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

Context: A 58-year-old man presents to the emergency department with a 4-hour history of severe abdominal pain.

Context: He has noted brief episodes of postprandial abdominal pain for the last 2 months, but this pain is much more severe and diffuse.

Context: He also reports nausea and has had several episodes of non-bloody, non-bilious emesis since the pain started.

Context: Past medical history is notable for hyperlipidemia diagnosed 10 years ago and managed with lifestyle modifications; he has never been hospitalized.

Context: Vital signs are unremarkable.

Choices:
A. Cholecystectomy
B. Colonoscopy
C. Endoscopic retrograde cholangiopancreatography (ERCP)
D. Esophagogastroduodenoscopy (EGD)

Answer: Endoscopic retrograde cholangiopancreatography (ERCP)

2. Patient has 4-hour history of severe abdominal pain.

3. Patient has had brief episodes of postprandial abdominal pain for the last 2 months.

4. Patient has nausea and several episodes of non-bloody, non-bilious emesis since the pain started.

5. Patient has past medical history of hyperlipidemia diagnosed 10 years ago and managed with lifestyle modifications.

8. Physical examination shows dry mucous membranes and a soft, non-distended abdomen that is diffusely tender.

9. Laboratory tests are notable for a lipase level of 3,125 U/L.

10. CT of the abdomen shows an enlarged gallbladder and peripancreatic fluid with dilation of the pancreatic and common bile ducts.


Question: Which of the following would most likely be observed in cells with this genetic change?

Context: He says that he has generally been feeling well; however, he has noticed that he has had some intermittent very low grade fevers of unknown etiology.

Context: A biopsy of the enlarged nodes is obtained and genetic testing shows that part of chromosomes 14 and 18 are joined together.

Choices:
A. Decreased activation of CD95
B. Decreased activity of p53
C. Decreased release of cytochrome c
D. Increased activation of Apaf-1

Answer: Decreased release of cytochrome c

1. A 55-year-old man presents to his primary care physician for his annual check-up.

2. He says that he has generally been feeling well.

3. He has noticed that he has had some intermittent very low grade fevers of unknown etiology.

4. His past medical history is significant for well-controlled hypertension and diabetes.

5. On physical exam he is found to have painless enlargement of a number of cervical and axillary lymph nodes.

6. A biopsy of the enlarged nodes is obtained.

7. Genetic testing shows that part of chromosomes 14 and 18 are joined together.

Molecular Genetic Pathology
Clinical Genetics and Genomics


Question: Which of the following adverse effects is most likely to occur?

Context: A 75-year-old man is brought to the emergency room because of dizziness and palpitations for the past hour.

Context: His pulse is 185/min and blood pressure is 100/52 mm Hg.

Context: A drug is administered that activates cardiac potassium channels and causes transient atrioventricular block.

Choices:
A. Chest pain
B. Dry cough
C. Perioral paresthesia
D. Yellow vision

Answer: Chest pain

1. A 75-year-old man is brought to the emergency room.

2. He has been experiencing dizziness and palpitations for the past hour.

5. An ECG shows a narrow-complex, regular tachycardia without P waves.

6. A drug is administered that activates cardiac potassium channels.

7. The drug causes transient atrioventricular block.


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

Context: A 70-year-old man is brought to the emergency department with painful discharge from his right ear with difficulty hearing for 3 days.

Context: His temperature is 39.5°C (103.1°F) and pulse is 120/minute.

Context: Physical examination shows mild facial asymmetry with the right corner of his mouth lagging behind the left when the patient smiles.

Choices:
A. Decreased intracranial perfusion
B. Glucose intolerance
C. Pus-filled mastoid air cells
D. Positive streptococcal culture

Answer: Glucose intolerance

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

2. He has painful discharge from his right ear.

3. He has difficulty hearing for 3 days.

6. Physical examination shows mild facial asymmetry.

7. The right corner of his mouth lags behind the left when the patient smiles.

8. There is severe ear pain when the right auricle is pulled superiorly.

9. Otoscopic examination shows granulation tissue at the transition between the cartilaginous and the osseous part of the ear canal.


Question: Which of the following drugs was this mother most likely taking during pregnancy?

Context: A 24-year-old female with a history of recurrent infections, bipolar disorder, and no prenatal care gives birth to a male infant.

Context: On physical exam in the delivery room, you observe a tuft of hair over the infant's lumbosacral region.

Choices:
A. Gentamicin
B. Lithium
C. Valproate
D. Folic acid

Answer: Valproate

1. A 24-year-old female gave birth to a male infant.

2. The female has a history of recurrent infections.

3. The female has a history of bipolar disorder.

5. On physical exam in the delivery room, a tuft of hair was observed over the infant's lumbosacral region.


Question: What structure is most likely to be affected by this patient's condition?

Context: A 25-year-old woman presents to the physician with the complaint of several episodes of headache in the past 4 weeks that are affecting her school performance.

Context: The episodes are getting progressively worse, and over-the-counter headache and migraine medication do not seem to help.

Context: She also mentions having to raise her head each time to look at the board when taking notes; she cannot simply glance up with just her eyes while facing her notes.

Context: She has no significant past medical or family history and was otherwise well prior to this visit.

Context: Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema.

Choices:
A. Third ventricle
B. Aqueduct of Sylvius
C. Tegmentum
D. Inferior colliculi

Answer: Aqueduct of Sylvius

1. A 25-year-old woman presents to the physician with the complaint of several episodes of headache in the past 4 weeks.

2. The episodes are affecting her school performance.

3. The episodes are getting progressively worse.

4. Over-the-counter headache and migraine medication do not seem to help.

5. She has to raise her head each time to look at the board when taking notes.

6. She cannot simply glance up with just her eyes while facing her notes.

7. She has no significant past medical or family history.

8. She was otherwise well prior to this visit.

9. Ophthalmic examination shows an upward gaze palsy.

10. Ophthalmic examination shows convergence-retraction nystagmus.

11. Ophthalmic examination shows papilledema.


Question: The patient is at greatest risk of which of the following adverse effects?

Context: A 75-year-old woman is brought to the emergency department because of a 6-hour history of severe headache, nausea, and 1 episode of vomiting.

Context: Her pulse is 50/min, respirations are 8/min and shallow, and blood pressure is 150/96 mm Hg.

Context: Appropriate pharmacotherapy with an intravenous drug is initiated, and the patient's urine output subsequently increases.

Choices:
A. Drug-induced hypersensitivity syndrome
B. Hyperuricemia
C. Tinnitus
D. Pulmonary edema

Answer: Pulmonary edema

1. A 75-year-old woman is brought to the emergency department.

2. She has a 6-hour history of severe headache, nausea, and 1 episode of vomiting.

3. On arrival, she is lethargic and oriented only to self.

5. Her respirations are 8/min and shallow.

7. Examination shows medial deviation of the left globe and ecchymoses of the upper eyelids.

8. Appropriate pharmacotherapy with an intravenous drug is initiated.

9. The patient's urine output subsequently increases.


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

Context: A 31-year-old gravida 2 para 2 woman presents to her primary care physician for follow up.

Context: The delivery was complicated by a vaginal laceration that required extensive suturing once the infant was delivered.

Context: She has a history of vaginal candidiasis and is worried that it may be recurring.

Context: Her temperature is 98.8°F (37.1°C), blood pressure is 122/73 mmHg, pulse is 88/min, respirations are 16/min, and BMI is 33 kg/m^2.

Context: The pH of the discharge is 6.4.

Choices:
A. Bacterial vaginosis
B. Rectovaginal fistula
C. Vaginal melanoma
D. Vesicovaginal fistula

Answer: Rectovaginal fistula

1. Patient is a 31-year-old gravida 2 para 2 woman.

2. Two weeks ago, she gave birth via vaginal delivery to a 9.5 lb (4.3 kg) male infant.

3. Delivery was complicated by a vaginal laceration that required extensive suturing once the infant was delivered.

4. Immediately after delivery of the placenta she experienced intense shaking and chills that resolved within 1 hour.

5. She has felt well since the delivery but admits to 6 days of malodorous smelling vaginal discharge that is tan in color.

6. She has a history of vaginal candidiasis.

7. Temperature is 98.8°F (37.1°C), blood pressure is 122/73 mmHg, pulse is 88/min, respirations are 16/min, and BMI is 33 kg/m^2.

8. Speculum exam reveals a 1.5 cm dark red, velvety lesion on the posterior vaginal wall with a tan discharge.


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

Context: A 50-year-old male presents to the emergency room after getting hit by a car while biking.

Context: Initially he has an uneventful post-operative course; however, on post-op day 4 he becomes confused and develops chest pain, tachypnea, and dyspnea.

Choices:
A. Lobar lung consolidation
B. Aspiration of stomach contents
C. Occlusion of the pulmonary vessels by fat globules
D. Spontaneous pneumothorax

Answer: Occlusion of the pulmonary vessels by fat globules

1. A 50-year-old male presents to the emergency room.

3. He complains of severe pain in both thighs.

4. His thighs appear swollen, bruised, and angulated.

5. Radiographic imaging demonstrates bilateral femoral shaft fractures.

6. He subsequently undergoes surgical fixation of his fractures.

7. Initially he has an uneventful post-operative course.

8. On post-op day 4 he becomes confused.

9. He develops chest pain, tachypnea, and dyspnea.

10. A new petechial rash is seen over his chest and neck.

11. Electrocardiogram reveals normal sinus rhythm.


Question: Which of the following statements regarding this results of this study is true?

Context: In this study, 60 subjects with hepatitis were asked details of their history of drug abuse, such as the duration of drug abstinence, the amount and duration of drug abuse, and the treatment history.

Context: Additionally, a source close to or related to each of the study subjects (most often a spouse) was asked similar questions about the subject by a second researcher who was blinded to the subject’s drug abuse history.

Context: Results revealed that the duration of drug abstinence correlated highly between subjects and the source (Spearman’s r = 0.94, p-value < 0.001), as did the individual's score on the stimulant relapse risk scale (SRRS, Spearman’s r = 0.74, p-value < 0.001), a ranked metric of relapse risk.

Choices:
A. If the authors had conducted a study on larger sample size, Pearson’s correlation coefficient for these data would have been calculated.
B. There is a linear relationship between the duration of drug abstinence as assessed by the subject and their close/related source.
C. Spearman’s correlation coefficient reveals a strong association between the SRRS scores, as assessed by the study subject and their related source.
D. We can conclude that 88.4% (= 0.94 x 0.94) of the variability in the duration of drug abstinence (as assessed by the study subjects) can be 'explained' by the variability in the duration of drug abstinence as assessed by their sources.

Answer: Spearman’s correlation coefficient reveals a strong association between the SRRS scores, as assessed by the study subject and their related source.

1. A group of researchers is conducting a study to assess the validity and reliability of patient history in determining the amount and duration of drug abuse.

2. 60 subjects with hepatitis were asked details of their history of drug abuse, such as the duration of drug abstinence, the amount and duration of drug abuse, and the treatment history.

3. A source close to or related to each of the study subjects (most often a spouse) was asked similar questions about the subject by a second researcher who was blinded to the subject’s drug abuse history.

4. Results revealed that the duration of drug abstinence correlated highly between subjects and the source (Spearman’s r = 0.94, p-value < 0.001).

