C. Urinary analgesia with phenazopyridine

D. Conjugated estrogens


Question: A 27-year-old man comes to the physician for a routine health maintenance examination. He says he feels well, but is worried because his 32-year-old brother recently had to start hemodialysis because of kidney disease. He reports that his grandfather had ""bad kidneys” as well. The patient does not have dysuria, hematuria, or flank pain. He has no history of serious illness. His vital signs are within normal limits. Physical examination shows no abnormalities. An ultrasound of his right kidney is shown. Which of the following is the most appropriate next step in management?"

Answer: Reassurance

A. Percutaneous aspiration

B. Reassurance

C. Abdominal CT scan

D. Partial nephrectomy


Question: A 45-year-old man is following up with his primary care doctor for follow up of his essential hypertension. This is his annual check-up, and he reports that he has been doing well since his appointment last year. He denies any negative side effects from his amlodipine or metformin. His physical examination is within normal limits, and his vital signs are all within normal limits, other than his blood pressure being 142/84 mm Hg. Which of the following best describes the mechanism of action for his blood pressure medication?

Answer: Dihydropyridine calcium channel blockers preferentially bind to a vascular smooth muscle

A. Dihydropyridine calcium channel blockers preferentially bind to a vascular smooth muscle

B. Calcium channel blockers only bind to channels on cardiac muscles

C. Non-dihydropyridine calcium channel blockers preferentially bind to a vascular smooth muscle

D. Calcium channel blockers only bind to channels on the sarcoplasmic reticulum


Question: A 50-year-old male visits his primary care physician with skin lesions on his knees and elbows. He reports joint pain, and physical examination reveals severe swelling of the fingers on both hands. Tests for serum rheumatoid factor are negative. Which of the following pairs of adjectives most likely characterize the patient’s skin lesions:

Answer: Silver, scaly

A. Honey-colored, crusting

B. Irregular, depigmented

C. Silver, scaly

D. Non-blanching, hemorrhagic


Question:
A 42-year-old woman comes to the physician because of a low-grade fever and generalized fatigue for a week. During this period, she has passed decreased amounts of urine. Two months ago, she underwent a renal allograft transplant because of reflux nephropathy. There is no family history of serious illness. Her current medications include prednisone, cyclosporine, and azathioprine. Her temperature is 37.8°C (100°F), pulse is 99/min, and blood pressure is 160/94 mm Hg. Examination shows several white patches within the oral cavity. There is a well-healed surgical incision over the right lower abdomen. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 12.1 g/dL
Leukocyte count 6,000/mm3
Platelet count 156,000/mm3
Serum
Urea nitrogen 89 mg/dL
Glucose 76 mg/dL
Creatinine 3.9 mg/dL
Donor-specific antibodies negative
A biopsy of the allograft shows mononuclear infiltrates with tubulitis and arteritis. C4d staining is negative. Oral fluconazole is administered. Which of the following is the most appropriate next step in the management of this patient?"

Answer: Methylprednisolone therapy

A. Intravenous immunoglobulin therapy

B. Methylprednisolone therapy

C. Removal of graft

D. Plasmapheresis


Question: A 55-year-old woman is brought to your office for evaluation of 6 months of anal discomfort, vaginal pruritus, and soreness that worsened in the last several months. The past medical history is significant for hypertension and smoking. The family history is negative for malignancies. The physical examination is unremarkable, except for the presence of white, atrophic papules merging into an ulcerated plaque, with some of the white lesions extending and surrounding the anus (see image). You order biopsies of the lesions and a follow-up appointment. 2 weeks later, the histology evaluation reports hyperkeratosis, significant epidermal thinning, and plugging of infundibular follicles. Which of the following lesions is the patient at risk to develop?

Answer: Differentiated squamous cell carcinoma (SCC)

A. Basal cell carcinoma (BCC)

B. Vulvar low-grade squamous intraepithelial lesion (LSIL)

C. Differentiated squamous cell carcinoma (SCC)

D. Vulvar high-grade squamous intraepithelial lesion (HSIL)


Question: A 32-year-old male presents to his primary care physician with complaints of chronic headaches that have developed and increased in frequency and severity over the last several months. Additionally, the patient has noted he has been less coordinated over the last few weeks, stumbling and tripping often when he is walking. Physical examination is significant for notably reduced hand grip strength bilaterally as well as decreased pain and temperature sensation along the upper back and down both arms to the hands. A referral to the appropriate specialist is made, and an MRI of the brain and neck is obtained. Results of the MRI are show in Figures A and B. Which of the following is the most likely diagnosis in this patient?

