Question: What is the histopathology of the most common large-artery complication of this disease?

Context: He has never been seen by a physician and reports that he has been in good health.

Context: You note a very tall, very thin male whose arm span is greater than his height.

Context: The patient reports that his father had a similar build but passed away suddenly in his 40s.

Choices:
A. Focal granulomatous inflammation with mural lymphocytes, macrophages, giant cells
B. Predominant neutrophilic infiltration with fibrinoid necrosis
C. Fibrinoid necrosis of blood vessel walls, endothelial swelling, and neutrophilic infiltrate in skin lesions
D. Cystic medial degeneration

Answer: Cystic medial degeneration

1. A 25-year-old male presents for a new primary-care visit.

2. He has never been seen by a physician.

3. He reports that he has been in good health.

4. The patient is very tall and very thin.

5. His arm span is greater than his height.

6. The patient's father had a similar build.

7. The patient's father passed away suddenly in his 40s.

8. You suspect a genetic disorder characterized by a defect in fibrillin-1.


Question: Assuming the investigators intend to keep the level of significance at 5%, which of the following changes would be most effective to increase the statistical power?

Context: They conducted a pilot study in which 15 participants were randomized to receive intranasal ketamine while 15 participants were randomized to receive placebo.

Context: The investigators ultimately found no statistically significant difference in suicidality after 30 days of follow up with the level of significance fixed at 5%.

Choices:
A. Decrease the sample size
B. Decrease the type II error rate
C. Increase beta
D. Increase the type I error rate

Answer: Decrease the type II error rate

1. A group of investigators is evaluating the efficacy of intranasal ketamine in decreasing acute suicidality in teenagers admitted to inpatient psychiatric units.

2. They conducted a pilot study in which 15 participants were randomized to receive intranasal ketamine.

3. 15 participants were randomized to receive placebo.

4. The investigators ultimately found no statistically significant difference in suicidality after 30 days of follow up.

5. The level of significance was fixed at 5%.

6. They suspect inadequate statistical power.


Question: Which of the following etiologies is the most likely cause of this patient’s neurologic findings?

Context: A 56-year-old man presents with severe back pain for the past hour.

Context: He says the pain started about 1 hour ago and has not improved.

Context: The patient describes the pain as sharp, 10/10, and located between his scapula.

Context: Past medical history is significant for hypertension, which he is noncompliant with medication.

Context: His vital signs are a blood pressure of 180/95 mm Hg and a pulse of 108/min.

Context: On physical examination, there is a loss of pain and temperature sensation in the lower trunk and extremities bilaterally.

Context: Strength is 4 out of 5 in all muscle groups in the lower extremities bilaterally.

Context: A contrast CT of the chest reveals findings consistent with a type B aortic dissection.

Choices:
A. Brown-Séquard syndrome
B. Spinal cord compression
C. Anterior cord syndrome
D. Spinal epidural hematoma

Answer: Anterior cord syndrome

2. Patient has severe back pain for the past hour.

3. Patient says pain started 1 hour ago and has not improved.

4. Patient describes pain as sharp, 10/10, and located between scapula.

5. Patient has past medical history of hypertension.

6. Patient is noncompliant with medication.

7. Patient's blood pressure is 180/95 mm Hg.

9. Patient has loss of pain and temperature sensation in lower trunk and extremities bilaterally.

10. Patient has strength of 4 out of 5 in all muscle groups in lower extremities bilaterally.

11. Contrast CT of chest reveals findings consistent with type B aortic dissection.

General Neurological Surgery
Spinal Cord Compression


Question: This patient's condition is most likely caused by a defect in a gene encoding a protein that is normally involved in which of the following processes?

Context: A 7-year-old girl is brought to the physician by her mother because of a 6-month history of worsening fatigue and frequent upper respiratory tract infections.

Context: She is at the 2nd percentile for height and 10th percentile for weight.

Context: Physical examination shows pallor, diffuse hyperpigmented macules, absence of the radial bones, and hypoplastic thumbs.

Context: Her hemoglobin concentration of 8.7 g/dL, leukocyte count is 2,500/mm3, and platelet count is 30,000/mm3.

Choices:
A. Hydrolysis of glucocerebroside
B. DNA interstrand crosslink repair
C. Maturation of erythroid progenitor cells
D. Ras signal transduction pathway

Answer: DNA interstrand crosslink repair

1. A 7-year-old girl is brought to the physician by her mother.

2. She has a 6-month history of worsening fatigue and frequent upper respiratory tract infections.

3. She is at the 2nd percentile for height.

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

6. Physical examination shows diffuse hyperpigmented macules.

7. Physical examination shows absence of the radial bones.

8. Physical examination shows hypoplastic thumbs.

9. Her hemoglobin concentration is 8.7 g/dL.


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

Context: She has a history of acral vitiligo.

Context: Her blood pressure is 90/60 mm Hg, temperature is 35.9°C (96.6°F), and pulse is 90/min.

Context: On physical examination, she is obtunded, skin turgor is reduced, and her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks.

Context: Lab results are shown: | Random plasma glucose 40 mg/dL | Serum osmolarity 275 mOsm/kg H₂O | Serum sodium 130 mEq/L | Serum potassium 6 mEq/L | Urine sodium level 30 mEq/L | ECG shows normal sinus rhythm without ST-T wave changes.

Context: Dextrose 5% is given and random plasma glucose becomes 60 mg/dL, but her blood pressure is still the same.

Choices:
A. Intravenous calcium gluconate
B. ACTH stimulation test
C. Oral dehydroepiandrosterone (DHEA)
D. Normal saline and intravenous dexamethasone

Answer: Normal saline and intravenous dexamethasone

1. A 36-year-old woman is brought to the emergency department because of loss of consciousness.

2. Her husband says that she complained of vomiting and dizziness for 2 days, but did not seek medical care.

7. On physical examination, she is obtunded.

9. Her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks.

11. Serum osmolarity is 275 mOsm/kg H₂O.

15. ECG shows normal sinus rhythm without ST-T wave changes.

17. Random plasma glucose becomes 60 mg/dL.

18. Her blood pressure is still the same.


Question: What is the most likely diagnosis?

Context: One year prior, the patient was able to ride a tricycle, stack 3 blocks, and speak in short sentences.

Context: Now, she is unable to feed herself and has recently started to point to objects she wants rather than asking.

Context: Vital signs are normal.

Context: The patient's mother reports that her 7-year-old son is doing well, and that they have no family history of mental retardation or other cognitive disorders.

Choices:
A. Angelman syndrome
B. Rett syndrome
C. Prader-Willi syndrome
D. McCune-Albright syndrome

Answer: Rett syndrome

1. A 4-year-old girl is seen by her pediatrician for developmental delay.

2. One year prior, the patient was able to ride a tricycle.

3. One year prior, the patient was able to stack 3 blocks.

4. One year prior, the patient was able to speak in short sentences.

6. Now, she has recently started to point to objects she wants rather than asking.

7. Physical exam reveals a well nourished child sitting in a stroller wringing her hands.

9. The patient's mother reports that her 7-year-old son is doing well.

10. The patient's mother reports that they have no family history of mental retardation.

11. The patient's mother reports that they have no family history of other cognitive disorders.


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

Context: A 49-year-old woman visits the emergency department with the acute onset of severe shortness of breath.

Context: She also reports right-sided calf pain that developed after a 22-hour flight from Beijing to Los Angeles, and that, several hours after she felt pain in her calf, she began to have trouble breathing.

Context: Currently, her shortness of breath is so severe that she is unable to speak clearly or quickly, but she manages to deny any recent surgery or history of recent bleeding.

Context: The vital signs include: blood pressure 111/69 mm Hg, pulse 142/min, and respiratory rate 33/min.

Context: On observation, she is using accessory muscles to breathe.

Context: On auscultation, her lungs are clear and her heart rate is rapid but regular.

Context: Her right calf is swollen, warm, and tender.

Context: The arterial blood gas test result reveals a pH of 7.5, partial pressure of carbon dioxide (PCO2) 22 mm Hg, and a partial pressure of oxygen (PaO2) 47 mm Hg on 6 L of oxygen by nasal cannula.

Choices:
A. Unfractionated heparin
B. Streptokinase
C. Low molecular-weight heparin
D. Embolectomy

Answer: Streptokinase

2. Patient has acute onset of severe shortness of breath.

3. Patient has right-sided calf pain that developed after a 22-hour flight from Beijing to Los Angeles.

4. Patient felt pain in her calf several hours before having trouble breathing.

5. Patient denies any recent surgery or history of recent bleeding.

6. Patient's blood pressure is 111/69 mm Hg.

8. Patient's respiratory rate is 33/min.

9. Patient is using accessory muscles to breathe.

10. Patient's lungs are clear on auscultation.

11. Patient's heart rate is rapid but regular.

12. Patient's right calf is swollen, warm, and tender.

13. Arterial blood gas test result reveals a pH of 7.5.

14. Arterial blood gas test result reveals a PCO2 of 22 mm Hg.

15. Arterial blood gas test result reveals a PaO2 of 47 mm Hg on 6 L of oxygen by nasal cannula.

Pulmonary Disease
General Pulmonary Disease


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

Context: A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor.

Context: She has had no prenatal care.

Context: The patient appears in acute distress.

Context: Her pulse is 98/min, respirations are 15/min, and blood pressure is 130/80 mm Hg.

Context: The abdomen is nontender and contractions are felt.

Choices:
A. Uterine rupture
B. Placenta previa
C. Placenta accreta
D.
Abruptio placentae
"

Answer: Placenta accreta

1. A 37-year-old woman is admitted to the hospital in active labor.

6. Her three children were delivered by lower segment transverse cesarean section.

7. The patient appears in acute distress.

13. The fetus is in a cephalic presentation.

14. The fetal heart rate is reactive with no decelerations.

15. One hour following vaginal delivery, the placenta is not delivered.

16. Manual separation of the placenta leads to profuse vaginal bleeding.

17. A firm, nontender uterine fundus is palpated at the level of the umbilicus.

General Obstetrics and Gynecology
Placenta accreta
Placenta previa


Question: An MRI of the brain will reveal an atrophy of which of the following structure?

Context: A 40-year-old man is brought to the clinic by his wife with a complaint of behavioral changes for the past few months.

Context: The past medical history is unremarkable.

Context: He does not smoke, drinks alcohol, or uses illicit drugs.

Choices:
A. Caudate nucleus
B. Cerebellum
C. Diffuse cortex
D. Frontal and temporal lobes

Answer: Caudate nucleus

1. A 40-year-old man is brought to the clinic by his wife.

2. He has been exhibiting behavioral changes for the past few months.

3. He is irritable and gets angry with trivial matters.

4. He sometimes screams in the middle of the night and remains restless.

5. His wife has recently noticed that he is forgetting things and repeats the same question multiple times.

6. For the past few weeks, he is also having abnormal movements of his body, more prominent in the arms and hands.

7. His past medical history is unremarkable.

8. His father died at the age of 28 years old in a road traffic accident.

9. His grandmother had similar symptoms after her retirement.

10. He does not smoke, drink alcohol, or use illicit drugs.

11. The physical examination reveals a restless ill-groomed man.

12. He is having intermittent involuntary dance-like movements.

13. The slit-lamp ophthalmic examination is normal.

14. His mini-mental state examination (MMSE) score is 22/30.

15. The complete blood count, basic metabolic profile, thyroid profile, liver profile, serum vitamin B12, and ceruloplasmin levels are within normal range.

