Question: A 55-year-old man with a history of diabetes and hypertension presents to the emergency department when he found half of his face paralyzed this morning. The patient was last seen normal the night before by his wife and woke up with these symptoms. He has a past medical history of diabetes and hypertension and is not currently taking any medications for these conditions. His temperature is 98.5°F (36.9°C), blood pressure is 177/118 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for an inability for the patient to move any part of his face on the right side. The rest of his neurological exam is within normal limits. Which of the following is the next best step in management for the most likely diagnosis?

Answer: Topical lubricants and discharge

A. Elevation of the head of the bed and intubation

B. MRI of the head

C. Tissue plasminogen activator

D. Topical lubricants and discharge


Question: A newborn boy develops excessive bilious vomiting 4 hours after delivery. The infant was born vaginally to a 29-year-old mother (gravida 2, para 1) at 38 weeks gestation. History was significant for polyhydramnios detected at 32 weeks and monitored for the duration of gestation. He was put to the breast right after birth and sucked actively. He still has not passed meconium. The patient’s vital signs include: blood pressure 77/50 mm Hg, heart rate 128/min, respiratory rate 37/min, and temperature 36.4℃ (97.5℉). On physical examination, the newborn appears fussy and mildly dehydrated. His abdomen appears rounded, soft and nontender on palpation, with no palpable organomegaly or masses. What is the most probable site of obstruction?

Answer: Duodenum, distal to Vater’s papilla

A. Esophagus

B. Gastric pylorus

C. Duodenum, distal to Vater’s papilla

D. Sigmoid colon


Question:
The patient is counselled about her risk of thyroid malignancy. Serum studies show:
Na+ 138 mEq/L
K+ 4.1 mEq/L
Cl- 101 mEq/L
TSH 0.03 μU/mL
Calcium 9 mg/dL
Which of the following is the most appropriate next step in management?"

Answer: Thyroid scintigraphy scan

A. Free T4 and T3 levels

B. Fine-needle aspiration biopsy

C. Open biopsy

D. Thyroid scintigraphy scan


Question: An 18-month-old girl is brought to her pediatrician because of swelling in her hands and feet. Her mother is concerned because she has been inconsolable for the last 8 hours. The mother adds that the girl has been getting tired easily recently. The vital signs include: temperature 38.0°C (100.4°F), blood pressure 90/55 mm Hg, and pulse 122/min. Gentle palpation of the metacarpal and metatarsal bones causes the infant to scream. The laboratory evaluation is remarkable for mild anemia, leukocytosis, and increased reticulocyte count. Her peripheral blood smear is shown in the picture. Which of the following best represents the etiology of this infant condition?

Answer: Abnormal globin chain structure

A. Red cell enzymatic deficiency

B. Abnormal heme synthesis

C. Abnormal globin chain structure

D. Abnormal globin chain synthesis


Question:
A 34-year-old gravida-1 at 8 weeks gestation seeks evaluation for a fever and sore throat for 3 days. She also reports generalized body pain and fatigue over this period. She was diagnosed with Graves’ disease 6 months ago. Before conception, methimazole was switched to propylthiouracil. She appears ill. The vital signs include: axillary temperature 38.0℃ (100.4℉), pulse 88/min, respiratory rate 12/min, and blood pressure 120/80 mm Hg. A 1 × 1 cm ulcer is seen on the side of the tongue. The ulcer is tender with surrounding erythema. Examination of the neck, lungs, heart, and abdomen shows no abnormalities. The laboratory studies show the following:
Hemoglobin 13.5 g/dL
Mean corpuscular volume 90 μm3
Leukocyte count 2,500/mm3
Segmented neutrophils 5%
Lymphocytes 88%
Platelet count 240,000/mm3
Alanine aminotransferase 18 U/L
Aspartate transaminase 16 U/L
Which of the following is the most appropriate next step in management?

Answer: Discontinuation of propylthiouracil

A. Acetaminophen for fever control

B. Discontinuation of propylthiouracil

C. Oral ampicillin

D. Rectal temperature measurement


Question: A 27-year-old man comes to the physician because of a 1-week history of fever and pain with urination. His temperature is 39°C (102.2°F). Physical examination shows no abnormalities. A photomicrograph of a urine sample is shown. This patient's findings indicate damage to which of the following structures?

Answer: Renal interstitium

A. Urethra

B. Ureter

C. Renal interstitium

D. Glomerulus


Question: Twelve hours after undergoing uncomplicated total knee replacement, a 55-year-old man develops increasing anxiety, agitation, hand tremor, and nausea. He told the nurse he saw a bear in his room. His pain has been controlled with intravenous morphine. He has a history of advanced liver disease. He drinks 7 cans of beer daily. He is diaphoretic. His temperature is 37.6°C (99.7°F), pulse is 118/min, respirations are 18/min, and blood pressure is 146/92 mm Hg. Administration of which of the following drugs is the most appropriate next step in management?

Answer: Lorazepam

A. Chlordiazepoxide

B. Lorazepam

C. Dantrolene

D. Carbamazepine


Question: A 45-year-old woman comes to the physician’s office with complaints of jaw pain. When she eats, yawns, or rubs her jaw, she gets intense, shooting pains down the left side of her jaw, including her lower lip and chin. These episodes last about 30 seconds and have recurred about 10 times per day for the last month. She finds these episodes extremely distressing and comes to the physician’s office in hope of finding a treatment. The patient denies any locking of her jaw. Physical exam is not notable for any tenderness to palpation over the jaw. She has no crepitus in her temporomandibular joint. The patient is able to open and close her jaw without pain. The nerve involved in this patient’s clinical presentation exits the skull through which of the following brain structures?

Answer: Foramen ovale

A. Superior orbital fissure

B. Foramen ovale

C. Foramen spinosum

D. Jugular foramen


Question: A 64-year-old woman presents to the hospital for chemotherapy. She has newly diagnosed acute myeloid leukemia. She is due to receive treatment with bendamustine for 2 days. On day 2 of her treatment, the patient complains of intense pain in her right great toe. On physical exam, the metatarsophalangeal joint of the 1st toe is warm, erythematous, swollen, and tender to both movement and palpation. An arthrocentesis is performed that reveals negatively birefringent needle-shaped crystals under polarized light. A Gram stain of the synovial fluid is negative. In addition to adequate intravenous hydration, which of the following if given would have most likely prevented the patient’s symptoms?

Answer: Allopurinol

A. Acetazolamide

B. Allopurinol

C. Colchicine

D. Corticosteroids


Question: A 29-year-old woman comes to the physician with complaints of fever, headache, and rash, which have gradually worsened over the past 6 days. The patient informs the physician that the rash appeared after 2 days of fever. The rash started at the wrists and ankles and then gradually spread to the trunk, palms, and soles. On examination, the physician notes a maculopapular rash as shown in the image below. Vital signs show a temperature of 39.4°C (103.0°F), a blood pressure of 110/70 mm Hg, and a pulse rate of 86/min. Which of the following is the most likely diagnosis?

Answer: Rocky Mountain spotted fever

A. Endemic typhus

B. Lyme disease

C. Rocky Mountain spotted fever

D. Q fever


Question: A 25-year-old man presents to the emergency department after paramedics picked him up from an electronic music festival. His temperature is 103°F (39.4°C), blood pressure is 167/105 mmHg, and pulse is 122/min. On physical exam, the patient is highly alert, agitated, and diaphoretic. Laboratory testing is significant for a serum sodium concentration of 130 mEq/L. Which of the following was most likely ingested by the patient?

Answer: 3,4-methylenedioxymethamphetamine

A. Heroin

B. Ketamine

C. 3,4-methylenedioxymethamphetamine

D. Lysergic acid diethylamide


Question:
A 1-day-old male is seen in the neonatal intensive care unit for respiratory distress. He was born at 37 weeks to a 24-year-old G3P11011 Rh- mother who had no prenatal care. On physical examination, temperature is 99°F (37.2°C), blood pressure is 120/85 mmHg, pulse is 120/min, respirations are 26/min, and pulse oximetry is 92% on room air. There is abdominal distention with a positive fluid wave. Laboratory results are as follows:

Serum:
Alkaline phosphatase: 80 U/L
ALT: 33 U/L
AST: 32 U/L
Bilirubin (total): 10 mg/dL
Bilirubin (conjugated): 0.2 mg/dL
Amylase: 76 U/L

Leukocyte count: 5,000/mm^3 with normal differential
Hemoglobin: 8 g/dL
Platelet count: 200,000/mm^3
Mean corpuscular volume: 80 µm^3
Reticulocyte count: 3%

What is the most likely diagnosis?

Answer: Erythroblastosis fetalis

A. Dubin-Johnson syndrome

B. Gilbert syndrome

C. Breast feeding jaundice

D. Erythroblastosis fetalis


Question: Study X examined the relationship between coffee consumption and lung cancer. The authors of Study X retrospectively reviewed patients' reported coffee consumption and found that drinking greater than 6 cups of coffee per day was associated with an increased risk of developing lung cancer. The same study in lab mice; however, did not come to a similar conclusion. Which of the following most likely explains the difference between these 2 studies?

Answer: Confounding

A. Confounding

B. Lead time bias

C. Observer bias

D. Selection bias


Question: A 2-day-old boy was born at 38 weeks gestation to a 37-year-old woman by vaginal delivery. Since birth, the boy has had difficulty latching onto the breast but has not vomited or passed meconium. Examination reveals a flat facial profile with epicanthal eyelids, low-set earlobes, and a transverse crease on each palm. The abdomen is distended with absent breath sounds in the hypogastric region. A digital rectal examination shows a patent anal canal and is followed by a projected expulsion of gas and stool. What is the most likely mechanism underlying this patient’s findings?

Answer: Failure of neural crest cell migration during embryologic development

A. Hypertrophic pylorus causing retrograde flow of gastric contents

B. Inspissated meconium causing intestinal obstruction

C. Failure of neural crest cell migration during embryologic development

D. Telescoping of 2 parts of the intestine into each other


Question: An otherwise healthy 23-year-old newly-married woman comes to the physician because of a 6-day history of discomfort in her vaginal area during and after sexual intercourse. Her last menstrual period was 3 weeks ago. Two years ago, she was diagnosed with genital herpes which was treated with acyclovir. She has been in a monogamous relationship for the past year and has been using an intrauterine device for contraception for the past month. Examination shows a 4-cm, mildly tender mass in the inferior aspect of the left labium minus with no signs of inflammation. Speculum examination causes her discomfort but shows no abnormalities. Which of the following is the most likely cause of these findings?

Answer: Obstructed orifice of the Bartholin duct

A. Obstructed orifice of the Bartholin duct

B. Reactivation of the genital herpes

C. Squamous cell carcinoma of the vulva

D. Allergic reaction to the intrauterine device


Question: A 22-year-old professional softball player is undergoing an annual check-up. Her medical history is significant for hallux valgus and scoliosis. She additionally notes that she frequently has bumps and bruises from playing softball, but she has no injuries today. Her family history is significant for heart disease. The patient's blood pressure is 110/70 mm Hg, heart rate is 78/min, and respiratory rate is 15/min. A physical examination is unremarkable except for an indurated palpable mass on her left breast. A biopsy of the mass is performed. Which biopsy findings are most likely to be present in this patient?

