Question: Based on these findings, which of the following is the most likely diagnosis?

Context: A 30-year-old woman seeks evaluation at a local walk-in clinic with a week-long history of lightheadedness and palpitations.

Context: She also complains of fatigability and shortness of breath of the same duration.

Context: The past medical history is significant for menarche at 9 years of age, heavy menstrual bleeding for the past several years and abdominal pain that worsens during menses.

Context: She stopped trying to conceive a child after 2 spontaneous abortions in the past 4 years and has been on iron oral supplementation for the last 2 years.

Context: She adds that she feels a dull pressure-like discomfort in her pelvis and constipation.

Context: The physical examination is significant for pale mucous membranes and a grade 2/6 ejection systolic murmur in the area of the pulmonic valve.

Context: The hemoglobin level is 10 g/dL and the hematocrit is 27%.

Choices:
A. Uterine leiomyoma
B. Endometrial hyperplasia
C. Endometrial carcinoma
D. Endometrial polyp

Answer: Uterine leiomyoma

2. Patient has a week-long history of lightheadedness and palpitations.

3. Patient has a week-long history of fatigability and shortness of breath.

4. Patient had menarche at 9 years of age.

5. Patient has had heavy menstrual bleeding for several years.

6. Patient has abdominal pain that worsens during menses.

7. Patient has had 2 spontaneous abortions in the past 4 years.

8. Patient has been on iron oral supplementation for the last 2 years.

9. Patient feels a dull pressure-like discomfort in her pelvis.

11. Physical examination is significant for pale mucous membranes.

12. Physical examination is significant for a grade 2/6 ejection systolic murmur in the area of the pulmonic valve.

13. Pelvic examination reveals an enlarged, mobile uterus with an irregular contour.


Question: What percentage of the risk of developing emphysema can be attributed to smoking?

Context: A study is conducted in a town with a population of 225,000, where the people are followed-up for the development of emphysema.

Context: A total of 1,000 smokers are selected and followed-up, out of which 200 actually develop the disease.

Context: A control group of 1,000 non-smokers is formed, out of which 20 develop emphysema.

Choices:
A. 40%
B. 20%
C. 10%
D. 18%

Answer: 18%

1. A study is conducted in a town with a population of 225,000.

2. The people are followed-up for the development of emphysema.

3. A total of 1,000 smokers are selected and followed-up.

4. Out of the 1,000 smokers, 200 actually develop the disease.

5. A control group of 1,000 non-smokers is formed.

6. Out of the 1,000 non-smokers, 20 develop emphysema.

7. The prevalence of smoking in the general population is 40%.

8. The researcher calculates all possible risk estimates, including the odds ratio.


Question: Which of the following faults to this study most likely explains why the result was considered meaningless?

Context: A medical student is performing clinical research by analyzing the aggregated data of all patients from a national database.

Context: In performing the study, she uses all the data collected from patients who had an appendectomy and analyzes the risk factors that are associated with readmission after discharge.

Context: She first excludes some of the data based on previously determined exclusion criteria and then performs analysis on the rest.

Context: She performs a multiple regression on all variables and finds that one of the risk factors demonstrates a < 5% probability of being the same between groups.

Context: She takes this result and presents it to faculty; however, they respond that the finding is meaningless.

Choices:
A. Data should not have been aggregated
B. Failure to consider clinical significance versus statistical significance
C. Single rather than multiple regression should have been performed
D. Usage of the wrong threshold for significance

Answer: Failure to consider clinical significance versus statistical significance

1. A medical student is performing clinical research.

2. The research involves analyzing aggregated data from a national database.

3. The data is from patients who had an appendectomy.

4. The research is analyzing risk factors associated with readmission after discharge.

5. The medical student excludes some of the data based on previously determined exclusion criteria.

6. The medical student performs a multiple regression on all variables.

7. The multiple regression finds that one of the risk factors has a < 5% probability of being the same between groups.

8. The medical student presents the finding to faculty.

9. The faculty respond that the finding is meaningless.


Question: Which of the following features is a contraindication for thrombolytic therapy in this patient?

Context: A 60-year-old man presents to the emergency department with ‘discomfort’ in his chest and a ‘squeezing’ sensation in his neck.

Context: The symptoms started 45 minutes ago while he was washing the dishes.

Context: He also complains of nausea.

Context: He has been a regular smoker for 45 years, averaging a pack of cigarettes each day.

Context: He also drinks heavily on weekends.

Context: His medical history is significant for a stroke 3 months ago, but the patient admits he has not been taking his medications.

Context: The chest is clear to auscultation and a 4th heart sound can be heard.

Context: Aspirin was administered upon arrival.

Context: His ECG is shown in the picture.

Choices:
A. Aspirin administration
B. Elevated blood pressure
C. History of smoking
D. Stroke 3 months ago

Answer: Stroke 3 months ago

2. Patient presents to the emergency department with ‘discomfort’ in his chest and a ‘squeezing’ sensation in his neck.

3. Symptoms started 45 minutes ago while he was washing the dishes.

5. Patient has been a regular smoker for 45 years, averaging a pack of cigarettes each day.

6. Patient also drinks heavily on weekends.

7. Patient's medical history is significant for a stroke 3 months ago.

8. Patient admits he has not been taking his medications.

9. Vital signs show: pulse 62/min, respiratory rate 20/min, blood pressure 176/94 mm Hg, and temperature 36.9°C (98.4°F).

10. Physical examination reveals a visibly distressed man who is sweating profusely.

11. Chest is clear to auscultation and a 4th heart sound can be heard.

12. Aspirin was administered upon arrival.

13. Patient's ECG is shown in the picture.

General Cardiology
Interventional Cardiology
Cardiovascular Disease


Question: What is the most likely diagnosis?

Context: A 3-year-old girl is brought by her parents to the office for bloody diarrhea and a seizure.

Context: The parents say she started having fever, abdominal pain, and diarrhea about 3 days ago, but the bloody diarrhea started 12 hours ago.

Context: The seizure was the last symptom to appear 3 hours ago, and it consisted of repetitive movement of arms and legs with loss of consciousness.

Context: Her vital signs include: blood pressure is 130/85 mm Hg, her respiratory rate is 25/min, her heart rate is 120/min, and her temperature is 39.2°C (102.6°F).

Context: On physical examination, she looks pale and sleepy, the cardiopulmonary auscultation is normal, the abdomen is painful on palpation, and the skin assessment reveals the presence of disseminated pinpoint petechiae.

Context: The urinalysis show hematuria.

Context: The Coombs test is negative.

Context: The complete blood count results are as follows: | Hemoglobin 7 g/dL | Hematocrit 25 % | Leukocyte count 17,000/mm3 | Neutrophils 70% | Bands 2% | Eosinophils 1% | Basophils 0% | Lymphocytes 22% | Monocytes 5% | Platelet count 7,000/mm3 | Her coagulation tests are as follows: | Partial thromboplastin time (activated) 30 seconds | Prothrombin time 12 seconds | Reticulocyte count 1 % | Thrombin time < 2 seconds deviation from control | .

Choices:
A. Disseminated intravascular coagulation
B. Henoch-Schonlein purpura
C. Systemic vasculitis
D. Hemolytic-uremic syndrome

Answer: Hemolytic-uremic syndrome

1. A 3-year-old girl is brought by her parents to the office.

2. The parents say she started having fever, abdominal pain, and diarrhea about 3 days ago.

3. The bloody diarrhea started 12 hours ago.

4. The seizure was the last symptom to appear 3 hours ago.

5. The seizure consisted of repetitive movement of arms and legs with loss of consciousness.

6. Her 4-year-old brother had a similar case with bloody diarrhea 2 weeks ago.

10. Her temperature is 39.2°C (102.6°F).

11. On physical examination, she looks pale and sleepy.

12. The cardiopulmonary auscultation is normal.

13. The abdomen is painful on palpation.

14. The skin assessment reveals the presence of disseminated pinpoint petechiae.

27. The Partial thromboplastin time (activated) is 30 seconds.

30. The Thrombin time is < 2 seconds deviation from control.

Pediatric Nephrology
Pediatric Gastroenterology


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

Context: A 68-year-old woman presents to the emergency room with productive cough and fever.

Context: Her past medical history includes COPD and her medications include ipratropium and fluticasone.

Context: On physical exam her temperature is 102.2°F (39°C), blood pressure is 131/78 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 95% on room air.

Context: You obtain a sputum sample and identify an organism that grows selectively on medium containing factors V and X.

Choices:
A. Haemophilus influenzae
B. Streptococcus pneumoniae
C. Mycoplasma pneumoniae
D. Fusobacterium species

Answer: Haemophilus influenzae

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

2. She has a productive cough and fever.

3. She has a chronic cough that has been getting progressively worse over the last 2 weeks.

4. Last night she developed a fever and vomited.

5. She smoked one pack of cigarettes per day for 40 years and recently quit.

6. Her past medical history includes COPD.

7. Her medications include ipratropium and fluticasone.

8. On physical exam her temperature is 102.2°F (39°C).

12. Her oxygen saturation is 95% on room air.

13. She has decreased breath sounds bilaterally with diffuse crackles.

15. An organism is identified that grows selectively on medium containing factors V and X.


Question: The mechanism of action of this drug is most similar to that of which of the following?

Context: A 36-year-old man comes to the physician because of progressive fatigue and night sweats for 2 months.

Context: During this time, he has also had a 10-kg (22-lb) weight loss.

Choices:
A. Trimethoprim
B. Sulfamethoxazole
C. Metronidazole
D. Chloramphenicol

Answer: Metronidazole

1. A 36-year-old man comes to the physician.

2. He has progressive fatigue and night sweats for 2 months.

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

4. Physical examination shows painless swelling of the cervical, axillary, and inguinal lymph nodes.

5. Examination of the abdomen shows hepatosplenomegaly.

6. Histologic examination of a lymph node biopsy specimen shows Reed-Sternberg cells.

7. A diagnosis of Hodgkin lymphoma is made.

8. The patient is started on a chemotherapeutic regimen that includes bleomycin.


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

Context: An 7-year-old girl is brought to the pediatrician by her concerned mother, because she is "more physically matured" than the rest of the girls in her class.

Context: Thyroid function tests and an MRI of the head are both within normal limits.

Choices:
A. Leuprolide
B. Finasteride
C. Octreotide
D. Anastrozole

Answer: Leuprolide

1. An 7-year-old girl is brought to the pediatrician by her concerned mother.

2. The girl is "more physically matured" than the rest of the girls in her class.

3. On physical exam, she is noted to have breast development and pubic hair.

4. On gonadotropin reseasing hormone (GnRH) stimulation, she has an increase in leutienizing hormone (LH) levels.

5. Thyroid function tests are within normal limits.

6. An MRI of the head is within normal limits.


Question: What is the most likely diagnosis?

