Question: Which of the following drugs most likely caused prolonged muscle paralysis in this patient?

Context: A 40-year-old man undergoes an elective cholecystectomy for repeated attacks of cholelithiasis over the last 5 years.

Context: In the operating room, rapid sequence intubation is performed using a certain muscle relaxant to prevent aspiration of gastric contents.

Context: During the procedure, atracurium is administered to maintain muscle relaxation and, 1.5 hours after the operation, the anesthesiologist administers neostigmine to reverse the paralysis.

Context: The patient, however, continues to remain paralyzed and cannot be extubated.

Choices:
A. Midazolam
B. Pancuronium
C. Succinylcholine
D. Tubocurarine

Answer: Succinylcholine

1. A 40-year-old man underwent an elective cholecystectomy.

2. The man had repeated attacks of cholelithiasis over the last 5 years.

3. Rapid sequence intubation was performed using a certain muscle relaxant to prevent aspiration of gastric contents.

4. Atracurium was administered to maintain muscle relaxation.

5. 1.5 hours after the operation, the anesthesiologist administered neostigmine to reverse the paralysis.

6. The patient continued to remain paralyzed and could not be extubated.


Question: The most likely pathology underlying this patient's symptoms is derived from which of the following embryonic layers?

Context: A 12-year-old boy is brought to the emergency department by ambulance after he was struck by a car while crossing the road.

Context: He is found to have a femur fracture and multiple bruises on presentation, but he is alert and hemodynamically stable.

Context: He says that the car "came out of nowhere" and that he has had multiple similar near misses in recent months.

Context: He has no past medical history but says that he has been having headaches that he describes as dull and continuous.

Context: He has also noticed that he has been waking up at night several times to go to the restroom.

Context: Otherwise, he has been healthy with no major concerns.

Choices:
A. Mesoderm
B. Neural crest
C. Neuroectoderm
D. Surface ectoderm

Answer: Surface ectoderm

1. A 12-year-old boy was brought to the emergency department by ambulance.

2. He was struck by a car while crossing the road.

3. He has a femur fracture and multiple bruises on presentation.

4. He is alert and hemodynamically stable.

5. He says the car "came out of nowhere" and he has had multiple similar near misses in recent months.

7. He has been having headaches that he describes as dull and continuous.

8. He has been waking up at night several times to go to the restroom.

9. He has been healthy with no major concerns.

10. A basic metabolic panel shows mild hypernatremia.

Neurodevelopmental Disabilities
Pediatric Emergency Medicine


Question: Which of the following is most likely to be the underlying cause for the fracture in this patient?

Context: A 40-year-old man presents with left hip pain.

Context: He says that symptoms started a month ago and have progressively worsened.

Context: He says the pain has rendered him unable to report to work for the last 2 weeks.

Context: The pain was initially 4/10 in intensity, dull with no radiation and was aggravated to 5/10 in intensity upon weight-bearing.

Context: Initially, it improved with rest and Tylenol.

Context: He initially attributed it to heavy work and took a few days off work, but he did not seek medical attention.

Context: However, it worsened over time to its present 8/10 intensity and does not respond to Tylenol anymore.

Context: The patient denies any history of injury, weight loss, change in appetite, or recent travel.

Context: His past medical history is significant for Crohn's disease, managed with a combination of prednisone and mesalamine and presently in remission.

Context: The rest of the examination, including a complete neurological examination, is unremarkable.

Context: On abdominal imaging of the left hip joint, a transcervical fracture is noted in the left hip with surrounding bony sclerosis.

Context: A DEXA scan shows a T-score of  -2.5 at the hips and -1.5 at the lumbar spine (normal T-score ≥ -1.0).

Choices:
A. Trauma
B. Chronic steroid use
C. Metastatic lesion
D. Sciatica

Answer: Chronic steroid use

3. Symptoms started a month ago and have progressively worsened.

4. Pain has rendered him unable to report to work for the last 2 weeks.

5. Pain initially 4/10 in intensity, dull with no radiation.

6. Pain aggravated to 5/10 in intensity upon weight-bearing.

7. Initially improved with rest and Tylenol.

8. Patient attributed it to heavy work and took a few days off work, but did not seek medical attention.

9. Pain worsened over time to 8/10 intensity and does not respond to Tylenol anymore.

10. Patient denies any history of injury, weight loss, change in appetite, or recent travel.

11. Patient's past medical history is significant for Crohn's disease, managed with a combination of prednisone and mesalamine and presently in remission.

12. On physical examination, there is limited flexion and extension at the left hip.

13. Rest of the examination, including a complete neurological examination, is unremarkable.

14. Abdominal imaging of the left hip joint shows a transcervical fracture with surrounding bony sclerosis.

15. DEXA scan shows a T-score of -2.5 at the hips and -1.5 at the lumbar spine (normal T-score ≥ -1.0).


Question: Where was the thoracentesis needle most likely placed?

Context: A 78-year-old woman with a history of breast cancer, status-post bilateral mastectomy, presents to the emergency department with progressive difficulty breathing, worsening fatigue, and 5 pounds of unintended weight loss over the past month.

Context: The ED resident performs thoracentesis with chest tube placement and admits her to the floor.

Context: Overnight, the patient requests multiple pain medications for right upper abdominal pain and is found to have increasingly sanguinous drainage.

Choices:
A. Lower border of the 10th rib at the right midaxillary line
B. Lower border of the 9th rib at the right midaxillary line
C. Upper border of the 7th rib at the right midclavicular line
D. Upper border of the 10th rib at the right midaxillary line

Answer: Lower border of the 10th rib at the right midaxillary line

1. A 78-year-old woman presents to the emergency department.

2. She has a history of breast cancer and a bilateral mastectomy.

3. She has progressive difficulty breathing and worsening fatigue.

4. She has lost 5 pounds in the past month.

5. A portable chest x-ray reveals a massive right pleural effusion.

6. The ED resident performs thoracentesis with chest tube placement.

7. The patient is admitted to the floor.

8. The patient requests multiple pain medications for right upper abdominal pain.

9. The patient has increasingly sanguinous drainage.


Question: Which of the following statements best describes the effects of molecule A on Vmax and Km on the metabolic reactions of the novel drug?

Context: While studying the metabolism of a novel drug, the researcher identifies a molecule that inhibits its metabolism by binding with enzyme E.

Context: Molecule A inhibits the enzyme E by reversibly binding at the same active site on the enzyme where the drug binds.

Choices:
A. Value of Vmax is unchanged but value of Km is increased
B. Value of Vmax is decreased but value of Km is unchanged
C. Values of both Vmax and Km are unchanged
D. Value of Vmax is unchanged but value of Km is decreased

Answer: Value of Vmax is unchanged but value of Km is increased

1. The researcher is studying the metabolism of a novel drug.

2. The researcher identifies a molecule, A.

4. Molecule A binds reversibly at the same active site on the enzyme where the drug binds.

Internal Medicine
Clinical Biochemical Genetics

Clinical Pharmacology
Clinical Pharmacology and Therapeutics
Clinical Pharmacology and Toxicology
General Medical Genetics and Genomics


Question: Inhibition of which of the following hormones would be most beneficial for this patient?

Context: A 70-year-old man presents to a physician’s office with shortness of breath for 1 month.

Context: He is “easily winded” and is unable to keep up with his grandchildren when playing in the park.

Context: Over the last few weeks, he had to increase the number of pillows under his head to sleep comfortably.

Context: He denies a cough and fever.

Context: The medical history includes hypercholesterolemia and hypertension.

Context: His current medications are aspirin, carvedilol, and rosuvastatin.

Context: The vital signs are as follows: blood pressure 150/90 mm Hg, pulse 90/min, and respiratory rate 14/min.

Context: The physical examination reveals distended jugular veins, bilateral pitting edema of the lower limbs, and fine crackles at the base of the lungs.

Context: An echocardiogram reveals an ejection fraction of 40%.

Choices:
A. Angiotensin II
B. Prostaglandin E1
C. Aldosterone
D. Epinephrine

Answer: Angiotensin II

2. Patient has shortness of breath for 1 month.

3. Patient is "easily winded" and cannot keep up with grandchildren when playing in the park.

4. Patient has had to increase number of pillows under head to sleep comfortably.

6. Patient has medical history of hypercholesterolemia and hypertension.

7. Patient is taking aspirin, carvedilol, and rosuvastatin.

11. Physical examination reveals distended jugular veins, bilateral pitting edema of lower limbs, and fine crackles at base of lungs.

12. Echocardiogram reveals ejection fraction of 40%.


Question: WBC 20–25/hpf | Which of the following would have most likely prevented this complication?"

Context: He was discharged 6 days ago.

Context: He has a history of hypertension.

Context: He appears anxious.

Context: His temperature is 37.8°C (100°F), pulse is 96/min, and blood pressure is 122/80 mm Hg.

Context: Urinalysis shows: | Blood 1+ | Protein 1+ | Nitrite positive | Leukocyte esterase positive | RBC 1–2/hpf | .

Choices:
A. Intermittent catheterization
B. Prophylactic oral ciprofloxacin
C. Topical mupirocin application
D. Screening for bacteriuria

Answer: Intermittent catheterization

1. A 51-year-old man comes to the physician because of severe pain while urinating for 4 days.

2. He has also had to urinate more often than usual.

3. Three weeks ago, he underwent surgery for an incarcerated hernia.

4. While recovering, he developed septic shock and was treated in the intensive care unit.

7. Current medications include amlodipine and oxycodone.

12. Examination shows tenderness to palpation in the suprapubic area; no guarding is present.

13. There is a well-healed surgical scar in the right inguinal region.

14. There is no costovertebral angle tenderness.

18. Urinalysis shows: Leukocyte esterase positive.


Question: Which of the following is the most appropriate pharmacotherapy for this patient's neurological symptoms?

Context: A 40-year-old woman with HIV infection comes to the emergency department because of a 4-week history of progressively worsening fatigue and headache.

Context: Analysis of this patient's cerebrospinal fluid (CSF) shows a leukocyte count of 30/mm3 (60% lymphocytes), a protein concentration of 52 mg/dL, and a glucose concentration of 37 mg/dL.

Context: An India ink stain of the CSF is shown.

Choices:
A. Pyrimethamine, sulfadiazine, and folinic acid
B. Isoniazid, rifampin, pyrazinamide, and ethambutol
C. Amphotericin B and flucytosine
D. Fluconazole

Answer: Amphotericin B and flucytosine

1. A 40-year-old woman with HIV infection comes to the emergency department.

2. She has a 4-week history of progressively worsening fatigue and headache.

3. On mental status examination, the patient is somnolent and oriented only to person.

4. Her CD4+ lymphocyte count is 80/mm3 (N ≥ 500).

5. Analysis of this patient's cerebrospinal fluid (CSF) shows a leukocyte count of 30/mm3 (60% lymphocytes).

6. Analysis of this patient's cerebrospinal fluid (CSF) shows a protein concentration of 52 mg/dL.

7. Analysis of this patient's cerebrospinal fluid (CSF) shows a glucose concentration of 37 mg/dL.

8. An India ink stain of the CSF is shown.

Neurology with Special Qualification in Child Neurology


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

Context: He drinks a few shots of vodka daily.

