Question: Which of the following should be started post-mastectomy to improve the patient’s prognosis?

Context: A 54-year-old woman presents to her primary care physician complaining of a lump in her right breast.

Context: She first noticed it 1 month ago.

Context: She claims that the lump is not painful or itchy, and she denies any abnormal nipple bleeding or discharge.

Context: She has a family history of breast cancer, including both her mother and older sister.

Context: A mammogram is performed, which identifies an irregular mass with a fibrotically stranded border.

Context: A biopsy is performed that is positive for invasive ductal carcinoma.

Context: The patient is started on radiation induction therapy and scheduled for a modified radical mastectomy.

Context: Following tumor gene testing, the patient is found to be positive or the HER-2/neu oncogene.

Choices:
A. Anastrozole
B. Corticosteroids
C. Leuprolide
D. Trastuzumab

Answer: Trastuzumab

1. A 54-year-old woman presents to her primary care physician.

2. She is complaining of a lump in her right breast.

4. Now she is worried that it may have grown.

5. She claims that the lump is not painful or itchy.

6. She denies any abnormal nipple bleeding or discharge.

7. She has a family history of breast cancer.

8. Her mother and older sister both have breast cancer.

9. Physical examination reveals a firm, immobile lump in the upper right breast.

11. The mammogram identifies an irregular mass with a fibrotically stranded border.

13. The biopsy is positive for invasive ductal carcinoma.

14. The patient is started on radiation induction therapy.

15. The patient is scheduled for a modified radical mastectomy.

16. Following tumor gene testing, the patient is found to be positive for the HER-2/neu oncogene.


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

Context: His temperature is 99.2°F (37.3°C), blood pressure is 177/108 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air.

Context: A 24-hour urine free cortisol is collected and demonstrates an elevated cortisol level; however, a high dose of dexamethasone when administered results in no attenuation of cortisol release.

Choices:
A. Adrenal adenoma
B. Decreased ACTH level
C. Enlargement of the facial bones
D. History of smoking

Answer: History of smoking

1. A 48-year-old man presents to his primary care physician concerned about his weight.

2. He states he has been gaining weight though does not feel he has changed his diet.

3. The patient also states he has felt fatigued lately and not himself.

4. He denies taking any medications or using any illicit substances at baseline.

9. Oxygen saturation is 98% on room air.

10. Physical exam is notable for an obese man with striae on his abdomen.

11. A 24-hour urine free cortisol is collected and demonstrates an elevated cortisol level.

12. A high dose of dexamethasone when administered results in no attenuation of cortisol release.

13. A CT scan of the abdomen is within normal limits.


Question: What is the Kozak consensus sequence?

Context: Advances in molecular biology have identified important factors and sequences required for transcription and translation of mRNA as well as multiple diseases associated with mutations.

Context: The Kozak sequence is one such finding from this research.

Choices:
A. A sequence box that binds to NF-1
B. An untranslated region downstream of the the stop codon
C. An initiator of translation proximal to the start codon
D. A site to which the 50S ribosome binds

Answer: An initiator of translation proximal to the start codon

1. Advances in molecular biology have identified important factors and sequences required for transcription and translation of mRNA.

2. Advances in molecular biology have identified multiple diseases associated with mutations.

3. The Kozak sequence is one finding from this research.

Molecular Genetic Pathology
Clinical Genetics and Genomics


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

Context: A 3-week-old male infant is brought to the physician by his parents because they noticed that his head has been tilted to the left since birth.

Context: Physical examination shows the head turned toward the left side and the chin rotated toward the right.

Choices:
A. Fetal macrosomia
B. Cesarean delivery
C. Intrauterine exposure to haloperidol
D. Preterm birth

Answer: Fetal macrosomia

1. A 3-week-old male infant is brought to the physician by his parents.

2. His parents noticed that his head has been tilted to the left since birth.

3. Physical examination shows the head turned toward the left side.

4. The chin is rotated toward the right.

5. He cries during an attempt to rotate the head to the right.

6. There is a firm, well-circumscribed mass on the left lower side of the neck.

General Orthopaedic Surgery
Pediatric Neurology


Question: What is the most likely cause for the underlying abnormalities?

Context: A 13-month-old boy was brought to the clinic due to failure-to-thrive and mental impairment.

Context: The parents are healthy, but they previously had a child who died at 14 months of age.

Choices:
A. Structural protein mutation
B. Genomic imprinting
C. Lysosomal enzyme mutation
D. Mitochondrial gene mutation

Answer: Lysosomal enzyme mutation

1. A 13-month-old boy was brought to the clinic.

2. The reason for the visit was failure-to-thrive and mental impairment.

3. Retinal findings are shown in the picture.

5. The parents previously had a child who died at 14 months of age.

Medical Genetics and Genomics
Pediatrics

General Medical Genetics and Genomics
Metabolic Genetics
General Pediatrics
Clinical Genetics and Genomics


Question: What is the most likely cause of this lab abnormality in this patient?

Context: A 24-year-old woman who is 16 weeks pregnant comes to your office requesting a referral for an abortion.

Context: Upon questioning she states that she is scared that her baby will be "deformed" because on routine screening she was found to have an elevated level of alpha-fetoprotein.

Choices:
A. Trisomy 13
B. Trisomy 18
C. Trisomy 21
D. Inaccurate gestational age

Answer: Inaccurate gestational age

1. A 24-year-old woman has come to the office.

3. She is requesting a referral for an abortion.

4. She is scared that her baby will be "deformed".

5. She had a routine screening which showed an elevated level of alpha-fetoprotein.


Question: Evaluation of this patient's urine before treatment is initiated is most likely to show which of the following?

Context: A previously healthy 45-year-old man is brought to the emergency department after being found by a search and rescue team in the mountains.

Context: He has been without food or water for 30 hours.

Context: His temperature is 37°C (98.6°F), pulse is 123/min, respirations are 20/min, and blood pressure is 90/55 mm Hg.

Context: Physical examination shows decreased skin turgor and dry mucous membranes.

Choices:
A. Low urine sodium and low urine osmolality
B. Low urine sodium with hyaline casts
C. High urine protein with fatty casts
D. Low urine osmolality with RBC casts

Answer: Low urine sodium with hyaline casts

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

2. He was found by a search and rescue team in the mountains.

3. He had been without food or water for 30 hours.

8. Physical examination showed decreased skin turgor.

9. Physical examination showed dry mucous membranes.


Question: Which of the following helps the bacterium in this infection bind to immunoglobulin and prevent phagocytosis when invading its host?

Context: A 14-year-old Caucasian male presents with painful erythematous and honey-colored crusted lesions around his mouth.

Context: Further analysis reveals bacteria that are beta-hemolytic, coagulase positive, catalase positive, and appear golden on the blood agar plate.

Choices:
A. Protein A
B. Staphylokinase
C. Exfoliatin A
D. Neurotoxin

Answer: Protein A

1. Patient is a 14-year-old Caucasian male.

2. Patient has painful erythematous and honey-colored crusted lesions around his mouth.

3. Culture of the lesions reveals gram-positive cocci in clusters.

4. Further analysis reveals bacteria that are beta-hemolytic.

5. Further analysis reveals bacteria that are coagulase positive.

6. Further analysis reveals bacteria that are catalase positive.

7. Further analysis reveals bacteria that appear golden on the blood agar plate.


Question: Which of the following is most likely to have contributed to this patient's condition?

Context: A 70-year-old man comes to the physician for the evaluation of abdominal pain over the past month.

Context: The patient describes epigastric pain that radiates to the back.

Context: He also reports a 10-kg (22-lb) weight loss over the past 6 months.

Context: He has a history of untreated type 2 diabetes mellitus.

Context: He has not seen a doctor in 15 years.

Context: He is retired and spends most of his time at home watching TV.

Context: He rarely cooks and mainly eats fast food.

Context: He has smoked one pack of cigarettes daily for the past 50 years.

Context: He drinks 2–3 cans of beer per day.

Context: He appears pale.

Context: His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 150/90 mm Hg.

Context: The abdomen is soft, with no rebound or guarding.

Choices:
A. Smoking history
B. Poor dietary habits
C. History of alcohol use
D. Diabetes mellitus

Answer: Smoking history

2. Patient has abdominal pain for the past month.

3. Patient describes epigastric pain that radiates to the back.

4. Patient has lost 10 kg (22 lbs) in the past 6 months.

5. Patient has a history of untreated type 2 diabetes mellitus.

6. Patient has not seen a doctor in 15 years.

7. Patient is retired and spends most of his time at home watching TV.

8. Patient rarely cooks and mainly eats fast food.

9. Patient has smoked one pack of cigarettes daily for the past 50 years.

10. Patient drinks 2-3 cans of beer per day.

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

14. Patient's blood pressure is 150/90 mm Hg.

15. Physical examination shows jaundice of the conjunctivae and the skin.

16. Abdomen is soft, with no rebound or guarding.

17. Laboratory studies show a serum glucose concentration of 260 mg/dL.

18. Abdominal sonography shows enlargement of the gallbladder.


Question: Of the following options, which is the most likely diagnosis?

Context: A 63-year-old African American man with a history of hypertension and dyslipidemia presents to the emergency department with facial swelling and difficulty breathing.

Context: His blood pressure is 110/74 mm Hg, heart rate is 94/min, and respiratory rate is 20/min.

Choices:
A. Erysipelas
B. Facial lymphedema
C. Drug-induced angioedema
D. Contact dermatitis

Answer: Drug-induced angioedema

1. A 63-year-old African American man presented to the emergency department.

2. He has a history of hypertension and dyslipidemia.

3. Symptoms began suddenly that morning and continued to worsen.

4. He started taking lisinopril several weeks ago.

8. Physical examination is notable for swelling of his lips and inspiratory stridor.

9. Clinical lab results suggest a normal C1 esterase inhibitor level.


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

Context: A 21-year-old female college student comes to the physician because of a two-week history of vaginal itching and burning.

Context: She also noticed white vaginal discharge despite cleaning her genital area daily using a ""soap-free, natural"" vaginal douche.

Context: She is worried that she might have contracted a sexually transmitted disease after meeting her new boyfriend around one month ago.

Context: She has type 1 diabetes mellitus.

Context: The patient swims for the college swimming team.

Context: She had an intrauterine device implanted 3 months ago and does not use barrier protection.

Context: She smokes one pack of cigarettes per day and does not drink alcohol.

Context: Her vaginal pH is 4.4 and the microscopic image of a KOH preparation shows multiple pseudohyphae.