Context: The patient's initial laboratory data return in the meantime: |  | Hemoglobin: 5 g/dL | Hematocrit: 18 % | Leukocyte count: 8,000/mm^3 with normal differential | Platelet count: 400,000/mm^3 |  | Serum: | Na+: 140 mEq/L | Cl-: 115 mEq/L | K+: 3.2 mEq/L | HCO3-: 26 mEq/L | BUN: 60 mg/dL | Glucose: 104 mg/dL | Creatinine: 1.1 mg/dL |  | Blood type: AB | Rhesus status: negative |  | After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours.

Context: She denies any other symptoms.

Context: No rash is seen.

Choices:
A. Febrile hemolytic reaction
B. Febrile nonhemolytic reaction
C. Transfusion related bacterial contamination
D. Transfusion related acute lung injury

Answer: Febrile nonhemolytic reaction

1. A 45-year-old woman presents to the emergency department with hematemesis.

2. Her son said that the patient had complained of gnawing abdominal pain that worsened before and improved after meals for the past 3 weeks.

3. She frequently travels for work and is often stressed.

4. She drinks alcohol socially and does not smoke tobacco or marijuana.

5. She has not had anything to eat or drink for the past 24 hours due to the pain, but coughed up "several cup of" frank red blood before arrival.

6. Her temperature is 98°F (37°C), blood pressure is 80/50 mmHg, pulse is 140/min, respirations are 23/min, and oxygen saturation is 96% on room air.

7. Gastric ultrasound reveals high gastric residual volume.

8. The patient is empirically started on 3 units of uncrossmatched O-negative blood transfusion and pantoprazole.

9. The patient's initial laboratory data return: Hemoglobin: 5 g/dL, Hematocrit: 18 %, Leukocyte count: 8,000/mm^3 with normal differential, Platelet count: 400,000/mm^3, Serum: Na+: 140 mEq/L, Cl-: 115 mEq/L, K+: 3.2 mEq/L, HCO3-: 26 mEq/L, BUN: 60 mg/dL, Glucose: 104 mg/dL, Creatinine: 1.1 mg/dL, Blood type: AB, Rhesus status: negative.

10. After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours.

11. The patient now complains of feeling hot with intermittent shivering.

13. Her temperature is 101°F (38.3°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air.

14. Her lungs are clear to auscultation bilaterally, and no accessory respiratory muscle use is observed.


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

Context: A 66-year-old man comes to the physician because of a 3-week history of shortness of breath with exertion.

Context: Current medications include aspirin, losartan, simvastatin, and insulin.

Context: His temperature is 37.1°C (98.8°F), pulse is 74/min, and blood pressure is 150/84 mm Hg.

Context: Cardiac examination is shown.

Choices:
A. Earlier onset of abnormal cardiac sound with standing
B. Elevated serum brain natriuretic peptide levels
C. Left-to-right shunt through the atrial septum
D. Bounding pulses of peripheral arteries

Answer: Elevated serum brain natriuretic peptide levels

1. A 66-year-old man comes to the physician.

2. He has a 3-week history of shortness of breath with exertion.

3. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus.

4. His current medications include aspirin, losartan, simvastatin, and insulin.

8. Pulse oximetry on room air shows an oxygen saturation of 96%.


Question: Which of the following would be the most appropriate recommendation for this patient?

Context: A 27-year-old gravida 2, para 2 woman presents to her OB/GYN’s office concerned that she may be pregnant.

Context: She has 2 children under the age of 3 and does not want another child at this time.

Context: She says she cannot take “the pill” because she had a blood clot in her leg after her last cesarean section successfully treated with 6 months of anticoagulation.

Context: She smokes cigarettes and drinks alcohol regularly.

Choices:
A. Reassure her that she is likely not pregnant
B. Refer her to an abortion clinic
C. Recommend etonogestrel implant
D. Recommend copper IUD

Answer: Recommend copper IUD

1. A 27-year-old woman presents to her OB/GYN's office.

3. She and her husband use condoms for contraception.

4. The night before, the condom broke during intercourse.

5. She has 2 children under the age of 3.

6. She does not want another child at this time.

7. She cannot take "the pill" because she had a blood clot in her leg after her last cesarean section.

8. The blood clot was successfully treated with 6 months of anticoagulation.


Question: Bloodwork is drawn and is shown below. |  | Serum: | Na+: 139 mEq/L | K+: 3.7 mEq/L | Cl-: 100 mEq/L | HCO3-: 28 mEq/L | Urea nitrogen: 9 mg/dL | Glucose: 122 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: 9.8 mg/dL | Mg2+: 1.7 mg/dL |  | After a physical exam is performed, which of the following is the best initial step in management for this patient's underlying condition?

Context: A 25-year-old Ashkenazi Jewish man presents to his primary care physician for a follow-up visit.

Context: His temperature is 99.5°F (37.5°C), pulse is 80/min, blood pressure is 182/100 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air.

Choices:
A. Begin lifestyle modification and weight loss program
B. Begin lifestyle modification, weight loss program, and hydrochlorothiazide
C. 24-hour urinary cortisol
D. Duplex ultrasound

Answer: Duplex ultrasound

1. A 25-year-old Ashkenazi Jewish man presented to his primary care physician for a follow-up visit.

2. One week ago, he presented with a chief complaint of priapism while engaging in intercourse with two of his partners.

3. During that visit, it was determined that his blood pressure was 175/100 mmHg.

4. He returns this week to have his vitals rechecked.

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


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

Context: A 63-year-old man is brought to the emergency department after having 8–9 episodes of red watery stool.

Context: He has no abdominal pain or fever.

Context: He underwent an angioplasty 4 years ago and received 2 stents in his left main coronary artery.

Context: He has hypertension, hypercholesterolemia, coronary artery disease, and chronic constipation.

Context: Current medications include aspirin, metoprolol, and simvastatin.

Context: He drinks one beer daily.

Context: He is in distress.

Context: His temperature is 37.3°C (99.1°F), pulse is 110/min, respirations are 14/min, and blood pressure is 86/58 mm Hg.

Context: Examination shows pale conjunctivae.

Context: The abdomen is soft and nontender.

Context: Bowel sounds are increased.

Context: The lungs are clear to auscultation.

Context: Cardiac examination shows an S4 gallop.

Context: Rectal examination shows frank blood.

Context: Laboratory studies show: | Hemoglobin 9.8 g/dL | Leukocyte count 7,800/mm3 | Platelet count 280,000/mm3 | Prothrombin time 14 seconds (INR=0.9) | Serum | Na+ 135 mEq/L | K+ 4.1 mEq/L | Cl- 101 mEq/L | Urea nitrogen 16 mg/dL | Glucose 96 mg/dL | Creatinine 0.7 mg/dL | Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered.

Context: A nasogastric tube is inserted.

Context: Directly afterwards, his pulse is 133/min and blood pressure is 80/54 mm Hg.

Choices:
A. Angiography
B. Laparotomy
C. Esophagogastroduodenoscopy
D. Enteroscopy

Answer: Angiography

2. Patient has had 8-9 episodes of red watery stool.

3. Patient has no abdominal pain or fever.

4. Patient underwent an angioplasty 4 years ago and received 2 stents in his left main coronary artery.

5. Patient has hypertension, hypercholesterolemia, coronary artery disease, and chronic constipation.

6. Patient's current medications include aspirin, metoprolol, and simvastatin.

9. Patient's temperature is 37.3°C (99.1°F).

12. Patient's blood pressure is 86/58 mm Hg.

14. Patient's abdomen is soft and nontender.

15. Patient's bowel sounds are increased.

16. Patient's lungs are clear to auscultation.

17. Patient's cardiac examination shows an S4 gallop.

18. Patient's rectal examination shows frank blood.

20. Patient's leukocyte count is 7,800/mm3.

21. Patient's platelet count is 280,000/mm3.

22. Patient's prothrombin time is 14 seconds (INR=0.9).

26. Patient's urea nitrogen is 16 mg/dL.

29. Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered.

31. Aspiration shows clear gastric content containing bile.

32. Patient's pulse is 133/min directly afterwards.

33. Patient's blood pressure is 80/54 mm Hg directly afterwards.


Question: Which of the following is a relative contraindication for administering one or more routine vaccinations in this patient at this time?

Context: A 15-month-old boy with Down syndrome is brought to the physician for a well-child examination.

Context: The mother is concerned about giving the child any more vaccinations, as she reports he had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12-months of age.

Context: He has had a runny nose for 2 days.

Context: He has a seizure disorder with a seizure lasting 1–2 minutes a few times a week that has not been controlled by medications.

Context: He was treated for intussusception at 6 months of age.

Context: His father was diagnosed with HIV 2 years ago.

Context: His medications include phenytoin, levetiracetam, and vitamin supplements.

Context: He is allergic to amoxicillin and has previously developed localized urticaria after consumption of eggs.

Context: His immunizations are up-to-date.

Context: Vital signs are within normal limits.

Choices:
A. Egg protein allergy
B. Fever of 38.7°C (101.7°F) after previous vaccination
C. Current upper respiratory tract infection
D.
Uncontrolled seizure disorder
"

Answer:
Uncontrolled seizure disorder
"

1. Patient is a 15-month-old boy with Down syndrome.

2. Mother is concerned about giving the child any more vaccinations.

3. Patient had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12-months of age.

4. Patient has had a runny nose for 2 days.

5. Patient has a seizure disorder with a seizure lasting 1–2 minutes a few times a week that has not been controlled by medications.

6. Patient was treated for intussusception at 6 months of age.

7. Patient's father was diagnosed with HIV 2 years ago.

8. Patient's medications include phenytoin, levetiracetam, and vitamin supplements.

10. Patient has previously developed localized urticaria after consumption of eggs.

11. Patient's immunizations are up-to-date.

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

13. Examination shows low-set ears, hypertelorism, and a flat head.

14. The remainder of the examination shows no abnormalities.


Question: Which of the following genetic conditions is most likely related to these clinical features?

Context: A 1-year-old boy is brought to his pediatrician’s office due to regression of development.

Context: She has observed that he is not progressing as he did during the 1st year of his life.

Context: There seems to be a regression in some behavioral and other milestones.

Context: She is also concerned about his facial development.

Context: Additionally, his lips are enlarged and corneal clouding is observed.

Choices:
A. Morquio syndrome
B. Tay-Sachs disease
C. Hurler syndrome
D. Fabry disease

Answer: Hurler syndrome

1. A 1-year-old boy is brought to his pediatrician's office.

2. The pediatrician has observed regression in some behavioral and other milestones.

3. The pediatrician is also concerned about his facial development.

4. On examination, the vital signs are normal.

5. He has coarse facial features with a bulging frontal bone.

8. Urine studies show an increase in dermatan sulfate.


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

Context: A 6-year-old African American girl is brought to the physician by her mother because she has recently developed axillary and pubic hair.

Context: She also has multiple pustules on her forehead and has had oily skin for 3 months.

Context: Her mother reports that she recently bought some deodorant for the girl because of her body odor.

Context: Her mother has hypothyroidism.

Context: She is at the 95th percentile for height and the 99th percentile for weight and BMI.

Context: Her vital signs are within normal limits.

Context: She has no palpable glandular breast tissue.

