Question: Which of the following vaccines should be administered for this patient at this visit?

Context: He is being breastfed exclusively and has 3–4 wet diapers a day.

Context: On physical exam, the vital signs include: temperature 37.0°C (98.6°F), blood pressure 85/45 mm Hg, pulse 140/min, and respiratory rate is 31/min.

Choices:
A. RV, Tdap, PCV, Hib
B. RV, DTaP, PCV, Hib, IPV
C. Hep B, DTaP, Influenza
D. RV, Hep B, Hep A

Answer: RV, DTaP, PCV, Hib, IPV

1. A 6-month-old boy is brought to her pediatrician for a checkup and vaccines.

2. He was born at 39 weeks gestation via spontaneous vaginal delivery.

3. He is meeting all the developmental milestones.

4. His prenatal history was complicated with maternal diabetes.

7. On physical exam, the vital signs include: temperature 37.0°C (98.6°F).

8. On physical exam, the vital signs include: blood pressure 85/45 mm Hg.

9. On physical exam, the vital signs include: pulse 140/min.

10. On physical exam, the vital signs include: respiratory rate is 31/min.

11. On physical examination, the patient is alert and responsive.

12. Height, weight, and head circumference are above the 90th percentile.


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

Context: A 23-year-old woman is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision where she was the unrestrained driver.

Context: On arrival, she appears lethargic.

Context: She is unable to provide a history.

Context: Her pulse is 133/min, respirations are 23/min, and blood pressure is 90/60 mm Hg.

Context: Examination shows a 2-cm laceration over the right upper extremity.

Context: The pupils are equal and reactive to light.

Context: There are multiple bruises over the chest and abdomen.

Context: The lungs are clear to auscultation.

Context: Cardiac examination shows no abnormalities.

Context: The abdomen is soft and not distended.

Context: Neurologic examination shows no focal findings.

Context: 0.9% saline infusion is begun.

Choices:
A. Observation
B. Exploratory laparotomy
C. CT scan of the abdomen
D. Ultrasonography

Answer: Ultrasonography

1. A 23-year-old woman was brought to the emergency department.

2. She was involved in a high-speed motor vehicle collision.

4. She was found thrown across the dashboard of the car.

10. Examination showed a 2-cm laceration over the right upper extremity.

11. The pupils were equal and reactive to light.

12. There were multiple bruises over the chest and abdomen.

13. The lungs were clear to auscultation.

14. Cardiac examination showed no abnormalities.

15. The abdomen was soft and not distended.

16. Neurologic examination showed no focal findings.

General Surgery
General Emergency Medicine


Question: Which of the following drugs is the most likely cause of this patient's worsening renal function?

Context: Three days after starting a new medication, a 66-year-old woman with resistant hypertension and hyperlipidemia comes to the doctor because of decreased urination.

Context: She denies dysuria, fevers, or chills.

Context: Blood pressure is 133/67 mm Hg.

Context: Compared to measurements from one week ago, the glomerular filtration rate is markedly decreased and plasma renin activity is elevated.

Context: A duplex ultrasound of the kidneys shows increased systolic flow velocity in both renal arteries when compared to the aorta.

Choices:
A. Furosemide
B. Spironolactone
C. Enalapril
D. Atenolol

Answer: Enalapril

1. A 66-year-old woman with resistant hypertension and hyperlipidemia comes to the doctor three days after starting a new medication.

2. She denies dysuria, fevers, or chills.

4. Physical examination shows no abnormalities.

5. Glomerular filtration rate is markedly decreased compared to measurements from one week ago.

6. Plasma renin activity is elevated compared to measurements from one week ago.

7. Duplex ultrasound of the kidneys shows increased systolic flow velocity in both renal arteries when compared to the aorta.


Question: Inhibition of which of the following steps of HIV infection is the most likely therapeutic effect of this experimental drug?

Context: An investigator is conducting an experiment to develop a new drug against HIV infection.

Context: HIV-infected and uninfected CD4 T-cell lines are mixed in-vitro with a chemically modified synthetic peptide triazole complex.

Context: The complex is found to have a high binding affinity to the gp120 protein, irreversibly inhibiting its function and reducing CD4 T cell infection.

Choices:
A. Incorporation of viral genome into host cell DNA
B. Transcription of the viral genome
C. Fusion and entry into CD4 T-cells
D. Attachment to host CD4 T-cells

Answer: Attachment to host CD4 T-cells

1. An investigator is conducting an experiment.

2. The experiment is to develop a new drug against HIV infection.

3. HIV-infected and uninfected CD4 T-cell lines are mixed in-vitro.

4. The mixture contains a chemically modified synthetic peptide triazole complex.

5. The complex has a high binding affinity to the gp120 protein.

6. The complex irreversibly inhibits the function of the gp120 protein.

7. The complex reduces CD4 T cell infection.

Infectious Disease
General Infectious Disease


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

Context: A 35-year-old man presents to the physician for a medical evaluation necessary before joining the armed force services.

Context: His vital signs are stable and his systemic examination is within normal limits.

Context: His laboratory investigations are within normal limits but his chest radiogram shows a solitary pulmonary nodule (SPN), size 9 mm (0.35 in) in diameter, in the middle zone of his right lung.

Choices:
A. No further workup
B. Thin-section computed tomography (CT) scan
C. Positron emission tomography (PET) scan
D. Follow-up after 12 months; if unchanged, no further follow-up

Answer: No further workup

1. A 35-year-old man presents to the physician for a medical evaluation.

2. He is a healthy man with no history of smoking or substance abuse.

3. His past medical history is not significant.

5. His systemic examination is within normal limits.

6. Examination of his respiratory system, including auscultation of his chest, does not reveal any abnormality.

7. His laboratory investigations are within normal limits.

8. His chest radiogram shows a solitary pulmonary nodule (SPN), size 9 mm (0.35 in) in diameter, in the middle zone of his right lung.

9. The physician compares the radiogram with a radiogram obtained 3 years back for pre-employment medical evaluation.

10. The physician notes that a similar SPN with the same size was present in the previous radiogram at the same location.

Thin
Diagnostic Radiology
Neuroradiology


Question: Which of the following would most likely be seen on a peripheral blood smear in this patient?

Context: A 32-year-old man presents to his primary care physician because he has been experiencing fatigue and back pain over the last 2 days.

Context: He suffered from malaria after going on vacation 5 years ago and recently started taking a medication to deal with a latent form of this infection.

Context: He started developing these symptoms 36 hours after taking the first dose and noticed his urine became progressively darker during that time.

Context: Labs are obtained with the following results: |  | Hematocrit: 32% (Normal: 41%-53%) | Hemoglobin: 10.6 g/dL (Normal: 13.5-17.5 g/dL) | Leukocyte count: 8500/mm3 (Normal: 4500-11,000/mm3) | Platelet count: 273,000/mm3 (Normal: 150,000-400,000/mm3) |  | .

Choices:
A. Helmet-shaped red blood cells
B. Small round inclusions of denatured hemoglobin
C. Small round inclusions of nuclear remnants
D. Target-shaped red blood cells

Answer: Small round inclusions of denatured hemoglobin

1. A 32-year-old man presents to his primary care physician.

2. He has been experiencing fatigue and back pain over the last 2 days.

3. He suffered from malaria after going on vacation 5 years ago.

4. He recently started taking a medication to deal with a latent form of this infection.

5. He started developing these symptoms 36 hours after taking the first dose.

6. He noticed his urine became progressively darker during that time.

7. On physical exam he is found to have scleral icterus and skin jaundice.

8. Labs are obtained with the following results: Hematocrit: 32% (Normal: 41%-53%).

9. Labs are obtained with the following results: Hemoglobin: 10.6 g/dL (Normal: 13.5-17.5 g/dL).

10. Labs are obtained with the following results: Leukocyte count: 8500/mm3 (Normal: 4500-11,000/mm3).

11. Labs are obtained with the following results: Platelet count: 273,000/mm3 (Normal: 150,000-400,000/mm3).


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

Context: Her temperature is 37.0°C (98.6°F), the blood pressure is 110/70 mm Hg, the pulse is 78/min, and the respirations are 12/min.

Context: Laboratory results and chest X-ray is shown below: | Serum chemistry |   Sodium 145 mEq/L |   Potassium 4.1 mEq/L |   Chloride 98 mEq/L |   Calcium 13 mEq/L |   Bicarbonate 20 mEq/L |   Blood urea nitrogen 8 mEq/L |   Creatinine 0.7 mEq/L |   Glucose 96 mEq/L | Urine toxicology Negative | .

Choices:
A. Increased ACE levels
B. Increased ADH levels
C. Presence of anti-dsDNA antibodies
D. Caseating granulomas in lung tissue biopsy

Answer: Increased ACE levels

1. A 30-year-old woman presents to the office for routine examination.

2. She has no medical complaints except for mild burning sensation in her eyes and an occasional dry cough.

3. She denies fever, headache, or any recent illnesses.

4. Past medical history is unremarkable and she takes no medications.

5. She does not smoke cigarettes or drinks alcohol.

10. Physical examination is normal except for bilateral conjunctival injection.

11. Laboratory results show serum sodium 145 mEq/L.

12. Laboratory results show serum potassium 4.1 mEq/L.

13. Laboratory results show serum chloride 98 mEq/L.

14. Laboratory results show serum calcium 13 mEq/L.

15. Laboratory results show serum bicarbonate 20 mEq/L.

16. Laboratory results show serum blood urea nitrogen 8 mEq/L.

17. Laboratory results show serum creatinine 0.7 mEq/L.

18. Laboratory results show serum glucose 96 mEq/L.


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

Context: A 60-year-old man presents to a physician with the complaint of a persistent cough for a year.

Context: He has visited multiple physicians to date, but there has been no conclusive diagnosis.

Context: He has been a smoker since the age of 30.

Context: There is no history of significant expectoration, blood in sputum, wheezing, or breathing difficulty, but he has lost approx.

Context: On physical examination, his vital signs are stable, and examination of the chest reveals decreased breath sounds over the left infrascapular region.

Context: His chest radiogram suggests atelectasis in the left lower lobe.

Context: A detailed evaluation confirms a diagnosis of non-small cell lung carcinoma involving the left main bronchus, which is 4 cm in size and is located 3.8 cm (1.5 in) from the carina.

Context: Ipsilateral hilar lymph nodes, ipsilateral subcarinal lymph nodes, and ipsilateral scalene lymph nodes are involved in metastasis with no distant metastasis.

Context: Investigations also suggest that the patient does not have any comorbidity that contraindicates any anti-cancer treatment modality and that his performance status is good.

Choices:
A. Surgery followed by adjuvant chemotherapy
B. Chemotherapy only
C. Concurrent chemoradiotherapy
D. Radiation therapy only

Answer: Concurrent chemoradiotherapy

2. Patient has had a persistent cough for one year.

3. Patient has visited multiple physicians with no conclusive diagnosis.

4. Patient has been a smoker since the age of 30.

5. Patient has no history of significant expectoration, blood in sputum, wheezing, or breathing difficulty.

6. Patient has lost approx. 6.35 kg (14 lb) of weight over the last 9 months.

7. Patient's vital signs are stable on physical examination.

8. Examination of the chest reveals decreased breath sounds over the left infrascapular region.

9. Chest radiogram suggests atelectasis in the left lower lobe.

10. Detailed evaluation confirms a diagnosis of non-small cell lung carcinoma involving the left main bronchus.

11. Carcinoma is 4 cm in size and is located 3.8 cm (1.5 in) from the carina.

12. Ipsilateral hilar lymph nodes, ipsilateral subcarinal lymph nodes, and ipsilateral scalene lymph nodes are involved in metastasis.