Answer: Arnold-Chiari malformation type 1

A. Arnold-Chiari malformation type 1

B. Arnold-Chiari malformation type 2

C. Arnold-Chiari malformation type 3

D. Arnold-Chiari malformation type 4


Question:
After hospitalization for urgent chemotherapy to treat Burkitt’s lymphoma, a 7-year-old boy develops paresthesias of the fingers, toes, and face. Blood pressure is 100/65 mm Hg, respirations are 28/min, pulse is 100/min, and temperature is 36.2°C (97.2°F). Inflating a blood pressure cuff on the boy’s arm produces carpal spasm. He has excreted 20 mL urine in the past 6 hours. Laboratory studies show the following:
Hemoglobin 15 g/dL
Leukocyte count 6,000/mm3 with a normal differential serum
K+ 6.5 mEq/L
Ca+ 6.6 mg/dL
Phosphorus 5.4 mg/dL
HCO3− 15 mEq/L
Uric acid 12 mg/dL
Urea nitrogen 54 mg/dL
Creatinine 3.4 mg/dL
Arterial blood gas analysis on room air:
pH 7.30
PCO2 30 mm Hg
O2 saturation 95%
Febuxostat is initiated. Which of the following is the most appropriate next step in management?

Answer: Hemodialysis

A. Hemodialysis

B. Intravenous 0.9% saline

C. Sodium bicarbonate

D. Orotracheal intubation


Question:
An 84-year-old woman with an indwelling urinary catheter and a history of recurrent nephrolithiasis is brought to the emergency department from her nursing home because of increasing confusion over the past day. On arrival, she is oriented only to person. Her temperature is 38.3°C (100.9°F). Examination shows dry mucous membranes. Urine studies show:
pH 8.3
WBC 40/hpf
Bacteria moderate
Nitrites positive
The urine has an ammonia odor. Which of the following is most likely to be present on this patient's urine culture?"

Answer: Gram-negative, oxidase-negative rods

A. Gram-negative, oxidase-positive rods

B. Gram-positive, novobiocin-resistant cocci

C. Gram-positive, gamma-hemolytic cocci

D. Gram-negative, oxidase-negative rods


Question: A 28-year-old woman who was recently hired at a new company feels intense physical attraction towards her supervisor. She feels he is exceptionally kind to her and finds herself fantasizing about him during work. While talking to her co-workers, she ardently raises complaints about her supervisor and declares that she finds him to be extremely repulsive, rude, and arrogant. Which of the following ego defenses is this patient most closely exhibiting?

Answer: Reaction formation

A. Denial

B. Isolation of affect

C. Reaction formation

D. Repression


Question: An 11-year-old boy presents to his pediatrician with his mother for a sore throat. His symptoms began approximately a few days ago after attending a birthday party with his friends. His symptoms are accompanied by nausea, vomiting, and a mild headache. He also has mild discomfort in his throat when eating food or drinking water. The patient denies rhinorrhea, conjunctivitis, cough, myalgias, or a rash. His mother said his temperature last night was 101°F (38.3°C). On physical exam, the patient has tender and enlarged anterior cervical lymph nodes. Upon oral inspection, there is pharyngeal inflammation and exudates with petechial lesions on the soft palate. Which of the following is the best next step in management?

Answer: Rapid antigen detection test

A. Azithromycin

B. Observation

C. Penicillin V

D. Rapid antigen detection test


Question: A 52-year-old male with follicular non-Hodgkin lymphoma undergoes chemotherapy. He develops suprapubic pain and hematuria. Which of the following compounds is most likely responsible for this patient's symptoms?

Answer: Cyclophosphamide

A. Cyclophosphamide

B. Mesna

C. Bleomycin

D. Carmustine


Question: A 68-year-old man comes to the physician because of a 1-week history of difficulty with urination. Two weeks ago, he was hospitalized for treatment of a cerebrovascular accident; his symptoms began after he was discharged. His vital signs are within normal limits. Neurologic examination shows mild dysarthria, right facial droop, and right hemiparesis. Rectal examination shows a normal prostate. The patient produces 70 mL of urine for a sample. Placement of a Foley catheter yields an additional 500 mL of urine. Which of the following is the most appropriate pharmacotherapy for this patient?

Answer: Muscarinic agonist

A. Muscarinic agonist

B. Muscarinic antagonist

C. Alpha-1 receptor agonist

D. 5-alpha-reductase inhibitor


Question: A 61-year-old woman presents with painless vaginal bleeding. Patient says the bleeding has been occurring occasionally for the past 3 years. Past medical history is significant for diabetes mellitus type 2 and hypertension, both managed medically. Current medications are atorvastatin, lisinopril, hydrochlorothiazide, and metformin. Patient has not been sexually active since the death of her husband 9 years ago. Menopause occurred 8 years ago, and she denies taking hormone replacement therapy or estrogen-containing oral contraceptives. Her last Pap smear 1 year ago was normal. Vital signs are temperature 37.0℃ (98.6℉), blood pressure 130/85 mm Hg, pulse 82/min, respiratory rate 13/min, and oxygen saturation 99% on room air. BMI is 33.8 kg/m2. On physical examination, patient is alert and cooperative. Cardiac exam is normal. Lungs are clear to auscultation. Abdomen is soft and non-tender with no masses or hepatosplenomegaly. Examination of the perineum shows pale, atrophic vaginal mucosa. Speculum examination shows no vaginal or cervical lesions. The cervix is movable and non-tender. There is trace blood in the vaginal vault and mild bleeding from the cervical os. The uterus is not enlarged but softened on palpation. Adnexa is non-palpable. Which of the following is the next best diagnostic step in this patient?

