Question: Which of the following terms describes the investigator's statistical measure of interest?

Context: The investigator uses statistical data from the local demographic institute to calculate the number of newly diagnosed cases of oral cleft deformities in Ireland over the past 5 years.

Choices:
A. Mortality rate
B. Relative risk
C. Cumulative incidence
D. Attributable risk

Answer: Cumulative incidence

1. An investigator is studying the maternal and fetal consequences of a recent spike in benzodiazepine addiction in Ireland.

2. She is particularly interested in whether benzodiazepine use contributes to oral cleft deformities in newborns exposed to alprazolam, clonazepam, or lorazepam during the first trimester.

3. The investigator uses statistical data from the local demographic institute.

4. The investigator is calculating the number of newly diagnosed cases of oral cleft deformities in Ireland over the past 5 years.


Question: What is the next best step in management of this patient?

Context: Her father died of a stroke at 59 years old and her mother died of a heart attack at 66 years old.

Context: Temperature is 37°C (98.7°F), blood pressure is 113/85 mm Hg, pulse is 69/min, respiratory rate is 14/min, and BMI is 24 kg/m2.

Context: Cardiopulmonary and abdominal examinations are negative. | Laboratory test | Complete blood count | Hemoglobin 12.5 g/dL | MCV 88 fl | Leukocytes 5,500/mm3 | Platelets 155,000/mm3 | Basic metabolic panel | Serum Na+ 135 mEq/L | Serum K+ 3.7 mEq/L | Serum Cl- 106 mEq/L | Serum HCO3- 25 mEq/L | BUN 10 mg/dL | Serum creatinine 0.8 mg/dL | Liver function test | Serum bilirubin 0.8 mg/dL | AST 30 U/L | ALT 35 U/L | ALP 130 U/L (20–70 U/L) | .

Choices:
A. Bone scan
B. Ultrasonography of the abdomen
C. Gamma glutamyl transferase
D. Anti mitochondrial antibody

Answer: Gamma glutamyl transferase

1. A 55-year-old woman comes to the office for preventive health care.

2. She has recently migrated to the United States from Hong Kong.

3. Her past medical history is noncontributory.

4. She denies smoking cigarettes or drinking alcohol.

5. She last saw a doctor at the age of 14 when she was diagnosed with appendicitis and underwent an appendectomy.

6. Her father died of a stroke at 59 years old.

7. Her mother died of a heart attack at 66 years old.

8. She has 2 daughters who are in good health.

14. Cardiopulmonary and abdominal examinations are negative.

15. Laboratory test: Complete blood count.

20. Laboratory test: Basic metabolic panel.

27. Laboratory test: Liver function test.


Question: Which is the most likely diagnosis of this condition?

Context: A 33-year-old man presents to his primary care practitioner, complaining about the presence of white spots in both of his hands.

Context: He states that the white spots have expanded in the last few months; they are not tender nor ulcerated.

Context: His past medical history is relevant for hypothyroidism.

Context: Upon physical examination, the patient shows hypopigmented macules on both hands and on the back and shoulders adjacent to a patch of skin, with signs of excoriation and scratching.

Context: Under the Wood’s lamp, the skin lesions on the hands, back, and shoulders show fluorescence.

Context: There are no signs of inflammation in any of the skin lesions.

Context: The vital signs of the patient are within normal limits.

Choices:
A. Vitiligo
B. Tinea versicolor
C. Pityriasis alba
D. Halo nevus

Answer: Vitiligo

2. Patient complains of white spots in both hands.

3. White spots have expanded in last few months.

4. White spots are not tender nor ulcerated.

5. Patient has past medical history of hypothyroidism.

6. Physical examination shows hypopigmented macules on both hands, back, and shoulders.

7. Skin lesions show signs of excoriation and scratching.

8. Skin lesions show fluorescence under Wood's lamp.

9. No signs of inflammation in any of the skin lesions.

10. Patient's vital signs are within normal limits.


Question: Which of the following is the most likely site where the aspirated foreign body is lodged?

Context: He has a heart rate is 120/min, respiratory rate is difficult to evaluate, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F).

Context: A stat chest X-ray is ordered.

Choices:
A. Basilar segment of the right upper lobe
B. Posterior segment of the right upper lobe
C. Basilar segment of the left lower lobe
D. Basilar segment of the right lower lobe

Answer: Posterior segment of the right upper lobe

1. A 3-year-old boy is brought to the emergency department by his mother.

2. He started violently coughing, wheezing, and having difficulty breathing about 10 minutes ago.

3. She had briefly left him lying on his back playing with toys and when she returned he was choking.

4. She attempted the Heimlich maneuver with no improvement.

6. He has a blood pressure of 110/65 mm Hg.

7. He has a temperature of 37.0°C (98.6°F).

8. His respiratory rate is difficult to evaluate.

9. A respiratory exam reveals wheezing and decreased breath sounds on the right side.


Question: Which of the following drugs should be prescribed to this patient?

Context: A 38-year-old man presents with weakness, loss of appetite, headaches, and irritability.

Context: He developed these symptoms gradually over the past 4 months.

Context: He was diagnosed with Crohn’s disease, which was moderate at the time of diagnosis 6 months ago.

Context: He takes methotrexate 15 mg, which effectively controls his symptoms.

Context: The patient’s vital signs include: blood pressure 105/70 mm Hg, heart rate 102/min, respiratory rate 16/min, and temperature 36.4℃ (97.5℉).

Context: On physical examination, the patient is pale.

Context: His lungs are clear to auscultation.

Context: His heart sounds are rhythmic; a short early systolic murmur can be heard over the apex of the heart.

Context: The rest of the exam is unremarkable.

Context: The patient’s blood test shows the following findings: | Erythrocytes 2.7 x 109/mm3 | Hb 9.3 g/dL | Hct 37% | Mean corpuscular hemoglobin  45.2 pg/cell (2.8 fmol/cell) | Mean corpuscular volume 122 µm3 (122 fL) | Reticulocyte count 0.4% | Total leukocyte count 3050/mm3 | Neutrophils 62% | Lymphocytes 32% | Eosinophils 1% | Monocytes 5% | Basophils 0% | Platelet count 199,000/mm3 | .

Choices:
A. Riboflavin
B. Niacin
C. Pyridoxine
D. Folic acid

Answer: Folic acid

2. Patient has weakness, loss of appetite, headaches, and irritability.

3. Symptoms developed gradually over the past 4 months.

4. Patient was diagnosed with Crohn's disease 6 months ago.

5. Disease was moderate at time of diagnosis.

6. Patient takes methotrexate 15 mg, which effectively controls symptoms.

11. Patient is pale on physical examination.

14. Short early systolic murmur can be heard over the apex of the heart.

16. Erythrocytes count is 2.7 x 109/mm3.

19. Mean corpuscular hemoglobin is 45.2 pg/cell (2.8 fmol/cell).

20. Mean corpuscular volume is 122 µm3 (122 fL).

General Neurology
General Internal Medicine


Question: What is the most likely cause of his hypercalcemia?

Context: A 75-year-old man with coronary artery disease and mitral valve stenosis status-post coronary artery bypass graft and mitral bioprosthetic valve replacement is evaluated in the intensive care unit.

Context: His postsurgical course was complicated by ventilator-associated pneumonia and bilateral postoperative pleural effusions requiring chest tubes.

Context: He has been weaned from the ventilator and has had his chest tubes removed but has required frequent suctioning to minimize aspirations.

Context: He has been dependent on a percutaneous gastrostomy tube for enteral nutrition for the past four weeks.

Context: He is currently on aspirin, carvedilol, atorvastatin, ceftazidime, and pantoprazole.

Context: He has a history of prostate cancer status post radical prostatectomy.

Context: His temperature is 96°F (35.6°C), blood pressure is 95/55 mmHg, pulse is 50/min, and respirations are 20/min.

Context: On physical exam, he is not alert and oriented but responds with moans when stimulated.

Context: His laboratory data are listed below: |  | Serum: | Na+: 145 mEq/L | Cl-: 110 mEq/L | K+: 3.4 mEq/L | HCO3-: 26 mEq/L | BUN: 10 mg/dL | Glucose: 112 mg/dL | Creatinine: 1.4 mg/dL | Thyroid-stimulating hormone: 10 µU/mL | Ca2+: 11.1 mg/dL | PO4-: 1.0 mg/dL | AST: 6 U/L | ALT: 10 U/L | Albumin: 2.5 mg/dL | Lactate dehydrogenase: 200 U/L (140-280 U/L) | Haptoglobin: 150 mg/dL (30-200 mg/dL) | 1,25-(OH)2 D3: 10 pg/mL (15-75 pg/mL) | Parathyroid hormone: 9 pg/mL (10-60 pg/mL) |  | Leukocyte count: 10,000 cells/mm^3 with normal differential | Hemoglobin: 9 g/dL | Hematocrit: 30 % | Platelet count: 165,000 /mm^3 |  | His electrocardiogram and chest radiograph are shown in Figures A and B.

Choices:
A. Euthyroid sick syndrome
B. Immobilization
C. Malignancy
D. Primary hyperparathyroidism

Answer: Immobilization

1. Patient is a 75-year-old man with coronary artery disease and mitral valve stenosis.

2. Patient has had coronary artery bypass graft and mitral bioprosthetic valve replacement.

3. Patient's postsurgical course was complicated by ventilator-associated pneumonia and bilateral postoperative pleural effusions requiring chest tubes.

4. Patient has been weaned from the ventilator and has had his chest tubes removed but has required frequent suctioning to minimize aspirations.

5. Patient has been dependent on a percutaneous gastrostomy tube for enteral nutrition for the past four weeks.

6. Patient is currently on aspirin, carvedilol, atorvastatin, ceftazidime, and pantoprazole.

7. Patient has a history of prostate cancer status post radical prostatectomy.

8. Patient's temperature is 96°F (35.6°C).

9. Patient's blood pressure is 95/55 mmHg.

12. Patient is not alert and oriented but responds with moans when stimulated.

18. Patient's serum glucose is 112 mg/dL.

19. Patient's serum creatinine is 1.4 mg/dL.

20. Patient's serum thyroid-stimulating hormone is 10 µU/mL.

25. Patient's serum albumin is 2.5 mg/dL.

26. Patient's serum lactate dehydrogenase is 200 U/L (140-280 U/L).

27. Patient's serum haptoglobin is 150 mg/dL (30-200 mg


Question: Which of the following would be the next best step in the treatment of this patient’s depression?

Context: The patient was diagnosed with major depressive disorder 16 months ago and has tried multiple medications with no improvement, namely bupropion, fluoxetine, sertraline, and imipramine.

Context: Upon inquiry, she assures the psychiatrist that she has been fully compliant with her medications so far but stopped her current medications a few weeks back as they did not help either.

Context: Her husband suggested her to try a herbal preparation for improving her mood.