14. Patient does not have any comorbidity that contraindicates any anti-cancer treatment modality.

15. Patient's performance status is good.

Pulmonary Disease
General Pulmonary Disease


Question: Processing of the sample with which of the following methods is most likely to confirm the diagnosis?

Context: A previously healthy 25-year-old woman comes to the physician because of a 3-week history of fever, recurrent headaches, and anorexia.

Context: Her temperature is 39.3°C (102.8°F).

Context: Examination shows a swelling in the left periorbital region and axillary, cervical, and inguinal lymphadenopathy.

Context: A blood sample is obtained.

Choices:
A. Staining with India ink
B. Staining with Giemsa dye
C. Staining of glycogen
D. Staining with silver

Answer: Staining with Giemsa dye

1. A 25-year-old woman came to the physician.

2. She had a 3-week history of fever, recurrent headaches, and anorexia.

3. One month ago, she returned from a camping trip in Chile.

5. Examination showed a swelling in the left periorbital region.

6. Examination also showed axillary, cervical, and inguinal lymphadenopathy.


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

Context: His temperature is 98.5°F (36.9°C), blood pressure is 168/111 mmHg, pulse is 95/min, respirations are 14/min, and oxygen saturation is 99% on room air.

Context: An initial ECG is unremarkable.

Context: Laboratory values are ordered as seen below. |  | Hemoglobin: 15 g/dL | Hematocrit: 45% | Leukocyte count: 6,300/mm^3 with normal differential | Platelet count: 222,000/mm^3 |  | Serum: | Na+: 141 mEq/L | Cl-: 103 mEq/L | K+: 4.5 mEq/L | HCO3-: 24 mEq/L | BUN: 42 mg/dL | Glucose: 129 mg/dL | Creatinine: 1.9 mg/dL | Ca2+: 10.2 mg/dL |  | .

Choices:
A. CT angiogram of the chest
B. D-dimer
C. Esmolol
D. Transesophageal echocardiography

Answer: Transesophageal echocardiography

1. A 57-year-old man presents to the emergency department with chest and back pain.

2. He states that his symptoms started suddenly 1 hour ago and have persisted.

3. He has a past medical history of hypertension and diabetes.

8. His oxygen saturation is 99% on room air.

9. Physical exam is notable for an uncomfortable man but is otherwise within normal limits.

13. His leukocyte count is 6,300/mm^3 with normal differential.


Question: Which of the following is the most appropriate course of action?

Context: His mother received regular prenatal care and the child was born at home under the guidance of a midwife and a doula.

Context: The child appears well.

Context: The parents tell you they do not plan to have their child receive any vaccines.

Choices:
A. Call child protective services
B. Refuse to continue to care for the child
C. Give any scheduled vaccines during that visit against the will of the parents
D. Document the visit, specifically the detailing of risks and benefits and the parents' refusal of treatment

Answer: Document the visit, specifically the detailing of risks and benefits and the parents' refusal of treatment

1. A 2-week-old infant is brought to the pediatrician for the first time by his parents.

2. His mother received regular prenatal care.

3. The child was born at home under the guidance of a midwife and a doula.

5. The parents tell the pediatrician they do not plan to have their child receive any vaccines.

6. After a discussion regarding the risks and benefits of vaccines, the parents are still adamant in their wishes to forgo.


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

Context: A 15-year-old boy is brought in to his pediatrician's office by his step-mother for uncontrollable behavior.

Context: She reports he has an extensive history of detention for outbursts in class.

Context: He recently got expelled from school for fist fighting.

Context: At home, he punches his younger brother when he’s angry.

Context: The family had to give their cat away to a neighbor because the patient tried to set it on fire.

Context: The patient’s medical history is significant for bed-wetting until he was 11.

Context: His father has adult attention deficit disorder.

Context: The patient states that he thinks school is a “joke.” He denies having close friends and says “the kids in my town are stupid anyway.” He calmly describes how he would like to burn down all their houses.

Context: He admits to trying alcohol and cocaine but denies any other illicit drugs.

Choices:
A. Antisocial personality disorder
B. Attention deficient hyperactivity disorder
C. Conduct disorder
D. Substance abuse

Answer: Conduct disorder

2. Patient is brought in by step-mother.

3. Patient has history of detention for outbursts in class.

4. Patient recently expelled from school for fist fighting.

5. Patient punches younger brother when angry.

6. Family had to give cat away to neighbor because patient tried to set it on fire.

7. Patient had bed-wetting until age 11.

8. Patient's father has adult attention deficit disorder.

10. Patient denies having close friends.

11. Patient says "the kids in my town are stupid anyway".

12. Patient calmly describes wanting to burn down all their houses.

13. Patient admits to trying alcohol and cocaine.

14. Patient denies any other illicit drugs.


Question: Methimazole interferes with the function of which of the following proteins?

Context: A 30-year-old female complains of heat intolerance, excessive sweating, and recent unintentional weight loss.

Context: She denies alcohol, tobacco, and other drug use and does not take any medications.

Context: You elect to manage the patient’s condition pharmacologically with methimazole.

Choices:
A. Sex-hormone binding globulin
B. Thyroid peroxidase
C. 5’-deiodinase
D. Sodium/iodide symporter

Answer: Thyroid peroxidase

2. Patient complains of heat intolerance, excessive sweating, and recent unintentional weight loss.

3. Patient denies alcohol, tobacco, and other drug use.

4. Patient does not take any medications.

5. Laboratory analysis reveals elevated serum T4 and decreased serum TSH.

6. Management plan is to use methimazole pharmacologically.


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

Context: A 40-year-old woman presents to her primary care physician with complaints of worsening muscle aches and diffuse weakness over the past several months.

Context: She states that she now has difficulty climbing stairs and extending her neck.

Context: Ultimately, she became more concerned when she began having trouble swallowing and experienced shortness of breath last night which has resolved.

Context: Her temperature is 98.5°F (36.9°C), blood pressure is 120/84 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air.

Context: The patient is tolerating oral secretions and has no difficulty swallowing or protecting her airway currently.

Choices:
A. Intravenous immunoglobulin
B. Methotrexate
C. Naproxen
D. Prednisone

Answer: Prednisone

2. Patient has worsening muscle aches and diffuse weakness over the past several months.

3. Patient has difficulty climbing stairs and extending her neck.

4. Patient had trouble swallowing and experienced shortness of breath last night which has resolved.

9. Oxygen saturation is 98% on room air.

10. Physical exam is notable for 2/5 strength of the proximal muscles of the upper and lower extremities.

11. Dermatologic, cardiac, and pulmonary exam are unremarkable.

12. Patient is tolerating oral secretions and has no difficulty swallowing or protecting her airway currently.

13. Laboratory studies are notable for an elevated CRP and aldolase.

General Rheumatology
Neuromuscular Medicine


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

Context: A 50-year-old woman visits her primary care practitioner with the complaints of generalized weakness, lightheadedness, and fatigability for the past month.

Context: She also claims to have epigastric pain, heartburn, and a sensation of a lump in her throat.

Context: Her family history is irrelevant, but her medical history is significant for a Pap smear that reported atypical squamous cells of undetermined significance (ASCUS), which was followed up with a cervical biopsy negative for malignancy.

Context: She occasionally takes over-the-counter medicines to cope with the heartburn, and recently her hemoglobin was found to be 11 g/dL, for which she received iron and vitamin B12 supplementation.

Context: Physical examination is unremarkable, except for pale skin, and a pulse of 120/min.

Choices:
A. Proton pump inhibitor
B. Anti-H2 agent
C. Endoscopy
D. Diet and lifestyle recommendations

Answer: Endoscopy

1. A 50-year-old woman visited her primary care practitioner.

2. She had generalized weakness, lightheadedness, and fatigability for the past month.

3. She also had epigastric pain, heartburn, and a sensation of a lump in her throat.

5. Her medical history is significant for a Pap smear that reported ASCUS.

6. This was followed up with a cervical biopsy negative for malignancy.

7. She occasionally takes over-the-counter medicines to cope with the heartburn.

8. Her hemoglobin was found to be 11 g/dL.

9. She received iron and vitamin B12 supplementation.

10. Physical examination is unremarkable, except for pale skin.

Endocrinology, Diabetes, and Metabolism
General Internal Medicine
Gastroenterology


Question: Which of the following tests is indicated at this time?

Context: According to his prior medical records, he last saw a physician 4 years ago and had no significant medical problems at that time.

Context: Records also show a normal EKG and normal colonoscopy results at that time.

Context: The patient reports feeling well overall, but review of systems is positive for 1 year of mild cough productive of clear sputum and 2 years of increased urinary frequency.

Context: He denies illicit drug use but has been drinking approximately 1-2 beers per night and smoking 1 pack of cigarettes per day since age 20.

Context: Physical exam is unremarkable.

Choices:
A. Abdominal ultrasound
B. Bladder ultrasound
C. Serum prostate specific antigen (PSA) testing
D. Sputum culture

Answer: Abdominal ultrasound

1. A 67-year-old man presents to a primary care clinic to establish care after moving from another state.

2. He last saw a physician 4 years ago and had no significant medical problems at that time.

3. Records show a normal EKG and normal colonoscopy results at that time.

4. The patient reports feeling well overall.

5. Review of systems is positive for 1 year of mild cough productive of clear sputum.

6. Review of systems is positive for 2 years of increased urinary frequency.

7. He denies fever, chills, dyspnea, dysuria or hematuria.

9. He has been drinking approximately 1-2 beers per night since age 20.

10. He has been smoking 1 pack of cigarettes per day since age 20.


Question: This drug is most likely to result in which of the following?

Context: Laboratory studies show a platelet count of 195,000/mm3, a partial thromboplastin time of 44 sec, and a prothrombin time of 12 sec.

Choices:
A. Decreased cAMP in renal tubular cells
B. Increased tubular fluid osmolarity in the loop of Henle
C. Increased permeability to urea in the collecting duct
D. Increased bleeding time

Answer: Increased permeability to urea in the collecting duct

1. An 8-year-old boy is brought to the physician for evaluation of an excessive bleeding after undergoing a dental procedure.

2. Laboratory studies show a platelet count of 195,000/mm3.

3. Laboratory studies show a partial thromboplastin time of 44 sec.

4. Laboratory studies show a prothrombin time of 12 sec.

5. A one-stage clotting assay shows a decreased factor VIII.

6. Therapy with a drug that acts on endothelial cells is initiated.


Question: Assuming normal development, which of the following milestones would be expected in a patient this age?

Context: She is at the 55th percentile for height and at the 40th percentile for weight.

Context: Vital signs are within normal limits.

Context: She is able to follow simple commands, such as “close your eyes, then stick out your tongue,” but she is unable to follow 3-step commands.

Context: She knows approximately 75 words, and half of her speech is understandable.

Context: She can say 2-word phrases, and she is able to name many parts of the body.