5. Results also revealed that the individual's score on the stimulant relapse risk scale (SRRS, Spearman’s r = 0.74, p-value < 0.001), a ranked metric of relapse risk correlated highly between subjects and the source.


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

Context: A 27-year-old man comes to the emergency department for progressive weakness and numbness in his legs for 5 days.

Context: Symptoms originally started with tingling in both feet and have progressed to involve the knees and hips; he is currently unable to walk without assistance.

Context: Lumbar puncture shows elevated CSF protein and no white blood cells.

Choices:
A. Postsynaptic acetylcholine receptors
B. Muscle endomysium
C. Schwann cells
D. Cerebral white matter

Answer: Schwann cells

1. A 27-year-old man comes to the emergency department.

2. He has progressive weakness and numbness in his legs for 5 days.

3. Symptoms originally started with tingling in both feet.

4. Symptoms have progressed to involve the knees and hips.

5. He is currently unable to walk without assistance.

6. Two weeks ago, the patient had diarrhea that subsided without antibiotics.

7. Neurologic examination shows weakness, decreased sensation, and absent patellar reflexes in both lower extremities.

8. Lumbar puncture shows elevated CSF protein.

9. Lumbar puncture shows no white blood cells.


Question: Which of the following is the most appropriate further management of this patient?

Context: A 23-year-old man presents to the emergency department presenting with sudden-onset dyspnea and left-sided chest pain over the last hour.

Context: This event started when he was in class sitting for an exam.

Context: He reports that the pain is worse with inspiration and does not radiate.

Context: He says he has anxiety and takes alprazolam as needed.

Context: He smokes half a pack of cigarettes a day and drinks alcohol socially.

Context: The temperature is 36.7°C (98.0°F), the blood pressure is 130/80 mm Hg, the pulse is 82/min, and the respiratory rate is 14/min.

Context: Pulse oximetry shows 97% on room air.

Context: The patient’s weight is 63.5 kg (140 lb), height is 185 cm (6 ft 1 in), and he has a BMI of 18.5 kg/m2.

Context: A chest X-ray is taken (see exhibit).

Context: After an hour of supplemental oxygen, rest, and careful monitoring his dyspnea improves and chest pain resolves without medication.

Choices:
A. Needle thoracostomy
B. IV antibiotics
C. Supplemental oxygen
D. CT angiogram of chest

Answer: Supplemental oxygen

2. Patient presents with sudden-onset dyspnea and left-sided chest pain over the last hour.

3. Event started when patient was in class sitting for an exam.

4. Pain is worse with inspiration and does not radiate.

5. Patient has anxiety and takes alprazolam as needed.

6. Patient smokes half a pack of cigarettes a day.

12. Pulse oximetry shows 97% on room air.

13. Patient's weight is 63.5 kg (140 lb).

14. Patient's height is 185 cm (6 ft 1 in).

17. After an hour of supplemental oxygen, rest, and careful monitoring, patient's dyspnea improves and chest pain resolves without medication.


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

Context: A 36-year-old male is brought to the emergency department by fire and rescue after being found down in his apartment by his wife.

Context: His wife reports that the patient had been complaining of chest pain for the last few hours but refused to go to the hospital.

Context: She went to the grocery store for about half an hour and found her husband unresponsive on the ground when she returned home.

Context: The patient’s wife reports that his past medical history is significant for a “heart murmur” and that the patient’s father died at age 32 for unknown reasons.

Context: In the trauma bay, the patient’s temperature is 98.8°F (37.1°C), blood pressure is 88/41 mmHg, pulse is 116/min, and respirations are 12/min.

Context: On physical exam, the patient has a Glascow Coma Score (GCS) of 7.

Context: He has a tall stature with long limbs and long, slender fingers.

Context: He is also noted to have a pectus deformity.

Context: On cardiac exam, the patient has a diastolic decrescendo murmur at the left third intercostal space.

Context: He has weak brachial and femoral pulses. |  | .

Choices:
A. Coronary atherosclerosis
B. Spontaneous rupture of the aorta
C. Spontaneous rupture of the mitral chordae tendinae
D. Spontaneous separation in the arterial wall

Answer: Spontaneous separation in the arterial wall

2. Patient was brought to the emergency department by fire and rescue.

3. Patient's wife found him unresponsive in his apartment.

4. Patient had been complaining of chest pain for the last few hours.

5. Patient's wife went to the grocery store for about half an hour.

6. Patient's past medical history is significant for a "heart murmur".

7. Patient's father died at age 32 for unknown reasons.

8. Patient's temperature is 98.8°F (37.1°C).

9. Patient's blood pressure is 88/41 mmHg.

12. Patient has a Glascow Coma Score (GCS) of 7.

13. Patient has a tall stature with long limbs and long, slender fingers.

15. Patient has a diastolic decrescendo murmur at the left third intercostal space.

16. Patient has weak brachial and femoral pulses.


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

Context: An x-ray of the lumbar spine shows decreased bone density and a compression fracture of the L2 vertebra.

Choices:
A. Low serum glucose levels
B. Suprasellar mass on cranial MRI
C. T-wave flattening on ECG
D. Positive Chvostek sign

Answer: T-wave flattening on ECG

1. A 44-year-old man comes to the physician because of severe lower back pain for 1 week.

2. He has also had fatigue, weight gain, and episodic headaches during the past 3 months.

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

4. His pulse is 88/min and blood pressure is 155/102 mm Hg.

5. Physical examination shows facial plethora and truncal obesity.

6. The skin appears stretched, with multiple ecchymotic patches over the upper and lower extremities bilaterally.

7. Cardiopulmonary examination shows no abnormalities.

8. There are bilateral paravertebral muscle spasms and severe tenderness over the second lumbar vertebra.

9. An x-ray of the lumbar spine shows decreased bone density.

10. An x-ray of the lumbar spine shows a compression fracture of the L2 vertebra.


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

Context: Two weeks after undergoing coronary artery bypass surgery for acute myocardial infarction, a 62-year-old man comes to the physician because of a 4-day history of fever, stabbing chest pain, and fatigue.

Context: Initially the pain was only present when he was lying supine, but now it is present all the time and only subsides when he is leaning forward.

Context: He has hypertension and mild mitral regurgitation.

Context: He has smoked one pack of cigarettes daily for 44 years but quit prior to surgery.

Context: His temperature is 38.3°C (102°F), pulse is 84/min and regular, respirations are 16/min, and blood pressure is 132/86 mm Hg.

Context: Heart sounds are faint.

Choices:
A. Increase in mean aortic pressure
B. Decreased left ventricular diastolic filling
C. Supraventricular arrhythmia
D.
Decreased right ventricular contractility
"

Answer: Decreased left ventricular diastolic filling

2. Patient has a 4-day history of fever, stabbing chest pain, and fatigue.

3. Initially the pain was only present when he was lying supine.

4. Now the pain is present all the time and only subsides when he is leaning forward.

5. Patient has hypertension and mild mitral regurgitation.

6. Patient smoked one pack of cigarettes daily for 44 years but quit prior to surgery.

7. Current medications include aspirin, clopidogrel, metoprolol, captopril, and atorvastatin.

8. Patient's temperature is 38.3°C (102°F).

9. Patient's pulse is 84/min and regular.

11. Patient's blood pressure is 132/86 mm Hg.

12. During inspiration the blood pressure drops to 117/80 mm Hg.

13. On physical examination there are jugular venous pulsations 4 cm above the sternal angle.

15. There is 2+ edema in the lower extremities.

16. Patient underwent coronary artery bypass surgery for acute myocardial infarction two weeks prior.


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

Context: A 28-year-old woman comes to the physician with her mother because of a 1-week history of feeling unusually energetic.

Context: The mother describes her state as “hyper” and reports that she often paces around her room.

Context: During this period, the patient has not slept.

Context: The mother also states that, for the past 8 months, the patient has believed she is a famous singer and is going on a world tour next year.

Context: The patient does not have a partner and has only a few friends.

Context: She was working as a dental technician until 6 months ago, when she started to hear voices telling her to quit.

Context: She has not held a job since then.

Context: She does not use illicit drugs.

Context: Vital signs are within normal limits.

Context: On mental status examination, her speech is pressured, but she suddenly stops talking in the middle of sentences and does not finish them.

Choices:
A. Schizoaffective disorder
B. Schizotypal personality disorder
C. Delusional disorder
D. Mood disorder with psychotic features

Answer: Schizoaffective disorder

1. A 28-year-old woman comes to the physician with her mother.

2. She has a 1-week history of feeling unusually energetic.

3. The mother describes her state as “hyper”.

5. She has not slept during this period.

6. She had similar episodes 2 months and 5 months ago.

7. For the past 8 months, she has believed she is a famous singer.

8. She believes she is going on a world tour next year.

9. She does not have a partner and has only a few friends.

10. She was working as a dental technician until 6 months ago.

11. She started to hear voices telling her to quit 6 months ago.

14. Vital signs are within normal limits.

15. Physical and neurological examinations show no abnormalities.

16. On mental status examination, her speech is pressured.

17. She suddenly stops talking in the middle of sentences and does not finish them.

18. She occasionally directs her attention to empty corners in the room, as if she were listening to someone.


Question: Which of the following investigations is indicated as part of his diagnostic evaluation at present?

Context: A 4-year-old boy presents the pediatrician with his parents for a consultation after his school teacher complained about his abnormal behavior and his inability to make friends in school.

Context: They mention that the boy does not interact well with others at home, school, or daycare.

Context: On physical examination, his vital signs are stable with normal weight, height, and head circumference for his age and sex.

Context: His recent audiologic evaluation shows normal hearing, and intellectual disability has been ruled out by a clinical psychologist.

Choices:
A. Magnetic Resonance Imaging (MRI) of brain
B. Positron Emission Tomography (SPECT) Scanning of head
C. Electroencephalography
D. No further testing is needed

Answer: No further testing is needed

1. A 4-year-old boy presents the pediatrician with his parents for a consultation.

2. His school teacher complained about his abnormal behavior and his inability to make friends in school.

3. His parents mention that the boy does not interact well with others at home, school, or daycare.

4. On physical examination, his vital signs are stable.

5. His weight, height, and head circumference are normal for his age and sex.

6. His general examination and systemic examination, including neurologic examination, are completely normal.

7. His recent audiologic evaluation shows normal hearing.

8. Intellectual disability has been ruled out by a clinical psychologist.

Developmental
Child and Adolescent Psychiatry


Question: Which of the following is the most likely explanation for this patient's current condition?

Context: A 57-year-old man comes to the physician because of a 5-day history of fever, joint pain, malaise, and a diffuse rash.

Context: Two months ago, he was diagnosed with latent tuberculosis and the appropriate treatment was administered.

Choices:
A. Decreased acetaldehyde dehydrogenase activity
B. Decreased acetyltransferase activity
C. Decreased cytochrome p450 activity
D. Decreased glucose-6-phosphate dehydrogenase activity

Answer: Decreased acetyltransferase activity

1. A 57-year-old man comes to the physician.

2. He has a 5-day history of fever, joint pain, malaise, and a diffuse rash.

3. Two months ago, he was diagnosed with latent tuberculosis.

4. The appropriate treatment for latent tuberculosis was administered.

5. Examination shows a scaly, maculopapular rash over the chest, arms, and back.


Question: What is the most likely additional finding?