Answer: Necrotic fat with calcifications and giant cells

A. Chronic inflammation with plasma cells

B. Necrotic fat with calcifications and giant cells

C. Leaf-like projections

D. Abundant extracellular mucin


Question: A 5-month-old male infant is brought to the physician by his parents for the evaluation of a progressive enlargement of his head circumference. His parents report that he has been healthy except for an episode of tonsillitis 3 months ago treated with penicillin. The patient was born at term by a lower segment transverse cesarean section because of a transverse lie. He has met all developmental milestones. His immunizations are up-to-date. The patient is at the 50th percentile for length, 50th percentile for weight, and 95th percentile for head circumference. He appears well-nourished. His temperature is 37°C (98.6°F), pulse is 120/min, and blood pressure is 90/60 mm Hg. Physical examination shows a tense anterior fontanelle. The eyes deviate inferiorly and the eyelids are retracted. Which of the following is the most appropriate next step in the management of this patient?

Answer: Ultrasound of the head

A. Serial lumbar punctures

B. CT scan of the head

C. Place a CSF shunt

D. Ultrasound of the head


Question: A 37-year-old G1P1001 delivers a male infant at 9 pounds 6 ounces after a C-section for preeclampsia with severe features. The mother has a history of type II diabetes with a hemoglobin A1c of 12.8% at her first obstetric visit. Before this pregnancy, she was taking metformin, and during this pregnancy, she was started on insulin. At her routine visits, her glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL. In addition, her routine third trimester culture for group B Streptococcus was positive. At 38 weeks and 4 days gestation, she was found to have a blood pressure of 176/103 mmHg and reported a severe headache during a routine obstetric visit. She denied rupture of membranes or vaginal bleeding. Her physician sent her to the obstetric triage unit, and after failure of several intravenous doses of labetalol to lower her blood pressure and relieve her headache, a C-section was performed without complication. Fetal heart rate tracing had been reassuring throughout her admission. Apgar scores at 1 and 5 minutes were 7 and 10. After one hour, the infant is found to be jittery; the infant's temperature is 96.1°F (35.6°C), blood pressure is 80/50 mmHg, pulse is 110/min, and respirations are 60/min. When the first feeding is attempted, he does not latch and begins to shake his arms and legs. After 20 seconds, the episode ends and the infant becomes lethargic. Which of the following is the most likely cause of this infant’s presentation?

Answer: ß-cell hyperplasia

A. ß-cell hyperplasia

B. Neonatal sepsis

C. Inborn error of metabolism

D. Neonatal encephalopathy


Question: A 65-year-old male presents to his cardiologist to discuss increasing episodes of dyspnea after climbing stairs. He also now needs three pillows at night to sleep. Physical examination reveals an early diastolic murmur best appreciated at the left sternal border with bounding peripheral pulses. The cardiologist is very concerned and immediately refers the patient for a surgical workup. What is the most likely diagnosis?

Answer: Aortic regurgitation

A. Mitral valve insufficiency

B. Aortic regurgitation

C. Mitral stenosis

D. Aortic stenosis


Question: A 42-year-old overweight restaurant waiter develops excruciating pain in the heel of his right foot. Symptoms are most intense after getting out of bed but get better after walking. On physical examination, both feet have a flat medial arch. There is tenderness to palpation along the inner aspect of the right heel bone, minimal active dorsiflexion, and pain at passive dorsiflexion. X-ray films reveal a bone spur at the level of the attachment of the right plantar fascia. The spur is also present in the comparison film of the left foot. He is diagnosed with plantar fasciitis and is told to lose weight, rest, use ice, and take anti-inflammatory medications. Which of the following is most accurate?

Answer: This was caused by excessive strain on the medial fascicle.

A. The central fascicle is the thinnest and the most likely to rupture.

B. The patient's windlass mechanism remains intact.

C. This was caused by excessive strain on the medial fascicle.

D. The pain in the right foot is caused by the bone spur.


Question: A 7-year-old boy is brought to the physician because of decreased vision, hearing, and speaking over the past 3 months. During this time, he has also had difficulty walking, concentrating, drawing, and feeding himself. His maternal male cousin had similar complaints and died at the age of 5 years. Examination shows hyperpigmented skin and nails. His speech is dysarthric. Neurologic examination shows an ataxic gait, spasticity, and decreased muscle strength in all extremities. Fundoscopy shows optic atrophy. Which of the following is the most likely cause of this patient's symptoms?

Answer: Dysfunction of ATP-binding cassette transporter

A. Deficiency of β-glucocerebrosidase

B. Dysfunction of ATP-binding cassette transporter

C. Deficiency of arylsulfatase A

D. Deficiency of lysosomal galactocerebrosidase


Question: A 55-year-old man comes to the physician because of a 4-month history of nocturia. He wakes up twice each night to urinate. He has no history of serious illness. He takes no medication. His younger brother was diagnosed with testicular cancer at the age of 35 years. Rectal examination shows a smooth, symmetrical prostate without nodules. The physician offers to discuss the advantages and limitations of the prostate specific antigen (PSA) test in diagnosing prostate cancer. He mentions that a a serum PSA of 4 ng/mL is generally used as a cutoff value. At this cutoff, the test has a sensitivity of 21% for detecting any prostate cancer and 51% for detecting high-risk prostate cancer, with a specificity of 91%. In patients without urinary retention, hematuria, back pain, or incontinence, the positive predictive value for PSA > 4 ng/mL is estimated at 30% and the negative predictive value for PSA ≤ 4 ng/mL at 85%. Based on this information, what is the probability that this patient does not have prostate cancer if his PSA is 4.3 ng/mL?

Answer: 70%

A. 79%

B. 15%

C. 70%

D. 9%


Question:
A 23-year-old woman presents to the emergency department for vomiting and abdominal pain. The patient states that she has been unable to eat or drink for the past 24 hours without vomiting. She also complains of worsening abdominal pain that started 3 days ago. The patient has a past medical history of IV drug abuse and alcohol abuse. She is not on any current medications. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, tenderness is elicited when the right lower quadrant of her abdomen is palpated. Deep palpation and release of the left lower quadrant of her abdomen also causes severe pain. Rectal exam reveals normal tone and stool is Guiac negative. Laboratory studies are ordered as seen below.

Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 11,500/mm^3 with normal differential
Platelet count: 197,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 27 mEq/L
BUN: 20 mg/dL
Glucose: 67 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
AST: 12 U/L
ALT: 15 U/L

Urine:
Cocaine: positive
Amphetamines: positive
ß-hCG: positive
Marijuana: positive
Heroin: negative
PCP: negative
MDMA: positive
Glucose: negative
Ketones: negative

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

Answer: Ultrasound

A. Chest radiograph

B. Abdominal CT

C. Ultrasound

D. Colonoscopy


Question: A 75-year-old man was brought in by his daughter since he was having increased incidences of forgetting things. His daughter said that he becomes increasingly frustrated searching for his glasses and keys most of the time. He was helped out a couple of times in the supermarket for forgetting the way out. He recently lost his driving license when he was spotted by the cops driving in the wrong direction on the interstate. Which of the following is the most likely pathology for this presentation?

Answer: Abnormal cleavage of amyloid precursor protein

A. Prion infection

B. α-synuclein defect

C. Depigmented substantia nigra and locus cerulus

D. Abnormal cleavage of amyloid precursor protein


Question: A 7-month-old male child is brought into your office for recent rhinorrhea and cough. The mother states that the child has had mild fevers of up to 100.7 F over the last three days along with clear nasal discharge, and a nonproductive cough, but the child has been working harder to breathe over the last day. The mother states the child was vaccinated for the flu one month ago. His vitals are significant for a temperature of 100.9F and his physical exam is significant for intercostal retractions along with expiratory wheezing. What is the most likely organism responsible?

Answer: Respiratory syncytial virus

A. Parainfluenza virus

B. Adenovirus

C. Respiratory syncytial virus

D. Echovirus


Question:
A 56-year-old man comes to the physician because of increasing generalized fatigue for 1 month. He also has had a 5.4 kg (12 lb) weight loss over the past 6 months. He has hypertension and type 1 diabetes mellitus. His father died of colon cancer at the age of 65 years. He has smoked one pack of cigarettes daily for 32 years and drinks one alcoholic beverage per week. He has numerous tattoos, several of which were acquired when he went backpacking through Southeast Asia as a young man. Current medications include enalapril and insulin. He is 180 cm (5 ft 11 in) tall and weighs 78 kg (172 lb); BMI is 24.1 kg/m2. His temperature is 37.0°C (98.6°F), pulse is 86/min, and blood pressure is 140/90 mm Hg. The abdomen is soft and nontender. The liver is palpated 3 cm below the right costal margin. Laboratory studies show:
Hemoglobin 12.6 g/dL
Mean corpuscular volume 86 μm3
Leukocyte count 8800/mm3
Platelet count 282,000/mm3
Hemoglobin A1C 6.3 %
Serum
Glucose 113 mg/dL
Creatinine 1.1 mg/dL
Albumin 4.1 mg/dL
Total bilirubin 1.1 mg/dL
Alkaline phosphatase 66 U/L
AST 100 U/L
ALT 69 U/L
Ferritin 180 ng/mL
α-fetoprotein
410 ng/mL (N < 10 ng/mL)
CT scan of the abdomen shows a 3.5 x 2 x 1.5 cm mass in segment 6 of the liver. Which of the following interventions most likely would have prevented this patient's condition?"

Answer: Hepatitis B vaccination

A. Regular phlebotomies

B. Hepatitis B vaccination

C. Penicillamine therapy

D. Antitrypsin replacement therapy


Question: A 6-year-old girl with polycystic kidney disease is started on a new medication after receiving a kidney transplant from a matched, unrelated donor. Two days after starting the medication, laboratory studies show a leukocyte count of 17,500/mm3 (90% segmented neutrophils, 4% bands, 1% eosinophils, 3% lymphocytes, and 1% monocytes). Which of the following drugs is the most likely cause of these laboratory findings?

Answer: Methylprednisolone

A. Methylprednisolone

B. Abciximab

C. Erythropoietin

D. Tacrolimus


Question: A clinical trial is conducted to investigate the efficiency of a new glucagon receptor antagonist in the treatment of type 2 diabetes mellitus. After 12 weeks of treatment with this drug, all participants in the study achieved statistically significant reductions in fasting and postprandial serum glucose. Three individuals reported symptoms of hypoglycemia while exercising. The activity of which of the following cellular enzymes is most likely to be decreased in response to treatment with this drug?

Answer: Protein kinase A

A. Mitogen-activated protein kinase

B. Guanylate cyclase

C. Protein kinase A

D. Phospholipase C


Question: A 19-year-old man is admitted to the medical intensive care unit with suspected sepsis. Blood cultures grow Gram-negative cocci containing lipooligosaccharide in their cell wall. Which of the following would you expect to find on a detailed history and physical examination of this patient?

