Question: Which of the following is the most likely diagnosis in this patient?

Context: The patient’s mother has become increasingly concerned about him since his high school graduation.

Context: Although she says that he had been an excellent student in high school, his grades have begun slipping in his second year in college, and he no longer socializes with friends.

Context: When she asked him why he no longer talks to his friends, she states that he told her, “They already know where I am.

Context: They can see me.

Context: We don’t need to talk.” She found this to be bizarre, as nearly all of his friends live hours away.

Context: The psychiatrist notices reduced spontaneous movements while the patient is speaking and that he speaks in a monotone with a voice that is soft in volume.

Context: He also appears suspicious and defensive, asking the psychiatrist “why are you asking me that?” after each evaluative question.

Context: His mood is generally flat with little reactivity or engagement during the course of his interview, but he denies any symptoms of depression or psychosis.

Context: No significant past medical history.

Choices:
A. Paranoid personality disorder
B. Schizophrenia
C. Drug abuse
D. Brain tumor

Answer: Schizophrenia

1. A 19-year-old man is brought to a psychiatrist by his mother.

2. His mother has become increasingly concerned about him since his high school graduation.

3. He had been an excellent student in high school.

4. His grades have begun slipping in his second year in college.

5. He no longer socializes with friends.

6. When she asked him why he no longer talks to his friends, he told her, “They already know where I am. They can see me. They watch me from my bedroom window, so they already know what I’m doing. We don’t need to talk.”

7. Nearly all of his friends live hours away.

8. The patient states that he feels fine and doesn’t understand why everyone thinks he is crazy.

9. The psychiatrist notices reduced spontaneous movements while the patient is speaking.

10. He speaks in a monotone with a voice that is soft in volume.

11. He appears suspicious and defensive, asking the psychiatrist “why are you asking me that?” after each evaluative question.

12. His mood is generally flat with little reactivity or engagement during the course of his interview.

13. He denies any symptoms of depression or psychosis.

14. No significant past medical history.

15. Family history is not available as he was adopted.

Child and Adolescent Psychiatry
Schizophrenia


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

Context: A 26-year-old woman comes to the physician because of progressively worsening episodic pelvic pain for 2 years.

Context: The pain starts a few days before her menstrual period and lasts about 10 days.

Context: She has tried taking ibuprofen, but her symptoms do not improve.

Context: Menses have occurred at regular 29-day intervals since menarche at the age of 11 years and last for 5–7 days.

Context: The first day of her last menstrual period was 2 weeks ago.

Context: She is sexually active with her boyfriend and has noticed that intercourse is often painful; they use condoms inconsistently.

Context: Vital signs are within normal limits.

Context: Urine pregnancy test is negative.

Choices:
A. Perform MRI of the pelvis
B. Prescribe gonadotropin-releasing hormone agonists
C. Prescribe androgenic steroids
D. Prescribe estrogen-progestin contraceptives

Answer: Prescribe estrogen-progestin contraceptives

2. Patient has had progressively worsening episodic pelvic pain for 2 years.

3. Pain starts a few days before her menstrual period and lasts about 10 days.

4. Patient has tried taking ibuprofen, but her symptoms do not improve.

5. Patient has had regular 29-day menstrual intervals since menarche at the age of 11 years.

7. First day of patient's last menstrual period was 2 weeks ago.

8. Patient is sexually active with her boyfriend.

9. Patient has noticed that intercourse is often painful.

10. Patient and her boyfriend use condoms inconsistently.

11. Vital signs are within normal limits.

12. Pelvic examination shows a normal vagina and cervix.

13. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses.

Complex Family Planning
General Obstetrics and Gynecology


Question: Which of the following will most likely reduce the type II error of this screening test?

Context: A research group has developed a new screening test for HIV that can detect infection 2 weeks earlier than the current gold standard.

Context: A rigorous clinical study of this new screening test involving n subjects yields a false-positive probability α, and a false-negative probability, β.

Choices:
A. Decreasing n
B. Increasing α
C. Increasing the specificity of the test
D. Decreasing the sensitivity of the test

Answer: Increasing α

1. A research group has developed a new screening test for HIV.

2. The new screening test can detect infection 2 weeks earlier than the current gold standard.

3. A rigorous clinical study of the new screening test was conducted involving n subjects.

4. The false-positive probability of the new screening test is α.

5. The false-negative probability of the new screening test is β.


Question: Which of the following is the pathophysiology of this patient's presentation?

Context: A 70-year-old female underwent a right total knee arthroplasty without complication.

Context: She was discharged to a rehab facility on post-operative day 3.

Context: Two days after her discharge from the hospital, she began experiencing pain and swelling of the right leg.

Context: Doppler ultrasound imaging at this time revealed a deep venous thrombosis in the right popliteal and tibial veins.

Context: The patient was re-admitted and started on an unfractionated heparin infusion.

Context: Five days later, doppler ultrasonography of the lower extremities revealed extension of the clot in the right lower extremity to include the common femoral, superficial femoral, popliteal, tibial, and saphenous veins.

Context: In addition, a thrombus was noted in the left common femoral vein as well.

Context: CBC showed a decrease in platelet count from 195,000/uL on admission to 83,000/uL.

Choices:
A. Excessive irreversible inactivation of the cyclo-oxygenase enzyme
B. Formation of antibodies to heparin-platelet factor-4 complex
C. Deposition of immune complex nuclear antigens in kidneys
D. Inherited mutation in clotting factor V, which cannot be degraded by activated protein C

Answer: Formation of antibodies to heparin-platelet factor-4 complex

2. Patient underwent right total knee arthroplasty without complication.

3. Patient was discharged to rehab facility on post-operative day 3.

4. Two days after discharge, patient began experiencing pain and swelling of right leg.

5. Doppler ultrasound imaging revealed deep venous thrombosis in right popliteal and tibial veins.

6. Patient was re-admitted and started on unfractionated heparin infusion.

7. Five days later, doppler ultrasonography revealed extension of clot in right lower extremity to include common femoral, superficial femoral, popliteal, tibial, and saphenous veins.

8. Doppler ultrasonography also revealed thrombus in left common femoral vein.

9. CBC showed decrease in platelet count from 195,000/uL on admission to 83,000/uL.


Question: Which of the following measures would be most effective?

Context: Three days after surgical repair of a distal right radius fracture, a 62-year-old man develops severe wound pain and fever.

Context: His temperature is 39.1°C (102.4°F).

Context: Physical examination shows erythema and edema of the right arm that extends up to the elbow.

Context: Yellow pus drains from the surgical wound.

Context: Cultures from the wound fluid grow gram-positive bacteria in grape-like clusters that are resistant to nafcillin.

Context: While treating the patient's condition, the hospital also wants to eradicate the causal pathogen in asymptomatic carriers.

Choices:
A. Permethrin hair wash
B. Colistin nebulized aerosol
C. Chlorhexidine hand disinfection
D. Mupirocin nasal ointment

Answer: Mupirocin nasal ointment

1. A 62-year-old man developed severe wound pain and fever three days after surgical repair of a distal right radius fracture.

2. His temperature was 39.1°C (102.4°F).

3. Physical examination showed erythema and edema of the right arm that extended up to the elbow.

4. Yellow pus drained from the surgical wound.

5. Cultures from the wound fluid grew gram-positive bacteria in grape-like clusters.

6. The bacteria were resistant to nafcillin.

7. The hospital wanted to eradicate the causal pathogen in asymptomatic carriers.


Question: For this reason (and to accurately answer the research question), the risk of the disease should be estimated in terms of which of the following?

Context: They designed a cohort study that included 68 individuals: 34 exposed and 34 unexposed to given risk factors, who were followed up for 4 years in total.

Context: During this time, the renal disease of interest was seen in 6 individuals among the exposed group and 6 individuals among the unexposed group; thus, the risk ratio (RR) of the disease development (exposed vs.

Context: unexposed) was 1.

Context: A survey administered for the last 2 years of the study showed that the prevalence ratio of disease between exposed and unexposed individuals was in fact 0.5 (at 2 years of follow-up there was only 1 case of the disease in the 34 exposed individuals, with a resulting prevalence of 2.94%; and only 2 cases of the disease in the 34 unexposed individuals, with a resulting prevalence of 5.88%), a value that deviates from the true RR (i.e.

Choices:
A. Incidence
B. Prevalence
C. Mortality
D. Survival rates

Answer: Incidence

1. A research group from Europe is investigating a potential link between certain lifestyle risk factors and the development of potentially fatal renal disease.

2. They designed a cohort study that included 68 individuals: 34 exposed and 34 unexposed to given risk factors.

3. The study was followed up for 4 years in total.

4. During this time, the renal disease of interest was seen in 6 individuals among the exposed group and 6 individuals among the unexposed group.

5. The risk ratio (RR) of the disease development (exposed vs. unexposed) was 1.

6. During the initial 2 years, there was 1 death in the exposed group, and another death in the unexposed group.

7. A survey administered for the last 2 years of the study showed that the prevalence ratio of disease between exposed and unexposed individuals was 0.5.

8. At 2 years of follow-up there was only 1 case of the disease in the 34 exposed individuals, with a resulting prevalence of 2.94%.

9. There were only 2 cases of the disease in the 34 unexposed individuals, with a resulting prevalence of 5.88%.

10. The prevalence ratio of 0.5 deviates from the true RR (i.e. 1).


Question: What is the most likely chromosomal translocation that is responsible for this patient's clinical presentation and lab results?

Context: A 55-year-old male with fever, fatigue, generalized weakness, and bleeding gums for the past 3 weeks presents to his family physician.

Context: The patient is referred to an oncologist, and a bone marrow aspiration is performed, demonstrating >20% myeloblasts with Auer rods that are myeloperoxidase positive.

Choices:
A. 15;17
B. 14;18
C. 11;14
D. 8;14

Answer: 15;17

1. A 55-year-old male presents to his family physician.

2. He has had fever, fatigue, generalized weakness, and bleeding gums for the past 3 weeks.

3. On exam, he has bilateral submandibular lymphadenopathy and hepatosplenomegaly.

4. CBC demonstrates decreased RBCs and mature WBCs.

5. The patient is referred to an oncologist.

6. A bone marrow aspiration is performed.

7. The bone marrow aspiration demonstrates >20% myeloblasts with Auer rods.

8. The Auer rods are myeloperoxidase positive.


Question: The patient is most likely experiencing adverse effects caused by a drug that works through which of the following mechanisms of action?

Context: A 59-year-old man with Parkinson disease is brought to the emergency department 1 hour after he had a syncopal episode.

Context: Over the past two weeks, the patient has felt light-headed upon standing and has noticed that his legs have been swollen.

Context: Vital signs show blood pressure 114/70 mm Hg when supine and 92/38 mm Hg upon standing.

Context: Examination of the lower extremities shows a lacy, purple rash and 2+ pitting edema.