Context: She also noted that she felt temporarily better while attending her sister’s wedding last weekend, but she still remains depressed most of the times.

Choices:
A. St John’s Wort
B. Selegiline
C. Phenelzine
D. Electroconvulsive therapy

Answer: Phenelzine

1. A 35-year-old woman presents for a follow-up.

2. The patient was diagnosed with major depressive disorder 16 months ago.

3. The patient has tried multiple medications with no improvement.

4. The medications tried were bupropion, fluoxetine, sertraline, and imipramine.

5. The patient has been fully compliant with her medications so far.

6. The patient stopped her current medications a few weeks back.

7. The patient's husband suggested her to try a herbal preparation for improving her mood.

8. The patient felt temporarily better while attending her sister’s wedding last weekend.

9. The patient still remains depressed most of the times.


Question: Which of the following best describes an effect of the next best step in management?

Context: A 17-year-old boy is brought in by paramedics to the emergency department.

Context: He was found down at a family picnic.

Context: Additionally, because it is springtime, many insects were out while he was playing football.

Context: His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 33/min, and oxygen saturation is 84% on room air.

Context: Physical exam is notable for tachycardia and very minimal breath sounds bilaterally.

Context: No jugular venous distention is noted and an abdominal exam is within normal limits.

Choices:
A. Decreased serum potassium
B. Equilibration of environmental and chest cavity pressure
C. Hypoglycemia
D. Increased systemic vascular resistance

Answer: Decreased serum potassium

1. A 17-year-old boy was brought in by paramedics to the emergency department.

2. He was found down at a family picnic.

3. The boy's parents state that he tried many new foods at the picnic.

5. Many insects were out while he was playing football.

10. His oxygen saturation is 84% on room air.

11. Physical exam is notable for tachycardia.

12. Very minimal breath sounds bilaterally.

13. No jugular venous distention is noted.

14. Abdominal exam is within normal limits.


Question: Which of the following is the best initial step in management?

Context: A 45-year-old woman comes to the emergency department with her 17-year-old son because she believes she has been poisoned by her ex-husband.

Context: She reports that her coffee tasted “strange” this morning.

Context: After breakfast, she then saw a black car drive by the house, which she concludes must have been her ex-husband, who also drives a black car.

Context: She says that since the divorce 3 years ago, her ex-husband has been seeking revenge and thinks that he has installed cameras in her apartment to spy on her and their son.

Context: She has never seen any of these cameras but when she is alone in the apartment, she can sometimes hear them beeping and feel them recording her.

Context: The son also reports his mother's coffee mug smelled of bitter almonds, which he suspects was cyanide.

Context: He agrees with the mother's distrust towards his father and reports that he has also occasionally heard a camera beeping but has not been able to find any cameras yet.

Context: The mother's vital signs are within normal limits.

Context: Toxicology screening is negative.

Choices:
A. Ziprasidone therapy
B. Repetitive transcranial magnetic stimulation
C. Examine mother and son separately
D. Report the case to the authorities

Answer: Examine mother and son separately

2. Patient is accompanied by her 17-year-old son.

3. Patient believes she has been poisoned by her ex-husband.

4. Patient reports her coffee tasted “strange” this morning.

5. Patient saw a black car drive by the house.

6. Patient's ex-husband drives a black car.

7. Patient and her ex-husband divorced 3 years ago.

8. Patient's ex-husband has been seeking revenge.

9. Patient believes her ex-husband has installed cameras in her apartment to spy on her and their son.

10. Patient has never seen any of these cameras.

11. Patient can sometimes hear cameras beeping and feel them recording her when she is alone in the apartment.

12. Patient's son reports her coffee mug smelled of bitter almonds.

13. Patient's son suspects the smell was cyanide.

14. Patient's son agrees with the mother's distrust towards his father.

15. Patient's son has occasionally heard a camera beeping but has not been able to find any cameras yet.

16. Patient's vital signs are within normal limits.

17. Physical examination shows no abnormalities.

18. Arterial blood gas analysis on room air shows a pH of 7.4.


Question: This patient is most likely deficient in which of the following enzymes?

Context: A 2-year-old boy is brought to the physician after his adoptive mother observed jerking movements of his arms and legs earlier that morning.

Choices:
A. Phenylalanine hydroxylase
B. α-ketoacid dehydrogenase
C. Cystathionine synthase
D. Homogentisate oxidase

Answer: Phenylalanine hydroxylase

1. A 2-year-old boy was brought to the physician.

2. His adoptive mother observed jerking movements of his arms and legs earlier that morning.

3. He was adopted from an orphanage in Albania at 4 months of age.

4. He has a history of intellectual disability.

5. Examination shows pale skin and light blue eyes.

6. There is a dry, eczematous, scaly rash on the extensor surfaces of the extremities.

Neurology with Special Qualification in Child Neurology


Question: Laboratory evaluation in this patient is most likely to show which of the following?

Context: A 45-year-old man comes to the physician because of a 4-month history of increased frequency of urination.

Context: He wakes up several times a night to urinate and feels fatigued during the day.

Context: He also complains of increased thirst; he drinks multiple liters of water and soda daily and still feels thirsty.

Context: Vital signs are within normal limits.

Context: Physical examination shows patches of velvety hyperpigmentation in the axilla and on the posterior neck.

Choices:
A. Elevated serum thyroxine concentration
B. Elevated glycated hemoglobin concentration
C. Positive urinary leukocyte esterase
D. Low urine osmolality

Answer: Elevated glycated hemoglobin concentration

1. A 45-year-old man comes to the physician.

2. He has a 4-month history of increased frequency of urination.

3. He wakes up several times a night to urinate.

6. He drinks multiple liters of water and soda daily.

8. Vital signs are within normal limits.

9. Physical examination shows patches of velvety hyperpigmentation in the axilla.

10. Physical examination shows patches of velvety hyperpigmentation on the posterior neck.


Question: Which of the following agents is most likely to improve the patient's long-term survival?

Context: A 69-year-old man comes to the physician with a 9-month history of worsening shortness of breath on exertion and need to urinate at night.

Context: He occasionally has palpitations but does not have chest pain.

Context: The patient had a transient ischemic attack 5 years ago for which he underwent right-sided carotid endarterectomy.

Context: He has hypertension and type 2 diabetes mellitus.

Context: Current medications include metformin, lisinopril, aspirin, and simvastatin.

Context: He appears fatigued.

Context: His pulse is 61/min, blood pressure is 120/75 mmHg, and respirations are 25/min.

Context: Pulse oximetry shows an oxygen saturation of 96%.

Context: Examination shows cold extremities.

Context: There are no murmurs or rubs on cardiac auscultation.

Context: Fine, bilateral crackles are heard at the lung bases.

Context: There is 2+ lower extremity edema.

Context: An ECG shows sinus rhythm and known T wave inversions in leads V1 to V4.

Choices:
A. Eplerenone
B. Ivabradine
C. Verapamil
D. Digoxin

Answer: Eplerenone

2. Patient has 9-month history of worsening shortness of breath on exertion and need to urinate at night.

3. Patient occasionally has palpitations but does not have chest pain.

4. Patient had transient ischemic attack 5 years ago and underwent right-sided carotid endarterectomy.

5. Patient has hypertension and type 2 diabetes mellitus.

6. Patient is currently taking metformin, lisinopril, aspirin, and simvastatin.

9. Patient's blood pressure is 120/75 mmHg.

11. Pulse oximetry shows oxygen saturation of 96%.

13. No murmurs or rubs on cardiac auscultation.

14. Fine, bilateral crackles heard at lung bases.

16. ECG shows sinus rhythm and known T wave inversions in leads V1 to V4.


Question: Which of the following is the next best step in diagnosis?

Context: A 22-year-old woman presents to her primary care provider complaining of a facial rash.

Context: She says the rash began 3 weeks ago after hiking in the White Mountains of New Hampshire this summer.

Context: Since that time she has also experienced pain in her hands and wrists that is worse in the morning and accompanied by subjective fevers.

Context: She denies chest pain, shortness of breath, nausea, or vomiting.

Context: Vital signs are 99.6°F (37.6°F), blood pressure is 134/82 mmHg, pulse is 88/min, and respirations are 18/min.

Context: Examination demonstrates a rash on the patient's face that spares the nasolabial folds along with oral ulcers.

Context: The metacarpophalangeal joints are tender to palpation, and range of motion is limited by pain.

Choices:
A. Anti-cardiolipin antibodies
B. Anti-dsDNA antibodies
C. Anti-nuclear antibodies
D. Anti-Smith antibodies

Answer: Anti-nuclear antibodies

2. Patient presents to primary care provider complaining of facial rash.

3. Patient says rash began 3 weeks ago after hiking in White Mountains of New Hampshire.

4. Patient has experienced pain in hands and wrists that is worse in the morning and accompanied by subjective fevers.

5. Patient denies chest pain, shortness of breath, nausea, or vomiting.

6. Vital signs are 99.6°F (37.6°C), blood pressure is 134/82 mmHg, pulse is 88/min, and respirations are 18/min.

7. Examination demonstrates rash on patient's face that spares the nasolabial folds along with oral ulcers.

8. Metacarpophalangeal joints are tender to palpation, and range of motion is limited by pain.

9. Complete blood count demonstrates normocytic anemia with thrombocytopenia.


Question: Which of the following organisms is the most likely cause of this patient’s condition?

Context: A 54-year-old man presents with fever and a painful jaw mass with a yellowish discharge.

Context: He says that he first noticed the jaw mass 6 weeks ago and that the mass has been progressively increasing in size.

Context: He reports a history of chronic alcoholism and currently takes more than 6 drinks daily.

Context: His temperature is 37.9°C (100.2°F).

Context: On physical examination, there is a 7 × 7 cm mass at the tip of the jaw bone with significant surrounding edema and sclerosis The mass is severely tender on light palpation and has a yellowish malodorous discharge.

Context: The oral cavity shows signs of very poor dentition.

Choices:
A. Peptostreptococcus magnus
B. Actinomyces israelii
C. Nocardia asteroides
D. Eikenella corrodens

Answer: Actinomyces israelii

3. Patient has a painful jaw mass with a yellowish discharge.

4. Patient first noticed the jaw mass 6 weeks ago.

5. Mass has been progressively increasing in size.

6. Patient has a history of chronic alcoholism.

7. Patient currently takes more than 6 drinks daily.

8. Patient's temperature is 37.9°C (100.2°F).

9. Physical examination reveals a 7 × 7 cm mass at the tip of the jaw bone with significant surrounding edema and sclerosis.

10. Mass is severely tender on light palpation.

11. Mass has a yellowish malodorous discharge.

12. Oral cavity shows signs of very poor dentition.

13. Laboratory analysis of the discharge reveals gram-positive anaerobic filamentous bacteria.

General Otolaryngology
Medical Microbiology Pathology


Question: Which of the following is the best initial diagnostic test for this patient’s condition?