Neurology with Special Qualification in Child Neurology


Question: Which of the following statements best describes the study?

Context: The mean hemoglobin level for the normal weight group is 13.4 g/dL and 13.8 g/dL for the overweight group.

Choices:
A. If the null hypothesis is not true, 10% or more of the volunteers would not show any association between hemoglobin level and weight.
B. If the null hypothesis is not true, there is still a 10% probability to not get this difference of 0.4 g/dL or higher due to chance.
C. If the null hypothesis is true, there is still a 10% probability of not getting this difference of 0.4 g/dL or higher due to chance.
D. If the null hypothesis is true, there is a 10% probability to get this difference of 0.4 g/dL or higher due to chance.

Answer: If the null hypothesis is true, there is a 10% probability to get this difference of 0.4 g/dL or higher due to chance.

1. A researcher is studying the association between hemoglobin levels and BMI.

2. He divides volunteers who wish to participate into 2 groups based on their BMI, a normal weight group and an overweight group.

3. He then measures the hemoglobin level of all of the volunteers.

4. His null hypothesis is that there is no association between hemoglobin levels and body weight.

5. The mean hemoglobin level for the normal weight group is 13.4 g/dL.

6. The mean hemoglobin level for the overweight group is 13.8 g/dL.

7. He obtains a mean difference of 0.4 g/dL between the 2 groups.

8. He does an unpaired t-test and gets a p-value of 0.10.


Question: Which of the following embryologic structures most likely gave rise to the structure that was damaged in this patient?

Context: A 51-year-old female with a history of papillary thyroid carcinoma who is two weeks status-post thyroidectomy presents to her surgeon complaining of difficulty with her voice.

Context: Following the operation, she developed immediate hoarseness and difficulty speaking.

Context: The hoarseness has not improved since the operation.

Context: Her past medical history is notable for hypertension and obesity.

Context: Her temperature is 99°F (37.2°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 16/min.

Choices:
A. First branchial arch
B. Second branchial arch
C. Fourth branchial arch
D. Sixth branchial arch

Answer: Sixth branchial arch

2. Patient has a history of papillary thyroid carcinoma.

3. Patient is two weeks status-post thyroidectomy.

4. Patient presents to her surgeon complaining of difficulty with her voice.

5. Patient developed immediate hoarseness and difficulty speaking following the operation.

6. Hoarseness has not improved since the operation.

7. Patient's past medical history is notable for hypertension and obesity.

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

9. Patient's blood pressure is 120/80 mmHg.

12. Physical examination reveals a healing surgical scar without evidence of infection or dehiscence.


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

Context: Six days after admission to the hospital for treatment of infective endocarditis, a 64-year-old woman develops persistent ringing in both ears, lightheadedness, and nausea.

Context: When she turns her head, she sees the light on the ceiling swinging from side to side.

Context: She has congestive heart disease, hypertension, and coronary artery disease.

Context: She was treated for a cerebrovascular accident 7 years ago and has no residual deficits.

Context: Current medications include intravenous vancomycin and gentamicin, as well as oral aspirin, atenolol, furosemide, and lisinopril.

Context: Her vital signs are within normal limits.

Context: While the patient fixates on a target, administration of brisk, horizontal head rotations to both sides results in corrective saccades to refixate back to the target.

Context: She has an unsteady gait.

Context: Muscle strength and sensation are normal.

Choices:
A. Decreased endolymph resorption
B. Suppurative labyrinthitis
C. Medication toxicity
D. Delirium

Answer: Medication toxicity

2. Patient has been admitted to the hospital for 6 days for treatment of infective endocarditis.

3. Patient has persistent ringing in both ears, lightheadedness, and nausea.

4. When patient turns her head, she sees the light on the ceiling swinging from side to side.

5. Patient has congestive heart disease, hypertension, and coronary artery disease.

6. Patient was treated for a cerebrovascular accident 7 years ago and has no residual deficits.

7. Patient is currently taking intravenous vancomycin and gentamicin, as well as oral aspirin, atenolol, furosemide, and lisinopril.

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

9. Cardiac examination shows a grade 3/6 holosystolic murmur along the left lower sternal border.

10. When patient fixates on a target, administration of brisk, horizontal head rotations to both sides results in corrective saccades to refixate back to the target.

12. Patient's muscle strength and sensation are normal.


Question: Which of the following cardiac conditions are the most likely long-term consequence of the patient’s clinical presentation and hospitalization?

Context: A patient with congestive heart failure with viral myocarditis due to coxsackievirus infection presents to a local hospital for treatment and then returns home.

Choices:
A. Concentric hypertrophy
B. Dilated cardiomyopathy
C. Endarteritis obliterans
D. Hypertrophic cardiomyopathy

Answer: Dilated cardiomyopathy

1. A patient presents to a local hospital.

2. The patient has congestive heart failure.

4. The cause of the viral myocarditis is coxsackievirus infection.


Question: This patient should be screened for abnormalities in which of the following organs?

Context: His mother has no complaints.

Choices:
A. Adrenal glands
B. Bone
C. Eyes
D. Kidneys

Answer: Kidneys

1. A 5-year-old male presents to the pediatrician with his mother for a well child visit.

3. The patient is doing well in preschool and appears to be ready for kindergarten.

4. He can begin to sound out letters and write out his first name.

5. He has many friends at school and enjoys playing with his older siblings.

6. The patient’s past medical history is notable for birth weight in the 99th percentile and unexplained hypoglycemia in the first week of life.

7. The patient’s mother denies any family history of genetic syndromes or malignancy.

8. The patient’s height and weight are in the 99th percentile.

9. On physical exam, the patient has an enlarged tongue with no other dysmorphic features.

10. He also has the physical exam findings seen in Figures A and B.


Question: What type of tissue is causing the scar to form on my abdomen?" The physician promptly answers:

Context: A first-year medical student undergoes a surgical procedure involving a midline laporotomy incision.

Context: The patient presents back to the surgeon approximately 3 months later and asks the surgeon: ".

Choices:
A. Keratin
B. Type 1 collagen
C. Type 2 collagen
D. Type 4 collagen

Answer: Type 1 collagen

1. A first-year medical student underwent a surgical procedure.

2. The surgical procedure involved a midline laporotomy incision.

3. The patient presented back to the surgeon approximately 3 months later.

4. The patient asked the surgeon a question.


Question: The patient’s lesion is likely composed of functional cells from which of the following regions:

Context: Her blood pressure is 180/140 mm Hg, and serum potassium is 3.2 mEq/L.

Context: Plasma renin levels are abnormally low.

Choices:
A. Zona glomerulosa
B. Zona fasciculata
C. Adrenal medulla
D. Posterior pituitary

Answer: Zona glomerulosa

1. A 40-year-old female complains of muscle weakness.

4. Her plasma renin levels are abnormally low.

5. A CT scan of her abdomen reveals a 3 cm lesion in her right adrenal gland.


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

Context: A 75-year-old woman is brought to the physician by her daughter because of a 1-month history of fatigue and a 3.5-kg (7-lb) weight loss.

Context: The patient has a history of hypertension, hyperlipidemia, and Alzheimer's dementia.

Context: Her daughter has hypothyroidism but there is no other history of serious illness in the family.

Context: The thyroid gland is not palpable.

Choices:
A. Graves disease
B. Exogenous levothyroxine use
C. Granulomatous thyroiditis
D. Iodine exposure

Answer: Exogenous levothyroxine use

1. A 75-year-old woman is brought to the physician by her daughter.

2. She has a 1-month history of fatigue and a 3.5-kg (7-lb) weight loss.

3. She has a history of hypertension, hyperlipidemia, and Alzheimer's dementia.

4. She lives with her daughter and requires assistance with all of her banking and meal preparation.

6. There is no other history of serious illness in the family.

7. She does not remember the names of her medications but says she takes them every day.

8. Her pulse is 114/min and blood pressure is 148/101 mm Hg.

9. Physical examination shows warm skin and a tremor.

11. The serum thyroid stimulating hormone level is undetectable.

12. Histological examination of a thyroid biopsy shows follicular atrophy.


Question: Which of the following types of shock best describes this patient's condition?

Context: A 42-year-old man is brought to the emergency department by EMS from the scene of an automobile accident, where he appeared to be an unrestrained passenger.

Context: The patient is confused and unable to answer questions.

Context: His temperature is 98.6°F (37°C), pulse is 120/min, blood pressure is 75/44 mmHg, and respiratory rate is 22/min.

Context: On physical exam, there is bruising over his sternum and left chest, with tenderness to palpation.

Context: He has marked jugular venous distention and bibasilar crackles on pulmonary auscultation with equal air entry bilaterally.

Context: His extremities are cool with prolonged capillary refill, and he is diaphoretic.

Context: The patient is admitted to the intensive care unit and hemodynamic monitoring is established, which reveals a pulmonary capillary wedge pressure (PCWP) of 22 mmHg (normal range 8-12 mmHg), central venous pressure (CVP) of 12 cmH2O (normal range 4-12 cmH2O), cardiac output (CO) of 2.2 L/min (normal range 4-8 L/min), and systemic vascular resistance (SVR) of 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5).

Choices:
A. Cardiogenic
B. Anaphylactic
C. Neurogenic
D. Obstructive

Answer: Cardiogenic

2. Patient was brought to the emergency department by EMS from the scene of an automobile accident.

3. Patient appeared to be an unrestrained passenger.

4. Patient is confused and unable to answer questions.

5. Patient's temperature is 98.6°F (37°C).

7. Patient's blood pressure is 75/44 mmHg.

8. Patient's respiratory rate is 22/min.

9. Patient has bruising over his sternum and left chest, with tenderness to palpation.

10. Cardiac auscultation reveals normal heart sounds with no murmurs, rubs, or gallops.

11. Patient has marked jugular venous distention.

12. Patient has bibasilar crackles on pulmonary auscultation with equal air entry bilaterally.

13. Abdominal and cranial nerve exams are within normal limits.

14. Patient's extremities are cool with prolonged capillary refill.

16. Patient is admitted to the intensive care unit.

17. Hemodynamic monitoring is established.

18. Pulmonary capillary wedge pressure (PCWP) is 22 mmHg (normal range 8-12 mmHg).

19. Central venous pressure (CVP) is 12 cmH2O (normal range 4-12 cmH2O).

20. Cardiac output (CO) is 2.2 L/min (normal range 4-8 L/min).

21. Systemic vascular resistance (SVR) is 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5).


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

Context: A 23-year-old man comes to the emergency department complaining of 10/10 abdominal pain.

Context: It started about 3 hours ago with no obvious precipitating factor.

Context: He denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes but endorses “red-colored urine” for the past day.

