Question: Further examination and testing would most likely reveal which of the following findings in this patient?

Context: A 17-year-old girl presents to the emergency department with a painful rash on her head.

Context: She says that she started noticing a rash 2 weeks ago that has gotten worse over time.

Context: In addition, she says that she has been very thirsty over the same time period and often needs to urgently use the restroom during the day, which has been disrupting her ability to pay attention in school.

Context: Otherwise she says that she has some headaches, but attributes this to migraines that run in her family.

Context: She does not take any medications, doesn't smoke, and drinks socially with her friends.

Context: On physical exam, a disfiguring red scalp rash is observed and radiographs reveal lytic appearing skull lesions.

Choices:
A. Anti-nuclear antibodies on serology
B. Granules with tennis racket shape on electron microscopy
C. HLA-B27 gene variant on genetic testing
D. Noncaseating granulomas with multinucleated giant cells on histology

Answer: Granules with tennis racket shape on electron microscopy

2. Patient presents to the emergency department with a painful rash on her head.

3. Patient started noticing the rash 2 weeks ago.

5. Patient has been very thirsty over the same time period.

6. Patient often needs to urgently use the restroom during the day.

7. Patient's need to use the restroom has been disrupting her ability to pay attention in school.

8. Patient has some headaches, which she attributes to migraines that run in her family.

9. Patient does not take any medications.

11. Patient drinks socially with her friends.

12. On physical exam, a disfiguring red scalp rash is observed.

13. Radiographs reveal lytic appearing skull lesions.


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

Context: A 57-year-old man presents to the emergency department with a change in his mental status.

Context: His wife noticed he was particularly somnolent this evening which prompted her to bring him in.

Context: The patient has a past medical history of congestive heart failure, diabetes, and hypertension.

Context: His temperature is 99.5°F (37.5°C), blood pressure is 97/58 mmHg, pulse is 40/min, respirations are 17/min, and oxygen saturation is 95% on room air.

Choices:
A. Calcium chloride
B. Dextrose
C. Glucagon
D. Transcutaneous pacing

Answer: Glucagon

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

2. His wife noticed he was particularly somnolent this evening.

3. His past medical history includes congestive heart failure, diabetes, and hypertension.

8. His oxygen saturation is 95% on room air.

9. A fingerstick blood glucose is notable for a value of 47 mg/dL.


Question: Which of the following is the next best diagnostic step?

Context: He's "trying to get in better shape.” The patient has no complaints except for occasional headaches when he is stressed about exams.

Context: The patient’s temperature is 98°F (36.7°C), blood pressure is 118/76 mmHg, and pulse is 79/min.

Context: His testes are less than 20 mL in volume, and his phallus measures less than 8 cm.

Context: Initial labs show testosterone levels of 95 ng/dL and a low follicle stimulating hormone/luteinizing hormone ratio.

Choices:
A. Adrenocorticotrophic hormone stimulation test
B. Semen analysis
C. Spectral karyotype
D. Thyroid-stimulating hormone and prolactin levels

Answer: Thyroid-stimulating hormone and prolactin levels

1. A 16-year-old boy comes to his primary care clinic for a sports physical.

2. He states that he wants to try out for his high school’s football team this year.

3. He's "trying to get in better shape.”

4. The patient has no complaints except for occasional headaches when he is stressed about exams.

5. The patient also mentions that he is embarrassed of his “small penis” and asks if there is something he can take for that.

6. The patient’s temperature is 98°F (36.7°C).

7. The patient’s blood pressure is 118/76 mmHg.

9. On physical examination, the patient is obese and has no visible facial hair.

10. His testes are less than 20 mL in volume.

11. His phallus measures less than 8 cm.

12. Initial labs show testosterone levels of 95 ng/dL.

13. Initial labs show a low follicle stimulating hormone/luteinizing hormone ratio.


Question: Which of the following statements regarding this patient’s myocardial tissue is true?

Context: A 72-year-old man presents to the hospital with retrosternal chest pain and shortness of breath.

Context: The pain started 5 hours prior to arrival and has not changed after sublingual nitroglycerin intake.

Context: The patient has a history of long-standing persistent atrial fibrillation but had not been taking anticoagulants at the time of presentation.

Context: He had also been diagnosed with iron-deficiency anemia 3 months before admission and is taking 120 mg of elemental iron daily.

Context: He has no history of ischemic heart disease.

Context: The patient is managed with percutaneous coronary intervention (PCI).

Context: Six hours after the PCI, the patient develops cardiogenic shock; 8 hours after presentation, he dies, despite intensive care management.

Context: The autopsy reveals widespread inferior-posterior myocardial infarction and thrombotic occlusion of the left circumflex artery.

Context: The microscopic image depicts a macroscopically intact myocardium.

Choices:
A. This slide shows changes in the myocardial tissue that result from lipid peroxidation during the patient's lifetime.
B. The changes shown on this slide are a result of iron overload.
C. The slide shows cardiac steatosis.
D. The microscopic image reveals cardiac tissue hypertrophy.

Answer: This slide shows changes in the myocardial tissue that result from lipid peroxidation during the patient's lifetime.

2. Patient presents with retrosternal chest pain and shortness of breath.

3. Pain started 5 hours prior to arrival.

4. Pain has not changed after sublingual nitroglycerin intake.

5. Patient has a history of long-standing persistent atrial fibrillation.

6. Patient was not taking anticoagulants at the time of presentation.

7. Patient had been diagnosed with iron-deficiency anemia 3 months before admission.

8. Patient is taking 120 mg of elemental iron daily.

9. Patient has no history of ischemic heart disease.

10. Clinical investigation confirms inferior ST-elevation myocardial infarction with occlusion of the right coronary artery.

11. Patient is managed with percutaneous coronary intervention (PCI).

12. Six hours after the PCI, the patient develops cardiogenic shock.

13. 8 hours after presentation, patient dies despite intensive care management.

14. Autopsy reveals widespread inferior-posterior myocardial infarction and thrombotic occlusion of the left circumflex artery.

15. Microscopic image depicts macroscopically intact myocardium.


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

Context: A 3-year-old boy is brought in by his parents for placement of a tracheostomy tube in order to allow for better ventilator support of his breathing.

Context: Since then, his weakness has progressively worsened such that he is unable to sit, eat, or breathe independently.

Context: Family history reveals that his grandfather was affected by a degenerative disorder at age 50, and his father had the same degenerative disorder at age 30.

Context: Examination is significant for tongue fasciculations and absent deep tendon reflexes.

Choices:
A. Autosomal dominant on chromosome 19
B. Autosomal recessive on chromosome 5
C. Autosomal recessive on chromosome 9
D. X-linked dominant

Answer: Autosomal recessive on chromosome 5

1. A 3-year-old boy is brought in by his parents for placement of a tracheostomy tube.

2. At birth, he was flaccid with a poor sucking reflex.

3. His weakness has progressively worsened such that he is unable to sit, eat, or breathe independently.

4. Family history reveals his grandfather was affected by a degenerative disorder at age 50.

5. His father had the same degenerative disorder at age 30.

6. Examination is significant for tongue fasciculations.

7. Examination is significant for absent deep tendon reflexes.

Pediatric Pulmonology
Pediatric Critical Care Medicine


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

Context: A 73-year-old man is brought to the emergency department 30 minutes after the sudden onset of right-sided body weakness.

Context: He has type 2 diabetes mellitus and has smoked 1 pack of cigarettes daily for 45 years.

Context: The patient speaks fluently, but he answers questions with nonsensical phrases and cannot repeat single words.

Choices:
A. Conduction aphasia
B. Global aphasia
C. Wernicke aphasia
D. Transcortical sensory aphasia

Answer: Wernicke aphasia

1. A 73-year-old man is brought to the emergency department.

3. The symptoms are right-sided body weakness.

4. His wife reports that he does not seem to understand simple questions.

6. He has smoked 1 pack of cigarettes daily for 45 years.

8. He answers questions with nonsensical phrases.


Question: This patient's skin finding is most likely associated with which of the following conditions?

Context: She feels well.

Context: She is 155 cm (5 ft 1 in) tall and weighs 79 kg (174 lb); BMI is 33 kg/m2.

Choices:
A. Niacin deficiency
B. Primary adrenal insufficiency
C. Polycystic ovarian syndrome
D. Hashimoto thyroiditis

Answer: Polycystic ovarian syndrome

1. A 23-year-old woman comes to physician for an annual health maintenance examination.

6. Examination shows a skin rash over both axillae.

7. A photograph of her left axilla is shown.


Question: Damage to which of the following structures is most likely to be responsible for her language deficits?

Context: A 72-year-old female is brought in by ambulance after being found down in her home.

Choices:
A. Arcuate fasciculus
B. Inferior frontal gyrus
C. Inferior frontal gyrus + superior temporal gyrus
D. Arcuate fasciculus + Inferior frontal gyrus + superior temporal gyrus

Answer: Arcuate fasciculus + Inferior frontal gyrus + superior temporal gyrus

1. A 72-year-old female is brought in by ambulance.

2. Her daughter discovered her after returning from work and does not know how long she has been down.

3. Physical exam reveals right sided paralysis with a positive babinski sign.

4. She is also found to produce strained stuttering speech with no perceivable meaning.

5. She is unable to follow any instructions and cannot repeat speech.

6. An MRI is obtained showing a left MCA infarct.

Neurology with Special Qualification in Child Neurology


Question: At steady state, which of the following sets of findings is most likely in this patient?

Context: A 66-year-old male with a history of diabetes and knee osteoarthritis presents to his primary care provider in July complaining of headaches and blurry vision.

Context: He reports a 6-month history of occasional dull diffuse headaches and blurry vision.

Context: He notes that the episodes have increased in severity since the weather got warmer and that he occasionally feels extremely itchy when he spends time outdoors.

Context: The patient lives in southern Arizona.

Context: Moreover, he has felt chronically fatigued and has lost 10 pounds without dieting or changing his appetite.

Context: He currently takes metformin and his most recent hemoglobin A1c was 6.5%.

Context: Multiple laboratory tests are pending.

Choices:
A. Increased plasma volume, increased RBC mass, decreased EPO, normal SaO2
B. Normal plasma volume, increased RBC mass, increased EPO, normal SaO2
C. Decreased plasma volume, normal RBC mass, normal EPO, normal SaO2
D. Increased plasma volume, decreased RBC mass, decreased EPO, normal SaO2

Answer: Increased plasma volume, increased RBC mass, decreased EPO, normal SaO2

1. A 66-year-old male presents to his primary care provider in July.

2. He has a history of diabetes and knee osteoarthritis.

3. He complains of headaches and blurry vision.

4. He has a 6-month history of occasional dull diffuse headaches and blurry vision.

5. The episodes have increased in severity since the weather got warmer.

6. He occasionally feels extremely itchy when he spends time outdoors.

9. He has lost 10 pounds without dieting or changing his appetite.

11. His most recent hemoglobin A1c was 6.5%.

12. Physical examination reveals multiple bruises on the bilateral upper and lower extremities and hepatosplenomegaly.

13. Fundoscopic examination demonstrates enlarged retinal veins.

14. Multiple laboratory tests are pending.


Question: This patient's behavior is characteristic of a condition that is most typically associated with which of the following?