Choices:
A. Increased dopamine release from central neurons
B. Inhibition of acetylcholine activity in the basal ganglia
C. Selective inhibition of monoamine oxidase type B
D. Inhibition of central methylation of dopamine

Answer: Increased dopamine release from central neurons

1. A 59-year-old man with Parkinson disease is brought to the emergency department.

2. He had a syncopal episode 1 hour prior.

3. Over the past two weeks, the patient has felt light-headed upon standing.

4. Over the past two weeks, the patient has noticed that his legs have been swollen.

5. He was started on a medication for early symptoms of Parkinson disease one month ago.

6. Vital signs show blood pressure 114/70 mm Hg when supine.

7. Vital signs show blood pressure 92/38 mm Hg upon standing.

8. Examination of the lower extremities shows a lacy, purple rash.

9. Examination of the lower extremities shows 2+ pitting edema.

10. Neurologic examination shows an ataxic gait.

11. The physician decreases the dose of medication.


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

Context: Her symptoms have progressively worsened over the course of several months, where she has experienced difficulty getting up from a chair, climbing the stairs, and placing her groceries on the top shelves of her kitchen.

Context: She also reports feeling tired lately and is unsure when this began.

Context: Physical examination is notable for muscle weakness in the deltoids and hip flexors with 2+ biceps, triceps, patellar, and ankle tendon reflexes.

Context: Laboratory testing demonstrates a creatine kinase level of 4,200 U/L (normal is 10-70 U/L), lactate dehydrogenase level of 150 U/L (normal is 45-90 U/L), and thyroid-stimulating hormone level of 1.5 µU/mL (normal is 0.5-5.0 µU/mL).

Choices:
A. Azathioprine
B. Intravenous immunoglobulin
C. Prednisone
D. Thyroxine

Answer: Prednisone

1. A 50-year-old woman presents to her primary care physician for muscle weakness.

2. Her symptoms have progressively worsened over the course of several months.

3. She has experienced difficulty getting up from a chair.

4. She has experienced difficulty climbing the stairs.

5. She has experienced difficulty placing her groceries on the top shelves of her kitchen.

8. Physical examination is notable for muscle weakness in the deltoids and hip flexors.

9. Biceps, triceps, patellar, and ankle tendon reflexes are 2+.

10. Laboratory testing demonstrates a creatine kinase level of 4,200 U/L.

11. Normal creatine kinase level is 10-70 U/L.

12. Laboratory testing demonstrates a lactate dehydrogenase level of 150 U/L.

13. Normal lactate dehydrogenase level is 45-90 U/L.

14. Laboratory testing demonstrates a thyroid-stimulating hormone level of 1.5 µU/mL.

15. Normal thyroid-stimulating hormone level is 0.5-5.0 µU/mL.


Question: The most likely cause of amenorrhea in this patient is an increase in production of which of the following hormones?"

Context: A 22-year-old woman comes to the physician because of a 5-kg (11-lb) weight gain and hair loss over the past 4 months.

Context: Menarche occurred at the age of 12 years and menses occurred at irregular intervals until she stopped having periods 2 months ago.

Context: She is 165 cm (5 ft 5 in) tall and weighs 82 kg (180 lb); BMI is 30 kg/m2.

Context: Serum studies show: | Thyroid-stimulating hormone 2 μU/mL | Luteinizing hormone 32 mIU/mL | Prolactin 11 ng/mL | Urine pregnancy test is negative.

Choices:
A. Progesterone in corpus luteum
B. Estrogen in adipose tissue
C. Follicle stimulating hormone in the adenohypophysis
D. Dopamine in the hypothalamus

Answer: Estrogen in adipose tissue

1. A 22-year-old woman comes to the physician.

2. She has experienced a 5-kg (11-lb) weight gain and hair loss over the past 4 months.

3. Menarche occurred at the age of 12 years.

4. Menses occurred at irregular intervals until she stopped having periods 2 months ago.

8. Physical examination shows a receding hairline and hair loss over the vertex of the head.

9. Serum studies show: Thyroid-stimulating hormone 2 μU/mL.

10. Serum studies show: Luteinizing hormone 32 mIU/mL.

11. Serum studies show: Prolactin 11 ng/mL.

13. Withdrawal bleeding occurs after a progestin challenge test.


Question: Which of the following drugs was most likely prescribed?

Context: A 70-year-old man with chronic myopia comes to the physician because of a 4-month history of difficulty seeing distant objects, especially at night, despite wearing glasses.

Context: Gonioscopy shows no abnormalities.

Context: He is prescribed a drug.

Context: At a follow-up examination several months later, intraocular pressure is normal, but darkening of the iris and an increase in the length of the eyelashes is observed.

Choices:
A. Timolol
B. Acetazolamide
C. Apraclonidine
D. Latanoprost

Answer: Latanoprost

1. A 70-year-old man has chronic myopia.

2. He has had difficulty seeing distant objects for 4 months, especially at night, despite wearing glasses.

3. Examination shows bilateral narrowing of peripheral visual fields, cupping of the optic discs, and elevated intraocular pressure.

6. At a follow-up examination several months later, intraocular pressure is normal.

7. At the follow-up examination, darkening of the iris is observed.

8. At the follow-up examination, an increase in the length of the eyelashes is observed.


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

Context: They are concerned because they have on occasion noticed a “swelling of the belly button.” Cord separation occurred at seven days of age.

Context: The bulge increases in size when the child cries and can be easily reduced inside the umbilical ring without apparent pain. |  | .

Choices:
A. Expectant management
B. Histopathologic evaluation
C. Elective surgical management
D. Immediate surgical management

Answer: Expectant management

1. A 3-week-old female presents with her parents to her pediatrician for a routine visit.

2. The parents report that the child is sleeping in regular two-hour intervals and feeding and stooling well.

3. They are concerned because they have on occasion noticed a “swelling of the belly button.”

4. Cord separation occurred at seven days of age.

5. The parents report that the swelling seems to come and go but is never larger than the size of a blueberry.

6. They deny any drainage from the swelling.

7. On physical exam, the child is in no acute distress and appears developmentally appropriate for her age.

8. Her abdomen is soft and non-tender with a soft, 1 cm bulge at the umbilicus.

9. The bulge increases in size when the child cries and can be easily reduced inside the umbilical ring without apparent pain.


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

Context: His temperature is 97.7°F (36.5°C), blood pressure is 94/54 mmHg, pulse is 170/min, respirations are 12/min, and oxygen saturation is 90% on room air.

Context: A 14-gauge needle is placed in the 2nd intercostal space on the patient’s left, and his blood pressure increases to 104/74 mmHg and his pulse decreases to 100/min.

Choices:
A. Chest radiograph
B. Pericardiocentesis
C. Thoracotomy
D. Tube thoracostomy

Answer: Tube thoracostomy

1. A 25-year-old man presents to the emergency department after a motor vehicle collision.

2. He is currently complaining of chest pain and shortness of breath and seems rather confused.

7. His oxygen saturation is 90% on room air.

8. A 14-gauge needle is placed in the 2nd intercostal space on the patient’s left.

9. His blood pressure increases to 104/74 mmHg.


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

Context: A 13-year-old girl presents with a rash on her left hand and forearm.

Context: She went hiking with friends the day before yesterday and awoke this morning to find her hand and forearm red and itchy.

Context: She denies any swelling of the face or throat, difficulty breathing, dizziness, or palpitations.

Context: She has no significant past medical history or known allergies.

Context: She is afebrile and her vital signs are within normal limits.

Context: On physical examination, there are multiple erythematous papules and fluid-filled vesicles in a linear pattern on her left hand and forearm as shown in the exhibit (see image).

Choices:
A. Oral prednisone
B. Topical clobetasol
C. Phototherapy
D. Azathioprine

Answer: Topical clobetasol

2. Patient went hiking with friends two days ago.

3. Patient awoke this morning with a rash on her left hand and forearm.

4. Patient denies any swelling of the face or throat, difficulty breathing, dizziness, or palpitations.

5. Patient has no significant past medical history or known allergies.

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

8. On physical examination, there are multiple erythematous papules and fluid-filled vesicles in a linear pattern on her left hand and forearm.

9. Exhibit (see image) shows the rash on the patient's left hand and forearm.


Question: This patient is most likely to die from which of the following complications?

Context: A 12-year-old boy is brought to the physician for multiple bruises.

Context: He has fallen multiple times over the past 4 months and has difficulty walking without assistance.

Context: Neurological examination shows bilateral nystagmus, decreased muscle strength, 1+ reflexes bilaterally, and a wide-based gait with irregular and uneven steps.

Context: His proprioception and vibration senses are absent.

Context: The remainder of the examination shows kyphoscoliosis and foot inversion with hammer toes.

Choices:
A. Renal cell carcinoma
B. Heart failure
C. Posterior fossa tumors
D.
Aspiration pneumonia
"

Answer: Heart failure

1. A 12-year-old boy is brought to the physician.

2. He has fallen multiple times over the past 4 months.

3. He has difficulty walking without assistance.

4. His speech is slow and difficult to understand.

5. Neurological examination shows bilateral nystagmus.

6. Neurological examination shows decreased muscle strength.

7. Neurological examination shows 1+ reflexes bilaterally.

8. Neurological examination shows a wide-based gait with irregular and uneven steps.

9. Neurological examination shows absent proprioception and vibration senses.

10. The remainder of the examination shows kyphoscoliosis.

11. The remainder of the examination shows foot inversion with hammer toes.


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

Context: A 28-year-old nulligravid woman comes to the physician for a routine health maintenance examination.

Context: Upon questioning, she reports that she and her husband have been trying to conceive for more than 1 year; they have unprotected sexual intercourse 3–4 times per week.

Context: Recently, she has not been enjoying sexual intercourse with her husband because of painful penetration.

Context: She also reports episodic back and pelvic pain over the past 6 months that lasts for 2–3 days; she has missed several days of work each month because of the pain.

Context: Menarche was at the age of 13 years, and menses occur at 26–28 day intervals.

Context: There is rectovaginal tenderness.

Choices:
A. Endometrial tisssue within the myometrium on biopsy
B. Multiple bilateral ovarian cysts on ultrasonography
C. Reddish-black peritoneal lesions on laparoscopy
D. Concentric, solid myometrial tumors on MRI

Answer: Reddish-black peritoneal lesions on laparoscopy

3. Patient and her husband have been trying to conceive for more than 1 year.

4. Patient and her husband have unprotected sexual intercourse 3-4 times per week.

5. Patient has not been enjoying sexual intercourse with her husband because of painful penetration.

6. Patient has episodic back and pelvic pain over the past 6 months.

8. Patient has missed several days of work each month because of the pain.

9. Patient's menarche was at the age of 13 years.

10. Patient's menses occur at 26-28 day intervals.

11. Pelvic examination shows a normal-appearing vulva and vagina.

12. Pelvic examination shows rectovaginal tenderness.

13. Ultrasonography of the pelvis shows a retroverted normal-sized uterus.


Question: What disease is the child suffering from?

Context: A 2-year-old Caucasian male presents with recurrent diaper rash and oral thrush.

Context: He has also experienced recurrent episodes of otitis media from repeat Streptoccous pneumoniae.

Context: He notably has reduced T and B cell counts.