Choices:
A. Separates easily from parents
B. Kicks a ball
C. Pedals a tricycle
D. Hops on one foot

Answer: Kicks a ball

1. A young girl is brought to the physician by her mother for a well-child examination.

2. She is at the 55th percentile for height.

3. She is at the 40th percentile for weight.

4. Vital signs are within normal limits.

5. Physical examination shows no abnormalities.

6. She is able to follow simple commands.

7. She is unable to follow 3-step commands.

9. Half of her speech is understandable.

11. She is able to name many parts of the body.


Question: Which of the following characteristics is generally true about this measurement?"

Context: Results are shown: | Patient Body weight (kg) | 1 7.0 | 2 6.0 | 3 6.1 | 4 6.8 | 5 7.2 | 6 6.4 | 7 6.2 | 8 6.8 | 9 6.5 | 10 7.3 | 11 6.3 | 12 8.5 | 13 6.9 | 14 6.6 | 15 5.2 | One of the computed measures of central tendency is 6.8 kg.

Choices:
A. It is not applicable for qualitative data analysis.
B. It is resistant to outliers.
C. Its value only occurs once in a data set.
D. It is useful to assess the extent of data variability.

Answer: It is resistant to outliers.

1. An investigator is studying the association between exclusive breastfeeding and body weight in infants.

2. The body weights of 15 exclusively breastfed infants at the age of 6 months are measured.

3. Patient 1 has a body weight of 7.0 kg.

4. Patient 2 has a body weight of 6.0 kg.

5. Patient 3 has a body weight of 6.1 kg.

6. Patient 4 has a body weight of 6.8 kg.

7. Patient 5 has a body weight of 7.2 kg.

8. Patient 6 has a body weight of 6.4 kg.

9. Patient 7 has a body weight of 6.2 kg.

10. Patient 8 has a body weight of 6.8 kg.

11. Patient 9 has a body weight of 6.5 kg.

12. Patient 10 has a body weight of 7.3 kg.

13. Patient 11 has a body weight of 6.3 kg.

14. Patient 12 has a body weight of 8.5 kg.

15. Patient 13 has a body weight of 6.9 kg.

16. Patient 14 has a body weight of 6.6 kg.

17. Patient 15 has a body weight of 5.2 kg.

18. One of the computed measures of central tendency is 6.8 kg.


Question: Additional questioning would most likely reveal which of the following additional features about this patient’s current symptoms?

Context: A 32-year-old man presents to his primary care provider with right leg weakness and numbness.

Context: He reports a 2-day history of “clumsiness” in his right lower extremity after playing in his company’s annual weekend-long charity baseball tournament.

Context: He says a similar episode happened 1 year ago during the same tournament.

Context: He has a history of major depressive disorder and right distal radius fracture status post-closed reduction and casting after falling 2 years ago.

Context: He takes fluoxetine.

Context: He also reports that he several years ago he had an isolated episode of decreased vision and inability to move his right eye that resolved on its own.

Context: He has a 15-pack-year smoking history and drinks 3-4 beers per week.

Context: His temperature is 98.4°F (36.9°C), blood pressure is 115/65 mmHg, pulse is 85/min, and respirations are 18/min.

Context: On exam, hip flexion, knee extension, and ankle dorsiflexion are all 3/5 on his right and 5/5 on his left.

Context: Right Achilles and patellar reflexes are 1+ on the right and 2+ on the left.

Context: He has decreased sensation to light touch throughout the right leg especially below the knee.

Choices:
A. Concomitant hyperreflexia
B. Symptom improvement in the heat
C. Symptom exacerbation in the heat
D. Symptom exacerbation with repetitive muscle contractions

Answer: Symptom exacerbation in the heat

2. Patient presents with right leg weakness and numbness.

3. Patient has a 2-day history of “clumsiness” in his right lower extremity after playing in his company’s annual weekend-long charity baseball tournament.

4. Patient had a similar episode 1 year ago during the same tournament.

5. Patient has a history of major depressive disorder.

6. Patient has a history of right distal radius fracture status post-closed reduction and casting after falling 2 years ago.

8. Patient had an isolated episode of decreased vision and inability to move his right eye several years ago that resolved on its own.

9. Patient has a 15-pack-year smoking history.

11. Patient's temperature is 98.4°F (36.9°C).

12. Patient's blood pressure is 115/65 mmHg.

15. Patient's hip flexion, knee extension, and ankle dorsiflexion are all 3/5 on his right and 5/5 on his left.

16. Patient's right Achilles and patellar reflexes are 1+ on the right and 2+ on the left.

17. Patient has decreased sensation to light touch throughout the right leg especially below the knee.

Neurology with Special Qualification in Child Neurology


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

Context: A 56-year-old man comes to the physician because of throat pain and increasing difficulty swallowing food for the past 5 months.

Context: He has also had episodic left ear pain for the past 3 months.

Context: He has hypertension.

Context: His only medication is amlodipine.

Context: His father died of laryngeal cancer at the age of 55 years.

Context: He has smoked one pack of cigarettes daily for 36 years.

Context: He drinks 2–3 beers daily.

Context: Vital signs are within normal limits.

Choices:
A. Nasopharyngoscopy
B. Panendoscopy
C. Barium swallow
D.
Laryngoscopy
"

Answer: Panendoscopy

2. Patient has had throat pain and difficulty swallowing food for the past 5 months.

3. Patient has had episodic left ear pain for the past 3 months.

5. Patient's only medication is amlodipine.

6. Patient's father died of laryngeal cancer at the age of 55 years.

7. Patient has smoked one pack of cigarettes daily for 36 years.

9. Vital signs are within normal limits.

10. Examination shows left cervical lymphadenopathy.

11. Oropharyngeal examination shows a 3-cm ulcerating left tonsillar mass.

12. Examination of both auditory canals is unremarkable.


Question: Which of the following is the best test for this patient's most likely diagnosis?

Context: A 23-year-old woman presents to the emergency department with abdominal pain.

Context: The patient states that she has pain in her back that radiates to her abdomen.

Context: The pain started yesterday and is episodic.

Context: She describes the pain as a 10/10 when it occurs.

Context: The patient has a past medical history of asthma, anxiety, and chlamydia that was appropriately treated.

Context: Her current medications include fluoxetine.

Context: The patient's lab values are ordered as seen below. |  | Hemoglobin: 14 g/dL | Hematocrit: 40% | Leukocyte count: 8,500 cells/mm^3 with normal differential | Platelet count: 225,000/mm^3 |  | Serum: | Na+: 140 mEq/L | Cl-: 100 mEq/L | K+: 4.9 mEq/L | HCO3-: 24 mEq/L | BUN: 22 mg/dL | Glucose: 89 mg/dL | Creatinine: 1.2 mg/dL | Ca2+: 10.0 mg/dL | AST: 11 U/L | ALT: 11 U/L |  | Urine: | Color: amber | Nitrites: negative | Na+: 12 mmol/24 hours | Beta-hCG: positive | Red blood cells: 11/hpf |  | .

Choices:
A. Abdominal CT
B. Transvaginal ultrasound
C. Abdominal ultrasound
D. Renal ultrasound

Answer: Renal ultrasound

2. Patient presents to the emergency department with abdominal pain.

3. Patient states that she has pain in her back that radiates to her abdomen.

4. Pain started yesterday and is episodic.

5. Patient describes the pain as a 10/10 when it occurs.

6. Patient has a past medical history of asthma, anxiety, and chlamydia that was appropriately treated.

7. Patient's current medications include fluoxetine.

10. Leukocyte count: 8,500 cells/mm^3 with normal differential

Gynecology
Emergency Medicine
Gastroenterology

General Emergency Medicine
General Obstetrics and Gynecology
General Gastroenterology


Question: What is the best treatment plan in the present case?

Context: A baby is delivered via cesarean section on the 31st gestational week.

Context: The child has tachypnea, nasal flaring, and subcostal, and intercostal retraction.

Context: Chest radiography shows bilateral, diffuse, ground-glass appearance, air bronchograms, and poor lung expansion.

Choices:
A. No therapy right away, only observation
B. Surfactant administration and oxygen therapy
C. Antibiotics
D. Emergency surgical repair of tracheoesophageal fistula

Answer: Surfactant administration and oxygen therapy

1. A baby was delivered via cesarean section on the 31st gestational week.

2. The child has tachypnea, nasal flaring, and subcostal and intercostal retraction.

3. Nasogastric tube was positioned without problems.

4. Chest radiography shows bilateral, diffuse, ground-glass appearance.

5. Chest radiography shows air bronchograms.

6. Chest radiography shows poor lung expansion.


Question: Which of the following is most likely to prevent future episodes of flank pain?

Context: A previously healthy 38-year-old man comes to the emergency department for evaluation of several hours of severe, right-sided, colicky flank pain that radiates to the groin.

Context: He drinks 2–3 energy drinks daily.

Choices:
A. Begin loop diuretic
B. Maintain acidic urine
C. Maintain adequate hydration
D. Start high-dose vitamin C

Answer: Maintain adequate hydration

1. A 38-year-old man comes to the emergency department.

2. He has severe, right-sided, colicky flank pain that radiates to the groin.

4. An x-ray of the abdomen shows a 4-mm radiopaque mass in the right ureter.

5. Microscopic examination of the urine shows biconcave, dumbbell-shaped crystals.


Question: Which of the following investigations is the main method for staging the patient’s condition?

Context: Cervical mobility is decreased.

Choices:
A. Pelvic MRI
B. Clinical examination
C. Pelvic CT
D. PET-CT

Answer: Clinical examination

1. A 45-year-old woman presents for evaluation of mild painless postcoital bleeding for the past 6 months.

2. Recently, she started to note irregular intermenstrual bleeding.

3. She has a regular menstrual cycle that lasts 30 days.

4. She has no history of genital infections or any other major gynecologic diseases.

5. She has 1 sexual partner and uses barrier contraception for birth control.

6. The pelvic examination shows an erosive necrotizing lesion (6 cm in diameter) that involves the posterior lip of the cervix and extends to the cervical canal and posterior vaginal apex.

8. The uterus is not enlarged and the ovaries are non-palpable.

9. A colposcopy is performed and a biopsy is obtained.

10. The histologic evaluation shows irregularly-shaped nests of squamous epithelium cells with large pleomorphic nuclei, inconspicuous nucleoli, a clear cytoplasm, and increased mitoses that infiltrate the stroma for greater than 10 mm.


Question: Which artery should be briefly clamped to prevent bleeding during the partial sigmoidectomy?

Context: A 69-year-old man presents for surgery due to chronic painful diverticula in the sigmoid colon.

Context: The patient is a Jehovah's witness and refuses a transfusion of blood products even in an emergency.

Choices:
A. Superior mesenteric artery
B. Inferior mesenteric artery
C. Celiac trunk
D. Inferior rectal artery

Answer: Inferior mesenteric artery

1. A 69-year-old man presents for surgery.

2. The surgery is due to chronic painful diverticula in the sigmoid colon.

4. The patient refuses a transfusion of blood products even in an emergency.


Question: What is the identity of these double-positive cells?

Context: A thymic sample from a fetus is examined.

Context: One cell type found was double-positive for the CD4 and CD8 receptors.