Choices:
A. Hereditary defect of amino acid transporter in the kidney
B. Infection with urease positive bacteria
C. Presence of antibodies to the glomerular basement membrane
D. Thinning and splitting of the glomerular basement membrane

Answer: Hereditary defect of amino acid transporter in the kidney

1. A 23-year-old man comes to the emergency department.

2. He is complaining of 10/10 abdominal pain.

3. He describes the pain as sharp, stabbing, intermittent, and concentrated at the left lower quadrant.

4. The pain started about 3 hours ago with no obvious precipitating factor.

5. He reports multiple similar episodes in the past but they have all resolved within 1 hour or so.

6. He denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes.

7. He endorses “red-colored urine” for the past day.

8. He just returned from an extensive hiking trip in Colorado.

9. A radiograph of the abdomen was unremarkable.


Question: Which of the following is a side-effect of definitive treatment for this patient?

Context: A 33-year-old African American woman presents to the emergency department due to diffuse pain and fatigue.

Context: The woman states that she feels like her bones and muscles diffusely hurt.

Context: She also has experienced some abdominal pain as well and states that she has trouble focusing.

Context: The patient has a past medical history of sickle cell disease for which she takes hydroxyurea.

Context: Her temperature is 98.1°F (36.7°C), blood pressure is 119/59 mmHg, pulse is 130/min, respirations are 16/min, and oxygen saturation is 98% on room air.

Choices:
A. Dilute urine
B. Peaked T-waves on ECG
C. QT shortening on ECG
D. Tetany

Answer: Tetany

1. A 33-year-old African American woman presents to the emergency department.

2. The woman states that she has diffuse pain and fatigue.

3. She also has experienced some abdominal pain.

5. The patient has a past medical history of sickle cell disease.

6. The patient takes hydroxyurea for her sickle cell disease.

7. The patient's temperature is 98.1°F (36.7°C).

8. The patient's blood pressure is 119/59 mmHg.

10. The patient's respirations are 16/min.

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

12. Laboratory values are ordered and are currently pending.

Endocrinology, Diabetes, and Metabolism
General Internal Medicine
Rheumatology


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

Context: A 40-year-old man with psoriatic arthritis comes to the physician because of progressively worsening pain and stiffness in both of his hands and feet for the past 3 weeks.

Context: Physical examination shows scaly plaques on both elbows and limited range of motion of most of the larger joints.

Choices:
A. Suppression of the bone marrow
B. Decreased ionization by the glomeruli
C. Formation of antidrug antibodies
D. Increased acetylation by the liver

Answer: Formation of antidrug antibodies

1. A 40-year-old man has psoriatic arthritis.

2. He has been experiencing progressively worsening pain and stiffness in both of his hands and feet for the past 3 weeks.

3. His psoriatic arthritis had been well-controlled with adalimumab for several years prior to this.

4. His only other medication is omeprazole.

5. Physical examination shows scaly plaques on both elbows.

6. Physical examination shows limited range of motion of most of the larger joints.


Question: This abnormal lab finding was most likely caused by increased activity of which of the following mediators?

Context: A 35-year-old African American female presents to the emergency department with a three day history of cough, chest pain, and fever.

Context: Upon presenting to the emergency department, her temperature is 101.4 °F (38.5 °C), blood pressure is 110/80 mmHg, pulse is 95/min, and respirations are 24/min.

Context: The patient undergoes lab tests in the emergency department that demonstrate an elevated level of C-reactive protein.

Choices:
A. IL-12
B. IL-8
C. IL-6
D. IL-2

Answer: IL-6

1. A 35-year-old African American female presents to the emergency department.

2. She has a three day history of cough, chest pain, and fever.

3. Her temperature is 101.4 °F (38.5 °C).

7. Lung auscultation reveals crackles over the left lung base.

8. Chest radiograph reveals a dense consolidation in the left lower lung.

9. The patient undergoes lab tests in the emergency department.

10. The lab tests demonstrate an elevated level of C-reactive protein.


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

Context: He has no shortness of breath.

Context: He drinks 1–2 beers a week.

Context: His temperature is 37.1°C (98.8°F), pulse is 78/min, and blood pressure is 126/72 mm Hg.

Context: An x-ray of the chest shows no fracture; there is a 5-mm lesion in the right upper lung field.

Choices:
A. Follow-up x-ray of the chest in 12 months
B. Positron emission tomography
C. CT scan of the chest
D. Reassurance

Answer: CT scan of the chest

1. A 50-year-old man comes to the physician after a fall on a flight of stairs earlier that day.

2. He slipped, causing him to fall and hit the handrail with the lateral part of his chest.

4. He returned from a 10-day trip to South Africa 4 weeks ago.

5. He smoked one pack of cigarettes daily for 10 years but stopped 18 years ago.

10. Examination shows normal breath sounds bilaterally.

11. The left lateral chest wall is tender to palpation.

12. An x-ray of the chest shows no fracture.

13. There is a 5-mm lesion in the right upper lung field.

14. There are no previous x-rays of the patient available.

General Orthopaedic Surgery
Orthopaedic Sports Medicine


Question: White blood cell (WBC) count  1,500/mm3 | Platelets 300,000/mm3 | Which of the following organisms is most likely responsible for this patient’s condition?

Context: A 62-year-old woman presents to a clinic with complaints of a worsening rash on her back, fevers with chills, and rigor for 2 days.

Context: She denies any headaches, nausea, or vomiting.

Context: She is currently on chemotherapy for multiple myeloma, which was diagnosed last year.

Context: The vital signs include: temperature 38.8°C (102.0°F), respirations 24/min, pulse 110/min, and blood pressure 100/90 mm Hg.

Context: Laboratory studies show: | Hemoglobin 8.4 g/dL | .

Choices:
A. Pseudomonas aeruginosa
B. Streptococcus pneumoniae
C. Haemophilus influenzae
D. Streptococcus pyogenes

Answer: Pseudomonas aeruginosa

2. Patient has a worsening rash on her back, fevers with chills, and rigor for 2 days.

3. Patient denies any headaches, nausea, or vomiting.

4. Patient is currently on chemotherapy for multiple myeloma, which was diagnosed last year.

5. On examination, there were multiple punched-out ulcers covered in crusts surrounded by raised, violaceous margins on her back. Some of the lesions have black necrotic centers.

6. Vital signs include: temperature 38.8°C (102.0°F), respirations 24/min, pulse 110/min, and blood pressure 100/90 mm Hg.

7. Laboratory studies show: Hemoglobin 8.4 g/dL.


Question: Which of the following enzymes is most likely inhibited by this toxin?

Context: The mushrooms in the soup had been picked from his family's backyard, and samples of mushrooms were sent to the lab for analysis.

Choices:
A. DNA gyrase
B. RNA polymerase II
C. RNA polymerase I
D. RNA polymerase III

Answer: RNA polymerase II

1. An 8-year-old boy developed nausea, abdominal pain, and watery diarrhea 6 hours after consuming homemade mushroom soup.

2. The boy is rushed to the emergency department.

3. He is severely dehydrated and his blood pressure is 60/40 mm Hg.

4. He is managed with intravenous fluids and other supportive treatment.

5. The mushrooms in the soup had been picked from his family's backyard.

6. Samples of mushrooms were sent to the lab for analysis.

7. The lab reports confirmed that the mushrooms contained some kind of toxin.


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

Context: A 6-year-old girl is brought to the physician because of generalized fatigue and dark urine for 4 days.

Context: Her temperature is 37°C (98.6°F) and blood pressure is 132/89 mm Hg.

Context: Her serum creatinine is 1.7 mg/dL.

Context: Urine studies show: | Blood 2+ | Protein 2+ | RBC 12–14/hpf with dysmorphic features | RBC casts numerous | .

Choices:
A. Granular subepithelial immune complex deposition
B. Systemic amyloid protein aggregation
C. Anti-type IV collagen antibody formation
D. DNA-anti-DNA antibody immune complex formation

Answer: Granular subepithelial immune complex deposition

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

2. She has had generalized fatigue and dark urine for 4 days.

3. Four weeks ago, she was treated with cephalexin for a skin infection.

6. Physical examination shows 1+ pretibial edema bilaterally.

10. Urine studies show: RBC 12–14/hpf with dysmorphic features.

11. Urine studies show: RBC casts numerous.


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

Context: A 7-year-old girl is brought to the physician by her mother for a 6-month history of irritability.

Context: She has no history of significant illness and is up-to-date on her immunizations.

Context: She appears markedly lethargic.

Context: Her hemoglobin concentration is 9.2 g/dL and mean corpuscular volume is 76 μm3.

Choices:
A. Necator americanus
B. Enterobius vermicularis
C. Trichuris trichiura
D. Taenia solium

Answer: Necator americanus

1. A 7-year-old girl is brought to the physician by her mother.

2. She has a 6-month history of irritability.

3. She has no history of significant illness.

4. She is up-to-date on her immunizations.

6. Her vital signs are within normal limits.

7. Physical examination shows subconjunctival pallor.

8. Her hemoglobin concentration is 9.2 g/dL.

9. Her mean corpuscular volume is 76 μm3.

10. A photomicrograph of a wet stool mount is shown.


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

Context: A 15-year-old girl is brought to the physician by her mother because of a 3-day history of lower abdominal pain.

Context: Over the past 9 months, she has had multiple similar episodes of abdominal pain, each lasting for 4–5 days.

Context: Menarche has not yet occurred.

Choices:
A. Labial adhesions
B. Androgen insensitivity
C. Endometriosis
D. Imperforate hymen

Answer: Imperforate hymen

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

3. Patient has a 3-day history of lower abdominal pain.

4. Patient has had multiple similar episodes of abdominal pain over the past 9 months.

5. Each episode of abdominal pain has lasted for 4–5 days.

6. Patient has not yet experienced menarche.

7. Examination shows suprapubic tenderness to palpation.

8. Pubic hair and breast development are Tanner stage 4.

9. Pelvic examination shows bulging, bluish tissue 1 cm inside the vaginal introitus.


Question: In addition to symptomatic treatment, which of the following antiviral drugs would most likely benefit this patient?

Context: A 6-year-old boy presents with high fever, sore throat, and cough for the past day.

Context: The patient’s mother also says he is complaining of generalized muscle aches and chills.

Context: Past medical history is significant for childhood asthma, managed with inhaled mometasone furoate.

Context: The patient’s temperature is 39.1°C (102.3°F), pulse is 120/min, and respiratory rate is 20/min.

Context: On physical examination, his oropharynx is erythematous with mild swelling of the pharyngeal tonsils.

Context: There are no signs of respiratory distress.

Choices:
A. Amantadine
B. Ribavirin
C. Rimantadine
D. Oseltamivir

Answer: Oseltamivir

2. Patient has high fever, sore throat, and cough for the past day.

3. Patient is complaining of generalized muscle aches and chills.

4. Patient has past medical history of childhood asthma, managed with inhaled mometasone furoate.

5. Patient's temperature is 39.1°C (102.3°F).

7. Patient's respiratory rate is 20/min.

8. Patient's oropharynx is erythematous with mild swelling of the pharyngeal tonsils.

9. Chest auscultation reveals crepitus over the lung bases bilaterally.

10. Patient has no signs of respiratory distress.

11. Rapid diagnostic testing for influenza B infection in this patient is positive.


Question: Which of the following is most likely to be below the normal range in her blood due to her current condition?

