question:
A 62-year-old woman with a history of type 2 diabetes and early-onset Alzheimer dementia was admitted to the intensive care unit (ICU) one week ago with sepsis. She was found to have Escherichia coli pyelonephritis, was treated with intravenous fluids and appropriate antibiotics, and slowly improved. However, today she developed recurrence of fever and confusion, and she also reports constant abdominal pain.

Her current vital signs include a temperature of 38.5°C, a heart rate of 125 beats per minute, a blood pressure of 85/55 mm Hg, a respiratory rate of 25 breaths per minute, and an oxygen saturation of 96% while she receives 2 liters of oxygen via nasal cannula. Her cardiac and lung sounds are normal. She grimaces with palpation of the abdomen, worst in the right upper quadrant.

Laboratory testing yields the following results:

|  | Patient value | Reference range |
| --- | --- | --- |
| Leukocyte count (per mm3) | 14,200 | 4500–11,000 |
| Hemoglobin (g/dL) | 12.0 | 12.0–16.0 |
| Hematocrit (%) | 36.0 | 36.0–46.0 |
| Platelet count (per mm3) | 265,000 | 150,000–350,000 |
| Creatinine (mg/dL) | 2.0 | 0.6–1.1 |
| Bilirubin, total (mg/dL) | 1.2 | 0.3–1.0 |
| Alkaline phosphatase (U/liter) | 160 | 30–120 |
| Aspartate aminotransferase (U/liter) | 120 | 0–35 |
| Alanine aminotransferase (U/liter) | 100 | 0–35 |

An abdominal ultrasound, performed one week ago, revealed a normal liver and biliary system. An upright abdominal radiograph is obtained today (figure).

What is the most appropriate next imaging study for this patient?
Answer Choices: (A) Endoscopic ultrasound (B) Cholescintigraphy (C) Endoscopic retrograde cholangiopancreatography (D) Abdominal ultrasound of the right upper quadrant (E) Magnetic resonance cholangiopancreatography

options:
A. Endoscopic ultrasound
B. Cholescintigraphy
C. Endoscopic retrograde cholangiopancreatography
D. Abdominal ultrasound of the right upper quadrant
E. Magnetic resonance cholangiopancreatography

label: D

medical_task: Diagnosis

body_system: Digestive

question_type: Reasoning


question:
A 78-year-old man presents to the emergency room with progressive shortness of breath over the last 2 weeks. He also complains of facial swelling over the last week and noticed that it was especially prominent this afternoon when he woke from his nap. The patient denies chest pain but does note a mild chronic cough, which has been stable for years. He has a history of chronic obstructive pulmonary disease (COPD) and his last exacerbation was 1 month ago and resolved with a course of oral glucocorticoids. The patient also had a myocardial infarction (MI) 9 years ago and underwent percutaneous angioplasty of his left anterior descending artery. Medications include a combined beta-2 agonist and anticholinergic inhaler, aspirin, rosuvastatin, metoprolol, and lisinopril. The patient has a 60-pack-year smoking history and currently smokes half a pack per day. In the emergency room, the patient’s temperature is 98.9°F (37.2°C), blood pressure is 141/82 mmHg, pulse is 75/min, respirations are 18/min, and oxygen saturation is 94% on room air. On exam, he appears slightly uncomfortable with mild use of accessory respiratory muscles. His face is shown in Figure A and distended veins are noted on his anterior chest wall. A cardiovascular exam is notable for a 2/6 systolic ejection murmur, and a lung exam reveals breath sounds that are louder in the right middle lung fields. The remainder of the exam is unremarkable. Which of the following is the most appropriate next step in management?
Answer Choices: (A) D-dimer (B) Chest radiograph (C) Bronchoscopy (D) Complete blood count (E) Echocardiogram

options:
A. D-dimer
B. Chest radiograph
C. Bronchoscopy
D. Complete blood count
E. Echocardiogram