Answer: Endometrial biopsy

A. Hysteroscopy

B. Pap test

C. Endometrial biopsy

D. Pelvic MRI


Question: A 20-year-old African American woman presents to the clinic after missing her last 2 periods. Her cycles are usually regular, occurring at 28–32 day intervals with moderate bleeding and some abdominal discomfort. She also complains of occasional diffuse and generalized headaches. She is a college student and works part-time as a bartender. The past medical history is benign. The blood pressure is 110/70 mm Hg, the pulse is 80/min, the respiratory rate is 14/min, and the temperature is 36.5°C (97.7°F). The physical examination is significant for mild breast tenderness and secretions from the nipple area. A urine pregnancy test is negative. Which of the following is the best initial step in her management?

Answer: Serum prolactin levels

A. MRI of the brain

B. Serum prolactin levels

C. LH:FSH ratio

D. Dopamine agonists


Question: A 50-year-old man comes to the physician because of an 8-month history of intermittent watery diarrhea and abdominal pain. He has had a 12-kg (26-lb) weight loss during this period. He has also had episodic pain of the ankle, wrist, and knee joints during the past 5 years. An endoscopy with small bowel biopsy is performed. Histopathologic examination of a tissue specimen shows foamy macrophages in the lamina propria with periodic acid-Schiff (PAS)-positive inclusions. Further evaluation is most likely to show which of the following?

Answer: Intracellular, gram-positive bacilli

A. Anti-tissue transglutaminase antibodies

B. Anti-cyclic citrullinated peptide antibody

C. Intracellular, gram-positive bacilli

D. Low serum TSH and high free T4 concentrations


Question: A 49-year-old woman comes to the physician because of a growing lump in the right breast that she first noticed 1 month ago. Physical examination of the right breast shows a 3.5-cm firm, fixed mass in the right upper quadrant. There is dimpling of the overlying skin. A mammogram shows a mass with poorly-defined margins and microcalcifications. Immunohistochemical analysis of a biopsy specimen from the mass shows malignant cells that stain negative for estrogen and progesterone receptors and positive for human epidermal growth factor receptor 2. The drug that most specifically targets this patient's tumor is also used in the treatment of which of the following conditions?

Answer: Gastric cancer

A. Multiple sclerosis

B. Gastric cancer

C. Osteoporosis

D. Rheumatoid arthritis


Question: A 17-year-old girl is brought to the physician because her mother is concerned about her lack of appetite. She has had a 4-kg (8.8-lb) weight loss over the past 4 months. The patient states that she does not “feel like eating so much”. Over the last year her academic performance in school has decreased and she has had a lot of disputes with her parents concerning her future. Her mother says that she has also become more nervous and restless. Her grandmother had a problem with her thyroid. She is sexually active with two male partners and uses condoms inconsistently. She is at 60th percentile for height and at 15th percentile for weight. She appears thin. Her temperature is 37°C (98.6°F), pulse is 104/min, and blood pressure is 135/80 mm Hg. The pupils are 9 mm large, round and minimally reactive to light. Deep tendon reflexes are 2+ bilaterally. There is fine tremor of her hands. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?

Answer: Obtain toxicology screening

A. Measure serum electrolytes

B. Perform abdominal ultrasound

C. Obtain toxicology screening

D. Obtain HIV screening test


Question: An 11-year-old male presents to the pediatrician to be evaluated for learning difficulties. His parents report that the patient’s grades have been falling since he started middle school this year. The patient previously attended a smaller elementary school that focused more on the arts and creative play. His parents report that at home the patient bathes and dresses himself independently but requires help with more difficult tasks, such as packing his backpack and making a schedule for homework. He enjoys reading comic books and playing video games. The patient’s parents report that he said his first word at 19 months and walked at 21 months. His mother notes that she herself struggled to pay attention in her classes and completed college in six years after taking a reduced course load. On physical exam, the patient has a long, narrow face with large ears. His testicles are larger than expected for his age. Which of the following additional findings is most likely to be found in this patient’s history?