Context: There is coarse hair under both axilla and sparse dark hair on the mons pubis and along the labia majora.

Choices:
A. High levels of insulin
B. Adrenal enzyme deficiency
C. Pituitary tumor
D. Ovarian cyst

Answer: High levels of insulin

1. Patient is a 6-year-old African American girl.

2. Patient was brought to the physician by her mother.

3. Patient has recently developed axillary and pubic hair.

4. Patient has multiple pustules on her forehead.

5. Patient has had oily skin for 3 months.

6. Patient's mother recently bought deodorant for her due to body odor.

8. Patient is at the 95th percentile for height.

9. Patient is at the 99th percentile for weight and BMI.

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

11. Patient has no palpable glandular breast tissue.

12. Patient has coarse hair under both axilla.

13. Patient has sparse dark hair on the mons pubis and along the labia majora.


Question: Which of the following factors is most likely involved in the pathogenesis of this patient's condition?

Context: Her BMI is 31 kg/m2.

Context: Laboratory studies show a hemoglobin A1c of 6.4% and an elevated serum insulin level.

Choices:
A. Increased serum levels of glucagon-like peptide-1
B. Increased levels of serum fatty acids
C. Decreased levels of serum cortisol
D. Positive HLA-DR4 serotype

Answer: Increased levels of serum fatty acids

1. A 45-year-old woman comes to the physician for a health maintenance examination.

2. Her father has a history of type 2 diabetes mellitus.

3. She has gained 18-kg (40-lb) since the birth of her son 6 years ago.

5. Physical examination shows hyperpigmented plaques in the axillae and posterior neck.

6. Laboratory studies show a hemoglobin A1c of 6.4%.

7. Laboratory studies show an elevated serum insulin level.


Question: What pathological step preceded calcification in her condition?

Context: An 89-year-old woman presents with worsening dyspnea on exertion and generalized fatigue.

Context: She has fainted once.

Context: Exam reveals a crescendo-decrescendo systolic ejection murmur that radiates to the carotids.

Choices:
A. Commissural fibrosis
B. Congenital bicuspid valve
C. Fibrillin-1 deficiency
D. Cellular injury and necrosis

Answer: Cellular injury and necrosis

2. Patient presents with worsening dyspnea on exertion and generalized fatigue.

4. Exam reveals a crescendo-decrescendo systolic ejection murmur.

General Cardiology
Cardiology
Pulmonary Disease


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

Context: He says that the chest pain began a few hours prior to presentation and is associated with nausea, abdominal discomfort, and sweating.

Context: He has experienced similar symptoms multiple times in the past, which brings him great concern because he believes he may be having a heart attack.

Context: This concern has persisted for 2 months.

Context: This has caused him to avoid taking long train rides or driving on divided highways.

Context: Physical examination is unremarkable.

Choices:
A. Adjustment disorder
B. Illness anxiety disorder
C. Panic disorder
D. Specific phobia

Answer: Panic disorder

1. A 22-year-old man presents to the emergency department for chest pain.

2. The chest pain began a few hours prior to presentation.

3. The chest pain is associated with nausea, abdominal discomfort, and sweating.

4. He has experienced similar symptoms multiple times in the past.

5. He believes he may be having a heart attack.

6. His concern has persisted for 2 months.

7. He has avoided taking long train rides or driving on divided highways.

8. Approximately 7 months ago his parents divorced.

9. Medical history is significant for obesity.

10. He denies any medications or illicit drug use.

11. Physical examination is unremarkable.

12. An electrocardiogram demonstrates sinus tachycardia with a pulse of 110/min.


Question: After the aminoacyl-tRNA binds to the A site, which of the following is the next step in protein formation?

Context: Eukaryote ribosomes are utilized to create a novel protein.

Choices:
A. Catalysis of peptide bond
B. Recognition of UAG codon by release factor
C. Assembly of 40s subunit with tRNA
D. Advancement of ribosome in 3' direction

Answer: Catalysis of peptide bond

1. An investigator is developing a new vaccine.

Molecular Genetic Pathology
Rheumatology


Question: Which of the following is the most significant risk factor for this patient’s most likely diagnosis?

Context: A 70-year-old Caucasian woman presents with a 2-week history of blood-tinged sputum.

Context: Her past medical history is significant for peptic ulcer disease for which she underwent triple-drug therapy.

Context: She is a lifetime non-smoker and worked as a teacher before retiring at the age of 60 years.

Context: A review of systems is significant for a weight loss of 6.8 kg (15 lb) over the last 5 months.

Context: Her vitals include: blood pressure 135/85 mm Hg, temperature 37.7°C (99.9°F), pulse 95/min, and respiratory rate 18/min.

Context: Physical examination is unremarkable.

Context: A contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung.

Context: A CT-guided biopsy is performed and reveals malignant tissue architecture and gland formation with a significant amount of mucus.

Choices:
A. Medications
B. Occupational history
C. Race
D. Sex

Answer: Sex

1. Patient is a 70-year-old Caucasian woman.

2. Patient has a 2-week history of blood-tinged sputum.

3. Patient has a past medical history of peptic ulcer disease.

4. Patient underwent triple-drug therapy for peptic ulcer disease.

6. Patient worked as a teacher before retiring at the age of 60 years.

7. Patient has had a weight loss of 6.8 kg (15 lb) over the last 5 months.

8. Patient's blood pressure is 135/85 mm Hg.

9. Patient's temperature is 37.7°C (99.9°F).

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

12. Physical examination is unremarkable.

13. Contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung.

14. CT-guided biopsy reveals malignant tissue architecture and gland formation with a significant amount of mucus.

General Pulmonary Disease
Pulmonary Disease


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

Context: Four days after admission to the hospital for community-acquired pneumonia, a 68-year-old woman has abdominal pain and multiple episodes of loose stools.

Context: They are watery, foul-smelling, and occasionally streaked with blood.

Context: She has approximately 6 episodes daily.

Context: She feels tired.

Context: She is currently being treated with intravenous ceftriaxone and oral azithromycin.

Context: She underwent a laparoscopic cholecystectomy 5 years ago.

Context: She returned from a trip to Bolivia 4 weeks ago.

Context: Her temperature is 37.5°C (99.5°F), pulse is 98/min, and blood pressure is 138/80 mm Hg.

Context: Bronchial breath sounds are heard over her right lung.

Context: The abdomen is not distended.

Context: The remainder of her examination shows no abnormalities.

Context: Her hemoglobin concentration is 12 g/dL, leukocyte count is 14,100/mm3, and erythrocyte sedimentation rate is 37 mm/h.

Choices:
A. Stool for ova and parasites
B. Fecal lactoferrin
C. Enzyme immunoassay for glutamate dehydrogenase antigen
D. Stool acidity test

Answer: Enzyme immunoassay for glutamate dehydrogenase antigen

2. Patient was admitted to the hospital four days ago for community-acquired pneumonia.

3. Patient has abdominal pain and multiple episodes of loose stools.

4. Loose stools are watery, foul-smelling, and occasionally streaked with blood.

5. Patient has approximately 6 episodes of loose stools daily.

7. Patient is currently being treated with intravenous ceftriaxone and oral azithromycin.

8. Patient underwent a laparoscopic cholecystectomy 5 years ago.

9. Patient returned from a trip to Bolivia 4 weeks ago.

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

12. Patient's blood pressure is 138/80 mm Hg.

13. Bronchial breath sounds are heard over patient's right lung.

14. Abdominal examination shows mild diffuse tenderness throughout the lower quadrants.

16. Remainder of patient's examination shows no abnormalities.

17. Patient's hemoglobin concentration is 12 g/dL.

18. Patient's leukocyte count is 14,100/mm3.

19. Patient's erythrocyte sedimentation rate is 37 mm/h.


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

Context: An otherwise healthy 52-year-old man comes to the physician because of a 2-month history of palpitations.

Context: He says that he can feel his heart beat in his chest all the time.

Context: For the past 3 weeks, he has shortness of breath on exertion.

Context: He has not had chest pain, orthopnea, or nocturnal dyspnea.

Context: He emigrated from Nepal at the age of 25 years.

Context: He does not take any medications.

Context: His temperature is 36.5°C (97.7°F), pulse is 103/min, and blood pressure is 138/56 mm Hg.

Context: The lungs are clear to auscultation.

Context: Cardiac examination is shown.

Choices:
A. Pulmonary valve stenosis
B. Aortic valve regurgitation
C. Tricuspid valve regurgitation
D. Mitral valve prolapse

Answer: Aortic valve regurgitation

2. Patient has a 2-month history of palpitations.

3. Patient feels his heart beat in his chest all the time.

4. Patient has shortness of breath on exertion for the past 3 weeks.

5. Patient has no chest pain, orthopnea, or nocturnal dyspnea.

6. Patient emigrated from Nepal at the age of 25 years.

7. Patient does not take any medications.

8. Patient's temperature is 36.5°C (97.7°F).

10. Patient's blood pressure is 138/56 mm Hg.

Cardiovascular Disease
Cardiology
General Cardiology


Question: Which of the following activities was most likely inhibited by the cause of this patient's presentation?

Context: On presentation he is comatose and very jaundiced despite having no previous medical history and dies shortly thereafter.

Context: They all recently returned from a several day camping trip where they slept in the woods and cooked with ingredients they were able to find in the wild.

Choices:
A. Transcription of mRNA
B. Transcription of rRNA
C. Transcription of tRNA
D. Translation of mRNA

Answer: Transcription of mRNA

1. A 55-year-old male presents to the emergency department after he was seen having a seizure.

2. On presentation he is comatose and very jaundiced.

5. Over the next several hours 5 more patients present to the ER with severe diarrhea, abdominal pain, and bleeding abnormalities.

6. They all recently returned from a several day camping trip.

7. They slept in the woods and cooked with ingredients they were able to find in the wild.

8. The original patient was also part of this camping trip.

9. Postmortem analysis reveals massive hepatic necrosis.

Neurology with Special Qualification in Child Neurology


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

Context: Blood glucose is 80 mg/dL.

Context: Her pulse is 100/min, blood pressure is 145/90 mm Hg, and respiratory rate is 24/min.

Choices:
A. Hypoglycemia
B. Benzodiazepine withdrawal
C. Alcohol withdrawal
D. Subdural hemorrhage

Answer: Benzodiazepine withdrawal

1. A 46-year-old woman is brought to the emergency department for respiratory depression.

2. Routine urine toxicology screening is positive for alcohol, fentanyl, and benzodiazepines.

4. Naloxone, flumazenil, and lactated Ringer's solution are administered intravenously.

5. Two hours later, the woman has a tonic-clonic seizure lasting for one minute.

9. Pulse oximetry on room air shows an oxygen saturation of 98%.

10. The patient appears drowsy and diaphoretic.

11. She is not oriented to place or time but responds to her name.

12. Examination shows a hematoma on her left temple.

13. Neurological examination shows stiff extremities and a tremor in both hands.

14. The remainder of the examination shows no abnormalities.

General Emergency Medicine
Neurocritical Care
Medical Toxicology


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

Context: A 22-year-old man comes to the emergency department because of sudden onset of facial swelling, abdominal pain, and nausea 1 hour after eating some trail mix.