Context: She is the product of a full-term vaginal delivery to a G2P2 36-year-old mother.

Context: The pregnancy was uncomplicated, and the only medication that the mother took was a prenatal vitamin.

Context: The baby has been exclusively breastfed, and she has an adequate latch.

Context: On physical examination, the newborn’s abdomen is distended and on digital rectal examination, reveals that the rectum is empty.

Choices:
A. Absence of ganglion cells in the submucosal plexus on suction biopsy of the rectum
B. Acid-producing mucosa visualized in a technetium scan
C. Abdominal ultrasound showing bowel-within-bowel
D. Inability to pass a 10-French catheter from the mouth into the stomach

Answer: Absence of ganglion cells in the submucosal plexus on suction biopsy of the rectum

1. A 40-hour-old baby girl is being evaluated for failure to pass meconium.

2. The baby is the product of a full-term vaginal delivery.

5. The mother only took a prenatal vitamin.

6. The baby has been exclusively breastfed.

8. On physical examination, the newborn's abdomen is distended.

9. On digital rectal examination, the rectum is empty.


Question: Which of the following is the best next step in diagnosing this patient’s condition?

Context: A 65-year-old man presents to the physician with a low-grade fever, fatigue, and anorexia for the past 10 days.

Context: The patient denies any chest pain, cough, or shortness of breath.

Context: He has been a smoker for the last 10 years and consumes alcohol occasionally.

Context: His past medical history is significant for colorectal carcinoma.

Context: His temperature is 38.3°C (101.0°F), the blood pressure is 130/90 mm Hg, and the pulse is 100/min.

Context: Physical examination shows reddish-brown spots under his nail bed (as shown in the exhibit) and tender erythematous fingers tips.

Context: Cardiac auscultation reveals a new holosystolic murmur best heard at the apex with no radiation.

Context: Chest X-ray, electrocardiogram, and urinalysis are normal.

Choices:
A. Obtain anti-CCP antibody titers
B. Echocardiography
C. Obtain blood samples for blood culture
D. Reassurance and symptomatic management

Answer: Obtain blood samples for blood culture

2. Patient has low-grade fever, fatigue, and anorexia for 10 days.

3. Patient denies chest pain, cough, or shortness of breath.

4. Patient has been a smoker for 10 years and consumes alcohol occasionally.

5. Patient has past medical history of colorectal carcinoma.

6. Patient's temperature is 38.3°C (101.0°F).

7. Patient's blood pressure is 130/90 mm Hg.

9. Physical examination shows reddish-brown spots under nail bed.

10. Physical examination shows tender erythematous fingers tips.

11. Cardiac auscultation reveals new holosystolic murmur best heard at apex with no radiation.


Question: Which of the following treatment regimens should be recommended for this patient given the fully suppressed viral load?

Context: A 27-year-old man presents for followup 3 months after starting an antiretroviral regimen consisting of efavirenz, tenofovir, and emtricitabine.

Context: Labs drawn just prior to presentation reveal an undetectable viral load and a T-lymphocyte count of 317/mm^3.

Context: By comparison, his viral load was 6100/mL and his T-lymphocyte count was 146/mm^3 at the time of treatment initiation.

Context: He reports that he is tolerating the medications well and is not experiencing any major side effects.

Choices:
A. Continue current regimen of efavirenz, tenofovir, and emtricitabine
B. Continue efavirenz and emtricitabine but discontinue tenofovir
C. Continue efavirenz and tenofovir but discontinue emtricitabine
D. Continue tenofovir and emtricitabine but discontinue efavirenz

Answer: Continue current regimen of efavirenz, tenofovir, and emtricitabine

2. Patient is 3 months into antiretroviral regimen.

3. Regimen consists of efavirenz, tenofovir, and emtricitabine.

4. Labs drawn prior to presentation reveal undetectable viral load.

5. Labs drawn prior to presentation reveal T-lymphocyte count of 317/mm^3.

6. At time of treatment initiation, viral load was 6100/mL.

7. At time of treatment initiation, T-lymphocyte count was 146/mm^3.

8. Patient is tolerating medications well.

9. Patient is not experiencing any major side effects.


Question: What type of cells were most likely injured in the initial stage of his disease?

Context: A 60-year-old male painter with severe chest pain is found to have atherosclerosis of his coronary arteries.

Choices:
A. Myocytes
B. Neutrophils
C. Endothelial cells
D. Smooth muscle cells

Answer: Endothelial cells

5. Patient has atherosclerosis of his coronary arteries.

General Cardiology
Interventional Cardiology


Question: Regarding Rh D immunoglobulin (RhoGam) administration, the most appropriate next step is which of the following?

Context: A 27-year-old woman, gravida 1, at 26 weeks gestation presents to the physician during a prenatal visit.

Context: She feels well.

Context: Her pregnancy has been uncomplicated.

Context: Her partner is blood type A+.

Context: At the clinic, her temperature is 37.2°C (99.0°F), and blood pressure is 108/60 mm Hg.

Context: Fetal heartbeats are normal.

Choices:
A. At 28 weeks gestation if anti-D screen is negative
B. At 28 weeks gestation if anti-D screen is positive
C. Within 72 hours after birth if anti-D screen is negative
D. Rh D immunoglobulin (RhoGam) is not required in this patient regardless of test results

Answer: At 28 weeks gestation if anti-D screen is negative

1. A 27-year-old woman is presenting to the physician during a prenatal visit.

5. Her pregnancy has been uncomplicated.

6. Her initial laboratory tests at 8 weeks confirmed her blood type as B-.

8. At the clinic, her temperature is 37.2°C (99.0°F).

10. Pelvic examination shows a uterus consistent in size with a 24-week gestation.

12. A sample of blood is collected for blood type screening and verification.


Question: What could be causing this patient’s newly-discovered dermatologic change?

Context: A 32-year-old obese man visits your dermatology clinic after his barber saw a darkened area on the back of his neck.

Context: He has not seen his primary care physician in many years and does not know if he has diabetes.

Context: Otherwise, he reports recent loss of appetite with slight weight loss.

Choices:
A. Gastric adenocarcinoma
B. Diabetes insipidus
C. Diabetes mellitus
D. Barrett’s esophagus

Answer: Gastric adenocarcinoma

1. A 32-year-old man visited a dermatology clinic.

2. His barber noticed a darkened area on the back of his neck.

3. He has not seen his primary care physician in many years.

5. A rapid blood glucose test showed a normal glucose level.


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

Context: A 59-year-old man comes to the physician because of a 6-month history of progressive blurry vision in both eyes.

Context: His blood pressure is 155/98 mm Hg.

Context: Physical examination shows his visual acuity to be 20/80 in the right eye and 20/60 in the left eye.

Choices:
A. Idiopathic intracranial hypertension
B. Open-angle glaucoma
C. Central retinal artery occlusion
D.
Diabetic retinopathy
"

Answer:
Diabetic retinopathy
"

1. A 59-year-old man comes to the physician.

2. He has a 6-month history of progressive blurry vision in both eyes.

3. His vision has not improved with the use of reading glasses.

5. Physical examination shows his visual acuity to be 20/80 in the right eye.

6. Physical examination shows his visual acuity to be 20/60 in the left eye.

7. A photograph of the fundoscopic examination of the right eye is shown.


Question: What is the most appropriate next step in the management of this patient’s symptoms?

Context: A 16-year-old high school cheerleader is brought by her mother to the emergency department after falling on her back during a stunt.

Context: She strongly believes that the accident happened because the team couldn’t catch her ‘enormous and bloated’ body.

Context: Lately, she has been in a lot of stress as dance regionals are coming up soon and she wants to lose 6.8 kg (15 lb).

Context: She is also experiencing intermittent palpitations and dizziness, even during rest.

Context: The physical examination reveals a slender girl with bilateral swelling on her cheeks and abrasions on the dorsum of her right hand.

Context: When her mother left the room, she admitted to taking furosemide that she found in the medicine cabinet.

Context: The vital signs include: temperature 36.2°C (97.2°F), blood pressure 90/60 mm Hg, pulse rate 50/min, respiratory rate 12/min, height 162 cm (5 ft 4 in), and weight 40.9 kg (90 lb).

Context: A magnetic resonance image (MRI) of the thoracic spine shows a vertebral compression fracture.

Context: She is refusing to eat anything but ice.

Choices:
A. Admit and start parenteral nutrition
B. Stabilize the fracture with a brace and discharge patient
C. Switch furosemide to hydrochlorothiazide
D. Refer to psychiatrist for outpatient cognitive behavioral therapy

Answer: Admit and start parenteral nutrition

1. Patient is a 16-year-old high school cheerleader.

2. Patient fell on her back during a stunt.

3. Patient believes the accident happened because the team couldn’t catch her ‘enormous and bloated’ body.

4. Patient is under a lot of stress due to upcoming dance regionals.

5. Patient wants to lose 6.8 kg (15 lb).

6. Patient is experiencing intermittent palpitations and dizziness, even during rest.

7. Physical examination reveals a slender girl with bilateral swelling on her cheeks and abrasions on the dorsum of her right hand.

8. Patient admitted to taking furosemide that she found in the medicine cabinet when her mother left the room.

9. Vital signs include: temperature 36.2°C (97.2°F), blood pressure 90/60 mm Hg, pulse rate 50/min, respiratory rate 12/min, height 162 cm (5 ft 4 in), and weight 40.9 kg (90 lb).

10. MRI of the thoracic spine shows a vertebral compression fracture.

11. Patient is refusing to eat anything but ice.


Question: Which of the following enzymes is primarily inhibited at the biochemical level by the chemical agent responsible for this patient’s condition?

Context: A 44-year-old man presents to an oncologist after being diagnosed with small cell lung carcinoma confirmed with a biopsy last week.

Context: Family history is unremarkable.

Choices:
A. Pyruvate dehydrogenase
B. Phosphofructokinase
C. Dihydrofolate reductase
D. Glucose-6-phosphate dehydrogenase

Answer: Pyruvate dehydrogenase

1. A 44-year-old man presents to an oncologist.

2. He was diagnosed with small cell lung carcinoma.

3. The diagnosis was confirmed with a biopsy last week.

4. He worked as a plant technician in the metal processing unit at a factory for the last 14 years.

6. It is concluded that this cancer is most likely mediated by mutations triggered by chronic chemical exposure at his work.

Internal Medicine
Medical Genetics and Genomics

Medical Oncology
Clinical Biochemical Genetics


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

Context: A 41-year-old woman presents to the emergency room with a 2-day history of flank pain, nausea, and vomiting.

Context: She denies any urinary frequency or urgency and denies any recent changes in her diet.

Context: Her temperature is 100.4°F (38°C), blood pressure is 152/96 mmHg, and pulse is 104/min.

Context: In addition, neurologic testing reveals decreased strength in her left upper extremity and an inability to sustain lateral gaze with her right eye.