Answer: Poor reciprocal emotional behavior

A. Compulsive completion of rituals

B. Cruelty to animals or fire-setting

C. Difficulty seeing the board at school

D. Poor reciprocal emotional behavior


Question: A 17-year-old girl comes to the primary care clinic with her father complaining of right knee pain. She reports that the pain started about a month ago, and since then it has gotten progressively worse. The knee pain is not constant but becomes most noticeable when going up or down the stairs. She also endorses that her knee becomes uncomfortable towards the end of class. Her father is worried because the pain is affecting her ability to play basketball, and she has college scouts coming to watch her play. The patient has no chronic medical conditions. She had a tonsillectomy as a child. She takes a multivitamin and uses ibuprofen as needed for the pain. On physical examination, there is tenderness at the inferior pole of the patella, without swelling or overlying skin changes. Which of the following is the most likely diagnosis?

Answer: Patellar tendonitis

A. Osgood-Schlatter disease

B. Patellar stress fracture

C. Patellar tendonitis

D. Patellofemoral syndrome


Question: A 60-year-old man presents to the physician for his 10-year colonoscopy screening. He has no complaints except for occasional diarrhea and dribbling of urine. He says that he is on a healthy diet and exercises 3 days a week. He quit smoking 5 years ago after smoking 1 pack of cigarettes per day for 20 years. He has hypertension and dyslipidemia. He has benign prostatic hyperplasia that was diagnosed last year. On physical examination, his abdomen is lax with no tenderness or rigidity. Rectal examination reveals no blood in the rectal vault. Colonoscopy reveals a 4 x 3 cm polyp in the sigmoid colon. Multiple biopsies are obtained and sent for pathologic examination. Genetic testing reveals a mutation in the KRAS gene. Which of the following pathological type of polyp does this patient most likely have that also puts him at higher risk of malignancy?

Answer: Villous adenomatous polyps

A. Hamartomatous polyps

B. Villous adenomatous polyps

C. Tubular adenomatous polyps

D. Hyperplastic polyps


Question: A 20-year-old healthy female volunteer is enrolled in a study involving renal perfusion. The medical history is unremarkable and she takes no medications. She denies smoking, drinking, and drug use. The family history is unremarkable. The physical examination reveals no abnormal findings. A drug which is known to selectively act on a segment of the renal vasculature is administered and the glomerular filtration rate (GFR) and filtration fraction (FF) both increase. Which of the following could be the mechanism of action of the administered drug?

Answer: Efferent arteriole constriction

A. Efferent arteriole constriction

B. Renal artery constriction

C. Increased peritubular capillary permeability

D. Afferent arteriole constriction


Question: A 3-year-old male is brought to the emergency room by his mother for a rash and fever. The mother reports that the child first developed a cough and malaise three days ago. Over the last 24 hours, a rash developed and the patient had a temperature up to 101.4°F (38.6°C) the night prior to presentation. The child’s medical history is notable for a prior hospitalization at the age of 2 for fever, vomiting, and lethargy. During that hospitalization, a cerebrospinal fluid sample demonstrated gram-negative diplococci. His current temperature is 100.9°F (38.3°C), blood pressure is 130/85 mmHg, pulse is 115/min, and respirations are 22/min. Physical examination reveals a lethargic male child with a diffuse petechial skin rash that is most prominent on the trunk and legs. This patient most likely has a deficiency in which of the following factors?

Answer: C5

A. C1q

B. C3

C. C4

D. C5


Question:
A 13-month-old boy is brought to the physician for the evaluation of rectal bleeding that occurred earlier that morning. The patient has also had several itchy and red skin lesions that started on his scalp and spread downwards. The parents report that their son has had six episodes of bilateral otitis media since birth. His immunizations are up-to-date. He is at the 3rd percentile for height and weight. His vital signs are within normal limits. Examination shows several eczematous lesions over the scalp, neck, and upper and lower extremities, as well as multiple red spots that do not blanch on pressure. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 9.4 g/dL
Leukocyte count 11,500/mm3
Platelet count 30,000/mm3
Prothrombin time 14 sec
Partial thromboplastin time 33 sec
Which of the following is the most likely diagnosis?"

Answer: Wiskott-Aldrich syndrome

A. Chronic granulomatous disease

B. DiGeorge syndrome

C. Chediak-Higashi syndrome

D. Wiskott-Aldrich syndrome


Question: A 28-year-old woman, gravida 3, para 2, at 34 weeks' gestation comes to the physician because of a 1-day history of dyspnea, dry cough, and chest pain. Her pulse is 112/min, respirations are 24/min, and blood pressure is 108/78 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Examination shows jugular venous distention and bilateral pitting edema below the knees that is worse on the right side. There is dullness to percussion over the right lung base. Which of the following is the most likely diagnosis?