Context: A 57-year-old homosexual man presents to the emergency department with epigastric pain.

Context: The patient has a past medical history of alcoholism and is homeless.

Context: He states that his symptoms at this time are constant and occur at all times of the day and are near his baseline.

Context: He also endorses fatty and foul smelling diarrhea during this time frame.

Choices:
A. CT scan
B. Lipase
C. Secretin stimulation test
D. Stool ova and parasite analysis

Answer: CT scan

1. A 57-year-old man presents to the emergency department with epigastric pain.

2. He has presented multiple times for the same complaint in the past.

3. The patient has a past medical history of alcoholism.

5. He states that his symptoms at this time are constant.

6. His symptoms occur at all times of the day.

8. He endorses fatty and foul smelling diarrhea during this time frame.


Question: Which of the following cells is responsible for the initial cascade by the release of TGF-β and PDGF?

Context: A 6-year-old boy is rushed to the emergency department after being involved in a motor vehicle accident.

Context: His wounds are cleaned and a pressure bandage is applied.

Context: Typically, neutrophils and macrophages are attracted toward the site of injury by various chemical mediators.

Choices:
A. Mast cells
B. Fibroblasts
C. Platelets
D. Basophils

Answer: Platelets

1. A 6-year-old boy is rushed to the emergency department.

2. He has abrasions on his left knee and left elbow.

5. Neutrophils and macrophages are typically attracted toward the site of injury.

6. Various chemical mediators attract neutrophils and macrophages.


Question: Which of the following is the most likely cause of this patient's presentation?

Context: A 70-year-old man comes to the emergency department after briefly losing consciousness and collapsing when rising from a chair.

Context: His blood pressure is 120/80 mm Hg supine and 100/70 mm Hg one minute after standing with no change in pulse rate.

Context: On cardiac auscultation, there is a plopping sound followed by a low-pitched, rumbling mid-diastolic murmur heard best at the apex.

Choices:
A. Stokes-Adams attack
B. Constricted aortic valve orifice
C. Cardiac tumor
D. Left ventricular dilation

Answer: Cardiac tumor

1. A 70-year-old man comes to the emergency department.

2. He briefly lost consciousness and collapsed when rising from a chair.

3. He did not sustain any injuries from his collapse.

4. He has had a two-week history of dizziness upon standing.

5. He has smoked one pack of cigarettes daily for 55 years.

6. He drinks three beers and two glasses of whiskey daily.

7. He currently takes dutasteride and tamsulosin for benign prostatic hyperplasia.

8. His blood pressure is 120/80 mm Hg supine.

9. His blood pressure is 100/70 mm Hg one minute after standing with no change in pulse rate.

10. Physical examination shows conjunctival pallor.

11. On cardiac auscultation, there is a plopping sound.

12. On cardiac auscultation, there is a low-pitched, rumbling mid-diastolic murmur heard best at the apex.


Question: Which of the following congenital heart diseases does this infant most likely present with?

Context: The parents deny any specific current complaints, but his facial features differ from those of other children in the family.

Context: An echocardiogram is performed which suggests that the infant has a congenital heart disease which is the most common form of congenital heart disease seen in children with this particular genetic disorder.

Choices:
A. Supravalvar aortic stenosis
B. Tetralogy of Fallot
C. Atrial septal defect
D. Atrioventricular septal defect

Answer: Atrioventricular septal defect

1. A 6-month-old infant is brought to a pediatrician for his scheduled immunizations.

2. The parents deny any specific current complaints.

3. His facial features differ from those of other children in the family.

4. During the physical examination, the pediatrician notes that the infant’s vital signs are stable.

5. His facial features include a medial epicanthic fold, a face that appears flat, and a flat occiput with low-set ears.

6. The pediatrician also notes a single transverse palmar crease on both hands.

8. The echocardiogram suggests that the infant has a congenital heart disease.

9. The congenital heart disease is the most common form of congenital heart disease seen in children with this particular genetic disorder.


Question: WBC 0–1/hpf | Fatty casts numerous | A renal biopsy specimen is most likely to show which of the following?"

Context: A 32-year-old white woman comes to the physician because of fatigue, lethargy, and swelling of the lower legs for 2 months.

Context: She reports recurrent episodes of pain in both wrists, her right knee, and her right ankle in the past year.

Context: She has had skin problems that are aggravated by exposure to sunlight for the past 18 months.

Context: She has smoked one pack of cigarettes daily for 13 years and drinks one alcoholic beverage daily.

Context: Her temperature is 37°C (98.6°F), pulse is 92/min, and blood pressure is 115/75 mm Hg.

Context: There are erythematous patches with scaling on both cheeks.

Context: Laboratory studies show: | Hemoglobin 11.2 g/dL | Leukocyte count 8500/mm3 | Platelet count 130,000/mm3 | Serum | Urea nitrogen 36 mg/dL | Glucose 77 mg/dL | Creatinine 0.9 mg/dL | Albumin 2.6 mg/dL | Total cholesterol 275 mg/dL | Triglycerides 180 mg/dL | Urine | Blood negative | Glucose negative | Protein 4+ | .

Choices:
A. Thickened capillary loops
B. Segmental sclerosis
C. Crescent formation
D. Hypercellular glomeruli

Answer: Thickened capillary loops

1. Patient is a 32-year-old white woman.

2. Patient has been experiencing fatigue, lethargy, and swelling of the lower legs for 2 months.

3. Patient has had recurrent episodes of pain in both wrists, her right knee, and her right ankle in the past year.

4. Patient has had skin problems that are aggravated by exposure to sunlight for the past 18 months.

5. Patient has smoked one pack of cigarettes daily for 13 years.

6. Patient drinks one alcoholic beverage daily.

7. Patient's temperature is 37°C (98.6°F).

9. Patient's blood pressure is 115/75 mm Hg.

10. Examination shows 2+ pretibial edema bilaterally and periorbital edema.

11. Examination shows erythematous patches with scaling on both cheeks.

12. Laboratory studies show hemoglobin 11.2 g/dL.

13. Laboratory studies show leukocyte count 8500/mm3.

14. Laboratory studies show platelet count 130,000/mm3.

15. Laboratory studies show serum urea nitrogen 36 mg/dL.

16. Laboratory studies show serum glucose 77 mg/dL.

17. Laboratory studies show serum creatinine 0.9 mg/dL.

18. Laboratory studies show serum albumin 2.6 mg/dL.

19. Laboratory studies show total cholesterol 275 mg/dL.

20. Laboratory studies show triglycerides 180 mg/dL.

21. Laboratory studies show urine blood negative.

22. Laboratory studies show urine glucose negative.

23. Laboratory studies show urine protein 4+.


Question: Which of the following is most likely responsible for this patient’s breathing pattern?

Context: A 60-year-old man presents to the clinic with his wife for “weird breathing” during the night.

Context: The patient’s wife says that his breathing pattern is irregular but he does not snore.

Context: The patient says he is not aware of these symptoms.

Context: Past medical history is remarkable for an NSTEMI when he was 50 years old.

Context: He spends a night at the sleep lab where his tidal volume is monitored overnight and a tracing is shown in the image below.

Choices:
A. Diabetic ketoacidosis
B. Hypothyroidism
C. Left ventricular heart failure
D. Obesity

Answer: Left ventricular heart failure

1. A 60-year-old man presents to the clinic with his wife.

2. The patient's wife reports that his breathing pattern is irregular.

4. The patient is not aware of these symptoms.

5. The patient's past medical history is remarkable for an NSTEMI when he was 50 years old.

6. The patient spends a night at the sleep lab.

7. The patient's tidal volume is monitored overnight.

8. An image of the tracing is shown below.


Question: Which of the following is the most likely diagnosis?

Context: A 72-year-old man with a history of chronic kidney disease presents to his primary care physician complaining of recurrent chest pain with activity.

Context: The patient used to have chest pain when he mowed his lawn.

Context: Now he gets chest pain whenever he walks short distances such as to get his mail.

Context: The pain resolves on its own when the patient sits and rests.

Context: His temperature is 98.2°F (36.8°C), blood pressure is 157/98 mm Hg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Context: Physical exam is notable for an obese man who is in no distress.

Context: An initial ECG is unchanged from a previous ECG.

Context: The patient's first troponin is 0.06 ng/mL which is unchanged from previous troponins.

Choices:
A. NSTEMI
B. Stable angina
C. Unstable angina
D. Variant angina

Answer: Unstable angina

2. Patient has a history of chronic kidney disease.

3. Patient presents to primary care physician with recurrent chest pain with activity.

4. Patient used to have chest pain when mowing lawn.

5. Patient now gets chest pain when walking short distances such as to get mail.

6. Pain resolves on its own when patient sits and rests.

7. Patient's temperature is 98.2°F (36.8°C).

8. Patient's blood pressure is 157/98 mm Hg.

11. Patient's oxygen saturation is 98% on room air.

12. Patient is obese and in no distress.

13. Initial ECG is unchanged from previous ECG.

14. Patient's first troponin is 0.06 ng/mL which is unchanged from previous troponins.

Internal Medicine
Cardiovascular Disease
Cardiology

Cardiovascular Disease
Cardiology
General Cardiology
General Internal Medicine


Question: Which of the following procedures involves the removal of an entire breast?

Context: A 55-year-old woman presents to the surgical oncology clinic as a new patient for evaluation of recently diagnosed breast cancer.

Context: She has a medical history of hypertension for which she takes lisinopril.

Context: She denies any surgical history.

Context: She is visibly anxious during the encounter, but physical examination is otherwise unremarkable.

Choices:
A. Vasectomy
B. Mastectomy
C. Lumpectomy
D. Arthroplasty

Answer: Mastectomy

1. A 55-year-old woman presents to the surgical oncology clinic as a new patient.

2. She has a medical history of hypertension.

3. She takes lisinopril for her hypertension.

5. Her family history is notable for breast cancer in her maternal grandmother.

6. She is visibly anxious during the encounter.

7. Physical examination is otherwise unremarkable.

8. Her primary concern today is which surgical approach will be chosen to remove her breast cancer.


Question: Which of the following did the physician add?

Context: A 14-year-old female is seeing her pulmonologist in clinic after a recent asthma exacerbation.

Context: She has been adherent to her original controller medication so the physician prescribes an additional new drug which prevents IgE binding to mast cells.

Choices:
A. Theophylline
B. Albuterol
C. Omalizumab
D. Beclamethasone

Answer: Omalizumab

1. A 14-year-old female is seeing her pulmonologist in clinic.

2. The visit is due to a recent asthma exacerbation.

3. She has been adherent to her original controller medication.

4. The physician prescribes an additional new drug.

5. The new drug prevents IgE binding to mast cells.


Question: Which of the following is the best next step in management for this patient?