Choices:
A. Drug allergy
B. Hereditary thrombophilia
C. Hypertension
D. Streptococcus infection

Answer: Hereditary thrombophilia

1. A 41-year-old woman presents to the emergency room.

2. She has a 2-day history of flank pain, nausea, and vomiting.

3. She denies any urinary frequency or urgency.

4. She denies any recent changes in her diet.

8. On physical exam, there is bilateral flank tenderness to palpation.

9. Neurologic testing reveals decreased strength in her left upper extremity.

10. Neurologic testing reveals an inability to sustain lateral gaze with her right eye.

11. An electrocardiogram reveals an irregularly irregular heart rhythm.


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

Context: A 20-year-old African American woman comes to the clinic after missing her last two periods.

Context: Her cycles are usually regular, occurring at 28-32 day intervals with moderate bleeding and some abdominal discomfort.

Context: Past medical history is insignificant.

Context: Blood pressure is 110/70 mm Hg, pulse rate is 80 /min, respiratory rate is 14 /min, and temperature is 36.5°C (97.7°F).

Context: Physical examination is significant for mild breast tenderness and some secretions from the nipple area.

Context: Urine pregnancy test is negative.

Choices:
A. Serum prolactin levels
B. LH/FSH ratio
C. Ultrasound of abdomen and pelvis
D. Dopamine agonists

Answer: Serum prolactin levels

1. A 20-year-old African American woman comes to the clinic.

3. Her cycles usually occur at 28-32 day intervals.

4. She experiences moderate bleeding and some abdominal discomfort.

5. She also complains of occasional diffuse and generalized headaches.

6. She is a college student and works part-time as a bartender.

7. Her past medical history is insignificant.

12. Physical examination is significant for mild breast tenderness.

13. Physical examination is significant for some secretions from the nipple area.


Question: Which of the following is the most likely explanation for the finding on this patient's peripheral blood smear?

Context: A 25-year-old man comes to the physician because he and his wife have been unable to conceive a child despite having regular unprotected sexual intercourse.

Context: He is 187 cm (6 ft 1 in) tall and weighs 79 kg (174 lb).

Context: Examination shows long extremities, bilateral gynecomastia, and small, firm testes.

Choices:
A. Acetylation of histone lysine residues
B. Methylation of cytosine nucleotides
C. Aggregation of ribosomes
D. Precipitation of oxidized hemoglobin

Answer: Methylation of cytosine nucleotides

1. A 25-year-old man comes to the physician.

2. He and his wife have been unable to conceive a child despite having regular unprotected sexual intercourse.

6. Examination shows bilateral gynecomastia.

7. Examination shows small, firm testes.

8. A peripheral blood smear shows a dense, dark-staining spot at the periphery of the nucleus of a cell.

Reproductive Endocrinology and Infertility


Question: Which of the following is a diagnostic criteria for the disorder that is most likely responsible for the patient’s presentation?

Context: A 22-year-old woman college student presents with diarrhea and crampy abdominal pain that is relieved by defecation.

Context: She states that she has had a lot of ‘stomach issues’ in the past, especially during exam weeks.

Context: The past medical history is significant for major depressive disorder diagnosed 2 years ago that has been managed with Prozac.

Context: She does not have a family history of irritable bowel disease, autoimmune disease, or cancer.

Context: The symptoms do not seem to be worse with any particular food, though she admits to eating a lot of pizza and deli sandwiches with minimal fruits and vegetables.

Context: She denies recent travel and has not experienced fever, weight loss, nausea, or vomiting.

Context: She has not noticed blood in her stool.

Context: The physical exam and laboratory findings are unremarkable.

Choices:
A. Symptoms present at least 6 months
B. Symptoms not relieved with defecation
C. Symptoms present at least 1 day per week for 3 consecutive months with symptom onset at least 6 months before diagnosis
D. No change in stool consistency

Answer: Symptoms present at least 1 day per week for 3 consecutive months with symptom onset at least 6 months before diagnosis

1. Patient is a 22-year-old female college student.

2. Patient presents with diarrhea and crampy abdominal pain that is relieved by defecation.

3. Patient states she has had a lot of ‘stomach issues’ in the past, especially during exam weeks.

4. Patient has a past medical history of major depressive disorder diagnosed 2 years ago that has been managed with Prozac.

5. Patient does not have a family history of irritable bowel disease, autoimmune disease, or cancer.

6. Patient's symptoms do not seem to be worse with any particular food, though she admits to eating a lot of pizza and deli sandwiches with minimal fruits and vegetables.

8. Patient has not experienced fever, weight loss, nausea, or vomiting.

9. Patient has not noticed blood in her stool.

10. Physical exam and laboratory findings are unremarkable.


Question: Which of the following findings are most likely on radiograph?

Context: On physical exam vitals are T 98.4 F HR 105 bpm BP 155/101 mmHg RR 16 SpO2 96%, abdominal exam is notable for distension, tympany to percussion, and tenderness to palpation without rebound or guarding.

Choices:
A. Apple core defect after lower GI series
B. Multiple punctate mucosal outpouchings through the serosa on lower GI series
C. Ladder-like series of distended bowel loops with air-fluid levels on abdominal radiograph
D. Loss of haustral markings and "lead pipe" appearance to the descending colon on lower GI series

Answer: Ladder-like series of distended bowel loops with air-fluid levels on abdominal radiograph

1. A 69-year-old female presents to the emergency department with crampy abdominal pain.

2. She has a past medical history of hypertension, dyslipidemia, and cholelithiasis status post cholecystectomy.

3. The patient states she has not passed stool or gas for 48 hrs.

4. On physical exam, her temperature is 98.4 F.

9. Abdominal exam is notable for distension.

10. Abdominal exam is notable for tympany to percussion.

11. Abdominal exam is notable for tenderness to palpation without rebound or guarding.


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

Context: A 56-year-old man comes to the physician because of a 2-month history of worsening pain in his left buttock.

Context: He does not report any recent trauma.

Context: He has hyperlipidemia.

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

Context: He does not use illicit drugs.

Context: His only medication is simvastatin.

Context: Chest x-ray and abdominal ultrasonography show no abnormalities.

Choices:
A. Giant cell tumor
B. Fibrosarcoma
C. Plasmacytoma
D. Chondrosarcoma

Answer: Chondrosarcoma

1. A 56-year-old man comes to the physician.

2. He has a 2-month history of worsening pain in his left buttock.

3. The pain is described as a deep, dull ache that is worse at night.

4. He does not report any recent trauma.

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

10. Physical examination shows tenderness over the left gluteal region.

11. Neurologic examination shows no focal findings.

12. An x-ray of the pelvis shows a 4-cm, poorly defined, osteolytic lesion in the left ilium with a moth-eaten pattern of bone destruction, multiple well-defined sclerotic lesions, and an aggressive periosteal reaction.

13. The remainder of the physical examination, including rectal examination, shows no abnormalities.

15. Abdominal ultrasonography shows no abnormalities.


Question: Microscopic examination of the mass will most likely show which of the following?

Context: An otherwise healthy 49-year-old man comes to the physician because of a 1-month history of worsening headaches and increasing irritability.

Context: An MRI of the brain shows a mass in the right temporal lobe with heterogeneous peripheral rim enhancement that crosses the midline.

Context: Gross examination shows a poorly-demarcated mass with areas of hemorrhage and necrosis.

Choices:
A. Closely-packed capillaries and foamy stromal cells
B. Pleomorphic cells forming pseudopalisades
C. Cells with clear cytoplasm and central round nuclei
D. Areas of lamellated calcification

Answer: Pleomorphic cells forming pseudopalisades

1. An otherwise healthy 49-year-old man comes to the physician.

2. He has a 1-month history of worsening headaches and increasing irritability.

3. Examination shows bilateral papilledema.

4. An MRI of the brain shows a mass in the right temporal lobe.

5. The mass has heterogeneous peripheral rim enhancement that crosses the midline.

6. He undergoes surgical resection of the mass.

7. Gross examination shows a poorly-demarcated mass.

8. The mass has areas of hemorrhage and necrosis.

Neurology with Special Qualification in Child Neurology


Question: What enzyme is most likely deficient in this patient’s case?

Context: He enters into a coma the next day and dies a week later.

Context: Histopathologic examination of the liver shows diffuse microvesicular steatosis, distinct focal hepatocellular fibrosis, and Kupffer cell glycogenosis.

Context: Citrulline levels are low.

Choices:
A. Carbamoyl phosphate synthetase I
B. Homogentisic acid dioxygenase
C. Ornithine transcarbamylase
D. Propionyl-CoA carboxylase

Answer: Carbamoyl phosphate synthetase I

1. A male newborn develops hyperammonemia, encephalopathy, and respiratory alkalosis 3 days after a normal delivery.

4. Family history is positive for parental consanguinity.

5. Histopathologic examination of the liver shows diffuse microvesicular steatosis.

6. Histopathologic examination of the liver shows distinct focal hepatocellular fibrosis.

7. Histopathologic examination of the liver shows Kupffer cell glycogenosis.


Question: Which of the following signs is most likely to be present in her chest radiogram?

Choices:
A. Deep sulcus sign with radiolucency along the costophrenic sulcus
B. Lung collapse at the hilum on one side and shift of the mediastinum to the opposite side
C. Bilateral asymmetric pulmonary infiltrates with peripheral distribution
D. Abrupt tapering of a pulmonary artery

Answer: Bilateral asymmetric pulmonary infiltrates with peripheral distribution

1. A 48-year-old woman is brought to the emergency department immediately following a motor vehicle accident in an unconscious state.

2. She is managed as per emergency treatment protocols with the airway, breathing, and circulation being appropriately managed by mechanical ventilation, intravenous fluids, and other supportive drugs.

3. A complete diagnostic evaluation suggests a diagnosis of traumatic brain injury and rules out the presence of fractures and other visceral injuries.

4. About 36 hours after the accident, pulse oximetry shows deteriorating oxygen saturation.

5. Chest auscultation reveals widespread rales over bilateral lung fields.

6. Her arterial blood gas analysis shows a PaO2 of 100 mm Hg at FiO2 of 60%.

7. Her bedside echocardiogram is normal and suggests a pulmonary capillary wedge pressure of 11 mm Hg.


Question: What is true about the medication prescribed to this patient?

Context: Five years ago, the patient had a mitral valve replacement with a porcine valve, but since then his heart failure symptoms have not improved.

Context: He developed persistent New York Heart Association class IV symptoms and was placed on the transplant waiting list.

Context: The heart to be transplanted originated from a deceased donor and the family has given consent for the transplantation.

Context: The patient is subsequently started on cyclosporine, and the postoperative period is unremarkable.

Choices:
A. Inhibits IMP dehydrogenase
B. Binds FK506 binding protein
C. Inhibits calcineurin
D. Is a precursor of 6-mercaptopurine

Answer: Inhibits calcineurin

1. A 58-year-old man with a history of heart failure is admitted to the hospital for a cardiac transplantation.

2. Five years ago, the patient had a mitral valve replacement with a porcine valve.

3. Since then his heart failure symptoms have not improved.

4. He developed persistent New York Heart Association class IV symptoms.

5. He was placed on the transplant waiting list.

6. The heart to be transplanted originated from a deceased donor.

7. The family has given consent for the transplantation.

8. The patient is subsequently started on cyclosporine.

9. The postoperative period is unremarkable.

10. He is readmitted to the emergency department 10 months later due to chest pain and severe shortness of breath.

Advanced Heart Failure and Transplant Cardiology


Question: Which of the following explains the measured decline in the calculated effective renal plasma flow?