Answer: Pulmonary embolism

A. Pulmonary embolism

B. Panic attack

C. Bacterial pneumonia

D. Acute pericarditis


Question:
A 55-year-old man comes to the physician for a follow-up examination. One month ago, he underwent a right-sided kidney transplantation due to severe polycystic kidney disease. Following the procedure, he was started on transplant rejection prophylaxis. He has had some chest and back pain as well as frequent coughing. He has also had 5–6 bowel movements per day of loose stool and occasional vomiting. He appears pale. Temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 155/90 mm Hg. Physical examination shows lower extremity pitting edema. Laboratory studies show:
Hemoglobin 10 g/dL
Leukocyte count 2,500/mm3
Platelet count 80,000/mm3
Serum
Urea nitrogen 30 mg/dL
Glucose 150 mg/dL
Which of the following is the most likely underlying cause of this patient's symptoms?"

Answer: Mycophenolate mofetil

A. Tacrolimus

B. Daclizumab

C. Mycophenolate mofetil

D. Azathioprine


Question: A 2-year-old boy with a history of multiple hospitalizations for fever and infection undergoes immunologic evaluation. Serum CH50 assay shows inappropriately low erythrocyte lysis and further workup confirms C8 deficiency. This patient is at increased risk for recurrent infections with which of the following pathogens?

Answer: Neisseria species

A. Neisseria species

B. Giardia species

C. Pneumocystis species

D.
Mycobacterium species
"


Question: A 55-year-old man is brought to the emergency department because of cough and poor appetite for the past week. Since it began, he has been coughing up small amounts of malodorous phlegm. During the past two nights, he has also had night sweats. He was diagnosed with HIV infection 5 years ago. He has hypertension, type 2 diabetes mellitus, and severe heartburn. The patient is homeless and does not take any medication. He has smoked a pack of cigarettes daily for 30 years. He drinks 8–10 beers daily. His temperature is 38.9°C (102.0°F), pulse is 101/min, respirations are 25/min and blood pressure is 145/92 mm Hg. The patient appears intoxicated. Physical examination shows crackles and dullness to percussion at the right lung base. Scattered expiratory wheezing is heard throughout both lung fields. A grade 2/6 mid-systolic ejection murmur is heard along the upper right sternal border. His CD4+T-lymphocyte count is 280/mm3 (Normal ≥ 500). An x-ray of the chest shows a hazy infiltrate in the right lower lung field. Which of the following is the most likely cause of this patient's symptoms?

Answer: Aspiration pneumonia

A. Pneumocystis pneumonia

B. Aspiration pneumonia

C. Mitral valve regurgitation

D.
Pharyngoesophageal diverticulum
"


Question: A 2-year-old boy is brought in to his pediatrician for his annual exam, flu vaccination, and to evaluate a diaper rash. The itchy pink rash has been bothering the boy for about 1 week and over the counter, remedies are not helping. He was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. During the discussion, his parents are frustrated by his behavior and inability to follow directions. Today, his vital signs are stable and normal for his age. On physical examination, the boy appears uncomfortable. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. There is a pink-red, raised rash in the anogenital region and medial thighs. Additionally, there are multiple bruises on the boy’s buttocks and the back of his thighs. Some are healing and some are fresh. When questioned about the bruising, the parents become evasive and end the discussion. Which of the following is the next best step in the management of the child?

Answer: To report to Child Protective Services

A. To report to Child Protective Services

B. To order patch testing for allergic contact dermatitis

C. To obtain skin scrapings for examination by light microscopy

D. Mupirocin cream


Question: A 62-year-old woman comes to the physician for the evaluation of a palpable mass in the left breast that she noticed 3 weeks ago. During this period, she has also had some left-sided blood-tinged discharge. She has hypertension, type 2 diabetes mellitus, and hypercholesterolemia. She has no children. The patient's menopause occurred at 57 years of age. Her mother died of colon cancer at the age of 65 years. The patient had smoked one pack of cigarettes daily for 30 years but quit 15 years ago. She does not drink alcohol. Her current medications include enalapril, metformin, atorvastatin, and a multivitamin. She is 165 cm (5 ft 5 in) tall and weighs 84 kg (187 lb); BMI is 30.9 kg/m2. She appears well. Her temperature is 37°C (98.6°F), pulse is 78/min, and blood pressure is 135/80 mm Hg. Examination of the breasts shows a left-sided single, nontender, firm mass with poorly defined margins in the upper outer quadrant. Biopsy of the mass confirms the diagnosis of pleomorphic lobular carcinoma in situ (LCIS) that is estrogen-receptor (ER) positive. The patient undergoes lumpectomy of the left breast and treatment with tamoxifen is started. The patient's therapy increases her risk of which of the following conditions?