Context: A 24-year-old man is brought in to the emergency room after being retrieved by firefighters from a burning building.

Context: The patient is responding coherently to questions but reports pain secondary to a burn on his leg.

Context: He states he also has a headache and feels dizzy.

Context: His temperature is 98.5°F (36.9°C), blood pressure is 129/66 mmHg, pulse is 126/min, respirations are 14/min, and oxygen saturation is 99% on room air.

Context: Physical exam is notable for a confused young man with dry and flushed skin.

Context: Cardiopulmonary exam reveals a normal S1 and S2 as well as clear breath sounds bilaterally.

Context: The patient’s neurological exam is within normal limits.

Context: Towards the end of his exam, the patient begins vomiting.

Context: Dermatologic exam reveals a superficial burn covering 1% of the patient’s body over his right leg.

Choices:
A. 100% oxygen
B. Hydroxocobalamin
C. Normal saline
D. Ondansetron

Answer: 100% oxygen

1. A 24-year-old man is brought in to the emergency room.

2. He was retrieved by firefighters from a burning building.

3. He is responding coherently to questions.

4. He reports pain secondary to a burn on his leg.

5. He also has a headache and feels dizzy.

10. His oxygen saturation is 99% on room air.

11. He is a confused young man with dry and flushed skin.

12. Cardiopulmonary exam reveals a normal S1 and S2.

13. Breath sounds are clear bilaterally.

14. His neurological exam is within normal limits.

15. Towards the end of his exam, he begins vomiting.

16. Dermatologic exam reveals a superficial burn covering 1% of his body over his right leg.


Question: Which of the following vitamin deficiencies is she most likely to develop?

Context: A 29-year-old female presents to her psychiatrist with concerns that she may be "OCD." She explains that she has become extremely obsessed with making sure that her fruits and vegetables are completely sanitized by first rinsing with water for exactly 60 seconds and then boiling for exactly 60 minutes.

Context: She refuses to eat any fruits or vegetables that did not undergo this process, which she began doing about 3 months ago.

Choices:
A. Vitamin A
B. Vitamin K
C. Vitamin C
D. Vitamin E

Answer: Vitamin C

1. A 29-year-old female presents to her psychiatrist.

2. She has concerns that she may be "OCD."

3. She rinses fruits and vegetables with water for exactly 60 seconds.

4. She boils fruits and vegetables for exactly 60 minutes.

5. She refuses to eat any fruits or vegetables that did not undergo this process.

6. She began this process about 3 months ago.


Question: What is the most likely diagnosis?

Context: A 73-year-old male is brought to his family practitioner by his daughter with the complaints of a spinning sensation for the past 4 weeks.

Context: He says that the room appears to be continuously spinning.

Context: This has progressively worsened over the last 4 weeks to the point that he has become bed bound and cannot walk without support.

Context: These spinning sensations are present throughout the day and do not change with position.

Context: They are associated with nausea and vomiting.

Context: He denies ear pain, ear discharge, ringing in the ear, hearing disturbances, ear fullness, head trauma, fever, or recent flu-like illness.

Context: He has a blood pressure of 133/80 mm Hg, heart rate of 80/min, respiratory rate of 12/min, and temperature of 36.7°C (98.2°F).

Context: His extraocular eye movements are normal in all directions, but a vertical nystagmus is present that does not disappear despite repetitive testing.

Context: Hearing tests are within normal limits.

Choices:
A. Acute labyrinthitis
B. Benign paroxysmal positional vertigo
C. Cerebellar tumor
D. Meniere's disease

Answer: Cerebellar tumor

2. Patient was brought to family practitioner by daughter.

3. Patient has been experiencing a spinning sensation for 4 weeks.

4. Spinning sensation has progressively worsened over 4 weeks.

5. Patient has become bed bound and cannot walk without support.

6. Spinning sensation is present throughout the day and does not change with position.

7. Spinning sensation is associated with nausea and vomiting.

8. Patient denies ear pain, ear discharge, ringing in the ear, hearing disturbances, ear fullness, head trauma, fever, or recent flu-like illness.

9. Patient's blood pressure is 133/80 mm Hg.

11. Patient's respiratory rate is 12/min.

12. Patient's temperature is 36.7°C (98.2°F).

13. Patient's extraocular eye movements are normal in all directions.

14. Patient has vertical nystagmus that does not disappear despite repetitive testing.

15. Patient's hearing tests are within normal limits.


Question: On physical exam, one would also expect:

Context: A 79-year-old man presents to the emergency room after a syncopal event.

Context: The patient has a history of hyperlipidemia for which he is taking atorvastatin.

Context: On physical examination, his vital signs are stable, but on cardiac auscultation, you detect a crescendo-decrescendo systolic murmur loudest on the right upper sternal border radiating to the neck.

Choices:
A. That the murmur would best be heard in the lateral left decubitus position
B. The character of the murmur would be machine-like
C. The murmur would also have a mid-systolic click loudest before S2
D. Palpation of the carotid pulse would be weak and late relative to the patient’s heart sounds

Answer: Palpation of the carotid pulse would be weak and late relative to the patient’s heart sounds

1. A 79-year-old man presents to the emergency room.

2. The patient has a history of hyperlipidemia.

5. Cardiac auscultation reveals a crescendo-decrescendo systolic murmur.

6. The murmur is loudest on the right upper sternal border.


Question: Which of the following best describes this type of study design?

Context: The researcher gathers all records of patients presenting with bronchitis for the past 10 years from the local hospital and contacts the qualifying subjects to ask them about exposure to the particular pesticide.

Context: Using the data he compiles, he is able to calculate an estimate for the relative and absolute risk for developing chronic bronchitis in people who have been exposed to that pesticide.

Choices:
A. Case-control study
B. Cross-sectional study
C. Cohort study
D. Double-blind, randomized, placebo-controlled clinical trial

Answer: Cross-sectional study

1. A researcher is designing a study to examine a possible correlation between exposure to a particular pesticide and chronic bronchitis.

2. The researcher gathers all records of patients presenting with bronchitis for the past 10 years from the local hospital.

3. The researcher contacts the qualifying subjects to ask them about exposure to the particular pesticide.

4. The researcher compiles data from the records and the subjects' responses.

5. The researcher is able to calculate an estimate for the relative and absolute risk for developing chronic bronchitis in people who have been exposed to that pesticide.


Question: Which of the following will most likely be found on cardiac auscultation?

Context: A 49-year-old woman presents to her primary care physician due to fatigue and shortness of breath.

Context: She finds herself being short of breath when climbing the stairs or walking uphill.

Context: Approximately 1 year ago, she was able to partake in long-distance running and weightlifting.

Context: Two weeks ago she noticed blood-tinged sputum after severely coughing during sleep.

Context: She emigrated from Mexico to the United States 3 years ago.

Context: Her temperature is 98°F (36.7°C), blood pressure is 100/62 mmHg, pulse is 135/min and irregularly irregular, and respirations are 21/min.

Context: On physical exam her speech is hoarse.

Context: She has bilateral crackles heard in the lung bases.

Choices:
A. Crescendo-decrescendo systolic ejection murmur
B. High-pitched, early diastolic decrescendo murmur
C. Holosystolic, high-pitched murmur loudest at the left lower sternal border
D. Opening snap with a mid-to-late diastolic murmur

Answer: Opening snap with a mid-to-late diastolic murmur

2. Patient presents to primary care physician due to fatigue and shortness of breath.

3. Patient finds herself being short of breath when climbing stairs or walking uphill.

4. Approximately 1 year ago, patient was able to partake in long-distance running and weightlifting.

5. Two weeks ago, patient noticed blood-tinged sputum after severely coughing during sleep.

6. Patient emigrated from Mexico to the United States 3 years ago.

7. Patient's temperature is 98°F (36.7°C).

8. Patient's blood pressure is 100/62 mmHg.

9. Patient's pulse is 135/min and irregularly irregular.

11. On physical exam, patient's speech is hoarse.

12. Patient has bilateral crackles heard in the lung bases.


Question: Which of the following is the most appropriate pharmacotherapy at this time?

Context: The laboratory test results are as follows: | Hemoglobin 10 g/dL | Mean corpuscular volume 88 μm3 | Leukocyte count 65,000/mm3 | Platelet count 500,000/mm3 | The peripheral blood smear shows a predominance of neutrophils and the presence of band cells, myelocytes, promyelocytes, and blasts (< 5%).

Choices:
A. All-trans retinoic acid
B. Aspirin
C. Imatinib
D. Hydroxyurea

Answer: Imatinib

1. A 60-year-old man presents to the physician for a follow-up examination.

2. During the previous visit, splenomegaly was detected on the abdominal exam, which has been confirmed by abdominal ultrasound.

3. He has no complaints other than fatigue for several months.

4. He has no history of serious illness and takes no medications.

5. The vital signs are within the normal range.

6. On percussion, spleen size is 15 cm (5.9 in).

7. Otherwise, the physical examination shows no abnormalities.

8. The laboratory test results are as follows: Hemoglobin 10 g/dL.

9. The laboratory test results are as follows: Mean corpuscular volume 88 μm3.

10. The laboratory test results are as follows: Leukocyte count 65,000/mm3.

11. The laboratory test results are as follows: Platelet count 500,000/mm3.

12. The peripheral blood smear shows a predominance of neutrophils and the presence of band cells, myelocytes, promyelocytes, and blasts (< 5%).

13. The molecular studies document the BCR-ABL1 rearrangement.


Question: What is the most likely cause of the following findings?

Context: A 45-year-old man presents to the outpatient unit with a complaint of lower extremity edema for the past few weeks.

Context: He has also been observing puffiness of the face lately.

Context: The urinalysis shows 4+ proteinuria.

Context: The serum creatinine is 3.5 mg/dL, and antinuclear antibodies are absent.

Context: The biopsy findings are given in the picture.

Choices:
A. Membranoproliferative glomerulonephritis
B. Rapidly progressive glomerlonephritis
C. Postinfectious glomerulonephritis
D. Membranous glomerulonephritis

Answer: Membranous glomerulonephritis

1. A 45-year-old man presents to the outpatient unit.

2. Complaint is lower extremity edema for the past few weeks.

3. Puffiness of the face has been observed lately.

7. Biopsy findings are given in the picture.


Question: If the child’s condition is left untreated, levels of which of the following hormones is most likely to be decreased most when the child reaches sexual maturity?

Context: A 2-year-old male is brought to his pediatrician by his parents because of a lack of testes in his scrotum.

Context: Physical examination confirms that testes are absent from the scrotal sac and palpable masses are found bilaterally around the inguinal canal.