Context: He has no history of severe illness.

Context: Vital signs are within normal limits.

Context: Laboratory studies show: | Hemoglobin 11.6 g/dL | Leukocyte count 8,700/mm3 | Platelet count 172,000/mm3 | Serum | Urea nitrogen 17 mg/dL | Creatinine 1.1 mg/dL | Bilirubin | Total 6 mg/dL | Direct 5.2 mg/dL | Alkaline phosphatase 220 IU/L | Ultrasonography shows dilated extrahepatic and pancreatic ducts and a distended gall bladder.

Choices:
A. Malignant biliary tract obstruction
B. Acetaminophen-induced liver injury
C. Hemolysis
D. Chronic pancreatitis

Answer: Malignant biliary tract obstruction

1. A 64-year-old man comes to the physician because of a 2-week history of intermittent epigastric discomfort.

2. He reports that his urine has been very dark, and his stools have been pale for the past week.

3. His appetite has decreased, and he has had a 4.5-kg (10-lb) weight loss during this period.

4. He has smoked 1 pack of cigarettes daily for 30 years.

5. He drinks a few shots of vodka daily.

7. He has chronic left knee pain, for which he takes acetaminophen.

8. Vital signs are within normal limits.

9. Examination shows jaundice of the skin and scleral icterus.

10. There are scratch marks on the extremities.

11. Abdominal examination shows a nontender, palpable mass in the right upper quadrant.

12. The remainder of the examination is normal.

13. Laboratory studies show: Hemoglobin 11.6 g/dL

14. Laboratory studies show: Leukocyte count 8,700/mm3

15. Laboratory studies show: Platelet count 172,000/mm3

16. Laboratory studies show: Serum Urea nitrogen 17 mg/dL

17. Laboratory studies show: Creatinine 1.1 mg/dL

18. Laboratory studies show: Bilirubin Total 6 mg/dL

19. Laboratory studies show: Direct 5.2 mg/dL

20. Laboratory studies show: Alkaline phosphatase 220 IU/L

21. Ultrasonography shows dilated extrahepatic and pancreatic ducts and a distended gall bladder.


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

Context: A 27-year-old woman is brought to the physician after passing out at home.

Context: She has no history of serious illness.

Context: Vital signs are within normal limits.

Choices:
A. Septal myectomy
B. Amlodipine
C. Cardiac pacemaker
D. Metoprolol

Answer: Metoprolol

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

2. Her husband reports that she suddenly lost consciousness for approximately 30 seconds while shoveling snow in the driveway.

3. Immediately before the episode, she felt light-headed and short of breath.

4. Two months ago, she experienced a similar episode while running in her yard with her children.

5. She has no history of serious illness.

6. Her father died of sudden cardiac death at the age of 44 years.

7. Vital signs are within normal limits.

8. Cardiac examination shows a systolic ejection murmur best heard along the left sternal border that decreases with hand grip.

9. The remainder of the examination shows no abnormalities.


Question: The patient most likely has a deficiency of which of the following enzymes?

Context: A 7-month-old male infant is brought to the physician because of a 2-month history of fatigue and weakness.

Context: He is at the 20th percentile for height and 3rd percentile for weight.

Context: Crackles are heard at both lung bases.

Context: Serum glucose is 105 mg/dL.

Choices:
A. Acid maltase
B. Iduronate sulfatase
C. Glucose-6-phosphatase
D. Alpha-galactosidase

Answer: Acid maltase

1. A 7-month-old male infant is brought to the physician.

2. The infant has a 2-month history of fatigue and weakness.

3. His mother reports that he has difficulty feeding.

4. He is at the 20th percentile for height.

5. He is at the 3rd percentile for weight.

6. Physical examination shows an enlarged tongue.

7. Crackles are heard at both lung bases.

8. The liver is palpated 1 cm below the right costal margin.

9. Neurologic examination shows decreased muscle tone in the extremities.

11. An x-ray of the chest shows cardiomegaly.

Pediatrics
Medical Genetics and Genomics

General Pediatrics
Clinical Biochemical Genetics


Question: What is the standard deviation for the systolic blood pressure readings?

Context: The systolic blood pressure readings over the last 5 days are as follows: | Day 1: 130 mm Hg | Day 2: 132 mm Hg | Day 3: 128 mm Hg | Day 4: 132 mm Hg | Day 5: 128 mm Hg | .

Choices:
A. 1 mm Hg
B. 1.5 mm Hg
C. 2 mm Hg
D. 2.5 mm Hg

Answer: 2 mm Hg

1. A 43-year-old man presents to a medical office for follow-up of hypertension.

2. He was recently diagnosed and has been managing his condition with diet modification and moderate-intensity exercise.

3. Today, he brings a list of his recent at-home morning blood pressure readings.

4. The systolic blood pressure reading on Day 1 was 130 mm Hg.

5. The systolic blood pressure reading on Day 2 was 132 mm Hg.

6. The systolic blood pressure reading on Day 3 was 128 mm Hg.

7. The systolic blood pressure reading on Day 4 was 132 mm Hg.

8. The systolic blood pressure reading on Day 5 was 128 mm Hg.

General Internal Medicine
General Family Medicine


Question: Based on this electrophoresis, which of the following types of hemoglobin are dominant in this patient's blood?

Context: An 11-year-old boy is brought to the physician by his mother because of worsening fatigue.

Context: His mother reports that he seems to have trouble keeping up with his older brothers when playing outside.

Context: This patient's results are shown in comparison to those of a patient with known sickle cell anemia and a child with normal hemoglobin.

Choices:
A. HbA and HbC
B. HbS only
C. HbA only
D. HbS and HbC

Answer: HbS and HbC

1. An 11-year-old boy is brought to the physician by his mother.

2. The mother reports that the boy has worsening fatigue.

3. The boy has trouble keeping up with his older brothers when playing outside.

4. Physical examination shows conjunctival pallor.

5. A hemoglobin electrophoresis is performed.

6. The patient's results are compared to those of a patient with known sickle cell anemia.

7. The patient's results are compared to those of a child with normal hemoglobin.


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

Context: His symptoms started 1 day before.

Context: Family history is unremarkable.

Context: His blood pressure is 230/130 mm Hg in both arms, the temperature is 36.9°C (98.4°F), and the pulse is 90/min.

Choices:
A. Hypertensive urgency
B. Hypertensive emergency
C. Aortic aneurysm
D. Malignant hypertension

Answer: Hypertensive emergency

1. A 55-year-old African American man presents to the emergency department with central chest pressure.

3. The pain was initially intermittent in nature but has become constant and radiates to his jaw and left shoulder.

4. He also complains of some difficulty breathing.

5. The patient was diagnosed with essential hypertension 1 year ago, but he is not taking any medications for it.

6. The patient denies smoking, alcohol, or drug use.

8. His blood pressure is 230/130 mm Hg in both arms.

11. ECG shows diffuse T wave inversion and ST depression in lateral leads.

12. Laboratory testing is significant for elevated troponin.

Cardiovascular Disease
General Emergency Medicine


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

Context: Vital signs are within normal limits.

Context: She is alert and fully oriented.

Choices:
A. Positive GM1 ganglioside autoantibodies
B. Positive Lyme ELISA test
C. Low vitamin B12 level
D. Elevated TSH and decreased FT4 levels

Answer: Positive GM1 ganglioside autoantibodies

1. A 38-year-old woman comes to the physician for the evaluation of progressive weakness and numbness for 3 months.

2. The symptoms started in her lower legs and gradually moved to her upper legs and arms.

3. During the last 5 days, she has also had bilateral facial weakness with headaches.

4. She has hepatitis B and Graves' disease.

5. She is sexually active with one male partner and they use condoms inconsistently.

6. Her current medications include methimazole and a multivitamin.

7. Vital signs are within normal limits.

9. She has bilateral upper and lower facial paralysis.

10. There is generalized weakness of the muscles.

11. Sensation to light touch is decreased throughout and is absent in her fingertips and toes.

12. Deep tendon reflexes are 1+ bilaterally.


Question: Infection with which of the following organisms would portend the worst prognosis with the highest mortality rate for this patient?

Context: A 32-year-old G2P1 at 32 weeks gestation presents to the emergency department with complaints of severe abdominal pain, fatigue, and nausea.

Context: Physical examination is significant for profound jaundice and tenderness to palpation of the right upper quadrant of the abdomen.

Context: The patient returned 2 weeks ago from a 1 month-long trip to India.

Context: She received sporadic pre-natal care while traveling and reports no known complications in her current pregnancy to date.

Context: She denies any past medical problems and states that her prior pregnancy proceeded as a normal vaginal birth without any complications.

Choices:
A. Hepatitis A
B. Hepatitis B
C. Hepatitis D
D. Hepatitis E

Answer: Hepatitis E

4. Patient presents to emergency department with severe abdominal pain, fatigue, and nausea.

5. Physical examination is significant for profound jaundice.

6. Physical examination is significant for tenderness to palpation of right upper quadrant of abdomen.

7. Patient returned 2 weeks ago from 1 month-long trip to India.

8. Patient received sporadic pre-natal care while traveling.

9. Patient reports no known complications in current pregnancy to date.

10. Patient denies any past medical problems.

11. Patient states prior pregnancy proceeded as normal vaginal birth without any complications.

Internal Medicine
Obstetrics and Gynecology

Infectious Disease
Gastroenterology
Maternal


Question: Pathologic examination of the biopsy specimen is most likely to show which of the following?

Context: A 42-year-old woman comes to the physician because of an episode of coughing with bloody sputum.

Context: Over the past 5 months, she has had a persistent nonproductive cough, excessive fatigue, and a 5.6-kg (12.3-lb) weight loss.

Context: She does not smoke.

Choices:
A. Small cell lung carcinoma
B. Large cell lung carcinoma
C. Bronchial carcinoid tumor
D. Adenocarcinoma

Answer: Adenocarcinoma

1. A 42-year-old woman comes to the physician.

2. She has had a persistent nonproductive cough for the past 5 months.

3. She has had excessive fatigue for the past 5 months.

4. She has had a 5.6-kg (12.3-lb) weight loss for the past 5 months.

6. Physical examination shows no abnormalities.

7. An x-ray of the chest shows a 2.0-cm nodule with irregular borders at the upper lobe of the left lung.

8. She had an episode of coughing with bloody sputum.

9. A CT-guided biopsy of the lung nodule is performed.

Pulmonary Pathology
Hematopathology
General Pulmonary Disease


Question: Which of the following statements is correct regarding this study result?

Context: A group of researchers is conducting a prospective study to examine if dietary fiber intake is protective against coronary heart disease.

Context: Specifically, they are looking at the frequency of coronary heart incidents in a group of middle-aged men taking various daily amounts of water-insoluble fiber.

Context: The Pearson correlation coefficient that was obtained regarding the relationship between the amount of daily water-insoluble fiber intake and the frequency of coronary heart incidents in their study was 0.11 with a p-value of 0.006.

Choices:
A. There is a significant correlation between the daily fiber intake and the frequency of coronary heart incidents because the correlation coefficient is significant.
B. There is a significant correlation between fiber intake and the frequency of coronary heart incidents because the correlation coefficient is not significant.
C. There is a significant correlation between fiber intake and the frequency of coronary heart incidents because the value of the correlation coefficient shows a very good and robust correlation.
D. There is no correlation between fiber intake and the frequency of coronary heart incidents because the correlation coefficient is significant.