Answer: Endometrial cancer

A. Myelosuppression

B. Osteoporosis

C. Endometrial cancer

D. Ovarian cancer


Question: A confused and disoriented 32-year-old man is brought to the emergency department by his wife. He was in his usual state of health until yesterday, when he started complaining of fever and headache. This morning he was complaining of worsened headache and was acting odd, prompting his wife to bring him to the hospital. His past medical history is unremarkable. At the hospital, his temperature is 39.2°C (102.5°F), pulse is 116/min, and blood pressure is 96/64 mm Hg. Physical examination is notable for neck stiffness and a large scar across his abdomen that his wife says is from a splenectomy operation following a car accident a few years ago. He has not seen a doctor since that time. A lumbar puncture shows elevated protein, low glucose, and 1,200 WBCs with 95% polymorphonuclear cells; gram staining shows gram-positive diplococci. Which of the following is the most likely risk factor contributing to this patient's underlying diagnosis?

Answer: Dysfunction of a single organ

A. Congenital humoral immunodeficiency

B. Dysfunction of a single organ

C. Dysfunction of multiple organs

D. Undiagnosed viral infection


Question: A group of scientists is verifying previous research on DNA replication. The diagram illustrates the theoretical DNA replication process in bacteria such as Escherichia coli. What does the letter ‘a’ represent in this process?

Answer: Okazaki fragments

A. RNA Primers

B. Okazaki fragments

C. The leading strand

D. Replication fork


Question:
A physician is involved in a research collaboration with a pharmaceutical company. The company invites her to give a lecture series for other physicians on new therapies in her field of expertise at a retreat center in the Caribbean. Which of the following is acceptable for the physician to accept?:
A) Compensation for travel expenses
B) An honorarium for speaking
C) Assistance with preparing her presentations

Answer: A and B

A. A only

B. B only

C. C only

D. A and B


Question: A 15-year-old teenager is brought to a pediatrician by his parents. They are concerned about his performance at school and have received several letters from his school noting that the adolescent has difficulty with reading and writing compared to his classmates and often misbehaves during class. A physical exam reveals some atypical findings. A Wechsler Intelligence Scale for Children (WISC) shows that the boy has a mild intellectual disability with an IQ of 84. Complete blood count and serum TSH levels are normal. After a careful review of all findings the pediatrician suspects the teenager may have a numerical chromosomal disorder and orders karyotype (see image). Which of the following set of findings were most likely found during the physical exam?

Answer: Tall Stature and gynecomastia

A. Arachnodactyly, scoliosis and aortic root dilation

B. Short stature, broad chest and thick skin folds in neck

C. Short stature, hypotonia and obesity

D. Tall Stature and gynecomastia


Question:
Ten days after delivery, a 1500-g (3.3-lb) male newborn is feeding poorly. He was born at 32 weeks' gestation. He has had frequent episodes of vomiting for the past 2 days. He has no fever, diarrhea, or hematemesis. He appears lethargic and is difficult to arouse. His temperature is 37°C (98.6°F), pulse is 145/min, respirations are 65/min, and blood pressure is 78/55 mm Hg. The lungs are clear to auscultation. The abdomen is hard with rebound tenderness. The patient is responsive only to painful stimuli. His hemoglobin concentration is 13.0 g/dL, leukocyte count is 10,900/mm3, and platelet count is 90,000/mm3. Arterial blood gas analysis on room air shows:
pH 7.31
PCO2 30 mm Hg
PO2 80 mm Hg
O2 saturation 98%
An x-ray of the abdomen is shown. Which of the following is the most appropriate treatment?"

Answer: Exploratory laparotomy

A. Nasogastric tube gut decompression

B. Exploratory laparotomy

C. Administration of ampicillin, gentamicin, and metronidazole

D.
Barium enema
"


Question: A 45-year-old man who underwent liver transplantation 3 months ago for chronic liver failure presents to the physician because of a backache following a fall from sitting. He is currently on immunosuppressive therapy with glucocorticoids and cyclosporine. He has no comorbidities. On physical examination, his vitals are within normal limits. He has tenderness over his lumbar spine. An X-ray of the lumbar spine shows a wedge compression fracture of the L1 vertebra. His serum testosterone and serum creatinine levels are normal. Bone mineral densitometry shows a T-score of –3.0. What is the most likely diagnosis?

Answer: Transplantation-related osteoporosis

A. Renal osteodystrophy

B. Osteopenia

C. Osteomalacia

D. Transplantation-related osteoporosis


Question: A 56-year-old woman presents to the emergency department with acute onset of pain and redness of the skin of her right arm for the past 3 days. She has had type 2 diabetes mellitus for the past 22 years, but she is not compliant with her medications. Her temperature is 38.0°C (100.4°F), pulse is 105/min, and blood pressure is 116/74 mm Hg. On physical examination, her forearm is tender and erythematous. She is diagnosed with acute cellulitis, and intravenous clindamycin is started. On the 6th day of antibiotic therapy, the patient complains of severe watery diarrhea, fever, and abdominal tenderness without rigidity. Which of the following is the best initial diagnostic test for her current complaint?