Context: His pulse is 90/min, respirations are 25/min, and blood pressure is 125/80 mm Hg.

Context: Shortly after, the abdominal pain and nausea have resolved, the swelling has improved, and the rash has started to fade.

Choices:
A. Recommend avoidance of peanuts
B. Perform patch test
C. Prescribe epinephrine autoinjector
D. Administer oral prednisone

Answer: Prescribe epinephrine autoinjector

1. A 22-year-old man comes to the emergency department.

2. He has sudden onset of facial swelling, abdominal pain, and nausea 1 hour after eating some trail mix.

3. He does not have shortness of breath or hoarseness.

4. He has never had a similar episode before.

5. He has asthma treated with an albuterol inhaler, which he uses less than once a month.

9. Pulse oximetry on room air shows an oxygen saturation of 99%.

10. Physical examination shows perioral swelling and scattered urticaria over the face and the fingers of his right hand.

11. There is no swelling of the oropharynx and no audible stridor.

12. The lungs are clear to auscultation bilaterally.

13. Treatment with intravenous diphenhydramine is begun.

14. Shortly after, the abdominal pain and nausea have resolved.


Question: The regions of this patient's lymph nodes that is likely abnormal also contains which of the following?

Context: A 2-year-old boy is referred by his primary care physician to a geneticist because of prolonged and recurrent infections.

Context: Specifically, he has had an abnormally large number of upper respiratory and gastrointestinal infections over the last year.

Context: He was born with a defect in the cardiac septum that was repaired right after birth and has remained asymptomatic since then.

Context: On evaluation, the patient appears to have hyperactive reflexes and his arm twitches upon blood pressure measurement.

Choices:
A. Efferent sinuses
B. High endothelial venules
C. Plasma cell cords
D. Primary follicles

Answer: High endothelial venules

1. A 2-year-old boy is referred by his primary care physician to a geneticist.

2. The referral is due to prolonged and recurrent infections.

3. The patient has had an abnormally large number of upper respiratory and gastrointestinal infections over the last year.

4. The patient was born with a defect in the cardiac septum.

5. The defect was repaired right after birth.

6. The defect has remained asymptomatic since then.

7. On evaluation, the patient appears to have hyperactive reflexes.

8. The patient's arm twitches upon blood pressure measurement.

Pediatric Immunology and Infectious Diseases


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

Context: A 45-year-old woman presents with a 2-year history of fatigue, paresthesia, diarrhea, and abdominal pain.

Context: She says she experiences 2–3 episodes of non-bloody diarrhea per month associated with crampy abdominal pain.

Context: She also has the bilateral tingling sensation of her upper and lower limbs in a glove and stocking pattern which is sometimes associated with the burning sensation of her hands and legs.

Context: Past medical history is unremarkable.

Context: The patient denies smoking, alcohol consumption, illicit drug use.

Context: Her vital signs include: blood pressure 100/60 mm Hg without postural changes, heart rate 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉).

Context: Laboratory findings are significant for the following: | Hgb 7.2 gm/dL | MCV 110 fL | RBC 3.6 X109/L | Platelets 10,000/mm3 | Total count  4,200/mm3 | Reticulocyte 0.8% | A peripheral blood smear demonstrates hypersegmented neutrophils.

Context: An upper GI series with small bowel follow-through is performed which shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string.

Choices:
A. Celiac disease
B. Crohn's disease
C. Bacterial overgrowth
D. Hypothyroidism

Answer: Crohn's disease

2. Patient has a 2-year history of fatigue, paresthesia, diarrhea, and abdominal pain.

3. Patient experiences 2–3 episodes of non-bloody diarrhea per month associated with crampy abdominal pain.

4. Patient has bilateral tingling sensation of her upper and lower limbs in a glove and stocking pattern which is sometimes associated with the burning sensation of her hands and legs.

5. Patient's past medical history is unremarkable.

6. Patient denies smoking, alcohol consumption, and illicit drug use.

7. Patient's vital signs include: blood pressure 100/60 mm Hg without postural changes, heart rate 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉).

8. Laboratory findings are significant for Hgb 7.2 gm/dL, MCV 110 fL, RBC 3.6 X109/L, Platelets 10,000/mm3, Total count 4,200/mm3, Reticulocyte 0.8%.

9. Peripheral blood smear demonstrates hypersegmented neutrophils.

10. Anti-intrinsic factor and anti-tissue transglutaminase antibodies were negative.

11. Upper GI series with small bowel follow-through shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string.


Question: Which of the following should be included in the work-up of this patient?

Context: A 15-month-old boy is brought to his pediatrician by his mother with a swollen and painful right elbow.

Context: She reports that he stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground.

Context: The mother reports that he did not appear to be in a great deal of pain after the fall, and that she noted the swelling of the joint a few hours after the fall.

Context: He does not have any known medical issues, and he is not currently on medication.

Context: The mother's pregnancy was without complications and the boy was delivered vaginally without complications at 40 weeks.

Choices:
A. Peripheral blood smear
B. Creatinine level and percutaneous kidney biopsy
C. Prothrombin time/partial thromboplastin time
D. 24 hour urine collection for porphyrin levels

Answer: Prothrombin time/partial thromboplastin time

1. A 15-month-old boy is brought to his pediatrician by his mother.

2. The boy has a swollen and painful right elbow.

3. The mother reports that he stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground.

4. The mother reports that he did not appear to be in a great deal of pain after the fall.

5. The mother noted the swelling of the joint a few hours after the fall.

6. He recently started walking approximately 2 weeks ago.

7. He does not have any known medical issues.

9. The mother's pregnancy was without complications.

10. The boy was delivered vaginally without complications at 40 weeks.

11. Aspiration of the right elbow joint reveals frank blood.

Pediatric Rheumatology
General Orthopaedic Surgery


Question: Which of the following structures has this patient injured in addition to the meniscus?

Context: A 45-year-old male comes into your office one week after he was tackled playing football with his friends.

Context: The patient states that the medial aspect of his knee collided with another player's knee.

Context: Since then, he has been taking ibuprofen for knee pain.

Context: On exam, the patient's right knee appears larger than his left knee with a small effusion.

Context: The patient has intact sensation and strength in both lower extremities.

Context: The patient's right knee has no laxity on valgus stress test, but is very lax on varus stress test.

Context: Lachman's test and posterior drawer test both have firm endpoints without laxity.

Context: McMurray's test is positive and the patient states he feels catching and locking during the test.

Choices:
A. Anterior cruciate ligament
B. Posterior cruciate ligament
C. Medial collateral ligament
D. Lateral collateral ligament

Answer: Lateral collateral ligament

2. Patient was tackled playing football one week prior.

3. Patient's medial knee collided with another player's knee.

4. Patient has been taking ibuprofen for knee pain.

5. Patient's right knee appears larger than left knee with a small effusion.

6. Patient has intact sensation and strength in both lower extremities.

7. Patient's right knee has no laxity on valgus stress test.

8. Patient's right knee is very lax on varus stress test.

9. Lachman's test and posterior drawer test have firm endpoints without laxity.

11. Patient states he feels catching and locking during McMurray's test.


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

Context: She was born at term and has been healthy.

Context: Her temperature is 37.3 °C (99.1 °F), pulse is 102/min, respirations are 24/min, and blood pressure is 102/54 mm Hg.

Context: She is at the 75th percentile for height and 80th percentile for weight.

Context: Cardiac examination shows a normal S1 and a split S2 during inspiration.

Context: A contrast echocardiogram is performed and reveals a mild transient right-to-left interatrial shunt that becomes apparent when the child coughs.

Choices:
A. No intervention
B. Aspirin therapy
C. Surgical closure
D. Regular echocardiographies

Answer: No intervention

1. A 19-month-old girl is brought for a well-child examination.

4. On physical examination, the child is alert and active.

5. Her temperature is 37.3 °C (99.1 °F).

9. She is at the 75th percentile for height.

10. She is at the 80th percentile for weight.

11. Cardiac examination shows a normal S1.

12. Cardiac examination shows a split S2 during inspiration.

13. A grade 2/6 soft mid-systolic murmur is heard maximally at the lower left sternal border.

14. A contrast echocardiogram is performed.

15. The contrast echocardiogram reveals a mild transient right-to-left interatrial shunt.

16. The shunt becomes apparent when the child coughs.


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

Context: A 6-year-old girl is brought to the emergency department because of right knee pain for the past 3 days.

Context: During this period, the girl has refused to walk.

Context: Her mother reports that her symptoms began after she fell down while playing.

Context: Her father has hemophilia A and has had repeated episodes of joint pain and swelling following minor injury.

Context: Her temperature is 38.1°C (100.6°F), pulse is 120/min, and respirations are 21/min.

Choices:
A. Gram-positive cocci in synovial fluid
B. Prolonged prothrombin time
C. Increased antistreptolysin O titers
D. Rhomboid crystals in synovial fluid

Answer: Gram-positive cocci in synovial fluid

1. A 6-year-old girl is brought to the emergency department.

2. The girl has right knee pain for the past 3 days.

4. Her symptoms began after she fell down while playing.

5. Three weeks ago, the patient had a sore throat and was treated with penicillin V.

7. Her father has had repeated episodes of joint pain and swelling following minor injury.

8. The patient's immunizations are up-to-date.

12. The right knee joint is warm and erythematous.

13. The girl starts to cry as soon as the physician tries to flex the knee joint.


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

Context: A physician in the climbing party performs a rudimentary physical exam which reveals a respiratory rate of 30/min, blood pressure of 130/90 mm Hg, heart rate of 108/min, and temperature of 36.4°C (97.5°F), with few basal crackles on the right side of chest.

Context: No jugular venous distension or dependent edema is noted.

Context: With this information, the mountain climber is sent down the mountain for further evaluation.

Context: Investigation reveals a normal chest X-ray with a normal heart size.

Choices:
A. Diffusion defect
B. Anemic hypoxia
C. Ischemic hypoxia
D. Hypoxemic hypoxia

Answer: Hypoxemic hypoxia

1. A 35-year-old man attempted to climb Mount Everest.

2. At an altitude of 7,000 meters, he became short of breath and developed a dusky blue tinge around his face and lips.

3. A physician in the climbing party performed a rudimentary physical exam.

4. The physical exam revealed a respiratory rate of 30/min.

5. The physical exam revealed a blood pressure of 130/90 mm Hg.

6. The physical exam revealed a heart rate of 108/min.

7. The physical exam revealed a temperature of 36.4°C (97.5°F).

8. The physical exam revealed few basal crackles on the right side of chest.

9. The physical exam revealed no jugular venous distension.

10. The physical exam revealed no dependent edema.

11. The mountain climber was sent down the mountain for further evaluation.

12. Investigation revealed a normal chest X-ray.

13. Investigation revealed a normal heart size.

Pulmonary Disease
General Pulmonary Disease


Question: Which of the following clinical features can be seen as a long-term complication of posterior pituitary dysfunction?