Choices:
A. B-cells
B. Immature T-cells of the thymic cortex
C. Immature T-cells of the thymic medulla
D. Macrophages

Answer: Immature T-cells of the thymic cortex

1. A thymic sample was taken from a fetus.

4. The cell type was double-positive for the CD4 receptor.

5. The cell type was double-positive for the CD8 receptor.


Question: Which of the following is most likely the organism being studied?"

Context: An investigator is studying the antimicrobial resistance profile of a bacterial pathogen using disk diffusion testing.

Context: The pathogen is isolated onto agar plates and antibiotic wafers are added to the plates.

Context: The inhibitory zone diameters are then recorded and used to define susceptibility thresholds.

Context: The results of the testing for the pathogen shown: | Drug Susceptibility | Penicillin G Resistant | Cefazolin Resistant | Doxycycline Susceptible | Imipenem Resistant | Azithromycin Susceptible | Vancomycin Resistant | .

Choices:
A. Staphylococcus aureus
B. Clostridioides difficile
C. Borrelia burgdorferi
D. Ureaplasma urealyticum

Answer: Ureaplasma urealyticum

1. An investigator is studying the antimicrobial resistance profile of a bacterial pathogen.

2. The pathogen is isolated onto agar plates.

3. Antibiotic wafers are added to the plates.

4. The inhibitory zone diameters are then recorded.

5. The results of the testing for the pathogen show Penicillin G resistance.

6. The results of the testing for the pathogen show Cefazolin resistance.

7. The results of the testing for the pathogen show Doxycycline susceptibility.

8. The results of the testing for the pathogen show Imipenem resistance.

9. The results of the testing for the pathogen show Azithromycin susceptibility.

10. The results of the testing for the pathogen show Vancomycin resistance.

Medical Microbiology Pathology
General Microbiology Pathology
General Pathology


Question: What is the most likely cause of this patient's serum finding?

Context: He does not smoke, drink, or take any medications.

Choices:
A. Increase in testicular temperature
B. Dysgenesis of vas deferens
C. Defect in Sertoli cell function
D.
Defect in GnRH production
"

Answer: Defect in Sertoli cell function

1. A 30-year-old man comes to the physician for evaluation of infertility.

5. Physical examination shows no abnormalities.

6. Serum analysis shows anti-sperm antibodies.


Question: Which of the following is a risk of the drug that the son is most likely using?

Context: A mother calls the psychiatrist, saying that she is concerned about her 18-year-old son who has become quite emaciated over the past several months.

Context: She has noticed that his pupils are enlarged, he has frequent nose bleeds, and he wears long sleeve shirts even in warm weather.

Context: His personality has changed quite dramatically as well, as he repeatedly steals from her and sells anything valuable in the house.

Context: He also has become overconfident, aggressive, and paranoid.

Choices:
A. Serotonin syndrome
B. Sudden cardiac arrest
C. CNS white matter lesions
D. Increased risk of schizophrenia in predisposed patients

Answer: Sudden cardiac arrest

2. The mother is concerned about her 18-year-old son.

3. The son has become quite emaciated over the past several months.

6. The son wears long sleeve shirts even in warm weather.

7. The son's personality has changed dramatically.

8. The son repeatedly steals from his mother.

9. The son sells anything valuable in the house.

Addiction Psychiatry
Adolescent Medicine


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

Context: A 48-year-old man is brought to the physician by his wife because he has become increasingly restless and anxious.

Context: His wife says that he has seemed sad and irritable for the past 4 months.

Context: He lost his job as a store clerk because he often lied to avoid work, and spent most of his days on the phone placing bets on football games.

Context: He avoids all family-related events because he has borrowed money from most of his relatives.

Context: He previously smoked 8–10 cigarettes daily but quit 1 month ago.

Context: He drinks beer on the weekends.

Context: He is mildly tremulous.

Context: Neurologic examination is normal.

Choices:
A. Gambling disorder
B. Alcohol withdrawal
C. Bipolar II disorder
D. Adjustment disorder

Answer: Gambling disorder

1. A 48-year-old man is brought to the physician by his wife.

2. His wife says he has been sad and irritable for the past 4 months.

5. He spent most of his days on the phone placing bets on football games.

7. He has borrowed money from most of his relatives.

8. He is hopeful that his symptoms will improve once he is able to win some of his money back.

9. He previously smoked 8–10 cigarettes daily.

12. On examination, he is uncooperative and dismissive.

15. He is oriented to person, place, and time.


Question: In addition to supplemental oxygen therapy, administration of which of the following drugs is most likely to provide acute relief in this patient?

Context: A 28-year-old man comes to the emergency department because of an excruciating headache that started 30 minutes ago.

Context: The pain is located around the right eye and it awoke him from sleep.

Context: Over the past two weeks, he has had similar headaches around the same time of the day, and he reports pacing around restlessly during these episodes.

Choices:
A. Sumatriptan
B. Amitriptyline
C. Prednisone
D. Oxycodone

Answer: Sumatriptan

1. A 28-year-old man comes to the emergency department.

2. He has an excruciating headache that started 30 minutes ago.

3. The pain is located around the right eye.

5. He has had similar headaches around the same time of the day over the past two weeks.

6. He reports pacing around restlessly during these episodes.

7. Physical examination shows conjunctival injection and tearing of the right eye.


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

Context: A 27-year-old woman presents with loss of consciousness at work.

Context: The patient’s colleagues say that she had been complaining of a headache all day.

Context: Her past medical history is significant for diabetes mellitus type 1.

Context: Her blood pressure is 70/60 mm Hg, pulse is 105/min, temperature is 37.2°C (99.0°F), and her respiratory rate is 28/min and shallow.

Context: On physical examination, there is a black eschar formation on her nose and her breath has a fruity odor.

Context: Laboratory findings are significant for serum glucose of 750 mg/dL, potassium of 3.3 mmol/L, and blood pH of 7.1.

Choices:
A. Diabetic ketoacidosis
B. Hyperosmolar coma
C. Lactic acidosis
D. Hypoglycemic coma

Answer: Diabetic ketoacidosis

2. Patient presented with loss of consciousness at work.

3. Patient's colleagues reported she had been complaining of a headache all day.

4. Patient has a past medical history of diabetes mellitus type 1.

5. Patient's blood pressure is 70/60 mm Hg.

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

8. Patient's respiratory rate is 28/min and shallow.

9. Physical examination revealed a black eschar formation on patient's nose.

11. Laboratory findings revealed serum glucose of 750 mg/dL.

12. Laboratory findings revealed potassium of 3.3 mmol/L.

13. Laboratory findings revealed blood pH of 7.1.


Question: Which of the following is most likely true about this patient?

Context: A 61-year-old male presents to his primary care doctor with a six-month history of progressively worsening cough, shortness of breath, and 15-pound weight loss.

Context: Over the same time period, he has also started to notice occasional weakness in his legs that has made it difficult for him to stand up from his chair and climb stairs.

Context: The weakness appears to improve when he exercises at his local aerobics class.

Context: His past medical history is notable for hypertension and hyperlipidemia.

Context: He has smoked 2 packs of cigarettes per day for 35 years.

Context: A biopsy of the lung lesion is shown.

Choices:
A. His weakness is due to a type III hypersensitivity reaction
B. He is at high risk of developing extraocular weakness
C. His weakness is due to antibodies directed against post-synaptic, voltage-gated ion channels
D. His weakness improves when calcium builds up in the presynaptic nerve terminal

Answer: His weakness improves when calcium builds up in the presynaptic nerve terminal

2. Patient has had a progressively worsening cough and shortness of breath for 6 months.

3. Patient has lost 15 pounds over the same time period.

4. Patient has noticed occasional weakness in his legs that makes it difficult to stand up from his chair and climb stairs.

5. Weakness improves with exercise at local aerobics class.

6. Patient has hypertension and hyperlipidemia in his past medical history.

7. Patient has smoked 2 packs of cigarettes per day for 35 years.

8. Chest radiographs demonstrate a perihilar mass in his right lung.

General Pulmonary Disease
Pulmonary Disease


Question: Which of the following findings would you also expect to see in this patient?

Context: A 45-year-old man with a history of hypertension, IV drug use, and type 1 diabetes is brought to the emergency room due to nausea, vomiting, and altered consciousness.

Context: He was brought in by his sister who found him asleep on her couch.

Context: He is difficult to arouse and does not respond to questions.

Context: His sister does not know his medications; however, he has a known history of medication noncompliance.

Context: On physical exam his temperature is 99°F (37.2°C), blood pressure is 100/70 mmHg, pulse is 112/min, respirations are 26/min, and pulse oximetry is 99% on room air.

Context: He is arousable but is not cooperative with the exam.

Context: His breaths are deep and you notice a fruity-smell coming from his mouth.

Context: Exam is otherwise unremarkable.

Choices:
A. Decreased total body potassium
B. Increased bicarbonate concentration
C. Decreased hydrogen ion concentration
D. Decreased free fatty acid concentration

Answer: Decreased total body potassium

2. Patient has a history of hypertension, IV drug use, and type 1 diabetes.

3. Patient was brought to the emergency room due to nausea, vomiting, and altered consciousness.

4. Patient was brought in by his sister.

5. Patient was found asleep on his sister's couch.

6. Patient is difficult to arouse and does not respond to questions.

7. Patient's sister does not know his medications.

8. Patient has a known history of medication noncompliance.

9. Patient's temperature is 99°F (37.2°C).

10. Patient's blood pressure is 100/70 mmHg.

13. Patient's pulse oximetry is 99% on room air.

14. Patient is arousable but is not cooperative with the exam.

16. Fruity-smell is coming from patient's mouth.


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

Context: A 31-year-old woman and her 32-year-old husband come to the physician because they have not been able to conceive since they married 1.5 years ago.

Context: She was diagnosed with cervicitis due to Chlamydia trachomatis infection 4 years ago, which was treated with oral azithromycin.

Context: The wife reports that she has regular menses and is otherwise healthy.

Choices:
A. Chromosomal karyotyping
B. Postcoital testing
C. Post-ejaculatory urinalysis
D. Semen analysis

Answer: Semen analysis

1. A 31-year-old woman and her 32-year-old husband come to the physician.

2. They have not been able to conceive since they married 1.5 years ago.

3. They are sexually active and have not used any form of contraception during this period.

4. She was diagnosed with cervicitis due to Chlamydia trachomatis infection 4 years ago.

5. She was treated with oral azithromycin.

6. The wife reports that she has regular menses.

8. Her last menstrual bleeding was 2 weeks ago.

9. Neither partner shows abnormalities on physical examination.

Reproductive Endocrinology and Infertility


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

Context: A 66-year-old man comes to the physician with a 4-month history of recurrent crusty lesions on the dorsal surface of his hands.

Context: He works as a landscaper.

Choices:
A. Sporotrichosis
B. Basal cell carcinoma
C. Actinic keratosis
D.
Seborrheic keratosis
"

Answer: Actinic keratosis

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

2. He has a 4-month history of recurrent crusty lesions on the dorsal surface of his hands.

3. When he scrapes off the crusts, they reappear after a few days.

4. The lesions are mildly pruritic and occasionally burn.

6. A photograph of his right hand is shown.


Question: Treatment of which of the following conditions most likely led to this patient's current condition?

Context: She says that the pain started suddenly and rates it as an 8/10 pain.