Answer: Polymerase chain reaction

A. Complete blood count with differential

B. Sigmoidoscopy or colonoscopy

C. Fecal occult blood test

D. Polymerase chain reaction


Question: A group of researchers attempts to determine the mean fasting triglyceride levels in patients between the ages of 30 and 60 in a suburb of Tampa, FL. Over the course of several years, the team manages to obtain the blood levels of a random sample of 10,000 volunteers who fit their inclusion criteria. The blood levels are measured and demonstrate a standard deviation of 5. Which of the following correlates with the estimated standard error of the mean for this population?

Answer: 0.05

A. 0.02

B. 0.05

C. 0.10

D. 0.15


Question: A 14-year-old girl is brought to the physician by her mother for evaluation of several bruises on her lower extremities. She has had these bruises for about 6 weeks, and the mother is concerned that she might be bullied at school. The patient has had increasing fatigue and paleness over the past several days. She has a history of recurrent generalized tonic-clonic seizures treated with carbamazepine. She appears pale and ill. Her temperature is 37.8°C (100.1°F), pulse is 115/min, and blood pressure is 100/60 mm Hg. The lungs are clear to auscultation. Examination shows a soft, nontender abdomen with no organomegaly. There are several subcutaneous purple spots on her legs bilaterally. Her hemoglobin concentration is 8.4 g/dL, leukocyte count is 2,600/mm3, platelet count is 18,000/mm3, and reticulocyte count is 0.3%. Serum electrolyte concentrations are within normal limits. Which of the following is the most likely underlying cause of this patient's symptoms?

Answer: Adverse effect of medication

A. Immune thrombocytopenic purpura

B. Sickle cell disease

C. Systemic lupus erythematosus

D. Adverse effect of medication


Question: A 51-year-old man comes to the emergency department because of a 3-day history of shortness of breath, fever, and chills. He has no history of serious illness. His temperature is 39.5°C (103.1°F). Physical examination shows a grade 4/6, holosystolic, blowing murmur over the apex that radiates to the axilla. Crackles are heard in both lower lung fields. Examination of the extremities shows several non-tender, non-blanching, erythematous macules on the palms and soles. Histopathologic examination of these macules is most likely to show which of the following?

Answer: Microabscesses with neutrophil infiltration of capillaries

A. Microabscesses with neutrophil infiltration of capillaries

B. Epithelioid cells with surrounding multinucleated giant cells

C. Cleft-like vacuoles within the arterioles

D. Spiral-shaped bacteria with axial filaments in the epidermis


Question: An investigator is studying the maternal and fetal consequences of a recent spike in benzodiazepine addiction in Ireland. She is particularly interested in whether benzodiazepine use contributes to oral cleft deformities in newborns exposed to alprazolam, clonazepam, or lorazepam during the first trimester. The investigator uses statistical data from the local demographic institute to calculate the number of newly diagnosed cases of oral cleft deformities in Ireland over the past 5 years. Which of the following terms describes the investigator's statistical measure of interest?

Answer: Cumulative incidence

A. Mortality rate

B. Relative risk

C. Cumulative incidence

D. Attributable risk


Question:
A 55-year-old woman comes to the office for preventive health care. She has recently migrated to the United States from Hong Kong. Her past medical history is noncontributory. She denies smoking cigarettes or drinking alcohol. She last saw a doctor at the age of 14 when she was diagnosed with appendicitis and underwent an appendectomy. Her father died of a stroke at 59 years old and her mother died of a heart attack at 66 years old. She has 2 daughters who are in good health. Temperature is 37°C (98.7°F), blood pressure is 113/85 mm Hg, pulse is 69/min, respiratory rate is 14/min, and BMI is 24 kg/m2. Cardiopulmonary and abdominal examinations are negative.
Laboratory test
Complete blood count
Hemoglobin 12.5 g/dL
MCV 88 fl
Leukocytes 5,500/mm3
Platelets 155,000/mm3
Basic metabolic panel
Serum Na+ 135 mEq/L
Serum K+ 3.7 mEq/L
Serum Cl- 106 mEq/L
Serum HCO3- 25 mEq/L
BUN 10 mg/dL
Serum creatinine 0.8 mg/dL
Liver function test
Serum bilirubin 0.8 mg/dL
AST 30 U/L
ALT 35 U/L
ALP 130 U/L (20–70 U/L)
What is the next best step in management of this patient?