Context: An investigator studying renal physiology uses para-aminohippuric acid (PAH) to estimate the renal plasma flow in a human volunteer.

Context: An intravenous infusion of 400 mg of PAH solution is administered to the subject; effective renal plasma flow is calculated to be 600 ml/min.

Context: Next, an intravenous infusion of 1000 mg of PAH solution is administered to the subject; effective renal plasma flow is calculated to be 400 mL/min.

Choices:
A. Decreased serum protein binding
B. Efferent arteriole dilation
C. Afferent arteriole dilation
D. Decreased PAH clearance

Answer: Decreased PAH clearance

1. An investigator is studying renal physiology.

2. Para-aminohippuric acid (PAH) is used to estimate the renal plasma flow in a human volunteer.

3. An intravenous infusion of 400 mg of PAH solution is administered to the subject.

4. Effective renal plasma flow is calculated to be 600 ml/min.

5. An intravenous infusion of 1000 mg of PAH solution is administered to the subject.

6. Effective renal plasma flow is calculated to be 400 mL/min.


Question: Which of the following findings would most likely also be seen in this patient?

Context: Selected lab results are presented as follows: |  | Hemoglobin: 9.1 g/dL | Hematocrit: 27% | Platelet count: 265,000/mm^3 | Mean corpuscular volume: 112 µm^3 | Reticulocyte count: 0.19% |  | .

Choices:
A. Elevated bilirubin levels
B. High methylmalonic acid and high homocysteine levels
C. High transferrin levels
D. Low haptoglobin levels

Answer: High methylmalonic acid and high homocysteine levels

1. A 55-year-old man presents to his primary care physician with a 2-month history of fatigue.

2. He says that he has been feeling tired, even after mild exertion, and decided to be evaluated because it has begun interfering with his job as a construction worker.

3. He reports that he has been feeling numbness and tingling in his feet and has been tripping more frequently.

4. His past medical history is significant for hypertension and type 2 diabetes well-controlled on metformin.

5. His surgical history is significant for weight-loss surgery 2 years ago.

6. Physical exam reveals bilateral vibration sensory deficits as well as conjunctival pallor.

7. Selected lab results are presented as follows: Hemoglobin: 9.1 g/dL.

8. Selected lab results are presented as follows: Hematocrit: 27%.

9. Selected lab results are presented as follows: Platelet count: 265,000/mm^3.

10. Selected lab results are presented as follows: Mean corpuscular volume: 112 µm^3.

11. Selected lab results are presented as follows: Reticulocyte count: 0.19%.


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

Context: A 27-year-old woman is brought to the emergency department by her coworker after having a generalized seizure at work.

Context: Her coworker reports that she is at 30 weeks' gestation and has mentioned headache and right upper quadrant pain earlier that day.

Context: Her temperature is 37°C (98.6°F), pulse is 91/min, and blood pressure is 170/102 mm Hg.

Choices:
A. Calcium gluconate
B. Aspirin
C. Phenytoin
D. Magnesium sulfate

Answer: Magnesium sulfate

1. A 27-year-old woman is brought to the emergency department.

2. Her coworker reports she is at 30 weeks' gestation.

3. She mentioned headache and right upper quadrant pain earlier that day.

7. Pulmonary examination shows bilateral rales.

8. There is diffuse edema in the lower extremities.

9. Deep tendon reflexes are increased bilaterally.

10. She is not oriented to person, place, and time.


Question: Which of the following disorders is most consistent with this patient's presentation?

Context: A 23-year-old woman presents to the emergency department because of nausea.

Context: She has been experiencing severe intermittent nausea and diarrhea for the last year and refuses to leave the emergency department until she is told what is causing her symptoms.

Context: She hates hospitals but has reluctantly undergone numerous workups and imaging studies in order to discern what is wrong.

Context: All of the studies have been normal.

Context: She says that these symptoms have been causing her severe distress and is impairing her ability to perform her job.

Context: She says that she feels as if the nausea is worse when she is trying to work but says that she will continue to work as an insurance agent despite the physical discomfort.

Context: She has started restricting her diet to only graham crackers because she thinks that helps her symptoms.

Context: She has also started avoiding eating lunch because of the nausea.

Choices:
A. Conversion disorder
B. Factitious disorder
C. Malingering
D. Somatic symptom disorder

Answer: Somatic symptom disorder

2. Patient presents to the emergency department due to nausea.

3. Patient has been experiencing severe intermittent nausea and diarrhea for the last year.

4. Patient refuses to leave the emergency department until she is told what is causing her symptoms.

6. Patient has reluctantly undergone numerous workups and imaging studies in order to discern what is wrong.

8. Symptoms have been causing her severe distress.

9. Symptoms are impairing her ability to perform her job.

10. Patient feels as if the nausea is worse when she is trying to work.

11. Patient will continue to work as an insurance agent despite the physical discomfort.

12. Patient has started restricting her diet to only graham crackers.

13. Patient has also started avoiding eating lunch because of the nausea.


Question: Which of the laboratory findings will be found in this patient?

Context: Upon arrival to the hospital, his blood pressure is 100/70 mm Hg, pulse rate is 90/min, respiratory rate is 18/min, and temperature is 38.9°C (102.0°F).

Context: Laboratory work is performed which shows: | Hemoglobin 10.9 g/dL | Hematocrit 37.7% | Leukocyte count 1,500/mm3 | Neutrophils 65% | Lymphocytes 30% | Monocytes 5% | Mean corpuscular volume 82.2 μm3 | Platelet count 190,000/mm3 | Erythrocyte sedimentation rate 35 mm/h | Aspartate aminotransferase 2,400 U/L | Alanine aminotransferase 3,200 U/L | CD4 count 27 cells/mm3 | HIV-1 antibody positive | Hepatitis C virus antibody positive | Quantiferon-gold test negative | .

Choices:
A. Atypical lymphocytes on blood smear
B. Positive blood culture
C. Elevated levels of cardiac troponin I and T
D. Positive sputum culture

Answer: Positive blood culture

1. A 37-year-old homeless man is brought in by ambulance to the emergency department after being found unresponsive.

2. He was found in an area of IV drug use with drug paraphernalia including glassine envelopes with a white powder residue.

3. There is no past medical history available.

4. He is treated with intranasal naloxone and stabilized in the field.

5. Upon arrival to the hospital, his blood pressure is 100/70 mm Hg.

9. On physical examination, the patient is jaundiced with white scrapable exudates on the oral mucosa.

10. His arms are covered with stigmata of IV drug use.

11. Heart auscultation reveals a holosystolic murmur that is loudest at the left sternal border.

12. The lungs are clear to auscultation bilaterally.

13. Laboratory work shows hemoglobin 10.9 g/dL.

21. Erythrocyte sedimentation rate 35 mm/h.

22. Aspartate aminotransferase 2,400 U/L.

26. Hepatitis C virus antibody positive.


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

Context: A 35-year-old woman, gravida 6, para 5, at 35 weeks' gestation comes to the emergency department because of vaginal bleeding for 2 hours.

Context: She has had no prenatal care.

Context: Her children were delivered vaginally.

Context: Her pulse is 122/min, respirations are 20/min, and blood pressure is 88/59 mm Hg.

Context: The abdomen is nontender, and no contractions are felt.

Context: The fetal heart rate is 110/min.

Context: Two large-bore peripheral intravenous cannulas are inserted and intravenous fluids are administered.

Choices:
A. Perform cesarean delivery
B. Hospitalization and observation
C. Administer magnesium sulfate
D. Perform cervical cerclage

Answer: Perform cesarean delivery

1. A 35-year-old woman comes to the emergency department.

2. She is gravida 6, para 5, at 35 weeks' gestation.

3. She has had vaginal bleeding for 2 hours.

4. This is her second episode in the past 2 days.

6. Her children were delivered vaginally.

12. There is active bright red vaginal bleeding.

14. Two large-bore peripheral intravenous cannulas are inserted.

15. Intravenous fluids are administered.

16. Three units of blood are typed and cross-matched.

Maternal
General Obstetrics and Gynecology


Question: Which of the following supplements is most important to prevent a potentially life-threatening condition in this newborn?

Context: A 2710-g (6-lb) male newborn is delivered at 38 weeks of gestation to a 26-year-old woman, gravida 2, para 2.

Context: Breastfeeding is initiated.

Choices:
A. Vitamin B1
B. Vitamin K
C. Folic acid
D. Iron

Answer: Vitamin K

1. A 2710-g (6-lb) male newborn is delivered.

2. The newborn is delivered at 38 weeks of gestation.

5. The pregnancy, labor, and delivery were uncomplicated.


Question: These findings support a diagnosis of which of the following?

Context: A 4-month-old adopted infant is brought to the pediatrician because of feeding problems and recurrent fungal and bacterial infections.

Context: Her family has almost no background information about the infant.

Context: They report that she is a little fragile and looks different compared to other infants her age.

Context: Further investigation reveals leukopenia and mild hypocalcemia.

Choices:
A. Chediak-Higashi syndrome
B. DiGeorge syndrome
C. Severe combined immunodeficiency (SCID)
D. Wiskott-Aidrich syndrome

Answer: DiGeorge syndrome

1. A 4-month-old adopted infant is brought to the pediatrician.

2. The infant has feeding problems and recurrent fungal and bacterial infections.

3. The family has almost no background information about the infant.

4. The family reports that the infant is a little fragile and looks different compared to other infants her age.

5. Physical evaluation reveals a cleft lip with intact hard and soft palate and mild jaw malformation.

6. An echocardiogram reveals an interrupted aortic arch.

7. Further investigation reveals leukopenia.

8. Further investigation reveals mild hypocalcemia.

Immunodeficiency
Immunology and Allergy
Pediatric Immunology and Allergy


Question: This presentation is consistent with which defect?

Context: A 48-year-old homeless man presents to clinic complaining of fatigue and fevers that "began recently." Cardiac exam reveals a holosystolic murmur, heard best over the left lower sternal border.

Context: The murmur increases on inspiration.

Context: He also has track marks on his arms bilaterally.

Choices:
A. Ventricular septal defect
B. Tricuspid regurgitation
C. Mitral regurgitation
D. Pulmonary stenosis

Answer: Tricuspid regurgitation

1. A 48-year-old homeless man presents to clinic.

2. He is complaining of fatigue and fevers.

3. The fatigue and fevers began recently.

4. Cardiac exam reveals a holosystolic murmur.

5. The murmur is heard best over the left lower sternal border.

7. He has track marks on his arms bilaterally.


Question: Which of the following management steps is most likely to decrease the risk for development of acute renal failure in this patient?

Context: A 65-year-old diabetic man presents to the emergency department with severe retrosternal chest pain, vomiting, and diaphoresis for the last half hour.

Context: He is on insulin therapy.

Context: The weight is 78 kg (172.0 lb).

Context: The lungs are clear to auscultation.

Context: The laboratory test results are as follows: | Laboratory test | Hemoglobin 15 g/dL | Leukocyte count 9,500/mm3 | Serum | Glucose 215 mg/dL | Na+ 140 mEq/L | Cl− 102 mEq/L | K+ 4.1 mEq/L | Urea nitrogen 22 mg/dL | Creatinine 1.4 mg/dL | Cardiac troponin I 0.8 ng/mL | The patient is being considered for primary percutaneous coronary intervention.