Context: A 38-year-old woman presents to the emergency department with nausea and progressive right upper quadrant abdominal pain for the past day.

Context: For the past year, she has had occasional pain in her right upper quadrant which is often relieved on its own after a few hours.

Context: She was recently diagnosed with multiple gallstones for which she underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago.

Context: Past medical history is otherwise unremarkable.

Context: Vital signs include blood pressure 110/68 mm Hg, pulse 98/min, temperature 36.2°C (97.2°F), and respiratory rate 11/min.

Context: Laboratory tests are pending.

Context: An imaging study of the abdomen confirms the most likely diagnosis.

Choices:
A. Trypsinogen
B. C-reactive protein
C. Glucose
D. Calcium

Answer: Calcium

2. Patient presents with nausea and progressive right upper quadrant abdominal pain for the past day.

3. Patient has had occasional pain in her right upper quadrant for the past year, which is often relieved on its own after a few hours.

4. Patient was recently diagnosed with multiple gallstones.

5. Patient underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago.

6. Patient's past medical history is otherwise unremarkable.

7. On physical examination, there is tenderness over the epigastrium with no guarding or rebound.

8. Patient's vital signs include blood pressure 110/68 mm Hg, pulse 98/min, temperature 36.2°C (97.2°F), and respiratory rate 11/min.

10. Imaging study of the abdomen confirms the most likely diagnosis.


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

Context: A 42-year-old woman comes to the emergency department because of hematuria and pain in both flanks.

Context: She also complains of swelling of both feet and facial puffiness.

Context: Her mother also has a history of urinary stone and underwent a kidney transplant.

Context: Her temperature is 38.0°C (100.4°F), pulse is 110/min, and blood pressure is 150/98 mm Hg.

Choices:
A. Osteolytic bone lesions
B. Multiple hepatic cysts
C. Mitral valve stenosis
D. Popliteal aneurysm

Answer: Multiple hepatic cysts

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

2. She has hematuria and pain in both flanks.

3. She has a history of recurrent urinary tract infections.

4. She complains of swelling of both feet and facial puffiness.

5. She has passed urinary stones twice before.

6. Her mother has a history of urinary stone and underwent a kidney transplant.

10. Abdominal examination shows palpable, bilateral flank masses.

11. Results of a complete blood count are within the reference range.

12. Her serum creatinine concentration is 2.7 mg/dL.


Question: Given the following options, what is the next best step in patient management?

Context: A 51-year-old man with a past medical history of peptic ulcer disease currently treated via outpatient triple therapy presents to the urgent care center complaining of acute abdominal pain which began suddenly less than 2 hours ago.

Context: The physical examination shows his abdomen to be mildly distended, diffusely tender to palpation, and positive for rebound tenderness.

Context: Physical exam is unremarkable.

Context: The vital signs include: temperature 36.7°C (98.0°F), blood pressure 96/54 mm Hg, heart rate 112/min, and respiratory rate 19/min.

Choices:
A. Abdominal radiographs
B. CT abdomen and pelvis
C. H. pylori testing
D. Serum gastrin level

Answer: CT abdomen and pelvis

1. A 51-year-old man has a past medical history of peptic ulcer disease.

2. He is currently treated via outpatient triple therapy.

3. He presents to the urgent care center complaining of acute abdominal pain.

4. The pain began suddenly less than 2 hours ago.

5. The physical examination shows his abdomen to be mildly distended.

6. His abdomen is diffusely tender to palpation.

7. His abdomen is positive for rebound tenderness.

8. His physical exam is otherwise unremarkable.


Question: Which of the following is mostly responsible for this patient's late onset of symptoms?

Context: A 10-month-old boy is brought to the physician because of fever and a cough for 3 days.

Context: He was also treated for pneumococcal pneumonia and H.

Context: influenzae meningitis this past month.

Context: He was delivered at term.

Context: He is at the 20th percentile for height and the 10th percentile for weight.

Context: His temperature is 39°C (102.2°F), pulse is 122/min, and respirations are 44/min.

Context: Palatine tonsils are absent.

Choices:
A. Reduced T-cell receptor excision circles by 6 months
B. Involution of the thymus begins at 6 months
C. Splenic dysfunction occurs by 6 months
D. Maternal IgG decreases by 6 months

Answer: Maternal IgG decreases by 6 months

1. A 10-month-old boy is brought to the physician.

2. He has had a fever and a cough for 3 days.

3. He was treated for otitis media 3 and 4 months ago.

4. He was treated for pneumococcal pneumonia and H. influenzae meningitis this past month.

6. Pregnancy and neonatal period were uncomplicated.

7. He was breast-fed until 6 months of age.

8. He has a maternal uncle who died of recurrent respiratory tract infections at 28 years of age.

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

10. He is at the 10th percentile for weight.

14. Examination shows crackles at the left lung base.

16. An x-ray shows an infiltrate in the left lower lung lobe.

17. Flow cytometry shows absence of B-cells.


Question: Which of the following is the most inclusive list of spinal roots that contribute to the affected nerve in this patient?

Context: A 55-year-old right-handed woman is being evaluated for a long history of numbness and tingling in both of her hands, particularly in the third digits, that is worse at night.

Context: She works as a medical office assistant in a local travel medicine clinic.

Context: Her past medical history is significant for hypothyroidism, managed medically with thyroxine.

Context: Physical examination showed thenar eminence atrophy, decreased sensation in the 3 first digits of both hands that extends proximally, and weakness on thumb abduction and thumb opposition; deep tendon reflexes are normal.

Context: Phalen and Tinel tests are positive.

Choices:
A. C4, C5
B. C6, C7, C8
C. C3, C4, C5
D. C5, C6, C7, C8, T1

Answer: C5, C6, C7, C8, T1

1. Patient is a 55-year-old right-handed woman.

2. Patient has a long history of numbness and tingling in both hands, particularly in the third digits, that is worse at night.

3. Patient works as a medical office assistant in a local travel medicine clinic.

4. Patient has a past medical history of hypothyroidism, managed medically with thyroxine.

5. Physical examination showed thenar eminence atrophy.

6. Physical examination showed decreased sensation in the 3 first digits of both hands that extends proximally.

7. Physical examination showed weakness on thumb abduction and thumb opposition.

8. Physical examination showed normal deep tendon reflexes.


Question: Surgical correction of this patient's condition will most likely prevent which of the following from developing later in life?

Context: A 7-year-old girl is referred to a pediatric cardiologist after a heart murmur was auscultated during a routine school health examination.

Context: She is healthy, does not have any significant medical history, and had an uneventful birth without any complications.

Context: Her vital signs are as follows: T 37.2 C, HR 92, BP 104/62, RR 24, SpO2 99%.

Context: Physical examination is significant for a midsystolic ejection murmur heard best at the 2nd intercostal space near the left sternal border, a loud S1 heart sound, a widely fixed split S2 heart sound, and no evidence of cyanosis or clubbing.

Context: An echocardiogram is conducted and reveals a left-to-right shunt across the interatrial septum.

Choices:
A. Arteriovenous fistula
B. Pulmonary stenosis
C. Pulmonary hypertension
D. Aortic root dilation

Answer: Pulmonary hypertension

1. A 7-year-old girl is referred to a pediatric cardiologist.

2. The referral is due to a heart murmur auscultated during a routine school health examination.

3. The patient has not experienced any symptoms of shortness of breath, fatigue, chest pain, or palpitations.

4. The patient is healthy and does not have any significant medical history.

5. The patient had an uneventful birth without any complications.

8. The patient's blood pressure is 104/62.

9. The patient's respiratory rate is 24.

11. Physical examination is significant for a midsystolic ejection murmur heard best at the 2nd intercostal space near the left sternal border.

12. Physical examination is also significant for a loud S1 heart sound.

13. Physical examination is also significant for a widely fixed split S2 heart sound.

14. Physical examination is also significant for no evidence of cyanosis or clubbing.

16. The echocardiogram reveals a left-to-right shunt across the interatrial septum.


Question: Which of the following is the most likely explanation of the patient's laboratory findings?"

Context: A 21-year-old man is brought to the emergency department by the police because of altered mental status.

Context: His temperature is 38.2°C (100.8°F), pulse is 100/min, respirations are 28/min, and blood pressure is 110/77 mm Hg.

Context: Laboratory studies show: | Serum | Na+ 140 mEq/L | Cl- 102 mEq/L | Arterial blood gas analysis on room air: | On admission Three hours later | pH 7.47 7.39 | PaCO2 24 mm Hg 31 mm Hg | PO2 84 mm Hg 82 mm Hg | HCO3- 20 mEq/L 18 mEq/L | .

Choices:
A. Salicylate toxicity
B. Diabetic ketoacidosis
C. Recurrent vomiting
D. Adrenal insufficiency

Answer: Salicylate toxicity

1. A 21-year-old man is brought to the emergency department by the police.

2. The police found him covering his ears and shouting near a highway rest area.

3. Upon questioning, he was unable to look directly at the police and answer coherently.

4. On the way to the hospital, he reported feeling nauseous and vomited twice.

9. He is admitted to the hospital for evaluation.

10. Three hours after admission, he has a tonic-clonic seizure.

13. Arterial blood gas analysis on room air pH on admission is 7.47.

14. Arterial blood gas analysis on room air PaCO2 on admission is 24 mm Hg.

15. Arterial blood gas analysis on room air PO2 on admission is 84 mm Hg.

16. Arterial blood gas analysis on room air HCO3- on admission is 20 mEq/L.

17. Arterial blood gas analysis on room air pH three hours later is 7.39.

18. Arterial blood gas analysis on room air PaCO2 three hours later is 31 mm Hg.

19. Arterial blood gas analysis on room air PO2 three hours later is 82 mm Hg.

20. Arterial blood gas analysis on room air HCO3- three hours later is 18 mEq/L.


Question: Which of the following is the most likely mechanism of action for this treatment?

Context: A 58-year-old man makes an appointment with his nephrologist because he has been feeling weak and increasingly fatigued over the last month.

Context: Specifically, he has not been able to do activities of daily living independently because he feels short of breath after several minutes of activity.

Context: Laboratory tests are obtained and results are shown below: |  | Hemoglobin: 8.9 g/dL (normal: 13.5-17.5 g/dL) | Platelet count: 198,000/mm^3 (normal: 150,000-400,000/mm^3) | Mean corpuscular volume: 87 µm^3 (normal: 80-100 µm^3) | Reticulocyte count: 0.1% (normal: 0.5-1.5%) |  | Based on these findings, the patient is given appropriate treatment to address his symptoms.

Choices:
A. Activation of receptors on erythroid progenitor cells
B. Chelation of heavy metals
C. Provision of finished blood products
D. Removal of red blood cell clearing organ

Answer: Activation of receptors on erythroid progenitor cells

1. A 58-year-old man makes an appointment with his nephrologist.

2. He has been feeling weak and increasingly fatigued over the last month.

3. He has not been able to do activities of daily living independently because he feels short of breath after several minutes of activity.