Context: While obtaining informed consent from the patient for appendectomy, the patient reports that she does not want to undergo surgery because she does not trust doctors.

Context: She states that all doctors are “bad” and all they think about is money.

Context: She adds that she thinks that nurses are “angels” and that they should take care of her instead of the “arrogant” doctors.

Choices:
A. Repeated performance of certain routines
B. Substance use disorder
C. Fear of social situations
D. Self-injurious behavior

Answer: Self-injurious behavior

1. A 25-year-old woman is brought to the emergency department for the evaluation of severe abdominal pain for the last hour.

2. Abdominal ultrasound shows a non-compressible and enlarged appendix.

3. The patient is diagnosed with acute appendicitis.

4. While obtaining informed consent from the patient for appendectomy, the patient reports that she does not want to undergo surgery.

5. The patient states that all doctors are “bad”.

6. The patient states that all doctors think about is money.

7. The patient states that nurses are “angels”.

8. The patient states that nurses should take care of her instead of the “arrogant” doctors.


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

Context: A 20-year-old woman presents with persistent sadness for the last 2 months.

Context: She says that she is always feeling tired and nothing seems to cheer her up.

Context: Although previously a top student at her college, she did not register for classes this term, because she does not feel like going to school anymore.

Context: She says her friends complain that she does not want to ‘hang out’ with them anymore.

Context: She is sleeping more than usual and often does not want to leave the bed in the morning.

Context: The patient denies any suicidal ideation or preoccupation with death.

Context: Her past medical history is unremarkable.

Context: She currently takes a daily multivitamin.

Context: The vital signs include pulse 64/min, respiratory rate 12/min, blood pressure 110/70 mm Hg, and temperature 36.9°C (98.5°F).

Context: Her body mass index (BMI) is 17.5 kg/m2.

Context: On physical examination, the patient is pale.

Choices:
A. Mirtazapine
B. Lorazepam
C. Bupropion
D. Amitriptyline

Answer: Mirtazapine

2. Patient has persistent sadness for the last 2 months.

3. Patient is always feeling tired and nothing seems to cheer her up.

4. Patient was previously a top student at her college.

5. Patient did not register for classes this term.

6. Patient's friends complain that she does not want to 'hang out' with them anymore.

8. Patient often does not want to leave the bed in the morning.

9. Patient denies any suicidal ideation or preoccupation with death.

10. Patient's past medical history is unremarkable.

11. Patient currently takes a daily multivitamin.

12. Patient's vital signs include pulse 64/min, respiratory rate 12/min, blood pressure 110/70 mm Hg, and temperature 36.9°C (98.5°F).

13. Patient's body mass index (BMI) is 17.5 kg/m2.

14. On physical examination, patient is pale.

15. Mucous membranes and oral cavity are dry with poor dentition.

16. Multiple calluses are present on the knuckles of her left hand.


Question: Which of the following was the most likely vector that transmitted the disease to this for patient?

Context: A 31-year-old man presents to the clinic with complaints of sudden onset of fever, headache, chills, and a painful “bump” in his right groin.

Context: His physical exam is notable for an enlarged lymph node in the inguinal region that is extremely tender to palpation.

Context: The patient is promptly treated with antibiotics, and his case is reported to the Centers for Disease Control and Prevention.

Choices:
A. Armadillo
B. Flea
C. Rat
D. Tick

Answer: Flea

1. A 31-year-old man presents to the clinic.

2. He has sudden onset of fever, headache, chills, and a painful “bump” in his right groin.

3. He recently spent three months working as a park ranger in New Mexico.

4. His physical exam is notable for an enlarged lymph node in the inguinal region.

5. The lymph node is extremely tender to palpation.

6. The patient is promptly treated with antibiotics.

7. His case is reported to the Centers for Disease Control and Prevention.


Question: Which of the devices has the best precision?

Context: As the only full-time inpatient endocrinologist at your hospital, you have been tasked with deciding which blood glucose measuring device to use on the wards.

Context: A medical device representative presents you with the data in Image A.

Context: All readings were performed on the same individual whose blood glucose was known to be 125 mg/dL at the time.

Choices:
A. Device B
B. Device C
C. Device D
D. Not enough information provided

Answer: Device D

1. The speaker is an inpatient endocrinologist.

2. The speaker works full-time at a hospital.

3. The speaker has been tasked with deciding which blood glucose measuring device to use on the wards.

4. A medical device representative presented the speaker with data in Image A.

5. All readings in Image A were performed on the same individual.

6. The individual's blood glucose was known to be 125 mg/dL at the time of the readings.

Endocrinology, Diabetes, and Metabolism
Chemical Pathology
Clinical Chemistry


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

Context: A 21-year-old male comes to the physician’s office with complaints of fatigue.

Context: The patient is a college intramural athlete and has noticed that during hard workouts with his team, he gets severe muscle pain and weakness to the point where he has to stop and rest.

Context: On exam, the patient has no acute symptoms and appears to be sitting comfortably with a completely normal exam.

Choices:
A. Glucose-6-phosphatase
B. Debranching enzyme
C. Glycogen phosphorylase
D. Acid maltase

Answer: Glycogen phosphorylase

1. A 21-year-old male comes to the physician's office with complaints of fatigue.

2. The patient is a college intramural athlete.

3. During hard workouts with his team, he gets severe muscle pain and weakness to the point where he has to stop and rest.

4. Usually he is able to recover and the cramps subside after rest.

5. After strenuous workouts he has also noticed that his urine is dark.

6. On exam, the patient has no acute symptoms.

7. The patient appears to be sitting comfortably with a completely normal exam.

8. The patient does not have any tenderness to palpation of his muscles.

Endocrinology, Diabetes, and Metabolism
General Pediatrics
Metabolic Genetics


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

Context: A 78-year-old man comes to the physician because of a 3-week history of dyspnea, chest pain, dry cough, painful swallowing, and a feeling of fullness in his head.

Context: The symptoms were initially mild but have progressively worsened.

Context: He has a history of gastroesophageal reflux disease treated with esomeprazole.

Context: He does not smoke cigarettes.

Context: His pulse is 99/min and blood pressure is 95/66 mm Hg.

Context: Examination shows swelling and redness of the face and neck.

Context: There is distention of the superficial veins of his neck and upper thorax.

Context: Plain radiographs of the chest show a widened mediastinum and unremarkable lung fields.

Choices:
A. Pancoast tumor
B. Constrictive pericarditis
C. Descending aortic aneurysm
D. Mediastinal lymphoma

Answer: Mediastinal lymphoma

2. Patient has 3-week history of dyspnea, chest pain, dry cough, painful swallowing, and feeling of fullness in head.

3. Symptoms initially mild but have progressively worsened.

4. Patient has history of gastroesophageal reflux disease treated with esomeprazole.

8. Examination shows swelling and redness of face and neck.

9. Distention of superficial veins of neck and upper thorax.

10. Plain radiographs of chest show widened mediastinum and unremarkable lung fields.


Question: A drug with which of the following mechanisms of action is most appropriate for this patient?

Context: A 52-year-old man is brought to the emergency department 30 minutes after his farmhand found him on the ground sweating profusely.

Context: On arrival, he is lethargic and unable to provide any history.

Context: His temperature is 37.5°C (99.5°F), pulse is 42/min, and blood pressure is 95/60 mm Hg.

Context: The pupils are constricted.

Choices:
A. Non-selective α adrenergic receptor antagonism
B. β2 adrenergic receptor agonism
C. Muscarinic acetylcholine receptor antagonism
D. Nicotinic acetylcholine receptor agonism

Answer: Muscarinic acetylcholine receptor antagonism

1. A 52-year-old man was brought to the emergency department.

2. His farmhand found him on the ground sweating profusely 30 minutes prior.

3. He is lethargic and unable to provide any history.

7. Physical examination shows diaphoresis and excessive salivation.

9. There is scattered expiratory wheezing throughout both lung fields.

10. His clothes are soaked with vomit, urine, and feces.


Question: What is the best next step in management?

Context: A 40-year-old woman is admitted to the hospital about four hours after her husband discovered that she ingested a bottle of acetaminophen in an attempted suicide.

Context: Vital signs include a blood pressure of 115/80 mmHg and pulse of 85/min.

Context: Physical exam is unremarkable.

Context: APAP level is 160 mcg/mL, and INR is 1.7.

Choices:
A. Administer NAC
B. Cancel the NAC order
C. Involve the patient's husband to guide medical care
D. Force the patient to accept NAC

Answer: Involve the patient's husband to guide medical care

1. A 40-year-old woman is admitted to the hospital.

2. Her husband discovered that she ingested a bottle of acetaminophen four hours prior.

3. The patient denies any symptoms at this time.

4. Blood pressure is 115/80 mmHg and pulse is 85/min.

6. AST and ALT levels are approximately 2500 U/L.

9. The patient refuses N-acetyl-cysteine (NAC) treatment.


Question: What is the pathophysiology of this patient’s condition?

Context: An 11-month-old baby boy is brought to the emergency room by his parents for vomiting.

Context: His mom reports that he has had a cold for the past week with a runny nose and low-grade fevers.

Context: However, his condition worsened today when he began coughing and struggling to breathe.

Context: During one of his coughing spells he threw up his milk as well.

Context: The parents deny any sick contacts, changes in diet, or bowel changes but endorse fatigue and decreased appetite.

Context: A physical examination demonstrates a healthy-looking baby with an intense cough and significant inspiratory stridor.

Choices:
A. Generation of reactive oxygen species
B. Production of IgA proteases
C. Toxin that inactivates Gi protein
D. Toxin that permanently activates Gs protein

Answer: Toxin that inactivates Gi protein

1. An 11-month-old baby boy is brought to the emergency room by his parents.

2. His mom reports he has had a cold for the past week with a runny nose and low-grade fevers.

3. His condition worsened today when he began coughing and struggling to breathe.

4. During one of his coughing spells he threw up his milk.

5. The parents deny any sick contacts, changes in diet, or bowel changes.

6. The parents endorse fatigue and decreased appetite.

7. A physical examination demonstrates a healthy-looking baby with an intense cough.

8. A physical examination demonstrates a healthy-looking baby with significant inspiratory stridor.


Question: Which of the following underlying conditions most likely predisposed this patient to develop this reaction?

Context: A 56-year-old male undergoes a pancreaticoduodenectomy for resection of a tumor of the head of the pancreas.

Context: His medical history is otherwise insignificant except for a series of minor respiratory and gastrointestinal infections since childhood that were effectively treated with antibiotics.

Context: Before today, he has not had any prior surgeries or required a blood transfusion.

Context: In the post anesthesia care unit, his hemoglobin is measured and found to be 5.2 g/dL.

Context: A transfusion of 2 units of packed red blood cells is ordered.

Context: Minutes after the transfusion is initiated, the patient reports severe itching, nausea, and shortness of breath.

Context: His vital signs show a drop in blood pressure from 138/88 to 92/47 and an increase in heart rate from 94 to 118.

Context: The patient's nurse stops the transfusion immediately.