Choices:
A. X-linked agammaglobulinemia
B. Isolated IgA deficiency
C. Severe combined immunodeficiency
D. DiGeorge syndrome

Answer: Severe combined immunodeficiency

1. Patient is 2-year-old Caucasian male.

2. Patient presents with recurrent diaper rash and oral thrush.

3. Patient has experienced recurrent episodes of otitis media.

4. Patient has repeat Streptoccous pneumoniae.

5. Patient has reduced T and B cell counts.

Pediatric Immunology
Pediatric Immunology and Allergy
Immunology and Allergy


Question: If the pregnancy is continued to term, the child is at an increased risk of developing which of the following conditions?

Context: Her blood pressure is 110/70 mm Hg, a heart rate of 95/min, a respiratory rate of 20/min, and a temperature of 36.4°C (97.5°F).

Context: Physical examination is unremarkable.

Context: Laboratory studies show decreased levels of PAPP-A and increased levels of β-hCG.

Choices:
A. Vaginal adenosis
B. Huntington disease
C. Alzheimer’s disease
D. Ebstein anomaly

Answer: Alzheimer’s disease

1. A 42-year-old primigravida woman presents to her gynecologist for a routine prenatal visit at 11 weeks of gestation.

2. Her pregnancy has been uneventful so far.

3. She denies smoking, using alcohol, or any illicit drugs.

4. Past medical history is significant for Hashimoto’s thyroiditis which is well-controlled with levothyroxine.

9. Physical examination is unremarkable.

10. A transvaginal ultrasound reveals increased nuchal translucency.

11. Laboratory studies show decreased levels of PAPP-A.

12. Laboratory studies show increased levels of β-hCG.


Question: Vaccination against the causal pathogen of this patient's current disease is most likely to also prevent which of the following conditions?

Context: An 18-month-old boy is brought to the emergency department by his babysitter because of lethargy and fever for 3 hours.

Context: He has not fully recovered from a middle ear infection that started a few days ago.

Context: His temperature is 39.1°C (102.3°F).

Context: A pathogen is isolated from the patient's cerebrospinal fluid that does not grow on regular blood agar plate but produces colonies when cocultured with Staphylococcus aureus.

Choices:
A. Bacterial rhinosinusitis
B. Epiglottitis
C. Chancroid
D. Impetigo

Answer: Epiglottitis

1. An 18-month-old boy is brought to the emergency department by his babysitter.

2. The boy has been lethargic and has had a fever for 3 hours.

3. The boy had a middle ear infection a few days ago.

4. The parents cannot be reached for further information.

5. The boy's temperature is 39.1°C (102.3°F).

6. Physical examination shows nuchal rigidity.

7. A pathogen is isolated from the patient's cerebrospinal fluid.

8. The pathogen does not grow on regular blood agar plate.

9. The pathogen produces colonies when cocultured with Staphylococcus aureus.


Question: The serum concentration of which of the following substances is most likely to also be increased in this patient?

Context: He is unable to walk without support and speaks in unclear 2-word phrases.

Context: Examination shows multiple bruises on the forehead and several healing wounds over the fingers.

Choices:
A. Phenylalanine
B. Deoxyadenosine trisphosphate
C. Phosphoribosyl pyrophosphate
D. Cytosine monophosphate

Answer: Phosphoribosyl pyrophosphate

1. A 20-month-old boy is brought to the physician for the evaluation of intellectual and behavioral abnormalities and abnormal movements of his extremities.

2. His mother reports that he often hits his head and limbs against furniture.

3. He is unable to walk without support.

5. Examination shows multiple bruises on the forehead.

6. Examination shows several healing wounds over the fingers.

7. There is increased muscle tone in all extremities.

8. Laboratory studies show an increased serum uric acid concentration.


Question: Which of the following is most likely this patient’s diagnosis?

Context: A 24-year-old man presents to the office for a physical exam and drug screening requested by his parole officer.

Context: Past medical records reveal testimonies from his mother describing episodes of physically aggressive behavior in school starting at before 12.

Context: Although a single parent, his mother states there were no stressful changes or issues at home.

Choices:
A. Substance use-related aggression
B. Conduct disorder
C. Antisocial personality disorder
D. Borderline personality disorder

Answer: Antisocial personality disorder

1. A 24-year-old man presents to the office for a physical exam and drug screening.

2. The drug screening was requested by his parole officer.

3. He has a history of multiple run-ins with the law, including theft, destruction of property, and assault and battery.

4. Patient confesses that he has always been the 'problem child' in his home and always got into trouble with authority figures.

5. Past medical records reveal testimonies from his mother describing episodes of physically aggressive behavior in school starting before 12.

7. His mother states there were no stressful changes or issues at home.

8. Today's urine toxicology screens are negative.


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

Context: A 47-year old woman is referred to a nephrologist due to hematuria over the last week and lower extremity edema.

Context: This causes her mild joint and muscle pain on most day and she manages her symptoms with ibuprofen and acetaminophen.

Context: Today, her heart rate is 90/min, the respiratory rate is 17/min, the blood pressure is 140/90 mm Hg, and the temperature is 37.1°C (98.8°F).

Context: Urine analysis shows 6-10 dysmorphic RBCs per high powered field and occasional cellular casts.

Context: Serum creatinine is 2.4 mg/dL and a 24 hour urine collection reveals 550mg of excreted protein.

Choices:
A. Methotrexate and folic acid
B. Intravenous immunoglobulin
C. Plasmapheresis
D. Cyclophosphamide and prednisolone

Answer: Cyclophosphamide and prednisolone

1. A 47-year old woman is referred to a nephrologist.

2. She has had hematuria over the last week.

4. She first noticed her feet and legs would swell in the mornings about 2 weeks ago.

5. Her past medical history is significant for systemic lupus erythematosus for the past 24 years.

6. This causes her mild joint and muscle pain on most days.

7. She manages her symptoms with ibuprofen and acetaminophen.

12. Urine analysis shows 6-10 dysmorphic RBCs per high powered field.

13. Urine analysis also shows occasional cellular casts.

15. A 24 hour urine collection reveals 550mg of excreted protein.

16. A kidney biopsy shows findings consistent with diffuse proliferative glomerulonephritis.


Question: Which pathological change would likely be seen on microscopy?

Context: A 6-year-old girl presents to your clinic two weeks after receiving a routine immunization in preparation for a trip overseas.

Context: Periorbital edema is present on exam, and 24 hour urine collection shows excretion of 4.3 grams of protein/day.

Choices:
A. Linear IgG deposition on light microscopy
B. IgA-immune complexes in the mesangium on electron microscopy
C. Subepithelial deposits with “spike and dome” appearance on electron microscopy
D. Podocyte effacement on electron microscopy

Answer: Podocyte effacement on electron microscopy

1. A 6-year-old girl presents to a clinic.

2. She received a routine immunization two weeks prior.

3. The immunization was in preparation for a trip overseas.

4. Periorbital edema is present on exam.

6. The urine collection showed excretion of 4.3 grams of protein/day.


Question: Which of the following sets of laboratory findings is most likely in this patient's serum? |  $$$ Calcium %%% Phosphorus %%% Parathyroid hormone %%% Calcitriol $$$

Context: A 9-year-old girl is brought to the physician by her father for evaluation of intermittent muscle cramps for the past year and short stature.

Context: She is at the 5th percentile for weight and 10th percentile for height.

Context: Physical examination shows nasal polyps and dry skin.

Context: An x-ray of the right wrist shows osteopenia with epiphyseal widening.

Choices:
D. Normal ↓ ↑ ↓

1. A 9-year-old girl is brought to the physician by her father.

2. She has had intermittent muscle cramps for the past year.

3. She has had recurrent upper respiratory tract infections since infancy.

4. She is at the 5th percentile for weight.

5. She is at the 10th percentile for height.

6. Physical examination shows nasal polyps.

8. An x-ray of the right wrist shows osteopenia.

9. An x-ray of the right wrist shows epiphyseal widening.


Question: Which of the following is the most likely explanation for his positive Candida culture?

Context: A 24-year-old medical student presents to urgent care with cough and rhinorrhea.

Context: He has been learning about HIV and immunosuppression in medical school, and he is worried that he is seriously ill.

Context: He has no significant medical history, and he is sexually active with his girlfriend.

Context: He consumes alcohol on weekends but does not use tobacco or other recreational drugs.

Context: He candidly reports that, in microbiology lab, he cultured his own sputum on Sabouraud agar, and Candida grew on the agar.

Context: You perform a nasal viral swab, which confirms that he has a rhinovirus infection.

Choices:
A. HIV virus infection
B. Xerostomia
C. Surreptitious drug use
D. Benign Candida colonization

Answer: Benign Candida colonization

3. Patient presents to urgent care with cough and rhinorrhea.

4. Patient has been learning about HIV and immunosuppression in medical school.

5. Patient is worried that he is seriously ill.

6. Patient has no significant medical history.

7. Patient is sexually active with his girlfriend.

8. Patient consumes alcohol on weekends.

9. Patient does not use tobacco or other recreational drugs.

10. Patient cultured his own sputum on Sabouraud agar, and Candida grew on the agar.

11. Examination of the oropharynx does not show any abnormalities.

12. Nasal viral swab confirms that patient has a rhinovirus infection.


Question: Which of the following medications would be most appropriate to assist the patient with her symptoms at this time?

Context: She has observed an increase in the frequency of her cough over the past few months and also the production of yellowish sputum on several occasions.

Context: She has never had the will to quit.

Context: Her respiratory rate is 18/min, pulse is 85/min, and blood pressure is 110/70 mm Hg.

Choices:
A. Albuterol
B. Fluticasone
C. Doxycycline
D. Prednisone

Answer: Albuterol

1. A 57-year-old woman comes to her physician with a persistent cough.

2. She has observed an increase in the frequency of her cough over the past few months.

3. She has also observed the production of yellowish sputum on several occasions.

4. She says that sputum production is greater in the morning compared to the rest of the day.

5. She has been a chain smoker for about 35 years now, smoking close to 3 packs a day.

7. Over the last 2 years, she has had this cough and doesn't recall being free of it for 3 months at a stretch.

8. On examination, there is a slight expiratory wheeze in the lower lung fields.

12. Her forced expiratory volume in the first second is 83% at this time.

13. Her FEV1/FVC post-bronchodilator ratio is 0.65.

14. Based on these findings, her physician recommends that she quit smoking.

15. She is also advised to take pneumococcal and influenza vaccinations over the next few months.


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

Context: A 56-year-old woman presents to her primary care physician for dizziness.

Context: She says that her symptoms began approximately 1 month prior to presentation and are associated with nausea and ringing of the ears.

Context: She describes her dizziness as a spinning sensation that has a start and end and lasts approximately 25 minutes.

Context: This dizziness is severe enough that she cannot walk or stand.

Context: Her symptoms are fluctuating, and she denies any tunnel vision or feelings of fainting.

Context: However, she has abruptly fallen to the ground in the past and denied losing consciousness.

Context: Medical history is significant for a migraine with aura treated with zolmitriptan, type 2 diabetes managed with metformin, and hypertension managed with lisinopril.

Context: Her blood pressure is 125/75 mmHg, pulse is 88/min, and respirations are 16/min.

Context: On physical exam, when words are whispered into her right ear, she is unable to repeat the whispered words aloud; however, this is normal in the left ear.

Context: Air conduction is greater than bone conduction with Rinne testing, and the sound of the tuning fork is loudest in the left ear on Weber testing.