Answer: There is no correlation between fiber intake and the frequency of coronary heart incidents because the correlation coefficient is significant.

1. A group of researchers is conducting a prospective study.

2. The study is examining if dietary fiber intake is protective against coronary heart disease.

3. The study is looking at the frequency of coronary heart incidents in a group of middle-aged men.

4. The men are taking various daily amounts of water-insoluble fiber.

5. The Pearson correlation coefficient obtained regarding the relationship between the amount of daily water-insoluble fiber intake and the frequency of coronary heart incidents was 0.11.

6. The p-value of the Pearson correlation coefficient was 0.006.


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

Context: A 24-year-old man comes to the physician because of a painful swelling above his buttocks for 1 week.

Context: He is unable to sit for extended periods because of the pain.

Context: He has obstructive sleep apnea and type 2 diabetes mellitus.

Context: His only medication is metformin.

Context: He appears anxious.

Context: He is 175 cm (5 ft 9 in) tall and weighs 114 kg (251 lb); BMI is 37 kg/m2.

Context: His temperature is 38.1°C (100.6°F), pulse is 96/min and blood pressure is 124/86 mm Hg.

Context: Examination shows facial acne.

Context: A cyst is seen above the natal cleft.

Context: There is tenderness to palpation at the cyst and surrounding tissue.

Context: The skin around the cyst is warm and erythematous.

Choices:
A. Coccygectomy
B. Incision and drainage
C. Retinoid therapy
D. Surgical resection and primary wound closure

Answer: Incision and drainage

2. Patient has a painful swelling above his buttocks for 1 week.

3. Patient is unable to sit for extended periods because of the pain.

4. Patient has obstructive sleep apnea and type 2 diabetes mellitus.

5. Patient's only medication is metformin.

10. Patient's temperature is 38.1°C (100.6°F).

12. Patient's blood pressure is 124/86 mm Hg.

14. Patient has a cyst above the natal cleft.

15. Patient has tenderness to palpation at the cyst and surrounding tissue.

16. Skin around the cyst is warm and erythematous.


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

Context: A 17-year-old girl comes to the physician because of a 3-year history of acne on her face and chest.

Context: She has no itching or scaling.

Context: She is concerned about the possibility of facial scarring and has never sought treatment.

Context: She has no history of serious illness.

Context: She takes no medications.

Context: She is 160 cm (5 ft 3 in) tall and weighs 58 kg (130 lb); BMI is 23 kg/m2.

Choices:
A. Oral antibiotics
B. Topical benzoyl peroxide
C. Topical antibiotic
D. Oral isotretinoin

Answer: Topical benzoyl peroxide

1. A 17-year-old girl comes to the physician.

2. She has a 3-year history of acne on her face and chest.

4. She is concerned about the possibility of facial scarring.

6. She has no history of serious illness.

11. Her vital signs are within normal limits.

12. Examination shows several open comedones on the face and chest.


Question: Which of the following drugs most likely has a similar mechanism of action as the drug prescribed to this patient?

Context: A 12-year-old boy is brought to the emergency department by his mother because he has been having difficulty breathing.

Context: He started having symptoms about 3 days ago when he started experiencing persistent coughing, runny nose, and a low grade fever.

Context: Since then he has been experiencing dyspnea that grew worse until he felt that he could no longer breathe.

Context: His mom says that this has happened many times before.

Context: During stabilization, he is prescribed a drug for treatment of his condition.

Context: The patient's mother recognizes the drug since her father, a 40-pack-year smoker, also takes the medication and she is told that the drug is able to beneficially inhibit a receptor on smooth muscle in both cases.

Choices:
A. Cortisol
B. Glycopyrrolate
C. Theophylline
D. Zileuton

Answer: Glycopyrrolate

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

3. Patient has been having difficulty breathing.

4. Patient started having symptoms 3 days ago.

5. Symptoms included persistent coughing, runny nose, and a low grade fever.

6. Patient has been experiencing dyspnea that grew worse until he felt he could no longer breathe.

7. Patient's mother says this has happened many times before.

8. On presentation, physical exam reveals an anxious, thin boy who is using his accessory muscles to breathe.

9. Prolonged expiratory wheezes are heard on auscultation of his lungs bilaterally.

10. During stabilization, patient is prescribed a drug for treatment of his condition.

11. Patient's mother recognizes the drug since her father, a 40-pack-year smoker, also takes the medication.

12. Drug is able to beneficially inhibit a receptor on smooth muscle in both cases.


Question: Which of the following medications would you prescribe for this patient?

Context: A 35-year-old taxi driver presents to his physician with complaints of itchy, watery eyes and excessive sneezing that have become more severe with the change of the seasons.

Context: He has previously taken an over-the-counter medication in the past with moderate relief of his symptoms, but it made him very drowsy.

Context: He asks to switch to a medication that will not cause drowsiness that may impair his driving.

Choices:
A. Cetirizine
B. Chlorpheniramine
C. Diphenhydramine
D. Hydroxyzine

Answer: Cetirizine

1. A 35-year-old taxi driver presents to his physician.

2. He has itchy, watery eyes and excessive sneezing.

3. His symptoms become more severe with the change of the seasons.

4. He has previously taken an over-the-counter medication with moderate relief of his symptoms.

5. The over-the-counter medication made him very drowsy.

6. He asks to switch to a medication that will not cause drowsiness.

7. The medication should not impair his driving.


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

Context: A 19-year-old female college student comes to the physician for a sudden loss of visual acuity of her right eye.

Context: She noticed that she was unable to read the time on the alarm clock when she woke up in the morning.

Context: She does not recall trauma to her eye but has been working long nights on her honors thesis.

Context: She has a history of occasional shoulder luxation.

Context: She is 180 cm (5 ft 11 in) tall, and weighs 62 kg (136 lbs); her BMI is 19.1 kg/m2.

Context: Her vital signs are within normal limits.

Context: She has several flat, demarcated brownish nevi on her left cheek.

Choices:
A. Joint hypermobility syndrome
B. Sturge-Weber syndrome
C. Ehlers-Danlos syndrome
D. Marfan syndrome

Answer: Marfan syndrome

1. Patient is a 19-year-old female college student.

2. Patient has sudden loss of visual acuity of her right eye.

3. Patient was unable to read the time on the alarm clock when she woke up in the morning.

4. When she closes her right eye, she is able to see sharply.

5. When she closes her left eye, she has blurry double vision.

6. Patient does not recall trauma to her eye.

7. Patient has been working long nights on her honors thesis.

8. Patient has a history of occasional shoulder luxation.

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

13. On physical examination, slender and long fingers are noted.

14. Patient has several flat, demarcated brownish nevi on her left cheek.

15. Ocular examination shows upward temporal subluxation of her right lens.


Question: Which of the following serum markers is most likely elevated in this patient?

Context: He reports a 6-month history of gradually progressive epigastric pain and 10 pounds of unexpected weight loss.

Context: He has also noticed that his skin feels itchier than usual.

Context: He has a 10-pack-year smoking history and a distant history of cocaine abuse.

Context: His temperature is 100.1°F (37.8°C), blood pressure is 135/85 mmHg, pulse is 100/min, and respirations are 20/min.

Context: On exam, he has notable hepatomegaly and a palpable gallbladder.

Choices:
A. Bombesin
B. CA-125
C. CA 19-9
D. S-100

Answer: CA 19-9

1. A 62-year-old man presents to his primary care provider complaining of abdominal pain.

2. He reports a 6-month history of gradually progressive epigastric pain.

3. He has also noticed 10 pounds of unexpected weight loss.

4. His past medical history is notable for gout, hypertension, and diabetes mellitus.

5. He takes allopurinol, enalapril, and glyburide.

6. He has a 10-pack-year smoking history.

7. He has a distant history of cocaine abuse.

12. On exam, he has notable hepatomegaly.

13. On exam, he has a palpable gallbladder.

14. A right upper quadrant ultrasound reveals an irregular extrahepatic mass originating from the gallbladder wall.


Question: Which of the following could be used to culture the most likely cause of this disorder?

Context: A 4-year-old girl from a recently immigrated family presents to the emergency department with episodes of severe coughing lasting up to several minutes followed by vomiting.

Context: She had a low grade fever and runny nose over the last 2 weeks but these coughing episodes just began one day prior to presentation.

Context: A complete blood count shows a lymphocytic infiltrate and Gram stain reveals a gram-negative coccobacillus.

Choices:
A. Charcoal yeast with iron and cysteine
B. Eaton agar
C. Loffler medium
D. Regan-Lowe medium

Answer: Regan-Lowe medium

1. A 4-year-old girl from a recently immigrated family presents to the emergency department.

2. She has episodes of severe coughing lasting up to several minutes followed by vomiting.

3. She had a low grade fever and runny nose over the last 2 weeks.

4. The coughing episodes just began one day prior to presentation.

5. A complete blood count shows a lymphocytic infiltrate.

6. Gram stain reveals a gram-negative coccobacillus.

7. The emergency department physician explains that this organism causes disease by toxin-mediated inactivation of an inhibitory signaling molecule.

Pediatric Pulmonology
Pediatric Infectious Diseases


Question: Which of the following histopathologic findings characteristic of this patient’s most likely diagnosis is marked by the yellow circle?

Context: A colonoscopy is performed and shows continuous erythema, superficial ulcers, and pseudopolyps in the rectum and sigmoid colon.

Choices:
A. Goblet cell hyperplasia
B. Paneth cells metaplasia
C. Crypt abscess
D. Enterocyte dysplasia

Answer: Crypt abscess

1. A 28-year-old man presents with episodic abdominal pain and bloody diarrhea for the past week.

2. He says that the abdominal pain is diffusely localized to the periumbilical region and is dull and cramping in character.

3. He also reports episodes of painful, bloody diarrhea up to 7 times per day.

5. The colonoscopy shows continuous erythema, superficial ulcers, and pseudopolyps in the rectum and sigmoid colon.

6. A biopsy is taken and sent for histological evaluation.

7. One of the slides from the biopsy is shown in the image below.


Question: Which of the following is the most likely underlying cause of these findings?"

Context: A 14-year-old boy is brought to the emergency department because of a 2-day history of fatigue.

Context: He reports that during this time he has had occasional palpitations and shortness of breath.

Context: He has sickle cell disease.

Context: Current medications include hydroxyurea and folic acid.

Context: He appears fatigued.

Context: His temperature is 38.3°C (100.9°F), pulse is 120/min, respirations are 24/min, and blood pressure is 112/74 mm Hg.

Context: Examination shows pale conjunctivae.

Context: Laboratory studies show: | Hemoglobin 6.4 g/dl | Leukocyte count 6,000/mm3 | Platelet count 168,000/mm3 | Mean corpuscular volume 84 μm3 | Reticulocyte count 0.1% | .