Answer: Petechial rash

A. Petechial rash

B. Ascending paralysis

C. History of exposure to rabbit hides

D. Rice water stools


Question: A 25-year-old male rugby player presents to the emergency room complaining of a severe headache. He is accompanied by his teammate who reports that he had a head-to-head collision with another player and briefly passed out before regaining consciousness. His past medical history is significant for a pilocytic astrocytoma as a child treated successfully with surgery. His family history is notable for stroke in his father. His temperature is 98.9°F (37.2°C), blood pressure is 160/90 mmHg, pulse is 60/min, and respirations are 20/min. On examination, he is lethargic but oriented to person, place, and time. The affected vessel in this patient directly branches from which of the following vessels?

Answer: Maxillary artery

A. Maxillary artery

B. Internal carotid artery

C. Superficial temporal artery

D. Anterior cerebral artery


Question: A 4-year-old boy presents with 3 days of fever, crampy abdominal pain, vomiting, and loose, bloody bowel movements containing mucus. The patient’s mother says that other children from his daycare class have also developed similar symptoms. The patient’s temperature is 39.0°C (102.2°F). On physical examination, the patient is irritable and inconsolable, and his abdomen is distended. Intravenous fluid resuscitation is initiated. Histopathologic analysis of his stool reveals numerous red and white blood cells. Which of the following is characteristic of the most likely microorganism responsible for this patient’s symptoms?

Answer: Inactivation of the 60S ribosome subunit

A. Inactivation of the 60S ribosome subunit

B. Permanent activation of Gs alpha subunit

C. Overactivation of guanylate cyclase

D. Disabling Gi alpha subunit


Question: A 23-year-old man develops a seizure on the medical floor. He was admitted 2 days ago with high-grade fever and severe headache. At the time of admission, he had photophobia, neck rigidity, and the following vital signs: temperature 39.5°C (103.1°F), blood pressure 130/70 mm Hg, and heart rate 120/min. A cerebral spinal fluid analysis was ordered, and he was started on intravenous antibiotics. The patient’s seizure terminates without any medication or intervention. An MRI is performed which reveals dilation of all the ventricles of the brain. Which of the following is the most likely cause of his abnormal radiologic findings?

Answer: Arachnoid granulation adhesions

A. Blood clot in the foramen of 3rd ventricle

B. Aqueductal stenosis

C. Arachnoid granulation adhesions

D. Mega cisterna magna


Question: A 27-year-old unconscious man is brought to the ED by EMS. He was found face down in the middle of the sidewalk at 2AM. The patient is disheveled and smells of alcohol. Physical exam reveals bruising and ecchymosis at the right temple and 1-mm pupils bilaterally. His temperature 97.1°F (36.3°C), blood pressure is 84/58 mmHg, pulse is 71/min, respirations are 8/min. Following initial stabilization and respiratory support, what is the best next step for this patient?

Answer: Naloxone

A. Flumazenil

B. Glucose

C. Naloxone

D. Warming blankets


Question:
A 43-year-old man presents to the clinic for pain with swallowing for a month. He says that the pain has gotten worse over the past few weeks. His past medical history is significant for AIDS. He states that he has not been able to afford his highly active antiretroviral therapy, so he is not currently taking any medications. His temperature is 98.6°F (37°C), respirations are 15/min, pulse is 70/min, and blood pressure is 100/84 mm Hg. Physical examination reveals no mucosal lesions. Evaluation of the blood reveals:
Hb%: 11 gm/dL
Total count (WBC): 2,400 /mm3
Differential count:
Neutrophils: 70%
Lymphocytes: 25%
Monocytes: 5%
CD4+ cell count: 51/mm3
What is the best pharmacotherapy for this patient's current symptom?

Answer: Oral fluconazole

A. Oral fluconazole

B. Oral nystatin liquid suspension

C. Intravenous amphotericin B

D. Oral acyclovir


Question: A 25-year-old man is brought by his roommate to the emergency department with chest pain, which began 90 minutes ago. His roommate says that he has not slept within the past 24 hours and has been taking pills to help him study longer for his upcoming national dental board exam. On examination, he is diaphoretic, extremely agitated, and attempts to remove his IV lines and ECG leads. His temperature is 38.9°C (102.2°F), pulse is 115/min, and blood pressure is 160/102 mmHg. His pupil size is 7 mm bilaterally. The lungs are clear to auscultation. The most appropriate next step in management is administration of which of the following?

Answer: Lorazepam

A. Lorazepam

B. Dantrolene

C. Ketamine

D.
Haloperidol
"


Question: A 65-year-old female presents to her primary care physician for a routine check-up. She reports feeling well but has noticed occasional weakness and constipation over the past few months. A complete blood count is within normal limits. Serum calcium is 11.9 mg/dL and serum phosphate is 2.4 mg/dL. Urine calcium output is 400 mg/24 h. A sestamibi scan demonstrates increased uptake near the inferior left pole of the thyroid gland. Which of the following mechanisms is most likely involved in this patient’s symptoms?

Answer: Increased RANK-L expression

A. Increased osteoprotegerin expression

B. Decreased RANK-L expression

C. Increased RANK-L expression

D. Increased ß-adrenergic receptor synthesis


Question: A 35-year-old male presents to his physician with a small mass that he found in the anterior of his neck a few days ago. The mass is not painful and does not affect his swallowing. He noticed no change in his weight. His history is significant for radiation exposure for treating his neuroblastoma at the age of 15. On examination, a nodule around the size of 2.2 cm is palpated in the right thyroid lobule; the nodule is firm and non-tender. There is cervical lymphadenopathy. His blood pressure is 118/75 mm Hg, respirations are 17/min, pulse is 67/min, and temperature is 37.5°C (99.5°F). Laboratory findings include serum Na+ of 136 mmol/L, K+ of 4.2 mmol/L, Cl– of 90 mmol/L, and bicarbonate of 24 mmol/L. Which of the following factors will most likely make the prognosis worse in this patient?

Answer: Bone metastases

A. Age

B. Bone metastases

C. Follicular histological variant

D. Hurthle cell variant


Question: An 18-year-old man is referred to a psychiatrist for evaluation after a recent suicide attempt. On questioning him, he says that he did it because he got fed up with life and feels that he is worthless. The patient’s father informs the doctor that his son has been gloomy most of the time over the last 2 months, and his academic performance has declined significantly. His father further adds that his son’s appetite has decreased significantly over the last 3 months, leading to a 5.0 kg (11.0 lb) weight loss.  The patient denies any history of manic or hypomanic episodes. Physical examination is unremarkable. Routine laboratory tests, including thyroid hormone and cortisol levels, are within normal limits. Which of the following patterns of abnormal brain activity would most likely be present in this patient?

Answer: Decreased norepinephrine levels in the cortical and limbic areas

A. Increased dopaminergic activity in the limbic system

B. Increased glutamatergic activity in the subthalamic nucleus

C. Decreased norepinephrine levels in the cortical and limbic areas

D. Decreased cholinergic activity in the hippocampus and amygdala


Question: A 10-year-old girl is evaluated for a suspected primary deficiency. She is the first child in a consanguineous marriage. She was born vaginally at full term after an uncomplicated pregnancy and was breastfed for 9 months. The patient has had an episode of meningococcal meningitis, recurrent bronchiolitis, and multiple bouts of pneumococcal pneumonia over the past 5 years. She has also suffered from chronic otitis media since the age of 5. After a thorough examination, the child is found to have a partial CD19 deficiency. Which of the following proteins is heavily involved with this pathogenesis?

Answer: CD21

A. CD8

B. CD16

C. CD21

D. CD25


Question: A 24-year old woman is brought to the emergency department after a motor vehicle collision. She was a restrained passenger at the time of impact. On examination, the patient is pale and in moderate distress. She complains of a sharp pain in the posterior aspect of the left shoulder. Vitals include temperature is 37.0°C (98.6°F), right arm blood pressure is 94/63 mm Hg, left arm blood pressure is 90/61 mm Hg, pulse is 122/min, and respirations are 24/min. Cardiopulmonary auscultation reveals normal heart sounds and clear lungs. Neck veins are not distended. Several, large ecchymoses are visible over the chest and abdomen in a seatbelt pattern. Her abdomen is tender on superficial palpation with mild rebound tenderness and rigidity. Her range of motion is normal with 5/5 motor strength in all extremities. Wrist drop is absent. A FAST scan is pending. Based on the patient’s current presentation, which organ is most likely affected?

Answer: Spleen

A. Pancreas

B. Heart

C. Spleen

D. Appendix


Question:
A 68-year-old woman presents to her primary care physician with complaints of fatigue, difficulty breathing upon exertion, and crampy lower abdominal pain. She also notices that her stools are dark. She has had essential hypertension for 20 years for which she takes bisoprolol. Her family history is positive for type 2 diabetes mellitus. On physical examination, she looks pale. Complete blood count shows the following:
Hemoglobin 10 g/dL
Mean corpuscular volume (MCV) 70 fL
Mean corpuscular hemoglobin (MCH) 25 pg/cell
Mean corpuscular hemoglobin concentration (MCHC) 27 g/dL
Red cell distribution width 16%
Platelet count 350,000/mm3
Serum ferritin is 9 ng/mL. The patient is referred to a gastroenterologist and conventional colonoscopy reveals a polypoid mass in the ascending colon. Biopsy shows poorly differentiated adenocarcinoma. A preoperative staging is performed and a laparoscopic cancer resection with postoperative chemotherapy are planned. Which of the following tests can be used for postoperative follow up of this patient?

Answer: Carcinoembryonic antigen (CEA)

A. Carcinoembryonic antigen (CEA)

B. Pelvic magnetic resonance imaging (MRI)

C. Transrectal endoscopic ultrasound (TRUS)

D. Cancer antigen 125 (CA 125)


Question: A 34-year-old man comes to the physician because of a 2-day history of progressively blurred vision. He also reports seeing flashing lights in his visual field. He does not have any pain. The patient has not been examined by a physician in several years. He appears emaciated. Examination shows right conjunctival injection. Visual acuity is 20/20 in the left eye and 20/100 in the right eye. Fundoscopic examination of the right eye is shown. His CD4+ T-lymphocyte count is 46/mm3. Which of the following is the most appropriate pharmacotherapy for this patient's eye condition?

Answer: Valganciclovir

A. Valganciclovir

B. Penicillin G

C. Sulfadiazine and pyrimethamine

D. Trimethoprim-sulfamethoxazole


Question: A 42-year-old man comes to the physician because of several episodes of rectal bleeding over 2 weeks. He has had pain around the anal area for the past month. Six months ago, he was diagnosed with esophageal candidiasis and was treated with oral fluconazole. He is HIV-positive. He has had 9 male sexual partners over his lifetime and uses condoms inconsistently. The patient's current medications include dolutegravir, tenofovir, and emtricitabine. He is 179 cm (5 ft 10 in) and weighs 66 kg (146 lb); BMI is 20.9 kg/m2. Vital signs are within normal limits. Digital rectal examination and anoscopy show a hard 2-cm mass palpable 0.5 cm above the anal verge that bleeds on contact. There is no inguinal lymphadenopathy. The abdomen is soft and nontender. The CD4+ T-lymphocyte count is 95/mm3(N ≥ 500/mm3). A biopsy confirms the diagnosis. This patient is most likely to benefit from which of the following interventions?