Choices:
A. Benign paroxysmal positional vertigo
B. Meniere disease
C. Migraine
D. Transient ischemic attack

Answer: Meniere disease

2. Patient presents to primary care physician for dizziness.

3. Symptoms began approximately 1 month prior to presentation.

4. Symptoms associated with nausea and ringing of the ears.

5. Dizziness described as a spinning sensation with a start and end, lasting approximately 25 minutes.

6. Dizziness severe enough that patient cannot walk or stand.

8. Patient denies tunnel vision or feelings of fainting.

9. Patient has abruptly fallen to the ground in the past and denied losing consciousness.

10. Medical history significant for migraine with aura treated with zolmitriptan.

11. Medical history significant for type 2 diabetes managed with metformin.

12. Medical history significant for hypertension managed with lisinopril.

16. When words are whispered into right ear, patient is unable to repeat the whispered words aloud.

17. When words are whispered into left ear, patient is able to repeat the whispered words aloud.

18. Air conduction is greater than bone conduction with Rinne testing.

19. Sound of tuning fork is loudest in left ear on Weber testing.

Neurology with Special Qualification in Child Neurology


Question: Which of the following is the most likely cause of this infant’s symptoms?

Context: A 3086-g (6-lb) male newborn is delivered at 39 weeks' gestation to a 29-year-old woman.

Context: Initial examination shows micrognathia, a broad nasal bridge, short philtrum, and a cleft palate.

Choices:
A. Deletion in chromosome 7
B. Deletion in chromosome 22
C. Nondisjunction of chromosome 21
D. Nondisjunction of chromosome 13

Answer: Deletion in chromosome 22

1. A 3086-g (6-lb) male newborn is delivered.

2. The newborn is delivered at 39 weeks' gestation.

4. Initial examination shows micrognathia.

5. Initial examination shows a broad nasal bridge.

6. Initial examination shows a short philtrum.

7. Initial examination shows a cleft palate.

8. Intermittent muscle spasms are seen predominantly in the hands and feet.

9. A harsh systolic murmur is heard over the lower left sternal border.


Question: Serum studies are most likely to show which of the following findings?"

Context: A 37-year-old woman comes to the emergency department because her eyes have had a yellow discoloration and she has had dark urine for the past 3 days.

Context: She has also had fever, itching, and severe fatigue.

Context: She reports having symptoms of the stomach flu a week ago, which resolved with over-the-counter medication.

Context: She does not smoke and drinks an average of 2 beers on weekends.

Context: She does not use illicit drugs.

Context: She appears ill.

Context: Her temperature is 39.3°C (102.7°F), pulse is 64/min, and blood pressure is 132/82 mm Hg.

Context: Cardiopulmonary examination is normal.

Context: Laboratory studies show: | Hemoglobin 11.6 g/dL | Leukocyte count 10,300/mm3 | Platelet count 256,000/mm3 | ESR 19 mm/hr | Prothrombin time 13 seconds | Serum | Urea nitrogen 28 mg/dL | Glucose 89 mg/dL | Creatinine 0.7 mg/dL | Bilirubin | Total 8 mg/dL | Direct 4 mg/dL | ALP 80 U/L | AST 312 U/L | ALT 569 U/L | An ultrasound of the abdomen shows no abnormalities.

Choices:
A. Anti-mitochondrial antibodies
B. Perinuclear anti-neutrophil cytoplasmic antibodies
C. Anti-HAV IgM
D. Anti-HEV IgG

Answer: Anti-HAV IgM

1. A 37-year-old woman comes to the emergency department.

2. She has had a yellow discoloration in her eyes for the past 3 days.

3. She has had dark urine for the past 3 days.

4. She has had fever, itching, and severe fatigue.

5. She had symptoms of the stomach flu a week ago, which resolved with over-the-counter medication.

6. She does not have diarrhea but says her stools are whitish in appearance.

7. She has no personal history of serious illness.

9. She drinks an average of 2 beers on weekends.

11. She has been sexually active with the same partner for 12 years and uses condoms consistently.

12. She works as a flight attendant for an international airline.

14. Her temperature is 39.3°C (102.7°F).

17. Examination shows scleral icterus, excoriation marks over her extremities, and parched lips.

18. The liver is tender on palpation; there is no splenomegaly.

19. Cardiopulmonary examination is normal.

20. Laboratory studies show: Hemoglobin 11.6 g/dL, Leukocyte count 10,300/mm3, Platelet count 256,000/mm3, ESR 19 mm/hr, Prothrombin time 13 seconds, Serum Urea nitrogen 28 mg/dL, Glucose 89 mg/dL, Creatinine 0.7 mg/dL, Bilirubin Total 8 mg/dL, Direct 4 mg/dL, ALP 80 U/L, AST 312 U/L, ALT 569 U/L.

21. An ultrasound of the abdomen shows no abnormalities.


Question: What is the mechanism of action of the drug which typically induces remission of this patient’s most likely condition?

Context: A 27-year-old man presents with diarrhea, fatigue and weight loss.

Context: He says he has been having occasional loose stools and abdominal pain for the past month, but he did not seek any medical attention because of work deadlines.

Context: He says the diarrhea is associated with cramping lower abdominal pain and an urgency to defecate.

Context: His stool is loose, occasionally blood-tinged, and contains mucus.

Context: He also says he feels fatigued and has lost 11 kg (24 lb) over the last 2 months.

Context: The patient denies any fever, sick contacts, or a history of recent travel.

Context: No significant past medical history.

Context: On physical examination, the patient has generalized pallor.

Context: A colonoscopy with biopsy is performed, which shows inflammation of the sigmoid colon and rectum.

Context: No evidence of granulomatous disease.

Choices:
A. Inhibition of prostaglandins and inflammatory cytokines
B. Antibody against tumor necrosis factor
C. Inhibition of cellular metabolism
D. Suppression of polymorphonuclear cell migration

Answer: Inhibition of prostaglandins and inflammatory cytokines

2. Patient has diarrhea, fatigue and weight loss.

3. Patient has had occasional loose stools and abdominal pain for the past month.

4. Patient did not seek medical attention due to work deadlines.

5. Diarrhea is associated with cramping lower abdominal pain and an urgency to defecate.

6. Stool is loose, occasionally blood-tinged, and contains mucus.

7. Patient feels fatigued and has lost 11 kg (24 lb) over the last 2 months.

8. Patient denies any fever, sick contacts, or a history of recent travel.

10. Family history is significant for colon cancer in his father, who died at the age of 50.

11. On physical examination, patient has generalized pallor.

12. Abdominal exam reveals mild tenderness to palpation in the left lower quadrant.

13. Laboratory investigations reveal microcytic anemia with an elevated ESR.

14. Colonoscopy with biopsy is performed, which shows inflammation of the sigmoid colon and rectum.

15. Biopsy shows a predominantly lymphoid infiltration of the mucosa and submucosa with multiple crypt abscesses.

16. No evidence of granulomatous disease.


Question: Which of the following translocations is likely to be seen in this patient?

Context: Her temperature is 98.1°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 88/min, respirations are 16/min, and oxygen saturation is 98% on room air.

Context: A complete blood count with differential shows the following: |  | Hemoglobin: 10 g/dL | Hematocrit: 30% | Leukocyte count: 166,500/mm^3 | Segmented neutrophils 92% | Leukocyte alkaline phosphatase: Low | Platelet count: 92,000/mm^3 |  | A bone marrow biopsy is performed demonstrating infiltration with a large number of normal-appearing neutrophils.

Choices:
A. t(8;14)
B. t(9;22)
C. t(12;21)
D. t(15;17)

Answer: t(9;22)

1. A 61-year-old woman presents to your office complaining of mild fatigue and weight loss over the past 6 months.

2. She states she has felt generally unwell and has had decreased appetite during this time frame.

7. Oxygen saturation is 98% on room air.

8. Physical exam reveals splenomegaly and a nontender abdomen.

13. Leukocyte alkaline phosphatase: Low.

15. A bone marrow biopsy is performed demonstrating infiltration with a large number of normal-appearing neutrophils.


Question: Which of the following is the most appropriate initial treatment of this patient?

Context: His temperature is 97.6°F (36.4°C), blood pressure is 104/64 mmHg, pulse is 130/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Context: Laboratory values are ordered as seen below. |  | Serum: | Na+: 141 mEq/L | Cl-: 102 mEq/L | K+: 4.4 mEq/L | HCO3-: 14 mEq/L | BUN: 25 mg/dL | Glucose: 99 mg/dL | Creatinine: 1.4 mg/dL | Ca2+: 10.2 mg/dL |  | .

Choices:
A. Glutathione formation
B. Inhibition of alcohol dehydrogenase
C. Muscarinic antagonism
D. Removal via dialysis

Answer: Inhibition of alcohol dehydrogenase

1. A 44-year-old homeless man is brought to the emergency department after he was arrested when found intoxicated in someone's garage.

2. The patient is acutely altered and is covered in urine, stool, and vomit.

7. His oxygen saturation is 98% on room air.

8. The patient is aroused with pain and begins answering basic questions.

9. He states his vision is blurry and he can't see anything.


Question: Which of the following laboratory abnormalities would you expect to find in this patient?

Context: A 32-year-old construction worker is brought to the Emergency Department after a block of concrete crushed his right leg.

Context: Upon admission his vitals were stable.

Context: Distal right pulses are absent.

Choices:
A. Fractional excretion of sodium (FeNa+) > 2%
B. Urine osmolality > 500 mOsmol/kg
C. Red-tinted plasma
D. Elevated haptoglobin

Answer: Fractional excretion of sodium (FeNa+) > 2%

1. A 32-year-old construction worker is brought to the Emergency Department.

2. A block of concrete crushed his right leg.

3. His coworkers tried to remove the block, but it was not possible until firemen arrived on the scene 30 minutes after the incident.

4. His personal medical history is unremarkable.

5. Upon admission his vitals were stable.

6. On physical examination the man is unconscious.

7. His right leg is deformed with lacerations and hematomas.

8. There are at least two fractures and several areas of the muscle appear pulpified.

10. An X-ray of the right leg reveals several displaced fractures of the tibia and fibula.

11. Blood samples and a urine specimens are sent to the lab for analysis.


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

Context: A 42-year-old primigravida woman goes into labor at 37 weeks.

Context: After several hours of labor, a boy is born with multiple physical abnormalities including cleft palate, micrognathia, and low-set ears.

Choices:
A. Microdeletion of the long arm of chromosome 22
B. Microdeletion of the long arm of chromosome 7
C. Microdeletion of the short arm of chromosome 5
D. Adenosine deaminase deficiency

Answer: Microdeletion of the long arm of chromosome 22

1. A 42-year-old primigravida woman goes into labor.

2. The woman goes into labor at 37 weeks.

3. After several hours of labor, a boy is born.

4. The boy has multiple physical abnormalities including cleft palate, micrognathia, and low-set ears.

5. Imaging reveals an absence of the thymic shadow.


Question: When this drug is used long-term, which of the following complications can develop?

Context: A 20-year-old woman presents following a seizure 2 hours ago.

Context: The patient's roommate describes seeing the patient suddenly 'freeze', collapse, and start having jerky movements involving her entire body.