Choices:
A. Parvovirus B19
B. Medication-induced hemolysis
C. Defect in erythrocyte membrane proteins
D. Hemolytic crisis

Answer: Parvovirus B19

2. Patient has a 2-day history of fatigue.

3. Patient has occasional palpitations and shortness of breath.

5. Patient is currently taking hydroxyurea and folic acid.

7. Patient's temperature is 38.3°C (100.9°F).

10. Patient's blood pressure is 112/74 mm Hg.

12. Cardiac examination shows a midsystolic ejection murmur.

13. Laboratory studies show hemoglobin 6.4 g/dl.

14. Laboratory studies show leukocyte count 6,000/mm3.

15. Laboratory studies show platelet count 168,000/mm3.

16. Laboratory studies show mean corpuscular volume 84 μm3.

17. Laboratory studies show reticulocyte count 0.1%.

Hematology
General Pediatrics
Pediatric Hematology


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

Context: A 44-year-old woman comes to the office because of 4 episodes of loss of consciousness over the past 2 weeks.

Context: For the past 6 months, she has also had increased shortness of breath, palpitations, and chest tightness that resolves with rest.

Context: Pulse is 115/min and irregular and blood pressure is 108/70 mm Hg.

Choices:
A. Increased pulmonary capillary wedge pressure
B. Increased central venous pressure
C. Increased oxygenated blood in the right ventricle
D. Increased mean arterial pressure

Answer: Increased pulmonary capillary wedge pressure

1. A 44-year-old woman comes to the office.

2. She has had 4 episodes of loss of consciousness over the past 2 weeks.

3. She recovered immediately and was not confused following the episodes.

4. She has also had increased shortness of breath, palpitations, and chest tightness for the past 6 months that resolves with rest.

5. She immigrated with her family from India 10 years ago.

8. Cardiac examination shows an accentuated and split S2.

9. There is an opening snap followed by a low-pitched diastolic murmur in the fifth left intercostal space at the midclavicular line.

10. An ECG shows atrial fibrillation and right axis deviation.


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

Context: A 43-year-old woman is brought to the emergency department because of severe central chest pain, mild shortness of breath, and one episode of coughing up blood since waking up that morning.

Context: The pain worsens on inspiration, and she describes it as 8 out of 10 in intensity.

Context: Her temperature is 37.8°C (100°F), pulse is 103/min, respirations are 20/min, and blood pressure is 102/74 mm Hg.

Context: The lungs are clear to auscultation.

Context: Laboratory studies show a normal complete blood count, creatinine of 1.0 mg/dL, and a creatinine clearance of 81 mL/min (N = 75–115).

Context: Arterial blood gas analysis on room air shows: | pH 7.49 | PCO2 29 mm Hg | PO2 69 mm Hg | HCO3- 22 mEq/L | An x-ray of the chest shows no abnormalities.

Choices:
A. CT pulmonary angiography
B. D-dimer levels
C. Catheter embolectomy
D. Low molecular weight heparin therapy

Answer: Low molecular weight heparin therapy

1. A 43-year-old woman is brought to the emergency department.

2. She has severe central chest pain, mild shortness of breath, and one episode of coughing up blood since waking up that morning.

3. The pain worsens on inspiration and is 8 out of 10 in intensity.

4. Three months ago, she underwent a left modified radical mastectomy for invasive ductal carcinoma.

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

10. The lungs are clear to auscultation.

11. Cardiac examination shows no abnormalities.

12. The left lower extremity is swollen and erythematous.

13. Laboratory studies show a normal complete blood count.

15. Creatinine clearance is 81 mL/min (N = 75–115).

16. Arterial blood gas analysis on room air shows: pH 7.49, PCO2 29 mm Hg, PO2 69 mm Hg, HCO3- 22 mEq/L.

17. An x-ray of the chest shows no abnormalities.


Question: Which of the following matches a drug with its correct characteristic?

Context: A 58-year-old Caucasian male with a history of peripheral vascular disease is admitted to the hospital with a painful, pulseless foot.

Context: He is prescribed antiplatelet and anticoagulant drugs.

Choices:
A. Warfarin: directly inhibits thrombin
B. Heparin: activates antithrombin 3
C. Aspirin: reversibly inhibits COX-1
D. Prasugrel: reduced risk of bleeding compared to other drugs in its class

Answer: Heparin: activates antithrombin 3

3. Patient has a history of peripheral vascular disease.

5. Patient has a painful, pulseless foot.

6. Patient is prescribed antiplatelet drugs.

7. Patient is prescribed anticoagulant drugs.


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

Context: A 64-year-old woman comes to the physician because of several episodes of dizziness during the last month.

Context: The episodes last between 30–40 seconds and during the episodes she feels as though she is spinning.

Context: They also sometimes happen when she suddenly turns her head to look at something.

Context: She has no nausea.

Choices:
A. Benign paroxysmal positional vertigo
B. Persistent postural-perceptual dizziness
C. Meniere disease
D. Acoustic neuroma

Answer: Benign paroxysmal positional vertigo

1. A 64-year-old woman comes to the physician.

2. She has experienced several episodes of dizziness in the last month.

3. The episodes last between 30–40 seconds.

4. During the episodes she feels as though she is spinning.

5. Episodes usually occur immediately after lying down or suddenly sitting up from a reclined position.

6. Episodes also sometimes happen when she suddenly turns her head to look at something.

8. Last month, she had an upper respiratory tract infection that resolved spontaneously.

9. She has hypertension treated with hydrochlorothiazide.

10. Otoscopic examination shows no abnormalities.

11. There is no lateralization when a vibrating 512 Hz tuning fork is placed in the middle of the forehead.


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

Context: A 31-year-old woman presents to her primary care physician because she has been experiencing diarrhea over the last several days.

Context: She returned from a cruise ship vacation 3 days ago and has recently been to many countries in Central and South America.

Context: Stool examination shows blood and neutrophils and imaging reveals abscesses in the liver.

Choices:
A. Acid fast cysts
B. Motile bacteria
C. Non-invasive trophozoites
D. Ulcers that are flask-shaped

Answer: Ulcers that are flask-shaped

1. A 31-year-old woman presents to her primary care physician.

2. She has been experiencing diarrhea over the last several days.

3. She returned from a cruise ship vacation 3 days ago.

4. She has recently been to many countries in Central and South America.

5. After returning, she developed bloody diarrhea, nausea, and right-upper quadrant abdominal pain.

6. Stool examination shows blood and neutrophils.

7. Imaging reveals abscesses in the liver.

In this case, the most relevant medical specialty would be Gastroenterology

In this case, the most relevant specialty would be Gastroenterology

General Gastroenterology.
General Gastroenterology
Gastroenterology


Question: Which of the following mechanisms most likely contributes to the efficacy of this patient's pharmacotherapy?

Context: A 35-year-old woman that is currently being treated for chronic hepatitis C comes to the physician because of progressive fatigue for 10 days.

Context: Examination shows pale conjunctivae.

Context: Her hemoglobin concentration is 10.1 g/dL, serum total bilirubin concentration is 1.9 mg/dL, and LDH is 259 U/L (N = 45–90 U/L).

Choices:
A. Activation of leukocytes
B. Inhibition of reverse transcriptase
C. Inhibition of RNA polymerase
D. Decreased GMP synthesis

Answer: Decreased GMP synthesis

1. A 35-year-old woman is being treated for chronic hepatitis C.

2. She comes to the physician because of progressive fatigue for 10 days.

4. Her hemoglobin concentration is 10.1 g/dL.

5. Her serum total bilirubin concentration is 1.9 mg/dL.

7. The normal range for LDH is 45–90 U/L.


Question: Which of the following effects are most likely to have occurred in this child’s eye from these eye drops?

Choices:
A. Contraction of the pupillary dilator muscle with no effect on the ciliary muscle
B. Relaxation of the pupillary dilator muscle with no effect on the ciliary muscle
C. Relaxation of the pupillary sphincter muscle with contraction of the ciliary muscle
D. Contraction of the pupillary dilator muscle with contraction of the ciliary muscle

Answer: Contraction of the pupillary dilator muscle with no effect on the ciliary muscle

1. A 7-year-old boy is brought to a pediatrician by his parents.

2. The parents say that the patient accidentally instilled a drop from a bottle of medicated eye drops into his right eye.

3. According to them, the patient’s grandfather uses the eye drops which were prescribed for him by an ophthalmologist.

4. The parents have brought the eye drops with them.

5. The pediatrician notes that the eye drops contain an α1 adrenergic agonist drug.

6. He examines the patient’s eye and finds that the eye drops have produced their expected effects.

7. He reassures the parents about the self-limited effect of the drug and the absence of any risk of long-term complications.


Question: The most effective medication for her disorder has what mechanism of action?

Context: For the past 9 months, the patient has been having a hard time falling asleep because she “can’t turn her mind off.” She is a student in a nearby university and spends hours at the end of each day worrying about her classes as well as her upcoming tests.

Context: When she doesn’t have tests, she worries about her family and her boyfriend even though admits she has no specific concerns about them.

Context: This constant worrying has led to insomnia and an inability to focus in class.

Context: She has also been fatigued and hasn’t had the energy to go the gym as she usually does.

Choices:
A. Inhibit reuptake of serotonin
B. Inhibition of monoamine oxidase
C. Increase norepinephrine and dopamine
D. Block dopamine receptors

Answer: Inhibit reuptake of serotonin

1. A 21-year-old female comes to the physician’s office because of insomnia.

2. For the past 9 months, the patient has been having a hard time falling asleep because she “can’t turn her mind off.”

3. She is a student in a nearby university.

4. She spends hours at the end of each day worrying about her classes.

5. She spends hours at the end of each day worrying about her upcoming tests.

6. She worries about her family and her boyfriend even though admits she has no specific concerns about them.

7. This constant worrying has led to insomnia.

8. This constant worrying has led to an inability to focus in class.

10. She hasn't had the energy to go the gym as she usually does.


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

Context: A 7-year-old girl is brought to the physician because of a slightly itchy rash that first appeared 3 days ago.

Context: Her mother says she has also been complaining of headaches and achy muscles since yesterday evening.

Context: The girl went on a camping trip for school 10 days ago.

Context: She recalls being bitten several times by mosquitoes.

Context: She has a history of atopic dermatitis.

Context: She lives in Massachusetts with both parents and her 4-year-old sister.

Context: Her temperature is 39°C (102.2°F).

Context: A photograph of the rash is shown.

Choices:
A. Amoxicillin
B. Ceftriaxone
C. Penicillin G
D. Azithromycin

Answer: Amoxicillin

2. Patient has a slightly itchy rash that first appeared 3 days ago.

3. Patient has been complaining of headaches and achy muscles since yesterday evening.

4. Patient went on a camping trip for school 10 days ago.

5. Patient recalls being bitten several times by mosquitoes.

6. Patient has a history of atopic dermatitis.

7. Patient lives in Massachusetts with both parents and her 4-year-old sister.

8. Patient's temperature is 39°C (102.2°F).

9. Physical examination shows a 3-cm, nontender rash on her left upper torso.

10. There are also multiple 5 to 8-mm erythematous papules over the lower legs and forearms.

General Dermatology
Pediatric Dermatology


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

Context: A 45-year-old man presents to the clinic for the third time in the past 3 weeks asking for an MRI of his lower back.

Context: The next day, he developed soreness in his lower back and spent the whole day online trying to figure out what was wrong with him.

Context: He has been to the emergency department a few times and subsequently has been redirected to the clinic where each time he was thoroughly examined and investigated for all the possible causes.