Context: She does not allow an abdominal exam.

Choices:
A. Asthma
B. Acquired immunodeficiency syndrome
C. Depression
D. Diabetes

Answer: Acquired immunodeficiency syndrome

1. A 50-year-old woman presents to the emergency department with severe abdominal pain and discomfort for several hours.

2. The pain started suddenly and rates it as an 8/10 pain.

3. There are no exacerbating factors but the pain gets relieved by leaning forward.

4. She also complains of nausea and vomiting.

5. She has vomited 4 times in the last 2 hours.

6. Her past medical history is significant for HIV, diabetes, asthma, depression, and acute angle glaucoma.

7. She states that she is very diligent with her medications and has never missed a pill.

8. She says that she does not smoke or drink alcohol.

9. Her temperature is 37°C (98.6°F), respirations are 15/min, pulse is 97/min, and blood pressure is 102/98 mm Hg.

10. On examination, she is pale, diaphoretic, and in extreme discomfort.

11. She does not allow an abdominal exam.

12. Laboratory results show a serum amylase of 456 U/L and a serum lipase of 562 U/L.

General Surgery
Gastroenterology
Emergency Medicine

General Surgery
General Gastroenterology
General Emergency Medicine


Question: Which of the following is the most likely cause of this patient’s acid-base abnormality?

Context: A 66-year-old man is brought to the emergency department after 3 consecutive days of nausea and multiple episodes of vomiting every day.

Context: The patient’s vital signs are as follows: blood pressure is 98/60 mm Hg, heart rate is 120/min, respiratory rate is 14/min, and body temperature is 36.5°C (97.7°F).

Context: The following tests are performed: | Laboratory test | Serum Na+ 136 mEq/L | Serum Cl- 78 mEq/L | Serum K+ 3.0 mEq/L | Serum creatinine (SCr)  1.0 mg/dL |     Arterial blood gas | pH 7.58 | PO2 95 mm Hg | PCO2 49 mm Hg | SO2% 98% | HCO3- 44.4 mEq/L | .

Choices:
A. Increased potassium secretion
B. Excessive hydrogen ion loss
C. Carbon dioxide retention
D. Decreased bicarbonate excretion

Answer: Excessive hydrogen ion loss

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

2. He has been experiencing nausea and vomiting for 3 consecutive days.

3. He has been receiving cisplatin as part of treatment for small cell lung carcinoma diagnosed about a year ago.

4. Upon admission, he is found to be drowsy with muscle weakness.

8. His body temperature is 36.5°C (97.7°F).

9. Physical examination reveals a mildly cachectic male with mild abdominal tenderness to palpation.

13. His serum creatinine (SCr) is 1.0 mg/dL.


Question: Which of the following best describes the mechanism of action of this drug?

Context: A 30-year-old woman presents with a white patch on her tongue that she noticed a few weeks ago.

Context: She denies any changes in taste sensation or pain, weight loss, or night sweats.

Context: Past medical history is significant for a 10-year history of type 1 diabetes mellitus, managed currently on insulin therapy.

Context: Her last HbA1c a month ago was 9%.

Context: On physical examination, there are white patches present over the dorsum of her tongue (as seen in the image) that can easily be scraped off.

Context: The patient is advised to have better blood glucose control and is prescribed a drug for these oral patches, which she is instructed to swish in her mouth for several minutes and then swallow.

Choices:
A. Inhibition of synthesis of lanosterol
B. Inhibit of synthesis of ergosterol
C. Disruption of cell membrane integrity
D. Inhibition of nucleic acid synthesis

Answer: Disruption of cell membrane integrity

2. Patient noticed a white patch on her tongue a few weeks ago.

3. Patient denies any changes in taste sensation, pain, weight loss, or night sweats.

4. Patient has a 10-year history of type 1 diabetes mellitus, managed currently on insulin therapy.

5. Patient's last HbA1c a month ago was 9%.

6. Physical examination reveals white patches present over the dorsum of her tongue.

7. White patches can easily be scraped off.

8. Microscopic examination of KOH treated scrapings shows pseudohyphae.

9. Patient is advised to have better blood glucose control.

10. Patient is prescribed a drug for these oral patches.

11. Patient is instructed to swish the drug in her mouth for several minutes and then swallow.


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

Context: A 34-year-old African-American woman comes to the physician because of a 6-month history of fatigue, increasing shortness of breath on exertion, and a dry cough.

Context: She also has chronic constipation with bowel movements once every two to three days.

Context: Her serum sodium is 138 mEq/L, potassium is 3.9 mEq/L, and calcium is 11.5 mg/dL.

Context: An x-ray of the chest shows bilateral hilar lymphadenopathy and normal lung parenchyma.

Choices:
A. Elevated 1,25-dihydroxyvitamin D3 levels
B. PTH-related protein production
C. Thiazide-induced renal calcium reabsorption
D. Chronic kidney disease

Answer: Elevated 1,25-dihydroxyvitamin D3 levels

1. A 34-year-old African-American woman comes to the physician.

2. She has a 6-month history of fatigue, increasing shortness of breath on exertion, and a dry cough.

3. She has chronic constipation with bowel movements once every two to three days.

4. She has not had fevers, night sweats, or weight loss.

5. She has a history of hypertension and arthritis of both ankle joints.

6. Current medications include hydrochlorothiazide and daily multivitamins.

7. Her vital signs are within normal limits.

11. An x-ray of the chest shows bilateral hilar lymphadenopathy.

12. An x-ray of the chest shows normal lung parenchyma.

Endocrinology, Diabetes, and Metabolism
Nephrology


Question: The nerve responsible for motor innervation of the affected muscle is also responsible for which of the following functions?

Context: A 78-year-old man comes to the physician because of difficulty swallowing and regurgitation of undigested food for the past several months.

Context: The patient reports that his symptoms have gotten progressively worse.

Context: Physical examination shows severe halitosis and a gurgling sound after he swallows a small amount of water.

Choices:
A. Parasympathetic innervation of the AV node
B. Sensory innervation of the posterior tongue
C. Visceral sensory innervation of the carotid sinus
D. Motor innervation of the ventral tongue

Answer: Parasympathetic innervation of the AV node

1. A 78-year-old man comes to the physician.

2. The patient has difficulty swallowing and regurgitation of undigested food for the past several months.

3. The patient's symptoms have gotten progressively worse.

4. Physical examination shows severe halitosis.

5. Physical examination shows a gurgling sound after the patient swallows a small amount of water.

6. Results of fluoroscopic barium esophagography are shown.

General Gastroenterology
General Otolaryngology


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

Context: A 1-day-old boy is brought to the emergency department by ambulance after his parents found him to be increasingly lethargic.

Context: Since then, his parents report that his head appears to be getting bigger over the past few hours.

Context: He also feeds poorly and has had a few episodes of vomiting.

Context: On presentation, he is found to have limb spasticity with adducted thumbs.

Context: His head circumference is bigger than expected and he appears to be unable to look up when following objects.

Choices:
A. Abnormally large posterior fossa
B. Downwardly displaced cerebellum
C. Obstruction of the cerebral aqueduct
D. Tuft of hair on the spine

Answer: Obstruction of the cerebral aqueduct

1. A 1-day-old boy is brought to the emergency department by ambulance.

2. He was born at home with inconsistent prenatal care.

3. His parents report that his head appears to be getting bigger over the past few hours.

4. He feeds poorly and has had a few episodes of vomiting.

5. On presentation, he has limb spasticity with adducted thumbs.

6. His head circumference is bigger than expected.

7. He appears to be unable to look up when following objects.

Neurosurgery (General Neurological Surgery)


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

Context: The patient’s symptoms started gradually after moving heavy objects during packing.

Context: She does not smoke.

Context: Her vitals are as follows: blood pressure 125/75 mm Hg; pulse 75/min; respiratory rate 14/min; and temperature 36.9℃ (98.4℉).

Context: An electrocardiogram is shown.

Choices:
A. Ibuprofen
B. Intercostal nerve block
C. Serial ECG for 12 hours
D. Sublingual nitroglycerin

Answer: Ibuprofen

1. A 48-year-old woman presents to the emergency department with a 2-day history of chest pain.

2. The patient's symptoms started gradually after moving heavy objects during packing.

3. The pain is constant and nagging but intensifies with lateral movement.

4. The patient has no history of serious illness and takes no medications, currently.

10. Examination of the anterior chest wall shows the absence of swelling, erythema, or warmth.

11. The 3rd and 4th left rib bones are tender anteriorly near the sternum.

13. The test for cardiac troponin I is negative.

Cardiovascular Disease
General Cardiology


Question: Which of the following organs is most likely to be spared in this patient?

Context: A 28-year-old woman who recently immigrated from Kenya presents with fatigue, shortness of breath, and palpitations for a few weeks.

Context: The patient is afebrile, and her vital signs are within normal limits.

Context: On physical examination, her voice seems hoarse, although her pharynx does not show signs of an inflammatory process.

Context: The patient is recommended to have her mitral valve replaced because of the risk for complications such as atrial fibrillation which may lead to the formation of a life-threatening blood clot that can travel to other parts of the body.

Choices:
A. Lungs
B. Spleen
C. Brain
D. Small bowel

Answer: Lungs

1. Patient is a 28-year-old woman who recently immigrated from Kenya.

2. Patient presents with fatigue, shortness of breath, and palpitations for a few weeks.

3. Review of systems is significant for a painful swollen knee.

5. Vital signs are within normal limits.

6. On physical examination, patient's voice seems hoarse.

7. Pharynx does not show signs of an inflammatory process.

8. Cardiopulmonary auscultation is significant for a loud first heart sound with a split second heart sound and a mid-diastolic rumbling murmur with an opening snap best heard over the cardiac apex.

9. Transthoracic echocardiography shows a calcified mitral valve with an opening area of 1.5 cm2 (normal: 3.0–3.5 cm2).

10. Patient is recommended to have her mitral valve replaced due to risk for complications such as atrial fibrillation.

11. Atrial fibrillation may lead to the formation of a life-threatening blood clot that can travel to other parts of the body.


Question: Which of the following is a property of the hormone that is deficient in this patient?

Context: A 14-year-old girl with a BMI of 17 complains of frequent urination, excessive thirst, and abdominal pain.

Context: Her parents have noticed that she appears to have lost some weight.

Context: Her past medical history is significant for celiac disease.

Context: A random plasma blood glucose is 267 mg/dL.

Choices:
A. Up-regulates glycogen phosphorylase activity
B. Enhances potassium uptake
C. Downregulates HMG-CoA reductase
D. Crosses the placenta to affect the fetus

Answer: Enhances potassium uptake

3. Patient complains of frequent urination.

4. Patient complains of excessive thirst.

6. Patient's parents have noticed weight loss.

7. Patient has a past medical history of celiac disease.

8. Patient's random plasma blood glucose is 267 mg/dL.


Question: Which of the following is a likely cause of this patient's iron studies findings?

Context: She does not smoke or drink alcohol.

Context: A CBC demonstrates a microcytic anemia.

Context: Iron studies are ordered and demonstrate the following: | Serum iron: 40 µg/dL (normal 50–170 µg/dL); | TIBC: 230 µg/dL (normal 250–370 µg/dL); | Transferrin saturation: 10% (normal 15–50%); | Serum ferritin: 180 µg/L (normal 15-150 µg/L); | .