label: B

medical_task: Diagnosis

body_system: Cardiovascular

question_type: Reasoning


question:
Which artery labeled in Figure A provides the predominant blood supply to the spinal cord?
Answer Choices: (A) C (B) D (C) A (D) B (E) None of the above

options:
A. C
B. D
C. A
D. B
E. None of the above

label: C

medical_task: Basic Medicine

body_system: Cardiovascular

question_type: Understanding


question:
A 24-year-old male presents to his primary care physician with progressive chest discomfort over the last month. The discomfort is constant and sometimes associated with shortness of breath. The patient has also noticed a 12-pound unintentional weight loss over the last 6 weeks. He also thinks his breasts have increased in size. He feels more fatigued than usual but denies night sweats, palpitations, and dizziness. The patient had unilateral cryptorchidism with successful orchiopexy as an infant. He also had an episode of hepatitis A during a trip to Mexico in college. He is now a graduate student, drinks socially, and occasionally smokes marijuana. His mother has type 2 diabetes and his father has alcohol use disorder. At this visit, his temperature is 99.9°F (37.7°C), blood pressure is 121/78 mmHg, pulse is 80/min, and respirations are 14/min. There is notable bilateral gynecomastia and fullness of the anterior chest wall. His labs are shown below:
Leukocyte count: 8,000/mm^3
Hemoglobin: 13.9 g/dL
Platelet count: 155,000/mm^3
Serum:Aspartate aminotransferase: 12 U/L
Alanine aminotransferase: 18 U/L
Alkaline phosphatase: 82 IU/L
Alpha-fetoprotein (AFP): 5,500 ng/mL
Serum ß-hCG: 31,000 IU/L
A chest radiograph is shown in Figure A. Which of the following is the most appropriate next step in management for this patient?
Answer Choices: (A) Chemotherapy (B) Surgical removal of mass (C) Orchiectomy (D) Biopsy of mass (E) Bone marrow biopsy

options:
A. Chemotherapy
B. Surgical removal of mass
C. Orchiectomy
D. Biopsy of mass
E. Bone marrow biopsy

label: D

medical_task: Treatment

body_system: Reproductive

question_type: Reasoning


question:
A 4-year-old boy is brought in by his grandmother for worsening seizure activity. She reports that occasionally he “suddenly drops” when running around the house. She says that his first seizure occurred 1 year ago. Since then, he has been on valproic acid but the seizure activity remains unchanged. He was recently enrolled in daycare because she could no longer care for him full-time. Since then, the seizure activity has increased and the daycare facility also noted concerns over his lack of response to voice commands. Family history is significant for a cousin who died suddenly at a young age. His temperature is 98.6°F (37°C), blood pressure is 105/52 mmHg, pulse is 110/min, and respirations are 25/min. A physical exam is significant for lack of response to auditory stimulation. An EEG is performed, which is unrevealing. An ECG is shown in Figure A. The patient is then startled when a door is closed quickly and he suddenly loses consciousness. An ECG is quickly performed and is shown in Figure B. An electrolyte panel is drawn with the following findings:
Serum:Na+: 142 mEq/L
Cl-: 88 mEq/dL
K+: 3.4 mEq/L
HCO3-: 24 mEq/L
BUN: 11 mg/dL
Glucose: 67 mg/dL
Creatinine: 0.6 mg/dL
Mg2+: 1.7 mg/dL
Which of the following is the most appropriate next step in management?
Answer Choices: (A) Administer intravenous lorazepam (B) Start ethosuximide (C) Implant a pacemaker (D) Replete potassium and magnesium and start procainamide (E) Replete potassium and magnesium and start a beta-blocker

options:
A. Administer intravenous lorazepam
B. Start ethosuximide
C. Implant a pacemaker
D. Replete potassium and magnesium and start procainamide
E. Replete potassium and magnesium and start a beta-blocker

label: E

medical_task: Treatment

body_system: Nervous

question_type: Reasoning