Context: The patient still exhibits worry and would like to get an MRI to make sure everything is ‘okay.’ .

Choices:
A. Illness anxiety disorder
B. Somatic symptom disorder
C. Factitious disorder
D. Munchausen syndrome

Answer: Illness anxiety disorder

1. A 45-year-old man presents to the clinic for the third time in the past 3 weeks.

2. He had initially gone to the gym as advised by his wife and had started doing some back exercises.

3. The next day, he developed soreness in his lower back.

4. He spent the whole day online trying to figure out what was wrong with him.

5. He has been to the emergency department a few times.

6. He has subsequently been redirected to the clinic.

7. Each time he was thoroughly examined and investigated for all the possible causes.

9. He would like to get an MRI to make sure everything is ‘okay.’


Question: What is the best initial step in management?

Context: She initially thought that it was just due to dust from moving boxes into her new apartment, but her symptoms did not improve after cleaning her belongings and vacuuming her floor.

Context: She feels some relief after splashing her face with cold water, but her symptoms recur within ten minutes.

Context: She has no pets and does not take any medications.

Context: No rales or wheezes are appreciated on lung auscultation, but bronchial breath sounds are heard at the bases.

Choices:
A. Oral loratadine
B. Intranasal corticosteroids
C. Sublingual oseltamivir
D. Oral montelukast

Answer: Intranasal corticosteroids

1. A 25-year-old woman presents to the urgent care clinic for cough for the past five days.

2. She recently moved to the area and has not yet established a primary care doctor.

3. She has noticed worsening runny nose with congestion, sneezing, and tearing over the past few days.

4. She initially thought that it was just due to dust from moving boxes into her new apartment.

5. Her symptoms did not improve after cleaning her belongings and vacuuming her floor.

6. She feels some relief after splashing her face with cold water.

7. Her symptoms recur within ten minutes.

10. Her physical exam reveals examples of findings shown in Figures A-C.

11. No rales or wheezes are appreciated on lung auscultation.

12. Bronchial breath sounds are heard at the bases.

13. The patient states that she will need to drive back home after this visit.

Pulmonary Disease
General Pediatrics
Infectious Disease
Pediatric Pulmonology


Question: What is her CHADS2 score?

Context: A 73-year-old woman with atrial fibrillation presents to your clinic to discuss the need for anticoagulation.

Context: Her PMH is significant for high blood pressure, diabetes mellitus type II, osteoporosis, and depression.

Context: She previously smoked but quit about 16 years ago.

Context: She has never had a stroke or TIA.

Context: Her physical examination is remarkable for an irregular heart rate.

Context: She has a blood pressure of 136/94 mm Hg and a heart rate of 74/min.

Choices:
A. 1
B. 2
C. 4
D. Too little information to tell

1. A 73-year-old woman presents to clinic to discuss need for anticoagulation.

2. Patient's past medical history (PMH) is significant for high blood pressure, diabetes mellitus type II, osteoporosis, and depression.

3. Patient previously smoked but quit about 16 years ago.

4. Patient has never had a stroke or TIA.

5. Patient's physical examination is remarkable for an irregular heart rate.

6. Patient's blood pressure is 136/94 mm Hg.


Question: Which of the following is most likely responsible for the improvement in this patient's neurological status?

Context: A 26-year-old woman is admitted to the hospital because of a 3-day history of tingling and weakness in the lower extremities.

Context: Over the next 3 weeks, the patient's condition progresses to involve both upper extremities, and she requires ventilatory support.

Context: Six weeks after admission, deep tendon reflexes are 1+ in the ankles, and she is able to wiggle her toes.

Choices:
A. Synthesis of monoamine neurotransmitters
B. Remyelination of peripheral nerves
C. Replication of oligodendrocyte precursor cells
D.
Lymphocytic infiltration in the endoneurium
"

Answer: Remyelination of peripheral nerves

1. A 26-year-old woman is admitted to the hospital.

2. She has a 3-day history of tingling and weakness in the lower extremities.

3. Neurologic examination shows areflexia of the ankle and knee joints bilaterally.

4. Motor strength is 1/5 in both lower legs.

5. Over the next 3 weeks, her condition progresses to involve both upper extremities.

7. Six weeks after admission, deep tendon reflexes are 1+ in the ankles.


Question: This patient is most likely deficient in a vitamin that has which of the following functions?

Context: A 42-year-old woman presents to her primary care physician for fatigue and blurry vision.

Context: She is a refugee from Syria who arrived in the United States 1 week ago.

Context: She has lived for the last 8 months in a refugee camp.

Context: She worked at a grocery store in Syria before being displaced from her home.

Context: She has one son who is 9 years old and was seen by a pediatrician the day prior.

Context: She reports that while she was in the refugee camp, she ate very little and gave most of her food to her son to ensure that he stayed healthy.

Context: She denies any past medical history and takes no medications.

Context: She does not smoke or drink alcohol.

Context: Her temperature is 97.8°F (36.6°C), blood pressure is 108/68 mmHg, pulse is 102/min, and respirations are 18/min.

Context: On exam, she appears fatigued but is fully cooperative with the examination.

Context: There are fissures at the corners of her mouth.

Context: A funduscopic examination reveals corneal vascularization in both eyes.

Context: Her tongue is darkly erythematous.

Choices:
A. Cofactor for homocysteine methyltransferase
B. Cofactor for pyruvate dehydrogenase enzyme
C. Precursor to FAD and FMN
D. Constituent of NAD+ and NADP+

Answer: Precursor to FAD and FMN

2. Patient presents with fatigue and blurry vision.

4. Patient arrived in the United States 1 week ago.

5. Patient lived in a refugee camp for 8 months.

6. Patient worked at a grocery store in Syria before being displaced from her home.

7. Patient has one son who is 9 years old.

8. Patient's son was seen by a pediatrician the day prior.

9. Patient ate very little and gave most of her food to her son while in the refugee camp.

10. Patient denies any past medical history and takes no medications.

11. Patient does not smoke or drink alcohol.

12. Patient's temperature is 97.8°F (36.6°C).

13. Patient's blood pressure is 108/68 mmHg.

16. Patient appears fatigued but is fully cooperative with the examination.

17. Patient has fissures at the corners of her mouth.

18. Funduscopic examination reveals corneal vascularization in both eyes.

19. Patient's tongue is darkly erythematous.


Question: Which of the following statements describing the patient’s current state is most accurate?

Context: A 70-year-old man was first evaluated for an enlarging neck mass with complaints of night sweats, fever, and weight loss.

Context: Excisional biopsy confirms the diagnosis of Burkitt lymphoma.

Context: The patient is started on a CODOX-M/IVAC chemotherapy regime.

Context: The physician notes a marked improvement, but is concerned about a common complication of chemotherapy.

Context: The patient is prescribed rasburicase in response to this complication.

Choices:
A. Rasburicase is a xanthine oxidase inhibitor
B. This complication only occurs in response to radiation
C. Rasburicase converts uric acid to allantoin, increasing its secretion
D. Hypophosphatemia is expected to develop in this patient

Answer: Rasburicase converts uric acid to allantoin, increasing its secretion

1. A 70-year-old man was first evaluated for an enlarging neck mass.

2. The man had complaints of night sweats, fever, and weight loss.

3. Excisional biopsy confirmed the diagnosis of Burkitt lymphoma.

4. The patient was started on a CODOX-M/IVAC chemotherapy regime.

5. The physician noted a marked improvement.

6. The physician was concerned about a common complication of chemotherapy.

7. The patient was prescribed rasburicase in response to this complication.


Question: The patient's condition is most likely associated with which of the following pathophysiologic changes?

Context: A previously healthy 41-year-old man is brought to the emergency department 30 minutes after collapsing at home.

Context: Cardiopulmonary resuscitation is attempted for 10 minutes without success.

Context: A photograph of sections of the heart obtained at autopsy is shown.

Choices:
A. Retrograde blood flow from the aorta into the left ventricle
B. Fixed obstruction of the left ventricular outflow tract
C. Marked noncompliance of the left ventricular wall
D. Severe narrowing of the left anterior descending artery

Answer: Marked noncompliance of the left ventricular wall

1. A 41-year-old man was brought to the emergency department.

3. He collapsed at home 30 minutes prior.

4. Cardiopulmonary resuscitation was attempted for 10 minutes.

6. A photograph of sections of the heart was obtained at autopsy.


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

Context: Laboratory studies show: | Hemoglobin 9.8 mg/dL | Serum | Urea nitrogen 50 mg/dL | Creatinine 2.8 mg/dL | Calcium 12.9 mg/dL | Urine | Protein negative | Blood negative | .

Choices:
A. Renal deposition of AL amyloid
B. Immunoglobulin light chains
C. Decreased cardiac ejection fraction
D. Anti-streptococcal antibodies

Answer: Immunoglobulin light chains

1. A 68-year-old woman comes to the physician with increasing fatigue and shortness of breath for 2 weeks.

2. She has only passed very small amounts of urine over the past few days.

3. During this time, she has also noticed that her feet appear unusually puffy for a few hours every morning.

4. Three weeks ago, she had a sore throat that resolved spontaneously after several days without antibiotic therapy.

5. She has a 6-month history of lower back and thoracic pain, for which she takes ibuprofen daily.

6. Her only other medication is a laxative for constipation, which she first experienced 8 months ago.

7. Her sister has systemic lupus erythematosus.

8. Her temperature is 37.9°C (98.9°F), pulse is 110/min, respirations are 22/min, and blood pressure is 150/100 mm Hg.

9. Examination shows pedal edema and conjunctival pallor.

10. There is tenderness to palpation over the lumbar spine and the 8th rib on the right.

11. Cardiac examination shows no abnormalities.

12. Laboratory studies show: Hemoglobin 9.8 mg/dL.


Question: From whom should the surgeon get consent for the procedure?

Context: A 13-month-old male needs to have surgery for an undescended testicle.

Context: His 19-year-old father is not involved.

Choices:
A. The mother
B. The father
C. A grandparent
D. The hospital's medical ethics committee

Answer: The mother

1. A 13-month-old male needs to have surgery.

2. The surgery is for an undescended testicle.

3. The child lives with his 16-year-old mother only.

4. His 19-year-old father is not involved.


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

Context: A 7-year-old boy is brought to the emergency department after he was bitten by a dog.

Context: The patient was at a friend's house, and he was bitten when he pulled the dog's tail while it was eating.

Context: The patient is currently doing well and has a dog bite on his right distal forearm.

Context: His temperature is 98.2°F (36.8°C), blood pressure is 100/60 mmHg, pulse is 123/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Context: The wound is thoroughly irrigated in the emergency department.

Choices:
A. Closure of the wound via sutures
B. Euthanasia of the animal
C. Quarantine and observe the animal
D. Rabies vaccine and rabies immunoglobulin

Answer: Quarantine and observe the animal

1. A 7-year-old boy was brought to the emergency department.

3. He was at a friend's house when he was bitten.

4. He pulled the dog's tail while it was eating.

6. He has a dog bite on his right distal forearm.

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

12. The wound was thoroughly irrigated in the emergency department.


Question: Which of the following set of laboratory results and peripheral blood smear findings would most likely be seen in this patient?