Choices:
A. Severe combined immunodeficiency disorder
B. Bruton's agammaglobulilnemia
C. Wiskott-Aldrich syndrome
D. Selective IgA deficiency

Answer: Selective IgA deficiency

2. Patient underwent pancreaticoduodenectomy.

3. Reason for surgery was resection of a tumor of the head of the pancreas.

4. Patient's medical history includes minor respiratory and gastrointestinal infections since childhood.

5. Patient has not had any prior surgeries or required a blood transfusion.

6. Hemoglobin measured in post anesthesia care unit was 5.2 g/dL.

7. 2 units of packed red blood cells were ordered for transfusion.

8. Minutes after transfusion was initiated, patient reported severe itching, nausea, and shortness of breath.

9. Patient's vital signs showed a drop in blood pressure from 138/88 to 92/47 and an increase in heart rate from 94 to 118.

10. Transfusion was stopped immediately by the patient's nurse.


Question: Which of the inheritance patterns can be attributed to the girl’s condition?

Context: The sclera of both eyes are blue.

Choices:
A. Pleiotropy
B. Anticipation
C. Locus heterogeneity
D. De novo mutation

Answer: Locus heterogeneity

1. A 5-year-old girl is brought to the emergency department after sustaining an atraumatic tibial fracture while playing with her friends.

2. This patient has a history of fractures in her upper and lower extremities.

3. Children's services have investigated the family several times in the past and found no abuse.

4. She was born at 39 weeks gestation via spontaneous vaginal delivery which resulted in several mild fractures.

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

6. The mother has a brother with a similar history that is still living.

7. Her vital signs show a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F).

8. Physical exam reveals a regular heart rate, and her lungs are clear to auscultation bilaterally.

10. Additionally, her teeth are brown and distorted.

11. Her leg is swollen, erythematous, and tender to palpation.

12. An X-ray reveals a tibia fracture, while multiple fractures at various stages of healing are also seen on her arms.

13. The physician suspects this is a genetic condition.


Question: Which of the following is the most likely mechanism of action for the medication that was started in this patient?

Context: A 72-year-old woman presents to her primary care physician because she is coughing pink sputum and has difficulty breathing.

Context: She says that she was feeling pretty good until she traveled to her grandson's wedding last week.

Context: Physical exam reveals swollen ankles, basilar crackles bilaterally, and a murmur best heard in the left lateral decubitus position.

Context: She is already taking several medications for this condition; however, given the recent worsening of symptoms she is started on an additional medication.

Choices:
A. Competitive inhibition of hormonal signaling
B. Decrease in adenylyl cyclase activity
C. Inhibition of Na-Cl symporter
D. Inhibition of Na-K-Cl cotransporter

Answer: Inhibition of Na-K-Cl cotransporter

1. A 72-year-old woman presents to her primary care physician.

2. She is coughing pink sputum and has difficulty breathing.

3. She was feeling pretty good until she traveled to her grandson's wedding last week.

4. Since then she has had increasing difficulty sleeping and walking due to her shortness of breath.

5. Physical exam reveals swollen ankles.

6. Physical exam reveals basilar crackles bilaterally.

7. Physical exam reveals a murmur best heard in the left lateral decubitus position.

8. She is already taking several medications for this condition.

9. Given the recent worsening of symptoms she is started on an additional medication.


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

Context: She reports that the pain is constant, 10/10, and is diffusely spread across her stomach.

Context: She reports nausea and 1 episode of vomiting 1 hour ago, painless bloody urine, and paresthesias in her hands bilaterally.

Context: Her temperature is 98.6°F (37°C), blood pressure is 148/98 mmHg, pulse is 103/min, respirations are 18/min, and oxygen saturation is 99% on room air.

Context: A physical examination demonstrates a patient in acute distress with diffuse abdominal tenderness and decreased sensation of the hands bilaterally.

Choices:
A. Implantation of the embryo outside of the uterus
B. Inflammation of the appendix
C. Mutation of the porphobilinogen deaminase enzyme
D. Obstruction of the cystic duct and subsequent inflammation of the gallbladder

Answer: Mutation of the porphobilinogen deaminase enzyme

1. A 37-year-old woman is brought to the emergency department for acute abdominal pain for the past 2 hours.

2. The pain is constant, 10/10, and is diffusely spread across her stomach.

3. She reports nausea and 1 episode of vomiting 1 hour ago.

4. She reports painless bloody urine and paresthesias in her hands bilaterally.

5. The patient claims similar episodes in the past following the use of alcohol, though with milder pain.

6. Her past medical history is significant for pelvic inflammatory disease that was adequately treated 5 years ago.

7. She is currently sexually active with her husband without contraceptive use.

12. Her oxygen saturation is 99% on room air.

13. A physical examination demonstrates a patient in acute distress with diffuse abdominal tenderness.

14. A physical examination demonstrates decreased sensation of the hands bilaterally.


Question: Which of the following represents the overall specificity of this novel test?

Context: Of the 300 patients enrolled, half are diagnosed with RA.

Context: In the subgroup of patients with RA, 125 are found positive for the novel blood test.

Context: In the control group, 45 are found positive.

Choices:
A. 105 / (105 + 25)
B. 125 / (125 + 105)
C. 105 / (105 + 45)
D. 125 / (125 + 25)

Answer: 105 / (105 + 45)

1. A medical research study is being conducted to evaluate the specificity of a novel blood test for rheumatoid arthritis.

2. 300 patients are enrolled in the study.

3. Half of the patients enrolled are diagnosed with RA.

4. The remaining patients are age-matched controls.

5. 125 patients with RA are found positive for the novel blood test.

6. 45 patients in the control group are found positive for the novel blood test.

Rheumatology
Clinical Biochemical Genetics


Question: In addition to placing the patient in the right lateral decubitus position, which of the following is the most appropriate next step in management?

Context: A 58-year-old man comes to the emergency department because of multiple episodes of coughing up blood over the past 2 hours.

Context: He says that he has coughed up approximately half a cup of bright-red blood each time.

Context: He has had progressively worsening shortness of breath on exertion and a productive cough with occasionally blood-tinged sputum for the past 6 months.

Context: He has a history of hypertension and chronic obstructive pulmonary disease.

Context: He has worked in a car manufacturing company for over 20 years.

Context: He drinks 2 to 3 beers every evening.

Context: He has smoked 1 pack of cigarettes daily for the past 30 years.

Context: His medications include amlodipine, tiotropium, and an albuterol inhaler as needed.

Context: His temperature is 37.2 °C (99.0 °F), blood pressure is 102/68 mm Hg, pulse is 108/min, and respirations are 22/min.

Context: He appears anxious and cachectic.

Context: His hemoglobin is 11.5 g/dL, leukocyte count is 8,800/mm3, and a platelet count is 160,000/mm3.

Context: His coagulation parameters are within normal limits.

Context: He is intubated and mechanically ventilated, and infusion of 0.9% saline is begun.

Context: An x-ray of the chest shows hyperinflation of the lung fields and a 2-cm nodule in the right lower lobe.

Choices:
A. Radionuclide scan
B. Upper endoscopy
C. Arteriography
D. Bronchoscopy

Answer: Bronchoscopy

2. Patient has had multiple episodes of coughing up blood over the past 2 hours.

3. Patient has coughed up approximately half a cup of bright-red blood each time.

4. Patient has had progressively worsening shortness of breath on exertion and a productive cough with occasionally blood-tinged sputum for the past 6 months.

5. Patient has a history of hypertension and chronic obstructive pulmonary disease.

6. Patient has worked in a car manufacturing company for over 20 years.

7. Patient drinks 2 to 3 beers every evening.

8. Patient has smoked 1 pack of cigarettes daily for the past 30 years.

9. Patient's medications include amlodipine, tiotropium, and an albuterol inhaler as needed.

10. Patient's temperature is 37.2 °C (99.0 °F).

11. Patient's blood pressure is 102/68 mm Hg.

14. Pulse oximetry on room air shows an oxygen saturation of 89%.

15. Patient appears anxious and cachectic.

16. Examination of the lung shows decreased breath sounds bilaterally.

17. There is no cervical or axillary lymphadenopathy.

19. Patient's leukocyte count is 8,800/mm3.

20. Patient's platelet count is 160,000/mm3.

21. Patient's coagulation parameters are within normal limits.

22. Serum studies and urine analysis show no abnormalities.

23. Patient is intubated and mechanically ventilated.

25. X-ray of the chest shows hyperinflation of the lung fields.

26. X-ray of the chest shows a 2-cm nodule in the right lower lobe.

General Pulmonary Disease
Pulmonary Disease


Question: Which of the following is the most appropriate next step for the physician?

Context: A previously healthy 3-year-old girl is brought to the physician because she refuses to use her left arm after “tripping over a stone” that morning on the way to the supermarket while holding her mother's hand.

Context: She did not hit the ground.

Context: She appears anxious.

Choices:
A. Administer ibuprofen and ice packs
B. Forced hyperpronation of the arm
C. Notify child protective services
D.
Perform nerve conduction studies and electromyography
"

Answer: Forced hyperpronation of the arm

1. A 3-year-old girl was brought to the physician.

3. She tripped over a stone that morning while holding her mother's hand.

5. Development has been normal for her age.

7. Her vital signs are within normal limits.

8. The left forearm is held close to her body in partial extension and pronation.

9. There is no swelling or bruising of the elbow or the forearm.

10. Palpation of the proximal radius produces pain.

11. The child cries on attempting to passively supinate the forearm.


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

Context: A previously healthy 29-year-old woman comes to the physician because of a 3-day history of low-grade fever, muscle aches, and a rash.

Context: She has had 4 male sexual partners over the past year and uses condoms inconsistently.

Context: Examination shows a diffuse maculopapular rash that includes the palms and soles.

Context: Testing for nonspecific anticardiolipin antibodies is positive.

Choices:
A. Assess for double-stranded DNA antibodies
B. Administer penicillin G
C. Analyze rash with darkfield microscopy
D. Test for fluorescent treponemal antibody absorption

Answer: Test for fluorescent treponemal antibody absorption

1. A 29-year-old woman came to the physician.

2. She had a 3-day history of low-grade fever, muscle aches, and a rash.

3. She had 4 male sexual partners over the past year.

5. Examination showed a diffuse maculopapular rash that included the palms and soles.

6. Testing for nonspecific anticardiolipin antibodies was positive.


Question: Of the following, which is true regarding aldosterone antagonists in patients with heart failure?

Context: A 59-year-old man with New York Heart Association Class II heart failure presents to your outpatient clinic for routine follow-up.

Context: His blood pressure is 134/89 mm Hg and heart rate is 75/min.

Context: You would like to add on spironolactone.

Choices:
A. Aldosterone antagonists do not require renal dosing
B. Aldosterone antagonists are indicated for patients in all stages of heart failure
C. Aldosterone antagonists decrease morbidity and mortality in heart failure patients
D. Aldosterone antagonists can cause visual disturbances

Answer: Aldosterone antagonists decrease morbidity and mortality in heart failure patients

1. A 59-year-old man presents to an outpatient clinic for routine follow-up.

2. The man has New York Heart Association Class II heart failure.

5. Physical examination reveals clear lung sounds bilaterally with normal S1 and S2 heart sounds.

6. He currently takes captopril, bisoprolol, and furosemide.

7. The doctor would like to add on spironolactone.


Question: The cells most likely affected in this patient’s current condition are analogous to which of the following cell types?