Choices:
A. Frequent vaginal douching
B. Unprotected sexual intercourse
C. Intrauterine device
D. Diabetes mellitus

Answer: Diabetes mellitus

1. Patient is a 21-year-old female college student.

2. Patient has a two-week history of vaginal itching and burning.

3. Patient has noticed white vaginal discharge despite cleaning her genital area daily using a "soap-free, natural" vaginal douche.

4. Patient is worried that she might have contracted a sexually transmitted disease after meeting her new boyfriend around one month ago.

5. Patient has type 1 diabetes mellitus.

6. Patient swims for the college swimming team.

7. Patient had an intrauterine device implanted 3 months ago and does not use barrier protection.

8. Patient smokes one pack of cigarettes per day and does not drink alcohol.

9. Speculum examination shows an erythematous vagina covered in copious white discharge.

11. Microscopic image of a KOH preparation shows multiple pseudohyphae.


Question: Which of the following likely contributes to her orthopedic problems?

Context: She suffers from regular joint pain in her fingers, and hip X-rays reveal low bone mineral density.

Context: She has a history of diabetes mellitus and was diagnosed 2 years ago with end-stage renal disease.

Choices:
A. Decreased serum aldosterone
B. Increased serum parathyroid hormone
C. Increased serum glucose
D. Chronic hypertension

Answer: Increased serum parathyroid hormone

1. A 72-year-old female recently fractured her hip in a fall.

2. She suffers from regular joint pain in her fingers.

3. Hip X-rays reveal low bone mineral density.

4. She has a history of diabetes mellitus.

5. She was diagnosed 2 years ago with end-stage renal disease.

6. Serum phosphate levels are markedly elevated.


Question: Which of the following chromosomes contain genes that may be mutated in this patient's disease?

Context: He says that he has no health concerns; however, his wife is concerned that he has become increasingly forgetful.

Context: For example, he has become forgetful during his daily activities and recently has been getting lost during errands like shopping.

Context: She says that these symptoms have been occurring for about a year.

Context: She says that she became alarmed when he started forgetting the names of their children.

Context: Finally, over the last month he has become more irritable, which has led to several confrontations at work.

Choices:
A. 1
B. 4
C. 18
D. 20

1. A 52-year-old man presents to his primary care physician for his annual check-up.

2. He says that he has no health concerns.

3. His wife is concerned that he has become increasingly forgetful.

4. He has become forgetful during his daily activities.

5. He has been getting lost during errands like shopping.

6. His wife says that these symptoms have been occurring for about a year.

7. He has started forgetting the names of their children.

8. Over the last month he has become more irritable.

9. This has led to several confrontations at work.

10. Based on the age of onset for his disease, the patient is referred for genetic testing.


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

Context: A 23-year-old woman, gravida 2, para 1, at 13 weeks gestation, comes to the physician because of a 2-day history of burning pain during urination.

Context: She has been sexually active with different male partners during the pregnancy and did not use condoms.

Context: She has not had any fever, chills, or pelvic pain.

Context: Urine dipstick shows leukocyte esterase, urinalysis shows 10 WBCs/hpf, and Gram stain of the urethral swab shows polymorphonuclear leukocytes with intracellular gram-negative diplococci.

Choices:
A. Oral levofloxacin
B. Intramuscular ceftriaxone
C. Oral erythromycin
D.
Intramuscular ceftriaxone and oral azithromycin
"

Answer:
Intramuscular ceftriaxone and oral azithromycin
"

4. Patient has a 2-day history of burning pain during urination.

5. Patient has been sexually active with different male partners during the pregnancy.

7. Patient has not had any fever, chills, or pelvic pain.

8. Physical examination shows thick, purulent discharge from the urethra.

9. Urine dipstick shows leukocyte esterase.

11. Gram stain of the urethral swab shows polymorphonuclear leukocytes with intracellular gram-negative diplococci.

12. Pelvic ultrasound shows a viable intrauterine pregnancy.


Question: What is the most likely diagnosis?

Context: A 20-year-old college student is brought to his primary care physician by his parents over the New Years holiday because they are concerned about his behavior since right after high school graduation in May the spring before.

Context: Prior to this year, he was generally an outgoing and social young man, who now reportedly has been spending the majority of his time alone in his dorm room and room at home, where his mother and father have overheard him talking to other people when he has no guests.

Context: When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove that will soon takeover the student union building by setting the trees on fire for all to see.

Context: On exam, his appears to be otherwise healthy and his urine toxicology screen is negative.

Choices:
A. Schizoaffective disorder
B. Major depression
C. Schizophrenia
D. Schizophreniform disorder

Answer: Schizophrenia

1. A 20-year-old college student is brought to his primary care physician by his parents.

2. The visit is over the New Years holiday.

3. The parents are concerned about his behavior since right after high school graduation in May the spring before.

4. Prior to this year, he was generally an outgoing and social young man.

5. He has been spending the majority of his time alone in his dorm room and room at home.

6. His mother and father have overheard him talking to other people when he has no guests.

7. When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove.

8. The oak grove will soon takeover the student union building.

9. The voice encourages him to set the trees on fire for all to see.

10. On exam, his appears to be otherwise healthy.

11. His urine toxicology screen is negative.

Child and Adolescent Psychiatry
Schizophrenia


Question: This patient is at greatest risk for which of the following complications?

Choices:
A. Hyperesthesia of the left ear lobe
B. Impaired taste of the posterior 1/3 of the tongue
C. Flushing of the right cheek while eating
D. Inability to wrinkle the left side of the forehead

Answer: Inability to wrinkle the left side of the forehead

1. A 58-year-old man comes to the physician for evaluation of an increasing left-sided cheek swelling and recurrent oral ulcers for 1 year.

2. He has smoked a pack of cigarettes daily for 25 years.

3. Examination shows a mild, nontender swelling above the angle of the left jaw.

4. An ultrasound-guided biopsy of the mass confirms the diagnosis of parotid adenoid cystic carcinoma.

5. A left-sided total parotidectomy is performed.

General Dermatology
General Otolaryngology


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

Context: A 34-year-old man comes to the physician for a routine health maintenance examination required for his occupation as a school bus driver.

Context: He feels well and healthy.

Context: Upon questioning, he reports that he has smoked 2 joints of marijuana every night after work for the past year for recreational purposes.

Context: He typically smokes 5 joints or more on weekends.

Choices:
A. """Let me know when you are ready to stop smoking marijuana. We can talk about specific strategies to help you quit at that time."""
B. """Have you ever experienced a situation in which you wished you smoked less marijuana?"""
C. """We have a great program to help patients with substance use disorder issues. Let me give you more information about specific details."""
D. """You should stop smoking marijuana because it is not good for your health."""

Answer: """Have you ever experienced a situation in which you wished you smoked less marijuana?"""

1. A 34-year-old man comes to the physician for a routine health maintenance examination.

2. The man's occupation is a school bus driver.

4. The man has smoked 2 joints of marijuana every night after work for the past year.

5. The man smokes marijuana for recreational purposes.

6. The man typically smokes 5 joints or more on weekends.


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

Context: A 6-year-old girl of Moroccan descent is brought to the pediatrician by her father who is concerned about the child developing a body odor.

Context: Her temperature is 99°F (37.2°C), blood pressure is 150/90 mmHg, pulse is 85/min, and respirations are 18/min.

Choices:
A. Aldosterone
B. Cortisol
C. 11-deoxycorticosterone
D. Leutenizing hormone

Answer: 11-deoxycorticosterone

1. A 6-year-old girl of Moroccan descent is brought to the pediatrician by her father.

2. The father is concerned about the child developing a body odor.

3. He reports that she has started to smell “like a teenage boy” especially after physical activity.

4. The child has had limited medical follow-up since being born in Morocco and immigrating to the United States at 3 years of age.

9. On exam, she has hair in her axillary and pubic regions.

10. Genital examination demonstrates clitoral enlargement and labioscrotal fusion.


Question: While getting up to leave, the patient asks “why is it that I always get these symptoms but my husband is fine?” What is the most appropriate answer to this patient’s question?

Context: She is a newlywed and reports 3 similar episodes within the past 4 months.

Context: She is currently sexually active with her husband and has an IUD.

Choices:
A. Her partner is an asymptomatic carrier
B. Inadequate treatment of her prior episodes
C. The female urethra is shorter
D. The patient is experiencing recurrence of her past chlamydial infection

Answer: The female urethra is shorter

1. A 25-year-old woman presents to the clinic for burning with urination.

2. She reports 3 similar episodes within the past 4 months.

3. She claims that since yesterday she has noticed a burning sensation whenever she urinates, an increase in urinary frequency, and some clear vaginal discharge.

4. She denies fever, chills, back pain, or chest pain.

5. Her past medical history is significant for chlamydia that was adequately treated 3 years ago.

7. She is currently sexually active with her husband.

9. She is subsequently prescribed a course of nitrofurantoin for her symptoms.


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

Context: A 17-year-old boy comes to the physician 1 week after noticing a lesion on his penis.

Context: He is sexually active with two female partners and uses condoms inconsistently.

Context: Five weeks ago, he returned from a trip to the Caribbean with some of his football teammates.

Context: He takes no medications.

Context: A photograph of the lesion is shown.

Choices:
A. Mycoplasma genitalium
B. Human papillomavirus
C. Treponema pallidum
D. Herpes simplex virus type 2

Answer: Treponema pallidum

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

2. He noticed a lesion on his penis 1 week ago.

3. There is no history of itching or pain associated with the lesion.

4. He is sexually active with two female partners.

6. He returned from a trip to the Caribbean with some of his football teammates 5 weeks ago.

8. He has recently started an intense exercise program.

9. His vital signs are within normal limits.

10. Physical examination shows multiple enlarged, nontender lymph nodes in the inguinal area bilaterally.

11. A photograph of the lesion is shown.


Question: Which of the following constitutes the first-line therapy in this patient?

Context: His temperature is 38.5°C (101.5°F).

Choices:
A. Erythromycin
B. Ceftazidime
C. Penicillin
D. Sulfisoxazole

Answer: Sulfisoxazole

1. A 36-year-old man presents to a physician for a post-transplant medical evaluation.

2. He has been taking prednisone and azathioprine for the last 6 months after receiving a cadaveric renal transplant.

3. He complains of fever, cough, and anorexia for the last 6-7 days.

4. His cough is productive of thick sputum.

6. The physical examination is significant for diminished breath sounds over the left lower lung with dullness on percussion and increased vocal resonance.

7. A left lower lobe nodule, 5 cm (2 in) in diameter with eccentric central cavitation, is visible on the chest X-ray.

8. A sputum analysis reveals branched, irregular, gram-positive filamentous rods.


Question: Which of the following is a reasonable first step in the management of this patient's condition?