4. His past medical history is significant for rapidly progressive glomerulonephritis that led to kidney failure.

5. He has been on hemodialysis for the last 6 months and has been compliant with attending every dialysis session.

6. Physical exam reveals conjunctival pallor.

7. Laboratory tests are obtained and results are shown below:

8. Hemoglobin: 8.9 g/dL (normal: 13.5-17.5 g/dL)

10. Mean corpuscular volume: 87 µm^3 (normal: 80-100 µm^3)

11. Reticulocyte count: 0.1% (normal: 0.5-1.5%)

12. Based on these findings, the patient is given appropriate treatment to address his symptoms.


Question: Which of the following best describes the pathogenesis of this patient's histopathological findings?

Context: A 33-year-old African American woman comes to the physician because of a 4-month history of progressive fatigue, shortness of breath, constipation, and a nonproductive cough.

Context: Physical examination is unremarkable.

Choices:
A. MHC I binding to CD8+ T cells
B. Antigen binding to IgM
C. TNF-α secretion by CD4+ T cells
D. IL-5 secretion by Th2 cells

Answer: TNF-α secretion by CD4+ T cells

1. A 33-year-old African American woman comes to the physician.

2. She has a 4-month history of progressive fatigue, shortness of breath, constipation, and a nonproductive cough.

3. She returned from a trip to Nigeria 6 months ago.

4. Physical examination is unremarkable.

5. Serum calcium concentration is 11.7 mg/dL.

6. An x-ray of the chest shows bilateral hilar lymphadenopathy with coarse, nodular opacities in both lower lobes.

7. A photomicrograph of a biopsy specimen of the affected area of the lungs is shown.


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

Context: A 15-day-old female newborn is brought to the physician for evaluation of red eyes with discharge for 3 days.

Context: She was born at 37 weeks' gestation to a 26-year-old woman.

Context: Examination of the newborn shows watery discharge in both eyes and mild eyelid swelling.

Choices:
A. Staphylococcus aureus
B. Chlamydia trachomatis
C. Neisseria gonorrhoeae
D. Herpes simplex virus 2

Answer: Chlamydia trachomatis

1. A 15-day-old female newborn was brought to the physician for evaluation of red eyes with discharge for 3 days.

2. The newborn was born at 37 weeks' gestation.

4. Pregnancy and delivery were uncomplicated.

5. The mother received irregular prenatal care during the 3rd trimester of pregnancy.

6. Examination of the newborn showed watery discharge in both eyes.

7. Examination of the newborn showed mild eyelid swelling.


Question: Which of the following consequences would be expected?

Context: He injects the spinal cord with a protease that cleaves SNARE proteins, thereby blocking the release of neurotransmitters from the Renshaw cells in the spinal cord.

Choices:
A. Disinhibited behavior
B. Hydrophobia
C. Positive Kernig sign
D. Spastic paralysis

Answer: Spastic paralysis

1. An investigator is studying central nervous system neurotransmitters in mice.

2. He injects the spinal cord with a protease.

4. The cleaving of SNARE proteins blocks the release of neurotransmitters from the Renshaw cells in the spinal cord.


Question: Her present condition places her at increased risk for which of the following:

Context: A 32-year-old G2P2 at 33 weeks and 4 days of gestation presents to the emergency room with low-grade fever, mild low back pain, and dysuria for 1 day.

Context: She has a history of urinary tract infections, including one during this current pregnancy that was treated successfully with cephalexin.

Context: On examination, she is nontoxic but mildly uncomfortable; she has CVA tenderness on her right side.

Context: Her urinalysis is positive for leukocyte esterase and nitrites, and she is admitted to the hospital for IV antibiotics with ceftriaxone.

Choices:
A. Low birth weight
B. Pre-eclampsia
C. Postpartum hemorrhage
D. Preterm labor

Answer: Preterm labor

1. A 32-year-old G2P2 is presenting to the emergency room.

2. She is 33 weeks and 4 days of gestation.

3. She has low-grade fever, mild low back pain, and dysuria for 1 day.

4. She has a history of urinary tract infections.

5. She had a UTI during this current pregnancy.

6. The UTI was treated successfully with cephalexin.

7. On examination, she is nontoxic but mildly uncomfortable.

8. She has CVA tenderness on her right side.

9. Her urinalysis is positive for leukocyte esterase and nitrites.

10. She is admitted to the hospital for IV antibiotics with ceftriaxone.

General Obstetrics and Gynecology
General Obstetrics and Gynecology.


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

Context: A 16-year-old African-American boy is brought to the physician because of a 2-month history of progressive right shoulder pain.

Context: He has had many episodes of joint and bone pain in the past, and as a child, had recurrent painful swelling of his hands and feet.

Context: His brother had a stroke at 6 years of age and now has an intellectual disability.

Context: The patient is at the 60th percentile for height and 55th percentile for weight.

Context: His vital signs are within normal limits.

Context: Physical examination shows tenderness of the right anterior humerus without noticeable swelling or skin changes.

Context: Active and passive range of motion of the right shoulder is decreased and there is pain with movement.

Context: The leukocyte count is 4600/mm3.

Context: An x-ray of the right shoulder shows subchondral lucency of the humeral head with sclerosis and joint space narrowing.

Choices:
A. Infection of the dermis and subcutaneous tissue
B. Infection of the bone
C. Infarction of the bone trabeculae
D. Loss of bone mineral density

Answer: Infarction of the bone trabeculae

3. Patient has had 2 months of progressive right shoulder pain.

4. Patient has had many episodes of joint and bone pain in the past.

5. Patient had recurrent painful swelling of hands and feet as a child.

6. Patient's brother had a stroke at 6 years of age.

7. Patient's brother has an intellectual disability.

8. Patient is at 60th percentile for height.

9. Patient is at 55th percentile for weight.

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

11. Physical examination shows tenderness of right anterior humerus without noticeable swelling or skin changes.

12. Active and passive range of motion of right shoulder is decreased.

13. Patient has pain with movement of right shoulder.

15. X-ray of right shoulder shows subchondral lucency of humeral head with sclerosis and joint space narrowing.


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

Context: A 50-year-old woman comes to the emergency department after waking up with facial swelling and with difficulties swallowing.

Context: She was recently diagnosed with hypertension and started on an antihypertensive drug.

Context: She follows a strict vegetarian diet.

Context: Her pulse is 110/min and blood pressure is 135/85 mm Hg.

Context: There is no rash.

Choices:
A. Deficiency of C1 esterase inhibitor
B. Scombroid poisoning
C. Nonimmunologic release of histamine
D. Impaired breakdown of kinins

Answer: Impaired breakdown of kinins

1. A 50-year-old woman comes to the emergency department.

2. She woke up with facial swelling and difficulties swallowing.

3. She was recently diagnosed with hypertension.

4. She started on an antihypertensive drug.

5. She follows a strict vegetarian diet.

8. Physical examination shows marked edematous swelling of the face, lips, and tongue.

10. Serum C4 levels are within the reference range.


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

Context: The vital signs include: blood pressure 140/90 mm Hg, heart rate 84/min, respiratory rate 18/min, and temperature 36.6°C (98.0°F).

Context: Urinalysis reveals: | Color Yellow | Clarity/turbidity Clear | pH 5.5 | Specific gravity 1.015 | Nitrites Negative | Leukocyte esterase Negative | .

Choices:
A. Anticholinergics
B. Surgery
C. Bladder catheterization
D. Pelvic floor muscle training

Answer: Bladder catheterization

1. An 82-year-old man presents to the primary care physician with complaints of urinary leakage over the last 2 months.

2. The leakage occurred without any additional symptoms.

3. He has a history of prostatic hyperplasia.

8. Physical examination reveals a palpable and distended bladder.

10. Urinalysis clarity/turbidity is Clear.

12. Urinalysis specific gravity is 1.015.

14. Urinalysis leukocyte esterase is Negative.

Female Pelvic Medicine and Reconstructive Surgery


Question: What phenomenon describes this?

Context: A 25-year-old female presents to her geneticist due to the fear that she may have inherited her father's disease.

Context: He was diagnosed at the age of 41 when his symptoms of chorea, coordination problems, and cognitive decline begin to occur.

Context: He was diagnosed with a disease resulting from the expansion of CAG repeats on chromosome 4 and later developed severe dementia and died at the age of 56.

Context: The daughter was found to have double the amount of CAG repeats and was told by the geneticist that she may have an earlier onset with increased severity of disease.

Choices:
A. Variable expression
B. Incomplete penetrance
C. Anticipation
D. Heteroplasmy

Answer: Anticipation

1. A 25-year-old female presents to her geneticist.

2. Her father was diagnosed with a disease at the age of 41.

3. His symptoms were chorea, coordination problems, and cognitive decline.

4. The disease was caused by the expansion of CAG repeats on chromosome 4.

5. Her father developed severe dementia and died at the age of 56.

6. The daughter was found to have double the amount of CAG repeats.

7. The geneticist told her she may have an earlier onset with increased severity of disease.


Question: Which of the following antibiotics will be most effective in treating this patient’s condition?

Context: He is conscious and in distress.

Context: A sample exudate is collected with a sterile swab and sent to the laboratory for culture, which yields the growth of aerobic gram-negative rods.

Choices:
A. Azithromycin with rifampin
B. Piperacillin with gentamicin
C. Piperacillin
D. Ticarcillin

Answer: Piperacillin with gentamicin

1. A 25-year-old man presents to the emergency department after being rescued from a house fire 30 minutes ago.

3. On examination, he is noted to have 1st-degree burns involving 54% of his total body surface area.

4. He has type 1 diabetes and takes insulin every day.

5. He is admitted to the burn unit and treated appropriately.

6. Ten days after admission, the physician notices blue-green pus oozing from the burn wounds.

7. He is afebrile with a pulse of 90/min and a blood pressure of 130/80 mm Hg.

8. A sample exudate is collected with a sterile swab and sent to the laboratory for culture.

9. The laboratory culture yields the growth of aerobic gram-negative rods.


Question: Which of the following is also likely to be found in this patient?

Context: A 67-year-old man with a past medical history of obesity and diabetes presents to the emergency department with fatigue.

Context: The patient has become more confused over the past several days and has been urinating profusely.

Context: His temperature is 99.0°F (37.2°C), blood pressure is 120/68 mmHg, pulse is 160/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Context: Physical exam is notable for a confused man with dry mucous membranes.

Context: He is unable to answer simple questions and is moving all extremities spontaneously.

Choices:
A. Blurred vision
B. Meningeal symptoms
C. Seizures
D. Tremulousness

Answer: Blurred vision

1. A 67-year-old man presents to the emergency department.

2. The patient has a past medical history of obesity and diabetes.

3. The patient has become more confused over the past several days.

4. The patient has been urinating profusely.

5. The patient's temperature is 99.0°F (37.2°C).

6. The patient's blood pressure is 120/68 mmHg.

8. The patient's respirations are 19/min.

9. The patient's oxygen saturation is 98% on room air.

10. The patient is confused and has dry mucous membranes.

11. The patient is unable to answer simple questions.

12. The patient is moving all extremities spontaneously.


Question: Which of the following is the most likely etiology of liver damage in this patient?