Context: A 35-year-old woman, otherwise healthy, presents with frequent nosebleeds and bruising on her legs.

Context: She says that her symptoms started about 6 months ago and have not improved.

Context: She remembers that her 8-year-old son had similar symptoms about a month ago following a viral respiratory infection, but his symptoms quickly resolved without treatment.

Context: Review of systems is significant for her last period 2 weeks ago being a bit heavier than usual.

Context: Her vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/75 mm Hg, pulse 98/min, respirations 15/min, and oxygen saturation 99% on room air.

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

Context: Cardiac exam is normal.

Context: Lungs are clear to auscultation.

Context: There is non-palpable purpura present on the lower extremities bilaterally.

Choices:
A. Platelets: Decreased | Bleeding time: Increased | PT: Normal | PTT: Normal | Blood smear: Schistocytes present
B. Platelets: Decreased | Bleeding time: Increased | PT: Increased| PTT: Increased | Blood smear: Schistocytes present
C. Platelets: Increased | Bleeding time: Decreased| PT: Normal| PTT: Normal | Blood smear: Schistocytes absent
D. Platelets: Decreased | Bleeding time: Increased | PT: Normal| PTT: Normal| Blood smear: Schistocytes absent

Answer: Platelets: Decreased | Bleeding time: Increased | PT: Normal| PTT: Normal| Blood smear: Schistocytes absent

3. Patient presents with frequent nosebleeds and bruising on her legs.

4. Symptoms started about 6 months ago and have not improved.

5. Patient's 8-year-old son had similar symptoms about a month ago following a viral respiratory infection, but his symptoms quickly resolved without treatment.

6. No significant past medical history and no current medications.

7. Family history is significant for her father dying at age 65 of myocardial infarction.

8. Patient's last period 2 weeks ago was a bit heavier than usual.

9. Vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/75 mm Hg, pulse 98/min, respirations 15/min, and oxygen saturation 99% on room air.

10. Patient is alert and cooperative on physical examination.

13. Non-palpable purpura present on the lower extremities bilaterally.


Question: Which of the following is the most appropriate modification in this patient’s drug therapy?

Context: Her medications include inhaled salmeterol and fluticasone propionate and oral amitriptyline, the dose of which was increased recently due to uncontrolled depressive symptoms.

Choices:
A. Adding ipratropium bromide inhaler
B. Reducing the dose of albuterol
C. Switching amitriptyline to fluoxetine
D. No change is required at this time

Answer: Switching amitriptyline to fluoxetine

1. A 65-year-old woman comes to the physician because of urinary straining and delayed flow of urine for 1 month.

2. She has a medical history significant for long-standing asthma.

3. Recently, she has been taking albuterol more frequently on an as-needed basis.

4. She was diagnosed with major depression last year.

5. Currently, her symptoms of depression are under control.

6. Her medications include inhaled salmeterol and fluticasone propionate and oral amitriptyline.

7. The dose of amitriptyline was increased recently due to uncontrolled depressive symptoms.

8. The vital signs include: temperature 37.1°C (99.8°F), pulse rate 80/min, respiratory rate 14/min, and blood pressure 110/70 mm Hg.

9. On examination, she has dry oral mucous membranes.

10. The remainder of the examination shows no abnormalities.


Question: Based on the description of these patients symptoms and current treatment regime, which of the following categories describes the severity of this child’s symptoms?

Context: On physical examination, she doesn’t seem to be in distress, and currently, the lungs are clear on auscultation.

Choices:
A. Mild intermittent
B. Mild persistent
C. Moderate persistent
D. Severe persistent

Answer: Moderate persistent

1. An 8-year-old girl is brought by her mother to her pediatrician’s office for a follow-up visit.

2. She was diagnosed with asthma about 4 years ago and has been on medications ever since.

3. She came into the doctor’s office about a month ago with an escalation of her symptoms.

4. She told her doctor that she has been struggling to breathe almost every single day.

5. This difficulty increased when she played outdoors with her friends.

6. She said that she used to wake up at least 3 times a week from sleep to use her inhaler.

7. She uses a short-acting β-agonist inhaler to control her symptoms.

8. At the previous visit, her doctor had started her on a small dose of fluticasone (inhaled) as well as a long-acting β-agonist inhaler.

9. She has some improvement in her symptoms.

10. On physical examination, she doesn’t seem to be in distress.

11. Currently, the lungs are clear on auscultation.

12. Her forced expiratory volume in one second is about 70% of the predicted value.


Question: Which drug is suitable in her case for the prevention of headaches?

Context: The pain is usually unilateral, pulsatile in character, exacerbated by light and noise, and usually lasts for a few hours to a full day.

Context: She also has essential tremors.

Choices:
A. Ergotamine
B. Verapamil
C. Valproic
D. Propranolol

Answer: Propranolol

1. An 18-year-old woman presents with recurrent headaches.

4. The pain is exacerbated by light and noise.

5. The pain usually lasts for a few hours to a full day.

6. The pain is sometimes triggered by eating chocolates.

7. These headaches disturb her daily routine activities.

8. The physical examination was within normal limits.


Question: An MRI scan of the head is most likely to show which of the following?

Context: A 26-year-old man is brought to the emergency department by the police after threatening to harm his roommate earlier today.

Context: His family reports that, during the past two years, the patient has become increasingly more withdrawn from family and friends.

Context: He states that he has spent the majority of the last year alone in his room “working on a project at home to save the earth from an evil alien power.” There is no family history of serious illness.

Context: Vital signs are within normal limits.

Context: On mental status examination, he has a flat affect and his speech is disorganized.

Choices:
A. Periventricular plaques and white matter lesions
B. Ring-enhancing lesion
C. Hyperintense temporal lobe lesion
D. Enlarged cerebral ventricles

Answer: Enlarged cerebral ventricles

1. A 26-year-old man is brought to the emergency department by the police.

2. He threatened to harm his roommate earlier today.

3. He reports that someone on the radio told him to do so.

4. His family reports that he has become increasingly more withdrawn from family and friends during the past two years.

5. He states that he has spent the majority of the last year alone in his room “working on a project at home to save the earth from an evil alien power.”

6. There is no family history of serious illness.

7. He has smoked marijuana on a daily basis since he was thirteen.

8. Vital signs are within normal limits.

9. On mental status examination, he has a flat affect.

10. On mental status examination, his speech is disorganized.


Question: Which of the following is the most life-threatening complication of amobarbital withdrawal?

Context: A 46-year-old anesthesiologist is found placing several syringes of amobarbital in his backpack prior to leaving the hospital.

Context: When confronted, the anesthesiologist admits that he began abusing the medication the previous year, after his divorce was finalized.

Context: He has been using it on a daily basis since then, and his most recent usage was 8 hours ago.

Choices:
A. Internal bleeding
B. Respiratory depression
C. Cardiovascular collapse
D. Self-inflicted violence

Answer: Cardiovascular collapse

1. A 46-year-old anesthesiologist was found placing several syringes of amobarbital in his backpack.

3. He admitted to abusing the medication since the previous year.

4. His divorce was finalized the previous year.

5. He has been using the medication on a daily basis since then.

6. His most recent usage was 8 hours ago.


Question: What is the mechanism of action of the medication that can be used in the management of this patient’s condition?

Context: A 55-year-old man is brought to the emergency department for 1 episode of bloody emesis.

Context: He reports feeling lightheaded this morning and shortly after breakfast, he felt nauseous and had an episode of bloody emesis.

Context: A physical examination demonstrates mild jaundice and ascites.

Choices:
A. Antagonists of ß1 and ß2 adrenergic receptors
B. Reversible block of histamine H2 receptors
C. Somatostatin analog leading to constriction of the splanchnic vessels
D. Stimulation of cGMP production leading to vascular smooth muscle relaxation

Answer: Somatostatin analog leading to constriction of the splanchnic vessels

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

2. He reports feeling lightheaded this morning.

3. He felt nauseous shortly after breakfast.

5. He denies any trauma, fever, abnormal ingestions, or recent infections.

6. He endorses black stools over the past few days.

7. His past medical history is significant for alcohol abuse and cirrhosis.

8. A physical examination demonstrates mild jaundice.

9. A physical examination demonstrates ascites.


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

Context: Shortly after undergoing a bipolar prosthesis for a displaced femoral neck fracture of the left hip acquired after a fall the day before, an 80-year-old woman suddenly develops dyspnea.

Context: The surgery under general anesthesia with sevoflurane was uneventful, lasting 98 minutes, during which the patient maintained oxygen saturation readings of 96–100% on 8 L of oxygen.

Context: She has a history of hypertension, osteoporosis, and osteoarthritis of her right knee.

Context: An ECG shows sinus tachycardia.

Choices:
A. Fat embolism
B. Thyrotoxic crisis
C. Malignant hyperthermia
D.
Meningitis
"

Answer: Fat embolism

1. An 80-year-old woman underwent a bipolar prosthesis for a displaced femoral neck fracture of the left hip acquired after a fall the day before.

2. The surgery was uneventful, lasting 98 minutes, during which the patient maintained oxygen saturation readings of 96–100% on 8 L of oxygen.

3. The patient has a history of hypertension, osteoporosis, and osteoarthritis of her right knee.

4. Her medications include ramipril, naproxen, ranitidine, and a multivitamin.

5. Shortly after the surgery, the patient suddenly develops dyspnea.

6. She appears cyanotic, drowsy, and is oriented only to person.

7. Her temperature is 38.6°C (101.5°F), pulse is 135/minute, respirations are 36/min, and blood pressure is 155/95 mm Hg.

8. Pulse oximetry on room air shows an oxygen saturation of 81%.

9. There are several scattered petechiae on the anterior chest wall.

10. Laboratory studies show a hemoglobin concentration of 10.5 g/dL, a leukocyte count of 9,000/mm3, a platelet count of 145,000/mm3, and a creatine kinase of 190 U/L.


Question: Laboratory studies will most likely demonstrate the following in this patient?

Context: A 34-year-old woman presents to her primary care physician complaining of weakness and rash for the past 2 months.

Context: She says her symptoms had a gradual onset at first, but over the past 2 weeks she has grown more concerned as she now has difficulty going up and down the stairs in her apartment.

Context: Her rash is nonpruritic and confined to her knuckles.

Context: She denies fever, chills, and changes in bowel habits, cough, or shortness of breath.

Context: Up until the onset of her symptoms she had been an avid hiker in upstate New York.

Context: Temperature is 98.0°F (36.7°C) blood pressure is 110/72 mmHg, pulse is 88/min, and respirations are 20/min.

Context: Physical examination demonstrates 4-/5 strength in the proximal lower extremities.

Context: The patient's cutaneous findings are demonstrated in figure A.

Choices:
A. Anti-histidyl tRNA synthetase antibodies
B. Anti-histone antibodies
C. Anti-HMG CoA reductase antibodies
D. Anti-mitochondrial antibodies

Answer: Anti-histidyl tRNA synthetase antibodies

2. Patient has been experiencing weakness and rash for the past 2 months.

3. Symptoms had a gradual onset at first.

4. Over the past 2 weeks patient has difficulty going up and down stairs.

5. Rash is nonpruritic and confined to knuckles.

6. Patient denies fever, chills, changes in bowel habits, cough, or shortness of breath.

7. Patient was an avid hiker in upstate New York prior to onset of symptoms.

12. Physical examination demonstrates 4-/5 strength in proximal lower extremities.

13. Cutaneous findings are demonstrated in figure A.


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

Context: A 4-day-old, full-term infant born by uncomplicated vaginal delivery is brought to a pediatrician by his mother, who notes that her son's skin appears yellow.