Context: A 54-year-old woman presents to her gynecologist complaining of incontinence.

Context: She reports leakage of a small amount of urine when she coughs or laughs as well as occasionally when she is exercising.

Context: She denies any pain with urination.

Context: She underwent menopause 2 years ago and noted that this problem has increased in frequency since that time.

Context: Her history is significant only for three uncomplicated pregnancies with vaginal births.

Context: Urinalysis, post-void residual, and cystometrogram are conducted and all show normal results.

Context: The patient's vital signs are as follows: T 37.5 C, HR 80, BP 128/67, RR 12, and SpO2 99%.

Context: Physical examination is significant for pelvic organ prolapse on pelvic exam.

Choices:
A. Kegel exercises
B. Bethanechol
C. Urethropexy
D. Tension-free vaginal tape

Answer: Kegel exercises

2. Patient is complaining of incontinence.

3. Patient reports leakage of small amount of urine when coughing, laughing, and exercising.

4. Patient denies any pain with urination.

5. Patient underwent menopause 2 years ago.

6. Problem has increased in frequency since menopause.

7. Patient has had three uncomplicated pregnancies with vaginal births.

8. Urinalysis, post-void residual, and cystometrogram show normal results.

14. Pelvic organ prolapse is present on pelvic exam.

Female Pelvic Medicine and Reconstructive Surgery


Question: What is this metric also known as?

Context: Researchers from a public health institute located in the United States conducted a multicenter cohort study on a large number of elderly individuals in order to evaluate the protective effect of the new vaccine for herpes zoster (commonly known as shingles) reactivation.

Context: After a long follow-up period, the data shows that shingles developed in 15% of study participants who received the new vaccine compared to 20% of diseased study participants in the control group that did not receive the vaccine.

Context: If the new vaccine showed identical efficacy in groups with higher and lower risks of herpes zoster reactivation (e.g., 40% and 10% risk), the calculated protective proportion of 25% would be maintained, regardless of the different baseline risk for shingles development.

Choices:
A. Event rate
B. Risk difference
C. Relative risk reduction
D. Absolute risk reduction

Answer: Relative risk reduction

1. Researchers from a public health institute located in the United States conducted a multicenter cohort study.

2. The study was conducted on a large number of elderly individuals.

3. The purpose of the study was to evaluate the protective effect of the new vaccine for herpes zoster (commonly known as shingles) reactivation.

4. After a long follow-up period, the data shows that shingles developed in 15% of study participants who received the new vaccine.

5. 20% of diseased study participants in the control group that did not receive the vaccine developed shingles.

6. If the new vaccine showed identical efficacy in groups with higher and lower risks of herpes zoster reactivation (e.g., 40% and 10% risk), the calculated protective proportion of 25% would be maintained.

7. This would be true regardless of the different baseline risk for shingles development.

Public Health and General Preventive Medicine


Question: Which of the following has most likely been the long-term mechanism of his disease development?

Context: PFTs are performed describing a restrictive lung process.

Choices:
A. Eosinophilic reaction
B. Phagocytosis of silica
C. Tuberculosis
D. Defective mucociliary transport

Answer: Phagocytosis of silica

1. A 55-year-old gentleman has been working in a sand blasting factory for over 25 years.

2. He presents to his primary care physician with what he describes as increasing shortness of breath.

4. PFTs describe a restrictive lung process.


Question: Which of the following pathogens is most likely responsible for this patient’s opportunistic infection?

Context: A 37-year-old man presents to the emergency department with acute loss of vision, slurred speech, and agitation.

Context: Past medical history is significant for HIV and hepatitis C, diagnosed 10 years ago for which he is non-compliant with medication.

Context: A T1 MRI of the brain shows asymmetric, hypointense white matter lesions.

Choices:
A. Herpes virus 8
B. Candida albicans
C. JC virus
D. Pneumocystis jirovecii

Answer: JC virus

1. A 37-year-old man presents to the emergency department.

2. Symptoms include acute loss of vision, slurred speech, and agitation.

3. Patient has a past medical history of HIV and hepatitis C.

4. HIV and hepatitis C were diagnosed 10 years ago.

5. Patient is non-compliant with medication.

7. MRI shows asymmetric, hypointense white matter lesions.


Question: Which of the following infectious agents is the most likely cause of this patient's skin condition?

Context: A 4-year-old girl is brought to the physician for evaluation of a rash that her mother noticed 5 months ago.

Context: The rash is not painful or itchy but she notices that her daughter sometimes picks at the “spots.” The girl's 2-year-old brother has also started developing similar skin lesions over the past month.

Context: The patient has no history of serious illness and takes no medications.

Context: She is in the 75th percentile for height and 50th percentile for weight.

Choices:
A. Human herpesvirus 8
B. Human papillomavirus
C. Poxvirus
D. Varicella-zoster virus

Answer: Poxvirus

1. A 4-year-old girl is brought to the physician for evaluation of a rash.

2. The rash was noticed by the mother 5 months ago.

4. The girl sometimes picks at the “spots.”

5. The girl's 2-year-old brother has also started developing similar skin lesions over the past month.

6. The patient has no history of serious illness.

8. The patient is in the 75th percentile for height.

9. The patient is in the 50th percentile for weight.

10. A photograph of the patient's rash is shown.


Question: This patient's symptoms are most likely due to taking an antibiotic that inhibits which of the following enzymes?

Context: He takes metformin and lisinopril.

Context: His temperature is 101°F (38.3°C).

Choices:
A. 30S ribosomal subunit
B. 50S ribosomal subunit
C. Dihydropteroate synthetase
D. DNA-dependent RNA polymerase

Answer: 50S ribosomal subunit

1. A 51-year-old police officer is brought to the emergency room after being shot in the abdomen.

2. His wound was packed and bandaged by emergency medical services before he was transported to the hospital.

3. His past medical history is notable for hypertension and diabetes.

5. He has a 20-pack-year smoking history and does not drink alcohol.

6. His temperature is 98.6°F (37°C), blood pressure is 142/86 mmHg, pulse is 120/min, and respirations are 24/min.

7. On exam, he appears uncomfortable but is able to answer questions appropriately.

8. He has a 1 cm x 1 cm wound in the left upper quadrant.

9. There is an exit wound in the left lower back.

10. After undergoing the appropriate laboratory and imaging tests, he undergoes a diagnostic laparotomy.

11. No involvement of the colon or small intestine is noted intraoperatively.

12. He is placed on the appropriate antibiotic and pain control regimens.

13. Three days later, he experiences several episodes of non-bloody diarrhea.

15. Sigmoidoscopy reveals multiple pseudomembranous plaques in the sigmoid and descending colon.

General Emergency Medicine
General Surgery


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

Context: A 3-year-old girl is brought to the physician by her parents for the evaluation of vaginal discharge for one month.

Context: Vital signs are within normal limits.

Context: Examination of the vulva and vaginal entrance shows an intact hymen, vaginal erythema with blood-tinged, foul-smelling discharge, and the tip of a white object.

Choices:
A. Vaginal irrigation with warm saline
B. Vacuum suction
C. Alert Child Protective Services
D. Administration of oral metronidazole

Answer: Vaginal irrigation with warm saline

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

2. The patient has had vaginal discharge for one month.

3. The discharge is foul-smelling and contains some blood.

4. The patient sometimes has pain with urination.

5. She has not had increased urinary frequency or abdominal pain.

6. Topical vaginal cream application did not improve the patient's symptoms.

7. There is no personal or family history of serious illness.

8. She lives with her parents and attends a local daycare center.

9. Vital signs are within normal limits.

10. Examination of the vulva and vaginal entrance shows an intact hymen.

11. Examination of the vulva and vaginal entrance shows vaginal erythema with blood-tinged, foul-smelling discharge.

12. Examination of the vulva and vaginal entrance shows the tip of a white object.

13. The remainder of the examination shows no abnormalities.

Pediatric Infectious Diseases
Pediatric Gastroenterology
Pediatric Urology


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

Context: A 60-year-old man comes to the physician because of a 3-month history of a slowly enlarging painless ulcer on his lower lip.

Context: One year ago he had a painful rash near his upper lip that resolved completely with acyclovir therapy.

Context: He has a 10-year history of type 2 diabetes mellitus treated with metformin.

Choices:
A. Squamous cell carcinoma
B. Aphthous stomatitis
C. Psoriasis
D. Seborrheic keratosis

Answer: Squamous cell carcinoma

1. A 60-year-old man comes to the physician.

2. He has a 3-month history of a slowly enlarging painless ulcer on his lower lip.

3. One year ago he had a painful rash near his upper lip.

4. The rash resolved completely with acyclovir therapy.

5. He has a 10-year history of type 2 diabetes mellitus.

7. He has worked in construction for the past 33 years.

8. He has smoked one pack of cigarettes daily for 35 years.

9. Examination shows a 0.5 x 0.5 cm nontender ulcer with everted edges on the midline of his lower lip.

10. The erythematous ulcer bleeds upon palpation.

11. He has numerous moles of varying sizes all over his body.

12. There are no palpable cervical lymph nodes.


Question: Which of the following is the patient most at risk for developing?

Context: A 3-year-old girl is brought to the pediatrician by her father for fever and cough.

Context: The patient’s father states that she had a sore throat and runny nose 2 weeks ago.

Context: Then last night she developed a productive cough and a fever.

Context: The father is worried that this is pneumonia again, and reports that she has been hospitalized 5 times already with pneumonia.

Context: Her medical history is also significant for chronic diarrhea.

Context: The father reports that the patient has 2 older brothers who are both healthy.

Context: The patient’s temperature is 102°F (38.9°C), blood pressure is 102/60 mmHg, pulse is 110/min, and respirations are 28/min with an oxygen saturation of 94% on room air.

Context: An antibody panel and flow cytometry are obtained in the setting of the patient’s recurrent infections.

Context: The results show a normal lymphocyte count with low levels of IgA, IgG, and IgE and elevated levels of IgM.