Context: The patient says she can not recall the episode but does remember 'seeing stars' before losing consciousness.

Context: She remembers being confused about where she was soon after the seizure and had urinated in her clothes when she regained consciousness.

Context: A persistent headache has troubled her since the seizure for which she took acetaminophen before coming to the hospital.

Context: Her past medical history is unremarkable.

Context: She denies alcohol and drug use.

Context: The physician starts her on an antiepileptic drug that acts in the motor cortex by blocking repeated activation of voltage-gated sodium channels and is also used in status epilepticus.

Choices:
A. Drug dependence
B. Drug-induced SLE
C. Renal failure
D. Liver failure

Answer: Drug-induced SLE

2. Patient presented 2 hours after a seizure.

3. Roommate described patient suddenly 'freezing', collapsing, and having jerky movements involving her entire body.

4. Patient cannot recall the episode but remembers 'seeing stars' before losing consciousness.

5. Patient was confused about where she was soon after the seizure.

6. Patient had urinated in her clothes when she regained consciousness.

7. Patient has had a persistent headache since the seizure.

8. Patient took acetaminophen before coming to the hospital.

9. Patient's past medical history is unremarkable.

10. Patient denies alcohol and drug use.

11. Physician started patient on an antiepileptic drug that acts in the motor cortex by blocking repeated activation of voltage-gated sodium channels.

12. Antiepileptic drug is also used in status epilepticus.


Question: Which of the following findings is most likely to be found in this patient?

Context: The patient states that it is very painful for him to walk around, and he has significant pain in his right and left toes.

Context: The patient has a past medical history of obesity, type II diabetes mellitus, anxiety, depression, COPD, and a 30 pack-year smoking history.

Context: The patient’s current medications include lisinopril, hydrochlorothiazide, insulin, metformin, fluoxetine, clonazepam, albuterol, home oxygen, varenicline, and fish oil and he is compliant with all medications.

Context: On physical exam, the patient’s toes appear pale and dirty.

Choices:
A. Bipedal edema
B. Increased reflexes of the lower extremities
C. Loss of vibration sensation in the lower extremities
D. Calf pain after walking moderate distance

Answer: Calf pain after walking moderate distance

1. A 68-year-old man presents to his primary care physician for pain in his feet.

2. The patient states that it is very painful for him to walk around.

3. The patient has significant pain in his right and left toes.

4. The patient has a past medical history of obesity.

5. The patient has a past medical history of type II diabetes mellitus.

6. The patient has a past medical history of anxiety.

7. The patient has a past medical history of depression.

8. The patient has a past medical history of COPD.

9. The patient has a 30 pack-year smoking history.

10. The patient's current medications include lisinopril.

11. The patient's current medications include hydrochlorothiazide.

12. The patient's current medications include insulin.

13. The patient's current medications include metformin.

14. The patient's current medications include fluoxetine.

15. The patient's current medications include clonazepam.

16. The patient's current medications include albuterol.

17. The patient's current medications include home oxygen.

18. The patient's current medications include varenicline.

19. The patient's current medications include fish oil.

20. The patient is compliant with all medications.

21. On physical exam, the patient's toes appear pale and dirty.

22. When inspecting his toes, shallow wounds with a pale base devoid of granulation tissue can be appreciated.

23. The patient has decreased pinprick sensation in his lower extremities bilaterally.

24. Pulmonary exam is notable for a prolonged expiratory phase.

Neuromuscular Medicine
Peripheral Neuropathy


Question: What additional finding would you expect from this patient?

Context: Per the patient, he was playing at his high-school football game when a member of the opposing team tackled him from behind, which resulted in him landing on his left arm.

Context: Physical examination demonstrates limited abduction secondary to pain and reduced muscle tone over the shoulder.

Choices:
A. Loss of sensation over the dorsal hand
B. Loss of sensation over the lateral 3 1/2 fingers
C. Loss of sensation over the lateral arm
D. Loss of sensation over the lateral forearm

Answer: Loss of sensation over the lateral arm

1. A 16-year-old man is brought to the emergency department for left arm pain.

2. The patient was playing at his high-school football game when a member of the opposing team tackled him from behind.

4. He felt a “popping” sensation and immediate, sharp pain at his left shoulder.

5. The patient is in mild distress and holds his arm against his abdomen.

6. Physical examination demonstrates limited abduction secondary to pain.

7. Physical examination demonstrates reduced muscle tone over the shoulder.

General Orthopaedic Surgery
Orthopaedic Sports Medicine


Question: Which of the following movements is most likely to be impaired in this patient?

Context: A 68-year-old woman is brought to the emergency room because of pain in her right shoulder after falling down the stairs in her apartment.

Context: Physical examination shows shortening of the right arm as well as tenderness and swelling over the right shoulder.

Choices:
A. Wrist extension
B. Elbow flexion
C. Arm abduction
D. Thumb adduction

Answer: Arm abduction

1. A 68-year-old woman is brought to the emergency room.

2. She fell down the stairs in her apartment.

3. She has a history of postmenopausal osteoporosis.

4. Her current medications are alendronate, vitamin D, and calcium supplementation.

6. Physical examination shows shortening of the right arm.

7. Physical examination shows tenderness and swelling over the right shoulder.

8. The range of motion of the right arm is limited by pain.

9. An x-ray of the right shoulder shows a fracture of the surgical neck of the humerus.


Question: The platelet counts of repeated measurements are shown in ascending order: | Historical hemocytometer 55,000 57,000 62,000 76,000 77,000 82,000 92,000 Mean: 72,000 | Modern automated CBC analyzer 71,000 71,000 72,000 72,000 73,000 74,000 74,000 Mean: 72,000 | If the measurements on a modern automated CBC analyzer are considered accurate, which of the following conclusions can be drawn about the historical hemocytometer?"

Context: A hematologist has found a historical hemocytometer used during the 1960s.

Context: Out of curiosity, he decides to obtain platelet counts from his brother, who has idiopathic thrombocytopenic purpura (ITP), with both the historical hemocytometer and a modern automated CBC analyzer.

Choices:
A. Test lacks accuracy
B. Test lacks validity
C. Test lacks specificity
D. Test lacks precision

Answer: Test lacks precision

1. A hematologist has found a historical hemocytometer.

2. The historical hemocytometer was used during the 1960s.

3. The hematologist decides to obtain platelet counts from his brother.

4. His brother has idiopathic thrombocytopenic purpura (ITP).

5. The platelet counts will be obtained with both the historical hemocytometer and a modern automated CBC analyzer.


Question: Which of the following is the mechanism of action of the toxin causing this child's symptoms?

Context: A 9-year-old female child whose family recently emigrated from Afghanistan presents to the county hospital with difficulty swallowing and generalized muscle rigidity.

Context: Her parents note that although she is in severe pain she always appears to be smiling.

Context: After getting a detailed history from the parents, the residents comes to the conclusion that the child's clinical presentation is due to a lack of immunizations and a deep wound on her knee resulting from a fall six days ago.

Choices:
A. Inhibiting protein synthesis via ADP-ribosylation of elongation factor 2
B. Overactivating adenylate cyclase by ADP-ribosylation of the Gs alpha subunit
C. Overactivating adenylate cyclase by disabling the Gi subunit
D. Preventing release of GABA by cleaving of synaptobrevin 2

Answer: Preventing release of GABA by cleaving of synaptobrevin 2

1. A 9-year-old female child presents to the county hospital.

2. Her family recently emigrated from Afghanistan.

3. She has difficulty swallowing and generalized muscle rigidity.

4. Her parents note that she is in severe pain but always appears to be smiling.

5. The residents get a detailed history from the parents.

6. The residents come to the conclusion that the child's clinical presentation is due to a lack of immunizations.

7. The child has a deep wound on her knee resulting from a fall six days ago.


Question: The area of the lung most likely affected by this patient's condition has which of the following characteristics?

Context: A 49-year-old obese man presents to the emergency department with a fever and a cough productive of bloody sputum.

Context: He has also been waking up at night frequently, which he attributes to sweating while asleep.

Context: He is also proud of recently losing some weight but denies actively trying to do so.

Context: He says that he has had these symptoms intermittently for the last several years but has not consistently sought treatment because his housing has been transient with periods of homelessness.

Context: He is started on a course of therapy and leaves against medical advice before his physician is able to explain the medications.

Context: He returns two days later because he is concerned that his eyes are bleeding.

Choices:
A. High perfusion, high ventilation, high V/Q ratio
B. High perfusion, high ventilation, low V/Q ratio
C. Low perfusion, low ventilation, high V/Q ratio
D. Low perfusion, low ventilation, low V/Q ratio

Answer: Low perfusion, low ventilation, high V/Q ratio

1. A 49-year-old man presented to the emergency department.

3. He had a fever and a cough productive of bloody sputum.

4. He was waking up at night frequently and attributed it to sweating while asleep.

5. He was proud of recently losing some weight but denied actively trying to do so.

6. He had these symptoms intermittently for the last several years.

7. He had not consistently sought treatment due to periods of homelessness.

8. He was started on a course of therapy.

9. He left against medical advice before his physician was able to explain the medications.

10. He returned two days later because he was concerned his eyes were bleeding.


Question: What is the next best step in management?

Context: A 66-year-old male presents to clinic for a blood glucose level of 169 mg/dL taken at a local pharmacy.

Context: He is a farmer in rural Alabama and has not seen a doctor for decades.

Context: He wants to be in excellent shape prior to his trip to visit his daughter at college.

Context: His past medical history and family history are unknown, and he does not take any medications.

Context: His diet consists of pork products and he does not smoke.

Context: His temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 169/90 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air.

Context: The patient is started on metformin, lisinopril, and a guided exercise program.

Context: Lab results are below: |  | Serum: | Na+: 145 mEq/L | Cl-: 100 mEq/L | K+: 4.9 mEq/L | HCO3-: 24 mEq/L | BUN: 18 mg/dL | Glucose: 211 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: 10.0 mg/dL |  | He returns from his trip, complaining of cough.

Context: He denies any other symptoms.

Context: His temperature is 99.5°F (37.5°C), pulse is 101/min, blood pressure is 160/85 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air.

Context: Repeat lab results are below: |  | Serum: | Na+: 145 mEq/L | Cl-: 100 mEq/L | K+: 5.3 mEq/L | HCO3-: 24 mEq/L | BUN: 22 mg/dL | Glucose: 169 mg/dL | Creatinine: 1.2 mg/dL | Ca2+: 10.1 mg/dL |  | .

Choices:
A. Switch blood pressure medication to losartan
B. Switch blood pressure medication to hydrochlorothiazide
C. Azithromycin
D. Loratadine

Answer: Switch blood pressure medication to losartan

3. Patient is a farmer in rural Alabama.

4. Patient has not seen a doctor for decades.

5. Patient wants to be in excellent shape prior to trip to visit daughter at college.

6. Patient's past medical history and family history are unknown.

7. Patient does not take any medications.

8. Patient's diet consists of pork products.

10. Patient's temperature is 99.5°F (37.5°C).

12. Patient's blood pressure is 169/90 mmHg.

14. Patient's oxygen saturation is 97% on room air.

15. Patient is started on metformin, lisinopril, and a guided exercise program.

21. Patient's serum glucose is 211 mg/dL.

22. Patient's serum creatinine is 1.0 mg/dL.

24. Patient returns from trip complaining of cough.

26. Patient's temperature is 99.5°F (37.5°C).

28. Patient's blood pressure is 160/85 mmHg.

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


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

Context: Her prior medical history is significant for seasonal allergies and a broken arm at age 12 that was treated in a long arm cast.