Context: A 32-year-old man comes to the physician because of a 1-week history of fever, nausea, headache, and confusion.

Context: He is sexually active with a new partner that he met 2 months ago and they use condoms inconsistently.

Context: He appears ill.

Choices:
A. Osteoblasts
B. Mast cells
C. Schwann cells
D. Langerhans cells

Answer: Langerhans cells

1. A 32-year-old man comes to the physician.

2. He has a 1-week history of fever, nausea, headache, and confusion.

3. Three weeks ago, he had an episode of a sore throat, diarrhea, and generalized lymphadenopathy.

4. He is sexually active with a new partner he met 2 months ago.

7. Physical examination shows nuchal rigidity.

8. Further evaluation shows infection with a single-stranded, positive-sense RNA virus.


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

Context: He states that he has felt abnormally weak during this time and has had trouble focusing in the setting of losing 5 pounds.

Context: The patient states he has a decreased appetite and also has not had a bowel movement in the past 5 days and feels uncomfortable.

Context: His temperature is 97.5°F (36.4°C), blood pressure is 132/83 mmHg, pulse is 115/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Context: His cranial nerve exam is unremarkable and his gait is stable.

Choices:
A. Calcium level
B. Lead level
C. Potassium level
D. TSH level

Answer: Calcium level

1. A 64-year-old man presents for a routine physical.

2. He states that he has felt abnormally weak during this time.

3. He has had trouble focusing in the setting of losing 5 pounds.

4. The patient states he has a decreased appetite.

5. He has not had a bowel movement in the past 5 days and feels uncomfortable.

6. On review of system, he endorses abdominal pain.

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

12. Physical exam is notable only for the patient being able to recall 1 of 3 objects.

13. His cranial nerve exam is unremarkable.

15. Urinalysis is initially notable for a clear and voluminous sample with a low specific gravity.

Geriatric Medicine
General Internal Medicine


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

Context: Ten days after a motor vehicle collision, a 28-year-old man develops jaundiced skin.

Context: Upon initial presentation for his injuries, the patient was taken for an emergency laparotomy, which revealed significant internal hemorrhage from blunt abdominal trauma to the spleen.

Context: He required rapid transfusion with a total of 7 units of packed red blood cells.

Context: He has recovered well from the procedure until this morning, when he began to develop jaundiced skin and sclerae.

Context: He does not have pruritus.

Context: He has had no prior surgeries and takes no other medications.

Context: He is sexually active with one female partner.

Context: Prior to the accident, he drank 4 beers per day.

Context: His vital signs are within normal limits.

Context: There are no palpable abdominal masses.

Context: There is a midline surgical scar with no erythema, purulence, or drainage.

Context: He has healing abrasions on the upper left side of his face and bruises over the anterior abdomen.

Context: Laboratory studies show: | Hemoglobin 9.7 g/dL | Hematocrit 30% | Leukocyte count 7,000/mm3 | Platelet count 135,000/mm3 | Serum | Total bilirubin 3.9 mg/dL | Indirect bilirubin 3.7 mg/dL | Direct bilirubin 0.2 mg/dL | Aspartate aminotransferase (AST) 60 U/L | Alanine aminotransferase (ALT) 92 U/L | .

Choices:
A. Biliary obstruction
B. Hepatocellular injury
C. Increased formation of bilirubin
D.
Decreased hepatic uptake of unconjugated bilirubin
"

Answer: Increased formation of bilirubin

2. Patient presented 10 days after motor vehicle collision.

3. Patient underwent emergency laparotomy due to blunt abdominal trauma to the spleen.

4. Patient required rapid transfusion with a total of 7 units of packed red blood cells.

5. Patient had no prior surgeries and takes no other medications.

6. Patient is sexually active with one female partner.

7. Prior to the accident, patient drank 4 beers per day.

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

9. Abdominal examination is limited due to pain.

11. Midline surgical scar with no erythema, purulence, or drainage.

12. Patient has healing abrasions on the upper left side of his face and bruises over the anterior abdomen.

13. CT scans show a resolving hematoma in the peritoneal cavity.

14. Patient has jaundiced skin and sclerae.

16. Laboratory studies show: Hemoglobin 9.7 g/dL, Hematocrit 30%, Leukocyte count 7,000/mm3, Platelet count 135,000/mm3, Total bilirubin 3.9 mg/dL, Indirect bilirubin 3.7 mg/dL, Direct bilirubin 0.2 mg/dL, Aspartate aminotransferase (AST) 60 U/L, Alanine aminotransferase (ALT) 92 U/L.


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

Context: A 69-year-old man comes to the physician because of a cough for the past 3 months.

Context: The cough is mostly dry, but the patient recalls a recent episode in which he coughed up mucus with dark red streaks.

Context: He has felt tired for the past few months.

Context: Over the past month, he has had poor appetite and a 5-kg (11-lb) weight loss.

Context: He also has occasional back pain, which has worsened in recent weeks.

Context: He has no recent travel history.

Context: He has smoked a pack of cigarettes daily for 30 years.

Context: He does not drink alcohol.

Context: His vitals are within normal limits.

Context: There is no peripheral lymphadenopathy.

Context: The liver is of normal size, and the spleen is not palpable.

Context: Laboratory studies show a hemoglobin concentration of 13.5 g/dL, serum calcium concentration of 12.3 mg/dL, and a total serum protein of 7.0 g/dL.

Context: X-rays of the chest are shown.

Choices:
A. Tuberculosis
B. Lobar pneumonia
C. Small cell lung carcinoma
D.
Squamous cell lung carcinoma
"

Answer:
Squamous cell lung carcinoma
"

2. Patient has had a cough for 3 months.

4. Patient recently coughed up mucus with dark red streaks.

5. Patient has felt tired for the past few months.

6. Patient has had poor appetite and a 5-kg (11-lb) weight loss over the past month.

7. Patient has occasional back pain, which has worsened in recent weeks.

8. Patient has no recent travel history.

9. Patient has smoked a pack of cigarettes daily for 30 years.

11. Patient's vitals are within normal limits.

12. Auscultation of the lungs reveals wheezing in the lower right lung field.

16. Laboratory studies show a hemoglobin concentration of 13.5 g/dL.

17. Laboratory studies show a serum calcium concentration of 12.3 mg/dL.

18. Laboratory studies show a total serum protein of 7.0 g/dL.


Question: This neoplasm most likely derived from which of the following types of epithelial tissue?

Context: A 37-year-old man comes to the physician because of a 3-month history of worsening painful swallowing, hoarseness, and bilateral otalgia.

Context: He does not smoke or drink alcohol.

Choices:
A. Stratified squamous epithelium with submucosal glands
B. Simple columnar epithelium with cilia
C. Pseudostratified columnar epithelium with cilia
D. Pseudostratified columnar epithelium with cartilage

Answer: Stratified squamous epithelium with submucosal glands

1. A 37-year-old man comes to the physician.

2. He has a 3-month history of worsening painful swallowing, hoarseness, and bilateral otalgia.

3. He has had a 10-kg (22-lb) weight loss during this period.

5. Laryngoscopic examination shows an abnormal mass located on the right true vocal cord.

6. Immunohistochemistry of the mass shows expression of HPV-16 DNA.


Question: These patients are at greatest risk for which of the following complications?

Context: An investigator is studying patients with an autosomal dominant mutation in the long arm of chromosome 10.

Context: This mutation alters the structure of CD95 receptors and impairs the binding of a ligand to this receptor.

Choices:
A. Partial albinism
B. Autoimmune cytopenia
C. Acute myeloid leukemia
D. Diabetes mellitus

Answer: Autoimmune cytopenia

1. An investigator is studying patients.

2. The patients have an autosomal dominant mutation.

3. The mutation is in the long arm of chromosome 10.

4. The mutation alters the structure of CD95 receptors.

5. The mutation impairs the binding of a ligand to this receptor.


Question: Which of the following is most likely a direct effect of these metabolites?

Context: He is following a 25-year-old female volunteer who is training for a marathon.

Context: Her training consists of running on a treadmill for increasing amounts of time.

Context: During her training sessions, laboratory studies show increased concentrations of adenosine and lactate in the active muscles.

Choices:
A. Decreased capillary pressure
B. Decreased systemic vascular resistance
C. Increased venous return
D. Increased mixed venous oxygen saturation

Answer: Decreased systemic vascular resistance

1. An investigator is studying cardiovascular changes during exercise.

2. The investigator is following a 25-year-old female volunteer.

3. The volunteer is training for a marathon.

4. The training consists of running on a treadmill for increasing amounts of time.

5. During her training sessions, laboratory studies show increased concentrations of adenosine in the active muscles.

6. During her training sessions, laboratory studies show increased concentrations of lactate in the active muscles.


Question: The patient's symptoms are most likely caused by antibodies against which of the following?

Context: A previously healthy 16-year-old girl is brought to the physician by her parents because of behavior changes and involuntary limb movements over the past 2 days.

Context: She also has a 2-week history of fever, headache, and fatigue.

Context: Her temperature is 38°C (100.4°F), pulse is 110/min, respirations are 20/min, and blood pressure is 102/72 mm Hg.

Context: Urine toxicology screening is negative.

Context: Cerebrospinal fluid analysis shows a leukocyte count of 70 cells/mm3 (90% lymphocytes) and a protein concentration of 51 mg/dL.

Choices:
A. Purkinje cell Yo antigens
B. GM1 ganglioside
C. Neuronal Hu antigens
D. Glutamate receptors

Answer: Glutamate receptors

2. Parents brought her to the physician due to behavior changes and involuntary limb movements over the past 2 days.

3. Patient has a 2-week history of fever, headache, and fatigue.

8. Mental status examination shows impaired speech and a disorganized thought process.

9. Muscle strength is 5/5 in all extremities.

10. Urine toxicology screening is negative.

11. Cerebrospinal fluid analysis shows a leukocyte count of 70 cells/mm3 (90% lymphocytes).

12. Cerebrospinal fluid analysis shows a protein concentration of 51 mg/dL.

13. Abdominal ultrasound shows a large right adnexal mass.


Question: The pathogen most likely responsible for this patient's presentation contains a toxin that acts by which of the following mechanisms?

Context: A 7-year-old boy is brought to the physician by his mother because of low-grade fevers and a cough lasting for 2 weeks.

Context: He has vomited several times after fits of coughing.

Context: He has no history of serious illness and has not received any routine childhood vaccinations.

Context: His temperature is 38.3°C (101°F).

Context: While in the exam room, he has a long series of consecutive coughs, during which he appears diaphoretic.

Context: The coughing is followed by a loud inspiratory gasp.