Choices:
A. FSH
B. LH
C. Inhibin
D. Prolactin

Answer: Inhibin

1. A 2-year-old male is brought to his pediatrician by his parents.

2. The reason for the visit is a lack of testes in his scrotum.

3. Physical examination confirms that testes are absent from the scrotal sac.

4. Palpable masses are found bilaterally around the inguinal canal.


Question: Which of the following is the volume of isotonic fluid that should be given to this patient over the next 24 hours?

Context: A 23-year-old man presents to the emergency department by ambulance after being rescued from a burning house.

Context: The patient was intubated in the field and is maintaining his oxygen saturation above 98%.

Context: His weight is 70 kg.

Choices:
A. 1,100 mL
B. 4,200 mL
C. 8,400 mL
D. 16,800 mL

Answer: 8,400 mL

1. A 23-year-old man presents to the emergency department by ambulance.

2. The patient was intubated in the field.

3. The patient is maintaining his oxygen saturation above 98%.

4. Physical exam reveals partial or full-thickness burns across an estimated 30% of his total body surface area.


Question: Which of the following statements best describes the rationale for administering RhO(D) immunoglobulins (RhoGAM) in this patient?

Context: A 28-year-old G1P0 primigravida woman at 28 weeks estimated gestational age presents for routine prenatal care.

Context: She has no complaints and says she can feel her baby move and respond to outside sounds.

Context: The patient has no significant past medical or family history.

Context: Currently, she is taking a prenatal multivitamin which contains iron and folic acid.

Context: Her blood type is A (-) negative, and her husband is A (+) positive.

Context: The patient says she stopped drinking alcohol 2 years ago and denies any history of smoking or recreational drug use.

Context: Her pulse is 90/min, blood pressure is 114/68 mm Hg, and respiratory rate is 18/min.

Context: She has gained 9.0 kg (19.8 lb) over the course of the pregnancy.

Context: Fetal heart sounds can be auscultated.

Context: The patient is administered an injection of RhO(D) immunoglobulin (RhoGAM).

Choices:
A. RhO(D) immunoglobulin will prevent hemolytic disease in this pregnancy.
B. The father requires RhO(D) immunoglobulin administration rather than the patient.
C. RhO(D) immunoglobulins will prevent anti-D antibody formation in the mother.
D. RhO(D) immunoglobulins will prevent anti-D antibody formation in the fetus.

Answer: RhO(D) immunoglobulins will prevent anti-D antibody formation in the mother.

1. Patient is a 28-year-old G1P0 primigravida woman.

2. Patient is at 28 weeks estimated gestational age.

4. Patient can feel her baby move and respond to outside sounds.

5. Patient has no significant past medical or family history.

6. Patient is taking a prenatal multivitamin which contains iron and folic acid.

7. Patient's blood type is A (-) negative.

8. Patient's husband's blood type is A (+) positive.

9. Patient stopped drinking alcohol 2 years ago.

10. Patient denies any history of smoking or recreational drug use.

12. Patient's blood pressure is 114/68 mm Hg.

13. Patient's respiratory rate is 18/min.

14. Patient has gained 9.0 kg (19.8 lb) over the course of the pregnancy.

15. Physical examination shows a gravid uterus, extending 28 cm above the pubic symphysis.

16. Occasional movements are observed in the abdomen.

17. There is no guarding or tenderness to palpation.

18. Fetal heart sounds can be auscultated.

19. The remainder of the examination is unremarkable.

20. Patient is administered an injection of RhO(D) immunoglobulin (RhoGAM).


Question: The underlying cause of this patient's condition is best classified as which of the following?

Context: He has a history of hypertension and diabetes mellitus.

Context: His wife recently filed for divorce.

Choices:
A. Hormonal
B. Neurogenic
C. Psychogenic
D. Vascular

Answer: Psychogenic

1. A 51-year-old man comes to the physician for evaluation of inability to attain an erection during sexual activity for 6 months.

2. He has had an active sexual life in the past.

3. He reports that early morning erections are present every other day.

5. He has a history of diabetes mellitus.

7. He has smoked one pack of cigarettes daily for 25 years.

8. His only medications are enalapril and metformin.

9. Physical examination shows no abnormalities.


Question: What is the most likely explanation for this patient’s symptoms?

Context: A 49-year-old G4P4 woman comes to the clinic complaining of repeated leakage of fluid from her vagina for the past 5 months.

Context: She noticed an increase in episodes following her cold last week when she was coughing and sneezing a lot.

Context: Her past medical history is significant for Crohn disease, which is well controlled with sulfasalazine.

Context: She is currently sexually active with multiple partners with inconsistent condom use.

Choices:
A. Prolapse of the bladder
B. Detrusor muscle overactivity
C. Genitourinary syndrome of menopause
D. Rectovaginal fistula

Answer: Prolapse of the bladder

1. A 49-year-old G4P4 woman comes to the clinic.

2. She has been experiencing repeated leakage of fluid from her vagina for the past 5 months.

3. She noticed an increase in episodes following her cold last week.

4. She was coughing and sneezing a lot during her cold.

5. Her past medical history is significant for Crohn disease.

6. Her Crohn disease is well controlled with sulfasalazine.

7. Her last menstrual period was 1 year ago.

8. She is currently sexually active with multiple partners.

10. She denies any vaginal itching, abnormal discharge, pain, subpubic pressure, urinary urges, or odors.

11. Physical examination is significant for a bulge at the anterior vaginal wall.

Female Pelvic Medicine and Reconstructive Surgery


Question: Which of the following cellular mechanisms best explains the effects of stimulation of sympathetic cardiac nerves on the pacemaker cells in the sinoatrial node?

Context: A 24-year-old woman presents to a physician with recurrent episodes of palpitations, shortness of breath, and perspiration.

Context: The episodes are self-limited and are usually preceded by specific social circumstances that she does not enjoy.

Context: After a complete history and physical examination, the physician diagnoses an anxiety disorder.

Context: He explains that anxiety is associated with the stimulation of the sympathetic nervous system which produces several symptoms related to anxiety such as tachycardia.

Choices:
A. Decreased intracellular cyclic adenosine monophosphate (cAMP) level in the sinoatrial node
B. Inactivation of L-type voltage-gated calcium channels
C. Facilitation of If currents through HCN channels
D. Opening of G-protein activated potassium channels

Answer: Facilitation of If currents through HCN channels

1. A 24-year-old woman presents to a physician.

2. She has recurrent episodes of palpitations, shortness of breath, and perspiration.

4. The episodes are usually preceded by specific social circumstances that she does not enjoy.

5. There is no significant past medical history.

6. The physician diagnoses an anxiety disorder.

7. Anxiety is associated with the stimulation of the sympathetic nervous system.

8. The sympathetic nervous system produces several symptoms related to anxiety such as tachycardia.


Question: What is the most likely etiology of this patient’s diagnosis?

Context: A 14-year-old boy is brought to the office by his parents because he states that for the past 2 months he has been feeling constantly tired, and also noticed a dull pain in the pit of his stomach.

Context: The patient has no relevant family history.

Context: The vital signs include a heart rate of 105/min, a respiratory rate of 16/min, a temperature of 37.0°C (98.6°F), and a blood pressure of 111/66 mm Hg.

Context: On physical exam, the abdomen is distended with hepatomegaly 5 cm underneath the xiphoid process.

Context: The complete blood count results are as follows: | Hemoglobin 17.6 g/dL | Hematocrit 64% | RBC 6.02 x 1012/L | Leukocyte count | 26,300/mm3 | Neutrophils 55% | Bands 2% | Eosinophils 1% | Basophils 0% | Lymphocytes 29% | Monocytes 2% | Platelet count 480,000/mm³ | Erythropoietin < 1.0 mU/mL | The coagulation test results are as follows: | Partial thromboplastin time (activated) 30.9 s | Prothrombin time 14.0 s | The abdominal Doppler ultrasound imaging is shown in the picture.

Choices:
A. Behçet's syndrome
B. Protein C deficiency
C. Factor V Leiden mutation
D. Polycythemia vera

Answer: Polycythemia vera

2. Patient has been feeling constantly tired for the past 2 months.

3. Patient has noticed a dull pain in the pit of his stomach.

4. Patient has no relevant family history.

9. Abdomen is distended with hepatomegaly 5 cm underneath the xiphoid process.

22. Partial thromboplastin time (activated) is 30.9 s.

24. Abdominal Doppler ultrasound imaging is shown in the picture.


Question: Which of the following is the best treatment for this patient?

Context: A 17-year-old girl is presented to the clinic by her mom for hair loss.

Context: Both the girl and her mom have noted random patches of hair loss across the girl's scalp, eyebrows, and eyelashes, 1st appearing several months ago.

Context: The girl has noticed no other symptoms, though the spots of hair loss are sometimes sore.

Context: On further questioning, the girl shares that she has been very stressed lately about getting good grades and applying to colleges.

Context: She knows she needs to do well on all of her homework in order to get into a good college, so she has sometimes had to stay up late into the night to rewrite her homework over and over again so that they are 'absolutely perfect'.

Context: There is diffuse hair loss and thinning across her scalp, with many different hair shafts of different lengths.

Choices:
A. Cognitive-behavioral therapy
B. Intralesional steroids
C. Oral griseofulvin
D. Systemic steroids

Answer: Cognitive-behavioral therapy

1. A 17-year-old girl is presented to the clinic by her mom.

2. Both the girl and her mom have noted random patches of hair loss across the girl's scalp, eyebrows, and eyelashes.

3. The hair loss 1st appeared several months ago.

4. The girl has noticed no other symptoms.

5. The spots of hair loss are sometimes sore.

6. The girl has been very stressed lately about getting good grades and applying to colleges.

7. She knows she needs to do well on all of her homework in order to get into a good college.

8. She has sometimes had to stay up late into the night to rewrite her homework over and over again so that they are 'absolutely perfect'.

9. The physical exam shows an anxious-appearing, somewhat quiet girl.

10. There is diffuse hair loss and thinning across her scalp.

11. There are many different hair shafts of different lengths.

12. There is no discernible pattern to the hair loss.


Question: Which of the following best describes the findings obtained from the study?

Context: In a town with a hepatitis B prevalence of 4%, a new screening test is introduced as part of a study.

Context: The first round of the study detects cases of hepatitis B using the new test, which has a sensitivity of 99% and a specificity of 77%.

Context: In the second round of the study, the same test is used again in a different population with a hepatitis B prevalence of 29%.

Choices:
A. The positive predictive value would increase in the second round.
B. The sensitivity would decrease in the second round.
C. The negative predictive value would increase in the second round.
D. The positive likelihood ratio would increase in the second round.

Answer: The positive predictive value would increase in the second round.

1. In a town, the hepatitis B prevalence is 4%.

2. A new screening test is introduced as part of a study.

3. The first round of the study uses the new test.

4. The new test has a sensitivity of 99%.

5. The new test has a specificity of 77%.

6. The second round of the study uses the same test.

7. The second round of the study is in a different population.

8. The hepatitis B prevalence in the second population is 29%.


Question: Which of the following is the most appropriate next step in management?