Choices:
A. Lead poisoning
B. Dysfunctional uterine bleeding
C. Splenic sequestration of RBCs
D. Rheumatoid arthritis

Answer: Rheumatoid arthritis

1. A 37-year-old woman presents to her primary care physician with a 6-month history of fatigue.

2. She denies any recent history of fevers, chills or headaches.

4. A CBC demonstrates a microcytic anemia.

6. Serum iron is 40 µg/dL (normal 50–170 µg/dL).

7. TIBC is 230 µg/dL (normal 250–370 µg/dL).

8. Transferrin saturation is 10% (normal 15–50%).

9. Serum ferritin is 180 µg/L (normal 15-150 µg/L).


Question: Which of the following statements regarding the test results in this patient is true?

Context: A 32-year-old man presents with epigastric gnawing pain occurring after meals.

Context: Occasionally, dull pain awakens him at night.

Context: He also complains of bloating and occasional constipation.

Context: He has been having these symptoms for almost 2 years and uses antacids and castor oil for relief.

Context: Recently, he began to note that these remedies provide less relief than in the past.

Context: He reports no significant weight loss, night sweats, or a change in stool color.

Context: He has no family history of peptic ulcer disease or gastrointestinal malignancies.

Context: The patient does not smoke cigarettes but drinks alcohol occasionally.

Context: He rarely uses NSAIDs for symptomatic treatment.

Context: His blood pressure is 120/80 mm Hg, heart rate is 85/min, respiratory rate is 14/min, and temperature is 36.6°C (97.9°F).

Context: A physical examination revealed epigastric tenderness on palpation and the abdomen was distended.

Context: A urea breath test was performed, which was positive.

Choices:
A. The test detected products of increased cellular breakdown by the causative agent induced by urea ingestion.
B. The causative agent possesses urease; thus, it is possible to detect urease by giving the patient urease with labeled N-14 orally and then measuring the ammonia content in the exhaled breath.
C. The causative agent possesses urease; thus, it is possible to detect urease by giving the patient urea with labeled C-14 orally and then measuring the carbon dioxide content in the exhaled breath.
D. The causative agent possesses urease; thus, it is possible to detect urease by giving the patient urease and then measuring the pH of the exhaled breath to determine whether or not there was an increased breakdown of ammonia.

Answer: The causative agent possesses urease; thus, it is possible to detect urease by giving the patient urea with labeled C-14 orally and then measuring the carbon dioxide content in the exhaled breath.

2. Patient presents with epigastric gnawing pain occurring after meals.

3. Patient occasionally experiences dull pain that awakens him at night.

4. Patient also complains of bloating and occasional constipation.

5. Patient has been having these symptoms for almost 2 years.

6. Patient uses antacids and castor oil for relief.

7. Patient reports that these remedies provide less relief than in the past.

8. Patient reports no significant weight loss, night sweats, or a change in stool color.

9. Patient has no family history of peptic ulcer disease or gastrointestinal malignancies.

11. Patient drinks alcohol occasionally.

12. Patient rarely uses NSAIDs for symptomatic treatment.

13. Patient's blood pressure is 120/80 mm Hg.

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

16. Patient's temperature is 36.6°C (97.9°F).

17. Physical examination revealed epigastric tenderness on palpation.

19. Urea breath test was performed and was positive.


Question: Which of the following findings would be most likely seen in this patient as a result of administering  this reversal agent?

Context: A 45-year-old man is brought into the emergency department after he was found collapsed in a housing development stairwell.

Context: His blood pressure is 100/70 mm Hg, pulse is 65/min, and respiratory rate is 6/min.

Choices:
A. Yawning
B. Miosis
C. Smooth skin
D. Tremulousness

Answer: Yawning

1. A 45-year-old man was brought into the emergency department.

2. He was found collapsed in a housing development stairwell.

3. He was found in a pool of vomit, barely breathing.

4. Used syringes and a tourniquet were found near the patient.

8. Physical examination reveals a thin and disheveled man with track marks on both arms.

9. The appropriate reversal agent is administered.


Question: This patient most likely received which of the following drugs?

Choices:
A. Follicle-stimulating hormone
B. Mifepristone
C. Human chorionic gonadotropin
D. Cyproterone citrate

Answer: Human chorionic gonadotropin

1. A 33-year-old woman comes to the physician because of a 1-year history of irregular menses and infertility.

2. She has a history of an eating disorder and has received dietary and behavioral therapy over the past 6 months with minimal improvement in her symptoms.

3. She is 170 cm (5 ft 7 in) tall and weighs 49 kg (104 lb); her BMI is 17 kg/m2.

4. Physical examination is significant for pallor and thin, soft, depigmented hair on the arms and back.

5. After an extensive workup, the physician recommends pulsatile GnRH therapy.

6. One week after initiating therapy, a pelvic ultrasound shows a 24-mm hypoechogenic cavity in the right ovary.

7. The patient subsequently receives a drug that results in the resumption of meiosis and the loss of gap junctions between the cumulus granulosa cells and the oocyte.


Question: In addition to a protein pump inhibitor (PPI), which of the following should be added to the treatment regime of this patient?

Context: A 52-year-old woman visits her primary care practitioner, who has been following her closely after she was diagnosed with peptic ulcer disease.

Context: She tested positive for H.

Context: pylori in a urea breath test, which was later confirmed by an endoscopic biopsy.

Context: Her family history is significant for colorectal carcinoma, as well as ovarian cancer.

Context: Her past medical history is relevant for cigarette smoking and peptic ulcer disease, which has been under treatment twice, initially with a clarithromycin-containing regime.

Context: This was followed by a bismuth-containing regime after a fecal antigen test was positive 4 weeks later.

Context: pylori in her stomach mucosa.

Choices:
A. Bismuth subsalicylate, metronidazole, tetracycline
B. Levofloxacin, amoxicillin
C. Clarithromycin, amoxicillin
D. Rifabutin, amoxicillin

Answer: Levofloxacin, amoxicillin

1. A 52-year-old woman visits her primary care practitioner.

2. She was diagnosed with peptic ulcer disease.

3. She tested positive for H. pylori in a urea breath test.

4. This was later confirmed by an endoscopic biopsy.

5. Her family history is significant for colorectal carcinoma.

6. Her family history is also significant for ovarian cancer.

7. Her past medical history is relevant for cigarette smoking.

8. Her past medical history is also relevant for peptic ulcer disease.

9. She has been under treatment twice for peptic ulcer disease.

10. Initially, she was treated with a clarithromycin-containing regime.

11. This was followed by a bismuth-containing regime.

12. A fecal antigen test was positive 4 weeks later.

13. A recent endoscopy and fecal antigen test detected H. pylori in her stomach mucosa.


Question: Which of the following techniques would most likely identify the cause of this patient’s presentation?

Context: Although her son is doing well, the mother has some concerns with regards to his overall health.

Context: She reports that he is shorter than his classmates and seems less developed physically than his older brother and sister when they were his age.

Context: Additionally, the boy’s teacher has some concerns regarding his learning capability not being at the level of his peers.

Context: He has a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F).

Context: He is small for his age.

Context: with upslanting palpebral fissures, flat occiput, low set ears, and a flat nose.

Choices:
A. Punnett square
B. Karyotype
C. Polymerase chain reaction
D. Gene mapping

Answer: Karyotype

1. An 8-year-old boy is brought to the pediatrician’s office with his mother for a routine check-up.

2. He was born at 39 weeks gestation via spontaneous vaginal birth.

3. He is up to date on all vaccines and has met most of developmental milestones.

4. The mother has some concerns with regards to his overall health.

6. He seems less developed physically than his older brother and sister when they were his age.

7. The boy’s teacher has some concerns regarding his learning capability not being at the level of his peers.

8. His height and weight are at the 10th and 15th percentile respectively.

10. He has a respiratory rate of 22/min.

11. He has a blood pressure of 110/65 mm Hg.

12. He has a temperature of 37.0°C (98.6°F).

13. At physical exam the child appears cheerful, well developed, and well nourished.

15. He has upslanting palpebral fissures.

Medical Genetics and Genomics
Pediatrics

Clinical Genetics and Genomics
General Pediatrics


Question: Which of the symptoms below is most commonly associated with the patient’s condition?

Context: She complains of recurrent headaches and involuntary weight loss, which she attributes to a constant pain along the right side of her jaw that occasionally radiates to her right eye.

Context: Today, her blood pressure is 135/90 mm Hg, heart rate is 88/min, respiratory rate is 15/min, and temperature is 36.6°C (97.9°F).

Choices:
A. Limb muscle weakness
B. Neck stiffness
C. Diplopia
D. Shock-like pain in face

Answer: Neck stiffness

1. A 55-year-old woman visits her primary care provider for concerns of frequent headaches.

2. She complains of recurrent headaches and involuntary weight loss.

3. She attributes the headaches and weight loss to a constant pain along the right side of her jaw that occasionally radiates to her right eye.

4. Her past medical history includes diabetes mellitus type 2 and chronic glomerulonephritis resulting in stage II chronic kidney disease.

5. Her mother passed away in her 70s and had been diagnosed with multiple sclerosis at the age of 50.

10. The right side of her face is painful to palpation from her jaw to the right side of her scalp.


Question: Which of the following additional findings is most strongly associated with this patient’s condition?

Context: His gait is normal.

Choices:
A. Abdominal bruit
B. Asymmetric upper extremity pulses
C. Continuous machine-like murmur
D. Costovertebral tenderness

Answer: Abdominal bruit

1. A 66-year-old man presents to his primary care provider for a routine checkup.

2. He says that he feels well overall but has experienced some intermittent back pain and vague epigastric pain over the past 6 months.

3. He also has experienced cramping in both legs that is worse whenever he walks for long periods of time.

4. He has a history of poorly controlled hypertension, diabetes mellitus, recurrent renal stones, and major depressive disorder.

5. He takes lisinopril, nifedipine, metformin, glyburide, and fluoxetine.

6. He has a 55-pack-year smoking history and drinks alcohol socially.

7. His temperature is 98.4°F (36.9°C), blood pressure is 155/85 mmHg, pulse is 92/min, and respirations are 16/min.

8. On exam, he is well-appearing and in no acute distress.

9. A normal S1 and S2 are heard on auscultation.

10. He has no abdominal tenderness to palpation.

11. A light pulsatile mass is felt in the mid-epigastrium.

12. Achilles and patellar reflexes are 2+ bilaterally.


Question: A mutation in which of the following proteins most likely contributed to this patient’s condition?

Context: He is unresponsive and pulseless.

Context: The patient had no past medical history other than a heart murmur as a child and he took no medications.

Choices:
A. Myosin heavy chain
B. Dystrophin
C. Fibrilin
D. Elastin

Answer: Myosin heavy chain

1. A 17-year-old male collapses 25 minutes into a soccer game.

3. Despite adequate resuscitation by a bystander, the patient is pronounced dead when the ambulance arrives.

4. The patient had no past medical history other than a heart murmur as a child.

6. His family history is notable for an uncle who died suddenly of unknown causes at the age of 25.


Question: Which of the following findings is most likely on ultrasound?