Choices:
A. Intravenous normal saline
B. Reduced intravenous contrast dose
C. Preemptive hemodialysis
D. Withholding losartan

Answer: Intravenous normal saline

1. A 65-year-old man presents to the emergency department with severe retrosternal chest pain, vomiting, and diaphoresis for the last half hour.

2. He has a history of diabetic chronic kidney disease.

4. Oral medications include aspirin, losartan, and metformin.

5. The vital signs include: temperature 36.8°C (98.2°F), pulse 88/min, respiration rate 14/min, and blood pressure 120/65 mm Hg.

8. Cardiac examination shows no abnormalities.

9. The electrocardiogram (ECG) shows ST-segment elevation in the precordial leads V-1–V-4.

10. Left ventricular ejection fraction is estimated at 55%.

11. Laboratory test results include hemoglobin 15 g/dL, leukocyte count 9,500/mm3, serum glucose 215 mg/dL, Na+ 140 mEq/L, Cl− 102 mEq/L, K+ 4.1 mEq/L, urea nitrogen 22 mg/dL, creatinine 1.4 mg/dL, and cardiac troponin I 0.8 ng/mL.

12. The patient is being considered for primary percutaneous coronary intervention.


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

Context: A 7-year-old boy is brought in to your clinic by his mother, who is complaining of her son’s “dry scalp and hair loss.” She reports a scaling spot on his scalp developed around 2 months ago, soon after moving to a new school, which then became a larger bald spot.

Context: She denies that anyone in the household is exhibiting similar symptoms, but does recall a note that came home from school warning of a lice outbreak.

Context: Thus far, she has only tried daily baths with little improvement.

Context: The patient denies pain or itchiness, but the mother reports she does notice him scratching his scalp.

Context: The mother also reports that since her son has started at the new school, she has noticed an increase in his tics including excessive blinking and clearing of his throat.

Context: The patient's medical history is significant for asthma, allergic rhinitis, and attention deficient hyperactivity disorder.

Context: His current medications include fluticasone, salmeterol, loratadine, and methylphenidate.

Context: Family history includes obsessive compulsive disorder in his older sister.

Context: The mother also reports her father had a debilitating skin and joint disorder.

Context: On examination, you note swollen lymph glands at the back of the patient's ears and neck, and there are residual black dots within a patch of alopecia.

Choices:
A. Nummular dermatitis
B. Psoriasis
C. Tinea capitis
D. Trichotillomania

Answer: Tinea capitis

3. Complaint is dry scalp and hair loss.

4. Scaling spot on scalp developed around 2 months ago.

6. No one in household exhibiting similar symptoms.

7. Note came home from school warning of lice outbreak.

8. Mother has only tried daily baths with little improvement.

10. Mother reports patient scratches scalp.

11. Since new school, increase in patient's tics including excessive blinking and clearing of throat.

12. Patient's medical history is significant for asthma, allergic rhinitis, and attention deficient hyperactivity disorder.

13. Current medications include fluticasone, salmeterol, loratadine, and methylphenidate.

14. Family history includes obsessive compulsive disorder in older sister.

15. Mother's father had a debilitating skin and joint disorder.

16. On examination, swollen lymph glands at back of patient's ears and neck.

17. Residual black dots within patch of alopecia.


Question: In addition to discontinuation of his current medication, administration of which of the following drugs is most appropriate in this patient?

Context: A 68-year-old man is brought to the emergency department because of a 1-day history of fever and cloudy urine.

Context: He lives in a group home and has a chronic indwelling urinary catheter for benign prostatic hyperplasia.

Context: He has depression, for which he takes vilazodone.

Context: His temperature is 38.3°C (100.9°F), pulse is 89/min, and blood pressure is 110/74 mm Hg.

Context: Urine cultures grow Enterococcus faecium resistant to vancomycin, and therapy with intravenous linezolid is initiated.

Context: His temperature is 39.6°C (103.3°F), pulse is 120/min, and blood pressure is 184/105 mm Hg.

Context: Neurologic examination shows increased deep tendon reflexes and clonus of the arms and legs.

Choices:
A. Flumazenil
B. Dantrolene
C. Octreotide
D. Cyproheptadine

Answer: Cyproheptadine

1. A 68-year-old man is brought to the emergency department.

2. He has a 1-day history of fever and cloudy urine.

4. He has a chronic indwelling urinary catheter for benign prostatic hyperplasia.

5. He has depression and takes vilazodone.

9. Urine cultures grow Enterococcus faecium resistant to vancomycin.

10. Therapy with intravenous linezolid is initiated.

11. Eight hours later, he becomes agitated and starts to sweat profusely.

12. His temperature is 39.6°C (103.3°F).

14. His blood pressure is 184/105 mm Hg.

15. Neurologic examination shows increased deep tendon reflexes.

16. Neurologic examination shows clonus of the arms and legs.


Question: Aside from size of the 2 molecules, which of the following features of the glomerular basement membrane accounts for this additional finding?

Context: He is curious about how glomerular filtration occurs and which molecules are filtered the fastest and slowest.

Choices:
A. Thickness
B. Positive charge
C. Negative charge
D. Presence of podocytes

Answer: Negative charge

1. A 54-year-old man is newly diagnosed with diabetes.

2. As part of his clinical care, he undergoes testing to determine his kidney function.

3. His glomerular filtration rate is found to be 80 mL/min.

4. He is curious about how glomerular filtration occurs.

5. He is curious about which molecules are filtered the fastest and slowest.

6. He is told that albumin is filtered less readily than sodium.


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

Context: A 2-year-old boy with recurrent ear infections is brought to the pediatrician for a follow-up examination.

Context: He can walk with support and his vocabulary consists of approximately 50 words.

Context: The abdomen is distended and both the liver and spleen tip are palpable.

Context: Laboratory studies show elevated total urinary glycosaminoglycan levels and an absence of plasma iduronate-2-sulfatase.

Choices:
A. Optic atrophy
B. Cherry-red macula
C. Corneal clouding
D. Aggressive behavior

Answer: Aggressive behavior

1. A 2-year-old boy is brought to the pediatrician for a follow-up examination.

4. His vocabulary consists of approximately 50 words.

5. His maternal uncle died in childhood from an unknown disease.

6. Physical examination shows coarse facial features with an enlarged tongue.

8. Both the liver and spleen tip are palpable.

9. Laboratory studies show elevated total urinary glycosaminoglycan levels.

10. Laboratory studies show an absence of plasma iduronate-2-sulfatase.

Pediatric Ophthalmology
Pediatric Otolaryngology


Question: Which of the following medical conditions is the physician referring to?

Context: A 29-year-old woman presents to a physician at 16 weeks gestation with fevers and a cough for 2 days.

Context: Her medical history is not significant.

Context: The physician explains that levofloxacin should be avoided during pregnancy because fetal exposure may increase the risk of a specific medical condition.

Choices:
A. Arthropathy
B. Congenital heart defect
C. Deafness
D. Neural tube defect

Answer: Arthropathy

1. A 29-year-old woman presents to a physician at 16 weeks gestation.

2. She has fevers and a cough for 2 days.

3. The cough is productive and occurs more often in the morning.

4. Her medical history is not significant.

5. Physical and laboratory evaluations suggest a diagnosis of community-acquired pneumonia.

6. The physician explains to her that she needs to be treated with antibiotic therapy.

7. She asks the physician if she can take levofloxacin because she tolerates levofloxacin.

8. The physician explains that levofloxacin should be avoided during pregnancy.

9. Fetal exposure to levofloxacin may increase the risk of a specific medical condition.


Question: Based on the study results, which of the following responses by the investigator is most accurate?"

Context: A large, multicenter study is conducted to assess the prevalence and mortality rate of pneumonia requiring hospitalization caused by various pathogens in 3 states over the past year.

Context: The results for five different pathogens are shown: | All cases Fatal cases | Pathogen Number Percentage Number Percentage | S.

Context: aureus 460 34.8 69 50.3 | Influenza virus 288 21.8 12 8.8 | P.

Context: aeruginosa 136 10.3 17 12.4 | S.

Context: pneumoniae 338 25.5 27 19.7 | Klebsiella spp.

Context: 101 7.6 12 8.8 | Total 1323 100 137 100 | A journalist would like to report the yearly case fatality rate of the pneumonia pathogen responsible for most hospitalizations in these states.

Choices:
A. 10.4%
B. 34.8%
C. 15.0%
D. 12.5%

Answer: 15.0%

1. A large, multicenter study was conducted to assess the prevalence and mortality rate of pneumonia requiring hospitalization caused by various pathogens in 3 states over the past year.

2. The study encompassed 250,000 adults between 45–79 years of age.

3. The results for five different pathogens are shown: S. aureus, Influenza virus, P. aeruginosa, S. pneumoniae, and Klebsiella spp.

5. The total number of fatal cases was 137.

6. The percentage of cases caused by S. aureus was 34.8%.

7. The percentage of fatal cases caused by S. aureus was 50.3%.

8. The percentage of cases caused by Influenza virus was 21.8%.

9. The percentage of fatal cases caused by Influenza virus was 8.8%.

10. The percentage of cases caused by P. aeruginosa was 10.3%.

11. The percentage of fatal cases caused by P. aeruginosa was 12.4%.

12. The percentage of cases caused by S. pneumoniae was 25.5%.

13. The percentage of fatal cases caused by S. pneumoniae was 19.7%.

14. The percentage of cases caused by Klebsiella spp. was 7.6%.

15. The percentage of fatal cases caused by Klebsiella spp. was 8.8%.

16. The yearly case fatality rate of the pneumonia pathogen responsible for most hospitalizations in these states is 50.3%.


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

Context: A 52-year-old woman is admitted to the surgical unit after a laparoscopic hysterectomy for uterine leiomyomas performed 2 days ago.

Context: The surgery was performed under general anesthesia, blood loss was minimal, and there were no intraoperative complications.

Context: Medical history is significant for multiple sclerosis that is well-controlled with ocrelizumab.

Context: Her temperature is 99°F (37.2 °C), blood pressure is 125/85 mmHg, pulse is 99/min, and respirations are 19/min.

Context: Neurologic exam is unremarkable.

Context: Laboratory studies show: |  | Serum: | Na+: 144 mEq/L | Cl-: 100 mEq/L | K+: 4.3 mEq/L | HCO3-: 26 mEq/L | Glucose: 105 mg/dL | Creatinine: 3.1 mg/dL |  | .

Choices:
A. Bethanechol administration
B. Bladder scan
C. Intravenous fluids
D. Urodynamic studies

Answer: Bladder scan

1. A 52-year-old woman is admitted to the surgical unit.

2. She had a laparoscopic hysterectomy for uterine leiomyomas 2 days ago.

3. The surgery was performed under general anesthesia.

4. Blood loss was minimal and there were no intraoperative complications.

5. The patient reports lower abdominal pain and discomfort.

6. Her medical history is significant for multiple sclerosis that is well-controlled with ocrelizumab.

7. Her last multiple sclerosis flare was approximately 7 years ago and presented with paresthesias and weakness of the upper extremities.