Choices:
A. Ataxia
B. Atopic dermatitis
C. Blurry vision
D. Scant tonsils

Answer: Blurry vision

1. A 3-year-old girl is brought to the pediatrician by her father.

2. The patient had a sore throat and runny nose 2 weeks ago.

3. Last night she developed a productive cough and a fever.

4. The father is worried that this is pneumonia again.

5. The patient has been hospitalized 5 times already with pneumonia.

6. The patient has a medical history of chronic diarrhea.

7. The patient has 2 older brothers who are both healthy.

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

9. The patient's blood pressure is 102/60 mmHg.

11. The patient's respirations are 28/min with an oxygen saturation of 94% on room air.

12. On physical examination, decreased breath sounds are appreciated on the right.

13. A chest radiography shows consolidation in the right upper lobe, consistent with pneumonia.

14. An antibody panel and flow cytometry are obtained in the setting of the patient's recurrent infections.

15. The results show a normal lymphocyte count.

16. The results show low levels of IgA, IgG, and IgE.

17. The results show elevated levels of IgM.


Question: Which type of patient would least likely have these same diagnostic findings?

Context: A 72-year-old man presents with urinary frequency resulting in frequent awakening to urinate at night.

Context: He is a retired elite runner and does not have a history of any chronic medical conditions.

Context: The patient denies weight loss, bone pain, or pain with urination.

Context: The patient is not in distress.

Context: Vitals show: temperature 36.8°C (98.2°F), heart rate 98/min, respiratory rate 15/min, and blood pressure 100/75 mm Hg.

Context: Physical exam is significant for a smooth, non-tender, uniformly enlarged prostate on digital rectal exam.

Context: There is no CVA tenderness.

Context: CBC, CMP, urinalysis, and abdominal ultrasound are ordered.

Context: Significant findings include: bilateral hydronephrosis on ultrasound, BUN/creatinine > 20:1, specific gravity > 1,020, FENa < 1%, urine Na < 20, and urine osmolality > 450 mOsm/kg.

Context: Furthermore, post-void residual volume is > 100 mL.

Choices:
A. A 55-year-old Egyptian man with painless hematuria, 18.1 kg (40 lb) incidental weight loss and confirmed Schistosoma hematobium infection
B. A 27-year-old woman with waxing and waning internuclear ophthalmoplegia, scanning speech, and optic neuritis
C. An ICU patient with a kinked Foley catheter
D. A 35-year-old woman with severe colicky pain radiating to the left flank

Answer: A 35-year-old woman with severe colicky pain radiating to the left flank

3. Patient has urinary frequency resulting in frequent awakening to urinate at night.

4. Patient does not have a history of any chronic medical conditions.

5. Patient denies weight loss, bone pain, or pain with urination.

11. Digital rectal exam reveals a smooth, non-tender, uniformly enlarged prostate.

13. Bilateral hydronephrosis on ultrasound.

19. Post-void residual volume is > 100 mL.


Question: Which of the following is the most likely etiology of his bruises?

Context: An 82-year-old man with Alzheimer disease is brought to the physician by his daughter because of extensive bruising on his arms.

Context: His hemoglobin concentration is 11.7 g/dL, mean corpuscular volume is 78 μm3, and platelet count is 180,000/mm3.

Choices:
A. Platelet aggregation inhibition
B. Intravascular coagulation with fibrinolysis
C. Nonaccidental trauma
D. Vitamin K deficiency

Answer: Nonaccidental trauma

1. An 82-year-old man has Alzheimer disease.

2. He was brought to the physician by his daughter.

3. He has extensive bruising on his arms.

4. He lives in an assisted living facility.

5. Physical examination shows large ecchymoses across both forearms and upper arms in varied stages of healing.

6. His hemoglobin concentration is 11.7 g/dL.

7. His mean corpuscular volume is 78 μm3.

9. Coagulation studies are within normal limits.


Question: On bimanual examination, the uterus is normal size, non-tender, and mobile adnexa is non-palpable. | The pap smear result is as follows: | The pap smear result is as follows: | Specimen adequacy: satisfactory for evaluation | Interpretation: negative for intraepithelial lesion or malignancy | Notes: absent transformation zone component | How should we proceed with the management of this patient?

Context: She is nulliparous, does not report any gynecologic or systemic diseases, and has no complaints.

Context: She is sexually active with one partner and uses oral contraceptive pills.

Context: Her vital signs are as follows: blood pressure 125/70 mm Hg, heart rate 81/min, respiratory rate 12/min, and temperature 36.6℃ (97.9℉).

Context: The breast examination is normal.

Context: No pathology is noted in the external genitalia and a speculum examination reveals a normal cervix with a closed external os and no discharge.

Choices:
A. Repeat Pap test in 3 years as a usual screening schedule suggests
B. Repeat Pap test within 2 weeks and ensure proper sampling from the transformation zone
C. Perform a screening test for high-risk human papillomavirus (HPV)
D. Perform a HPV testing and Pap smear in one year

Answer: Repeat Pap test in 3 years as a usual screening schedule suggests

1. A 23-year-old woman presents to her gynecologist for a routine visit.

3. She does not report any gynecologic or systemic diseases.

5. She is sexually active with one partner.

11. The physical examination is within normal limits.

13. No pathology is noted in the external genitalia.

14. A speculum examination reveals a normal cervix with a closed external os and no discharge.

15. A specimen is obtained from the cervical portion for a Pap smear.


Question: Which of the following best describe the primary disorder in this patient?

Choices:
A. Obstruction of the lumen of the appendix
B. Inflammation of the renal parenchyma, calyces and pelvis
C. Herniation of mucosa and submucosa through the muscular layer of the colon
D. Inflammation of the upper genital tract

Answer: Herniation of mucosa and submucosa through the muscular layer of the colon

1. A 57-year-old woman presents to the emergency department with acute pain in the left lower abdomen associated with nausea and vomiting for the past 24 hours.

2. Prior to this episode, the patient did not have any significant gastrointestinal (GI) problems except for occasional constipation and indigestion after heavy meals.

3. She has had hypertension and hypercholesterolemia for the past 7 years.

4. Her family history is negative for GI disorders.

5. Vital signs include a temperature of 38.0°C (100.4°F), blood pressure of 120/80 mm Hg, and pulse of 85/min.

6. On physical examination, there is tenderness in the left lower abdominal quadrant.

7. Abdominal CT scan shows thickening of the bowel wall and streaky mesenteric fat.


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

Context: A 35-year-old woman comes to the emergency department because of a 3-day history of pain in the left cheek.

Context: The pain occurs every few hours, lasts 30–60 seconds, and is aggravated by chewing and brushing.

Choices:
A. Cluster headache
B. Trigeminal neuralgia
C. Postherpetic neuralgia
D. Temporal arteritis

Answer: Trigeminal neuralgia

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

2. She has a 3-day history of pain in the left cheek.

5. The pain is aggravated by chewing and brushing.

6. She has a history of pain with a vesicular rash in the right axillary area one year ago.

7. She had an upper respiratory infection 2 weeks ago.

8. Physical examination shows no abnormalities.

General Neurology
Pain Medicine
Headache Medicine


Question: Which of the following chromosomes is most likely mutated in association with this patient's condition?

Context: The patient's vitals are: BP 120/65, RR 16, 100% on room air, HR 78 bpm and he appears to be in no acute distress.

Context: Upon obtaining a history you learn that this patient also complains that at times the "room feels like it's spinning." You also notice throughout the interview that you have to speak loudly as the patient has difficulty hearing.

Context: The patient is then lost to follow up for his current condition.

Context: The patient returns several years later with worsening symptoms and as part of this patient's workup a MRI is obtained (Image A).

Choices:
A. Chromosome 13
B. Chromosome 17
C. Chromosome 22
D. The X chromosome

Answer: Chromosome 22

1. A 45 year old male presents to clinic complaining of a ringing in his ears.

3. Patient appears to be in no acute distress.

4. Patient also complains that at times the "room feels like it's spinning."

6. Patient is then lost to follow up for his current condition.

7. Patient returns several years later with worsening symptoms.


Question: What is the most likely diagnosis?

Context: A 35-year-old is brought into the emergency room after a bicycle vs motored vehicle accident.

Context: He was unconscious after hitting the side of his head on the road, but recovered consciousness after a few minutes.

Context: He started to ride his bicycle again, but then developed a severe headache with nausea and vomiting, at which time he called EMS.

Context: While in the hospital, the patient is confused and cannot provide a history.

Context: He quickly loses consciousness and his CT scan is displayed in Figure 1.

Choices:
A. Subdural hematoma
B. Epidural hematoma
C. Subgaleal hematoma
D. Caput succedaneum

Answer: Epidural hematoma

1. A 35-year-old was brought into the emergency room.

2. The patient was involved in a bicycle vs motored vehicle accident.

3. He was unconscious after hitting the side of his head on the road.

4. He recovered consciousness after a few minutes.

5. He started to ride his bicycle again.

6. He then developed a severe headache with nausea and vomiting.

8. While in the hospital, the patient was confused and could not provide a history.

10. His CT scan is displayed in Figure 1.


Question: Which of the following auscultation findings is most likely to correlate with the severity of this patient's valvular disease?

Context: A 39-year-old man comes to the physician because of a 2-month history of shortness of breath with exertion.

Context: His pulse is 88/min, respirations are 18/min, and blood pressure is 120/80 mm Hg.

Context: Echocardiography shows thickened mitral valve leaflets with reduced motion and a narrowed mitral valve orifice diameter.

Choices:
A. Decreased time between S2 and opening snap
B. Radiation of murmur to the axilla
C. Increased intensity of the murmur
D. Absence of A2 heart sound

Answer: Decreased time between S2 and opening snap

1. A 39-year-old man comes to the physician.

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

3. He immigrated to the United States from Ghana 20 years ago.

7. Echocardiography shows thickened mitral valve leaflets.

8. Echocardiography shows reduced motion of the mitral valve leaflets.

9. Echocardiography shows a narrowed mitral valve orifice diameter.

Cardiovascular Disease
Valvular Heart Disease
General Cardiology


Question: Analysis of the bone marrow aspirate of this patient is most likely to show which of the following findings?

Context: A 6-year-old boy is brought to the physician because of worsening fatigue for the past 4 weeks.

Context: Examination of the head and neck shows conjunctival pallor, grayish-brown spots on the irises, prominent epicanthal folds, and a broad nasal bridge.

Context: He has a single transverse palmar crease, and there are scattered petechiae over the chest.

Context: An ultrasound of the abdomen shows enlargement of the liver and spleen.

Choices:
A. Translocation t(15;17)
B. Ringed sideroblasts
C. CD10 positive cells
D. Hypocellular bone marrow

Answer: CD10 positive cells

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

2. The boy has been experiencing worsening fatigue for the past 4 weeks.

3. Examination of the head and neck shows conjunctival pallor.

4. Examination of the head and neck shows grayish-brown spots on the irises.

5. Examination of the head and neck shows prominent epicanthal folds.

6. Examination of the head and neck shows a broad nasal bridge.

7. The boy has a single transverse palmar crease.

8. There are scattered petechiae over the chest.

9. An ultrasound of the abdomen shows enlargement of the liver.

10. An ultrasound of the abdomen shows enlargement of the spleen.


Question: What is the diagnosis in this patient?