Context: A 36-year-old woman, gravida 3, para 2, at 31 weeks' gestation comes to the emergency department because of painless, bright red vaginal bleeding for one day.

Context: She has not felt any contractions.

Context: Her other children were delivered by Cesarean section because of breech position.

Choices:
A. Retroplacental hematoma
B. Adnexal bleeding
C. Placenta over the cervical os
D. Gestational sac in a dilated cervix

Answer: Placenta over the cervical os

1. A 36-year-old woman comes to the emergency department.

4. She has painless, bright red vaginal bleeding for one day.

6. Her other children were delivered by Cesarean section.

7. The Cesarean section was due to breech position.

8. Fetal heart rate is reactive with no decelerations.


Question: Which of the following best describes the most likely diagnosis?

Context: A 24-year-old man is brought to the emergency department for bowling at a local bowling alley while inappropriately dressed.

Context: The patient refused to speak with police and was seen conversing with inanimate objects in the back of the police car.

Choices:
A. Dehydration
B. Dopamine blockade
C. Inadequate evaporative cooling
D. Infection

Answer: Dopamine blockade

1. A 24-year-old man is brought to the emergency department.

2. The patient was bowling at a local bowling alley while inappropriately dressed.

3. The patient refused to speak with police.

4. The patient was seen conversing with inanimate objects in the back of the police car.

5. The patient states that his clothes were contaminated by assassins who have been tracking him for years.

6. The patient refuses to answer any further questions, and continues to whisper toward someone else.

7. The patient has a past medical history of homelessness, alcohol abuse, marijuana use, and cocaine abuse.

8. Physical exam is notable for a healthy young man who seems mistrustful of all hospital personnel.

9. The patient is started on a medication and is transferred to the psychiatric inpatient unit.

10. The patient’s condition improves, but he still often speaks of a contamination that is on his clothes and skin that is coming from external parties.

11. The patient is started on a new medication.

12. He is then sent to group therapy, followed by physical activity in the yard.

13. The physician is called over when the patient is found down in the recreation yard while he was exercising.

14. The patient is not responsive, and his limbs seem to resist passive force.

15. His temperature is 104°F (40°C), pulse is 112/min, blood pressure is 140/90 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air.


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

Context: The patient is started on haloperidol and most of his symptoms improve dramatically; however, he continues to refuse to eat food from the hospital as he believes it to be contaminated.

Context: The patient stays on the inpatient psychiatric unit and lab values are drawn and return as follows: |  | Serum: | Na+: 135 mEq/L | K+: 3.0 mEq/L | Cl-: 92 mEq/L | HCO3-: 22 mEq/L | BUN: 7 mg/dL | Ca2+: 8.4 mg/dL | Creatinine: 0.6 mg/dL | Glucose: 70 mg/dL |  | That patient is started on an intravenous solution containing potassium chloride and is closely monitored.

Context: Lab values are ordered again the following day and return as follows: |  | Serum: | Na+: 137 mEq/L | K+: 2.9 mEq/L | Cl-: 95 mEq/L | HCO3-: 22 mEq/L | BUN: 8 mg/dL | Ca2+: 9.0 mg/dL | Creatinine: 1.0 mg/dL | Glucose: 77 mg/dL |  | The patient is continued on IV fluids and his clinical symptoms seem to further improve.

Choices:
A. Discharge the patient on IM haloperidol
B. IV fluids containing potassium
C. IV fluids containing magnesium
D. Increase oral intake

Answer: IV fluids containing magnesium

1. A 23-year-old male presents to the emergency department after he was found naked wandering his neighborhood.

2. The patient is disheveled and has not bathed in months.

3. The patient has a past medical history of alcohol abuse and schizophrenia that is well controlled with haloperidol.

4. The patient is started on haloperidol and most of his symptoms improve dramatically.

5. The patient continues to refuse to eat food from the hospital as he believes it to be contaminated.

6. The patient stays on the inpatient psychiatric unit.

7. Lab values are drawn and return as follows: Serum Na+: 135 mEq/L, K+: 3.0 mEq/L, Cl-: 92 mEq/L, HCO3-: 22 mEq/L, BUN: 7 mg/dL, Ca2+: 8.4 mg/dL, Creatinine: 0.6 mg/dL, Glucose: 70 mg/dL.

8. The patient is started on an intravenous solution containing potassium chloride and is closely monitored.

9. His oral intake also seems to be improving.

10. Lab values are ordered again the following day and return as follows: Serum Na+: 137 mEq/L, K+: 2.9 mEq/L, Cl-: 95 mEq/L, HCO3-: 22 mEq/L, BUN: 8 mg/dL, Ca2+: 9.0 mg/dL, Creatinine: 1.0 mg/dL, Glucose: 77 mg/dL.

11. The patient is continued on IV fluids and his clinical symptoms seem to further improve.

12. Repeat labs the following three days remains largely unchanged.

13. The patient's symptoms improve and he is determined to be at his baseline in terms of functioning.

General Psychiatry
General Emergency Medicine


Question: Without treatment, which of the following is this patient most likely to develop?

Context: A 2-year-old girl is brought to the physician because of high-grade fever and crying while passing urine.

Context: Her temperature is 39.2°C (102.6°F) and pulse is 123/min.

Context: Urine dipstick shows leukocyte esterase; urinalysis shows WBCs.

Context: Urine culture shows Escherichia coli sensitive to cefixime.

Context: A voiding cystourethrogram is shown.

Choices:
A. Renal cell carcinoma
B. Hypotension
C. Renal scarring
D. Nephrotic syndrome

Answer: Renal scarring

1. A 2-year-old girl is brought to the physician.

2. Four months ago, she was treated for a febrile urinary tract infection with cefixime.

3. There is no family history of serious illness.

6. Physical examination shows no abnormalities.

7. Urine dipstick shows leukocyte esterase.

9. Urine culture shows Escherichia coli.

10. Escherichia coli is sensitive to cefixime.

11. A voiding cystourethrogram is shown.

12. The girl is crying while passing urine.


Question: What is the most likely diagnosis?

Choices:
A. Avoidant personality disorder
B. Major depressive disorder
C. Schizoid personality disorder
D. Schizotypal personality disorder

Answer: Schizoid personality disorder

1. A 37-year-old man presents to his primary care physician with a chief complaint of diarrhea.

2. The patient states that his symptoms have worsened recently.

3. He works as a farmer and is dressed in tattered and old denim.

4. He lives alone, and this is the first time he has come to town in years.

5. The patient’s diet is mostly dairy products and some meat products.

6. He denies any systemic symptoms and states that diarrhea tends to occur right after a meal.

7. He also claims that at times he struggles to fall asleep, and sometimes he feels he lacks energy.

8. The patient is instructed to avoid consuming dairy products for a week and to return with a report of his symptoms.

9. As you set up the return appointment with this patient you notice that he is rather emotionless.

10. He also states that he lacks anybody that he can list as an emergency contact so he leaves that section of his medical forms blank.


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

Context: The patient’s daughter states that he can cook and clean up after himself and only needs help paying bills.

Context: Yesterday the patient seemed fine; however, this morning she noticed that he struggled to perform simple tasks and was forgetful while cooking, leaving the stove on.

Context: They recently returned from a trip to Mexico and admit to drinking unfiltered water and eating local cuisines while abroad.

Context: His temperature is 97.5°F (36.4°C), blood pressure is 187/118 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 100% on room air.

Choices:
A. Alzheimer dementia
B. Lewy body dementia
C. Normal pressure hydrocephalus
D. Vascular dementia

Answer: Vascular dementia

1. A 77-year-old man presents to the emergency department with a change in his mental status.

2. The patient's daughter states that he can cook and clean up after himself and only needs help paying bills.

4. This morning she noticed that he struggled to perform simple tasks and was forgetful while cooking, leaving the stove on.

5. They recently returned from a trip to Mexico.

6. They admit to drinking unfiltered water and eating local cuisines while abroad.

7. The patient has a past medical history of hypertension and diabetes.

12. His oxygen saturation is 100% on room air.


Question: Which of the following most likely accounts for this patient’s dyspnea?

Context: A 65-year-old male with a past medical history of left ventricular hypertrophy presents to the emergency room because of a history of progressive shortness of breath and a cough productive of frothy pink sputum.

Context: The patient denies fever, chills, or any recent infection.

Context: A radiograph of the chest shows septal lines and areas of opacification in both lung fields (see image). | .

Choices:
A. Destruction of interalveolar septa
B. Excess mucous production in bronchiolar epithelium
C. A collection of air in the pleural space
D. Alveolar and interstitial fluid accumulation

Answer: Alveolar and interstitial fluid accumulation

2. Patient has a past medical history of left ventricular hypertrophy.

3. Patient presents to the emergency room due to progressive shortness of breath and a cough productive of frothy pink sputum.

4. Physical examination reveals crackles at the lung bases bilaterally.

5. Patient denies fever, chills, or any recent infection.

6. Radiograph of the chest shows septal lines and areas of opacification in both lung fields.

Pulmonary Disease
Cardiovascular Disease
Cardiology


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

Context: A 42-year-old man is brought to the emergency department because of several episodes of black, tarlike stool and lightheadedness over the past couple of days.

Context: He underwent an appendectomy at the age of 16.

Context: He has hypertension and tension headaches.

Context: He drinks 4 beers daily.

Context: Current medications include amlodipine and naproxen.

Context: His temperature is 36.7°C (98°F), pulse is 100/min, and his blood pressure is 100/70 mm Hg.

Context: The lungs are clear to auscultation bilaterally.

Context: The abdomen is soft, nondistended, and nontender.

Context: The liver is palpated 3 cm below the right costal margin.

Context: His hemoglobin concentration is 10 g/dL.

Context: An esophagogastroduodenoscopy is performed, which does not show bleeding.

Choices:
A. Double-balloon enteroscopy
B. Colonoscopy
C. Laparotomy
D.
Angiography
"

Answer: Colonoscopy

2. Patient has had several episodes of black, tarlike stool and lightheadedness over the past couple of days.

3. Patient had an appendectomy at the age of 16.

4. Patient has hypertension and tension headaches.

6. Patient is currently taking amlodipine and naproxen.

7. Patient's temperature is 36.7°C (98°F).

9. Patient's blood pressure is 100/70 mm Hg.

10. Lungs are clear to auscultation bilaterally.

11. Abdomen is soft, nondistended, and nontender.

12. Liver is palpated 3 cm below the right costal margin.

13. Patient's hemoglobin concentration is 10 g/dL.

14. Intravenous fluid resuscitation is begun.

15. Esophagogastroduodenoscopy is performed, which does not show bleeding.


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

Context: He has a history of hypertension, calcium pyrophosphate crystal arthritis, and alcoholic cirrhosis.

Context: Current medications include hydrochlorothiazide, rifaximin, lactulose, and naproxen as needed for the joint pain.

Context: He quit drinking 5 years ago.

Context: He does not smoke cigarettes.

Context: Serum studies show: | Creatinine 1.1 mg/dL | Calcium 11.8 mg/dL | Phosphorus 2.1 mg/dL | Magnesium 1.6 mg/dL | Total protein 6 g/dL | Albumin 3.1 g/dL | AST 53 U/L | ALT 43 U/L | .