Context: Past medical history is significant for COPD diagnosed 4 years ago, managed medically, and admission for acute pancreatitis 6 months ago.

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

Choices:
A. α1-antitrypsin (AAT) deficiency
B. Glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency)
C. Dubin–Johnson syndrome
D. Hepatitis C

Answer: α1-antitrypsin (AAT) deficiency

1. A 42-year-old man presents with acute onset jaundice.

2. Past medical history is significant for COPD diagnosed 4 years ago.

4. Patient had an admission for acute pancreatitis 6 months ago.

5. Patient denies any history of smoking.

6. Patient denies any history of alcohol use.

7. Patient denies any history of recreational drugs.

Gastroenterology
General Gastroenterology
Hepatology


Question: Of the following options, which is the most appropriate next step in the management of this patient?

Context: An 8-year-old girl presents to the emergency department with respiratory distress, facial edema, and a skin rash after eating a buffet dinner with her family.

Context: Her parents say they were eating at a seafood buffet when, all of a sudden, the patient began to cough and feel short of breath.

Context: They say nothing like this has ever happened before.

Context: The patient has a history of seasonal allergies for which she occasionally takes cetirizine.

Context: Her blood pressure is 80/52 mm Hg; heart rate, 122/min; and respiratory rate, 22/min.

Context: On physical examination, the patient has severe edema over her face and audible stridor.

Choices:
A. Intramuscular epinephrine
B. Intravenous epinephrine
C. Extra-strength topical diphenhydramine
D. Inhaled sodium cromolyn

Answer: Intramuscular epinephrine

2. Patient presented to the emergency department with respiratory distress, facial edema, and a skin rash.

3. Patient was eating at a seafood buffet with her family when she began to cough and feel short of breath.

4. Patient's parents say nothing like this has ever happened before.

5. Patient has a history of seasonal allergies for which she occasionally takes cetirizine.

6. Patient's blood pressure is 80/52 mm Hg.

8. Patient's respiratory rate is 22/min.

9. Patient has severe edema over her face.


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

Context: A 33-year-old man presents to his physician complaining of a small mass he noticed in his scrotum about 1 month ago.

Context: He is married with 2 children.

Context: Examination shows a 1-cm spherical mass in the superior part of the right testis that has a smooth border.

Context: It transilluminates with a flashlight.

Context: Scrotal ultrasonography shows an extratesticular hypoechoic mass near the epididymal head of the right testicle with posterior acoustic enhancement and without internal shadows.

Choices:
A. Ligation of processus vaginalis
B. Microsurgical varicocelectomy
C. Orchiectomy
D. No therapy at this time

Answer: No therapy at this time

1. A 33-year-old man presents to his physician.

2. He noticed a small mass in his scrotum about 1 month ago.

3. The mass feels loosely attached to the right testicle and is firm, and not painful.

4. He has no history of a serious illness and takes no medications.

6. His vital signs are within normal limits.

7. Examination shows a 1-cm spherical mass in the superior part of the right testis.

9. It transilluminates with a flashlight.

10. The mass does not enlarge when the patient coughs or bears down.

11. Scrotal ultrasonography shows an extratesticular hypoechoic mass near the epididymal head of the right testicle.

12. The mass has posterior acoustic enhancement and without internal shadows.


Question: Which of the following interventions is a proper management strategy for the presented patient?

Context: A 51-year-old asymptomatic woman undergoes colposcopy due to a high-grade intraepithelial lesion based on a Pap smear.

Context: Colposcopy shows a visible lesion 2 cm in diameter located on the posterior cervical lip and confined to the cervix with sharp borders, a coarse mosaic pattern after application of acetic acid, and contact bleeding.

Context: The histologic evaluation of the biopsy shows glandular epithelial cells with nuclear hyperchromasia and enlargement, increased mitoses, a fusion of glands, and stromal infiltration to 8 mm.

Context: The chest X-ray and abdominal ultrasound are negative for any additional findings.

Choices:
A. Loop electrosurgical excision procedure (LEEP)
B. Modified radical (Wertheim) hysterectomy
C. Platinum-based chemotherapy
D. Simple hysterectomy with bilateral salpingo-oophorectomy

Answer: Modified radical (Wertheim) hysterectomy

1. A 51-year-old asymptomatic woman underwent colposcopy.

2. The colposcopy was due to a high-grade intraepithelial lesion based on a Pap smear.

3. Colposcopy showed a visible lesion 2 cm in diameter located on the posterior cervical lip and confined to the cervix with sharp borders.

4. Colposcopy showed a coarse mosaic pattern after application of acetic acid.

6. The histologic evaluation of the biopsy showed glandular epithelial cells with nuclear hyperchromasia and enlargement.

7. The histologic evaluation of the biopsy showed increased mitoses.

8. The histologic evaluation of the biopsy showed a fusion of glands.

9. The histologic evaluation of the biopsy showed stromal infiltration to 8 mm.

10. The chest X-ray was negative for any additional findings.

11. The abdominal ultrasound was negative for any additional findings.


Question: In the formation of an atherosclerotic plaque, which of the following pairings is correct?

Context: A 65-year-old man presents to the Emergency Department complaining of substernal chest pain.

Context: An acute coronary event is suspected and a coronary catheterization procedure reveals an atherosclerotic plaque in the patient's left anterior descending artery.

Choices:
A. Fibroblasts -- foam cells
B. Smooth muscle cells (SMC) -- extracellular matrix (ECM) deposition
C. Endothelial cells -- downregulation of VCAM-1
D. LDL chemical reduction -- endothelial dysfunction

Answer: Smooth muscle cells (SMC) -- extracellular matrix (ECM) deposition

1. A 65-year-old man presents to the Emergency Department.

2. He is complaining of substernal chest pain.

3. An acute coronary event is suspected.

4. A coronary catheterization procedure is performed.

5. An atherosclerotic plaque is found in the patient's left anterior descending artery.

General Cardiology
Interventional Cardiology


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

Context: A 15-year-old boy is brought to the physician by his mother because of a 2-month history of pain in his left hip.

Context: The pain started suddenly and has worsened over the past 2 weeks.

Context: The pain radiates down the thigh and is aggravated by movement.

Context: He had a fall while cycling around a month ago.

Context: He had a urinary tract infection 3 months ago that resolved with trimethoprim/sulfamethoxazole.

Context: There is no family history of serious illness.

Context: His immunizations are up-to-date.

Context: He is 165 cm (5 ft 5 in) tall and weighs 85 kg (187 lb); BMI is 31.2 kg/m2.

Context: His temperature is 37.5°C (99.5°F), pulse is 65/min, and blood pressure is 104/70 mm Hg.

Context: Examination shows an antalgic gait.

Context: The left groin is tender to palpation and internal rotation is limited due to pain.

Context: His leukocyte count is 9,800/mm3 and erythrocyte sedimentation rate is 12 mm/h.

Context: An x-ray of the pelvis is shown.

Choices:
A. Long leg cast
B. Surgical pinning of femoral head
C. Intra-articular lidocaine
D. Proximal femoral osteotomy

Answer: Surgical pinning of femoral head

2. Patient has had pain in his left hip for 2 months.

3. Pain started suddenly and has worsened over the past 2 weeks.

4. Pain radiates down the thigh and is aggravated by movement.

5. Patient had a fall while cycling around a month ago.

6. Patient had a urinary tract infection 3 months ago that resolved with trimethoprim/sulfamethoxazole.

7. No family history of serious illness.

9. Patient is 165 cm (5 ft 5 in) tall and weighs 85 kg (187 lb); BMI is 31.2 kg/m2.

10. Temperature is 37.5°C (99.5°F), pulse is 65/min, and blood pressure is 104/70 mm Hg.

12. Left groin is tender to palpation and internal rotation is limited due to pain.

13. Flexing the hip causes external rotation and abduction.

14. Leukocyte count is 9,800/mm3 and erythrocyte sedimentation rate is 12 mm/h.


Question: What is the preferred treatment for this condition?

Context: A 58-year-old man is hospitalized and treated with clindamycin for a pulmonary abscess.

Context: During his hospital stay he develops abdominal pain and bloody diarrhea, and has a WBC of 14,000; serum creatinine is 0.9 mg/dL.

Context: On teaching rounds, you learn that the responsible pathogen produces a multi-unit toxin that binds to the colonic mucosa, causing actin depolymerization that results in cell death and mucosal necrosis.

Choices:
A. Metronidazole
B. Penicillin G
C. Tetracycline
D. Erythromycin

Answer: Metronidazole

2. He is treated with clindamycin for a pulmonary abscess.

3. During his hospital stay he develops abdominal pain and bloody diarrhea.

6. The responsible pathogen produces a multi-unit toxin.

7. The toxin binds to the colonic mucosa.

9. Actin depolymerization results in cell death and mucosal necrosis.

General Infectious Disease
Infectious Disease


Question: Which result would you expect to find on her screening tests?

Context: A 61-year-old Caucasian woman presents to her physician for a routine checkup.

Context: She has primary hypertension and rheumatoid arthritis.

Context: She currently does not report any relevant symptoms, such as weight change, increased or decreased appetite, sleep or mood problems, gastrointestinal symptoms, fever, or night sweats.

Context: Her medications include valsartan 160 mg, hydrochlorothiazide 25 mg daily, and methylprednisolone 28 mg every other day.

Context: According to her diary, her blood pressure varies from 130/80 to 120/60 mm Hg.

Context: In the past year, she had humeral and tibial fractures from a self-height fall and stepping over a fence, respectively, that occurred 6 months apart.

Context: She is in menopause and is not on hormone replacement therapy.

Context: Currently, she does not smoke but has a 10-pack-year history of smoking.

Context: She consumes alcohol occasionally.

Context: She weighs 56 kg (123.5 lb), and her height is 169 cm (5 ft 7 in).

Context: She does not report a family history of any cancer.

Context: Her father died after a myocardial infarction at the age of 63.

Context: She performs daily household activities but is not engaged in either aerobic or strength training.

Context: She mainly consumes vegetables, cereals, and dairy products.

Context: Her blood pressure is 125/80 mm Hg, heart rate is 67/min, respiratory rate is 14/min, and temperature is 36.5°C (97.7°F).

Context: Her physical examination is unremarkable.

Choices:
A. A score of 17 on PHQ-9 test
B. T score –2.01 on DEXA scan
C. Dilation of the abdominal aorta on ultrasound examination
D. Presence of focal hyperintensities on mammography

Answer: T score –2.01 on DEXA scan

1. Patient is a 61-year-old Caucasian woman.

2. Patient has primary hypertension and rheumatoid arthritis.

3. Patient does not report any relevant symptoms.

4. Patient's medications include valsartan 160 mg, hydrochlorothiazide 25 mg daily, and methylprednisolone 28 mg every other day.