Context: She is at the 45th percentile for height and 51st percentile for weight.

Context: Vital signs are within normal limits.

Context: There is no vaginal discharge.

Choices:
A. Potassium hydroxide preparation
B. Perianal cellophane-tape examination
C. Cultures for chlamydia and gonorrhea
D. Stool microscopy

Answer: Perianal cellophane-tape examination

1. A 5-year-old girl is brought to the physician for a well-child examination.

2. Her mother says she has been having trouble sleeping for 3 weeks because of pruritus in her genital area.

3. The girl has otherwise been feeling well.

4. She is at the 45th percentile for height.

5. She is at the 51st percentile for weight.

6. Vital signs are within normal limits.

7. Pelvic examination shows erythema of the vulva and perianal region.


Question: Which of the following is the most likely underlying cause of this patient's symptoms?

Context: A 25-year-old man comes to the emergency department because of left flank pain for 2 hours.

Context: The pain is colicky in nature and he describes it as 8 out of 10 in intensity.

Context: He has nausea and has vomited once.

Context: He is a second-year medical student and has been consuming more coffee and energy drinks than normal to stay awake and study for the past 2 days.

Context: He does not smoke or drink alcohol.

Context: He takes no medications.

Context: His temperature is 37.3°C (99.1°F), pulse is 98/min, and blood pressure is 124/78 mm Hg.

Context: The abdomen is soft and nontender.

Context: Urinalysis is unremarkable.

Choices:
A. Bilateral renal cysts
B. Glomerular IgA deposits
C. Ureteropelvic junction obstruction
D.
Ascending urinary tract infection
"

Answer: Ureteropelvic junction obstruction

1. A 25-year-old man comes to the emergency department.

4. He describes the pain as 8 out of 10 in intensity.

6. He had a similar episode 6 months ago for which he took naproxen.

7. There is no personal or family history of serious illness.

9. He has been consuming more coffee and energy drinks than normal to stay awake and study for the past 2 days.

16. Examination of the back shows no costovertebral angle tenderness.

17. The remainder of the examination shows no abnormalities.


Question: What is the next best step in management?

Context: An otherwise healthy 6-year-old boy presents for a follow-up visit to his pediatrician's office for persistent nocturnal enuresis.

Context: He has never been dry at night and throughout the last year the pediatrician has seen him multiple times for this issue.

Context: He and his family have tried not drinking liquids 2 hours before bed, bed wetting alarms, and a reward sticker chart with limited success.

Context: His 2 older brothers had nocturnal enuresis that resolved on its own when they were 8 years of age, but the patient often sleeps over at a friend's house and is very bothered by this problem.

Context: He has 1 soft stool a day, denies abdominal pain, dysuria, or frequency, and has been continent during the day since 3 years of age.

Context: He has a completely normal physical exam, urinalysis, and basic metabolic panel.

Choices:
A. Cognitive behavioral therapy
B. Desmopressin
C. Imipramine
D. Oxybutynin

Answer: Desmopressin

2. Patient presents for follow-up visit for persistent nocturnal enuresis.

4. Pediatrician has seen patient multiple times for this issue in the last year.

5. Patient and family have tried not drinking liquids 2 hours before bed, bed wetting alarms, and a reward sticker chart with limited success.

6. Patient's two older brothers had nocturnal enuresis that resolved on its own when they were 8 years of age.

7. Patient often sleeps over at a friend's house and is very bothered by this problem.

9. Patient denies abdominal pain, dysuria, or frequency.

10. Patient has been continent during the day since 3 years of age.

11. Patient has a completely normal physical exam.

12. Patient has a completely normal urinalysis.

13. Patient has a completely normal basic metabolic panel.


Question: Which of the following is the next best step in the management of this patient?

Context: A 41-year-old woman presents with acute right flank pain for the past 6 hours.

Context: She says the pain is severe, colicky, ‘comes in waves’, and is localized to the right flank.

Context: She also has associated nausea and vomiting.

Context: The patient is afebrile, and her vital signs are within normal limits.

Context: On physical examination, she is writhing in pain and moaning.

Context: There is severe right costovertebral angle tenderness.

Context: Gross hematuria is present on urinalysis.

Context: A noncontrast CT of the abdomen and pelvis reveals a 4-mm-diameter radiopaque stone obstructing the right ureteropelvic junction.

Context: Aggressive IV fluid hydration is started, and ondansetron is administered.

Choices:
A. Renal ultrasound
B. 24-hour urine chemistry
C. Potassium citrate
D. Hydrocodone/acetaminophen

Answer: Hydrocodone/acetaminophen

2. Patient has had acute right flank pain for the past 6 hours.

3. Patient describes the pain as severe, colicky, and ‘coming in waves’.

4. Pain is localized to the right flank.

5. Patient has associated nausea and vomiting.

7. Vital signs are within normal limits.

8. On physical examination, patient is writhing in pain and moaning.

9. Severe right costovertebral angle tenderness is present.

11. Noncontrast CT of abdomen and pelvis reveals a 4-mm-diameter radiopaque stone obstructing the right ureteropelvic junction.

12. Aggressive IV fluid hydration is started.


Question: Which of the following drugs has the most similar mechanism to inflixmab?

Context: A 36-year-old female presents with a 6-month history of stiffness in her joints.

Context: She reports bilateral knee pain that is worse in the morning prior to activity and stiffness of the fingers in both hands.

Context: Anti-CCP antibody tests are positive.

Context: Over several months, the patient's symptoms prove unresponsive to NSAIDs and methotrexate, and the decision is made to begin infliximab.

Choices:
A. Imatinib
B. Cyclophosphamide
C. Trastuzumab
D. Allopurinol

Answer: Trastuzumab

2. She has a 6-month history of stiffness in her joints.

4. The knee pain is worse in the morning prior to activity.

5. She has stiffness of the fingers in both hands.

6. Anti-CCP antibody tests are positive.

7. The patient's symptoms are unresponsive to NSAIDs and methotrexate.

8. The decision is made to begin infliximab.


Question: Which of the following is the best explanation for this patient’s improvement in symptoms?

Context: A 55-year-old man presents to the emergency department with chest pain that started 1 hour ago and has not been improving.

Context: He has a past medical history of diabetes, hypertension, and obesity.

Context: His temperature is 98.5°F (36.9°C), blood pressure is 147/68 mmHg, pulse is 130/min, respirations are 13/min, and oxygen saturation is 100% on room air.

Context: The patient is given nitroglycerin, and his chest pain improves.

Choices:
A. Coronary artery vasodilation
B. Decreased adrenergic tone
C. Mu receptor agonism
D. Preload reduction

Answer: Preload reduction

1. A 55-year-old man presents to the emergency department with chest pain.

2. The chest pain started 1 hour ago and has not been improving.

3. The patient has a past medical history of diabetes, hypertension, and obesity.

8. His oxygen saturation is 100% on room air.

9. Physical exam is notable for jugular venous distension and bilateral lower extremity pitting edema.

Interventional Cardiology
Cardiovascular Disease


Question: This increase in serum lactate is necessary to regenerate an essential cofactor for which of the following enzymes?

Context: Baseline serum lactate levels at rest are recorded and repeat levels are obtained directly after a 1000-meter sprint.

Choices:
A. Glycogen phosphorylase
B. Glyceraldehyde-3 phosphate dehydrogenase
C. Phosphofructokinase-1
D. Pyruvate carboxylase

Answer: Glyceraldehyde-3 phosphate dehydrogenase

1. An investigator is studying energy metabolism in athletes.

2. Baseline serum lactate levels at rest are recorded.

3. Repeat levels are obtained directly after a 1000-meter sprint.

4. Compared to the baseline measurements, the serum lactate levels are significantly increased after the sprint.

Endocrinology, Diabetes, and Metabolism
Sports Medicine


Question: Which of the following processes is responsible for the loss of these marked CD8+ cells?

Context: Once injected into the thymus, these cells bind tightly to MHC I self-antigen complexes.

Choices:
A. Positive selection
B. Negative selection
C. APC antigen presentation
D. IL-2 stimulation

Answer: Negative selection

1. A scientist is studying the development of CD8+ T cells.

2. In his experiments, he uses a radioactive isotope to mark a population of T cells.

3. The marked cells are injected into the thymus.

4. The marked cells bind tightly to MHC I self-antigen complexes.

5. Later in the experiment, the scientist cannot find any marked cells in the peripheral blood.


Question: Based on CXR and biopsy slides shown, you feel that all of the following would be consistent with her diagnosis EXCEPT?

Context: A 65-year-old woman who has smoked 2 packs per day for forty years comes to your practice complaining of a chronic cough, dyspnea, hemoptysis, and difficulty rising from a chair.

Choices:
A. Decreasing muscle strength with repetitive stimulation
B. Antibodies to presynaptic calcium channels
C. Dry mouth
D. Orthostatic hypotension

Answer: Decreasing muscle strength with repetitive stimulation

2. Patient has smoked 2 packs per day for 40 years.

3. Patient is complaining of a chronic cough.

5. Patient is complaining of hemoptysis.

6. Patient is complaining of difficulty rising from a chair.


Question: What is the most likely diagnosis?

Context: A 16-month-old boy is brought to the pediatrician after his parents noticed the appearance of a rash on his face, torso, and limbs.

Context: The boy has been ill for almost 2 weeks, initiating with fever, malaise, coryza, headache, nausea, diarrhea, and a rash on both of his cheeks.

Context: Physical examination is unremarkable except for an erythematous maculopapular rash on the face, trunk, and extremities with a reticular pattern (as shown in the photograph).

Choices:
A. Measles
B. Chickenpox
C. Erythema infectiosum
D. Roseola infantum

Answer: Erythema infectiosum

1. A 16-month-old boy is brought to the pediatrician.

2. His parents noticed the appearance of a rash on his face, torso, and limbs.

3. The boy has been ill for almost 2 weeks.

4. The illness initiated with fever, malaise, coryza, headache, nausea, diarrhea, and a rash on both of his cheeks.

5. Physical examination is unremarkable except for an erythematous maculopapular rash on the face, trunk, and extremities.

6. The rash has a reticular pattern (as shown in the photograph).

General Pediatrics
Pediatric Dermatology


Question: This patient’s symptoms are likely due to irritation of a nerve that passes through which of the following foramina?

Context: A 27-year-old woman presents to a neurologist complaining of facial pain.

Context: She reports that over the past 6 months, she has developed intermittent burning unilateral facial pain that happens over 10 seconds to 3 minutes.

Context: She is worried whenever she goes out that another attack will happen and she is sad that this has limited her ability to work as a lawyer.

Context: She takes an oral contraceptive pill.

Context: Her temperature is 98.6°F (37°C), blood pressure is 130/75 mmHg, pulse is 75/min, and respirations are 18/min.