Context: A 42-year-old female presents to the emergency department with two days of severe abdominal pain and fever.

Context: The patient has a history of gallstones, for which she was scheduled to have a cholecystectomy in two weeks.

Context: The patient is noticeably jaundiced.

Context: Laboratory evaluation is notable for a leukocytosis and a total bilirubin of 6.4 mg/dL.

Choices:
A. Acute pancreatitis
B. Chronic pancreatitis
C. Acute cholangitis
D. Primary sclerosing cholangitis

Answer: Acute cholangitis

1. A 42-year-old female presents to the emergency department.

2. She has two days of severe abdominal pain and fever.

4. She was scheduled to have a cholecystectomy in two weeks.

5. On physical exam, her abdomen is tender to palpation over the epigastrium, without rebound or guarding.

7. Laboratory evaluation is notable for a leukocytosis.

8. Laboratory evaluation is notable for a total bilirubin of 6.4 mg/dL.


Question: Which of the following characteristics of this patient most likely increased her risk for this disorder?

Context: A 52-year-old woman presents to her primary care physician because she has been feeling pain in her right leg.

Context: She also has been taking estrogen replacement therapy and drinking alcohol to cope with her symptoms of menopause.

Context: This lesion feels thick and hardened on palpation and is tender to the touch.

Context: She is started on compression therapy as well as NSAIDs for pain management.

Choices:
A. Alcohol use
B. Diabetes
C. Estrogen therapy
D. Hypertension

Answer: Estrogen therapy

1. A 52-year-old woman presents to her primary care physician.

2. She has been feeling pain in her right leg.

3. Specifically, she says that an area on her right thigh has been feeling tender and swollen over the past few weeks.

4. Her past medical history is significant for obesity, poorly controlled diabetes, and hypertension.

5. She has been taking estrogen replacement therapy.

6. She has been drinking alcohol to cope with her symptoms of menopause.

7. Her family history is significant for cardiomyopathy.

8. On physical exam, there is erythema and edema along a cord-like lesion in her thigh.

9. This lesion feels thick and hardened on palpation.

11. She is started on compression therapy.

12. She is started on NSAIDs for pain management.


Question: What medication did the patient take?

Context: A 34-year-old woman presents to the clinic complaining of constipation and dry mouth.

Context: She had uncontrollable diarrhea for 1 day and took some medications afterwards.

Context: She also denies melena, hematochezia, nausea, or vomiting.

Context: Vitals are within normal limits.

Choices:
A. Loperamide
B. Oral vancomycin
C. Sulfasalazine
D. Setraline

Answer: Loperamide

1. A 34-year-old woman presents to the clinic.

2. She is complaining of constipation and dry mouth.

3. She had uncontrollable diarrhea for 1 day.

4. She took some medications afterwards.

5. Patient denies any recent hospitalizations or antibiotic use.

6. Patient denies melena, hematochezia, nausea, or vomiting.


Question: What is the most likely cause of this patient’s high blood pressure?

Context: A 25-year-old arrives at a gynecology clinic for a consult as she and her husband plan to conceive a baby soon.

Context: She is currently taking no medications, doesn’t smoke, and drinks alcohol socially.

Context: Her father passed away at the age of 51 due to heart failure.

Context: Her vital signs include blood pressure 150/100 mm Hg, heart rate 67/min, respiratory rate 16/min, and temperature 36.7°C (98.0°F).

Context: Physical examination is unremarkable.

Context: When asked about her high blood pressure, the patient says that her primary care physician once told her that her blood pressure was elevated on most of her visits; the physician emphasized that she should exercise and control her diet, but she never followed up with him as she always felt good.

Context: A number of tests are run to find out the etiology of her elevated blood pressure.

Choices:
A. Atherosclerosis
B. Adult polycystic kidney disease
C. Fibromuscular hyperplasia
D. Pheochromocytoma

Answer: Fibromuscular hyperplasia

1. A 25-year-old is at a gynecology clinic for a consult.

2. The patient and her husband plan to conceive a baby soon.

3. The patient is not taking any medications.

6. The patient's father passed away at the age of 51 due to heart failure.

7. The patient's blood pressure is 150/100 mm Hg.

9. The patient's respiratory rate is 16/min.

10. The patient's temperature is 36.7°C (98.0°F).

11. The physical examination is unremarkable.

12. The patient's primary care physician told her that her blood pressure was elevated on most of her visits.

13. The primary care physician emphasized that the patient should exercise and control her diet.

14. The patient never followed up with her primary care physician as she always felt good.

15. Tests are run to find out the etiology of the patient's elevated blood pressure.

16. Everything is within the normal range except for a renal angiogram shown in the picture.


Question: Which of the following embryonic structures most likely gave rise to the thickening described here?

Context: Since part of this ligament lies over the part of the liver that needs to be resected, the ligament is incised to allow for removal of the tumor.

Context: The free edge of the ligament is found to have a thickening with small remnant blood vessels.

Choices:
A. Ductus venosus
B. Left umbilical vein
C. Right umbilical artery
D. Ductus arteriosus

Answer: Left umbilical vein

1. A 73-year-old man is found to have an early stage hepatocellular carcinoma in the left lobe of his liver.

2. He decides to undergo surgery to remove the tumor through partial liver resection.

3. During the procedure, a ligament is found that attaches the liver to the anterior abdominal wall.

4. Part of this ligament lies over the part of the liver that needs to be resected.

5. The ligament is incised to allow for removal of the tumor.

6. The free edge of the ligament is found to have a thickening.

7. The thickening has small remnant blood vessels.


Question: Which of the following parameters are most likely to affect the x-axis in the diagram?

Context: He documents specific observations and plots some of them as a Darrow-Yannet diagram.

Context: In his study, some diagrams are normal, while most are abnormal.

Context: The abnormalities in the diagram are mostly in the form of changes in the x-axis, changes in the y-axis or changes in both axes of the diagram.

Choices:
A. Fluid osmolality
B. Fluid surface tension
C. Fluid viscosity
D. Fluid volume

Answer: Fluid volume

1. A researcher is conducting an experiment on the physiology of body fluids.

3. He plots some of the observations as a Darrow-Yannet diagram.

6. The abnormalities in the diagram are mostly in the form of changes in the x-axis.

7. The abnormalities in the diagram are mostly in the form of changes in the y-axis.

8. The abnormalities in the diagram are mostly in the form of changes in both axes of the diagram.


Question: Which of the following drugs is most likely suggested by the pediatrician?

Context: An 11-year-old girl is brought to a pediatrician by her parents with recurrent wheezing for the last 3 years.

Context: After a detailed history, complete physical examination, and thorough diagnostic evaluation, the pediatrician informs the parents that the girl has mild persistent asthma, which will be most effectively treated with inhaled corticosteroids (ICS).

Context: However, her parents firmly object to the use of corticosteroids in any form, despite being told that the side effects associated with ICS are negligible.

Context: Therefore, the pediatrician suggests the regular use of a drug that does not contain a corticosteroid.

Context: The pediatrician mentions that the drug is used as prophylaxis only and will not be useful to treat acute bronchospasm.

Choices:
A. Subcutaneous terbutaline
B. Inhaled ipratropium bromide
C. Inhaled cromolyn sodium
D. Oral roflumilast

Answer: Inhaled cromolyn sodium

1. An 11-year-old girl is brought to a pediatrician by her parents.

2. The girl has had recurrent wheezing for the last 3 years.

3. The pediatrician has conducted a detailed history, complete physical examination, and thorough diagnostic evaluation.

4. The pediatrician has informed the parents that the girl has mild persistent asthma.

5. The most effective treatment for the girl's asthma is inhaled corticosteroids (ICS).

6. The parents object to the use of corticosteroids in any form.

7. The pediatrician has informed the parents that the side effects associated with ICS are negligible.

8. The pediatrician has suggested the regular use of a drug that does not contain a corticosteroid.

9. The drug is used as prophylaxis only and will not be useful to treat acute bronchospasm.


Question: Based on this knowledge, provided the concentration and actions of reactant B and enzyme E are same in both normal hepatocytes and hepatocytes of fatty liver patients, which of the following is the most likely possibility if drug A is administered to hypertensive patients with fatty liver?

Context: A team of scientists is researching the synthesis of a drug that would potentially reduce blood pressure in hypertensive patients by a novel mechanism of action.

Context: The drug A is an inactive prodrug and enters hepatocytes, reacts with reactant B, a native material in the cell, and creates products C and D.

Context: D has a blood pressure lowering effects.

Context: The researcher observes that, for the above chemical reaction, Gibbs free energy change (ΔG) is less than zero in normal hepatocytes whereas, in hepatocytes of patients with fatty liver, ΔG is more than 0 due to some unknown reason.

Choices:
A. Drug A will decrease blood pressure only if reactant B is also supplemented in necessary dose
B. Drug A will decrease blood pressure only if enzyme E is also supplemented in necessary dose
C. Drug A will not decrease blood pressure, regardless of its dose or supplementation of B or E
D. Drug A will decrease blood pressure in same dose as required for patients with a healthy liver

Answer: Drug A will not decrease blood pressure, regardless of its dose or supplementation of B or E

1. A team of scientists is researching the synthesis of a drug that would potentially reduce blood pressure in hypertensive patients.

2. The drug A is an inactive prodrug and enters hepatocytes.

3. The drug A reacts with reactant B, a native material in the cell.

4. The reaction creates products C and D.

5. Product D has a blood pressure lowering effect.

6. The reaction requires the presence of enzyme E.

7. The researcher observes that, for the above chemical reaction, Gibbs free energy change (ΔG) is less than zero in normal hepatocytes.

8. In hepatocytes of patients with fatty liver, ΔG is more than 0 due to some unknown reason.


Question: In addition to analgesia, which of the following is the most appropriate next step in management?

Context: A 70-year-old man comes to the physician because of a 4-month history of progressively worsening lower back pain.

Context: He describes the pain as a constant, dull ache that interferes with his sleep and is only partially relieved with ibuprofen.

Context: Two years ago, he was diagnosed with advanced prostate cancer, for which he underwent radiation therapy of the prostate and bilateral orchiectomy.

Context: He missed his previous follow-up visit.

Context: Vital signs are within normal limits.

Context: The serum PSA concentration is 16 ng/mL (N<4).

Context: A technetium-99m bone scan shows increased uptake at the second and third lumbar vertebral bodies.