5. Patient's blood pressure varies from 130/80 to 120/60 mm Hg.

6. Patient had humeral and tibial fractures from a self-height fall and stepping over a fence, respectively, that occurred 6 months apart.

7. Patient is in menopause and is not on hormone replacement therapy.

8. Patient currently does not smoke but has a 10-pack-year history of smoking.

9. Patient consumes alcohol occasionally.

10. Patient weighs 56 kg (123.5 lb) and her height is 169 cm (5 ft 7 in).

11. Patient does not report a family history of any cancer.

12. Patient's father died after a myocardial infarction at the age of 63.

13. Patient performs daily household activities but is not engaged in either aerobic or strength training.

14. Patient mainly consumes vegetables, cereals, and dairy products.

15. Patient's blood pressure is 125/80 mm Hg, heart rate is 67/min, respiratory rate is 14/min, and temperature is 36.5°C (97.7°F).

16. Patient's physical examination is unremarkable.


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

Context: A 24-year-old man is brought to the emergency department by his sister because she has noticed that he has been behaving differently over the past 4 weeks.

Context: Today, the patient attempted to set their house on fire while yelling that he was trying to “save us all.” The patient has a history of psychotic symptoms treated with aripiprazole.

Context: His sister states that he stopped taking his medications about 3 weeks ago.

Context: He works as a dishwasher but has not been to work for several days.

Context: His vital signs are within normal limits.

Context: Mental status examination shows a blunted affect.

Context: Throughout the interview, the patient continuously stares at the ceiling and makes little eye contact with the physician.

Context: When asked about the incident today, he states that he has been hearing the voice of “the great one” who has informed him that aliens are in his neighborhood in the form of rats and cockroaches that need to be “torched to prevent the alien invasion.” He is refusing treatment and insists on going home.

Choices:
A. Administer aripiprazole and follow-up after 24 hours
B. Refer the patient to a psychologist for cognitive behavioral therapy
C. Involuntarily hospitalize the patient
D. Ask the patient's sister to convince him to stay overnight

Answer: Involuntarily hospitalize the patient

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

3. Sister noticed patient behaving differently over the past 4 weeks.

4. Patient attempted to set their house on fire while yelling.

5. Patient has a history of psychotic symptoms treated with aripiprazole.

6. Sister states patient stopped taking medications 3 weeks ago.

8. Patient has not been to work for several days.

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

10. Mental status examination shows blunted affect.

11. Patient continuously stares at the ceiling and makes little eye contact with the physician.

12. Patient has been hearing the voice of “the great one”.

13. Voice has informed patient that aliens are in his neighborhood in the form of rats and cockroaches.

14. Patient believes aliens need to be “torched to prevent the alien invasion.”

15. Patient is refusing treatment and insists on going home.


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

Context: A 13-year-old girl is brought to the emergency department by her father because of a severe nosebleed.

Context: She takes no medications and has no history of serious medical illness but has had frequent nosebleeds in the past.

Context: Laboratory studies show: | Hemoglobin 8 g/dL | Platelet count 195,000/mm3 | Prothrombin time 12 sec | Partial thromboplastin time 49 sec | Fibrin split products negative | The bleeding time is 11 minutes.

Choices:
A. Prothrombin complex concentrate
B. Rituximab
C. Desmopressin
D. Intravenous immunoglobulin

Answer: Desmopressin

1. A 13-year-old girl is brought to the emergency department by her father.

3. She has no history of serious medical illness.

4. She has had frequent nosebleeds in the past.

5. Physical examination shows brisk bleeding from the right nare and pooled blood in the posterior pharynx.

6. Laboratory studies show Hemoglobin 8 g/dL.

7. Laboratory studies show Platelet count 195,000/mm3.

8. Laboratory studies show Prothrombin time 12 sec.

9. Laboratory studies show Partial thromboplastin time 49 sec.

10. Laboratory studies show Fibrin split products negative.


Question: Which of the following is the most appropriate treatment for the most likely diagnosis?

Context: He states that since yesterday he has had joint pain, and today he noticed a rash.

Context: The patient smokes cigars, drinks 1 to 4 drinks per day, is sexually active, and uses cocaine occasionally.

Context: His temperature is 101°F (38.3°C), blood pressure is 125/65 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 98% on room air.

Context: Physical exam reveals pustular skin lesions and an inflamed and painful right knee that is warm to the touch.

Choices:
A. Cefixime and azithromycin
B. Ceftriaxone
C. Ceftriaxone and vancomycin
D. Piperacillin and tazobactam

Answer: Cefixime and azithromycin

1. A 33-year-old man presents to the emergency department with joint pain.

2. He states that since yesterday he has had joint pain.

4. The patient does not have a significant past medical history.

6. The patient drinks 1 to 4 drinks per day.

8. The patient uses cocaine occasionally.

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

14. Physical exam reveals pustular skin lesions.

15. Physical exam reveals an inflamed and painful right knee that is warm to the touch.


Question: Which of the following is the primary mechanism of action of levonorgestrel?

Context: A 20-year-old woman presents to a physician following unprotected coitus with her boyfriend about 10 hours ago.

Context: She tells the physician that although they usually use a barrier method of contraception, but this time they did not.

Context: She does not want to become pregnant.

Context: She also mentions that she has been diagnosed with major depression and does not want to take an estrogen-containing oral contraceptive pill.

Context: After counseling, the physician prescribes an enteric-coated pill containing 1.5 mg of levonorgestrel.

Choices:
A. Delayed ovulation through inhibition of follicular development
B. Thickening of cervical mucus
C. Atrophy of endometrium
D. Reduction in motility of cilia in fallopian tubes

Answer: Delayed ovulation through inhibition of follicular development

1. A 20-year-old woman presented to a physician.

2. The woman had unprotected coitus with her boyfriend about 10 hours ago.

3. The woman and her boyfriend usually use a barrier method of contraception.

4. This time they did not use a barrier method of contraception.

5. The woman does not want to become pregnant.

6. The woman has been diagnosed with major depression.

7. The woman does not want to take an estrogen-containing oral contraceptive pill.

8. The physician prescribed an enteric-coated pill containing 1.5 mg of levonorgestrel.


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

Context: A 4-year-old girl is brought to the emergency department because of colicky abdominal pain for 1 day.

Context: Urinalysis shows red blood cells and hexagonal-shaped crystals.

Choices:
A. Increased stool fat content
B. Inability of intercalated cells to secrete H+
C. Impaired intestinal ornithine reabsorption
D. Urease-positive bacteria in the renal pelvis

Answer: Impaired intestinal ornithine reabsorption

1. A 4-year-old girl is brought to the emergency department.

2. She has colicky abdominal pain for 1 day.

3. She has had two similar episodes in the past.

5. Urinalysis shows hexagonal-shaped crystals.

6. Urine sodium cyanide nitroprusside test is positive.


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

Context: A 49-year-old woman, gravida 1, para 1, comes to the physician because of shorter and less frequent menstrual periods over the past year.

Context: During this time, she has also had frequent mood swings and a 2.5-kg (5-lb) weight loss.

Context: She occasionally wakes up at night because she is too warm and sweating profusely.

Context: These episodes are followed by chills and anxiety that subside within minutes.

Context: She has no history of abnormal Pap smears.

Context: She is sexually active with her husband, who had a vasectomy 10 years prior.

Context: She is 163 cm (5 ft 3 in) tall and weighs 70 kg (154 lb); BMI is 26 kg/m2.

Context: Her temperature is 37°C (98.6°F), pulse is 103/min, respirations are 16/min, and blood pressure is 129/84 mm Hg.

Choices:
A. Perform transvaginal ultrasound
B. Measure serum β-hCG concentration
C. Obtain endometrial biopsy
D. Measure serum TSH concentration

Answer: Measure serum TSH concentration

3. Patient has had shorter and less frequent menstrual periods over the past year.

4. Patient has had frequent mood swings over the past year.

5. Patient has had a 2.5-kg (5-lb) weight loss over the past year.

6. Patient occasionally wakes up at night because she is too warm and sweating profusely.

7. Patient experiences chills and anxiety after waking up at night, which subside within minutes.

8. Patient has no history of abnormal Pap smears.

9. Patient is sexually active with her husband, who had a vasectomy 10 years prior.

13. Patient's temperature is 37°C (98.6°F).

16. Patient's blood pressure is 129/84 mm Hg.

17. Abdominal and genitourinary examination shows no abnormalities.


Question: Which of the following findings is most likely to be detected in a skeletal survey?

Context: An 8-year-old boy is brought by his parents to the emergency department with a tender and swollen right leg.

Context: The boy said that he was playing soccer when he accidentally kicked a metal goal post.

Context: A review of his medical history reveals that he had a fracture of the left tibia at 4-years-old and a fracture of the right radius 6 months ago.

Context: Neither of the two was associated with major trauma and both healed well.

Context: There is no muscular hypotonia.

Context: His height and weight are normal for his age and sex and the skin is normal.

Choices:
A. A healed right scapular fracture
B. Ground-glass appearance of the cortices of the long bones
C. Widening and cupping of the metaphyses of the long bones
D. Wormian bones in the skull

Answer: Wormian bones in the skull

1. An 8-year-old boy is brought by his parents to the emergency department.

2. The boy said he was playing soccer when he accidentally kicked a metal goal post.

3. The boy was born at 39 weeks gestation via spontaneous vaginal delivery.

4. He is up to date on all vaccines and is meeting all developmental milestones.

5. A review of his medical history reveals a fracture of the left tibia at 4-years-old.

6. A review of his medical history reveals a fracture of the right radius 6 months ago.

7. Neither of the two fractures was associated with major trauma and both healed well.

8. At the hospital, his vital signs are stable and his sclerae are white-blue.

10. His height and weight are normal for his age and sex.

12. A tender swelling is present over his right leg and he can not put weight on that leg.

13. The radiograph of his right leg confirms a fracture of the shaft of the tibia at the junction of its upper one-third and lower two-thirds.

14. The clinician suspects physical abuse and orders a skeletal survey.


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

Context: A previously healthy 34-year-old man comes to the physician because of loose stools for the past 4 months.

Context: On average, he has 1 episode of loose non-bloody bowel movement with abdominal cramps each day around noon.

Context: He has no diarrhea when he does not have breakfast in the morning.

Context: He also complains of excess flatus but no bowel incontinence or urgency.

Context: He has had no fever or weight loss.

Context: His symptoms are not associated with stress.

Context: He has had no overseas or mountainous trips over the past year.

Context: He takes no medications.

Context: His vital signs are within normal limits.

Choices:
A. Cholestyramine
B. Elimination of all dairy products
C. Empirical therapy with metronidazole
D. Loperamide

Answer: Elimination of all dairy products

2. Patient has had loose stools for 4 months.

3. Patient has 1 episode of loose non-bloody bowel movement with abdominal cramps each day around noon.

4. Patient has no diarrhea when he does not have breakfast in the morning.

5. Patient complains of excess flatus but no bowel incontinence or urgency.

6. Patient has had no fever or weight loss.

7. Patient's symptoms are not associated with stress.

8. Patient has had no overseas or mountainous trips over the past year.

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

11. Physical examination shows no abnormalities.


Question: Which of the following physiologic changes is most likely expected after being prescribed that medication?