Context: A 28-year-old man who was involved in a motorcycle accident presents to the nearest trauma center to get his wounds treated.

Context: After the initial evaluation and resuscitation by the emergency trauma team, a CT scan shows a skull base fracture.

Choices:
A. Erectile dysfunction
B. Decreased lean body mass
C. Polydipsia
D. Cold intolerance

Answer: Polydipsia

1. A 28-year-old man was involved in a motorcycle accident.

2. He presents to the nearest trauma center to get his wounds treated.

3. The emergency trauma team performs an initial evaluation and resuscitation.

4. A CT scan shows a skull base fracture.


Question: The dosage of which of the following types of insulin was most likely changed in this patient's medication regimen?

Context: She has a history of type 1 diabetes mellitus and is compliant with her medications.

Context: After reviewing the patient's recent blood sugar levels, the physician changes the patient's antidiabetic regimen by changing the dosage of an insulin that does not produce an observable peak in serum insulin concentration.

Choices:
A. Insulin glargine
B. Insulin glulisine
C. Regular insulin
D. Insulin lispro

Answer: Insulin glargine

1. A 19-year-old woman comes to the physician for a follow-up examination.

2. She has a history of type 1 diabetes mellitus.

3. She is compliant with her medications.

4. The physician reviews the patient's recent blood sugar levels.

5. The physician changes the patient's antidiabetic regimen.

7. The insulin does not produce an observable peak in serum insulin concentration.

Internal Medicine
Endocrinology, Diabetes, and Metabolism

Endocrinology, Diabetes, and Metabolism
General Endocrinology


Question: Which of the following organisms would be most likely isolated in this patient?

Context: A 31-year-old woman visits her local walk-in clinic for 2 days of dysuria, increased voiding frequency, urgency, and intense suprapubic pain.

Context: She just came back a day ago from a short honeymoon trip to Prague.

Context: On physical examination, the patient is found with exquisite suprapubic pain.

Context: Costovertebral tenderness is absent and pelvic examination is normal.

Context: Her vital signs are: temperature 36.5°C (97.7°F), heart rate 78/min, respiratory rate 15/min.

Choices:
A. Streptococcus agalactiae
B. Enterococcus faecalis
C. Klebsiella pneumoniae
D. Staphylococcus saprophyticus

Answer: Staphylococcus saprophyticus

1. A 31-year-old woman visited her local walk-in clinic.

2. She had dysuria, increased voiding frequency, urgency, and intense suprapubic pain.

3. She had recently returned from a honeymoon trip to Prague.

4. On physical examination, the patient had exquisite suprapubic pain.

5. Costovertebral tenderness was absent.


Question: Which of the following is the most appropriate recommendation by the physician?

Context: A 14-year-old boy is brought to the physician by his mother because of a 1-week history of fever, fatigue, and throat pain.

Context: He appears lethargic.

Context: His temperature is 38.5°C (101.3°F).

Choices:
A. Start antiretroviral therapy
B. Schedule bone marrow biopsy
C. Avoid contact sports
D. Avoid crowded places

Answer: Avoid contact sports

1. A 14-year-old boy is brought to the physician by his mother.

2. He has a 1-week history of fever, fatigue, and throat pain.

5. Physical examination shows bilateral cervical lymphadenopathy.

6. Oral examination shows the findings in the photograph.

7. A peripheral blood smear shows lymphocytosis with atypical lymphocytes.

8. A heterophile antibody test is positive.


Question: What is the most likely pathogenesis leading to the X-ray findings?

Context: A 62-year-old carpenter presents to your clinic complaining of worsening joint pain in her hands.

Context: She states that the pain is present in all of her fingers, but is worse in the right hand and that it gets better when she has a few days off from work.

Context: On examination, the patient is afebrile and all vital signs are stable.

Context: She has hard, non-tender lesions overlying the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand and all 5 digits on this hand have a decreased range of motion.

Context: An X-ray of her hands is shown.

Choices:
A. Repetitive movement injury
B. Overgrowth of a gram-positive bacteria
C. Deposition of monosodium urate crystals
D. Production of rheumatoid factor and other autoantibodies

Answer: Repetitive movement injury

1. A 62-year-old carpenter presents to your clinic.

2. She is complaining of worsening joint pain in her hands.

3. The pain is present in all of her fingers.

5. The pain gets better when she has a few days off from work.

6. She notes no paresthesias, fever, or fatigue.

7. On examination, the patient is afebrile.

9. She has hard, non-tender lesions overlying the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand.

10. All 5 digits on the right hand have a decreased range of motion.


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

Context: A 7-year-old girl presents to the emergency department with a bloody nose that spontaneously started bleeding 20 minutes ago.

Context: Her heart has a regular rate and rhythm, her lungs are clear to auscultation bilaterally, and her abdomen is soft without hepatosplenomegaly, but she does have petechiae over her lower extremities.

Context: A complete blood count is obtained and reveals a leukocyte count of 11,300 cells/mcL, hemoglobin 12.1 g/dL, hematocrit 36%, and platelets 15,000/mcL.

Context: Her mother reports that she had a viral infection 2 weeks ago but has been otherwise healthy.

Choices:
A. Start intravenous immunoglobulin
B. Perform a splenectomy
C. Perform a bone marrow aspiration
D. Observation

Answer: Start intravenous immunoglobulin

1. A 7-year-old girl presents to the emergency department with a bloody nose.

2. The nose spontaneously started bleeding 20 minutes ago.

3. On physical examination, she appears well and has no lymphadenopathy.

4. Her heart has a regular rate and rhythm.

5. Her lungs are clear to auscultation bilaterally.

6. Her abdomen is soft without hepatosplenomegaly.

7. She has petechiae over her lower extremities.

13. A peripheral smear shows a few morphologically normal platelets.

14. Her mother reports she had a viral infection 2 weeks ago.


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

Context: A 2-year-old boy is brought to the physician by his parents because their son frequently avoids eye contact and has no friends in daycare.

Context: He was born at term and has been healthy except for an episode of otitis media 6 months ago.

Context: His immunizations are up-to-date.

Context: He is at the 95th percentile for height, 20th percentile for weight, and 95th percentile for head circumference.

Context: Vital signs are within normal limits.

Context: He continually opens and closes his mother's purse and does not maintain eye contact.

Choices:
A. CGG trinucleotide repeat expansion on X-chromosome
B. Deletion of the long arm on chromosome 7
C. Genomic imprinting on chromosome 15
D. An additional X chromosome

Answer: CGG trinucleotide repeat expansion on X-chromosome

1. A 2-year-old boy is brought to the physician by his parents.

2. The boy frequently avoids eye contact and has no friends in daycare.

4. He has been healthy except for an episode of otitis media 6 months ago.

6. He is at the 95th percentile for height.

7. He is at the 20th percentile for weight.

8. He is at the 95th percentile for head circumference.

9. Vital signs are within normal limits.

10. Examination shows elongated facial features and large ears.

11. The patient is shy and does not speak or follow instructions.

12. He continually opens and closes his mother's purse.


Question: What best explains the change in this patient’s lipid profile over this time period?

Context: His lab results from 1 week ago and from his day of admission to hospital are as follows: | 7 days ago | On admission to hospital | Serum glucose (random)  130 mg/dL | Serum electrolytes | Sodium 142 mEq/L | Potassium 3.9 mEq/L | Chloride 101 mEq/L | Serum creatinine 0.8 mg/dL | Blood urea nitrogen 9 mg/dL | Cholesterol, total 170 mg/dL | HDL-cholesterol 42 mg/dL | LDL-cholesterol 110 mg/dL | Triglycerides 130 mg/dL | Serum glucose (random)  100 mg/dL | Serum electrolytes | Sodium 140 mEq/L | Potassium 4.0 mEq/L | Chloride 100 mEq/L | Serum creatinine 0.9 mg/dL | Blood urea nitrogen 11 mg/dL | Cholesterol, total 130 mg/dL | HDL-cholesterol 30 mg/dL | LDL-cholesterol 80 mg/dL | Triglycerides 180 mg/dL | .

Choices:
A. COPD exacerbation
B. Drug side effect
C. Physiological response
D. Undiagnosed dyslipidemia

Answer: Physiological response

1. A 78-year-old man is admitted to hospital for treatment of a severe attack of pneumonia he has been experiencing for the past three days.

2. A week earlier, he had been feeling well until he developed what he describes as a mild cold.

3. Over the next few days, he began to have difficulty breathing and developed a productive cough and fever.

4. As his condition worsened despite antibiotic therapy at home, he was admitted for intravenous antibiotics and observation.

5. He has a 50-pack-year history of smoking and has been diagnosed with chronic obstructive pulmonary disease (COPD).

6. Prior to admission, the man was taking inhaled formoterol, budesonide, and oxygen at home.

7. He has been drinking 3 alcoholic drinks daily for the last 60 years and smoked marijuana during his 20s.

8. His lab results from 1 week ago show a serum glucose (random) of 130 mg/dL, sodium of 142 mEq/L, potassium of 3.9 mEq/L, chloride of 101 mEq/L, serum creatinine of 0.8 mg/dL, and blood urea nitrogen of 9 mg/dL.

9. His lab results from his day of admission to hospital show a serum glucose (random) of 100 mg/dL, sodium of 140 mEq/L, potassium of 4.0 mEq/L, chloride of 100 mEq/L, serum creatinine of 0.9 mg/dL, and blood urea nitrogen of 11 mg/dL.

10. His lab results from 1 week ago show a cholesterol, total of 170 mg/dL, HDL-cholesterol of 42 mg/dL, LDL-cholesterol of 110 mg/dL, and triglycerides of 130 mg/dL.

11. His lab results from his day of admission to hospital show a cholesterol, total of 130 mg/dL, HDL-cholesterol of 30 mg/dL, LDL-cholesterol of 80 mg/dL, and triglycerides of 180 mg/dL.


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

Context: A 42-year-old woman comes to the physician because of a 4-week history of progressive difficulty swallowing solid foods.

Context: The patient reports feeling like food gets stuck in her throat, and that she has to drink a lot of water to swallow her meals.

Context: Over the past 3 months, she has had progressive fatigue and occasional dyspnea while performing her daily activities.

Context: Her pulse is 104/min, respirations are 19/min, and blood pressure is 110/70 mm Hg.

Context: Physical examination shows conjunctival pallor, erythema around the corners of the mouth, and dry, scaly lips.

Context: Her fingernails appear spoon-shaped and brittle.