Answer: Gamma glutamyl transferase

A. Bone scan

B. Ultrasonography of the abdomen

C. Gamma glutamyl transferase

D. Anti mitochondrial antibody


Question: A 33-year-old man presents to his primary care practitioner, complaining about the presence of white spots in both of his hands. He states that the white spots have expanded in the last few months; they are not tender nor ulcerated. His past medical history is relevant for hypothyroidism. Upon physical examination, the patient shows hypopigmented macules on both hands and on the back and shoulders adjacent to a patch of skin, with signs of excoriation and scratching. Under the Wood’s lamp, the skin lesions on the hands, back, and shoulders show fluorescence. There are no signs of inflammation in any of the skin lesions. The vital signs of the patient are within normal limits. Which is the most likely diagnosis of this condition?

Answer: Vitiligo

A. Vitiligo

B. Tinea versicolor

C. Pityriasis alba

D. Halo nevus


Question: A 3-year-old boy is brought to the emergency department by his mother. He started violently coughing, wheezing, and having difficulty breathing about 10 minutes ago. She had briefly left him lying on his back playing with toys and when she returned he was choking. She attempted the Heimlich maneuver with no improvement. He has a heart rate is 120/min, respiratory rate is difficult to evaluate, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F). A respiratory exam reveals wheezing and decreased breath sounds on the right side. A stat chest X-ray is ordered. Which of the following is the most likely site where the aspirated foreign body is lodged?

Answer: Posterior segment of the right upper lobe

A. Basilar segment of the right upper lobe

B. Posterior segment of the right upper lobe

C. Basilar segment of the left lower lobe

D. Basilar segment of the right lower lobe


Question:
A 38-year-old man presents with weakness, loss of appetite, headaches, and irritability. He developed these symptoms gradually over the past 4 months. He was diagnosed with Crohn’s disease, which was moderate at the time of diagnosis 6 months ago. He takes methotrexate 15 mg, which effectively controls his symptoms. The patient’s vital signs include: blood pressure 105/70 mm Hg, heart rate 102/min, respiratory rate 16/min, and temperature 36.4℃ (97.5℉). On physical examination, the patient is pale. His lungs are clear to auscultation. His heart sounds are rhythmic; a short early systolic murmur can be heard over the apex of the heart. The rest of the exam is unremarkable. The patient’s blood test shows the following findings:
Erythrocytes 2.7 x 109/mm3
Hb 9.3 g/dL
Hct 37%
Mean corpuscular hemoglobin  45.2 pg/cell (2.8 fmol/cell)
Mean corpuscular volume 122 µm3 (122 fL)
Reticulocyte count 0.4%
Total leukocyte count 3050/mm3
Neutrophils 62%
Lymphocytes 32%
Eosinophils 1%
Monocytes 5%
Basophils 0%
Platelet count 199,000/mm3
Which of the following drugs should be prescribed to this patient?

Answer: Folic acid

A. Riboflavin

B. Niacin

C. Pyridoxine

D. Folic acid


Question:
A 75-year-old man with coronary artery disease and mitral valve stenosis status-post coronary artery bypass graft and mitral bioprosthetic valve replacement is evaluated in the intensive care unit. His postsurgical course was complicated by ventilator-associated pneumonia and bilateral postoperative pleural effusions requiring chest tubes. He has been weaned from the ventilator and has had his chest tubes removed but has required frequent suctioning to minimize aspirations. He has been dependent on a percutaneous gastrostomy tube for enteral nutrition for the past four weeks. He is currently on aspirin, carvedilol, atorvastatin, ceftazidime, and pantoprazole. He has a history of prostate cancer status post radical prostatectomy. His temperature is 96°F (35.6°C), blood pressure is 95/55 mmHg, pulse is 50/min, and respirations are 20/min. On physical exam, he is not alert and oriented but responds with moans when stimulated. His laboratory data are listed below:

Serum:
Na+: 145 mEq/L
Cl-: 110 mEq/L
K+: 3.4 mEq/L
HCO3-: 26 mEq/L
BUN: 10 mg/dL
Glucose: 112 mg/dL
Creatinine: 1.4 mg/dL
Thyroid-stimulating hormone: 10 µU/mL
Ca2+: 11.1 mg/dL
PO4-: 1.0 mg/dL
AST: 6 U/L
ALT: 10 U/L
Albumin: 2.5 mg/dL
Lactate dehydrogenase: 200 U/L (140-280 U/L)
Haptoglobin: 150 mg/dL (30-200 mg/dL)
1,25-(OH)2 D3: 10 pg/mL (15-75 pg/mL)
Parathyroid hormone: 9 pg/mL (10-60 pg/mL)

Leukocyte count: 10,000 cells/mm^3 with normal differential
Hemoglobin: 9 g/dL
Hematocrit: 30 %
Platelet count: 165,000 /mm^3

His electrocardiogram and chest radiograph are shown in Figures A and B. What is the most likely cause of his hypercalcemia?

Answer: Immobilization

A. Euthyroid sick syndrome

B. Immobilization

C. Malignancy

D. Primary hyperparathyroidism