Choices:
A. Foramen rotundum
B. Inferior orbital fissure
C. Jugular foramen
D. Superior orbital fissure

Answer: Foramen rotundum

1. A 27-year-old woman presents to a neurologist.

3. She reports that over the past 6 months, she has developed intermittent burning unilateral facial pain.

4. The pain happens over 10 seconds to 3 minutes.

5. The pain is severe enough to completely stop her from her activities.

6. She is worried whenever she goes out that another attack will happen.

7. She is sad that this has limited her ability to work as a lawyer.

8. Her past medical history is notable for irritable bowel syndrome and polycystic ovarian syndrome.

9. She takes an oral contraceptive pill.

14. On exam, she is a well-appearing woman who is alert, oriented, and appropriately interactive.

15. Her pupils are 2 mm and reactive to light bilaterally.

16. Fundoscopic examination is unremarkable.

17. Her strength and range of motion are full and symmetric in her upper and lower extremities.


Question: Which of the following is the most likely causal organism?

Context: A 26-year-old man comes to the physician because of high-grade fever, fatigue, nausea, and headache for 4 days.

Context: The headache is constant and feels like a tight band around his head.

Context: He also reports that his eyes hurt while looking at bright lights.

Context: He has been taking acetaminophen and using cold towels to help relieve his symptoms.

Context: He works as an assistant for a nature camp organization but has been unable to go to work for 3 days.

Context: His immunization records are unavailable.

Context: His temperature is 38.5°C (101.3°F), pulse is 92/min, and blood pressure is 108/74 mm Hg.

Context: He is oriented to time, place, and person.

Context: There is no rash or lymphadenopathy.

Context: A lumbar puncture is done; cerebrospinal fluid analysis shows an opening pressure of 80 mm H2O, leukocyte count of 93/mm3 (78% lymphocytes), a glucose concentration of 64 mg/dL, and a protein concentration of 50 mg/dL.

Choices:
A. Borrelia burgdorferi
B. Mycobacterium tuberculosis
C. Herpes simplex virus 1
D. Coxsackievirus

Answer: Coxsackievirus

2. Patient has high-grade fever, fatigue, nausea, and headache for 4 days.

3. Headache is constant and feels like a tight band around his head.

4. Eyes hurt while looking at bright lights.

5. Patient has been taking acetaminophen and using cold towels to help relieve his symptoms.

6. Patient works as an assistant for a nature camp organization.

7. Patient has been unable to go to work for 3 days.

8. Patient's immunization records are unavailable.

9. Patient's temperature is 38.5°C (101.3°F).

11. Patient's blood pressure is 108/74 mm Hg.

12. Patient is oriented to time, place, and person.

14. Flexion of the neck results in flexion of the knee and hip.

15. Lumbar puncture done; cerebrospinal fluid analysis shows an opening pressure of 80 mm H2O.

16. Leukocyte count of 93/mm3 (78% lymphocytes).

General Infectious Disease
Infectious Disease


Question: Which of the following congenital defects is the most likely cause of these findings?

Context: A 4-year-old girl presents to the pediatrician’s office for a physical examination prior to starting preschool.

Context: She was born at 39 weeks gestation via spontaneous vaginal delivery.

Context: She is up to date on all vaccines and is meeting all developmental milestones.

Context: Past medical history is noncontributory.

Context: She takes no medications but does take a chewable vitamin daily.

Context: She lives with her parents and older brother in a house.

Context: Today, her blood pressure is 110/65 mm Hg, heart rate is 90/min, respiratory rate is 22/min, and temperature of 37.0°C (98.6°F).

Context: On physical exam, she appears well developed and pleasant.

Context: She sits listening to the conversation and follows directions.

Context: Auscultation reveals a normal S1 but the S2 is split and remains split during inhalation and exhalation.

Context: Additionally, there is a medium pitched midsystolic murmur that is loudest between ribs 2 and 3 on the left side and a very soft diastolic rumble.

Choices:
A. Atrial septal defect
B. Coarctation of the aorta
C. Patent ductus arteriosus
D. Tetralogy of Fallot

Answer: Atrial septal defect

2. Patient was born at 39 weeks gestation via spontaneous vaginal delivery.

3. Patient is up to date on all vaccines and is meeting all developmental milestones.

4. Patient's past medical history is noncontributory.

5. Patient takes no medications but does take a chewable vitamin daily.

6. Patient lives with her parents and older brother in a house.

7. Patient's blood pressure is 110/65 mm Hg.

9. Patient's respiratory rate is 22/min.

10. Patient's temperature is 37.0°C (98.6°F).

11. On physical exam, patient appears well developed and pleasant.

12. Patient sits listening to the conversation and follows directions.

13. Palpation of the heart reveals a mild parasternal heave.

15. Auscultation reveals S2 is split and remains split during inhalation and exhalation.

16. Auscultation reveals a medium pitched midsystolic murmur that is loudest between ribs 2 and 3 on the left side.

17. Auscultation reveals a very soft diastolic rumble.


Question: Which of the following is the most appropriate next step in management?

Context: A 24-year-old man is brought to the emergency department after his head was hit with a bat during a baseball game.

Context: His teammates state that he was unresponsive after the incident but regained consciousness after 15 minutes.

Context: He is oriented to person and place.

Context: His temperature is 37.1 (98.8°F), pulse is 78/min, respiratory rate is 16/min, and blood pressure is 148/87 mm Hg.

Context: A CT scan of the head is shown.

Context: He withdraws from painful stimuli.

Context: His respiratory rate is 10/min and he is intubated in the emergency department.

Choices:
A. Adminster hypotonic saline
B. Administer dexamethasone
C. Perform craniotomy
D. Perform brain MRI

Answer: Perform craniotomy

1. A 24-year-old man was brought to the emergency department.

2. His head was hit with a bat during a baseball game.

3. His teammates state he was unresponsive after the incident but regained consciousness after 15 minutes.

4. The patient initially refused to go to the hospital and sat on the bench for the remainder of the game.

5. He initially appeared fine but became increasingly confused.

6. He appears lethargic but opens his eyes to loud verbal commands.

12. Examination shows an area of soft-tissue swelling over the left temporal region.

13. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.

15. After returning from the CT scan, the patient only opens his eyes to painful stimuli and responds to questions with incomprehensible sounds.

17. On repeat examination, the left pupil is 6 mm in diameter and reacts minimally to light.

18. The right pupil is 3 mm in diameter and reacts normally to light.

20. He is intubated in the emergency department.


Question: Laboratory studies show: | Today 6 months ago | Hemoglobin A1c 6.2% 6.4% | Serum | Creatinine 1.3 mg/dL 1.1 mg/dL | Urine | Albumin:creatinine ratio (N < 30) 470 mg/g 260 mg/g | The addition of which of the following medications is most likely to have prevented this patient's progressively worsening renal function?"

Context: Her temperature is 37.2°C (99°F), pulse is 92/min, respirations are 14/min, and blood pressure is 152/98 mm Hg.

Choices:
A. Losartan
B. Aspirin
C. Atorvastatin
D. Amlodipine

Answer: Amlodipine

1. A 58-year-old woman comes to the physician for a routine follow-up examination.

2. She has a history of type 2 diabetes mellitus, hypertension, and asthma.

3. Last year, she received laser photocoagulation for proliferative retinopathy.

4. Her current medications include metformin, lisinopril, and an albuterol inhaler.

5. Her mother died of complications from diabetes.

6. She drinks 1 glass of wine daily with dinner and does not smoke.

11. Cardiopulmonary examination is unremarkable.

12. There is decreased sensation to monofilament testing of the plantar surfaces of both feet.


Question: Which of the following is the most effective intervention for this patient's skin lesion?

Context: A 4-year-old boy is brought to the physician by his mother because of a rash on his hands and feet for the past two weeks.

Context: It is intensely pruritic, especially at night.

Context: He has not had fever, headache, or diarrhea.

Context: His mother has a history of eczema.

Context: The child was due for an appointment later in the week to follow up on any potentially missing vaccinations.

Context: His temperature is 37.8°C (100.1°F).

Choices:
A. Oral acyclovir
B. Supportive care
C. Topical permethrin
D. Topical clotrimazole

Answer: Topical permethrin

1. A 4-year-old boy is brought to the physician by his mother.

2. The boy has had a rash on his hands and feet for the past two weeks.

3. The rash is intensely pruritic, especially at night.

4. The boy has not had fever, headache, or diarrhea.

5. The boy's mother has a history of eczema.

6. The boy was due for an appointment later in the week to follow up on any potentially missing vaccinations.

7. The boy's temperature is 37.8°C (100.1°F).

8. Examination shows a maculopapular rash with linear patterns affecting the interdigital spaces of the fingers and toes.

9. The remainder of the examination shows no abnormalities.


Question: Which of the following stages does this patient's behavior most likely represent?

Context: A 32-year-old man comes with his wife to the primary care physician because she is concerned about his drinking behavior.

Context: Specifically, he drinks 7 drinks every day and has abandoned many social activities that he previously enjoyed.

Context: In addition, he starts drinking in the morning because he feels shaky when he does not have a drink.

Context: When asked about his behavior, the man says that he knows that he probably should drink less but feels that he is not motivated enough to change.

Context: He says that perhaps the topic should be addressed again next year.

Choices:
A. Contemplation
B. Precontemplation
C. Preparation
D. Relapse

Answer: Contemplation

1. A 32-year-old man comes with his wife to the primary care physician.

2. His wife is concerned about his drinking behavior.

4. He has abandoned many social activities that he previously enjoyed.

6. He feels shaky when he does not have a drink.

7. When asked about his behavior, he says he knows he should drink less.

8. He feels he is not motivated enough to change.

9. He suggests the topic should be addressed again next year.


Question: Which of the following is the most appropriate next step in management?

Context: An 18-month-old boy is brought to the emergency department 25 minutes after an episode of loss of consciousness.

Context: The child began crying after his 4-year-old brother snatched a toy from him.

Context: The brief shrill cry was followed by a period of expiration; he then turned blue, became unconscious, and briefly lost his muscle tone, before he stiffened and had jerky movements of his arms and legs for 15 seconds.

Context: He had a similar episode 2 weeks ago when his father refused to give him a juice box.

Context: Vital signs are within normal limits.

Context: He is alert and active.

Choices:
A. CT scan of the head
B. Echocardiography
C. Reassurance
D. Tilt table test

Answer: Reassurance

1. An 18-month-old boy was brought to the emergency department 25 minutes after an episode of loss of consciousness.

2. The episode began when the child's 4-year-old brother snatched a toy from him.

3. The child had a brief shrill cry, followed by a period of expiration.

4. He then turned blue, became unconscious, and briefly lost his muscle tone.

5. He then had jerky movements of his arms and legs for 15 seconds.

6. After this episode, he immediately regained consciousness.

7. Two weeks ago, he had a similar episode when his father refused to give him a juice box.

8. He has been healthy and has met all his developmental milestones.

9. His vital signs are within normal limits.

11. Cardiopulmonary examination shows no abnormalities.

12. Neurologic examination shows no focal findings.


Question: What is the most likely cause of this patient’s visual loss?