Choices:
A. External beam radiotherapy to the lumbar vertebrae
B. Leuprolide therapy
C. Finasteride therapy
D. Observation with no further treatment

Answer: External beam radiotherapy to the lumbar vertebrae

2. Patient has 4-month history of progressively worsening lower back pain.

3. Patient describes pain as constant, dull ache.

4. Pain interferes with sleep and is only partially relieved with ibuprofen.

5. Two years ago, patient was diagnosed with advanced prostate cancer.

6. Patient underwent radiation therapy of the prostate and bilateral orchiectomy.

7. One year postoperatively, serum prostate-specific antigen (PSA) was undetectable.

8. Patient missed previous follow-up visit.

9. Current medications include over-the-counter ibuprofen.

10. Vital signs are within normal limits.

11. Physical examination shows tenderness of the spinous process of the third lumbar vertebra.

12. Digital rectal examination shows a hard, nontender prostate.

13. The remainder of the examination shows no abnormalities.

14. Serum PSA concentration is 16 ng/mL (N<4).

15. Technetium-99m bone scan shows increased uptake at the second and third lumbar vertebral bodies.


Question: What is the most likely causative organism?

Context: You perform a KOH prep, and notice an abnormal smell.

Context: On microscopy in your office, you observe the findings in figure A. |  | .

Choices:
A. Trichomonas vaginalis
B. Candida albicans
C. Escherichia coli
D. Gardnerella vaginalis

Answer: Gardnerella vaginalis

1. A 24-year-old woman presents complaining of a new onset vaginal odor.

2. She reports that she is sexually active in a monogamous relationship with the same partner for two years.

5. On microscopy in your office, you observe the findings in figure A.


Question: In addition to securing the airway, which of the following is the most appropriate next step in management?

Context: A 22-year-old woman is brought to the emergency department 4 hours after the ingestion of 25 tablets of an unknown drug in an attempt to commit suicide.

Context: Her temperature is 36.7°C (98°F), pulse is 41/min, respirations are 14/min, and blood pressure is 88/55 mm Hg.

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

Context: She is confused and oriented only to person.

Context: The pupils are equal and reactive to light.

Context: Examination shows cold, clammy extremities.

Context: Scattered expiratory wheezing and rhonchi are heard throughout both lung fields.

Context: The abdomen is soft.

Context: Fingerstick blood glucose concentration is 65 mg/dL.

Context: ECG shows prolonged PR intervals and narrow QRS complexes.

Context: Two large bore cannulas are inserted and intravenous normal saline, dextrose, and atropine are administered.

Context: Five minutes later, pulse is 51/min and blood pressure is 95/61 mm Hg.

Choices:
A. Glucagon
B. Activated charcoal
C. Sodium bicarbonate
D. Hemodialysis

Answer: Glucagon

1. A 22-year-old woman was brought to the emergency department.

2. She had ingested 25 tablets of an unknown drug 4 hours prior.

3. The attempt was in an attempt to commit suicide.

8. Pulse oximetry on room air showed an oxygen saturation of 93%.

9. She was confused and oriented only to person.

10. Her pupils were equal and reactive to light.

11. Examination showed cold, clammy extremities.

12. Scattered expiratory wheezing and rhonchi were heard throughout both lung fields.

14. Fingerstick blood glucose concentration was 65 mg/dL.

15. ECG showed prolonged PR intervals and narrow QRS complexes.

16. Two large bore cannulas were inserted.

17. Intravenous normal saline, dextrose, and atropine were administered.

18. Five minutes later, pulse was 51/min.

19. Five minutes later, blood pressure was 95/61 mm Hg.


Question: The bacteria causing this patient's dental problems most likely exhibits which of the following properties?

Context: A 56-year-old patient reports a history of recurrent dental caries.

Choices:
A. Inhibition of growth on optochin sensitivity test
B. Production of dextrans from glucose
C. Presence of catalase enzyme
D. Soluble in bile

Answer: Production of dextrans from glucose

2. Patient has a history of recurrent dental caries.

Pediatric Infectious Diseases
General Dermatology


Question: Which of the following autoantibodies is most likely to be present in this patient?"

Context: She also has generalized itching.

Context: Laboratory studies show: | Hemoglobin 14.1 g/dL | Leukocyte count 7,200/mm3 | Erythrocyte sedimentation rate 26 mm/h | Serum | Thyroid-stimulating hormone 4.2 μU/ml | Bilirubin | Total 1.7 mg/dL | Direct 1.0 mg/dL | Alkaline phosphatase 370 U/L | Aspartate aminotransferase 80 U/L | Alanine aminotransferase 46 U/L | Cholesterol 320 mg/dL | Gamma-glutamyl transferase 98 U/L (N = 5–50) | Magnetic resonance cholangiopancreatography shows no gallstones and no evidence of extrahepatic biliary obstruction.

Choices:
A. Anti-liver-kidney microsomal-1 antibodies
B. Anti-mitochondrial antibodies
C. Anti-smooth muscle antibodies
D. Perinuclear anti-neutrophil cytoplasmic antibodies

Answer: Anti-mitochondrial antibodies

1. A 40-year-old woman comes to the physician for a follow-up examination.

2. She says she has felt fatigued for about 3 months.

3. She does not have enough energy for her job as a physician's assistant and often has to lie down and rest during shifts.

4. She no longer adheres to her usual exercise routine because of exhaustion.

5. During this time, she has noticed that her stools are sometimes pale and foul smelling.

7. The patient does not have abdominal pain, fever, or weight loss.

8. She takes levothyroxine for hypothyroidism.

9. She has smoked one pack of cigarettes weekly for 20 years.

10. Physical examination shows no abnormalities.

11. Laboratory studies show: Hemoglobin 14.1 g/dL, Leukocyte count 7,200/mm3, Erythrocyte sedimentation rate 26 mm/h, Serum Thyroid-stimulating hormone 4.2 μU/ml, Bilirubin Total 1.7 mg/dL, Direct 1.0 mg/dL, Alkaline phosphatase 370 U/L, Aspartate aminotransferase 80 U/L, Alanine aminotransferase 46 U/L, Cholesterol 320 mg/dL, Gamma-glutamyl transferase 98 U/L (N = 5–50).

12. Magnetic resonance cholangiopancreatography shows no gallstones and no evidence of extrahepatic biliary obstruction.

13. Liver biopsy shows nonsuppurative destructive cholangitis with lymphocytic infiltration of portal areas and periductal granulomas.


Question: Inhibition of which of the following best describes this drug’s mechanism of action?

Context: He has recently made lifestyle modifications, such as losing 4.5 kg (10 lb) but his erectile symptoms have not improved.

Choices:
A. 5-alpha reductase
B. cGMP phosphodiesterase
C. Estrogen receptors
D. Testosterone receptors

Answer: cGMP phosphodiesterase

1. A 73-year-old man seeks evaluation for difficulty developing and maintaining erections.

2. He has recently made lifestyle modifications, such as losing 4.5 kg (10 lb).

3. His erectile symptoms have not improved.

4. He was prescribed a drug by his physician.


Question: Which of the following regions of the brain is most likely affected?

Context: A 65-year-old woman with hypertension comes to the emergency department because of sudden onset of a severe headache 2 hours ago.

Context: Her temperature is 35°C (95°F) and blood pressure is 189/115 mm Hg.

Context: A CT scan of the head shows a subarachnoid hemorrhage and she is started on appropriate pharmacotherapy.

Choices:
A. Ventral lateral thalamic nucleus
B. Pineal gland
C. Preoptic nucleus
D. Caudate nucleus

Answer: Preoptic nucleus

1. A 65-year-old woman comes to the emergency department.

3. She has sudden onset of a severe headache 2 hours ago.

6. A CT scan of the head shows a subarachnoid hemorrhage.

7. She is started on appropriate pharmacotherapy.


Question: Which of the following should be tested weekly?

Context: A 35-year-old woman with a one-year history of auditory hallucinations and periods of anhedonia and amotivation is being seen by her psychiatrist.

Context: She was started on haloperidol at her last visit, but she was told to stop taking the medication since she developed muscle stiffness and spasms soon after taking the drug.

Context: Today, her temperature is 97.7°F (36.5°C), blood pressure is 132/76 mmHg, pulse is 98/min, and respirations are 12/min.

Context: The patient is now started on a new medication that will seek to avoid the same side effects as her previous one; however, she will need to come in for weekly testing.

Choices:
A. Electrocardiogram
B. Electrolytes
C. Gonadotropin releasing hormone
D. White blood cell count

Answer: White blood cell count

1. A 35-year-old woman has a one-year history of auditory hallucinations and periods of anhedonia and amotivation.

2. She was started on haloperidol at her last visit.

3. She was told to stop taking the medication since she developed muscle stiffness and spasms soon after taking the drug.

4. Today, her temperature is 97.7°F (36.5°C).

8. She is now started on a new medication that will seek to avoid the same side effects as her previous one.

9. She will need to come in for weekly testing.


Question: Which of the following is the most common viral cause of this child's condition?

Context: A 9-year-old boy is brought to the emergency room by his concerned mother after he "urinated blood." The boy reports that, starting this morning, he experienced significant pain with urination and his urine appeared a bright red color.

Context: These symptoms were not present before today; however, he reports a cough, runny nose, and sore throat that started approximately 3 days ago.

Context: Vital signs are as follows: T 38.4 deg C, HR 101, BP 110/65, RR 14, SpO2 99%.

Context: Physical examination is significant for bilateral conjunctivitis, tenderness to suprapubic palpation, and a small amount of clotted blood is noted surrounding the urethral meatus.

Context: A urine sample is obtained, and urinalysis shows 3+ blood, and urine microscopy demonstrates gross blood with too many cells to count per high powered field.

Choices:
A. Parvovirus B19
B. Coronavirus
C. Adenovirus
D. Coxsackie A virus

Answer: Adenovirus

2. Patient was brought to the emergency room by his concerned mother.

4. Patient experienced significant pain with urination.

5. Patient's urine appeared a bright red color.

6. Symptoms were not present before today.

7. Patient reports a cough, runny nose, and sore throat that started approximately 3 days ago.

9. Physical examination is significant for bilateral conjunctivitis.

10. Physical examination is significant for tenderness to suprapubic palpation.

11. A small amount of clotted blood is noted surrounding the urethral meatus.

12. Urine sample obtained, and urinalysis shows 3+ blood.

13. Urine microscopy demonstrates gross blood with too many cells to count per high powered field.


Question: Of the following proposed mechanisms, which one would best serve the researcher's purpose?