Context: She reports that the child cries several times per day, but sleeps 7-8 hours at night, uninterrupted.

Context: She has been breastfeeding exclusively and feels that he has been feeding well.

Context: He has been having a bowel movement on average once every 3 days.

Choices:
A. Breastfeeding jaundice
B. Breast milk jaundice
C. Glucose-6-phosphate dehydrogenase deficiency
D. Hepatitis A

Answer: Breastfeeding jaundice

1. A 4-day-old, full-term infant was born by uncomplicated vaginal delivery.

2. The infant was brought to a pediatrician by his mother.

3. The mother noted that her son's skin appears yellow.

4. The child cries several times per day.

5. The child sleeps 7-8 hours at night, uninterrupted.

6. The mother has been breastfeeding exclusively.

7. The mother feels that the infant has been feeding well.

8. The infant has been having a bowel movement on average once every 3 days.


Question: Which of the following is the strongest predisposing factor for this patient's condition?

Context: A 23-year-old female comes to the office because of a 3-week history of vaginal discharge and itching despite cleaning her genitals with a vaginal douche.

Context: She has an intrauterine device and does not use barrier protection.

Context: Vaginal pH is 4.3 and a KOH test shows multiple pseudohyphae on microscopy.

Choices:
A. Suppression of vaginal bacterial flora
B. Increased vaginal pH
C. Intrauterine device
D. Unprotected sexual intercourse

Answer: Suppression of vaginal bacterial flora

1. A 23-year-old female comes to the office.

2. She has a 3-week history of vaginal discharge and itching.

3. She has been cleaning her genitals with a vaginal douche.

4. Her last menstrual period was one week ago.

5. She is sexually active with her new boyfriend.

8. She was treated for a sore throat infection one month ago.

9. Speculum examination shows erythema around the vaginal introitus and copious white discharge.

11. A KOH test shows multiple pseudohyphae on microscopy.


Question: Which of the following interventions would have been most effective to prevent this condition?

Context: A 3-year-old boy who has no known past medical or family history is brought by his parents to his pediatrician for new symptoms.

Context: Specifically, his parents state that he has suffered from a fever associated with diarrhea and conjunctivitis over the past week or so.

Context: His parents note that he has never had an episode of diarrhea like this previously, but that several other children at his daycare had been ill recently.

Context: The blood pressure is 112/70 mm Hg, heart rate is 94/min, respiratory rate is 14/min, and temperature is 37.0°C (98.6°F).

Context: The physical exam is significant for preauricular adenopathy.

Choices:
A. Appropriate immunization
B. Better hand-washing practices
C. Keeping all food stored in the refrigerator
D. Avoiding undercooked seafood

Answer: Better hand-washing practices

2. Patient has no known past medical or family history.

3. Patient has been suffering from a fever associated with diarrhea and conjunctivitis over the past week or so.

4. Patient has never had an episode of diarrhea like this previously.

5. Several other children at patient's daycare had been ill recently.

6. Patient's blood pressure is 112/70 mm Hg.

8. Patient's respiratory rate is 14/min.

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

10. Physical exam is significant for preauricular adenopathy.


Question: What would be the most likely finding on wet mount?

Context: A 24-year-old woman with no past medical history presents to her PCP for a routine checkup.

Context: She feels generally healthy but has noticed a new vaginal discharge that has a strange odor.

Context: The patient has been in a long-term relationship and denies any new sexual partners.

Context: Vital signs are within normal limits.

Context: The physical exam reveals thin, greyish-white vaginal discharge but is otherwise unremarkable.

Choices:
A. Motile, flagellated protozoans
B. Long, branching filamentous structures
C. Epithelial cells with stippling
D. Large mucoid capsules

Answer: Epithelial cells with stippling

1. A 24-year-old woman presents to her PCP for a routine checkup.

3. She has noticed a new vaginal discharge with a strange odor.

4. She has been in a long-term relationship.

6. She denies vaginal itching, abnormal menstruation, or dyspareunia.

7. Vital signs are within normal limits.

8. The physical exam reveals thin, greyish-white vaginal discharge.

9. The physical exam is otherwise unremarkable.

10. A sample of this discharge is collected.

Internal Medicine
Obstetrics and Gynecology
Pathology

Infectious Disease
General Obstetrics and Gynecology
Medical Microbiology Pathology


Question: Laboratory studies show: | Hemoglobin 13.5 g/dL | Leukocyte count 9,520/mm3 | Platelet count 853,000/mm3 | Serum | Na+ 136 mEq/L | K+ 3.7 mEq/L | Cl- 96 mEq/L | Ca2+ 11.0 mg/dL | HCO3- 25 mEq/L | Glucose 102 mg/dL | Creatinine 1.0 mg/dL | Uric acid 10.5 mg/dL | Further evaluation of this patient is most likely to show which of the following?

Context: A 50-year-old African-American woman comes to the physician because of right elbow pain for the past 12 hours.

Context: The pain is currently at 7 out of 10 in intensity.

Context: She has not had any trauma to the right elbow.

Context: She also reports general malaise.

Context: She had a miscarriage at the age of 37 years.

Context: One year ago, she had carpal tunnel syndrome that was treated with a volar splint.

Context: Three months ago, she was diagnosed with thrombophlebitis, which responded well to treatment with ibuprofen and compression therapy.

Context: She runs 5 km (3.1 miles) per week.

Context: She works as an accountant.

Context: She drinks 1–2 glasses of wine on weekends.

Context: She is 171 cm (5 ft 7 in) tall and weighs 70 kg (154 lbs); BMI is 23.9 kg/m2.

Context: Her pulse is 110/min, blood pressure is 130/80 mm Hg, and temperature is 38.3°C (101°F).

Context: On physical examination, the skin above her right elbow is erythematous and severely tender to palpation.

Choices:
A. Mutation in Janus kinase 2 gene
B. Howell-Jolly bodies
C. Antibodies against citrullinated peptides
D. Anti-phospholipid antibodies

Answer: Mutation in Janus kinase 2 gene

1. Patient is a 50-year-old African-American woman.

2. Patient has right elbow pain for the past 12 hours.

3. Pain is currently at 7 out of 10 in intensity.

4. Patient has not had any trauma to the right elbow.

5. Patient also reports general malaise.

6. Patient had a miscarriage at the age of 37 years.

7. Patient had carpal tunnel syndrome one year ago.

8. Patient was treated with a volar splint for carpal tunnel syndrome.

9. Patient was diagnosed with thrombophlebitis three months ago.

10. Patient was treated with ibuprofen and compression therapy for thrombophlebitis.

11. Patient runs 5 km (3.1 miles) per week.

13. Patient drinks 1–2 glasses of wine on weekends.

18. Patient's blood pressure is 130/80 mm Hg.

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

20. On physical examination, the skin above patient's right elbow is erythematous and severely tender to palpation.


Question: Which of the following is a treatment option for the patient’s most likely diagnosis?

Context: A 64-year-old man is brought to his primary care physician by his daughter for forgetfulness.

Context: The patient’s daughter reports that over the past 2 weeks the patient has become more confused.

Context: He did not remember to pick up his car from the body shop last week, and yesterday, he did not show up to his grandson’s birthday party.

Context: When she went over to the patient’s house to check on him, she noticed the mailbox was stuffed with unopened letters.

Context: The patient says “I’m fine.

Context: I just have a headache.” The patient’s daughter adds, “I just hope you’re not drinking again dad.

Context: Your neighbor saw you fall outside the house a few weeks ago, and the other day you said you were nauseous and vomited.” The patient’s medical history is significant for a history of alcohol abuse, hypertension, hyperlipidemia, and atrial fibrillation.

Context: He takes aspirin, amlodipine, metoprolol, atorvastatin, and warfarin.

Context: He smokes cigars, but denies alcohol use since he started psychotherapy 7 months ago.

Context: The patient’s temperature is 97°F (36.1°C), blood pressure is 144/92 mmHg, and pulse is 82/min.

Context: Gait is normal.

Context: The patient’s INR is 2.5.

Context: Imaging is pending.

Choices:
A. Alteplase
B. Burr hole
C. Donepezil
D. Thiamine supplementation

Answer: Burr hole

1. A 64-year-old man is brought to his primary care physician by his daughter.

2. The daughter reports that the patient has become more confused over the past 2 weeks.

3. The patient did not remember to pick up his car from the body shop last week.

4. The patient did not show up to his grandson’s birthday party yesterday.

5. The daughter noticed the mailbox was stuffed with unopened letters when she went to check on the patient.

7. The daughter is concerned the patient is drinking again.

8. The patient's neighbor saw him fall outside the house a few weeks ago.

9. The patient said he was nauseous and vomited the other day.

10. The patient's medical history is significant for a history of alcohol abuse, hypertension, hyperlipidemia, and atrial fibrillation.

11. The patient takes aspirin, amlodipine, metoprolol, atorvastatin, and warfarin.

13. The patient denies alcohol use since he started psychotherapy 7 months ago.

14. The patient's temperature is 97°F (36.1°C).

15. The patient's blood pressure is 144/92 mmHg.

17. On physical examination, there is a 3 cm ecchymosis on the right scalp.

18. No focal neurological deficits are appreciated.

20. An initial complete blood count shows normocytic anemia.


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

Context: There is no history of serious illness.

Context: The temperature is 36.7℃ (98.1℉), pulse is 68, respirations are 12/min, and blood pressure is 125/70 mm Hg.

Context: The laboratory test results are as follows: | Hemoglobin 10 g/dL | Mean corpuscular volume 90 μm3 | Leukocyte count 80,000/mm3 | Platelet count 450,000/mm3 | The peripheral blood smear shows a predominance of neutrophils and the presence of band cells, myelocytes, promyelocytes, and blasts (< 5%).

Context: The cytogenetic study shows t(9;22).

Choices:
A. Acute lymphoid leukemia
B. Chronic myeloid leukemia
C. Hairy cell leukemia
D. Burkitt lymphoma

Answer: Chronic myeloid leukemia

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

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

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

4. There is no history of serious illness.

5. His only medication is acetaminophen for knee pain.

10. On physical examination, the spleen size on percussion is 16 cm (6.2 in).

11. Otherwise, the physical examination shows no abnormalities.

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

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

17. The cytogenetic study shows t(9;22).


Question: Which of the following enzymes is most likely impaired?

Context: Neurologic examination shows normal strength in all extremities and decreased sense to vibration in his lower extremities bilaterally.

Context: A peripheral blood smear is shown.

Choices:
A. Succinate dehydrogenase
B. Propionyl-CoA carboxylase
C. Pyruvate carboxylase
D. Methylmalonyl-CoA mutase

Answer: Methylmalonyl-CoA mutase

1. A 55-year-old man comes to the physician because of balance problems.

2. He follows a vegan diet and does not eat meat, eggs, or dairy.

3. Physical examination shows pale oral mucosa and conjunctivae.

4. Neurologic examination shows normal strength in all extremities.

5. Neurologic examination shows decreased sense to vibration in his lower extremities bilaterally.

Balance problems could be related to a neurological issue. The subspecialty that would be most relevant for this patient is General Neurology.