Choices:
A. Increases intracellular cAMP
B. Increases intracellular cGMP
C. Inactivates host elongation factor
D. Inactivates host 60S ribosome

Answer: Increases intracellular cAMP

2. Patient's mother brought him to the physician.

3. Patient has low-grade fevers and a cough lasting for 2 weeks.

4. Patient has vomited several times after fits of coughing.

5. Patient has no history of serious illness.

6. Patient has not received any routine childhood vaccinations.

7. Patient's temperature is 38.3°C (101°F).

8. Physical examination shows erythema of the nasal and oral mucosa.

9. Patient has a long series of consecutive coughs, during which he appears diaphoretic.

10. Coughing is followed by a loud inspiratory gasp.

11. Laboratory studies show a leukocyte count of 16,300/mm3 (67% lymphocytes).


Question: The CSF analysis will most likely reveal which of the following?

Context: A 21-year-old college student is rushed to the ER because of a high-grade fever that started this morning.

Context: She vomited several times last night.

Context: She is complaining of a severe, unremitting headache.

Context: Her temperature is 38.9°C (102.0°F), respiratory rate is 20/min, pulse is 112/min, and blood pressure is 105/78 mm Hg.

Context: She is highly sensitive to light.

Context: Her neck feels stiff on passive flexion, with positive Kernig’s and Brudzinski’s signs.

Context: There is a non-blanching maculopapular rash all over the body.

Context: Cerebrospinal fluid (CSF) samples are sent to the lab for analysis and she is started on intravenous fluids and antibiotics.

Choices:
A. Eosinophils
B. Decreased protein concentration
C. Lymphocytosis
D. Polymorphonuclear leukocytosis

Answer: Polymorphonuclear leukocytosis

1. A 21-year-old college student is rushed to the ER.

2. The student has a high-grade fever that started this morning.

3. The student vomited several times last night.

4. The student is complaining of a severe, unremitting headache.

5. The student's temperature is 38.9°C (102.0°F).

6. The student's respiratory rate is 20/min.

8. The student's blood pressure is 105/78 mm Hg.

9. The student is highly sensitive to light.

10. The student's neck feels stiff on passive flexion.

11. The student has positive Kernig’s and Brudzinski’s signs.

12. The student has a non-blanching maculopapular rash all over the body.

13. Cerebrospinal fluid (CSF) samples are sent to the lab for analysis.

14. The student is started on intravenous fluids and antibiotics.


Question: In addition to discontinuing the propranolol, which of the following drugs should be administered?

Context: A 58-year-old man with chronic obstructive pulmonary disease and hypertension comes to the physician because of shortness of breath 3 days after starting propranolol.

Context: His temperature is 36.7°C (98.1°F), pulse is 64/min, respirations are 20/min, and blood pressure is 138/88 mm Hg.

Choices:
A. Albuterol
B. Prednisone
C. Tiotropium bromide
D. Theophylline

Answer: Albuterol

1. A 58-year-old man has chronic obstructive pulmonary disease and hypertension.

2. He came to the physician because of shortness of breath 3 days after starting propranolol.

7. Auscultation of the lungs shows diffuse expiratory wheezes.


Question: Which of the following would be expected on a peripheral blood smear?

Context: A 6-year-old boy is admitted with a one-week history of diarrhea, which was sometimes bloody and originally began after a birthday party.

Context: He has become lethargic and has not been eating or drinking.

Context: His vital signs are as follows: T 38.5 C, HR 135, BP 82/54.

Context: Physical examination is significant for petechiae on his legs and diffuse abdominal tenderness to palpation.

Context: Lab-work shows BUN 72 mg/dL, creatinine 8.1 mg/dL, and platelet count < 10,000.

Context: PT and PTT are within normal limits.

Choices:
A. Rouleaux formation
B. Fragmented red blood cells
C. Spur cells
D. Giant platelets

Answer: Fragmented red blood cells

2. He has a one-week history of diarrhea.

4. The diarrhea originally began after a birthday party.

10. Physical examination is significant for petechiae on his legs.

11. Physical examination is significant for diffuse abdominal tenderness to palpation.

13. Lab-work shows creatinine 8.1 mg/dL.

14. Lab-work shows platelet count < 10,000.

15. PT and PTT are within normal limits.


Question: Which of the following cells express molecules encoded by these genes?

Context: He is interested in the human major histocompatibility complex (MHC) and human leukocyte antigens (HLAs).

Context: While studying, he learns that both class I and class II MHC molecules are expressed on specific types of cells.

Context: Currently, he is studying the HLA-DP, HLA-DQ, HLA-DRα, and HLA-DRβ genes.

Choices:
A. Eosinophils
B. Mesenchymal cells
C. Platelets
D. Thymic epithelial cells

Answer: Thymic epithelial cells

1. A microbiology student is studying the different types of cell surface markers on immune cells.

2. He is interested in the human major histocompatibility complex (MHC).

3. He is interested in human leukocyte antigens (HLAs).

4. Both class I and class II MHC molecules are expressed on specific types of cells.

5. He is currently studying the HLA-DP gene.

6. He is currently studying the HLA-DQ gene.

7. He is currently studying the HLA-DRα gene.

8. He is currently studying the HLA-DRβ gene.


Question: Which of the following is the incidence of lung cancer per 1,000 people per year?

Context: The data gathered from the study are given in the table below: | Time point Total cases of lung cancer | t = 0 years 100 | t = 5 years 500 | t = 10 years 600 | .

Choices:
A. 104
B. 0.6
C. 87
D. 125

Answer: 87

1. A 10-year study of 1,000 residents in a small US town is conducted to determine the risk of developing lung cancer.

2. The study assesses each subject with a comprehensive physical exam and chest X-ray at 3-time points: at baseline, at the 5-year point, and at the conclusion of the study.

3. At each time point, the total number of cases of lung cancer in the population is recorded.

4. The data gathered from the study is given in the table below.

5. At time point t = 0 years, there are 100 total cases of lung cancer.

6. At time point t = 5 years, there are 500 total cases of lung cancer.

7. At time point t = 10 years, there are 600 total cases of lung cancer.


Question: If a kidney biopsy had been performed while the patient’s condition was pathologic, which of the following would you expect to find upon glomerular electron microscopy?

Context: Urine protein excretion is 5.2 g over 24 hours, and serum analysis reveals hyperlipidemia.

Context: The patient responds to treatment with prednisone, and, 8 weeks later, his urine does not contain measurable protein.

Choices:
A. Effacement of podocyte foot processes
B. Subepithelial ‘spike and dome’ deposits
C. Subepithelial humps
D. Subendothelial thickening

Answer: Effacement of podocyte foot processes

1. A 7-year-old boy suffers from generalized edema.

2. Urine protein excretion is 5.2 g over 24 hours.

3. Serum analysis reveals hyperlipidemia.

4. The patient responds to treatment with prednisone.

5. 8 weeks later, his urine does not contain measurable protein.


Question: Which of the following would most likely improve this patient's symptoms?

Context: A previously healthy 3-month-old girl is brought to the emergency department because her lips turned blue while passing stools 20 minutes ago.

Context: She has not stopped crying since then.

Context: She was born at 38 weeks' gestation.

Context: She is at the 50th percentile for length and below the 30th percentile for weight.

Context: She is alert and agitated.

Context: Her temperature is 36.6°C (98°F), pulse is 180/min, respirations are 50/min, and blood pressure is 70/50 mm Hg.

Context: Pulse oximetry on room air shows an oxygen saturation of 70%, which increases to 81% on administration of 100% oxygen.

Choices:
A. Knee-chest positioning
B. Supine positioning
C. Lower limb elevation
D. Prone positioning

Answer: Knee-chest positioning

1. A 3-month-old girl was brought to the emergency department.

3. She has not stopped crying since then.

5. She is at the 50th percentile for length.

6. She is below the 30th percentile for weight.

12. Pulse oximetry on room air shows an oxygen saturation of 70%.

13. Oxygen saturation increases to 81% on administration of 100% oxygen.

14. Physical examination shows perioral cyanosis and retractions of the lower ribs with respiration.

15. Cardiac examination shows a harsh grade 2/6 systolic crescendo-decrescendo murmur at the left upper sternal border.

Pediatric Cardiology
General Pediatrics
Pediatric Emergency Medicine


Question: Which of the following best describes the pathogenesis of the disease process in this patient?"

Context: Laboratory studies show: | Hemoglobin 11.0 g/dL | Mean corpuscular volume 74 μm3 | Red cell distribution width 14 (N=13-15) | Serum ferritin 77 ng/mL | Peripheral blood smear shows small, pale red blood cells.

Context: Hemoglobin electrophoresis is normal.

Choices:
A. Decreased production of β-globin proteins
B. Amino acid substitution in the β-globin protein
C. Cis deletion of α-globin genes
D. Acquired inhibition of heme synthesis

Answer: Cis deletion of α-globin genes

1. An 8-year-old girl of Asian descent is brought to the physician because of fatigue.

2. She is not able to keep up with the rest of her classmates in gym class because she tires easily.

3. Physical examination shows pale conjunctivae.

4. Laboratory studies show Hemoglobin 11.0 g/dL.

5. Laboratory studies show Mean corpuscular volume 74 μm3.

6. Laboratory studies show Red cell distribution width 14 (N=13-15).

7. Laboratory studies show Serum ferritin 77 ng/mL.

8. Peripheral blood smear shows small, pale red blood cells.

9. Hemoglobin electrophoresis is normal.


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

Context: A 52-year-old postmenopausal woman comes to the physician with a 6-month history of difficulty biting down and chewing that is becoming progressively worse.

Context: She has been taking acetaminophen for headaches and nonspecific pain in her hips and back.

Context: She also complains that her hearing has been deteriorating as she gets older.

Context: Vital signs are within normal limits.

Context: Laboratory studies show: | Hemoglobin 14.6 g/dL | Leukocyte count 9,000/mm3 | Platelet count 256,000/mm3 | Serum | Alkaline phosphatase 1100 U/L | Vitamin D 40 ng/ml (N = 20–100 ng/mL) | Calcium 9.5 mg/dL | Parathyroid hormone 300 pg/mL | A plain x-ray of the skull is shown.

Choices:
A. Hematopoietic cell transplantation
B. Transsphenoidal hypophysectomy
C. Intravenous zoledronate
D. Estrogen replacement therapy

Answer: Intravenous zoledronate

1. Patient is a 52-year-old postmenopausal woman.

2. Patient has a 6-month history of difficulty biting down and chewing that is becoming progressively worse.

3. Patient has been taking acetaminophen for headaches and nonspecific pain in her hips and back.

4. Patient complains that her hearing has been deteriorating as she gets older.

5. Vital signs are within normal limits.

6. Examination shows a mildly tender, 1-cm, bony, immobile swelling in the left side of her forehead.

7. Intraoral examination shows bilateral expansion of the maxillary alveolus and malocclusion.

8. Audiometry shows bilateral mixed conductive and sensorineural hearing loss.

9. Laboratory studies show: Hemoglobin 14.6 g/dL, Leukocyte count 9,000/mm3, Platelet count 256,000/mm3, Serum Alkaline phosphatase 1100 U/L, Vitamin D 40 ng/ml (N = 20–100 ng/mL), Calcium 9.5 mg/dL, Parathyroid hormone 300 pg/mL.