Answer: Radiochemotherapy

A. Radiochemotherapy

B. Local 5-fluorouracil therapy

C. Injection sclerotherapy

D.
Submucosal hemorrhoidectomy
"


Question: A 19-month-old boy comes into the emergency department with his parents. He has burns on his buttocks and perineal area. The patient’s mother says she was at home with the patient when she heard him screaming from the kitchen. She says she ran to the room to find that the patient had pulled down a container of hot water on himself. Which of the following burn patterns would be most indicative of child abuse in this patient?

Answer: Circular burns of equal depth restricted to the buttocks, with sparing of the hands and feet

A. Burns to flexor and anterior surfaces

B. Burns with irregular borders, uneven depth of burns, and splash pattern

C. Burns with some areas blistering but with others not blistering

D. Circular burns of equal depth restricted to the buttocks, with sparing of the hands and feet


Question: A 44-year-old woman presents to the physician for evaluation of recurrent episodes of pounding headache, palpitations, excessive sweating, anxiety, tremors, and pallor, with occasional vomiting for the last 2 weeks. She has presented to the same physician with similar complaints in the past; however, she is frustrated with the lack of proper diagnosis and now insists on a detailed workup. She does not take any medications. She has a history of progressively increasing thyroid swelling as well as multiple bone pain for the past 2 months. On physical examination, she is very lean and appears anxious and apprehensive. She has clammy and moist hands. Her temperature is 37.1°C (98.9°F), the pulse is 110/min, the blood pressure is 176/94 mm Hg, and the respiratory rate is 27/min. Her weight is 43 kg (94.8 lb), height is 145 cm (4 ft 7 in), and body mass index (BMI) is 20.4 kg/m2. A firm thyroid nodule is palpable in the right lobe. Physical examination is otherwise normal. What is the most appropriate initial management for this patient?

Answer: 24-h urine catecholamine by-products (vanillylmandelic acid (VMA), metanephrine, and normetanephrine)

A. Serum epinephrine and norepinephrine

B. Clonidine test

C. 24-h urine catecholamine by-products (vanillylmandelic acid (VMA), metanephrine, and normetanephrine)

D. Serum calcium and PTH


Question: A 54-year-old male is involved in a high speed motor vehicle collision and is brought to the emergency department. On arrival, his vitals are temperature 98.6 °F (37 °C), blood pressure 110/70 mmHg, pulse 100/min, and respirations are 20/min. His Glasgow Coma Score (GCS) is 13 (eye opening 3, verbal response 5, and motor response 5). Physical exam is notable for a rapid and thready pulse, and a rigid and distended abdomen with positive rebound tenderness. FAST exam reveals a large hypoechoic stripe in the hepatorenal recess. Two large bore IV's are started and the patient is given a 1L bolus of normal saline. The patient’s mental status rapidly deteriorates and he becomes unresponsive. His pulse is 149/min and blood pressure is 70/40 mmHg. The patient is started on a medication while additional fluids are administered. Subsequently his vitals, his pulse is 80/minute and blood pressure is 120/80 mmHg. While the patient is being taken to the operating room, he develops pain in all four distal extremities. His digits appear blue and are cool to the touch. Which medication is most likely responsible for this complication?

Answer: Norepinephrine

A. Epinephrine

B. Norepinephrine

C. Vasopressin

D. Ephedrine


Question: A 20-year-old man with a history of cystic fibrosis presents to his pulmonologist for a regular checkup. He generally feels well but noticed that he has had an increase in stool frequency. He describes his stools as loose and “greasy”, often staining the toilet bowl. He regularly uses albuterol and budesonide inhalers and has chest physical therapy several times a month. Physical exam is unremarkable. Serum level of which of the following coagulation factors is likely abnormal in this patient?

Answer: II

A. II

B. V

C. VIII

D. XI


Question: A 6-year-old boy is brought to the physician by his father for an annual health maintenance examination. His father notes that he has several pigmented areas on his skin and a few fleshy bumps. He has also had some blurred vision in his left eye. He has no history of serious medical illness. He lives at home with both parents and is up-to-date on all his immunizations. His father has similar skin findings. His mother has epilepsy and glaucoma. Vital signs are within normal limits. Visual acuity testing shows 20/50 in the left eye and 20/20 in the right eye. Slit-lamp examination shows pigmented iris nodules. Examination of his skin shows eight brownish macules and numerous soft, non-tender, pedunculated lesions on the back, chest, and abdomen. Which of the following is the most appropriate next step in management?

Answer: MRI of the brain

A. MRI of the brain

B. Electroencephalogram

C. B-scan ultrasound

D. Gonioscopy


Question: A 43-year-old man is brought to the emergency department because of a fever, cough, pleuritic chest pain, and dyspnea. Two days ago, he returned from a construction site along the Mississippi River. Abdominal examination shows a palpable spleen. An x-ray of the chest shows diffuse reticulonodular infiltrates. Therapy with a drug that binds ergosterol is initiated. This patient is most likely to experience which of the following adverse effects?

Answer: Hypomagnesemia

A. Hypomagnesemia

B. Histamine release

C. Leukopenia

D. Cytochrome P450 induction


Question: A 49-year-old African man presents to the physician with a 3-month history of fatigue, shortness of breath, and abdominal distention. He immigrated to the US approximately 6 months ago. He has no other medical problems and is currently not on medication. He previously worked as a farmer but stopped due to his inability to keep up with the work. His blood pressure is 112/58 mm Hg, pulse is 90/min, respiratory rate is 19/min, and temperature is 37.8°C (100.0°F). Physical examination reveals bilateral pedal edema up to the knees, jugular venous distention, and abdominal distention with free fluid. Chest auscultation reveals the following sound. Jugular venous pressure tracing reveals prominent ‘x’ and ‘y’ descents. Radial pulse is absent during inspiration bilaterally. Which of the following is the primary underlying cause of this patient’s presentation?

Answer: Tuberculosis

A. Coxsackie A virus

B. Tuberculosis

C. Protozoan infection

D. Tricuspid endocarditis


Question: A 25-year-old primigravida is admitted to the hospital at 35 weeks gestation with lower leg edema. She denies any other symptoms. Prior to admission, the antepartum course was unremarkable and she was compliant with recommended  prenatal care. The vital signs were as follows: blood pressure, 155/90 mm Hg; heart rate, 84/min; respiratory rate, 16/min; and temperature, 36.6℃ (97.9℉). The fetal heart rate was 142/min. The physical examination shows 2+ pitting edema. A 24-hour urine assessment showed proteinuria (1.2 g). An ultrasound examination showed a normally developing fetus without structural abnormalities. The placental margin was located 3 cm away from the internal os. Which of the following options describes the  proper management in this patient assuming that no deterioration occurs up to the time of delivery?

Answer: Induction of vaginal delivery at 37 weeks’ pregnancy if not begin spontaneously earlier

A. Induction of vaginal delivery at 37 weeks’ pregnancy if not begin spontaneously earlier

B. Cesarean delivery after a course of a corticosteroid treatment

C. Vaginal delivery induction after a course of corticosteroid treatment

D. Watch for a spontaneous vaginal delivery at any term from the moment of presentation


Question: A 12-year-old female presents to the emergency room difficult to arouse and occasionally vomiting. On physical exam, her oral mucosa looks dry, her breath has a fruity odor, and her breathing is slow, deep and labored. What is the most likely primary metabolic disturbance?

Answer: Anion gap metabolic acidosis

A. Anion gap metabolic acidosis

B. Non-anion gap metabolic acidosis

C. Metabolic alkalosis

D. Respiratory alkalosis


Question: A 36-year-old man presents to the emergency room with subacute worsening of chronic chest pain and shortness of breath with exertion. The patient is generally healthy, lifts weights regularly, and does not smoke. His temperature is 97.8°F (36.6°C), blood pressure is 122/83 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Cardiac auscultation reveals a crescendo-decrescendo murmur heard right of the upper sternal border with radiation into the carotids. An ECG shows left axis deviation and meets criteria for left ventricular hypertrophy. An initial troponin is < 0.01 ng/mL. Which of the following is the most likely diagnosis?

Answer: Bicuspid aortic valve

A. Bacterial endocarditis

B. Bicuspid aortic valve

C. Cardiac myxoma

D. Senile calcific changes


Question: A 66-year-old man is admitted to the intensive care unit for management of laboratory-confirmed septic shock. His current plan includes appropriate management of airway and breathing, intravenous antibiotics, fluid resuscitation, and supportive care. After the administration of adequate intravenous isotonic fluids, his temperature is 37.2°C (99.0°F), the pulse rate is 120/min, the blood pressure is 90/50 mm Hg, and the respiratory rate is 22/min. His extremities are warm and capillary refill time is normal. The patient is started on vasopressor therapy, and norepinephrine is chosen over epinephrine. Which of the following characteristics of norepinephrine best explains this choice in this patient?

Answer: Norepinephrine has more α1-adrenergic effects compared to epinephrine

A. Norepinephrine has less α1-adrenergic effects compared to epinephrine

B. Norepinephrine has more β2-adrenergic activity compared to epinephrine

C. Norepinephrine has similar α1-adrenergic effects compared to epinephrine

D. Norepinephrine has more α1-adrenergic effects compared to epinephrine


Question: A 67-year-old man comes to the physician because of a worsening tremor that began one year ago. The tremor affects his left hand and improves when he uses his hand to complete a task. He also reports feeling stiffer throughout the day, and he has fallen twice in the past year. He has not noticed any changes in his cognition or mood. He has not had difficulty sleeping, but his wife says that he would kick and punch while dreaming for almost a decade. He drinks two cans of beer daily. He takes no medications. He appears healthy and well nourished. His vital signs are within normal limits. He maintains a blank stare throughout the visit. Further evaluation is most likely to show which of the following?

Answer: Reduced amplitude on foot tapping

A. Reduced amplitude on foot tapping

B. Extensor plantar response

C. Choreiform movements

D.
No abnormalities
"


Question:
A 25-year-old African American man comes to the emergency department for “red urine.” Patient reports that he just returned from a skiing trip in the Rocky Mountains and developed the reddish urine today. He denies upper respiratory infection symptoms, chest pain, fever, or chills but does endorse some right flank pain that developed 3 days ago. Physical examination was unremarkable except for some tenderness upon palpation at the right flank. Laboratory findings are as follows:

Serum:
Na+: 137 mEq/L
K+: 4.9 mEq/L
Cl-: 100 mEq/L
HCO3-: 25 mEq/L
Osmolality: 275 Osm/kg

Urine:
Color: Red
Protein: 3+
RBC: 4 cells/hpf
Osmolality: 214 Osm/kg
Specific gravity: 1.004

Which finding would you most likely expect with this patient?

Answer: HbS on hemoglobin electrophoresis

A. Cystic mass of the right kidney on CT abdomen/pelvis

B. HbS on hemoglobin electrophoresis

C. Renal stones on CT abdomen/pelvis

D. Segmental sclerosis and hyalinosis of renal glomeruli on light microscopy


Question: A 62-year-old man presents to his primary care physician because of lower back pain and radiating leg pain. He says that the pain is searing and goes from the buttock into the posterior thigh and lateral leg. It is moderate in intensity and he has noticed that it worsens with sitting and improves with standing. His past medical history is significant for well controlled hypertension, but he has otherwise been healthy. He works as a laborer loading packages in a warehouse and is concerned because the pain does not allow him to work. On physical exam, he is found to have pain and paresthesia while performing a straight leg raise. Radiographs show loss of disk height and MRI shows significant degeneration and posterolateral herniation of the disk in between the L5 and S1 vertebrae. Adjacent disks appear to be relatively normal without notable herniation. Which of the following sets of findings would most likely be seen in this patient?