12. On physical exam, the patient appears restless and uncomfortable.

13. The surgical incision sites are mildly erythematous and without discharge.

14. There is tenderness with deep suprapubic palpation.


Question: The presence of which of the following in this patient’s serum would most help 'rule in' a diagnosis of rheumatoid arthritis:

Context: A 38-year-old female visits your office complaining of several years of joint swelling and stiffness that is worse in the morning and improves throughout the day.

Context: Physical examination reveals bilateral deformities at her proximal interphalangeal and metacarpophalangeal joints.

Choices:
A. Anti-nuclear antibody
B. Anti-citrullinated protein antibody
C. Anti-centromere antibody
D. Anti-smooth muscle antibody

Answer: Anti-citrullinated protein antibody

1. A 38-year-old female visits your office.

2. She is complaining of several years of joint swelling and stiffness.

3. The joint swelling and stiffness is worse in the morning.

4. The joint swelling and stiffness improves throughout the day.

5. Physical examination reveals bilateral deformities at her proximal interphalangeal joints.

6. Physical examination reveals bilateral deformities at her metacarpophalangeal joints.


Question: Which of the following is a complication associated with the best treatment for this patient?

Context: A 3-week-old infant presents to the emergency department with thick white discharge from his eyes that has persisted for the past 24 hours.

Context: The patient's birth was not complicated, and he was born at home vaginally with a mid-wife supervising the birth.

Context: The patient has a documented allergy to penicillin which caused anaphylaxis after it was given secondary to a maternal syphilis infection.

Context: His temperature is 97.6°F (36.4°C), blood pressure is 75/40 mm Hg, pulse is 130/min, respiratory rate is 24/min, and oxygen saturation is 98% on room air.

Context: The patient is currently sleeping.

Context: Physical exam is notable for bilateral purulent drainage from the eyes.

Choices:
A. Damage to the lacrimal ducts
B. Non-bilious projectile vomiting
C. Possible anaphylaxis and urticaria
D. Sedation and increased sleepiness

Answer: Non-bilious projectile vomiting

2. Patient has thick white discharge from eyes for past 24 hours.

4. Patient was born at home vaginally with mid-wife supervising.

5. Patient has documented allergy to penicillin.

6. Patient had anaphylaxis after penicillin given secondary to maternal syphilis infection.

7. Patient's temperature is 97.6°F (36.4°C).

8. Patient's blood pressure is 75/40 mm Hg.

10. Patient's respiratory rate is 24/min.

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

13. Physical exam is notable for bilateral purulent drainage from eyes.


Question: Which of the following histopathological findings will most likely be seen on the liver biopsy in this patient?

Context: His parents gave him aspirin.

Context: Over the next few days, the boy developed jaundice, became irritable, lethargic, and had seizures.

Context: A liver biopsy is performed.

Choices:
A. Hepatic granulomas
B. Iron accumulation and proliferation of smooth endoplasmic reticulum
C. Hepatocytes proliferation
D. Cytoplasmic fatty vacuolization in hepatocytes and swollen mitochondria

Answer: Cytoplasmic fatty vacuolization in hepatocytes and swollen mitochondria

1. A 10-year-old boy initially presented with a runny nose, fever, and watery eyes.

3. Over the next few days, the boy developed jaundice.

4. The boy became irritable and lethargic.

6. The hepatic transaminases were significantly raised.

7. The blood ammonia levels were also increased.

Pediatric Infectious Diseases
General Pediatrics


Question: Which of the following antibiotics would be best to administer to this patient?

Context: An 18-year-old woman presents with a dry cough for the past 2 weeks.

Context: She also says that she is tired all the time and feels feverish and chilly at times.

Context: She is a college student and lives in a dormitory and says that her roommate has a similar cough.

Context: Past medical history is unremarkable.

Context: The patient denies any smoking history, alcohol or recreational drug use.

Context: Her vitals signs include: temperature 36.8°C (98.2°F), pulse 72/min, blood pressure 118/63 mm Hg, and respiratory rate 15/min.

Context: Physical examination is unremarkable.

Context: A chest radiograph reveals interstitial infiltrates that look worse than her symptoms.

Context: A nasopharyngeal swab is sent to the lab for a bacterial culture which shows colonies having fried-egg appearance on Eaton’s agar.

Context: Cold agglutinins are positive.

Choices:
A. Penicillin
B. Ceftriaxone
C. Erythromycin
D. Aztreonam

Answer: Erythromycin

2. Patient has had a dry cough for 2 weeks.

3. Patient is tired all the time and feels feverish and chilly at times.

4. Patient is a college student and lives in a dormitory.

5. Patient's roommate has a similar cough.

6. Patient's past medical history is unremarkable.

7. Patient denies any smoking history, alcohol or recreational drug use.

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

10. Patient's blood pressure is 118/63 mm Hg.

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

12. Patient's physical examination is unremarkable.

13. Chest radiograph reveals interstitial infiltrates that look worse than her symptoms.

14. Nasopharyngeal swab is sent to the lab for a bacterial culture.

15. Bacterial culture shows colonies having fried-egg appearance on Eaton’s agar.


Question: Which of the following could have prevented this patient's chief complaints?

Context: A 9-year-old boy comes to the physician because of pain with swallowing and a burning sensation in his mouth for the past 10 days.

Context: Over the past 3 weeks, he has had increasing fatigue and runs out of breath easily.

Context: His father had gallstones, for which he underwent a cholecystectomy at the age of 30 years.

Context: The boy appears weak and lethargic.

Context: His temperature is 37.7°C (99.8°F), blood pressure is 110/68 mm Hg, pulse is 105/min, and respirations are 28/min.

Context: A complete blood cell count shows a hemoglobin concentration of 9.8 g/dL, mean corpuscular volume of 102 μm3, and a reticulocyte count of 0.4%.

Choices:
A. Folic acid supplementation
B. Cholecystectomy
C. Gluten-free diet
D. Vitamin B12 injections

Answer: Folic acid supplementation

1. A 9-year-old boy comes to the physician.

2. He has had pain with swallowing and a burning sensation in his mouth for the past 10 days.

3. He has had increasing fatigue and runs out of breath easily for the past 3 weeks.

4. His father had gallstones and underwent a cholecystectomy at the age of 30 years.

10. Examination shows pallor of the mucosal membranes, mild scleral icterus, and a swollen, red tongue.

11. His spleen is enlarged and palpable 2–3 cm below the left costal margin.

12. A complete blood cell count shows a hemoglobin concentration of 9.8 g/dL.

13. His mean corpuscular volume is 102 μm3.

15. His peripheral blood smear shows erythrocytes without central pallor.


Question: In addition to discontinuation of spironolactone, which of the following is the most appropriate next step in management of this patient's hyperkalemia?"

Context: A 62-year-old man is brought to the hospital because of a 6-hour history of worsening upper abdominal pain, nausea, and vomiting.

Context: He is diagnosed with acute calculous cholecystitis and scheduled for cholecystectomy the next day.

Context: Current medications include metoprolol and simvastatin.

Context: Preoperative serum studies show: | Na+ 138 mEq/L | K+ 6.1 mEq/L | Cl- 100 mEq/L | HCO3- 22 mEq/L | Urea nitrogen 13 mg/dL | Creatinine 1.0 mg/dL | An ECG shows normal sinus rhythm.

Choices:
A. Administer intravenous saline with furosemide
B. Administer intravenous sodium bicarbonate
C. Order dietary modification
D. Administer intravenous calcium gluconate

Answer: Administer intravenous saline with furosemide

1. A 62-year-old man is brought to the hospital.

2. He has a 6-hour history of worsening upper abdominal pain, nausea, and vomiting.

3. He is diagnosed with acute calculous cholecystitis.

4. He is scheduled for cholecystectomy the next day.

5. He has congestive heart failure, hyperlipidemia, and hypertension.

6. Physical examination shows no abnormalities.

7. His current medications include metoprolol and simvastatin.

8. One month ago, spironolactone was added to his medication regimen.

9. Preoperative serum studies show Na+ 138 mEq/L, K+ 6.1 mEq/L, Cl- 100 mEq/L, HCO3- 22 mEq/L, Urea nitrogen 13 mg/dL, and Creatinine 1.0 mg/dL.


Question: This patient is at greatest risk for which of the following adverse effects of this new drug?

Context: She has a history of type 2 diabetes mellitus and coronary artery disease.

Context: Her body mass index is 30 kg/m2.

Context: Her hemoglobin A1c concentration is 8%.

Context: She does not want to start insulin injection therapy and is afraid that a new medication is going to cause weight gain.

Choices:
A. Localized lipodystrophy
B. Vaginal candidiasis
C. Hypoglycemia
D. Lactic acidosis

Answer: Vaginal candidiasis

1. A 48-year-old woman comes to the physician for a follow-up examination.

2. She has a history of type 2 diabetes mellitus.

3. She has a history of coronary artery disease.

4. Current medications include metformin, aspirin, pravastatin, and losartan.

6. Physical examination shows no abnormalities.

7. Her hemoglobin A1c concentration is 8%.

8. She does not want to start insulin injection therapy.

9. She is afraid that a new medication is going to cause weight gain.

10. Empagliflozin is added to her diabetes regimen.


Question: Which of the following adverse effects is most commonly associated with long-term use of this medication?

Context: A 62-year-old man with coronary artery disease and type 2 diabetes mellitus comes to the emergency department because of frequent episodes of palpitations for 4 days.

Context: Intravenous pharmacotherapy is begun with a highly lipophilic drug that prolongs the duration of the myocardial action potential and refractory period and inhibits adrenergic stimulation of the myocardium.

Choices:
A. Priapism
B. Angle-closure glaucoma
C. Hyperthyroidism
D. Hepatic adenoma

Answer: Hyperthyroidism

1. A 62-year-old man has coronary artery disease and type 2 diabetes mellitus.

2. He comes to the emergency department because of frequent episodes of palpitations for 4 days.

3. His pulse is 165/min and blood pressure is 98/70 mm Hg.

4. An ECG shows monomorphic ventricular tachycardia.

5. Intravenous pharmacotherapy is begun with a highly lipophilic drug.

6. The drug prolongs the duration of the myocardial action potential and refractory period and inhibits adrenergic stimulation of the myocardium.

7. The patient's ventricular tachycardia converts to normal sinus rhythm.

8. He is discharged home with an oral formulation of the same drug.


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

Context: Labs are obtained, as shown below: |  | Serum: | Na+: 130 mEq/L | K+: 4.1 mEq/L | Cl-: 101 mEq/L | BUN: 16 mg/dL | Glucose: 125 mg/dL | Creatinine: 0.9 mg/dL | Aspartate aminotransferase (AST): 56 U/L | Alanine aminotransferase (ALT): 70 U/L | Creatine kinase (CK): 223 U/L (normal 22 to 198 U/L) |  | Hemoglobin A1c: 5.3 | Total cholesterol: 264 mg/dL (normal < 200 mg/dL) | Low-density lipoprotein (LDL) cholesterol: 117 mg/dL (normal < 100 mg/dL) | High-density lipoprotein (HDL) cholesterol: 48 (normal > 50 mg/dL) | Triglycerides: 163 mg/dL (normal < 150 mg/dL) |  | .