Choices:
A. Altered sense of smell
B. Intolerance to cold temperatures
C. Thickening of the skin
D. Craving for non-nutritive substances

Answer: Craving for non-nutritive substances

2. Patient has had difficulty swallowing solid foods for 4 weeks.

3. Patient feels like food gets stuck in her throat.

4. Patient has to drink a lot of water to swallow meals.

5. Patient has had progressive fatigue for 3 months.

6. Patient has occasional dyspnea while performing daily activities.

9. Patient's blood pressure is 110/70 mm Hg.

10. Physical examination shows conjunctival pallor.

11. Physical examination shows erythema around the corners of the mouth.

12. Physical examination shows dry, scaly lips.

13. Patient's fingernails appear spoon-shaped and brittle.

14. Auscultation of the heart shows a grade 1/6 systolic murmur best heard at the second left intercostal space.

15. Esophagogastroduodenoscopy shows thin membranes that are protruding into the upper third of the esophagus.


Question: Which of the following statements regarding the management of this patient is correct?

Context: A 27-year-old nullipara makes an appointment with her gynecologist to discuss the results of her cervical cancer screening.

Context: She is not vaccinated against HPV and has a single sexual partner.

Context: She and her partner are planning pregnancy, so she recently discontinued oral contraception and began to take folate and iron supplements.

Context: Her first Pap smear showed atypical squamous cells of undetermined significance, but 2 subsequent Pap smears had normal results.

Context: Colposcopy was performed at the next visit and a biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone.

Context: The pathologic assessment shows CIN 3.

Choices:
A. The annual rate of progression of CIN 3 to cancer is > 10%, so the patient should be treated as soon as possible.
B. Close follow-up with cytology and colposcopy may be considered in this patient.
C. Additional HPV testing would be useful to guide the therapy.
D. Pregnancy is not recommended in women with high-grade cervical lesions, so treatment is reasonable.

Answer: Close follow-up with cytology and colposcopy may be considered in this patient.

1. A 27-year-old nullipara makes an appointment with her gynecologist.

4. She and her partner are planning pregnancy.

5. She recently discontinued oral contraception.

6. She began to take folate and iron supplements.

7. She has no history of gynecologic diseases.

8. Her first Pap smear showed atypical squamous cells of undetermined significance.

9. Two subsequent Pap smears had normal results.

10. The most recent Pap smear was reported as a high-grade squamous intraepithelial lesion.

11. Colposcopy was performed at the next visit.

12. A biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone.

13. The pathologic assessment shows CIN 3.


Question: Which of the following findings most closely correlates with this patient's symptoms?

Context: A 47-year-old woman comes to the physician because of a 3-month history of recurrent episodes of nausea and feeling like the room is spinning.

Context: Each episode lasts less than a minute and usually occurs when she gets out of bed in the morning or suddenly turns her head.

Context: She has not vomited and does not have headaches.

Context: She is asymptomatic between episodes.

Choices:
A. Intention tremor
B. Nystagmus
C. Abnormal Rinne test
D. Orthostatic hypotension

Answer: Nystagmus

1. A 47-year-old woman comes to the physician.

2. She has a 3-month history of recurrent episodes of nausea.

3. She also has a feeling like the room is spinning.

4. Each episode lasts less than a minute.

5. The episodes usually occur when she gets out of bed in the morning or suddenly turns her head.

8. She is asymptomatic between episodes.


Question: Which of the following is the most likely precipitating factor for this patient's symptoms?

Context: A 56-year-old man is brought to the emergency department by his wife because of increasing confusion and lethargy for the past 12 hours.

Context: He is oriented only to person.

Context: His temperature is 37.3°C (99.1°F), pulse is 109/min, respirations are 18/min, and blood pressure is 108/67 mm Hg.

Context: Examination shows abdominal distention and several erythematous, lacy lesions on the chest that blanch with pressure.

Choices:
A. Elevated systemic vascular resistance
B. Destruction of gut anaerobes
C. Presence of hemoglobin in the intestine
D. Low protein consumption

Answer: Presence of hemoglobin in the intestine

1. A 56-year-old man is brought to the emergency department by his wife.

2. He has been experiencing increasing confusion and lethargy for the past 12 hours.

8. Examination shows abdominal distention.

9. Examination shows several erythematous, lacy lesions on the chest.

10. The lesions on the chest blanch with pressure.

11. His hands make a flapping motion when they are dorsiflexed.


Question: The patient was most likely treated with a drug that predominantly acts on which of the following parts of the cell?

Context: A 63-year-old man comes to the physician because of a 4-hour history of severe pain in the right knee.

Context: His temperature is 38.0°C (100.1°F).

Context: Examination shows erythema, edema, and warmth of the right knee; range of motion is limited by pain.

Context: Arthrocentesis of the knee joint yields cloudy fluid with a leukocyte count of 24,000/mm3 (74% segmented neutrophils).

Context: Five hours after treatment with a drug is begun, he develops abdominal cramp, diarrhea, and vomiting.

Choices:
A. Cell wall
B. Cytosolic enzyme
C. Nucleus
D. Cytoskeleton

Answer: Cytoskeleton

1. A 63-year-old man comes to the physician.

2. He has a 4-hour history of severe pain in the right knee.

4. Examination shows erythema, edema, and warmth of the right knee.

6. Arthrocentesis of the knee joint yields cloudy fluid.

7. Leukocyte count of the fluid is 24,000/mm3 (74% segmented neutrophils).

8. Polarized light microscopy shows needle-shaped, negatively birefringent crystals.

9. Five hours after treatment with a drug is begun, he develops abdominal cramp.


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

Context: A 1-year-old boy presents to the emergency department for several days of irritability and poor feeding.

Context: His parents are very concerned that he has been acting differently.

Context: The patient has an unremarkable past medical history and has been followed by a pediatrician.

Context: His temperature is 102°F (38.9°C), blood pressure is 57/38 mmHg, pulse is 170/min, respirations are 35/min, and oxygen saturation is 99% on room air.

Context: Fundoscopy is within normal limits.

Choices:
A. Blood and urine cultures
B. Lumbar puncture
C. Vancomycin and ceftriaxone
D. Vancomycin, ceftriaxone, and prednisone

Answer: Lumbar puncture

1. A 1-year-old boy presents to the emergency department.

2. The parents are concerned that he has been acting differently.

3. The patient has an unremarkable past medical history.

4. The patient has been followed by a pediatrician.

5. The patient's temperature is 102°F (38.9°C).

6. The patient's blood pressure is 57/38 mmHg.

8. The patient's respirations are 35/min.

9. The patient's oxygen saturation is 99% on room air.

10. During the exam the infant is irritable and is crying.

11. Musculoskeletal exam reveals that the patient's knee can not be extended while the patient's hip is in a flexed position without significant patient irritation.

13. Abdominal, cardiac, and pulmonary exam are within normal limits.

Pediatric Infectious Diseases
General Pediatrics


Question: Which of the following is the most likely underlying mechanism of this patient's cardiomyopathy?

Context: A 74-year-old man comes to the physician because of a 2-month history of shortness of breath and leg swelling.

Context: He has hypertension and was diagnosed with multiple myeloma 6 months ago.

Context: Current medications include hydrochlorothiazide.

Context: Cardiopulmonary examination shows jugular venous distention, bibasilar crackles, and pitting edema in the lower extremities.

Context: Transthoracic echocardiography shows a thickened myocardium with elevated diastolic filling pressures.

Choices:
A. Chronic vasoconstriction
B. Myosin gene mutation
C. Amyloid deposition
D. Chronic hypercalcemia

Answer: Amyloid deposition

1. A 74-year-old man comes to the physician.

2. He has a 2-month history of shortness of breath and leg swelling.

3. He has trouble climbing one flight of stairs due to dyspnea.

5. He was diagnosed with multiple myeloma 6 months ago.

6. His current medications include hydrochlorothiazide.

7. Cardiopulmonary examination shows jugular venous distention.

8. Cardiopulmonary examination shows bibasilar crackles.

9. Cardiopulmonary examination shows pitting edema in the lower extremities.

10. Transthoracic echocardiography shows a thickened myocardium.

11. Transthoracic echocardiography shows elevated diastolic filling pressures.


Question: The next appropriate step in the management of this patient involves passing a tube through an incision through which of the following structures?

Context: A 47-year-old man is brought to the emergency department 30 minutes after he was involved in a motor vehicle collision.

Context: On arrival, he is unconscious and unresponsive to painful stimuli.

Context: His pulse is 120/min, respirations are 10/min, and his blood pressure is 88/60 mm Hg.

Context: Infusion of 0.9% saline is begun, and intubation is attempted without success.

Context: Pulse oximetry on 20 L/min of oxygen via bag mask shows an oxygen saturation of 78%.

Choices:
A. Investing layer of deep cervical fascia
B. Annular ligament
C. Cricotracheal ligament
D. Prevertebral layer of deep cervical fascia

Answer: Investing layer of deep cervical fascia

1. A 47-year-old man was brought to the emergency department 30 minutes after a motor vehicle collision.

2. On arrival, he was unconscious and unresponsive to painful stimuli.

7. Intubation was attempted without success.

8. Pulse oximetry on 20 L/min of oxygen via bag mask showed an oxygen saturation of 78%.

General Surgery
General Emergency Medicine


Question: What is the most likely diagnosis?

Context: Parents bring an 11-month-old baby to the clinic because the baby has a fever of 39.0°C (102.2°F).

Context: She is up to date on immunizations.

Context: A complete physical examination reveals no significant findings, and all laboratory tests are negative.

Choices:
A. Roseola
B. Erythema infectiosum
C. Rubella
D. Kawasaki disease

Answer: Roseola

1. Parents bring an 11-month-old baby to the clinic.

2. The baby has a fever of 39.0°C (102.2°F).

3. The baby is irritated and crying constantly.

4. The baby is up to date on immunizations.

5. A complete physical examination reveals no significant findings.

7. Five days after resolution of her fever, she develops a transient maculopapular rash.


Question: Which of the following statements would best explain the mechanism of action of these drugs?

Context: A 67-year-old man is brought to his primary care practitioner by his daughter who has noticed a ‘pill-rolling’ tremor in his right hand, along with a progressively slow, shuffling gait.

Context: The patient’s daughter says that these symptoms gradually started 2 weeks ago and have progressively worsened.

Context: His past medical history is significant for hypertension, which is well-controlled with losartan.

Context: He does not take any other medications.

Context: Physical examination reveals a slow shuffling gait, difficulty initiating movements, a resting tremor in his right hand that decreases in intensity with voluntary movement, and cogwheel-like rigidity in the right arm.

Context: The primary care practitioner decides to prescribe levodopa and carbidopa.

Choices:
A. Inhibition of the enzyme monoamine oxidase (MAO) B
B. Blockade of muscarinic receptors
C. Inhibition of dopamine reuptake
D. Increased dopamine synthesis

Answer: Increased dopamine synthesis

2. Patient's daughter noticed a "pill-rolling" tremor in his right hand.

3. Patient's daughter noticed a progressively slow, shuffling gait.

4. Symptoms gradually started 2 weeks ago and have progressively worsened.

5. Patient has a past medical history of hypertension.

6. Hypertension is well-controlled with losartan.

7. Patient does not take any other medications.

8. Physical examination reveals a slow shuffling gait.

9. Physical examination reveals difficulty initiating movements.

10. Physical examination reveals a resting tremor in his right hand that decreases in intensity with voluntary movement.

11. Physical examination reveals cogwheel-like rigidity in the right arm.

12. Primary care practitioner decides to prescribe levodopa and carbidopa.


Question: Which of the following is the most likely underlying pathogenesis?