Context: She has not had any major illnesses in the previous year and does not currently have any major complaints.

Context: Given her elevated blood pressure, she is prescribed captopril; however, 1 week later she presents to the emergency department with hypertensive urgency.

Choices:
A. Bilateral fibromuscular dysplasia
B. Conn syndrome
C. Renin secreting tumor
D. Unilateral fibromuscular dysplasia

Answer: Bilateral fibromuscular dysplasia

1. A 25-year-old woman presents to her primary care physician for her annual physical exam.

2. Her prior medical history is significant for seasonal allergies.

3. She had a broken arm at age 12 that was treated in a long arm cast.

4. She has not had any major illnesses in the previous year.

5. She does not currently have any major complaints.

6. On physical exam her blood pressure is found to be 152/95 mmHg.

7. Laboratory findings reveal elevated levels of renin and aldosterone.

8. Given her elevated blood pressure, she is prescribed captopril.

9. 1 week later she presents to the emergency department with hypertensive urgency.

10. At that point captopril is immediately stopped.


Question: Which of the following is a possible explanation for the group marked with the letter E?

Choices:
A. Lymphoma
B. End-stage kidney disease
C. Thyroidectomy
D. Multiple endocrine neoplasia

Answer: Lymphoma

1. An investigator is analyzing the serum calcium and parathyroid hormone levels of 100 patients.

2. A scatter plot of the findings is shown.


Question: Which of the following tests should be performed to confirm the diagnosis in this patient?

Context: A 56-year-old male is admitted to the emergency department with sudden onset of pain, left-sided scrotal swelling, and nausea.

Context: The patient states that the symptoms started three hours ago after he lifted up a heavy pack.

Context: He says that the swelling had been intermittently present for several years already and was most prominent when physically straining or coughing, but it had never been painful.

Context: Past medical history is unremarkable.

Context: Patient reports a 26-pack-year history of smoking.

Context: Vital signs are as follows: blood pressure 150/90 mm Hg, heart rate 85/min, respiratory rate 14/min, and temperature 37.8℃ (100℉).

Context: BMI is 32.9 kg/m2.

Context: Patient’s respiratory and cardiovascular exams are within normal limits.

Context: The abdomen is moderately distended.

Context: There is a tender erythematous scrotal swelling on the left, which cannot be manually reduced.

Choices:
A. Ultrasonography
B. No further tests are needed
C. Fine needle biopsy
D. Laparoscopy

Answer: No further tests are needed

1. A 56-year-old male is admitted to the emergency department.

2. Patient has sudden onset of pain, left-sided scrotal swelling, and nausea.

3. Symptoms started three hours ago after he lifted up a heavy pack.

4. Swelling had been intermittently present for several years already.

5. Swelling was most prominent when physically straining or coughing, but it had never been painful.

6. Patient's past medical history is unremarkable.

7. Patient has a 26-pack-year history of smoking.

13. Patient's respiratory and cardiovascular exams are within normal limits.

15. There is a tender erythematous scrotal swelling on the left.

16. Swelling cannot be manually reduced.


Question: Which of the following mechanisms is most likely associated with this patient's presentation?

Context: He was recently adopted from abroad and his parents want to establish care in the United States.

Context: His medical history is unclear and there are no records on any family history.

Context: On presentation, he is found to fall below the 5th percentile in height for his age with shortened 4th and 5th digits.

Context: Radiographs reveal decreased bone mineral density and several healing fractures.

Choices:
A. Decreased production of parathyroid hormone
B. Inadequate intake of vitamin D
C. Malabsorption of nutrients
D. Resistance to effects of parathyroid hormone

Answer: Resistance to effects of parathyroid hormone

1. A 6-year-old boy presents to a pediatrician for initial evaluation.

3. His parents want to establish care in the United States.

5. There are no records on any family history.

6. On presentation, he is found to fall below the 5th percentile in height for his age.

8. Physical exam reveals wrist spasms when his blood pressure is taken.

9. Radiographs reveal decreased bone mineral density.

10. Radiographs reveal several healing fractures.


Question: Which of the following physiologic mechanisms is primarily responsible for this patient's current presentation?

Context: A 12-year-old boy is brought to the emergency department with a 2-month history of increasing difficulty with physical activity.

Context: Specifically, he says that he gets short of breath quickly with exertion even though he used to participate in all activities without a problem.

Context: When asked, he endorses sometimes coughing up flecks of blood.

Context: His past medical history is unclear because he was recently adopted from abroad and has not yet established care.

Context: Physical exam reveals blue discoloration of his lips and fingernails as well as a holosystolic murmur best heard at the lower left sternal border.

Choices:
A. Increasing size of ventricular septal defect
B. Left ventricular outflow tract obstruction
C. New atrial septal defect
D. Pulmonary artery hypertension

Answer: Pulmonary artery hypertension

1. A 12-year-old boy is brought to the emergency department.

2. He has a 2-month history of increasing difficulty with physical activity.

3. He used to participate in all activities without a problem.

4. He endorses sometimes coughing up flecks of blood.

6. He was recently adopted from abroad and has not yet established care.

7. Physical exam reveals blue discoloration of his lips and fingernails.

8. Physical exam reveals a holosystolic murmur best heard at the lower left sternal border.


Question: Which of the following molecules make up part of the structure that was separated?

Context: He performs a northern blot to isolate nucleic acid sequences of interest.

Choices:
A. RNA polymerase
B. Transfer RNA
C. Ribosomal RNA
D. Mitochondrial RNA

Answer: Ribosomal RNA

1. A scientist isolates the rough endoplasmic reticulum from HeLa cells.

3. He isolates nucleic acid sequences of interest.


Question: Which of the following is the most likely diagnosis in this patient?

Context: A 14-month-old girl is brought to the pediatrician after her parents noticed her being increasingly irritable with frequent vomiting for the past 2 weeks.

Context: Parents deny any history of fever.

Context: They recently immigrated to the country and, unfortunately, the mother did not receive prenatal care during pregnancy due to a lack of health insurance.

Context: A magnetic resonance imaging (MRI) of her brain shows an enlargement of the posterior fossa, cystic dilation of the 4th ventricle, and hypoplasia of the cerebellar vermis (see image).

Choices:
A. Chiari II malformation
B. Chiari III malformation
C. Dandy-Walker malformation
D. Klippel Feil syndrome

Answer: Dandy-Walker malformation

2. Parents noticed her being increasingly irritable with frequent vomiting for the past 2 weeks.

4. Parents recently immigrated to the country.

5. Mother did not receive prenatal care during pregnancy due to a lack of health insurance.

6. Physical examination is unremarkable except for a head circumference over 2 standard deviations larger than the mean for her age, and delay in meeting motor developmental milestones.

7. MRI of her brain shows an enlargement of the posterior fossa.

8. MRI of her brain shows cystic dilation of the 4th ventricle.

9. MRI of her brain shows hypoplasia of the cerebellar vermis.


Question: Which of the following brain regions, if lesioned, would most likely result in no change in this patient’s symptoms?

Context: She says the episodes are typically triggered by hunger, mental stress, physical exertion, and lack of sleep, although many times the trigger is not known.

Context: The patient says that each episode usually lasts for 6–24 hours and is often accompanied by nausea, vomiting, and intolerance to light.

Choices:
A. Red nucleus
B. Locus coeruleus
C. Nucleus raphe magnus
D. Periaqueductal gray

Answer: Red nucleus

1. A 28-year-old woman presents with a 3-year history of recurrent headaches.

2. The episodes are typically triggered by hunger, mental stress, physical exertion, and lack of sleep.

4. She describes her headaches as unilateral, severe, throbbing, and aggravated by movement.

5. Each episode usually lasts for 6–24 hours.

6. The episodes are often accompanied by nausea, vomiting, and intolerance to light.


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

Context: His pulse is 98/min, respirations are 25/min and blood pressure is 134/88 mm Hg.

Context: Spirometry shows an FEV1:FVC ratio of 63% and an FEV1 of 65% of predicted.

Choices:
A. Asthma
B. Congestive heart failure
C. Emphysema
D.
Asbestosis
"

Answer: Emphysema

1. A 68-year-old man comes to the physician for a routine health maintenance examination.

2. He has had increasing shortness of breath and a productive cough for the past 1 year.

3. He can walk up a flight of stairs without stopping.

4. He has hypertension and his only medication is amlodipine.

5. He has a history of asthma during childhood.

6. He smoked 1 pack of cigarettes daily for 30 years but quit 16 years ago.

7. He used to work at a shipyard and retired 5 years ago.

11. Pulse oximetry on room air shows an oxygen saturation of 93%.

12. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields.

13. Cardiac examination shows no murmurs, rubs, or gallops.

14. Spirometry shows an FEV1:FVC ratio of 63%.

16. His diffusing capacity for carbon monoxide (DLCO) is 40% of predicted.

Geriatric Medicine
General Internal Medicine


Question: Which of the following substances was most likely elevated in his mother's serum during her pregnancy?

Context: A 9-year-old boy presents to his orthopedic surgeon for ongoing evaluation of his lower extremity deformities.

Context: Specifically, his hips have been dislocating over the last year despite bracing in hip-knee-ankle-foot orthoses.

Context: He is paralyzed from below the L2 nerve root and has difficulty with both bladder and bowel incontinence.

Context: He has had these abnormalities since birth due to a lower back lesion that required surgical closure during infancy.

Choices:
A. Alpha-fetoprotein
B. Beta-human chorionic growth hormone
C. Estriol
D. Sphingomyelin

Answer: Alpha-fetoprotein

1. A 9-year-old boy presents to his orthopedic surgeon.

2. His hips have been dislocating over the last year.

3. He has been wearing hip-knee-ankle-foot orthoses.

4. He is paralyzed from below the L2 nerve root.

5. He has difficulty with bladder and bowel incontinence.

6. He has had these abnormalities since birth.

7. He had a lower back lesion that required surgical closure during infancy.


Question: Which of the following is NOT necessary for PCR?

Context: PCR allows for amplification of a single piece of genetic material to produce trillions of idential copies.

Choices:
A. Taq polymerase
B. Reverse transcriptase
C. Primers
D. Target DNA strand

Answer: Reverse transcriptase

1. Polymerase chain reaction (PCR) has revolutionized the molecular biology field.

2. PCR allows for amplification of a single piece of genetic material.

3. Amplification of a single piece of genetic material produces trillions of identical copies.


Question: Which of the following is the most likely mechanism for these findings?

Context: An investigator is studying the efficacy of antiviral drugs in infected human cells.

Context: In comparison with the control plates, the subsequent application of a guanosine analog to the experimental cell sets induces cell death in the virally infected cells but not in the healthy cells.