10. A plain x-ray of the skull is shown.

Neurology
Dermatology
Orthopaedic Surgery
Otolaryngology

Neuromuscular Medicine
General Otolaryngology
General Orthopaedic Surgery
General Dermatology


Question: Serum studies obtained 5 days after admission show: | Na+ 138 mEq/L | Cl− 101 mEq/L | Mg2+ 1.3 mEq/L | Urea nitrogen 42 mg/dL | Creatinine 1.8 mg/dL | Arterial blood gas analysis on room air: | pH 7.51 | PCO2 52 mm Hg | PO2 60 mm Hg | HCO3- 33 mmol/L | Further evaluation of this patient is most likely to show which of the following findings?"

Context: A 66-year-old man is brought to the emergency department because of worsening shortness of breath and progressive swelling of his legs for 1 week.

Context: He has hypertension and hyperlipidemia.

Context: Current medications include amlodipine and pravastatin.

Context: His temperature is 37.5°C (99°F), pulse is 95/min, respirations are 12/min, and blood pressure is 113/70 mm Hg.

Context: An S3 gallop is heard on auscultation.

Context: There is jugular venous distension and pitting edema of both ankles.

Context: He is admitted to the hospital and treatment with intravenous bumetanide is initiated.

Choices:
A. Elevated serum aldosterone
B. Decreased urine chloride
C. Decreased serum renin
D. Elevated serum potassium

Answer: Elevated serum aldosterone

1. A 66-year-old man is brought to the emergency department.

2. He has worsening shortness of breath and progressive swelling of his legs for 1 week.

3. He has hypertension and hyperlipidemia.

4. His current medications include amlodipine and pravastatin.

9. Pulmonary examination shows bilateral coarse crackles.

10. An S3 gallop is heard on auscultation.

12. There is pitting edema of both ankles.

14. Treatment with intravenous bumetanide is initiated.


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

Context: A 16-year-old boy is brought to the emergency department by his parents after collapsing at home.

Context: He was resting at home after an uneventful dental procedure that involved the extraction of several teeth.

Context: He became drowsy and then unconscious and was unrousable.

Context: At the hospital, his temperature is 37.0° C (98.6° F), respiratory rate is 15/min, pulse rate is 67/min, and blood pressure is 122/98 mm Hg.

Context: Oxygen saturation is 85% on room air.

Context: The patient is deeply cyanosed despite a good respiratory effort and a clear airway.

Context: His lungs are clear to auscultation, bilaterally.

Context: Even though an endotracheal tube is introduced and assisted ventilation is induced, his condition does not improve.

Context: A review of dental records reveals the details of the procedure where the local anesthetic pilocarpine was administered.

Choices:
A. Cyanide poisoning
B. Methemoglobinemia
C. Sulfhemoglobinemia
D. Carbon monoxide poisoning

Answer: Methemoglobinemia

2. Patient was brought to the emergency department by his parents.

4. Patient had an uneventful dental procedure involving the extraction of several teeth.

5. Patient became drowsy and then unconscious and was unrousable.

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

7. Patient's respiratory rate is 15/min.

9. Patient's blood pressure is 122/98 mm Hg.

10. Patient's oxygen saturation is 85% on room air.

11. Patient is deeply cyanosed despite a good respiratory effort and a clear airway.

12. Patient's lungs are clear to auscultation, bilaterally.

13. An endotracheal tube was introduced and assisted ventilation was induced, but patient's condition did not improve.

14. Dental records reveal the details of the procedure where the local anesthetic pilocarpine was administered.


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

Context: Patient Information.

Context: Age: 1 day.

Context: Sex: F.

Context: Ethnicity: Hispanic.

Context: Site of Care: office.

Context: History.

Context: Reason for Visit/Chief Concern: brought in by her parents because “her arm looks funny”.

Context: History of Present Illness: mother had no prenatal care.

Context: labor was spontaneous with rupture of membranes yielding fluid with dark green streaks.

Context: the infant was delivered vaginally 1 day ago at home at approximately 39 weeks' gestation.

Context: the delivery was complicated by shoulder dystocia, which was managed with suprapubic pressure and the McRoberts maneuver.

Context: father reports that the infant's right arm “just hangs by the side” and that she never bends her right elbow.

Context: the infant is breastfeeding, stooling, and voiding without complication.

Context: Past Medical History: none.

Context: Family History: mother has type 2 diabetes mellitus.

Context: Medications: none.

Context: Immunizations: has not received any routine vaccinations.

Context: Allergies: no known drug allergies.

Context: Social History: the infant lives with her mother, father, and paternal grandmother.

Context: no one in the residence smokes.

Context: Physical Examination.

Context: Temp Pulse Resp BP O2 Sat Ht Wt Head circumference.

Context: 154/min 45/min 87/49 mm Hg.

Context: 50 cm.

Context: (20 in; 69th percentile).

Context: 4,400 g.

Context: (9 lb 11 oz; 99th percentile).

Context: 35 cm.

Context: (13.8 in; 82nd percentile).

Context: Appearance: well-appearing; crying during the examination.

Context: HEENT: red reflex is seen bilaterally; there is a fluctuant area over the left parietal bone that crosses suture lines.

Context: Pulmonary: clear to auscultation.

Context: Cardiac: regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops.

Context: Abdominal: no tenderness, masses, or hepatosplenomegaly; bowel sounds normal; umbilical stump is intact and clamped.

Context: Extremities: hips are stable bilaterally.

Context: Musculoskeletal: clavicles are intact bilaterally; the right upper extremity hangs limply from the shoulder in full extension, adduction, and fixed internal rotation; the hand is pronated, and the wrist and fingers are flexed.

Context: Skin: dry, warm; no jaundice.

Context: Neurologic: normal suck and grasp reflexes; the Moro reflex is normal in the left upper extremity and absent in the right upper extremity; deep tendon reflexes are 2+ bilaterally. Please refer to the summary above to answer this question.

Choices:
A. Injury to the median nerve
B. Damage to the upper trunk of the brachial plexus
C. Damage to the lower trunk of the brachial plexus
D. Aspiration of meconium

Answer: Damage to the upper trunk of the brachial plexus

- Reason for Visit/Chief Concern: brought in by her parents because “her arm looks funny”

- History of Present Illness: mother had no prenatal care

- Labor was spontaneous with rupture of membranes yielding fluid with dark green streaks

- The infant was delivered vaginally 1 day ago at home at approximately 39 weeks' gestation

- The delivery was complicated by shoulder dystocia, which was managed with suprapubic pressure and the McRoberts maneuver

- Father reports that the infant's right arm “just hangs by the side” and that she never bends her right elbow

- The infant is breastfeeding, stooling, and voiding without complication

- Family History: mother has type 2 diabetes mellitus

- Immunizations: has not received any routine vaccinations

- Social History: the infant lives with her mother, father, and paternal grandmother; no one in the residence smokes

- Wt: 4,400 g (9 lb 11 oz; 99th percentile)

- Head circumference: 35 cm (13.8 in; 82nd percentile)

- Appearance: well-appearing; crying during the examination

- HEENT: red reflex is seen bilaterally; there is a fluctuant area over the left parietal bone that crosses suture lines

- Cardiac: regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops

- Abdominal: no tenderness, masses, or hepatosplenomegaly; bowel sounds normal; umbilical stump is intact and clamped

- Extremities: hips are stable bilaterally

- Musculoskeletal: clavicles are intact bilaterally; the right upper extremity hangs limply from the shoulder in full extension, adduction, and fixed internal rotation; the hand is pronated, and the wrist and fingers are flexed

- Neurologic: normal suck and grasp reflexes; the Moro reflex is normal in the left upper extremity and absent in the right upper extremity; deep tendon reflexes are 2+ bilaterally.

General Orthopaedic Surgery
Surgery of the Hand


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

Context: A 34-year-old man presents with severe left inguinal pain and swelling since last night.

Context: He has just returned from a summer trip to the southwestern United States where he spent most of his time working with homeless and unemployed people in an area that straddles New Mexico and Utah.

Context: Upon further inquiry, he denies any contact with wild or domestic animals including pets, but he does remember occasionally seeing mice in his motel room and found their droppings on the floor.

Context: On physical exam his temperature is 38.5°C (101.3°F), pulse is 95/min, respiration rate is 18/min, and blood pressure is 130/85 mm Hg.

Context: The left inguinal area is swollen.

Context: There is no skin erythema and it is not warm to palpation.

Context: There are several enlarged and soft lymph nodes with a hard underlying core.

Context: The area is very tender and surrounded by edema.

Context: A localized rash is found in the ipsilateral inner thigh above the knee (see image).

Context: Examination of the heart, lungs, abdomen, and other limbs shows no abnormalities.

Choices:
A. Hantavirus
B. Rhabdovirus
C. Borrelia burgdorferi
D. Yersinia pestis

Answer: Yersinia pestis

2. Patient has severe left inguinal pain and swelling since last night.

3. Patient recently returned from a summer trip to the southwestern United States.

4. Patient spent most of his time working with homeless and unemployed people in an area that straddles New Mexico and Utah.

5. Patient denies any contact with wild or domestic animals including pets.

6. Patient remembers occasionally seeing mice in his motel room and found their droppings on the floor.

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

9. Patient's respiration rate is 18/min.

10. Patient's blood pressure is 130/85 mm Hg.

12. No skin erythema and not warm to palpation.

13. Several enlarged and soft lymph nodes with a hard underlying core.

14. Area is very tender and surrounded by edema.

15. Localized rash found in ipsilateral inner thigh above the knee.

16. Examination of heart, lungs, abdomen, and other limbs shows no abnormalities.


Question: Which of the following is the most appropriate advice for this patient’s mother?

Context: A 10-year-old unvaccinated girl presents to her pediatrician with a rash.

Context: Her mother reports that she has had a fever, “red eyes,” sore throat, and rash on her face for the last day.

Context: On physical examination, the girl appears sick but not toxic, and has nonpurulent conjunctivitis and an erythematous posterior pharynx without exudate or tonsillar hypertrophy.

Context: She has lymphadenopathy bilaterally.

Context: Her heart has a regular rate without murmurs, her lungs are clear to auscultation bilaterally, and her abdomen is soft without hepatosplenomegaly.

Context: She has red cheeks with circumoral pallor and no other skin findings.

Choices:
A. This infection could have been prevented with a vaccine.
B. Her symptoms were caused by human herpesvirus type 6 (HHV-6) or human herpesvirus type 7 (HHV-7).
C. She will likely develop a maculopapular truncal rash in a few days that will fade to become a lacy rash.
D. She should be started on oral valacyclovir.

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

1. A 10-year-old unvaccinated girl presents to her pediatrician.

2. Her mother reports that she has had a fever.

3. Her mother reports that she has had "red eyes".

4. Her mother reports that she has had a sore throat.

5. Her mother reports that she has had a rash on her face for the last day.

6. On physical examination, the girl appears sick but not toxic.

7. On physical examination, the girl has nonpurulent conjunctivitis.

8. On physical examination, the girl has an erythematous posterior pharynx without exudate or tonsillar hypertrophy.

9. On physical examination, the girl has lymphadenopathy bilaterally.

10. On physical examination, the girl's heart has a regular rate without murmurs.

11. On physical examination, the girl's lungs are clear to auscultation bilaterally.

12. On physical examination, the girl's abdomen is soft without hepatosplenomegaly.

13. On physical examination, the girl has red cheeks with circumoral pallor.

14. On physical examination, the girl has no other skin findings.

General Pediatrics
Pediatric Infectious Diseases


Question: Which of the following changes in forced expiratory volume (FEV1) and forced vital capacity (FVC) are expected if she takes a pulmonary function test?