Context: He brainstorms several ideas but is informed by his mentor that only one of his ideas will most likely help him achieve the desired result.

Choices:
A. Decrease lactic acid production by skeletal muscle
B. Increase fetal hemoglobin concentration in circulation
C. Increase relaxed form hemoglobin in muscle capillaries
D. Increase taut form hemoglobin in muscle capillaries

Answer: Increase taut form hemoglobin in muscle capillaries

1. A young researcher wants to develop a method of increasing oxygen delivery to the peripheral tissues.

3. His mentor informs him that only one of his ideas will most likely help him achieve the desired result.


Question: Administration of which of the following is most likely to have prevented this patient's current symptoms?

Context: Three months ago, he was diagnosed with pulmonary tuberculosis and started on antituberculosis therapy.

Context: His hemoglobin concentration is 10.4 g/dL and mean corpuscular volume is 76 μm3.

Choices:
A. Iron
B. Vitamin E
C. Folic acid
D. Pyridoxine

Answer: Pyridoxine

1. A 29-year-old man comes to the physician for a follow-up examination.

2. He has had numbness and tingling of his legs for the past 10 days.

3. Three months ago, he was diagnosed with pulmonary tuberculosis.

4. He started on antituberculosis therapy three months ago.

5. Examination shows dry scaly lips and cracks at the corner of the mouth.

6. Sensation to pinprick and light touch is decreased over the lower extremities.

7. His hemoglobin concentration is 10.4 g/dL.

8. His mean corpuscular volume is 76 μm3.


Question: Which investigation should be performed next in this patient?

Context: A 36-year-old woman presents with a 2-month history of urinary incontinence, accompanied by urgency, nocturia, and occasional hematuria.

Context: Her symptoms are present day and night and have no known triggers.

Context: She was diagnosed with grade 2 pelvic organ prolapse (cystocele) 1 year ago, which is managed with pelvic floor training exercises and a vaginal pessary.

Context: She is otherwise healthy and does not take any medications.

Context: The blood pressure is 120/80 mm Hg, the heart rate is 67/min, the respiratory rate is 14/min, and the temperature is 36.8℃ (98.2℉).

Context: The physical examination is significant for suprapubic tenderness.

Context: There are no signs of vulvar inflammation, and no urethral or vaginal discharge.

Context: The vaginal mucosa is normal and there is no cervical discharge.

Context: A vaginal pessary is placed.

Context: The cervix is non-tender and mobile, the uterus is not enlarged, and the adnexa have no masses. | The urinalysis shows the following findings: |  Color:  Pale yellow |  Clarity:  Clear |  pH:  6.2 |  Specific gravity:  1.023 |  Glucose:  Negative |  Ketones:  Negative |  Nitrites:  Positive |  Leukocyte esterase:  Positive |  Bilirubin:  Negative |  Urinary bilirubin:  Negative |  Protein: Negative |  RBCs:  47 RBCs/hpf |  WBCs:  21 WBCs/hpf |  Epithelial cells:  27 squamous epithelial cells/hpf |  Casts:  5 hyaline casts/lpf |  Crystals:  Occasional urates |  Bacteria:  None noted |  Yeast:  None noted | The urinary culture is negative.

Choices:
A. Cystoscopy
B. Ultrasound examination
C. Cystometry
D. Pelvic CT scan

Answer: Ultrasound examination

2. Patient has a 2-month history of urinary incontinence, accompanied by urgency, nocturia, and occasional hematuria.

3. Symptoms are present day and night and have no known triggers.

4. Patient was diagnosed with grade 2 pelvic organ prolapse (cystocele) 1 year ago.

5. Patient is managed with pelvic floor training exercises and a vaginal pessary.

6. Patient is otherwise healthy and does not take any medications.

11. Physical examination is significant for suprapubic tenderness.

12. No costovertebral angle tenderness is present.

21. Urinalysis shows pale yellow color, clear clarity, pH 6.2, specific gravity 1.023, negative glucose, negative ketones, positive nitrites, positive leukocyte esterase, negative bilirubin, negative urinary bilirubin, negative protein, 47 RBCs/hpf, 21 WBCs/hpf, 27 squamous epithelial cells/hpf, 5 hyaline casts/lpf, occasional urates, no bacteria, and no yeast.


Question: Which of the following is closest to the probability of a female and a male with normal vision having a daughter with red-green color blindness?

Context: The incidence of red-green color blindness in males in a certain population is 1/100.

Choices:
A. 1/100
B. 1/50
C. 98/100
D. 0

1. The incidence of red-green color blindness is 1/100.

2. The population is a certain population.


Question: The most likely cause of this patient's condition is a defect in which of the following molecular structures?

Context: He is also concerned about fertility, as he and his wife have been trying to conceive for 5 years unsuccessfully.

Context: A CT scan of the chest is shown.

Choices:
A. IL-2R gamma chain
B. NADPH oxidase
C. CFTR protein
D. Dynein arm

Answer: Dynein arm

1. A 31-year-old man comes to the physician for evaluation of chronic cough, sinus pain, and nasal discharge.

2. He has a history of frequent upper respiratory infections and recurrent sinusitis since childhood.

3. He and his wife have been trying to conceive for 5 years unsuccessfully.

4. Pulmonary examination shows crackles and wheezing throughout both lung fields.

General Allergy and Immunology
Pediatric Pulmonology


Question: Which of the following is most likely to have prevented this patient's condition?

Context: A 3-year-old boy is brought to the emergency department because of abdominal pain and watery diarrhea for the past 3 days.

Context: This morning he also had nausea and his stool had a red tint.

Context: Four days ago, he and his parents returned home from a vacation, during which they visited a petting zoo and consumed many new foods.

Context: He lives with his family and they have cats and dogs at home.

Context: The patient attends daycare.

Context: His immunizations are up-to-date.

Context: His temperature is 38°C (100.4°F), pulse is 140/min, and blood pressure is 80/45 mm Hg.

Context: Examination shows dry mucus membranes.

Context: The abdomen is soft, and there is tenderness to palpation of the right lower quadrant with rebound.

Choices:
A. Hand-washing at daycare
B. Avoiding the consumption of undercooked pork
C. Avoiding the consumption of deli meats
D. Avoiding the consumption of unwashed vegetables

Answer: Avoiding the consumption of undercooked pork

2. Patient has had abdominal pain and watery diarrhea for the past 3 days.

5. Patient and his parents returned home from a vacation 4 days ago.

6. Patient and his family visited a petting zoo during the vacation.

7. Patient and his family consumed many new foods during the vacation.

9. Patient's family has cats and dogs at home.

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

12. Patient's temperature is 38°C (100.4°F).

14. Patient's blood pressure is 80/45 mm Hg.

17. Patient has tenderness to palpation of the right lower quadrant with rebound.

18. Stool culture grows Yersinia enterocolitica.


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

Context: A 61-year-old woman dies unexpectedly.

Context: Examination of the heart during autopsy shows hypertrophy of the left ventricular wall and enlargement of the left ventricular chamber.

Context: Microscopic examination shows lengthening of individual muscle fibers due to duplication of sarcomeres in series.

Choices:
A. Increased pulmonary arterial pressure
B. Decreased left ventricular contractility
C. Decreased left ventricular compliance
D. Increased left ventricular end diastolic volume

Answer: Increased left ventricular end diastolic volume

1. A 61-year-old woman dies unexpectedly.

2. She had not seen a physician in 10 years.

3. Examination of the heart during autopsy shows hypertrophy of the left ventricular wall.

4. Examination of the heart during autopsy shows enlargement of the left ventricular chamber.

5. Microscopic examination shows lengthening of individual muscle fibers.

6. Microscopic examination shows duplication of sarcomeres in series.

General Cardiology
Cardiovascular Disease


Question: What is the mechanism of action of this drug?

Context: A 57-year-old man with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and obstructive sleep apnea presents to your office for routine screening.

Context: He reports compliance with his medications but admits to difficulty maintaining the diet and exercise routines discussed during his last visit.

Context: He does not have any other complaints.

Context: He drinks 3-4 beers on the weekends and does not smoke cigarettes.

Context: His current medications include metformin, atorvastatin, and hydrochlorothiazide.

Context: On physical examination, his temperature is 99°F (37.2°C), blood pressure is 130/85 mmHg, pulse is 85/min, and respirations are 18/min.

Context: Laboratory results are shown below: |  | Serum: | Na+: 138 mEq/L | Cl-: 100 mEq/L | K+: 3.9 mEq/L | HCO3-: 23 mEq/L | BUN: 13 mg/dL | Glucose: 160 mg/dL |  | You decide to start the patient on a medication that triggers insulin release.

Choices:
A. Close potassium channels
B. Increase insulin sensitivity
C. Delay gastric emptying
D. Increase ATP generation

Answer: Close potassium channels

2. Patient has a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and obstructive sleep apnea.

3. Patient reports compliance with medications.

4. Patient has difficulty maintaining diet and exercise routines.

5. Patient does not have any other complaints.

6. Patient drinks 3-4 beers on the weekends.

8. Patient's current medications include metformin, atorvastatin, and hydrochlorothiazide.

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

10. Patient's blood pressure is 130/85 mmHg.

19. Patient is to be started on a medication that triggers insulin release.


Question: Which of the following is the most likely organism responsible for the patient's condition?

Context: A 28-year-old woman presents to the emergency department with fever and abdominal pain for the past several days.

Context: She says she feels like she has a slight fever.

Context: She denies nausea or vomiting.

Context: Physical examination shows pain in the right upper quadrant to deep palpation with rebound tenderness and guarding.

Context: A laparoscopy is performed which shows string-like, fibrous scar tissue in the perihepatic recesses.

Choices:
A. Giardia lamblia
B. Gardnerella vaginalis
C. Trichomonas vaginalis
D. Neisseria gonorrhoeae

Answer: Neisseria gonorrhoeae

1. A 28-year-old woman presents to the emergency department.

2. She has had fever and abdominal pain for several days.

3. She feels like she has a slight fever.

5. Physical examination shows pain in the right upper quadrant to deep palpation.

6. Physical examination also shows rebound tenderness and guarding.

8. The laparoscopy shows string-like, fibrous scar tissue in the perihepatic recesses.

General Infectious Disease
Infectious Disease


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

Context: A 30-year-old woman comes to the emergency department because of a 1-day history of sharp chest pain radiating to the left shoulder.

Context: Examination shows a symmetric, erythematous rash on her nose and cheeks, and erythematous patches with scaling and plugged follicles over her hands.