Choices:
A. Serum parathyroid-related protein level
B. Urine and serum protein electrophoresis
C. Serum parathyroid hormone level
D. X-ray of the chest

Answer: Serum parathyroid hormone level

1. A 68-year-old man comes to the physician because of constipation and decreased appetite during the past several months.

2. In the past 2 weeks, he has also noticed an increasing frequency of urination.

3. He has not had any dysuria or flank pain.

5. He has a history of calcium pyrophosphate crystal arthritis.

6. He has a history of alcoholic cirrhosis.

7. Current medications include hydrochlorothiazide.

8. Current medications include rifaximin.

9. Current medications include lactulose.

10. Current medications include naproxen as needed for the joint pain.

13. His vital signs are within normal limits.

14. Physical examination shows decreased bowel sounds but is otherwise unremarkable.

15. Serum studies show creatinine 1.1 mg/dL.

16. Serum studies show calcium 11.8 mg/dL.

17. Serum studies show phosphorus 2.1 mg/dL.

18. Serum studies show magnesium 1.6 mg/dL.

19. Serum studies show total protein 6 g/dL.

20. Serum studies show albumin 3.1 g/dL.


Question: Which of the following tests would most likely confirm the diagnosis in this patient?

Context: A 68-year-old African American male presents to his primary care provider complaining of progressively worsening back pain.

Context: The pain is localized to the lower back and sometimes wakes him up from sleep.

Context: He has a history of hypertension and admits to a 50 pack-year smoking history.

Context: Further questioning reveals that he has also experienced fatigue and an unintentional weight loss of 18 pounds over the past year.

Choices:
A. Renal biopsy
B. Fine needle aspiration of the thyroid
C. Transrectal ultrasound-guided prostate biopsy
D. Chest radiograph

Answer: Transrectal ultrasound-guided prostate biopsy

1. A 68-year-old African American male presents to his primary care provider.

2. He is complaining of progressively worsening back pain.

3. The pain is localized to the lower back.

4. The pain sometimes wakes him up from sleep.

6. He admits to a 50 pack-year smoking history.

8. He has experienced an unintentional weight loss of 18 pounds over the past year.

9. Laboratory analysis is notable for an elevated alkaline phosphatase.

10. A radiograph of the patient’s spine demonstrates multiple sclerotic lesions in the lumbar vertebral bodies.

General Orthopaedic Surgery
Orthopaedic Sports Medicine


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

Context: A 75-year-old man presents to his primary care physician because he has been experiencing increasing muscle and joint pain over the last 3 months.

Context: He says that he also feels increasingly fatigued and weak despite no change to his daily routine.

Context: His past medical history is significant for an infection when he was 12 years of age that led to 2 months of paralysis and mechanical ventilation through a tracheostomy tube.

Context: At the time, he developed the paralysis after 3 days of fever and sore throat.

Context: He recalls that he was still able to feel everything and was embarrassed that his daily activities had to be performed for him by caregivers.

Choices:
A. DNA virus
B. Enveloped (-) stranded RNA virus
C. Naked (+) stranded RNA virus
D. Naked (-) stranded RNA virus

Answer: Naked (+) stranded RNA virus

1. A 75-year-old man presents to his primary care physician.

2. He has been experiencing increasing muscle and joint pain over the last 3 months.

3. He also feels increasingly fatigued and weak despite no change to his daily routine.

4. His past medical history is significant for an infection when he was 12 years of age.

5. The infection led to 2 months of paralysis and mechanical ventilation through a tracheostomy tube.

6. He developed the paralysis after 3 days of fever and sore throat.

7. He recalls that he was still able to feel everything.

8. He was embarrassed that his daily activities had to be performed for him by caregivers.


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

Context: A 2-year-old boy was rushed to the emergency department in the early morning by his mother because he was unresponsive to deep pain stimuli.

Context: The patient’s mother said that he has been suffering from a fever, cough and runny nose for the last 10 days.

Context: When she gave him the medication yesterday, the patient had 3 episodes of vomiting and his condition rapidly worsened.

Context: This morning, the patient did not wake up, even after multiple attempts.

Context: Significant hepatomegaly is noted.

Choices:
A. Decrease in beta-oxidation
B. Increase in gluconeogenesis
C. Increase in beta-oxidation
D. Increase in glycolysis

Answer: Decrease in beta-oxidation

1. A 2-year-old boy was rushed to the emergency department in the early morning by his mother.

2. The patient's mother said he has been suffering from a fever, cough and runny nose for the last 10 days.

3. 2 days ago, they visited a free clinic and received medication.

4. When she gave him the medication yesterday, the patient had 3 episodes of vomiting.

5. His condition rapidly worsened this morning, and he did not wake up, even after multiple attempts.

6. On physical examination, the patient is febrile, hypotensive, and tachycardic.

7. Peripheral pulses are 1+, and his extremities are pale and cool to touch.

8. Pupils are equal and slowly reactive to light.


Question: Which of the following drugs has a mechanism of action that is similar to the pathophysiology of this patient's disease?

Context: A 24-year-old patient presents to your gastroenterology practice on a referral from her primary care provider.

Choices:
A. Omeprazole
B. Bismuth
C. Octreotide
D. Magnesium hydroxide

Answer: Magnesium hydroxide

1. A 24-year-old patient presents to a gastroenterology practice.

2. The patient was referred by her primary care provider.

3. The patient has been experiencing postprandial bloating and abdominal pain for one year.

4. Symptoms occur following the ingestion of milk products.


Question: In which location is dimeric IgA most likely to be found in highest concentrations?

Choices:
A. Colostrum
B. Blood from the fetus
C. Blood from the mother
D. Fetal bone marrow

Answer: Colostrum


Question: If this patient's symptoms are allowed to progress without intervention, which of the following would be expected to occur?

Context: Vital signs are stable.

Context: Neurological exam reveals that his right pupil is dilated and his right lid is drooping.

Choices:
A. Right sided hemiparesis
B. Down and in gaze of the right pupil
C. Right sided homonymous hemianopsia.
D. Right eye with an inability to abduct

Answer: Right sided hemiparesis

1. A 25-year-old man presents to the ER after a street fight.

2. His girlfriend reports that he was struck with a bat in the head.

3. After the initial hit, she reported that he briefly lost consciousness but then was normal for several hours.

4. Since then, he has been rapidly decompensating.

5. He is grabbing his head in pain and his mental status is altered.

7. Neurological exam reveals that his right pupil is dilated.

8. Neurological exam reveals that his right lid is drooping.


Question: Which of the following was the portal of entry for the most likely causal organism?

Context: A 7-year-old girl is brought to the emergency department because of diffuse abdominal pain and multiple episodes of vomiting for 2 hours.

Context: On arrival, she is unresponsive.

Context: Her temperature is 40.3°C (104.5°F) and palpable blood pressure is 45 mm Hg.

Choices:
A. Nasopharynx
B. Genital mucosa
C. Choroid plexus
D. Gastrointestinal tract

Answer: Nasopharynx

1. A 7-year-old girl is brought to the emergency department.

2. She has diffuse abdominal pain and multiple episodes of vomiting for 2 hours.

3. She started developing fever, headache, and neck pain 3 days ago.

7. Physical examination shows diffuse purpuric skin lesions.

8. In spite of all appropriate therapy, she dies shortly thereafter.

9. Autopsy shows massive parenchymal hemorrhage of the adrenal glands.

General Pediatrics
Pediatric Gastroenterology


Question: Which of the following, if seen microscopically, would indicate that her calf myocytes are more likely to recover without permanent damage?

Context: A 50-year-old female comes to the emergency department with sudden onset left-sided calf pain starting 20 minutes ago.

Context: Upon arrival to the emergency department, her blood pressure is 150/91 mmHg, pulse is 100/min, and respirations of 22/min.

Choices:
A. Cellular swelling
B. Mitochondrial vacuolization
C. Nuclear pyknosis
D. Fragmented cells and debris

Answer: Cellular swelling

1. A 50-year-old female comes to the emergency department.

2. She has sudden onset left-sided calf pain starting 20 minutes ago.

3. Her past medical history is notable for diabetes, hypertension, and chronic atrial fibrillation controlled on an anti-arrhythmic.

4. Upon arrival to the emergency department, her blood pressure is 150/91 mmHg.

7. Examination of the leg reveals a pale left calf with diminished dorsalis pedis and posterior tibial pulses.

8. Prompt intervention relieves the patient’s symptoms.

Cardiology
General Pathology
Cardiovascular Disease


Question: Damage to which of the following structures is most likely responsible for this patient's current symptoms?

Context: A 56-year-old man comes to the physician because of progressive worsening of vision in both his eyes over the past 6 months.

Context: He reports that he first noticed some blurring of his vision and glare in the evenings, which have both gotten worse in this period.

Context: He works as a tower crane operator and spends most of his day outdoors.

Context: A photograph of the eye is shown.

Choices:
A. Aqueous humor
B. Vitreous body
C. Lens
D. Retina

Answer: Lens

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

2. His vision has been progressively worsening over the past 6 months.

3. He first noticed blurring of his vision and glare in the evenings.

4. His vision has gotten worse in this period.

7. Ophthalmologic examination shows visual acuity of 20/100 in both eyes.


Question: What is the most likely pathology giving rise to this patient’s condition?

Context: A 25-year-old man presents to the clinic with the complaint of yellow discoloration of his skin.

Context: He reports that the discoloration appeared gradually over the past 5 days.

Context: He does not have any other complaints.

Context: He never had similar symptoms before.

Context: Past medical history is only significant for a recent flu infection that was so bad that he missed work for a week.

Context: Liver function tests reveal: | Total bilirubin level 5 mg/dL | Direct bilirubin level 0.4 mg/dL | Aspartate aminotransferase (AST) 25 U/L | Alanine aminotransferase (ALT) 15 U/L | .

Choices:
A. Decreased conjugation of bilirubin by uridine-diphosphate glucuronyltransferase
B. Bile duct obstruction
C. Hemolysis
D. Decreased transport of bile into the bile canaliculi

Answer: Decreased conjugation of bilirubin by uridine-diphosphate glucuronyltransferase

2. Patient has yellow discoloration of skin.

3. Discoloration appeared gradually over the past 5 days.

5. Patient never had similar symptoms before.

6. Patient's past medical history is significant for a recent flu infection.

7. Patient missed work for a week due to the flu infection.

8. Physical exam is significant for yellow sclera and slight yellowish discoloration of the skin over the face and neck.

10. Direct bilirubin level is 0.4 mg/dL.

11. Aspartate aminotransferase (AST) is 25 U/L.

12. Alanine aminotransferase (ALT) is 15 U/L.


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

Context: A 17-year-old girl is brought to the physician by her father because of concerns about her behavior.

Context: She worries excessively about her weight and body image, and has frequent diarrhea.

Context: She is 170 cm (5 ft 7 in) tall and weighs 63.5 kg (140 lb); BMI is 22 kg/m2.

Context: She appears anxious but well.

Context: Vital signs are within normal limits.

Choices:
A. Parotid gland swelling
B. Elevated blood pressure
C. Right upper quadrant tenderness
D. Jugular venous distention

Answer: Parotid gland swelling

1. A 17-year-old girl is brought to the physician by her father.

2. She worries excessively about her weight and body image.

8. Vital signs are within normal limits.

9. Physical examination shows calluses on the knuckles of her right hand.