Choices:
A. Secretion of interferons by virally infected cells
B. Mutation of viral DNA polymerase
C. Phosphorylation by virally-encoded thymidine kinase
D. Inhibition of RNA-dependent DNA polymerase

Answer: Phosphorylation by virally-encoded thymidine kinase

1. An investigator is studying the efficacy of antiviral drugs.

2. Harvested human cells are inoculated onto four cell culture plates.

3. Live varicella-zoster virus (VZV) is administered to cells on two of the culture plates.

4. One healthy and one infected cell set are set aside as controls.

5. In comparison with the control plates, the subsequent application of a guanosine analog induces cell death in the virally infected cells.

6. The guanosine analog does not induce cell death in the healthy cells.


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

Context: A 13-year-old boy is brought to the physician because of pain and redness on his back for 2 days.

Context: He returned yesterday from a vacation to East Africa with his parents, where he took multiple rides on hot air balloons.

Context: Examination shows a tender, nonpruritic, erythematous rash with edema covering the extensor surface of both forearms, the shoulders, and the upper back, with small patches of skin exfoliation.

Choices:
A. Dress wound with wet gauze
B. Administer 2 liters of intravenous fluids
C. Apply topical mupirocin
D.
Apply aloe vera-based moisturizer
"

Answer:
Apply aloe vera-based moisturizer
"

1. A 13-year-old boy is brought to the physician.

2. He has had pain and redness on his back for 2 days.

3. He returned yesterday from a vacation to East Africa with his parents.

4. He took multiple rides on hot air balloons.

5. His vital signs are within normal limits.

6. Examination shows a tender, nonpruritic, erythematous rash with edema.

7. The rash covers the extensor surface of both forearms, the shoulders, and the upper back.

8. There are small patches of skin exfoliation.

9. The rash becomes pale when pressed and then rapidly regains color.

10. The remainder of the examination shows no abnormalities.


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

Context: A 55-year-old man comes to the emergency department because of headache, fever, chills, shortness of breath, and abdominal pain for 1 week.

Context: He also feels tired and nauseous.

Context: He has type 2 diabetes mellitus.

Context: He has smoked one pack of cigarettes daily for the past 30 years and drinks a glass of beer daily.

Context: His temperature is 39.3°C (102.8°F), pulse is 122/min, respirations are 28/min, and blood pressure is 109/84 mm Hg.

Context: Examination shows jaundice.

Context: Laboratory studies show: | Hemoglobin 9.2 g/dL | Leukocyte count 9,400/mm3 | Platelet count 90,000/mm3 | Serum | Na+ 137 mEq/L | Cl- 102 mEq/L | K+ 5.2 mEq/L | HCO3- 13 mEq/L | Glucose 69 mg/dL | Lactate dehydrogenase 360 U/L | Creatinine 0.9 mg/dL | Bilirubin | _ Total 4.2 mg/dL | _ Direct 0.8 mg/dL | AST 79 U/L | ALT 90 U/L | Urine | Blood 3+ | Protein trace | RBC 0–1/hpf | WBC 1–2/hpf | Arterial blood gas analysis on room air shows a pH of 7.31.

Choices:
A. Coombs test
B. Blood culture
C. Blood smear
D. Serology

Answer: Blood smear

1. A 55-year-old man comes to the emergency department.

2. He has been experiencing headache, fever, chills, shortness of breath, and abdominal pain for 1 week.

4. He returned from a trip to Botswana 2 weeks ago.

6. He has smoked one pack of cigarettes daily for the past 30 years.

8. His only current medication is metformin.

13. Pulse oximetry on room air shows an oxygen saturation of 94%.

15. A few scattered inspiratory crackles are heard in the thorax.

16. The liver is palpated 2 cm below the right costal margin.

17. Laboratory studies show a hemoglobin of 9.2 g/dL.

18. Laboratory studies show a leukocyte count of 9,400/mm3.

19. Laboratory studies show a platelet count of 90,000/mm3.

20. Laboratory studies show a serum Na+ of 137 mEq/L.

21. Laboratory studies show a serum Cl- of 102 mEq/L.

22. Laboratory studies show a serum K+ of 5.2 mEq/L.

23. Laboratory studies show a serum HCO3- of 13 mEq/L.

24. Laboratory studies show a glucose of 69 mg/dL.

25. Laboratory studies show a lactate dehydrogenase of 360 U/L.

26. Laboratory studies show a creatinine of 0.9 mg/dL.

27. Laboratory studies show a total bilirubin of 4.2 mg/dL.

28. Laboratory studies show a direct bilirubin of 0.8 mg/dL.

29. Laboratory studies show an AST of 79 U/L.

30. Laboratory studies show an ALT of 90 U/L.

31. Laboratory studies show a urine blood of 3+.


Question: Which of the following was the most common finding in this cohort?

Context: A population study was conducted to evaluate coronary artery disease in the general population.

Context: A cohort of 700 patients underwent coronary angiography to evaluate the geographic distribution of coronary arteries throughout the heart.

Choices:
A. The SA node is supplied by a branch of the right coronary artery.
B. The AV node is supplied by a branch of the right coronary artery.
C. Right coronary artery dominance
D. A SA node is supplied by a branch of the left coronary artery.

Answer: Right coronary artery dominance

2. The study was to evaluate coronary artery disease in the general population.

4. The patients underwent coronary angiography.

5. The angiography was to evaluate the geographic distribution of coronary arteries throughout the heart.


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

Context: A 24-year-old woman comes to the physician because of intermittent episodes of stabbing facial pain for 4 months.

Context: The pain occurs over her left cheek, is 9 out of 10 in intensity, radiates towards her mouth, and lasts around half a minute before subsiding.

Context: These episodes commonly occur when she washes her face, brushes her teeth, or eats a meal.

Context: She does not have visual disturbances, weakness of her facial muscles, or hearing loss.

Context: She had a tooth extracted about 2 months ago, but the facial pain has persisted.

Context: She has hypothyroidism and vitiligo.

Context: Her mother has major depressive disorder.

Context: She appears anxious.

Context: Vital signs are within normal limits.

Choices:
A. Microvascular decompression
B. Botulinum toxin injection
C. Radiofrequency rhizotomy
D. Carbamazepine

Answer: Carbamazepine

2. Patient has intermittent episodes of stabbing facial pain for 4 months.

6. Pain lasts around half a minute before subsiding.

7. Episodes commonly occur when she washes her face, brushes her teeth, or eats a meal.

8. Patient does not have visual disturbances, weakness of her facial muscles, or hearing loss.

9. Patient had a tooth extracted about 2 months ago.

11. Patient has hypothyroidism and vitiligo.

12. Patient's mother has major depressive disorder.

13. Current medications include levothyroxine and a herbal cream.

15. Vital signs are within normal limits.

16. Cardiopulmonary examination shows no abnormalities.

17. Neurologic examination shows no focal findings.


Question: Occlusion of which of the following arteries is the most likely cause of this patient's symptoms?

Context: A 67-year-old man is brought to the emergency department after the sudden onset of dizziness, blurry vision, and a raspy voice.

Context: He has type 2 diabetes mellitus, hypercholesterolemia, coronary artery disease, and hypertension.

Context: He has smoked two packs of cigarettes daily for 30 years.

Context: He drinks three to four beers daily.

Context: His current medications include metformin, atenolol, lisinopril, furosemide, and aspirin.

Context: His temperature is 36.6°C (98°F), pulse is 85/min, respirations are 18/min, and blood pressure is 142/90 mm Hg.

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

Context: The pupil on the left is pinpoint.

Context: There is ptosis of the left eye.

Context: Horizontal nystagmus is present.

Context: The gag reflex is diminished.

Context: When he stands without support, he falls towards his left side.

Context: There is loss of pain and temperature sensation over the left face and right trunk and limbs.

Choices:
A. Right middle cerebral artery
B. Left posterior inferior cerebellar artery
C. Right internal carotid artery
D. Left posterior cerebral artery

Answer: Left posterior inferior cerebellar artery

2. Patient has sudden onset of dizziness, blurry vision, and raspy voice.

3. Patient has type 2 diabetes mellitus, hypercholesterolemia, coronary artery disease, and hypertension.

4. Patient has smoked two packs of cigarettes daily for 30 years.

5. Patient drinks three to four beers daily.

6. Patient's current medications include metformin, atenolol, lisinopril, furosemide, and aspirin.

7. Patient's temperature is 36.6°C (98°F).

10. Patient's blood pressure is 142/90 mm Hg.

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

16. Patient falls towards left side when standing without support.

17. Patient has loss of pain and temperature sensation over left face and right trunk and limbs.


Question: What is the most likely cause of her recent mental impairment?

Context: A 67-year-old woman with a recently found hepatic carcinoma has been an inpatient for more than a week.

Context: The patient was known to drink often, but reported that she has not consumed alcohol in weeks leading up to her admission.

Context: She is not jaundiced and has no metabolic imbalance upon laboratory tests.

Choices:
A. Delirium
B. Substance abuse
C. Brain metastasis
D. Delirium tremens

Answer: Delirium

1. A 67-year-old woman has been an inpatient for more than a week.

2. She has a recently found hepatic carcinoma.

3. During morning rounds, she was abnormally disoriented to time and place along with a shortened attention span.

4. The overnight resident reports that she was coming in and out of this state for the past couple nights.

5. The patient was known to drink often.

6. She reported that she has not consumed alcohol in weeks leading up to her admission.

8. She has no metabolic imbalance upon laboratory tests.


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

Context: A 51-year-old man comes to the physician because of recurrent episodes of dizziness, tinnitus, and hearing loss on the left side for 6 weeks.

Context: These episodes last for hours at a time and are associated with the sensation that the room is spinning.

Context: He has no history of major medical illness and takes no medications.

Context: The Rinne test is positive bilaterally.

Choices:
A. Dislodged otoliths
B. Acoustic neuroma
C. Endolymphatic hydrops
D. Posterior inferior cerebellar artery infarction

Answer: Endolymphatic hydrops

1. A 51-year-old man comes to the physician.

2. He has recurrent episodes of dizziness, tinnitus, and hearing loss on the left side for 6 weeks.

3. The episodes last for hours at a time.

4. He has the sensation that the room is spinning.

5. He has no history of major medical illness.

7. Examination shows horizontal nystagmus to the left.

8. Weber test shows lateralization to the right ear.

9. The Rinne test is positive bilaterally.


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

Context: A 37-year-old farmer presents to the emergency department with acute onset of complaints of diarrhea, excessive tearing, and increased saliva production.

Context: He is concerned that he is dehydrated, as he has also been urinating with increased frequency over the past several hours.

Context: His temperature is 97.6°F (36.4°C), blood pressure is 111/64 mmHg, pulse is 60/min, respirations are 10/min, and oxygen saturation is 98% on room air.

Context: Physical exam is significant for a moderately agitated and diaphoretic man who demonstrates pinpoint pupils.

Choices:
A. Atropine
B. Diphenhydramine
C. Naloxone
D. Physostigmine

Answer: Atropine

1. A 37-year-old farmer presents to the emergency department.

2. Complaints of diarrhea, excessive tearing, and increased saliva production.

3. He is concerned that he is dehydrated.

4. He has been urinating with increased frequency over the past several hours.

9. Oxygen saturation is 98% on room air.

10. Physical exam is significant for a moderately agitated and diaphoretic man.


Question: Arterial blood gas analysis on room air shows: | pH 7.52 | PCO2 25 mm Hg | PO2 65 mm Hg | O2 saturation 92% | Physical examination is most likely to show which of the following findings?"