Context: A 37-year-old male with a history of diabetes is prescribed a drug that would decrease the risk of the patient developing glomerular renal capillary damage, nodular glomerular sclerosis, and eventual nephrotic syndrome.

Context: After some time being on this medication, the patient complains of a bad cough.

Choices:
A. Decreased aldosterone, decreased GFR, decreased renal plasma flow, increased bradykinin
B. Increased aldosterone, increased GFR, decreased renal plasma flow, increased bradykinin
C. Decreased aldosterone, decreased GFR, increased renal plasma flow, increased bradykinin
D. Increased aldosterone, increased GFR, increased renal plasma flow, increased bradykinin

Answer: Decreased aldosterone, decreased GFR, increased renal plasma flow, increased bradykinin

1. A 37-year-old male has a history of diabetes.

2. The patient was prescribed a drug to decrease the risk of developing glomerular renal capillary damage, nodular glomerular sclerosis, and eventual nephrotic syndrome.

3. After some time being on this medication, the patient complained of a bad cough.


Question: Which of the following would be the best treatment for this patient’s change in mental status?

Context: A 69-year-old woman presents with insomnia and altered mental status.

Context: The patient is accompanied by her husband who says her symptoms began acutely 4 days ago with no obvious trigger and have not improved.

Context: Before this point, she had been living independently with no signs of cognitive impairment.

Context: The patient’s husband says that the patient is often non-compliant with medication and eats and drinks little unless prompted.

Context: Past medical history is significant for hypertension, diabetes mellitus type 2, chronic pyelonephritis, and depression.

Context: Current medications are aspirin, metoprolol, hydrochlorothiazide, losartan, metformin, and trazodone.

Context: Vitals include: temperature 38.1℃ (100.6℉), blood pressure 130/70 mm Hg, pulse 91/min, respiratory rate 17/min, and oxygen saturation 99% on room air.

Context: On physical examination, the patient is agitated and easily distracted.

Context: Oriented x 1.

Context: She believes it is 1967, and she is at the bookstore.

Context: She talks to non-existent people and uses words inappropriately.

Context: Lungs are clear to auscultation.

Context: Urinalysis is pending.

Choices:
A. Changing trazodone to amitriptyline
B. Antibiotic therapy
C. Discontinuation of metoprolol
D. Lifelong administration of memantine

Answer: Antibiotic therapy

2. Patient presents with insomnia and altered mental status.

3. Patient's husband says symptoms began acutely 4 days ago with no obvious trigger and have not improved.

4. Patient had been living independently with no signs of cognitive impairment.

5. Patient's husband says patient is often non-compliant with medication and eats and drinks little unless prompted.

6. Patient has past medical history of hypertension, diabetes mellitus type 2, chronic pyelonephritis, and depression.

7. Patient is currently taking aspirin, metoprolol, hydrochlorothiazide, losartan, metformin, and trazodone.

8. Patient's vitals include temperature 38.1℃ (100.6℉), blood pressure 130/70 mm Hg, pulse 91/min, respiratory rate 17/min, and oxygen saturation 99% on room air.

9. Patient is agitated and easily distracted on physical examination.

11. Patient believes it is 1967 and she is at the bookstore.

12. Patient talks to non-existent people and uses words inappropriately.

13. Cardiac sounds are muffled but otherwise normal.

15. On abdominal examination, the tip of the urinary bladder can be palpated.

16. Costovertebral angle tenderness is present bilaterally.

17. Catheterization of the bladder yields cloudy, foul-smelling urine.


Question: Which of the following medical treatments is indicated for this patient’s condition?

Context: A 65-year-old man presents to the physician with a concern for several lumps on his jaw.

Context: He has a history of dental caries and admits to maintaining poor oral hygiene.

Context: On physical examination, he has 3 nontender and indurated masses at the angle of his jaw that are draining thick yellow pus.

Choices:
A. Amoxicillin-clavulanate
B. Dapsone and rifampin
C. Penicillin
D. Trimethoprim-sulfamethoxazole

Answer: Penicillin

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

3. He admits to maintaining poor oral hygiene.

4. On physical examination, he has 3 nontender and indurated masses at the angle of his jaw.

5. The masses are draining thick yellow pus.

6. Microscopy of the drained pus reveals yellow granules filled with bacteria.


Question: Which of the following was most likely the second compound administered to this patient?

Context: A 23-year-old man presents with severe right lower quadrant abdominal pain for the past 2 hours.

Context: He says the pain started in the periumbilical region and has now shifted to the lower right quadrant.

Context: He describes the pain as spasmodic.

Context: Past medical history is insignificant, and the patient denies any history of smoking, alcohol, or drug use.

Context: The patient’s vital signs show: pulse 88/min, respiratory rate 18/min, blood pressure 126/84 mm Hg, and temperature 38.4°C (101.0°F).

Context: On physical examination, there is severe tenderness to palpation in the right lower quadrant with rebound and guarding.

Context: The patient is rushed to the operating room for a laparoscopic appendectomy.

Context: The following preoperative laboratory tests are obtained: | Serum glucose (random) 123 mg/dL |   Serum electrolytes | Sodium 143 mEq/L | Potassium 4.7 mEq/L | Chloride 102 mEq/L |     Serum creatinine 1.7 mg/dL | Blood urea nitrogen 32 mg/dL |     Hemoglobin (Hb%) 12.5 g/dL | Mean corpuscular volume (MCV)  80 fl | Reticulocyte count 1% | Erythrocyte count 5.1 million/mm³ | Leukocyte count 14,000/mm³ | Neutrophils 80% | During the induction of anesthesia, isoflurane and a second compound are administered.

Context: About 25 minutes after induction, the patient develops significant muscle rigidity and his temperature increases to 40.8°C (105.4°F).

Context: The patient’s blood pressure is now 158/94 mm Hg.

Choices:
A. Atracurium
B. Nitrous oxide
C. Neostigmine
D. Succinylcholine

Answer: Succinylcholine

2. Patient has had severe right lower quadrant abdominal pain for the past 2 hours.

3. Pain started in the periumbilical region and has shifted to the lower right quadrant.

5. Patient denies any history of smoking, alcohol, or drug use.

6. Patient's vital signs: pulse 88/min, respiratory rate 18/min, blood pressure 126/84 mm Hg, temperature 38.4°C (101.0°F).

7. Physical examination reveals severe tenderness to palpation in the right lower quadrant with rebound and guarding.

8. Patient is rushed to the operating room for a laparoscopic appendectomy.

9. Preoperative laboratory tests: serum glucose (random) 123 mg/dL, serum electrolytes (sodium 143 mEq/L, potassium 4.7 mEq/L, chloride 102 mEq/L), serum creatinine 1.7 mg/dL, blood urea nitrogen 32 mg/dL, hemoglobin (Hb%) 12.5 g/dL, mean corpuscular volume (MCV) 80 fl, reticulocyte count 1%, erythrocyte count 5.1 million/mm³, leukocyte count 14,000/mm³, neutrophils 80%.

10. During induction of anesthesia, isoflurane and a second compound are administered.

11. 25 minutes after induction, patient develops significant muscle rigidity and temperature increases to 40.8°C (105.4°F).

12. Patient's blood pressure is now 158/94 mm Hg.

General Surgery
Emergency Medicine
Surgery

General Surgery
General Emergency Medicine


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

Context: A 16-year-old boy is brought to the physician because of a 3-week history of loose stools.

Context: He has 2–3 episodes of loose stools a day that are occasionally bloody.

Context: During this period, he has also had crampy abdominal pain, generalized fatigue, and a 2-kg (5-lb) weight loss.

Context: His temperature is 37.1°C (98.8°F), pulse is 82/min, and blood pressure is 106/68 mm Hg.

Context: His hemoglobin concentration is 11.8 g/dL, leukocyte count is 12,400/mm3, and erythrocyte sedimentation rate is 14 mm/h.

Context: A colonoscopy shows inflamed, friable mucosa extending just beyond the rectum that bleeds on contact with the endoscope.

Context: A biopsy confirms the diagnosis.

Choices:
A. Gluten-free diet
B. Proctocolectomy
C. Mesalamine therapy
D.
Cyclosporine therapy
"

Answer: Mesalamine therapy

2. Patient has had loose stools for 3 weeks.

3. Patient has 2-3 episodes of loose stools per day.

4. Loose stools are occasionally bloody.

5. Patient has had crampy abdominal pain, generalized fatigue, and a 2-kg (5-lb) weight loss.

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

8. Patient's blood pressure is 106/68 mm Hg.

9. Examination shows mild lower abdominal tenderness to palpation.

10. Test of the stool for ova and parasites is negative.

11. Patient's hemoglobin concentration is 11.8 g/dL.

12. Patient's leukocyte count is 12,400/mm3.

13. Patient's erythrocyte sedimentation rate is 14 mm/h.

14. Colonoscopy shows inflamed, friable mucosa extending just beyond the rectum that bleeds on contact with the endoscope.

General Gastroenterology
Pediatric Gastroenterology


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

Context: A 26-year-old man presents with a 6-month history of headaches.

Context: Over the past 6 months, he has developed headaches that are 4/10 in intensity and occur every other day for 1–2 hours.

Context: The headaches are bilateral and feel like a ‘band is squeezing his head’.

Context: He denies photophobia, phonophobia, nausea, and vomiting.

Context: He has had no visual loss or photopsia.

Context: No significant past medical history.

Context: He is an avid weightlifter and works at a moving company, where he is constantly lifting heavy items.

Context: Additionally, he recently got his 21-year-old girlfriend and his other 23-year-old girlfriend pregnant, which he says is causing a lot of stress.

Context: Physical examination is unremarkable.

Choices:
A. Amitriptyline
B. Magnetic resonance image (MRI) of the head
C. Ophthalmologic evaluation
D. Ibuprofen

Answer: Ibuprofen

2. Patient has had headaches for 6 months.

4. Headaches occur every other day for 1-2 hours.

5. Headaches are bilateral and feel like a ‘band is squeezing his head’.

6. Patient denies photophobia, phonophobia, nausea, and vomiting.

7. Patient has had no visual loss or photopsia.

8. Patient has no significant past medical history.

10. Patient works at a moving company, where he is constantly lifting heavy items.

11. Patient recently got his 21-year-old girlfriend and his other 23-year-old girlfriend pregnant.

12. Patient states this is causing a lot of stress.

13. Physical examination is unremarkable.


Question: Which of the following best describes the primary function that the cells highlighted in blue serve?

Context: A special stain is used to identify a specific glial cell that makes up the lining of the central canal and ventricles in the central nervous system.

Choices:
A. Production and circulation of CSF
B. Protective membrane surrounding spinal cord
C. Conduct voluntary muscle action potentials
D. Increasing action potential conduction velocity

Answer: Production and circulation of CSF

1. A histologic section is obtained from the central canal of the spinal cord.

3. The special stain is used to identify a specific glial cell.

4. The glial cell makes up the lining of the central canal and ventricles in the central nervous system.