Context: A 67-year-old woman presents to the ophthalmologist with complaints of worsening visual loss.

Context: She states that her vision is blurry.

Context: Driving has become difficult, particularly at night, as she experiences substantial glare and sees halos around lights.

Choices:
A. Age-related macular degeneration
B. Cataracts
C. Open-angle glaucoma
D. Refractive error

Answer: Cataracts

1. A 67-year-old woman presents to the ophthalmologist.

2. She has complaints of worsening visual loss.

3. She states that her vision is blurry.

4. Driving has become difficult, particularly at night.

7. On physical examination, there is absence of a red reflex.


Question: Further evaluation of this patient is most likely to show which of the following findings?

Context: A 30-year-old woman comes to the physician because of headaches and nausea for the past 3 weeks.

Context: The headaches are holocranial and last up to several hours.

Context: During this period, she has also had a swishing sound in both ears, which decreases when she turns her head to either side.

Context: She has had multiple episodes of blurring of vision and double vision for the past 2 weeks.

Context: She has vomited twice in the past week.

Context: She has nodular cystic acne and polycystic ovarian disease.

Context: She is 163 cm (5 ft 4 in) tall and weighs 89 kg (196 lb); BMI is 33.5 kg/m2.

Context: Her temperature is 37.3°C (99.1°F), pulse is 70/min, and blood pressure is 128/82 mm Hg.

Context: She is oriented to time, place, and person.

Context: Hirsutism is present.

Context: Visual acuity is 20/20 in both eyes.

Context: There is esotropia of the left eye.

Choices:
A. Hyperpigmentation of palmar creases
B. Bilateral optic disc swelling
C. Raised intra-ocular pressure
D. Weakness of left upper and lower extremities

Answer: Bilateral optic disc swelling

2. Patient has had headaches and nausea for the past 3 weeks.

3. Headaches are holocranial and last up to several hours.

4. Patient has had a swishing sound in both ears, which decreases when she turns her head to either side.

5. Patient has had multiple episodes of blurring of vision and double vision for the past 2 weeks.

6. Patient has vomited twice in the past week.

7. Patient has nodular cystic acne and polycystic ovarian disease.

8. Current medications include an oral contraceptive, metformin, and isotretinoin.

9. Patient is 163 cm (5 ft 4 in) tall and weighs 89 kg (196 lb); BMI is 33.5 kg/m2.

10. Patient's temperature is 37.3°C (99.1°F), pulse is 70/min, and blood pressure is 128/82 mm Hg.

11. Patient is oriented to time, place, and person.

12. Examination shows acne over her cheeks and back.

14. Visual acuity is 20/20 in both eyes.


Question: A history involving which of the following conditions is most likely to explain the administration of this drug instead of another nonsteroidal anti-inflammatory drug?

Context: A 64-year-old woman with knee osteoarthritis comes to the physician for a follow-up examination.

Context: She reports significantly improved pain control since starting celecoxib 1 month ago.

Choices:
A. Reye syndrome
B. Sulfa drug allergy
C. Glanzmann thrombasthenia
D. Gout

Answer: Glanzmann thrombasthenia

1. A 64-year-old woman comes to the physician for a follow-up examination.

3. She has been taking celecoxib for 1 month.

4. She reports significantly improved pain control since starting celecoxib.


Question: Which of the following drugs was administered?

Context: A 48-year-old woman is admitted to the hospital and requires anticoagulation.

Context: She is administered a drug that binds tightly to antithrombin III.

Choices:
A. Aspirin
B. Warfarin
C. Dabigatran
D. Enoxaparin

Answer: Enoxaparin

1. A 48-year-old woman is admitted to the hospital.

4. The drug binds tightly to antithrombin III.


Question: Which of the following best describes the properties of the most likely virus involved?

Context: A 20-year-old woman comes to the physician because of a 2-day history of low-grade fever and painful lesions on her left index finger.

Context: Two weeks ago, she had a painful rash on the right labia majora that resolved without treatment.

Context: Physical examination shows tender lymphadenopathy of the left epitrochlear and right inguinal region.

Choices:
A. Naked virus with a double-stranded, circular DNA structure
B. Naked virus with a single-stranded, positive sense, linear RNA structure
C. Enveloped virus with a double-stranded, linear DNA structure
D. Enveloped virus with a partially double-stranded, circular DNA structure

Answer: Enveloped virus with a double-stranded, linear DNA structure

1. A 20-year-old woman comes to the physician.

2. She has a 2-day history of low-grade fever.

3. She has painful lesions on her left index finger.

4. Two weeks ago, she had a painful rash on the right labia majora.

6. Physical examination shows tender lymphadenopathy of the left epitrochlear region.

7. Physical examination shows tender lymphadenopathy of the right inguinal region.

8. A photograph of the left index finger is shown.


Question: Which of the following is the most appropriate next step in management?

Context: A 37-year-old man comes to the emergency department because of unsteady gait that started after waking up that morning.

Context: He works as a logger in Washington.

Context: The patient appears pale.

Context: He is alert and responsive.

Context: His temperature is 37°C (98.9°F), pulse is 100/min, respirations are 11/min, and blood pressure is 136/86 mm Hg.

Context: The patient develops tachypnea and is admitted to the intensive care unit.

Choices:
A. Perform enzyme‑linked immunosorbent assay
B. Administer doxycycline
C. Administer botulism antitoxin
D. Locate and remove tick

Answer: Locate and remove tick

1. A 37-year-old man comes to the emergency department.

2. His gait became unsteady after waking up that morning.

3. He has no fever, chills, headache, or myalgia.

5. His younger sister has multiple sclerosis.

12. Examinations shows intact cranial nerves.

13. There is bilateral flaccid paralysis of his lower extremities.

14. Lower extremity deep tendon reflexes are absent.

16. He is admitted to the intensive care unit.

17. Assisted breathing is started because of respiratory weakness.


Question: What is the next best step in the management of this patient?

Context: He says he has been having trouble falling asleep for as long as he can remember, but it has become increasingly worse after he and his wife moved to their new house.

Context: His wife even had to cancel the housewarming party that was planned for the neighbors because of her husband’s behavior.

Choices:
A. Respond in a straightforward manner, be honest and non-threatening
B. Encourage the patient to inform the police
C. Set rules and be firm with adhering to them
D. Refer this patient to another physician

Answer: Respond in a straightforward manner, be honest and non-threatening

1. A 43-year-old man presents requesting a sleep aid for long-standing insomnia.

2. He has been having trouble falling asleep for as long as he can remember.

3. His insomnia has become increasingly worse after he and his wife moved to their new house.

4. He claims that his new neighbors are jealous of his huge swimming pool and are trying to sabotage it while he sleeps.

5. His wife had to cancel the housewarming party that was planned for the neighbors.

6. When probed further on this topic, the patient accuses the physician of being angry and hostile.


Question: Which of the following medications was most likely given to this patient?

Context: A 22-year-old man presents to the emergency room after an altercation with the police.

Context: On physical examination, the patient is disoriented, does not respond to questioning, and appears to be reacting to internal stimuli.

Context: Laboratory tests are performed, which are all within normal limits, including a toxicology screen.

Context: The patient becomes aggressive and is given a medication to address his acute psychotic episode.

Context: An hour later, he is found in a sustained rigid posture in his bed, with his eyes in a fixed upward gaze.

Choices:
A. Citalopram
B. Haloperidol
C. Phenelzine
D. Alprazolam

Answer: Haloperidol

1. A 22-year-old man presents to the emergency room.

2. The police were called because the man was acting erratically in public.

3. On physical examination, the patient is disoriented.

4. The patient does not respond to questioning.

5. The patient appears to be reacting to internal stimuli.

7. The laboratory tests are all within normal limits.

10. The patient is given a medication to address his acute psychotic episode.

11. An hour later, the patient is found in a sustained rigid posture in his bed.

12. The patient's eyes are in a fixed upward gaze.


Question: Which of the following antibiotic therapies would be most suitable for this patient?

Context: A 42-year-old man is brought to the emergency department by his wife with chills and a temperature of 38.5°C (101.3°F) for the past 2 days.

Context: The patient’s wife mentions that he recently injured his leg 5 days ago, after which she noticed that his calf was swollen, red, and painful.

Context: She says there was no pus, but that her husband was in excruciating pain.

Context: His vital signs include: temperature 38.9°C (102.1°F), blood pressure 110/75 mm Hg, and  respiratory rate 18/min.

Context: On physical examination, there is a tender mass over the left calf which is red and inflamed.

Context: Blood and wound cultures are taken.

Context: The patient is started on empiric antibiotics with vancomycin, but shows no improvement.

Choices:
A. IV nafcillin
B. Dicloxacillin
C. IV daptomycin
D. Doxycycline

Answer: IV daptomycin

2. Patient has had chills and a temperature of 38.5°C (101.3°F) for the past 2 days.

4. Patient's calf was swollen, red, and painful.

6. Patient's vital signs include temperature 38.9°C (102.1°F), blood pressure 110/75 mm Hg, and respiratory rate 18/min.

7. Physical examination reveals a tender mass over the left calf which is red and inflamed.

9. Patient is started on empiric antibiotics with vancomycin.

11. Culture results reveal that the causative organism is resistant to the current antibiotic as well as penicillin.


Question: Which of the following is the next best step?

Context: A 63-year-old man presents to the emergency department with the sudden onset of excruciating chest pain, which he describes as a tearing sensation

Context: He was diagnosed with essential hypertension 20 years ago, but he is not compliant with his medications

Context: On physical examination, the temperature is 37.1°C (98.8°F), heart rate is 95/min, and blood pressure is 195/90 mm Hg in the right arm and 160/80 mm Hg in the left arm

Context: The pulses are absent in his right leg and diminished in his left leg

Context: A chest X-ray shows a widened mediastinum.

Choices:
A. CT scan
B. Surgery
C. D-dimer
D. Intravenous ultrasound

Answer: CT scan

A 63-year-old man presents to the emergency department.

He is experiencing sudden, excruciating chest pain.

He describes the pain as a tearing sensation.

He was diagnosed with essential hypertension 20 years ago.

He is not compliant with his hypertension medications.

His physical examination reveals a temperature of 37.1°C (98.8°F).

His blood pressure is 195/90 mm Hg in the right arm.

His blood pressure is 160/80 mm Hg in the left arm.

The blood pressure difference between his arms is 35/10 mm Hg.

General Cardiology
Cardiovascular Disease