Answer: Weak ankle plantarflexion and diminished Achilles reflex

A. Weak ankle dorsiflexion and diminished Achilles reflex

B. Weak ankle dorsiflexion and hallucis extension

C. Weak ankle plantarflexion and diminished Achilles reflex

D. Weak ankle plantarflexion and diminished patellar reflex


Question:
A 46-year-old woman presents to her primary care provider with pain in both of his hands and wrists. She notes that it is hard for her to prepare breakfast or wash dishes in the morning due to stiffness. It seems to subsides later in the day. She also complains of a constant fatigue and unintentional weight loss during the last few months. The past medical history is significant for hypertension. She takes captopril and aspirin daily, and occasional ibuprofen for the pain in her hands. Her mother developed similar symptoms in her hands resulting in hand deformity. The blood pressure is 140/90 mm Hg, heart rate is 67/min, respiratory rate is 13/min, and temperature is 37.0°C (98.6°F). Physical examination shows redness, edema, and tenderness on palpation at the metacarpophalangeal and proximal interphalangeal joints of both hands. The blood tests show the following findings:
Red blood cell count 3.3 million/mm3
Hb 12.1 mg/dL
Leukocyte count 10,101/mm3
ESR 48 mm/h
C-reactive protein 3.9 mg/L
Anti-cyclic citrullinated peptide 45 μ/mL
Which of the following medications is first-line therapy to slow disease progression?

Answer: Methotrexate

A. Intra-articular corticosteroid injections

B. Methotrexate

C. Meloxicam

D. Etanercept


Question: A 27-year-old woman presents to her primary care physician’s office complaining of trouble sleeping. She reports that for the past 10 months she has experienced difficulty falling asleep due constant worrying. The content of her worry include items such as whether or not her child will feel lonely in day care and the health of her parents. These worrying episodes typically begin toward the end of the day and last for several hours. She states that she has trouble concentrating at work as well and describes her heart as "racing" during these episodes. She denies any alcohol or illicit drug use. Which of the following neurotransmitters is most likely decreased in this patient?

Answer: GABA

A. Acetylcholine

B. Dopamine

C. GABA

D. Norepinephrine


Question:
A 10-year-old boy is brought to the physician because of fever and bloody diarrhea for the past few days. His parents report that he has become increasingly lethargic and irritable. His temperature is 38.6°C (101.4°F), pulse is 102/min, and respirations are 22/min. He has no significant past medical history. His parents say that he mostly only eats a diet of chicken, hamburgers, fries, cheese, and milk. On physical examination, pallor and edema in both legs are present. His laboratory studies show:
Hemoglobin 8.9 gm/dL
Leukocyte count 9,300/mm3
Platelet count 67,000/mm3
Blood urea nitrogen 43 mg/dL
Serum creatinine 2.46 mg/dL
Coombs test Negative
Which of the following is the most likely diagnosis?

Answer: Escherichia-induced hemolytic uremic syndrome

A. Thrombotic thrombocytopenic purpura

B. Genetic form of hemolytic uremic syndrome

C. Hemolytic uremic syndrome associated with systemic disease

D. Escherichia-induced hemolytic uremic syndrome


Question: A 50-year-old white male who works in construction comes to your office because of pain in his upper arm. He states that over the last few months, he has been having pain in his upper arm that worsens with raising objects overhead. He states that he also recently fell on his outstretched hand and that seemed to worsen his pain. His vital signs are within normal limits. He has no pain on internal or external rotation. He also had no pain with the lift off test, but does have significant pain with the empty can test and the arm drop test. Which structure has he most likely injured?

Answer: Supraspinatus tendon

A. Pectoralis major tendon

B. Deltoid muscle

C. Supraspinatus tendon

D. Subscapularis tendon


Question: A 76-year-old man presents to the physician with a severe, pruritic rash as shown in the image. He has lost sleep over the past week because of itchiness and discomfort. He has not noticed any insect bites. He is not experiencing any pain. He currently lives in an elderly home where several other residents are experiencing a similar problem. He has no history of a serious illness and does not take any medications. His vital signs are within normal limits. A similar rash is seen on his face and below the knees on both sides. The skin of the groin, genital and perianal area, buttocks, and thighs show no abnormalities. The remainder of the physical examination is unremarkable. Which of the following pathogens is the most likely cause of this patient’s condition?

Answer: Cimex lectularius

A. Cimex lectularius

B. Dermatobia hominis

C. Varicella zoster

D. Sarcoptes scabiei


Question: A 6-month-old girl is brought to the hospital by her parents for evaluation due to poor feeding for the last month. Her parents say that she has not been eating well over the last two months, yet her abdomen has grown larger. Physical exam shows a thin female infant with an enlarged liver and palpable spleen. Eye exam reveals a red spot on the retina. She has an intact muscle tone and reflexes. Which of the following enzymes is deficient in this patient?

Answer: Sphingomyelinase

A. Hexosaminidase A

B. α-galactosidase A

C. Sphingomyelinase

D. Galactocerebrosidase


Question: A 24-year-old female is brought to the ED from a nearby nightclub by the local police due to aggressive and violent behavior over the past hour. A friend accompanying the patient reports that the patient smoked marijuana that "seemed different" approximately one hour ago. The patient has never had this kind of reaction to marijuana use in the past. On examination, the patient is combative with slurred speech and active visual hallucinations; eye examination shows prominent vertical nystagmus. This patient's presentation can be best explained by intoxication with a substance that acts at which of the following receptors?

Answer: NMDA

A. Serotonin

B. Cannabinoid

C. NMDA

D. Norepinephrine


Question: A 2-month-old infant comes to the clinic because of progressive weakness and fatigue over the past 4 weeks. He is his mother’s first-born boy. She was in Mexico during the delivery and says that she had a regular 39-week gestation. She took folic acid during her pregnancy. The infant was born through vaginal delivery with no complications. Apgar scores were 10 and 9 at 1 and 5 minutes, respectively. The neonate did not go through a newborn screening process. His pulse is 130/min, respiratory rate is 43/min, temperature is 37.2°C (99.0°F), and blood pressure is 90/60 mm Hg. Physical examination shows lethargy, hypotonia, and a weak response to primitive reflexes. There is a “honey-like” odor around his diaper which the mother says has been present since birth. Which of the following enzymes is most likely deficient in this patient?

Answer: Branched-chain alpha-ketoacid dehydrogenase

A. Branched-chain alpha-ketoacid dehydrogenase

B. Cystathionine synthase deficiency

C. Phenylalanine hydroxylase

D. Propionyl-CoA carboxylase


Question: A 35-year-old engineer is told by his boss that his team will need to work extra evening hours in the coming week in order to meet a project deadline. This frustrates the engineer, who already feels he is working too many hours. Instead of discussing this directly with his boss, the engineer calls in sick and leaves his work for his boss to finish. Which of the following psychological defense mechanisms is this individual demonstrating?

Answer: Passive aggression

A. Displacement

B. Acting out

C. Passive aggression

D. Blocking


Question: A 29-year-old woman comes to the physician because of a 4-month history of fever, progressive shortness of breath, and a dry cough. During this time, she has also had a 5-kg (11-lb) weight loss. Two months ago, she was in Kenya for several weeks to visit her family. Physical examination shows fine crackles and wheezing over both lung fields. Her serum calcium concentration is 11.8 mg/dL. An x-ray of the chest shows reticular opacities in both lungs and bilateral hilar lymphadenopathy. Which of the following is the most likely underlying mechanism of this condition?

Answer: Granulomatous inflammation

A. Necrotizing inflammation

B. Granulomatous inflammation

C. Monoclonal plasma cell production

D.
Neoplastic transformation
"


Question: A 58-year-old man undergoes coronary angiography that demonstrates a 90% stenosis of the left anterior descending coronary artery. The circumflex branch of the left coronary artery is not significantly obstructed. Prior to the angiogram, he underwent a pharmacologic cardiac stress test. When administered, the pharmacologic agent caused the left circumflex artery to vasodilate, with resulting increased blood supply to its supplied myocardium that was already well-perfused at baseline. This increased flow through the circumflex artery shunted blood flow away from the myocardium supplied by the stenosed left anterior descending artery, resulting in ischemia that manifested as a perfusion defect on radionuclide imaging. Which of the following agents is most strongly associated with this phenomenon described above?

Answer: Dipyridamole

A. Metoprolol

B. Verapamil

C. Diltiazem

D. Dipyridamole


Question: A 51-year-old woman comes to the physician because of a 3-week history of fatigue, non-productive cough, and worsening shortness of breath while walking. She was diagnosed with HIV 11 years ago. Two years ago, she was treated for esophageal thrush with fluconazole. She takes no medications because she does not feel like she needs them. She occasionally uses intravenous illicit drugs and has smoked a pack of cigarettes daily for 35 years. She appears ill. Her temperature is 38.4°C (101.1°F), respiratory rate is 25/min, pulse is 116/min, and blood pressure is 115/70 mm Hg. Pulse oximetry shows an oxygen saturation of 89% on room air. Inspiratory crackles are heard over bilateral lung fields. Cardiac examination shows no abnormalities. Laboratory studies show a CD4 count of 67/mm3 (N ≥ 500/mm3) and an elevated HIV viral load. An x-ray of the chest shows diffuse interstitial infiltrates bilaterally. In addition to starting antiretroviral therapy, the appropriate treatment for her current illness is initiated. Maintaining the patient on this medication to prevent recurrence of her current illness will also prevent infection with which of the following pathogens?

Answer: Toxoplasmosa gondii

A. Varicella zoster virus

B. Toxoplasmosa gondii

C. Cryptococcus neoformans

D. Candida albicans


Question:
A 37-year-old man presents with right lower extremity weakness and low back pain. The patient states that he has had chronic mild to moderate low back pain for several years, but, 3 days ago after lifting a box, the pain increased in intensity and spread to his right leg. He describes the pain as severe, electrical in character, and descending from his right gluteal region along his right posterior thigh and leg to his right lateral ankle and foot. The patient also says that he has been having difficulty walking due to stumbling over his right foot. His temperature is 37.0℃ (98.6℉), the blood pressure is 125/80 mm Hg, the pulse is 72/min, the respiratory rate is 16/min, and the oxygen saturation is 98% on room air. On physical examination, the patient is alert and cooperative. Musculoskeletal examination of the lower extremities shows the following results:
Functional Muscle Group/DTR Tested Right Side Left Side
               Strength
Hip extension 5/5 5/5
Hip abduction 4/5  5/5
Hip adduction  5/5  5/5
Hip flexion 5/5 5/5
Knee flexion 5/5 5/5
Knee extension 5/5 5/5
Foot plantar flexion 5/5 5/5
Foot dorsiflexion 4/5 5/5
Foot inversion 4/5 5/5
Foot eversion 4/5 5/5
Toe extension 3/5 5/5
              Reflexes
Knee 3+ 3+
Achilles 1+ 3+
Plantar 2+ 3+
               Sensory
Sensation Decreased on the lateral aspect of the lower leg and dorsum of the foot Normal over all the surface
Lassegue test Positive at 30 deg. Negative
Which of the following is the most likely mechanism giving rise to this patient’s condition?