Context: A 42-year-old woman presents to the clinic for worsening fatigue and difficulty breathing for the last 6 months.

Context: Previously, she could routinely walk 3 miles after dinner, but now she can no longer walk more than 2 blocks without being short of breath.

Context: She also reports being tired soon after starting any type of physical activity.

Context: On further questioning, she recalls having on and off fevers, occasional night sweats, and losing 5 kg (11 lb) over the last 6 months.

Context: Her past medical history reveals 2 cesarean deliveries in her twenties and a hospitalization for acute appendicitis in her teens.

Context: She currently takes no medications and also denies smoking and recreational drug use.

Context: She drinks half a glass of wine with her evening meals.

Context: Her vitals include a respiratory rate of 14/min, a pulse rate of 87/min, a blood pressure of 110/89 mm Hg, and a temperature of 36.7°C (98.0°F).

Context: Physical examination is normal.

Context: A chest X-ray shows bilateral hilar lymphadenopathy.

Choices:
A. FEV1: decrease and FVC: decreased
B. FEV1: decreased and FVC: no change
C. FEV1: decreased and FVC: increased
D. FEV1: no change and FVC: no change

Answer: FEV1: decrease and FVC: decreased

2. Patient has been experiencing worsening fatigue and difficulty breathing for the last 6 months.

3. Patient used to be able to walk 3 miles after dinner, but now can only walk 2 blocks without being short of breath.

4. Patient reports being tired soon after starting any type of physical activity.

5. Patient has had on and off fevers, occasional night sweats, and has lost 5 kg (11 lb) over the last 6 months.

6. Patient's past medical history includes 2 cesarean deliveries in her twenties and a hospitalization for acute appendicitis in her teens.

8. Patient denies smoking and recreational drug use.

9. Patient drinks half a glass of wine with her evening meals.

10. Patient's vitals include a respiratory rate of 14/min, a pulse rate of 87/min, a blood pressure of 110/89 mm Hg, and a temperature of 36.7°C (98.0°F).

12. Chest X-ray shows bilateral hilar lymphadenopathy.

General Pulmonary Disease
General Pulmonology


Question: This patient's symptoms are most likely caused by a side effect of which of the following medications?

Context: A 42-year-old woman is brought to the emergency department because of a severe, throbbing, occipital headache for 2 hours.

Context: The patient has recurrent migraine headaches and depression, for which she takes medication daily.

Context: Her temperature is 37.2°C (98.9 F), pulse is 88/min, respirations are 19/min, and blood pressure is 190/128 mmHg.

Choices:
A. Tranylcypromine
B. Almotriptan
C. Topiramate
D. Doxepin

Answer: Tranylcypromine

1. A 42-year-old woman is brought to the emergency department.

2. She has a severe, throbbing, occipital headache for 2 hours.

3. She also reports nausea, photophobia, and chest tightness.

4. The symptoms developed shortly after she had a snack consisting of salami and some dried fruits at a wine tasting event.

5. The patient has recurrent migraine headaches and depression.

6. She takes medication daily for her migraine headaches and depression.

7. She is mildly distressed, diaphoretic, and her face is flushed.

12. Deep-tendon reflexes are 2+ bilaterally.


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

Context: A 70-year-old man is brought to the emergency department because of severe back pain that began when he was lifting a box 1 hour ago.

Context: He also has a 2-year history of increasingly severe right hip pain.

Context: Physical examination shows tenderness to palpation of the lower spine as well as erythema of the skin over the right hip.

Context: Neurologic examination shows decreased hearing in the left ear; the Weber test localizes to the left side.

Context: Serum studies show an alkaline phosphatase concentration of 410 U/L, calcium concentration of 9.5 mg/dL, and parathyroid hormone level of 322 pg/mL.

Choices:
A. Osteoporosis
B. Osteomalacia
C. Osteitis deformans
D. Osteonecrosis

Answer: Osteitis deformans

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

2. The man has severe back pain that began 1 hour ago.

3. The man has a 2-year history of increasingly severe right hip pain.

4. Physical examination shows tenderness to palpation of the lower spine.

5. Physical examination also shows erythema of the skin over the right hip.

6. Neurologic examination shows decreased hearing in the left ear.

7. The Weber test localizes to the left side.

8. Serum studies show an alkaline phosphatase concentration of 410 U/L.

9. Serum studies show a calcium concentration of 9.5 mg/dL.

10. Serum studies show a parathyroid hormone level of 322 pg/mL.

11. An x-ray of the spine shows a fracture of the L4 vertebra.

Orthopaedic Sports Medicine
General Orthopaedic Surgery


Question: Which of the following is true about cross-over study designs?

Context: A study investigating the use of adalimumab for the relief of peripheral arthropathy in patients with psoriatic arthritis was conducted.

Context: The study utilizes a crossover design in which half of the study participants are given adalimumab for a month while the other half takes placebo.

Context: After a 2 week washout period in which no one takes any adalimumab, the group that was originally on adalimumab is given placebo for a month while the group that was originally taking placebo is given adalimumab for a month.

Choices:
A. Crossover studies avoid the ethical issue of not giving all participants access to a novel therapeutic agent
B. Crossover studies minimize the effects of differences between participants
C. The purpose of the washout period is to increase the length of the study to gather more data
D. 1 and 2

Answer: 1 and 2

1. A study was conducted investigating the use of adalimumab for the relief of peripheral arthropathy in patients with psoriatic arthritis.

2. The study utilizes a crossover design.

3. Half of the study participants are given adalimumab for a month.

5. After a 2 week washout period, the group that was originally on adalimumab is given placebo for a month.

6. The group that was originally taking placebo is given adalimumab for a month.

7. Pain in all affected joints is assessed clinically by follow-up visits every two weeks for the duration of the study.


Question: Which medication is likely responsible for these symptoms?

Context: A 64-year-old woman presented to the community health clinic complaining of nausea, bloating, pain in both knees, and a burning sensation in her feet.

Context: She has recently immigrated to the United States and was previously diagnosed with diabetes mellitus, hypertension, and osteoarthritis but no medical records are currently available.

Context: She has stopped taking her medication since immigrating; however, she does recall being on insulin but cannot recall the dosage or the specific type.

Context: She has a blood pressure of 172/120 mm Hg, heart rate of 95/min, respiratory rate of 15/min, and temperature of 37.0°C (98.6°F).

Context: Her random serum glucose is 364 mg/dL.

Choices:
A. Atorvastatin
B. Metoclopramide
C. Ramipril
D. Acetaminophen

Answer: Metoclopramide

1. A 64-year-old woman presented to the community health clinic.

2. She was complaining of nausea, bloating, pain in both knees, and a burning sensation in her feet.

3. She has recently immigrated to the United States.

4. She was previously diagnosed with diabetes mellitus, hypertension, and osteoarthritis.

5. No medical records are currently available.

6. She has stopped taking her medication since immigrating.

7. She recalls being on insulin but cannot recall the dosage or the specific type.

12. Her random serum glucose is 364 mg/dL.

13. She is started on atorvastatin, amlodipine, ramipril, aspirin, duloxetine, metoclopramide, acetaminophen, and insulin detemir.

14. Three weeks later, she presents with generalized weakness, walking difficulty, and hand tremors.

15. Physical examination reveals bilateral hand tremors, cogwheel rigidity, and bradykinesia.

16. She is walking with small narrow steps and reduced arm swing.

17. Today her random serum glucose is 150 mg/dL.

18. Her symptoms are presumed to be caused by a drug.


Question: This patient most likely has an injury to which of the following muscle tendons?

Context: A 51-year-old man presents to the emergency room after being the victim of a robbery and assault.

Context: Upon resisting, the stranger stabbed the patient’s right distal forearm before stealing his wallet and evading the scene.

Context: The patient was able to call an ambulance and has remained conscious despite mild bleeding from the injury site.

Context: He reports severe pain in his forearm and an inability to move his 2nd and 3rd fingers.

Context: He has no medical conditions and takes no medications.

Context: He is allergic to penicillin and ibuprofen.

Choices:
A. Flexor digitorum longus
B. Flexor digitorum profundus
C. Flexor digitorum superficialis
D. Flexor pollicis longus

Answer: Flexor digitorum profundus

1. A 51-year-old man presents to the emergency room.

2. He was the victim of a robbery and assault.

3. He was walking down an alley when he was approached by a stranger with a knife.

4. Upon resisting, the stranger stabbed the patient’s right distal forearm.

5. The stranger stole the patient's wallet and evaded the scene.

6. The patient was able to call an ambulance.

8. The patient has mild bleeding from the injury site.

9. The patient reports severe pain in his forearm.

10. The patient reports an inability to move his 2nd and 3rd fingers.

11. The patient has no medical conditions.

13. The patient is allergic to penicillin.

14. The patient is allergic to ibuprofen.

15. On exam, the patient is able to flex the proximal interphalangeal (PIP) joints of his 2nd through 5th fingers.

16. When the PIP joints of his 2nd through 5th fingers are restrained by the examiner, flexion is noted at the DIP joints of the 4th and 5th fingers but not the 2nd and 3rd digits.

17. Thumb flexion at the metacarpophalangeal (MCP) joint and interphalangeal (IP) joint is preserved.

18. Sensation is intact over the palmar and dorsal aspects of the radial and ulnar hand.


Question: Which of the following natural substances are most similar to the concentration profiles of drug X and drug Y in the proximal tubule?

Context: Researchers develop a drug X that acts on the loop of Henle but discover that it does not reach its intended site of action within the nephron.

Context: It is freely filtered but rapidly disappears from the proximal tubule.

Context: They modify several of the chemical properties of drug X to produce drug Y, which cannot be reabsorbed from the proximal tubule.

Choices:
A. Drug X: creatinine; Drug Y: glucose
B. Drug X: glucose; Drug Y: creatinine
C. Drug X: glucose; Drug Y: potassium
D. Drug X: potassium; Drug Y: creatinine

Answer: Drug X: glucose; Drug Y: creatinine

3. Drug X does not reach its intended site of action within the nephron.

5. Drug X rapidly disappears from the proximal tubule.

6. Researchers modify several of the chemical properties of drug X.

7. Drug X is modified to produce drug Y.

8. Drug Y cannot be reabsorbed from the proximal tubule.


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

Context: A 66-year-old woman comes to the emergency department because of fever and difficulty swallowing for 5 hours.

Context: She appears anxious.

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

Context: Her voice is muffled and there is inspiratory stridor.

Context: There is tender bilateral cervical lymphadenopathy and pain upon palpation of the hyoid.

Context: Laboratory studies show a leukocyte count of 18,800/mm3 with 85% neutrophils.