Context: A 54-year-old woman comes to the emergency department because of sharp chest pain and shortness of breath for 1 day.

Context: She has been coughing intermittently, which worsens the pain.

Context: She has osteoporosis, for which she takes raloxifene.

Choices:
A. Unilateral swelling of the leg
B. Increased anteroposterior diameter of the thorax
C. Grouped vesicles on the right hemithorax
D. Absent left radial pulse

Answer: Unilateral swelling of the leg

1. A 54-year-old woman comes to the emergency department.

2. She has sharp chest pain and shortness of breath for 1 day.

3. She has been coughing intermittently.

6. She takes raloxifene for her osteoporosis.

Pulmonary Disease
General Pulmonary Disease


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

Context: A previously healthy 18-year-old woman comes to the emergency department because of diarrhea and abdominal cramps since the previous evening.

Context: She recollects eating out 2 days ago.

Context: She takes no medications and has not traveled anywhere recently.

Context: Her temperature is 36.8°(98.2°F), pulse is 73/min, and blood pressure is 110/70 mm Hg.

Context: Examination shows dry mucous membranes.

Context: Abdominal examination is unremarkable.

Choices:
A. Rotavirus
B. Norovirus
C. Vibrio vulnificus
D. Bacillus cereus

Answer: Norovirus

1. A previously healthy 18-year-old woman comes to the emergency department.

2. She has had diarrhea and abdominal cramps since the previous evening.

3. She has had around 3–4 episodes of watery stools.

4. She feels nauseous and has vomited twice.

5. She recollects eating out 2 days ago.

6. She has been on a vegan diet for 6 months.

8. She has not traveled anywhere recently.

12. Examination shows dry mucous membranes.

13. Abdominal examination is unremarkable.


Question: The patient’s condition is most likely associated with impaired formation of which of the following?

Context: His mother says, “Sometimes when my son forgets to flush, his urine leaves dark stains in the toilet.” She is unconcerned because her son already had dark-colored urine as a baby and he has never had any health issues.

Choices:
A. Cystathionine
B. Methylmalonate
C. Tyrosine
D. Maleylacetoacetate

Answer: Maleylacetoacetate

1. A 6-year-old boy is brought to the physician for a well-child examination.

2. He has no history of major medical illness.

3. His mother says, “Sometimes when my son forgets to flush, his urine leaves dark stains in the toilet.”

4. She is unconcerned because her son already had dark-colored urine as a baby and he has never had any health issues.

5. His vital signs are within normal limits.

6. Physical examination shows no abnormalities.

General Medical Genetics and Genomics
Clinical Genetics and Genomics


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

Context: A 72-year-old man presents with a recent episode of slurred speech and numbness in his left arm and left leg 2 hours ago that resolved completely within 45 minutes.

Context: He says he was having breakfast when he noticed that he had difficulty talking and the left side of his body was numb.

Context: The patient denies any past similar symptoms.

Context: Past medical history is significant for type 2 diabetes mellitus, hypertension, and ischemic heart disease.

Context: He had a coronary artery bypass graft 12 years ago and a percutaneous intervention 3 years ago.

Context: Current medications are aspirin, metformin, nitrates, and rosuvastatin.

Context: His vital signs include: blood pressure 143/97 mm Hg, pulse 80/min, oxygen saturation 98% on room air.

Context: On physical examination, the patient is alert and oriented.

Context: Higher mental functions are intact.

Context: Muscle strength is 5 out of 5l in both upper and lower limbs bilaterally.

Context: The sensation is intact.

Context: Cerebellar signs are absent and his gait is normal.

Choices:
A. Add clopidogrel and discharge the patient
B. Admit the patient for observation and workup
C. Discharge now and ask him to visit again when symptoms reoccur
D. Start antiepileptic drugs

Answer: Admit the patient for observation and workup

2. Patient had an episode of slurred speech and numbness in his left arm and left leg 2 hours ago that resolved completely within 45 minutes.

3. Patient was having breakfast when he noticed difficulty talking and numbness on left side of body.

4. Patient denies any past similar symptoms.

5. Patient has past medical history of type 2 diabetes mellitus, hypertension, and ischemic heart disease.

6. Patient had coronary artery bypass graft 12 years ago and percutaneous intervention 3 years ago.

7. Patient is currently taking aspirin, metformin, nitrates, and rosuvastatin.

8. Patient's blood pressure is 143/97 mm Hg, pulse 80/min, oxygen saturation 98% on room air.

9. Patient is alert and oriented with higher mental functions intact.

10. Muscle strength is 5 out of 5 in both upper and lower limbs bilaterally.


Question: Which of the following is the most appropriate pharmacotherapy?"

Context: His temperature is 37°C (98.6°F), pulse is 126/min, respirations are 30/min and shallow, and blood pressure is 84/44 mm Hg.

Context: He is unresponsive to painful stimuli.

Context: The lungs are clear to auscultation.

Context: Laboratory studies show: | Serum | Na+ 146 mmol/L | K+ 7.7 mmol/L | Cl- 111 mmol/L | Urea nitrogen 5.8 mmol/L | Glucose 83 mg/dL | Lactate 11.2 mmol/L | Serum osmolality 379 mosm/kg | Arterial blood gas analysis shows: | pH 6.69 | pCO2 53 mm Hg | pO2 84 mm Hg | HCO3- 4.3 mmol/L | The patient is intubated and fluid resuscitation is begun.

Choices:
A. N-acetylcysteine
B. Fomepizole
C. Naloxone
D. Flumazenil

Answer: Fomepizole

1. A 29-year-old man is brought to the emergency department after being found unresponsive at home.

2. The patient's roommate says that the patient had previously been feeling well.

3. The patient and his roommate had a celebration the night before, where they drank homemade liquor.

8. Pulse oximetry on room air shows an oxygen saturation of 96%.

9. He is unresponsive to painful stimuli.

10. The pupils are 3 mm, equal, round, and reactive to light.

11. The lungs are clear to auscultation.

12. Cardiac examination shows a grade 2/6 systolic murmur along the left parasternal border.

13. Laboratory studies show: Na+ 146 mmol/L, K+ 7.7 mmol/L, Cl- 111 mmol/L, Urea nitrogen 5.8 mmol/L, Glucose 83 mg/dL, Lactate 11.2 mmol/L, Serum osmolality 379 mosm/kg.

14. Arterial blood gas analysis shows: pH 6.69, pCO2 53 mm Hg, pO2 84 mm Hg, HCO3- 4.3 mmol/L.

Medical Toxicology
General Emergency Medicine


Question: Which of the following is the most likely diagnosis for this patient?

Context: A 22-year-old woman presents with an episodic history of swelling of the face, hands, and neck and a single episode of difficulty swallowing.

Context: She also has a history of frequent, severe abdominal pain.

Context: At the time of her visit, her blood pressure is 126/84 mm Hg, heart rate is 82/min, and respiratory rate is 15/min.

Context: Physical examination is unremarkable except for a swollen right hand as shown in the image below.

Context: Her C1 inhibitor level is less than 6% of the reference value.

Choices:
A. DiGeorge syndrome
B. Hereditary angioedema
C. Paroxysmal nocturnal hemoglobinuria
D. Chediak-Higashi syndrome

Answer: Hereditary angioedema

2. Patient has episodic history of swelling of the face, hands, and neck.

3. Patient has a single episode of difficulty swallowing.

4. Patient has a history of frequent, severe abdominal pain.

5. Patient's blood pressure is 126/84 mm Hg.

7. Patient's respiratory rate is 15/min.

8. Physical examination is unremarkable except for a swollen right hand.

9. Imaging studies are normal and do not reveal any cause of her pain.

10. Patient's C1 inhibitor level is less than 6% of the reference value.


Question: Which of the following is the most appropriate statement by the physician at this time?

Context: A 60-year-old man calls his hospital and asks to speak to his physician about laboratory test reports ordered because of a 3-month history of abdominal fullness and generalized fatigue.

Context: The referral note shows that he was constipated for the previous week.

Context: His abdominal examination had shown distention, and a 7-cm, hard, irregular, nontender mass was palpable on rectal examination.

Context: His colonoscopy report reveals a low anterior circumferential rectal lesion.

Context: An MRI of the pelvis shows a rectal mass with involvement of the prostate and seminal vesicles.

Context: A brief review of the results shows that an endoscopic biopsy confirms the clinical diagnosis of advanced rectal adenocarcinoma.

Context: His serum carcinoembryonic antigen concentration is 21.0 ng/mL (N < 2.5).

Context: The physician is tasked with delivering the diagnosis to the patient.

Choices:
A. """Your lab reports show that you have a locally advanced rectal adenocarcinoma"""
B. """Would you like to know all the details of your diagnosis, or would you prefer I just explain to you what our options are?"""
C. """I would like to meet later today at 4:00 PM so that we have enough time to discuss the lab results. If you'd like a friend or family member to accompany you, feel free to bring them along."""
D. """You must be be curious as to why all these tests were ordered, and you may even be anxious about the results."""

Answer: """I would like to meet later today at 4:00 PM so that we have enough time to discuss the lab results. If you'd like a friend or family member to accompany you, feel free to bring them along."""

1. A 60-year-old man called his hospital.

2. He asked to speak to his physician about laboratory test reports.

3. The laboratory test reports were ordered because of a 3-month history of abdominal fullness and generalized fatigue.

4. The referral note showed that he was constipated for the previous week.

5. His abdominal examination had shown distention.

6. A 7-cm, hard, irregular, nontender mass was palpable on rectal examination.

7. His colonoscopy report revealed a low anterior circumferential rectal lesion.

8. An MRI of the pelvis showed a rectal mass with involvement of the prostate and seminal vesicles.

9. A brief review of the results showed that an endoscopic biopsy confirmed the clinical diagnosis of advanced rectal adenocarcinoma.

10. His serum carcinoembryonic antigen concentration was 21.0 ng/mL (N < 2.5).

11. The physician was tasked with delivering the diagnosis to the patient.


Question: Prior to discharge, administration of which of the following is most appropriate in this patient?

Context: A 50-year-old man has a kidney transplantation for end-stage renal disease in the setting of long-standing polycystic kidney disease.

Context: He had smoked one pack of cigarettes daily for 20 years but quit 5 years ago.

Context: He does not drink alcohol or use illicit drugs.

Choices:
A. Azithromycin
B. Trimethoprim-sulfamethoxazole
C. Acyclovir
D. Varicella vaccine

Answer: Trimethoprim-sulfamethoxazole

1. A 50-year-old man has a kidney transplantation.

2. The transplantation is for end-stage renal disease.

3. The end-stage renal disease is in the setting of long-standing polycystic kidney disease.

4. His postoperative course is uncomplicated.

5. He smoked one pack of cigarettes daily for 20 years.

9. Current medications include basiliximab, mycophenolate mofetil, and prednisone.

10. His vital signs are within normal limits.

11. On physical examination, the surgical incisions appear clean and intact.