Answer: Protrusion of the L4/L5 intervertebral disk

A. Protrusion of the L4/L5 intervertebral disk

B. Entrapment of the femoral nerve in the femoral canal

C. Inflammation of the S2-3 spinal roots

D. Herniation of the L2/3 intervertebral disk


Question: A 21-year-old woman comes to the physician because of a 5-day history of pain with urination and vaginal itching. She is sexually active with multiple partners and uses condoms inconsistently. Pelvic examination shows erythema of the vulva and vaginal mucosa, punctate hemorrhages on the cervix, and green-yellow, malodorous discharge. A photomicrograph of the discharge is shown. Which of the following is the most likely causal organism?

Answer: Trichomonas vaginalis

A. Neisseria gonorrhoeae

B. Treponema pallidum

C. Candida albicans

D. Trichomonas vaginalis


Question: A 9-year-old girl has recently begun having daily staring-spells in which she becomes unresponsive for several seconds. Following these episodes, she rapidly returns to normal with no recollection of the event. Her performance in school has begun to deteriorate. The child's pediatrician refers her to a pediatric neurologist, and, after an appropriate neurological work-up, the child is diagnosed with absence seizures. Her neurologist recommends initiating an anti-seizure medication, but the patient adamantly refuses due to fear of side effects and her belief that the condition is not affecting her quality of life. Which of the following is the most appropriate next step?

Answer: Obtain consent from one parent before initiating therapy

A. Prescribe a long acting depot medication

B. Discuss the patient's school performance with her teachers

C. Obtain consent from one parent before initiating therapy

D. Obtain consent from both parents before initiating therapy


Question: A 44-year-old woman comes to the physician because of pain and swelling below her left eye for 3 days. She has also had excessive watering from her eyes during this period. She has no history of serious illness and takes no medications. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 110/70 mm Hg. Examination shows erythema, tenderness, warmth, and swelling below the medial canthus of the left eye. There is purulent discharge from the lower lacrimal punctum on palpation of the swelling. The remainder of the examination shows no abnormalities. The discharge is sent for cultures. Which of the following is the most appropriate next step in management?

Answer: Oral amoxicillin-clavulanate therapy

A. Topical ciprofloxacin

B. Irrigation of lacrimal cannaliculi

C. Oral amoxicillin-clavulanate therapy

D.
CT scan of the orbit
"


Question:
A 40-year-old man comes to the physician because of decreased sexual arousal and erectile dysfunction that has put strain on his marriage for the last year. He has also had fatigue and generalized weakness for the past 9 months. He has noticed his bowel movements have not been as frequent as usual. He has occasional dry coughing and back pain. He has not had fever, headache, or changes in vision. One year ago, he traveled to South Africa with his wife. He looks fatigued. He is 168 cm (5 ft 6 in) tall and weighs 89 kg (196 lb); BMI is 31.6 kg/m2. His temperature is 36.5°C (97.7°F), pulse is 50/min, and blood pressure is 125/90 mm Hg. Physical examination shows dry skin and a distended abdomen. Neurological examination reveals delayed deep tendon reflexes. Laboratory studies show:
Hemoglobin 11.0 g/dL
Platelet count 380,000/mm3
Serum
Na+ 130 mEq/L
Cl- 97 mEq/L
K+ 4.5 mEq/L
HCO3- 25 mEq/L
Glucose 95 mg/dL
TSH 0.2 μU/mL
Which of the following is the most likely cause of these findings?"

Answer: Pituitary adenoma

A. Hemochromatosis

B. Pituitary adenoma

C. Graves disease

D. Hashimoto thyroiditis


Question:
A 52-year-old man with limited, unresectable small cell lung cancer comes to the emergency department because of fever for the past 2 days. He has been on numerous chemotherapy regimens. His last round of treatment was with cisplatin and etoposide and ended 10 days ago. He feels fatigued but has not had nausea or vomiting. His temperature is 38.5°C (101.3°F), blood pressure is 100/60 mm Hg, and pulse is 115/min. The lungs are clear to auscultation. Examination shows a soft, nontender abdomen. Laboratory studies show:
Hemoglobin 10.2 g/dL
Leukocyte count 4,000/mm3
Total neutrophils 8%
Eosinophils 2%
Lymphocytes 80%
Monocytes 10%
Urinalysis shows no abnormalities. Blood culture samples are obtained. Which of the following is the most appropriate next step in management?"

Answer: Cefepime

A. Cefepime

B. Piperacillin

C. Clindamycin

D. High-resolution chest CT


Question: A 28-year-old woman presents in respiratory distress. Auscultation of the lungs reveals bilateral crepitations and a friction rub. Lab findings show pancytopenia, proteinuria, and a false-positive test for syphilis. A chest X-ray shows bilateral pleural effusions. Which of the following findings are most likely?

Answer: Photosensitivity

A. Photosensitivity

B. Urethritis

C. Xerostomia

D. Esophageal dysmotility


Question:
A 2-month-old infant is brought in by his mother for runny nose and cough. She reports he had an ear infection 2 weeks ago, and since then he has had a productive cough and nasal congestion. His medical history is significant for multiple ear infections and eczematous dermatitis. He has also been hospitalized for 2 episodes of severe viral bronchiolitis. The mother reports that the infant has a good appetite but has had intermittent, non-bloody diarrhea. The patient is at the 20th percentile for weight. On physical examination, the patient has widespread, dry, erythematous patches, mucopurulent nasal drip, and crusting of the nares. His tongue is coated by a thick white film which is easily scraped off. Crackles are heard at the left lung base. Labs are drawn, as shown below:

Hemoglobin: 12.8 g/dL
Platelets: 280,000/mm^3
Leukocytes: 7,500/mm^3
Neutrophils: 5,500/mm^3
Lymphocytes: 2,000/mm^3

Serum:
Na+: 138 mEq/L
Cl-: 96 mEq/L
K+: 4.3 mEq/L
HCO3-: 23 mEq/L
Urea nitrogen: 18 mg/dL
Glucose: 90 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: : 9.2 mg/dL

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

Answer: Adenosine deaminase deficiency

A. 22q11.2 deletion

B. Adenosine deaminase deficiency

C. Defective leukocyte adhesion

D. WAS gene mutation


Question: A 51-year-old inmate was released from prison 1 month ago and visits his general practitioner for evaluation of a positive HIV diagnosis he received from a local free clinic a week ago. The patient states that he had spent the last 2 years in prison and that, during that time, he had engaged in multiple unprotected sexual acts with fellow male inmates. When he was released from prison recently, he decided to get tested for HIV and was diagnosed positive. He is currently married with 2 children and has been paroled back to the home he shares with them. He has not told either his wife or his children of his diagnosis. He adamantly states that he is not homosexual, but that his wife would assume that he is if she found out he had contracted HIV while in prison. He states that he is terrified his wife will leave him or possibly keep his children from seeing him if she finds out about his HIV status.  He wants to be treated without the threat of his wife finding out. He insists that he will use the proper precautions to ensure his wife and children don’t contract HIV from him and reiterates the importance of keeping his diagnosis a secret. He continues and states that “they are all I have. If they leave me, I have no one.” Which of the following is the most appropriate response in this patient’s case?

Answer: Advise the patient the positive diagnosis will be reported to the public health office, but you would also encourage him to have a discussion with his family.

A. Honor the patient’s wishes and treat him without telling his wife or reporting him to the Department of Health

B. Tell the patient you will honor his wishes, but report him to the Department of Health so they can tell his wife

C. Consult an ethics committee to determine whether or not to report him to the Department of Health

D. Advise the patient the positive diagnosis will be reported to the public health office, but you would also encourage him to have a discussion with his family.


Question: A 62-year-old man with end-stage renal disease is brought to the emergency department because of fever, severe abdominal pain, and shaking chills for 4 hours. His last hemodialysis was 2 days ago. On arrival, he appears ill and is poorly responsive. Blood cultures grow gram-positive, catalase-positive cocci that express mecA. Intravenous antibiotic therapy is begun with an agent that disrupts cell membranes by creating transmembrane channels. Which of the following adverse events is associated with the use of this agent?

Answer: Rhabdomyolysis

A. Photosensitivity

B. Rhabdomyolysis

C. Ototoxicity

D. QT prolongation


Question: A 25-year-old woman comes to the physician because of pain and weakness in her left leg that started 2 days ago while running a marathon. Physical examination shows impaired flexion of the left knee joint and impaired extension of the left hip joint. An MRI of the left lower extremity shows injury to the long head of the biceps femoris muscle and the semitendinosus muscle. Which of the following is the most likely origin of the injured muscles?

Answer: Ischial tuberosity

A. Ischial tuberosity

B. Anterior superior iliac spine

C. Greater trochanter

D. Linea aspera


Question: A 32-year-old man and his 29-year-old wife come to the physician because they have been unable to conceive despite regular unprotected sexual intercourse for 13 months. The woman reports regular menstrual cycles since the age of 13. Menses occur at regular 28-day intervals and last 5–7 days. Ovulation predictor kits consistently turn positive around day 14. The man has a negative history of mumps. They each smoked one pack of cigarettes per day until one year ago. The man works in construction and his wife is a secretary for a law firm. Examination of the scrotum in a standing position shows soft bands palpated in the upper pole of the left scrotum with an intact left testicle. Following Valsalva maneuver, the patient reports a dull, aching pain in his left hemiscrotum. A light held behind the scrotum does not shine through. The right scrotum appears normal. Semen studies show normal sperm count with moderately decreased motility and abnormal morphology. Which of the following is most likely to improve the patient's ability to conceive?

Answer: Ligation of dilated pampiniform venous plexus

A. Ligation of dilated pampiniform venous plexus

B. Conservative management with scrotal support

C. Surgical excision of the hydrocele sac

D. Administration of ceftriaxone and doxycycline


Question: A 29-year-old man comes into his primary care physician's office with a chief complaint of a cough. The patient states that the cough started yesterday and he is asking if he needs antibiotics. While conversing with the patient, you note that he seems cold, mistrustful, and does not display much emotion. The patient worked for a software company but recently took a different position that allows him to work from home. The patient states that he switched positions because while at the office he made a mistake during a presentation. He felt that afterwards, his fellow workers thought less of him and he was embarrassed to show his face around the office. The patient wishes he could have related better to his coworkers. He currently lives in a barn on the outskirts of town with his many cats. On physical exam you note a healthy young man, adorned in overalls and denim shoes. His physical exam is notable for erythema of the posterior pharynx. The patient is informed that he has a viral upper respiratory infection and is sent home with instructions to rest and hydrate himself. Which of the following personality disorders best characterizes this patient?