Choices:
A. Haemophilus influenzae type b
B. Streptococcus pyogenes
C. Corynebacterium diphtheriae
D.
Parainfluenza virus
"

Answer: Haemophilus influenzae type b

1. A 66-year-old woman comes to the emergency department.

2. She has had fever and difficulty swallowing for 5 hours.

5. Physical examination shows an extended neck and excessive drooling.

8. There is tender bilateral cervical lymphadenopathy.

9. There is pain upon palpation of the hyoid.

10. Laboratory studies show a leukocyte count of 18,800/mm3.

11. Laboratory studies show 85% neutrophils.

Otolaryngology
Internal Medicine
Pediatrics

General Otolaryngology
Pediatric Infectious Diseases
Infectious Disease


Question: What is the cause of the persistent symptoms?

Context: A 65-year-old man with a history of coronary artery disease presents to your office complaining of ongoing chest pain with exertion.

Context: The patient has had a recent cardiac work-up that showed no areas of acute ischemia.

Context: At the last visit, the patient was prescribed sublingual nitroglycerin for symptom relief of stable angina.

Context: On further questioning, the patient states that he has been swallowing the tablet whole instead of allowing it to dissolve because he “does not like the taste”.

Choices:
A. Nitroglycerin tolerance
B. Unstable angina
C. First pass metabolism of nitroglycerin
D. Concomitant use of sildenafil

Answer: First pass metabolism of nitroglycerin

1. A 65-year-old man presents to the office.

2. The patient has a history of coronary artery disease.

3. The patient is complaining of chest pain with exertion.

4. The patient had a recent cardiac work-up that showed no areas of acute ischemia.

5. At the last visit, the patient was prescribed sublingual nitroglycerin.

6. The patient has been swallowing the tablet whole instead of allowing it to dissolve.

7. The patient does not like the taste of the nitroglycerin.


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

Context: A 5-year-old boy is brought to the physician by his mother because of a 3-day history of low-grade fever and sore throat.

Context: This morning, she noticed a rash on his buttocks, hands, and feet.

Context: He does not have pruritus.

Context: His temperature is 38.3°C (100.9°F), pulse is 99/min, and blood pressure is 123/78 mm Hg.

Choices:
A. Herpes simplex virus 1
B. Coxsackie A virus
C. Parvovirus B19
D. Epstein-Barr virus

Answer: Coxsackie A virus

1. A 5-year-old boy is brought to the physician by his mother.

2. He has a 3-day history of low-grade fever and sore throat.

3. This morning, his mother noticed a rash on his buttocks, hands, and feet.

8. Physical examination shows oral vesicles.

9. A photograph of the rash on the feet is shown.


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

Context: An 8-year-old African-American male is found to have a holosystolic, harsh-sounding murmur upon physical examination.

Context: The murmur is best appreciated at the left sternal border, and is found to be louder when the patient squats.

Choices:
A. Ventricular septal defect
B. Patent ductus arteriosus
C. Atrial septal defect
D. Tricuspid atresia

Answer: Ventricular septal defect

1. An 8-year-old African-American male is found to have a holosystolic, harsh-sounding murmur.

2. The murmur is best appreciated at the left sternal border.

3. The murmur is louder when the patient squats.


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

Context: A 29-year-old G1P0 woman at 32 weeks of gestation comes to the emergency department complaining of vaginal bleeding for the past hour.

Context: She noticed some blood on the toilet paper when she went to the bathroom an hour ago, but now she is bleeding through her underwear.

Context: She denies any trauma, pain, abnormal discharge or odor, fever, or recent infections.

Context: The patient mentioned that that during her last ultrasound, the doctor told her that, “there’s an abnormality but not to worry,” but she can’t remember the name of the condition.

Context: Her temperature is 100.1°F (37.8°C), blood pressure is 120/70 mmHg, pulse is 86/min, and respirations are 15/min .

Context: A fetal heart tracing is obtained and shows a fetal heart rate of 130-140, long-term variability, and appropriate accelerations.

Choices:
A. Abnormal placental spiral artery development
B. Attachment of the placenta to the lower placental segment over the internal os
C. Cystic swelling of chorionic villi and trophoblast proliferation
D. Fetal vessels in close proximity to the cervical os

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

3. Patient is complaining of vaginal bleeding for the past hour.

4. Patient noticed some blood on the toilet paper an hour ago.

5. Patient is now bleeding through her underwear.

6. Patient denies any trauma, pain, abnormal discharge or odor, fever, or recent infections.

7. Patient mentioned that during her last ultrasound, the doctor told her that “there’s an abnormality but not to worry,” but she can’t remember the name of the condition.

8. Patient's temperature is 100.1°F (37.8°C).

9. Patient's blood pressure is 120/70 mmHg.

12. Fetal heart tracing shows a fetal heart rate of 130-140.

13. Fetal heart tracing shows long-term variability.

14. Fetal heart tracing shows appropriate accelerations.

Placenta Previa
General Obstetrics and Gynecology


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

Context: Her mother has rheumatoid arthritis for which she takes methotrexate, and her father died of prostatic carcinoma 7 years ago.

Context: No lymphadenopathy is noted.

Context: Laboratory results are shown below: | Complete blood count: | Hemoglobin 10 g/dL | Leukocytes   13,500/mm3 | Platelets 170,000/mm3 | ESR 65 mm/hr |    Antinuclear antibody Positive | Rheumatoid factor Positive | Anti dsDNA Negative | Anti Ro Positive | Anti-CCP Negative | Anti Jo 1   Negative | .

Choices:
A. Rheumatoid arthritis
B. Systemic lupus erythematosus
C. Primary Sjogren’s syndrome
D. Polymyositis

Answer: Primary Sjogren’s syndrome

1. A 55-year-old woman comes to the office complaining of a dry mouth for the past few months.

2. She has to drink water more frequently, as she finds it difficult to chew and swallow solid foods.

3. She has to wake up 3–5 times each night to drink due to intense thirst.

4. She also complains of a foreign body sensation in both the eyes for the past month.

5. She has had no joint pain, fever, weight loss, or urinary or bowel changes.

6. She does not smoke cigarettes but drinks alcohol socially.

7. Her mother has rheumatoid arthritis for which she takes methotrexate.

8. Her father died of prostatic carcinoma 7 years ago.

9. Her temperature is 36.7°C (98°F), blood pressure is 130/75 mm Hg, pulse is 80/min, respirations are 14/min, and BMI is 28 kg/m2.

10. On examination, the eyes and oral cavity appear dry, and dental caries are present.

12. Cardiopulmonary and abdominal examinations are negative.

13. Laboratory results show a hemoglobin of 10 g/dL, leukocytes of 13,500/mm3, platelets of 170,000/mm3, and ESR of 65 mm/hr.


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

Context: Despite confirmed H.

Context: The body mass index is 19 kg/m2.

Context: The laboratory studies show the following: | Laboratory test | Hemoglobin 10 g/dL | Mean corpuscular volume 75 μm3 | Leukocyte count 7500/mm3 with a normal differential | Serum   | Na+ 145 mEq/L | K+ 4.5 mEq/L | Ca+ 9.5 mg/dL | Phosphorus 4 mg/dL | Urea nitrogen 18 mg/dL | Creatinine 1.0 mg/dL | .

Choices:
A. Chronic alcohol consumption
B. Gastrin-secreting tumor
C. Primary hyperparathyroidism
D. Tobacco use

Answer: Gastrin-secreting tumor

1. A 42-year-old woman presents to the physician with chronic abdominal pain.

2. She was initially diagnosed with an ulcer in the 2nd part of the duodenum and severe esophagitis 6 years ago.

3. Despite confirmed H. pylori eradication and long-term therapy with pantoprazole, she has had frequent recurrences of duodenal and gastric ulcers.

4. The medical history is otherwise unremarkable.

5. She is a 10 pack-year smoker and consumes alcohol regularly.

6. Her father had severe gastric ulcer disease.

7. The vital signs are within normal limits.

9. Mild epigastric tenderness is noted on deep palpation of the epigastrium.

10. The laboratory studies show the following: Hemoglobin 10 g/dL.

11. The laboratory studies show the following: Mean corpuscular volume 75 μm3.

12. The laboratory studies show the following: Leukocyte count 7500/mm3 with a normal differential.

13. The laboratory studies show the following: Serum Na+ 145 mEq/L.

14. The laboratory studies show the following: Serum K+ 4.5 mEq/L.

15. The laboratory studies show the following: Serum Ca+ 9.5 mg/dL.

16. The laboratory studies show the following: Serum Phosphorus 4 mg/dL.

17. The laboratory studies show the following: Serum Urea nitrogen 18 mg/dL.

18. The laboratory studies show the following: Serum Creatinine 1.0 mg/dL.


Question: What imaging finding would you expect in this patient?

Context: A 33-year-old woman comes to the emergency department for severe abdominal pain for the past hour.

Context: She denies fever, weight changes, headaches, palpitations, bowel changes, or chest pain, but endorses nausea and stool that is hard to flush.

Choices:
A. Gallbladder thickening and presence of cholelithiasis on ultrasound
B. Increase in appendicular diameter and fat stranding on computer tomography (CT)
C. Lack of an intrauterine pregnancy on ultrasound
D. Multiple pancreatic calcifications on CT

Answer: Multiple pancreatic calcifications on CT

1. A 33-year-old woman comes to the emergency department for severe abdominal pain.

2. The pain is 10/10, stabbing, and concentrated around the epigastric region with radiation to the back.

3. She had 2 episodes of emesis and complains of nausea.

4. She has had multiple similar episodes over the past 3 months which are not correlated with oral intake.

5. She denies fever, weight changes, headaches, palpitations, bowel changes, or chest pain.

6. She endorses nausea and stool that is hard to flush.

7. Her medical history is significant for diabetes that is controlled with metformin.

8. Her surgical history is significant for an elective cesarean section 5 years ago.

9. She is currently sexually active with contraceptive use.


Question: This patient’s symptoms are most likely attributable to which of the following medications?

Context: A 37-year-old female presents to her primary care provider for a normal follow-up visit.

Context: Her past medical history is notable for poorly controlled type II diabetes mellitus despite good treatment adherence to oral medications.

Context: She has been trialed on metformin and glyburide but stopped them due to rapid weight gain, respectively.

Context: She was started on a new oral diabetes medication three months ago.

Context: Since starting the new medication, she has noticed slowly progressive swelling in her lower extremities.

Context: Her temperature is 99.2°F (37.3°C), blood pressure is 120/75 mmHg, pulse is 105/min, and respirations are 22/min.

Context: She has gained 10 pounds since her last visit.

Context: A hemoglobin A1c lab test is drawn.

Choices:
A. Glipizide
B. Exenatide
C. Pioglitazone
D. Acarbose

Answer: Pioglitazone

2. Patient is presenting for a normal follow-up visit.

3. Patient has a past medical history of poorly controlled type II diabetes mellitus.

4. Patient has been adherent to oral medications.

5. Patient was trialed on metformin and glyburide but stopped due to rapid weight gain.

6. Patient was started on a new oral diabetes medication three months ago.

7. Patient has noticed slowly progressive swelling in her lower extremities since starting the new medication.

8. Patient's temperature is 99.2°F (37.3°C).

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

12. Patient has gained 10 pounds since her last visit.

13. Physical examination reveals 1+ pitting edema in the bilateral legs.

Endocrinology, Diabetes, and Metabolism
General Internal Medicine