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

Context: Laboratory values are ordered as seen below. |  | Hemoglobin: 10 g/dL | Hematocrit: 32% | MCV: 78 µm^3 | Ferritin: 10 mg/mL | Total iron binding capacity: 620 mcg/dL | Leukocyte count: 6,500/mm^3 with normal differential | Platelet count: 190,000/mm^3 |  | Serum: | Na+: 141 mEq/L | Cl-: 102 mEq/L | K+: 4.1 mEq/L | HCO3-: 24 mEq/L | BUN: 20 mg/dL | Glucose: 99 mg/dL | Creatinine: 1.1 mg/dL | Ca2+: 10.2 mg/dL | TSH: 4.7 mIU/mL | AST: 12 U/L | ALT: 10 U/L |  | .

Choices:
A. Vitamin B9
B. Vitamin B12
C. Iron
D. Assess for depression

Answer: Iron

1. A 32-year-old woman presents to her primary care physician for generalized fatigue.

2. She states that she is doing well but that she always feels tired.

3. She started exercising to have more energy, finds that she tires easily, and has not felt motivated to return to the gym.

4. She is doing well and is excelling at her job.

5. She recently started a vegan diet in order to try and become healthy.

6. She is currently struggling with dating and is unable to find a compatible mate and feels hopeless about this.

7. The patient has a past medical history of uterine leiomyomas.

8. Her temperature is 99.5°F (37.5°C), blood pressure is 100/68 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 98% on room air.

9. Laboratory values are ordered as seen below.

14. Total iron binding capacity: 620 mcg/dL

15. Leukocyte count: 6,500/mm^3 with normal differential


Question: The hormone responsible for the observed laboratory changes most likely increases glucose transport into which of the following types of cells?

Context: A 28-year-old woman, gravida 1, para 0, at 24 weeks' gestation comes to the physician for a prenatal visit.

Context: She feels well.

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

Context: Her fasting serum glucose is 91 mg/dL.

Choices:
A. Spermatocytes
B. Islet cells
C. Adipocytes
D. Placental cells

Answer: Adipocytes

1. A 28-year-old woman comes to the physician for a prenatal visit.

2. She is gravida 1, para 0, and at 24 weeks' gestation.

4. She has no history of medical illness.

6. Her fasting serum glucose is 91 mg/dL.

7. One hour after drinking a concentrated glucose solution, her serum glucose concentration is 94 mg/dL.


Question: Which of the following risk factors is associated with the most likely diagnosis?

Context: Laboratory studies are ordered as seen below. |  | Hemoglobin: 15 g/dL | Hematocrit: 43% | Leukocyte count: 6,500/mm^3 with normal differential | Platelet count: 194,000/mm^3 |  | Serum: | Na+: 138 mEq/L | Cl-: 102 mEq/L | K+: 4.4 mEq/L | HCO3-: 24 mEq/L | BUN: 20 mg/dL | Glucose: 120 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: 10.2 mg/dL | pH: 7.44 | PaCO2: 10 mmHg | PaO2: 90 mmHg | AST: 12 U/L | ALT: 10 U/L |  | The patient complains about difficulty breathing.

Context: Repeat laboratory values are notable for the findings below. |  | pH: 7.35 | PaCO2: 30 mmHg | PaO2: 80 mmHg |  | The patient is intubated and sent to the MICU.

Choices:
A. Female sex living in a Northern latitude
B. Hiking in tick-infested woods
C. Consuming meats cooked over a campfire
D. Central cervical spine trauma

Answer: Consuming meats cooked over a campfire

1. A 27-year-old woman presents to the emergency department with weakness of her legs which has progressed to an inability for her to stand.

2. The patient works as a school teacher in Alaska and regularly goes hiking and camping.

3. She recently returned from a camping trip where she hiked through tall brush and drank from mountain streams.

4. The patient was also involved in a motor vehicle accident 2 days ago but did not seek treatment.

5. The patient has a medical history that is unremarkable and is currently taking multivitamins and other than a recent bout of diarrhea is generally healthy.

6. Her temperature is 99.5°F (37.5°C), blood pressure is 120/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

7. Physical exam is notable for a very anxious woman with 1/5 strength of the patient’s lower extremities and 2/5 strength of her trunk muscles with diminished sensation.

8. Laboratory studies are ordered as seen below: Hemoglobin: 15 g/dL, Hematocrit: 43%, Leukocyte count: 6,500/mm^3 with normal differential, Platelet count: 194,000/mm^3, Serum: Na+: 138 mEq/L, Cl-: 102 mEq/L, K+: 4.4 mEq/L, HCO3-: 24 mEq/L, BUN: 20 mg/dL, Glucose: 120 mg/dL, Creatinine: 1.0 mg/dL, Ca2+: 10.2 mg/dL, pH: 7.44, PaCO2: 10 mmHg, PaO2: 90 mmHg, AST: 12 U/L, ALT: 10 U/L.

9. The patient complains about difficulty breathing.

10. Repeat laboratory values are notable for the findings below: pH: 7.35, PaCO2: 30 mmHg, PaO2: 80 mmHg.

11. The patient is intubated and sent to the MICU.


Question: Which of the following reaction is favored under this condition?

Context: An 18-year-old male presents to the emergency room smelling quite heavily of alcohol and is unconscious.

Context: A previous medical history states that he does not have diabetes.

Context: The metabolism of ethanol in this patient's hepatocytes resulted in an increase of the [NADH]/[NAD+] ratio.

Choices:
A. Pyruvate to acetyl-CoA
B. Citrate to isocitrate
C. Oxaloacetate to malate
D. Oxaloacetate to phosphoenolpyruvate

Answer: Oxaloacetate to malate

1. An 18-year-old male presents to the emergency room.

2. The patient smells quite heavily of alcohol.

4. A blood test reveals severe hypoglycemic and ketoacidemia.

5. The patient does not have diabetes according to their medical history.

6. The metabolism of ethanol in the patient's hepatocytes increased the [NADH]/[NAD+] ratio.


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

Context: A previously healthy 7-year-old girl is brought to the physician for a well-child examination.

Context: She feels well.

Context: She emigrated from India 3 months ago.

Context: There is no family history of serious illness.

Context: Her immunizations are up-to-date.

Context: She is at 60th percentile for height and weight.

Context: Her temperature is 37°C (98.6°F), pulse is 90/min, and respirations are 26/min.

Context: Examination shows no abnormalities.

Context: Laboratory studies show: | Hemoglobin 13.2 g/dL | Leukocyte count 8900/mm3 | Platelet count 310,000/mm3 | Serum | Hepatitis B surface antigen negative | Hepatitis B antibody positive | Interferon-γ release assay positive | An x-ray of the chest shows no abnormalities.

Choices:
A. Perform acid-fast stain on induced sputum
B. Administer isoniazid
C. Perform tuberculin skin test
D. Administer isoniazid, rifampin, ethambutol and pyrazinamide

Answer: Administer isoniazid

3. Patient emigrated from India 3 months ago.

4. No family history of serious illness.

6. Patient is at 60th percentile for height and weight.

14. Serum Hepatitis B surface antigen is negative.

15. Serum Hepatitis B antibody is positive.

16. Interferon-γ release assay is positive.

17. X-ray of the chest shows no abnormalities.


Question: Based on the study results, which of the following statements best addresses the mother's question?"

Context: Please refer to the summary above to answer this question | An 8-year-old boy is brought to the physician by his mother for a well-child examination at a clinic for low-income residents.

Context: Although her son's elementary school offers free afterschool programming, her son has not been interested in attending.

Context: Both the son's maternal and paternal grandmothers have major depressive disorder.

Context: The mother is curious about the benefits of afterschool programming and asks for the physician's input.

Choices:
A. The patient's family history of psychiatric illness prevents any conclusions from being drawn from the study.
B. High-quality afterschool programming for low-income 8-year-olds may correlate with decreased bipolar disorder risk in adults.
C. High-quality afterschool programming should be free of charge for low-income children to improve adult mental health.
D.
High-quality afterschool programming for low-income 8-year-olds may correlate with decreased ADHD risk in adults.
"

Answer:
High-quality afterschool programming for low-income 8-year-olds may correlate with decreased ADHD risk in adults.
"

1. An 8-year-old boy is brought to the physician by his mother.

2. The examination is at a clinic for low-income residents.

3. The son's elementary school offers free afterschool programming.

4. The son has not been interested in attending the afterschool programming.

5. The son's maternal grandmother has major depressive disorder.

6. The son's paternal grandmother has major depressive disorder.

7. The mother is curious about the benefits of afterschool programming.

8. The mother asks for the physician's input.


Question: Which of the following is the child most likely to develop?

Context: Two days after delivery, a 2450-g (5-lb 6-oz) male newborn has three episodes of green vomitus.

Context: He was born at 34 weeks' gestation.

Context: He appears irritable.

Context: His temperature is 37.3°C (99.1°F), pulse is 161/min, respirations are 56/min, and blood pressure is 62/44 mm Hg.

Context: Examination shows a distended abdomen; there is diffuse tenderness to palpation over the abdomen.

Context: Bowel sounds are decreased.

Choices:
A. Infertility
B. Alzheimer's disease
C. Asthma
D. Necrotizing enterocolitis

Answer: Infertility

1. Two days after delivery, a 2450-g (5-lb 6-oz) male newborn has had three episodes of green vomitus.

2. He has passed urine twice a day, but has not yet passed stool.

9. Examination shows a distended abdomen.

10. There is diffuse tenderness to palpation over the abdomen.

12. Digital rectal examination is unremarkable.

13. The remainder of the examination shows no abnormalities.

14. An x-ray of the abdomen shows dilated bowel loops.

15. Contrast enema demonstrates inspissated meconium plugs in the distal ileum and microcolon.


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

Context: However, a week after delivery he developed a respiratory infection involving an aggressive cough followed by a high-pitched intake of breath.

Context: On examination, the infant’s vitals are normal but he appears lethargic and mildly dehydrated with depressed fontanelles and decreased skin turgor.

Choices:
A. Deficiency of nitric oxide synthase
B. Antibiotic use
C. Inadequate myenteric plexus innervation
D. Telescoping of the proximal bowel into a distal segment

Answer: Antibiotic use

1. A 6-week-old boy is brought to see his pediatrician.

2. His mother says that he has not been feeding well and forcefully vomited after every feed over the past 4 days.

3. The infant was born at 39 weeks gestation via spontaneous vaginal delivery.

4. He is up to date on all vaccines and is meeting all developmental milestones.

5. A week after delivery he developed a respiratory infection involving an aggressive cough followed by a high-pitched intake of breath.

6. Respiratory cultures were positive for a gram-negative coccobacilli for which he received erythromycin.

7. Since then he has remained healthy until now.

8. On examination, the infant’s vitals are normal.

9. He appears lethargic and mildly dehydrated with depressed fontanelles and decreased skin turgor.

10. A firm non-tender mass is palpated in the epigastric region.

Pediatric Surgery
Pediatric Gastroenterology