Context: A 79-year-old man with a long-standing history of hypertension and diabetes presents to the emergency department with sudden-onset of loss of motor function on the left side of his body.

Context: MRI of the brain is obtained and shows a small sub-cortical infarct involving a perforating vessel.

Choices:
A. Embolism originating from the left atrium
B. Berry aneurysm
C. Lipohyalinosis of small vessels
D. Fibromuscular dysplasia

Answer: Lipohyalinosis of small vessels

2. Patient has a long-standing history of hypertension and diabetes.

3. Patient presents to the emergency department with sudden-onset of loss of motor function on the left side of his body.

4. Neurologic exam shows normal sensation throughout the body.

6. MRI of the brain shows a small sub-cortical infarct involving a perforating vessel.


Question: If the cardiologist was aware of Berkson’s bias (also known as the admission rate bias), he could minimize it by which of the following?

Context: A cardiology specialist working in the university hospital center noticed that a large number of his patients who had myocardial infarctions also had some sort of malignancy in their medical history.

Context: In order to determine whether a relationship existed between myocardial infarction and malignant processes, he decided to pursue a case-control study.

Context: His selected cases consisted of a sample of patients hospitalized in an internal ward with a history of a myocardial infarction, while control cases were patients on the same ward without a history of a myocardial infarction.

Choices:
A. Including the diagnoses negatively related to the risk factor being studied
B. Excluding controls that present a probability of hospital admission similar to cases
C. Recruiting the controls from different wards to increase disease variability
D. Excluding those patients with preferential recollection of exposures

Answer: Recruiting the controls from different wards to increase disease variability

1. A cardiology specialist was working in the university hospital center.

2. A large number of his patients who had myocardial infarctions also had some sort of malignancy in their medical history.

3. He decided to pursue a case-control study to determine whether a relationship existed between myocardial infarction and malignant processes.

4. The selected cases consisted of a sample of patients hospitalized in an internal ward with a history of a myocardial infarction.

5. The control cases were patients on the same ward without a history of a myocardial infarction.

6. Their charts and medical documentation were then reviewed for a history of any type of malignancy.

7. The results of the study led the cardiologist to conclude that, for patients with malignancy, the odds of having a myocardial infarction were 3.2 times higher when compared to patients without malignancy.


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

Context: A 27-year-old woman presents to her primary care physician’s office with fatigue, headaches, and concentration difficulties.

Context: Throughout this time, she reports problems with initiating and remaining asleep, has noticed periods of muscle soreness, and has feelings of restlessness.

Context: She states that she is very concerned about whether she will be able to pay her monthly expenses and if her parents are satisfied with her career choices.

Context: She takes a daily multivitamin.

Context: She occasionally drinks alcohol during social gatherings, does not smoke, and denies any illicit drug use.

Context: Her temperature is 99°F (37.2 °C), blood pressure is 110/75, pulse is 101/min, and respirations are 18/min.

Context: Physical examination is unremarkable.

Choices:
A. Buspirone
B. Mirtazapine
C. Olanzapine
D. Trazodone

Answer: Buspirone

1. A 27-year-old woman presents to her primary care physician's office.

2. She has fatigue, headaches, and concentration difficulties.

3. Her symptoms began approximately 7 months prior to presentation.

4. She reports problems with initiating and remaining asleep.

5. She has noticed periods of muscle soreness and has feelings of restlessness.

6. She is very concerned about whether she will be able to pay her monthly expenses and if her parents are satisfied with her career choices.

7. She is also worried about how her colleagues and supervisor think of her performance at work.

8. She denies any significant past medical history besides occasional palpitations.

10. Family history is significant for panic disorder in her mother.

11. She currently lives alone and at times socializes with friends.

12. She occasionally drinks alcohol during social gatherings.

13. She does not smoke and denies any illicit drug use.

18. Physical examination is unremarkable.

General Psychiatry
General Internal Medicine


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

Context: A 73-year-old man comes in to the emergency department because of nausea and severe pain in his upper abdomen and right shoulder blade for the past day.

Context: He has smoked half a pack of cigarettes daily for 40 years and drinks 4 beers every week.

Context: He appears acutely distressed.

Context: His temperature is 38.8°C (102°F), pulse is 124/min, and blood pressure is 92/68 mm Hg.

Context: The abdomen is soft and there is tenderness to palpation of the right upper quadrant with soft crepitus.

Context: Laboratory studies show: | Hemoglobin 14.3 g/dL | Leukocyte count 18,100/mm3 | Platelet count 216,000/mm3 | Serum | Aspartate aminotransferase (AST, SGOT) 41 U/L | Alanine aminotransferase (ALT, SGPT) 19 U/L | Alkaline phosphatase 110 U/L | Total bilirubin 0.9 mg/dL | Direct bilirubin 0.2 mg/dL | Albumin 4.1 g/dL | Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen.

Choices:
A. Chronic pancreatitis with pseudocyst rupture
B. Emphysematous cholecystitis
C. Gallstone ileus
D. Primary sclerosing cholangitis

Answer: Emphysematous cholecystitis

1. A 73-year-old man comes in to the emergency department.

2. He has nausea and severe pain in his upper abdomen and right shoulder blade for the past day.

3. He was able to eat a little for breakfast but vomited up the meal a couple of hours later.

4. He has type 2 diabetes mellitus treated with metformin.

5. He has smoked half a pack of cigarettes daily for 40 years.

11. Pulse oximetry on room air shows an oxygen saturation of 95%.

13. There is tenderness to palpation of the right upper quadrant with soft crepitus.

14. The remainder of the examination shows no abnormalities.

15. Laboratory studies show a hemoglobin of 14.3 g/dL.

16. Laboratory studies show a leukocyte count of 18,100/mm3.

17. Laboratory studies show a platelet count of 216,000/mm3.

18. Laboratory studies show an aspartate aminotransferase (AST, SGOT) of 41 U/L.

19. Laboratory studies show an alanine aminotransferase (ALT, SGPT) of 19 U/L.

20. Laboratory studies show an alkaline phosphatase of 110 U/L.

21. Laboratory studies show a total bilirubin of 0.9 mg/dL.

22. Laboratory studies show a direct bilirubin of 0.2 mg/dL.

23. Laboratory studies show an albumin of 4.1 g/dL.

24. Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen.


Question: Which of the following is associated with his condition?

Context: On presentation to the clinic, the blood pressure is 190/110 mm Hg; the femoral pulse is reduced compared to the radial pulse, and an ejection click is heard.

Context: There was no murmur.

Choices:
A. Ventricular septal defect (VSD)
B. Wolff-Parkinson-White syndrome
C. Coarctation of the aorta
D. Atrial septal defect (ASD)

Answer: Coarctation of the aorta

1. A 26-year-old man presented with a headache and fatigue for the past few months.

2. On presentation to the clinic, the blood pressure is 190/110 mm Hg.

3. The femoral pulse is reduced compared to the radial pulse.


Question: Which of the following strategies is most likely to decrease the likelihood that the procedure will exacerbate the patient’s renal failure?

Context: A 57-year-old man with a history of diabetes and stage 3 chronic kidney disease is admitted to the hospital for elective coronary angiography.

Context: The senior resident admitting the patient to the ward is concerned about his chronic renal impairment and the scheduled angiography, which will require the use of intravenous contrast.

Choices:
A. Intravenous mannitol before and during the procedure
B. Intravenous N-acetyl cysteine before and during the procedure
C. Use non-iodinated contrast medium
D. Forced diuresis with furosemide

Answer: Use non-iodinated contrast medium

1. A 57-year-old man has a history of diabetes.

2. The man has stage 3 chronic kidney disease.

3. The man is admitted to the hospital for elective coronary angiography.

4. The senior resident admitting the patient is concerned about the man's chronic renal impairment.

5. The scheduled angiography will require the use of intravenous contrast.


Question: Presuming it is an inherited condition, what is the most likely genetic pathophysiology of this disorder?

Context: A 17-year-old girl is brought in a wheelchair because of gradually progressive difficulty in walking, incoordination, and frequent falls.

Context: She later experienced difficulties with coordination, which later involved her arms and trunk.

Context: The physical examination reveals severely ataxic gait, nystagmus, absent deep tendon reflexes, and loss of vibration and proprioception.

Choices:
A. GAA trinucleotide repeats
B. Mitochondrial DNA mutation
C. NOTCH3 mutation
D. PMP22 gene duplication

Answer: GAA trinucleotide repeats

1. A 17-year-old girl is brought in a wheelchair.

2. She has gradually progressive difficulty in walking, incoordination, and frequent falls.

3. Her symptoms started at 9 years old with clumsiness while walking.

4. Her difficulties with coordination later involved her arms and trunk.

5. She was born at term with normal developmental milestones.

6. The physical examination reveals severely ataxic gait.

7. The physical examination reveals nystagmus.

8. The physical examination reveals absent deep tendon reflexes.

9. The physical examination reveals loss of vibration and proprioception.

Neurodevelopmental Disabilities
Neuromuscular Medicine


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

Context: A previously healthy 51-year-old man is brought to the emergency department because of confusion for 2 hours.

Context: On arrival, he is unconscious.

Context: His temperature is 37.1°C (98.8°F), pulse is 54/min, respirations are 8/min and irregular, and blood pressure is 198/106 mm Hg.

Context: The right pupil is dilated and fixed; the left pupil is round and reactive to light.

Context: A mannitol infusion is begun.

Choices:
A. Right-sided hemiplegia
B. Left-side facial nerve palsy
C. Bilateral spasticity
D. Multifocal myoclonus

Answer: Right-sided hemiplegia

1. A 51-year-old man is brought to the emergency department because of confusion for 2 hours.

2. His wife reports that he fell and hit his head while changing a ceiling light the previous evening.

6. His respirations are 8/min and irregular.

8. The right pupil is dilated and fixed.

9. The left pupil is round and reactive to light.

10. There is extension of the extremities to painful stimuli.

11. He is intubated and mechanically ventilated.

13. A noncontrast CT scan of the brain shows herniation of the right medial temporal lobe.


Question: In addition to her current therapy, what additional steps should be taken during the management of this child's UTI?

Context: A 1-year-old female presents to the emergency department with 2 days of fever up to 103ºF.

Context: During the course of her work-up, a urine culture reveals gram negative rods and a urinary tract infection (UTI) is diagnosed.

Context: She is placed on ceftriaxone and quickly defervesces.

Context: coli, without any concerning resistance patterns and was susceptible to ceftriaxone.

Context: This is her first UTI and there is no family history of renal abnormalities or vesicourethral reflux.