Choices:
A. Fludrocortisone
B. Liver biopsy
C. Muscle biopsy
D. Thyroxine

Answer: Thyroxine

1. A 45-year-old woman presents to her primary care physician complaining of weight gain.

2. She states that for the past few months she has gained 10 pounds, especially around her abdomen.

3. She says that this is despite going to kickboxing classes 5 days a week.

4. She reports mild fatigue and muscle soreness, which she attributes to her exercise classes.

5. She also complains of dry skin and hair, but feels that this might be due to showering twice a day.

6. Her medical history is significant for major depressive disorder.

7. She takes citalopram and a multivitamin.

8. She smokes a half pack of cigarettes a day.

9. She drinks 1 glass of red wine every night after dinner, and 3-4 drinks mixed with hard liquor on the weekend with friends.

10. Her temperature is 98°F (36.7°C), blood pressure is 122/75, and pulse is 65/min.

11. Her physical examination is unremarkable, except for xerosis.

12. Labs are obtained, with serum Na+ of 130 mEq/L, K+ of 4.1 mEq/L, Cl- of 101 mEq/L, BUN of 16 mg/dL, glucose of 125 mg/dL, creatinine of 0.9 mg/dL, AST of 56 U/L, ALT of 70 U/L, CK of 223 U/L, hemoglobin A1c of 5.3, total cholesterol of 264 mg/dL, LDL cholesterol of 117 mg/dL, HDL cholesterol of 48 mg/dL, and triglycerides of 163 mg/dL.


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

Context: A 31-year-old woman comes to the physician because of white lesions in her mouth that she first noticed 5 days ago.

Context: The lesions are not painful or itchy.

Context: She appears healthy.

Context: Vital signs are within normal limits.

Context: Oral examination shows white plaques on the buccal mucosa and hard palate that are firmly adherent and cannot be scraped off.

Choices:
A. Topical nystatin
B. Biopsy of the lesions
C. Smoking cessation
D. Culture of the lesions

Answer: Biopsy of the lesions

1. A 31-year-old woman comes to the physician.

2. She first noticed white lesions in her mouth 5 days ago.

3. The lesions are not painful or itchy.

4. She has asthma treated with theophylline, inhaled β-adrenergic agonists, and corticosteroids.

5. She smokes half a pack of cigarettes daily.

7. Vital signs are within normal limits.

8. Oral examination shows white plaques on the buccal mucosa and hard palate.

9. The plaques are firmly adherent and cannot be scraped off.

10. She has no cervical or axillary lymphadenopathy.


Question: Which of the following chromosomes most likely contains the gene mutation responsible for this patient's symptoms?

Context: An 11-year-old male is brought to his pediatrician for continuing management of a chronic lung infection.

Context: He has had many lung infections throughout childhood, and current sputum samples show oxidase positive, non-lactose fermenting gram-negative rods that produce a blue-green pigment.

Context: He has also recently been experiencing floating foul smelling diarrhea, so he is prescribed enzymes and vitamin supplementation tablets.

Choices:
A. 7
B. 17
C. 22
D. X

Answer: 7

1. An 11-year-old male is brought to his pediatrician.

2. He has had many lung infections throughout childhood.

3. Current sputum samples show oxidase positive, non-lactose fermenting gram-negative rods.

4. These rods produce a blue-green pigment.

5. Physical exam shows nasal polyps and nail clubbing.

6. He has recently been experiencing floating foul smelling diarrhea.

7. He is prescribed enzymes and vitamin supplementation tablets.

Medical Genetics and Genomics
Pediatrics

Pediatric Pulmonology
Clinical Genetics and Genomics
General Medical Genetics and Genomics


Question: The patient is most likely to develop which of the following complications?

Context: A 16-year-old girl is brought to the physician for a routine health maintenance examination.

Context: Her last visit was over a year ago.

Context: Menarche was at the age of 12 years; her last menstrual period was 4 months ago.

Context: She is on the school's gymnastics team and is currently preparing for an important competition.

Context: She is 165 cm (5 ft 5 in) tall and weighs 45 kg (99 lbs); BMI is 16.5 kg/m2.

Context: Her temperature is 36.8°C (98.2°F), pulse is 53/min, and blood pressure is 98/64 mm Hg.

Context: There are bilateral soft symmetric masses below her mandible.

Context: The skin over the dorsal side of her right hand is thickened.

Choices:
A. Recurrent infections
B. Ovarian cancer
C. Fractures
D. Hyperthyroidism

Answer: Fractures

4. Last menstrual period was 4 months ago.

5. Patient is on school's gymnastics team.

6. Patient is preparing for an important competition.

13. Examination shows yellowish discoloration of the skin.

14. Bilateral soft symmetric masses below mandible.

15. Skin over dorsal side of right hand is thickened.


Question: Which of the following activities is inhibited by this medication?

Context: A 32-year-old female is seeing an endocrinologist for the first time after a recently-diagnosed illness by her primary care physician.

Context: Her temperature is 99.7 °F (37.6 °C), blood pressure is 110/65 mmHg, pulse is 89/min, and respirations are 11/min.

Context: Prior to starting medical management, the patient is cautioned to alert her providers if she becomes pregnant, as this medication crosses the placenta and is known to cause aplasia cutis.

Choices:
A. Coupling of iodine with tyrosine residues
B. Production of TRH
C. Response of peripheral tissues to thyroid hormone
D. Sensitivity of anterior pituitary to TRH

Answer: Coupling of iodine with tyrosine residues

1. A 32-year-old female is seeing an endocrinologist for the first time.

2. She was recently diagnosed with an illness by her primary care physician.

3. Her temperature is 99.7 °F (37.6 °C).

7. Prior to starting medical management, the patient is cautioned to alert her providers if she becomes pregnant.

8. This medication crosses the placenta.

9. This medication is known to cause aplasia cutis.


Question: What vitamin deficiency is this woman most likely suffering from?

Context: A 62 year old woman presents to her doctor complaining of painful tingling and burning in her feet for the past year.

Context: Lab results reveal elevated urine and plasma methylmalonic acid concentrations.

Choices:
A. Vitamin C
B. Vitamin B1
C. Vitamin B12
D. Biotin

Answer: Vitamin B12

1. A 62 year old woman presents to her doctor.

2. She is complaining of painful tingling and burning in her feet for the past year.

3. Careful physical exam demonstrates that she has poor position sense in her bilateral lower extremities.

4. Lab results reveal elevated urine methylmalonic acid concentrations.

5. Lab results reveal elevated plasma methylmalonic acid concentrations.


Question: Which of the following best describes the symptoms this patient is expressing?

Context: A 52-year-old man visits his psychiatrist saying he feels sad most of the time.

Context: 5 months ago, he lost his daughter in a motor vehicle accident and since then has been unable to cope with this loss.

Context: He spends most of his day thinking about her and this often distracts him from his daily activities.

Context: He also admits to hearing his daughter’s voice in his sleep and sometimes has dreams about her.

Context: Other than this, he is able to get along his daily life and has never contemplated suicide.

Choices:
A. Brief psychotic disorder
B. Major depressive disorder
C. Normal grief reaction
D. Post-traumatic stress disorder

Answer: Normal grief reaction

1. A 52-year-old man visits his psychiatrist.

3. 5 months ago, he lost his daughter in a motor vehicle accident.

4. Since then, he has been unable to cope with this loss.

5. He spends most of his day thinking about her.

6. This often distracts him from his daily activities.

7. He admits to hearing his daughter’s voice in his sleep.

9. During the day, he sometimes gets brief glimpses of her.

10. He believes this is because he was not able to do anything to help her during the last moments of her life.

11. Other than this, he is able to get along his daily life.

13. But he often wishes he could be close to his daughter again.


Question: Which of the following is the primary mechanism of action of this drug?

Context: A 68-year-old woman with hypertension and congestive heart failure is brought to the emergency department because of a 2-day history of shortness of breath and confusion.

Context: Her pulse is 112/min, respirations are 22/min, and blood pressure is 73/45 mm Hg.

Context: Examination shows cool extremities, jugular venous distention, and diffuse crackles in the lungs.

Choices:
A. α2-adrenergic agonism
B. β2-adrenergic antagonism
C. β1-adrenergic agonism
D. α1-adrenergic antagonism

Answer: β1-adrenergic agonism

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

2. She has hypertension and congestive heart failure.

3. She has a 2-day history of shortness of breath and confusion.

8. Examination shows jugular venous distention.

9. Examination shows diffuse crackles in the lungs.

10. Treatment with intravenous dobutamine is begun.


Question: Which of the following health maintenance recommendations is most appropriate at this time?

Context: A 58-year-old man comes to the physician for a follow-up examination dressed in a vampire costume.

Context: He is on his way to a Halloween party at an assisted-living facility, where he works as a patient care attendant.

Context: He feels well.

Context: He was also diagnosed with type 2 diabetes two months ago during a routine check up.

Context: He used to smoke half a pack of cigarettes daily for 10 years but quit 15 years ago.

Context: His temperature is 37°C (98.6°F), pulse is 90/min, respirations are 14/min, and blood pressure is 138/90 mm Hg.

Choices:
A. Hemoglobin A1c measurement
B. Influenza vaccine
C. Prostate-specific antigen measurement
D. Colonoscopy

Answer: Influenza vaccine

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

3. He is on his way to a Halloween party at an assisted-living facility.

4. He works as a patient care attendant at the assisted-living facility.

6. He has a history of hypertension that is well controlled.

7. He was diagnosed with type 2 diabetes two months ago during a routine check up.

8. His current medications include lisinopril and metformin.

9. His father died of colon cancer at 52 years of age.

10. His screening colonoscopy at age 55 was normal.

11. He used to smoke half a pack of cigarettes daily for 10 years.

17. Physical examination shows no abnormalities.

18. His hemoglobin A1c two months ago was 7.6%.

General Internal Medicine
Geriatric Medicine


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

Context: His temperature is 98.7°F (37.1°C), blood pressure is 117/68 mmHg, pulse is 80/min, respirations are 10/min, and oxygen saturation is 98% on room air.

Context: Neurological exam reveals 4 mm pupils, which are equal and reactive to light, and a patient who responds incoherently to questions when stimulated.

Context: The patient has normoactive bowel sounds and is non-tender in all 4 quadrants.

Context: Laboratory values are ordered as seen below. |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.3 mEq/L | HCO3-: 25 mEq/L | BUN: 20 mg/dL | Glucose: 99 mg/dL | Creatinine: 1.1 mg/dL | Ca2+: 10.2 mg/dL | Ethanol: negative |  | An initial ECG is unremarkable.

Choices:
A. Flumazenil
B. Fomepizole
C. Observation
D. Sodium bicarbonate

Answer: Observation

1. A 33-year-old homeless man presents to the emergency department with an altered mental status.

2. The patient was found minimally responsive at a local mall and was brought in by police.

3. The patient has a past medical history of polysubstance abuse, anxiety, depression, and panic disorder.

4. His current medications include sertraline, clonazepam, and amitriptyline.

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

10. Physical exam is notable for a somnolent man.

11. Neurological exam reveals 4 mm pupils, which are equal and reactive to light.

12. The patient responds incoherently to questions when stimulated.

13. The patient has normoactive bowel sounds.

14. The patient is non-tender in all 4 quadrants.

General Emergency Medicine
Neurocritical Care