Answer: Avoidant

A. Avoidant

B. Schizoid

C. Schizotypal

D. Paranoid


Question: A 49-year-old man is undergoing an elective hernia repair. No significant past medical history or current medications. The patient has been working as a cardiovascular surgeon in the same hospital for the past 15 years. In obtaining informed consent, the patient’s doctor has described all the available options for the procedure with their pros and cons, has offered different materials for the hernioplasty, and described the exact procedure. He has not focused too much on the possible complications and the risks and benefits of not performing the operation, because the patient insists he already knows everything that can happen since he is a surgeon himself. The patient has given his consent, but on the day of the operation, he changes his mind regarding the material of the synthetic mesh to be used for the hernioplasty. Which of the following is true about informed consent in this case?

Answer: The patient’s doctor should have included possible complications of the given operation and risks and benefits of not performing it, regardless of the patient’s education or prior experience.

A. The informed consent obtained from this patient in this hospital is invalid because he works in the hospital.

B. There is no need to receive an informed consent from a patient who is a doctor himself.

C. The patient’s doctor should have included possible complications of the given operation and risks and benefits of not performing it, regardless of the patient’s education or prior experience.

D. Even though the patient has changed his mind about the type of mesh material, since the basic procedure is still the same, informed consent does not need to be obtained from the patient again.


Question: A 55-year-old man presents to his primary care provider complaining of blood clots in his urine. On further questioning, he also reports suprapubic discomfort and a feeling of bladder fullness with difficulty voiding. The patient reports recently starting treatment for a newly diagnosed non-Hodgkin lymphoma. Vital signs are within normal limits. Physical exam reveals pain on palpation of the suprapubic region. What is the mechanism of action of the drug most likely responsible for the patient’s complaints?

Answer: Alkylating agent

A. Alkylating agent

B. Intercalating agent

C. Reverse transcriptase inhibitor

D. Microtubule inhibitor


Question: A 25-year-old man presents to his primary care physician with lower back pain. He states that he has had the pain for the past two years. The patient works as a butcher, and recently was moving heavy meat carcasses. The patient states that his pain is worse in the morning and that nothing improves it aside from swimming. The patient has a past medical history of anabolic steroid abuse, acne, hypertension and obesity. His current medications are hydrochlorothiazide, ibuprofen, topical benzoyl peroxide, and acetaminophen. On physical exam there is no tenderness upon palpation of the spine. There is limited range of motion of the spine in all 4 directions. Which of the following is most likely to confirm the most likely diagnosis in this patient?

Answer: MRI of the sacroiliac joint

A. Radiograph of the spine

B. The straight leg test and the clinical presentation

C. MRI of the sacroiliac joint

D. HLA typing


Question:
A 42-year-old African American female presents to your clinic complaining of excessive thirst and urination. She reports that these symptoms began one week ago, and they have been affecting her ability to work as a schoolteacher. Labs are drawn and are listed below.

Serum:
Na+: 145 mEq/L
Cl-: 101 mEq/L
K+: 4.4 mEq/L
HCO3-: 25 mEq/L
Urea nitrogen: 24 mg/dL
Glucose: 115 mg/dL
Creatinine: 0.7 mg/dL
Hemoglobin: 10.5 g/dL
Hematocrit: 25%
Leukocyte count: 11,000/mm^3
Platelets: 200,000/mm^3

Urine:
Specific gravity: 1.006
Epithelial cells: 5/hpf
Glucose: negative
Protein: 20 mg/dL
RBC: 6/hpf
WBC: 1/hpf
Leukocyte esterase: negative
Nitrites: negative
Bacterial: none

A water deprivation test is performed with the following results:

Serum osmolality: 305 mOsm/kg
Urine osmolality: 400 mOsm/kg
Urine specific gravity: 1.007

Desmopressin is administered, and the patient's urine osmolality increases to 490 mOsm/kg. The patient's antidiuretic hormone is measured and is within normal limits. Which of the following may be associated with this patient’s condition?

Answer: Dactylitis

A. Coarse tremor

B. Auditory hallucinations

C. Amenorrhea

D. Dactylitis


Question: A 42-year-old male with a history of schizophrenia presents to his psychiatrist for a normal follow-up visit. He is accompanied by his case manager. The patient was diagnosed with schizophrenia at the age of 27. After being trialed on two different medications, he was deemed to be stable on a third medication which he has been taking for the past 10 years. He reports that he occasionally hears voices. He lives in supportive housing, and his caretakers report that he prefers to be alone but is not disruptive. His temperature is 99°F (37.2°C), blood pressure is 130/90 mmHg, pulse is 105/min, and respirations are 18/min. On exam, he demonstrates a flattened affect and disorganized speech. A funduscopic examination reveals pigmented plaques at the retinal periphery. No deposits are seen in the cornea or anterior lens. This patient has most likely been treated with which of the following medications?

Answer: Thioridazine

A. Fluphenazine

B. Olanzapine

C. Chlorpromazine

D. Thioridazine


Question: A 6-month-old girl is brought to the emergency department because her lips turned blue for several minutes earlier during feeding. Her father reports that the patient had similar episodes while playing that resolved quickly. During the examination, she sits calmly in her father's lap. When her ears are examined, the patient begins to cry and her lips and fingers begin to turn blue. Further evaluation of this patient is most likely to show which of the following?

Answer: Right axis deviation on ECG

A. Diminutive left ventricle on echocardiogram

B. Decreased blood pressure in both lower extremities

C. Pulmonary vascular congestion on chest x-ray

D. Right axis deviation on ECG


Question: A 52-year-old female presents to clinic complaining of sudden onset of flank tenderness that was fluctuating and radiating into her groin. Laboratory analysis reveals a serum calcium of 12.4 (normal 8.4-10.2) and a serum phosphorous of 2.5 (normal 2.7-4.5) and a chloride:phosphorous ratio >33. You suspect primary hyperparathyroidism. Which of the following mechanisms is responsible for the patient’s current condition?

Answer: Increased RANK-L production

A. PTH binding to receptors on osteoclasts

B. Parafollicular, or C-cell, synthesis of calcitonin

C. Increased RANK-L production

D. Decreased M-CSF production


Question: A 53-year-old man comes to the physician because of a 2-week history of fatigue, generalized itching, and yellowing of the eyes and skin. He underwent a liver transplantation because of acute liver failure following α-amanitin poisoning 1 year ago. Physical examination shows scleral icterus and abdominal distention with shifting dullness. A liver biopsy specimen shows decreased hepatic duct density. Further histological examination of the liver biopsy specimen is most likely to show which of the following findings?

Answer: Interstitial fibrosis

A. Graft vessel vasculitis

B. Fibrinoid necrosis

C. Interstitial fibrosis

D.
Viral inclusions
"


Question:
A 23-year-old man comes to the emergency department because of a 5-day history of progressively worsening dyspnea. He has had intermittent episodes of chest pain, which was 4/10 in intensity and increased on inspiration. He does triathlons and has not been able to train because of the discomfort. He has had no fever or syncopal episodes. He had an upper respiratory tract infection 3 weeks ago. His father died of heart disease at the age of 55 years. His temperature is 36.8°C (98.2°F), pulse is 113/min, and blood pressure is 100/70 mm Hg. Examination shows jugular venous distention. Inspiratory crackles are heard throughout the thorax. Cardiac examination shows an S3 gallop. Laboratory studies show:
Hemoglobin 14.8 g/dL
Leukocyte count 9200/mm3
Platelet count 230,000/mm3
ESR 41 mm/hr
Serum
Creatinine 1.1 mg/dL
Glucose 92 mg/dL
LDH 120 U/L
Troponin I 0.204 ng/mL (N< 0.1 ng/mL)
An x-ray of the chest shows an enlarged cardiac silhouette and prominent vascular markings in both lung fields. An ECG shows diffuse T-wave inversions. Which of the following echocardiographic findings is most likely in this patient?"

Answer: Left ventricular dilation and global hypokinesis

A. Swinging heart with compression of the left heart chambers

B. Mitral valve stenosis with left atrial enlargement

C. Left ventricular dilation and global hypokinesis

D. Vegetations on the mitral valve


Question: Two days after undergoing abdominal surgery for lysis of adhesions, a 52-year-old man has nausea and one episode of bilious vomiting. The patient's nausea is somewhat alleviated in the prone position. The patient has had a 70-kg (154-lb) weight loss since undergoing bariatric surgery 1 year ago. Physical examination shows abdominal distention. Sudden movement of the patient elicits a sloshing sound on auscultation of the abdomen. An upper gastrointestinal series of the abdomen with oral contrast shows no passage of contrast past the third segment of the duodenum. The obstruction in this patient is most likely caused by which of the following structures?

Answer: Superior mesenteric artery

A. Superior mesenteric artery

B. Common bile duct

C. Portal vein

D. Inferior vena cava


Question: A 16-year-old girl is brought to the physician because her mother is concerned about her lack of appetite and poor weight gain. She has had a 7-kg (15-lb) weight loss over the past 3 months. The patient states that she should try to lose more weight because she does not want to be overweight anymore. She maintains a diary of her daily calorie intake. Menarche was at the age of 13 years, and her last menstrual period was 3 months ago. She is on the high school track team. She is sexually active with 2 male partners and uses condoms inconsistently. She is at 50th percentile for height and below the 5th percentile for weight and BMI. Her temperature is 37°C (98.6°F), pulse is 58/min and blood pressure is 96/60 mm Hg. Examination shows fine hair over the trunk and extremities. Which of the following is the most likely diagnosis?

Answer: Anorexia nervosa

A. HIV infection

B. Type 1 diabetes mellitus

C. Hyperthyroidism

D. Anorexia nervosa


Question: A 25-year-old male presents with progressively worsening headaches over the past two months. He also feels that he has been losing his balance more often over the past week, but he denies any motor weakness or sensory impairment. His neurological exam reveals impaired upward gaze, pupils that constrict poorly to light but react to accommodation, and bilateral upper eyelid retraction. On tandem walking, he tends to fall on both sides. The remainder of the physical examination is unremarkable. What is the most likely diagnosis in this patient?

Answer: Pineal tumor

A. Multiple sclerosis

B. Pituitary mass

C. Pineal tumor

D. Craniopharyngioma


Question: A 32-year-old woman presents to an urgent care facility after having sustained a deep cut 8 hours ago while hiking in the Appalachian mountains. Immediately after she sustained the injury she rinsed out the dirt with a bottle of saline from her first aid kit. She immigrated to the United States at age 20 and was unvaccinated upon arrival. Her medical records indicate that she has since received one dose of Tdap and one Td booster 3 years ago. She is afebrile, well appearing, and her wound appears clean without signs of infection at this time. What is the next best step in management?

Answer: Tetanus toxoid and tetanus immunoglobulin

A. Tetanus immunoglobulin only

B. Tetanus titers and if negative, tetanus toxoid and immunoglobulin within 48 hours

C. Tetanus toxoid and tetanus immunoglobulin

D. Tetanus toxoid and tetanus immunoglobulin today; tetanus toxoid again on days 3, 7, and 14 after exposure


Question: A 39-year-old woman presents to the emergency department with a chief concern of abdominal pain. She states that her symptoms occurred shortly after she began eating dinner that evening. She states that the pain is in the right side of her abdomen and travels to her right shoulder. She has a past medical history of polycystic ovarian syndrome, obesity, type II diabetes mellitus, and hypertension. Her current medications include metformin, insulin, atorvastatin, aspirin, and lisinopril. Her temperature is 99.5°F (37.5°C), blood pressure is 110/75 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 99% on room air. On abdominal exam, the patient demonstrates tenderness in the right upper quadrant. The patient is started on IV fluids and morphine. Four hours later, she states that the pain has abated. Which of the following is associated with this patient's most likely diagnosis?