Choices:
A. Prophylactic antibiotic therapy to prevent future UTIs
B. Voiding cystourethrogram
C. Renal bladder ultrasound
D. Repeat urine culture

Answer: Renal bladder ultrasound

1. A 1-year-old female presents to the emergency department.

3. A urine culture reveals gram negative rods.

7. Follow-up of the urine culture reveals the causal bacteria was E. coli.

8. There are no concerning resistance patterns.

9. The bacteria is susceptible to ceftriaxone.

11. There is no family history of renal abnormalities.

12. There is no family history of vesicourethral reflux.


Question: Which of the following mechanisms was most likely involved in the development of this patient's symptoms?

Context: A 22-year-old woman presents to her primary care physician because she has been having severe pruritus on her left leg.

Context: She says the symptoms started 1 week ago after she went on a hiking trip with her friends.

Context: She wore shorts during the hike and felt as if something brushed her skin on the front of her leg just below the knee.

Context: She has no past medical history and no family history of autoimmune diseases.

Choices:
A. Activation of cell surface receptors by antibodies
B. Cross-linking of IgE antibodies
C. Cytotoxicity due to T-cells
D. Immune complex deposition

Answer: Cytotoxicity due to T-cells

1. A 22-year-old woman presents to her primary care physician.

2. She has been having severe pruritus on her left leg.

4. She went on a hiking trip with her friends.

6. She felt as if something brushed her skin on the front of her leg just below the knee.

8. She has no family history of autoimmune diseases.

9. On physical exam, she has red pruritic papules and vesicles on her left leg.


Question: Which of the following is the trinucleotide repeat linked to this patient’s most likely condition?

Context: An adopted 7-year-old boy is brought to a pediatrician with a history of progressive muscular weakness, intellectual impairment, and speech problems.

Context: The adoptive parents say that the patient was normal at birth, but as he grew older, his muscular weakness increased.

Context: Physical examination reveals the wasting of muscles of the dorsal forearm and the anterior compartment of the lower legs.

Context: Thenar and hypothenar eminences are also flattened.

Context: However, deep tendon reflexes are 2+ bilaterally.

Context: His face has an atypical appearance with thin cheeks and temporal wasting.

Context: When he was asked to make a tight fist and open his hands quickly, he could not open them immediately, and relaxation of the contracted muscles was very slow.

Choices:
A. CTG
B. CGG
C. GAA
D. CGT

Answer: CTG

1. An adopted 7-year-old boy is brought to a pediatrician.

2. The patient has a history of progressive muscular weakness, intellectual impairment, and speech problems.

3. The adoptive parents say the patient was normal at birth.

4. As the patient grew older, his muscular weakness increased.

5. Physical examination reveals wasting of muscles of the dorsal forearm and the anterior compartment of the lower legs.

6. Thenar and hypothenar eminences are flattened.

7. Deep tendon reflexes are 2+ bilaterally.

8. The patient's face has an atypical appearance with thin cheeks and temporal wasting.

9. When asked to make a tight fist and open his hands quickly, the patient could not open them immediately.

10. Relaxation of the contracted muscles was very slow.

11. The pediatrician suspects genetic muscular dystrophy.


Question: Which of the following is most consistent with this physical exam finding?

Context: She says that she has been experiencing some mild shortness of breath, but otherwise has no medical complaints.

Context: Her past medical history is significant for allergies and asthma as a child, but she is not currently taking any medications or supplements.

Context: She does not smoke and drinks about 2 glasses of wine per week as a social activity.

Choices:
A. Asthma recurrence
B. Atrial septal defect
C. Left bundle branch block
D. Pulmonary stenosis

Answer: Left bundle branch block

1. A 36-year-old woman presents to her primary care physician for her yearly physical exam.

2. She says that she has been experiencing some mild shortness of breath.

4. Her past medical history is significant for allergies and asthma as a child.

5. She is not currently taking any medications or supplements.

7. She drinks about 2 glasses of wine per week as a social activity.

8. On physical exam she is asked to take deep breaths during cardiac auscultation.

9. The physician notices that the splitting of S2 decreases during inspiration.


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

Context: A 47-year-old woman presents to the emergency department with calf pain and swelling that has persisted for the past 24 hours.

Context: She recently had an elective cholecystectomy performed 3 days ago that was complicated intraoperatively by bleeding requiring a transfusion of 1 unit of packed red blood cells.

Context: The patient is otherwise healthy, and her vitals are within normal limits.

Choices:
A. CT angiogram of the chest
B. Heparin
C. Inferior vena cava filter
D. Warfarin

Answer: Heparin

1. A 47-year-old woman presents to the emergency department.

2. She has calf pain and swelling that has persisted for the past 24 hours.

3. She recently had an elective cholecystectomy performed 3 days ago.

4. The cholecystectomy was complicated intraoperatively by bleeding.

5. The bleeding required a transfusion of 1 unit of packed red blood cells.

8. Physical exam is notable for an enlarged and tender right calf.

9. Ultrasound with doppler reveals non-compressible veins of the affected leg.


Question: Which of the following options describe the most likely mechanism underlying the patient’s seizure?

Context: A 24-year-old primigravida is admitted to the hospital at 36 weeks gestation with a headache and blurred vision.

Context: The vital signs are as follows: blood pressure, 170/95 mm Hg; heart rate, 88/min; respiratory rate, 15/min; and temperature, 36.6℃ (97.9℉).

Context: Meningeal signs are negative.

Context: The dipstick test shows 1+ proteinuria.

Context: While the blood is being drawn, the patient has a generalized tonic-clonic seizure.

Choices:
A. Increase in the extracellular sodium concentration
B. Failure of cerebral vasoregulation
C. Inhibition of brain GABA-signaling
D. Increased activation of NMDA receptors

Answer: Failure of cerebral vasoregulation

1. A 24-year-old primigravida is admitted to the hospital at 36 weeks gestation.

2. The patient has a headache and blurred vision.

3. The patient's blood pressure is 170/95 mm Hg.

5. The patient's respiratory rate is 15/min.

6. The patient's temperature is 36.6℃ (97.9℉).

7. The physical examination is significant for pitting edema of the lower extremity.

9. The ophthalmoscopic exam shows vascular narrowing and a cotton-like fundal exudate.

10. The dipstick test shows 1+ proteinuria.

11. The patient has a generalized tonic-clonic seizure while the blood is being drawn.

Maternal
Vascular Neurology
Maternal–Fetal Medicine


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

Context: A 12-month-old girl is brought in by her mother to the pediatrician for the first time since her 6-month checkup.

Context: The mother states that her daughter had been doing fine, but the parents are now concerned that their daughter is still not able to stand up or speak.

Context: On exam, the patient has a temperature of 98.5°F (36.9°C), pulse is 96/min, respirations are 20/min, and blood pressure is 100/80 mmHg.

Context: She plays by herself and is making babbling noises but does not respond to her own name.

Context: A previous clinic note documents typical development at her 6-month visit and mentioned that the patient was sitting unsupported at that time.

Choices:
A. Language disorder
B. Rett syndrome
C. Fragile X syndrome
D. Trisomy 21

Answer: Rett syndrome

1. A 12-month-old girl is brought in by her mother to the pediatrician.

2. The mother states that her daughter had been doing fine.

3. The parents are now concerned that their daughter is still not able to stand up or speak.

4. The patient has a temperature of 98.5°F (36.9°C).

6. The patient's respirations are 20/min.

7. The patient's blood pressure is 100/80 mmHg.

8. The child appears to have difficulty supporting herself while sitting.

9. The patient has no other abnormal physical findings.

10. She plays by herself and is making babbling noises.

11. The patient does not respond to her own name.

12. She appears to have some purposeless motions.

13. A previous clinic note documents typical development at her 6-month visit.

14. The patient was sitting unsupported at her 6-month visit.


Question: In addition to adequate hydration, the patient is most likely to benefit from which of the following?

Context: A 55-year-old man comes to the emergency department because of cramps and left-sided flank pain, nausea, and urinary frequency for 3 hours.

Context: His temperature is 37.2°C (99.0°F), pulse is 107/min, and blood pressure is 145/80 mm Hg.

Context: Abdominal ultrasound shows a 4-mm stone in the distal left ureter and a scatter of small stones in the left renal pelvis.

Choices:
A. Probenecid
B. Potassium citrate
C. High-protein diet
D. Hydrochlorothiazide

Answer: Potassium citrate

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

2. He has cramps and left-sided flank pain, nausea, and urinary frequency for 3 hours.

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

4. He drinks 2–3 alcoholic beverages daily.

8. Examination of the back shows left costovertebral angle tenderness.

9. An x-ray of the abdomen shows no abnormalities.

10. Abdominal ultrasound shows a 4-mm stone in the distal left ureter.

11. Abdominal ultrasound shows a scatter of small stones in the left renal pelvis.

12. Urinalysis shows RBCs and needle-shaped crystals, but no WBCs.

13. Pain medication and intravenous fluids are administered.


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

Context: A 4-year-old boy is brought to the physician because of a 1-month history of generalized fatigue.

Context: During the past week, he has also had fever and severe leg pain that keeps him awake at night.

Context: His liver is palpated 4 cm below the right costal margin and the spleen is palpated 3 cm below the left costal margin.

Context: His hemoglobin concentration is 10.2 g/dL, leukocyte count is 64,500/mm3, and platelet count is 29,000/mm3.

Context: A bone marrow aspirate predominantly shows immature cells that stain positive for CD10, CD19, and TdT.

Choices:
A. Idiopathic thrombocytopenic purpura
B. Acute myeloid leukemia
C. Acute lymphoblastic leukemia
D. Hodgkin lymphoma

Answer: Acute lymphoblastic leukemia

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

2. He has a 1-month history of generalized fatigue.

3. During the past week, he has had fever and severe leg pain.

4. The leg pain keeps him awake at night.

5. Examination shows cervical and axillary lymphadenopathy.

6. His liver is palpated 4 cm below the right costal margin.

7. His spleen is palpated 3 cm below the left costal margin.

8. His hemoglobin concentration is 10.2 g/dL.

11. A bone marrow aspirate predominantly shows immature cells.

12. The immature cells stain positive for CD10.

13. The immature cells stain positive for CD19.

14. The immature cells stain positive for TdT.


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

Context: A 41-year-old man comes to the physician because of a 10-day history of generalized weakness.

Context: He has also had headaches and night sweats and is a known user of illicit intravenous drugs.

Context: His temperature is 39.1°C (102.4°F), pulse is 110/min, respirations are 17/min, and blood pressure is 127/78 mm Hg.

Context: Laboratory studies show a leukocyte count of 13,900/mm3 and an erythrocyte sedimentation rate of 58 mm/h.

Choices:
A. Hematuria
B. Rupture of nail-bed capillaries
C. Pulmonary embolism
D. Painful nodules on pads of the fingers

Answer: Pulmonary embolism

1. A 41-year-old man comes to the physician.

2. He has a 10-day history of generalized weakness.

3. He has also had headaches and night sweats.

4. He is a known user of illicit intravenous drugs.

9. There are several track marks on his forearms.

10. A holosystolic murmur that increases on inspiration is heard along the left sternal border.

11. Laboratory studies show a leukocyte count of 13,900/mm3.

12. Laboratory studies show an erythrocyte sedimentation rate of 58 mm/h.