Answer: Cholecystokinin

A. Acetylcholine

B. Cholecystokinin

C. Gastrin

D. Secretin


Question: A 12-year-old girl is brought to the primary physician because of severe ear pain and yellow discharge from her left ear for the past 2 days. It is also mildly pruritic. The pain started during her last day of summer camp, where she spent a lot of time outdoors hiking, horseback riding, and swimming. Her temperature is 37°C (98.6°F), pulse is 76/min, and blood pressure is 110/75 mm Hg. Examination shows tragal tenderness and a red and edematous external auditory canal. A diagnostic tuning fork is placed in the middle of the patient's forehead. The patient reports hearing the sound more loudly in the left ear. To complete the workup, the tuning fork is placed on the mastoid process of the left ear. Once she can no longer hear the sound, the tuning fork is placed in front of the auricle, and she reports no longer hearing the sound. On the right side, once the sound from the mastoid process subsides and the tuning fork is placed in front of the right ear, she reports hearing the sound again. Which of the following is the most likely cause of the patient's symptoms?

Answer: Infection with Pseudomonas aeruginosa

A. Infection with Aspergillus species

B. Abnormal squamous epithelial growth

C. Infection with Pseudomonas aeruginosa

D.
Pleomorphic replacement of normal bone
"


Question:
A 50-year-old man comes to the emergency department because of severe lower chest pain for the past hour. The pain radiates to the back and is associated with nausea. He has had two episodes of non-bloody vomiting since the pain started. He has a history of hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 30 years. He drinks five to six beers per day. His medications include enalapril and metformin. His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. The lungs are clear to auscultation. Examination shows a distended abdomen with epigastric tenderness and guarding but no rebound; bowel sounds are decreased. Laboratory studies show:
Hemoglobin 14.5 g/dL
Leukocyte count 5,100/mm3
Platelet count 280,000/mm3
Serum
Na+ 133 mEq/L
K+ 3.5 mEq/L
Cl- 98 mEq/L
Total bilirubin 1.0 mg/dL
Amylase 160 U/L
Lipase 880 U/L (N = 14–280)
An ECG shows sinus tachycardia. Which of the following is the most likely diagnosis?"

Answer: Acute pancreatitis

A. Acute mesenteric ischemia

B. Peptic ulcer disease

C. Myocardial infarction

D. Acute pancreatitis


Question: A 29-year-old woman presents to the physician’s office complaining of swollen hands for the past 3 weeks. It is associated with stiffness in the morning, which lasts about 10 minutes. The patient’s medical history is significant for hypothyroidism that is managed with levothyroxine. She has no recent travel history. Vital signs are normal. On examination, the patient has a butterfly-shaped, non-blanching rash on her face with mild cervical lymphadenopathy. The metacarpophalangeal and proximal interphalangeal joints are tender and appear swollen. Cardiopulmonary examination reveals a grade 2/6 holosystolic murmur heard best at the apex. Which of the following tests is the best next step in evaluating this patient?

Answer: Antinuclear antibody

A. Anti-double-stranded-DNA antibody

B. Anti-U1 ribonucleoprotein antibody

C. Antinuclear antibody

D. Anti-histone antibody


Question: A 61-year-old male dies in a motor vehicle accident. Autopsy of the heart reveals dilatation of the left atrium and expansion of the left ventricular cavity with associated eccentric hypertrophy. The structural changes in this patient's heart are most likely associated with which of the following?

Answer: Mitral insufficiency

A. Pulmonic stenosis

B. Mitral insufficiency

C. Chronic hypertension

D. Congenital atrial septal defect


Question: A 52-year-old business executive presents to his physician with complaints of intermittent chest pain which started 2 months ago. He describes his pain as crushing, centrally located, and typically lasting about 5 minutes but never more than 10 minutes. The pain radiates to his left arm and jaw, occurs only when he climbs the stairs or runs on a treadmill, and is relieved by rest. He has been hypertensive and diabetic for the last 10 years and has been compliant with his medications. His physical exam findings are within normal limits. Lab tests are normal except for a significantly elevated LDL-cholesterol level. A stress ECG shows ST-segment depression in the anterior chest leads when his heart rate and blood pressure increase to over 40% from their baseline values. The physician decides to initiate a medication to relieve his symptoms. Which of the following changes best describes the direct effect of the prescribed medication on his cardiovascular physiology in the cardiac output/venous return versus right atrial pressure graph?

Answer: iv

A. i

B. iii

C. iv

D. vi


Question: A 34-year-old man comes to the physician for a follow-up appointment. He was diagnosed with HIV 6 years ago and has been on highly active antiretroviral therapy with emtricitabine, tenofovir, and darunavir. He reports that he has been compliant with his medication regimen. His last CD4+ T-lymphocyte count was 520/mm3 (N > 500) and HIV viral load was undetectable. Today, his CD4+ T-lymphocyte count is 410/mm3 and his HIV viral load is 240 copies/mL. Further evaluation shows resistance to emtricitabine and tenofovir. Mutations in which of the following genes are most likely responsible for these findings?

Answer: pol

A. tat

B. pol

C. rev

D. env


Question: A 61-year-old woman with a history of stage IV pancreatic cancer comes to the emergency department with insomnia due to intractable midepigastric pain. The pain had been constant for months but has worsened over the past few weeks despite the fact that she is already taking hydrocodone 10 mg and ibuprofen 400 mg. She has a past medical history of chronic pain and major depressive disorder. In the past month, she has been taking her pain medications with increasing frequency, going from twice a day to four times a day. Her other medications include venlafaxine and eszopiclone. She describes her mood as low, but states she does not have any suicidal thoughts. She appears fatigued and slightly cachectic. Her temperature is 36°C (96.8°F), pulse is 100/min, and blood pressure is 128/65 mm Hg. Physical examination shows a mass in the midepigastric region. Which of the following is the most appropriate next step in management?

Answer: Switch from hydrocodone to hydromorphone

A. Discontinue hydrocodone and ibuprofen, and start IV ketorolac

B. Switch from hydrocodone to hydromorphone

C. Switch from eszopiclone to zolpidem

D.
Allow the patient to take hydrocodone and ibuprofen up to every four hours
"


Question: Two days into hospitalization for pyelonephritis and sepsis, a 48-year-old woman develops severe sudden-onset dyspnea. She has no history of serious cardiopulmonary disease. She is fatigued and pale. Her blood pressure is 115/65 mm Hg, the pulse is 120/min, the respiratory rate is 36/min, and the temperature is 39.7°C (103.5°F). Her oxygen saturation is 80% on 60% FiO2. She has severe nasal flaring, supraclavicular and intercostal respiratory retractions, and paradoxical abdominal movements. Inspiratory crackles are heard over both lung fields. Cardiac examination shows no murmurs. A chest X-ray, taken before orotracheal intubation, is shown. Which of the following is the most appropriate next step in management?

Answer: Low tidal volume ventilation

A. Broad-spectrum antibiotics

B. High-dose glucocorticoids

C. Intravenous fluids

D. Low tidal volume ventilation


Question: A 48-year-old man presents to the physician with a cough with expectoration and breathlessness on exertion for the last 4 years. There is no history of any other medical conditions. He has been a smoker for the last 10 years. He recently immigrated from a developing country and his immunization status is unknown. After a complete physical examination of the patient, the physician orders a chest radiogram which shows increased bronchovascular markings and flattening of the diaphragm. His spirometry findings include an FEV1 of 82% of predicted, which increases to 88% of predicted at 15 minutes after the administration of inhaled albuterol. The FEV1/FVC ratio is 0.66. The physician explains the diagnosis to the patient and emphasizes the importance of smoking cessation. He also offers him specific vaccinations. However, the patient mentions that he does not have medical insurance and due to his poor financial situation, he can afford only 1 of the suggested vaccines. In such a situation, which of the following vaccines should definitely be recommended to this patient?

Answer: Influenza vaccine

A. 23-valent pneumococcal polysaccharide vaccine

B. Haemophilus influenzae type b vaccine

C. Influenza vaccine

D. Pertussis vaccine


Question:
A five-year-old female presents to the pediatrician for a well visit. The patient’s parents report that she recently entered kindergarten and her teacher expressed concern that the patient is not meeting developmental milestones. She struggles to name colors and has not expressed any interest in learning to read. The patient’s parents have also noticed that the patient is not completing tasks that her older siblings were doing by this age, including dressing herself independently and going to the bathroom by herself. The patient rolled over at 9 months, sat without support at 12 months, and walked at 20 months. Her parents also report that the patient is very social, and that adults frequently comment on her friendly personality. The patient is in the 15th percentile for weight and 5th percentile for height. On physical exam, the patient has a broad forehead, flat nasal bridge, long philtrum, and a wide mouth. She has a strabismus on neurological exam, and her cardiac exam is significant for a heart murmur. Laboratory testing is below:

Serum:
Na+: 145 mEq/L
K+: 3.9 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/
Urea nitrogen: 11 mg/dL
Glucose: 76 mg/dL
Creatinine: 0.9 mg/dL
Ca2+: 11.9 mg/dL

Which of the following cardiac abnormalities is associated with this condition?

Answer: Supravalvular aortic stenosis

A. Bicuspid aortic valve

B. Coarctation of the aorta

C. Supravalvular aortic stenosis

D. Tetralogy of Fallot


Question: A 20-year-old male comes to the physician because of a 1-week-history of a painless ulceration on his penis. The patient is sexually active with multiple partners and does not use barrier protection. Physical examination shows a shallow, firm ulcer with a smooth base along the shaft of the penis and nontender bilateral inguinal adenopathy. Which of the following is most likely to confirm the diagnosis in this patient?

Answer: Dark field microscopy

A. Tzanck preparation

B. Culture swab

C. Dark field microscopy

D. Serologic detection of antibodies


Question: A 31-year-old man presents to the clinic as a follow-up visit after recently being diagnosed with medullary thyroid cancer. Last year, he was diagnosed with a pheochromocytoma that was successfully resected. His family history is positive for medullary thyroid cancer in his father and paternal grandmother with a mucosal neuroma in his brother. What additional finding is most likely to be present in this patient on physical examination?

Answer: Marfanoid habitus

A. Ash leaf spot

B. Pituitary adenoma

C. Neurofibromas

D. Marfanoid habitus


Question: Digestion begins in the mouth by breaking food up into smaller particles through mastication and mixing it with saliva containing amylase. Food then enters the stomach, where gastric acid and pepsin initiate protein digestion. The resulting chyme is then expelled into the duodenum where pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids. These digested lipids are then ready for absorption across the gastrointestinal mucosa. Resection of which of the following segments of the gastrointestinal tract would prevent the absorption of these digested lipids?

Answer: Jejunum

A. Jejunum

B. Ileum

C. Descending colon

D. Rectum