Choices:
A. Increased distension of jugular veins during inspiration
B. 18 mm Hg decrease in systolic blood pressure during inspiration
C. Triphasic scratchy heart sound of varying intensity
D. Holosystolic blowing murmur heard best at the apex

Answer: Triphasic scratchy heart sound of varying intensity

1. A 30-year-old woman comes to the emergency department.

2. She has a 1-day history of sharp chest pain radiating to the left shoulder.

3. The pain worsens when she coughs, breathes deeply, or lies down.

4. She has had a mild fever and a cough for the past 2 days.

5. She takes ibuprofen for hip and knee pain, which started 4 months ago.

6. Examination shows a symmetric, erythematous rash on her nose and cheeks.

7. Examination shows erythematous patches with scaling and plugged follicles over her hands.


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

Context: A 22-year-old man comes to the physician because he has been increasingly worried and stressed in recent weeks.

Context: He started a marketing job three months ago, which involves traveling between Washington and California several times a year.

Context: Two months ago, he was supposed to fly to Seattle, but he experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane, causing him great embarrassment.

Context: He had never been on a plane before; his parents died in a plane crash when he was younger.

Context: A week ago, he called in sick when he was supposed to go on a business trip.

Context: He worries that he will lose his job.

Context: He is otherwise well and has no history of serious illness.

Context: He takes no medications.

Context: His temperature is 37.2°C (99°F), pulse is 85/min, respirations are 12/min, and blood pressure is 130/80 mm Hg.

Context: On mental status examination, he is alert and cooperative.

Context: His speech is normal and his thought process is organized.

Context: His memory, attention, and concentration are intact.

Choices:
A. Oral paroxetine
B. Oral alprazolam
C. Observation
D. Cognitive behavioral therapy

Answer: Cognitive behavioral therapy

2. Patient has been increasingly worried and stressed in recent weeks.

3. Patient started a marketing job three months ago.

4. Job involves traveling between Washington and California several times a year.

5. Two months ago, patient experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane.

6. Patient had never been on a plane before.

7. Patient's parents died in a plane crash when he was younger.

8. A week ago, patient called in sick when he was supposed to go on a business trip.

9. Patient worries that he will lose his job.

10. Patient is otherwise well and has no history of serious illness.

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

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

16. Physical examination shows no abnormalities.

17. On mental status examination, patient is alert and cooperative.

19. Patient's thought process is organized.

20. Patient's memory, attention, and concentration are intact.


Question: What is the appropriate medication for this patient’s condition?

Context: A 52-year-old man presents to the office complaining of a 2-week history of fatigue, progressively worsening shortness of breath, and swelling of his lower legs and feet.

Context: His past medical history is only significant for slightly elevated blood pressure.

Context: The patient denies tobacco use although he does admit to drinking 8-10 beers, daily, for the past 10 years.

Context: He takes a low dose of aspirin daily, ever since he had an anterior myocardial infarction 2 years ago.

Context: The patient works as a financial consultant and frequently travels for work.

Context: The current temperature is 36.8°C (98.3°F), the pulse rate is 68/min, the blood pressure is 152/84 mm Hg, and the respiratory rate is 16/min.

Context: His weight is 102 kg (224 lb) and height 180 cm (5 ft 9 in).

Choices:
A. Nifedipine
B. Procainamide
C. Ibuprofen
D. Spironolactone

Answer: Spironolactone

2. Patient has a 2-week history of fatigue, progressively worsening shortness of breath, and swelling of his lower legs and feet.

3. Patient's past medical history is only significant for slightly elevated blood pressure.

5. Patient admits to drinking 8-10 beers daily for the past 10 years.

6. Patient takes a low dose of aspirin daily since he had an anterior myocardial infarction 2 years ago.

7. Patient works as a financial consultant and frequently travels for work.

8. Current temperature is 36.8°C (98.3°F).

14. Echocardiography demonstrates an ejection fraction of 35% and a thin left ventricular wall.

General Internal Medicine
Cardiovascular Disease
Cardiology


Question: Which of the following medications was most likely used to treat this patient's symptoms?

Choices:
A. Oxybutynin
B. Dutasteride
C. Terazosin
D. Tadalafil

Answer: Dutasteride

1. A 70-year-old man comes to the physician for a follow-up evaluation.

2. Eight months ago, he presented with a 6-month history of increased urinary frequency, difficulty to initiate urination, and straining to maintain the urinary stream.

3. Digital rectal examination showed symmetrically enlarged, nontender prostate with rubbery texture.

4. Laboratory studies showed a prostate-specific antigen (PSA) level of 2 ng/mL.

5. Abdominal ultrasound showed a post-void residual urine volume of 250 ml and bladder wall thickening.

6. The patient received appropriate treatment.

7. His vital signs are within normal limits.

8. Laboratory studies now show a PSA level of 1 ng/mL.


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

Context: The patient also admits that he has had numerous loose, foul-smelling stools over the last few weeks with associated nausea.

Context: His blood pressure is 132/76 mm Hg, respiratory rate is 14/min, and heart rate is 75/min.

Choices:
A. H. pylori infection
B. Intestinal type gastric adenocarcinoma
C. NSAID induced peptic ulcer disease
D. Zollinger-Ellison syndrome

Answer: Zollinger-Ellison syndrome

1. A 53-year-old man presents to the office complaining of persistent abdominal pain.

2. He states that he has gained 4.5 kg (10.0 lb) because the pain is only relieved by eating.

3. The patient has had numerous loose, foul-smelling stools over the last few weeks with associated nausea.

4. He has taken some over the counter antacids without relief or change in symptoms.

8. Physical examination reveals mild tenderness to palpation of the upper abdomen.


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

Context: A 68-year-old man with advanced dementia is brought to the preoperative unit prior to an elective cholecystectomy for biliary colic.

Context: He begins yelling at unit staff and requests to leave.

Context: His designated medical power of attorney, who had previously signed the surgery consent forms, is present.

Choices:
A. Cancel the surgery and allow the patient to leave
B. Ask the patient about his concerns and try to address them
C. Call family members and schedule a family meeting
D. Perform cognitive screening evaluation

Answer: Ask the patient about his concerns and try to address them

1. A 68-year-old man has advanced dementia.

2. He was brought to the preoperative unit prior to an elective cholecystectomy for biliary colic.

3. He says he does not want the surgery anymore.

6. His designated medical power of attorney is present.

7. The medical power of attorney had previously signed the surgery consent forms.

Geriatric Medicine
Geriatrics
Anesthesiology
Internal Medicine

Geriatric Medicine
General Geriatric Medicine
General Geriatrics


Question: Which of the following pathogens should be considered before initiating treatment for the current episode?

Context: A 67-year-old man presents to his physician’s office with a progressive cough.

Context: It has been increasing in intensity over the past week.

Context: He has also been noticing an increase in the amount of sputum he usually produces, which is thick and yellow.

Context: He also complains of increased difficulty in breathing, more so than he previously experienced.

Context: He was diagnosed with chronic obstructive lung disease (COPD) about 3 years ago and has been on treatment for it since then.

Context: He doesn’t report any fever, chills, or night sweats.

Context: He has observed a foul smell to his sputum.

Context: His blood pressure is 100/65 mm Hg, the respirations are 23/min and the pulse is about 110/min.

Context: Currently, his FEV1 is around 48% of the normal predicted value.

Context: He is currently receiving a yearly influenza shot and has taken the pneumococcal vaccination at the time of his diagnosis.

Context: In spite of this, he has had acute exacerbations of his symptoms 4 times over the last year.

Context: His last episode was 2 months ago, for which he was treated with a short course of antibiotics.

Context: He is also currently receiving treatment for diabetes.

Choices:
A. S. pneumonia
B. H. influenzae
C. P. aeruginosa
D. Syncytial virus

Answer: P. aeruginosa

2. Patient has a progressive cough for the past week.

3. Patient has increased sputum production, which is thick and yellow.

4. Patient has increased difficulty in breathing.

5. Patient was diagnosed with COPD 3 years ago and has been on treatment since then.

6. Patient does not report fever, chills, or night sweats.

8. Patient's blood pressure is 100/65 mm Hg.

11. Patient's FEV1 is 48% of the normal predicted value.

12. Patient receives a yearly influenza shot.

13. Patient has taken the pneumococcal vaccination at the time of diagnosis.

14. Patient has had 4 acute exacerbations of symptoms in the last year.

15. Patient's last episode was 2 months ago and was treated with a short course of antibiotics.

16. Patient is currently receiving treatment for diabetes.

Pulmonary Disease
General Pulmonary Disease


Question: Which of the following structures is involved in the development of an epidural hematoma?

Context: A 27-year-old man who was involved in a motor vehicle collision is brought into the emergency room with a fractured skull.

Context: The paramedics report that the patient was conscious and lucid on the way to the hospital but now is unresponsive.

Context: His vitals are a blood pressure of 122/78 mm Hg, temperature of 37.0°C (98.6°F), pulse rate of 88/min, and respiratory rate of 14/min.

Choices:
A. Middle meningeal artery
B. Bridging cortical veins
C. Arteriovenous malformation
D. Lenticulostriate vessels

Answer: Middle meningeal artery

1. A 27-year-old man was involved in a motor vehicle collision.

2. The patient was conscious and lucid on the way to the hospital.

4. The patient's blood pressure is 122/78 mm Hg.

5. The patient's temperature is 37.0°C (98.6°F).

7. The patient's respiratory rate is 14/min.

8. A noncontrast CT scan of the head shows an epidural hematoma.


Question: Which of the following characteristics is true of the most likely cause of this patient's disorder?

Context: A 54-year-old woman presents to the emergency department due to recent onset of a high fever, accompanied by severe headache and neck stiffness.

Context: She is currently on immunosuppressants after a kidney transplant performed 6 months ago.

Context: On presentation, her temperature is 102.2°F (39°C), blood pressure is 112/71 mmHg, pulse is 107/min, and respirations are 22/min.

Choices:
A. Anaerobic spore forming rods
B. Catalase-negative
C. Coagulase-positive
D. Tumbling motility in broth

Answer: Tumbling motility in broth

1. A 54-year-old woman presents to the emergency department.

2. She has a high fever, severe headache, and neck stiffness.

3. Her past medical history is significant for rapidly progressive glomerulonephritis.

4. She is currently on immunosuppressants after a kidney transplant 6 months ago.

9. Physical exam reveals severe pain with neck flexion and reciprocal knee flexion.

10. Laboratory tests reveal a gram-positive organism with endotoxin.


Question: Which of the following antibiotics is recommended for this patient?

Context: A 2-year-old boy is brought to see the pediatrician by his mother due to a “bad” cough.

Context: He has no known allergies.

Context: His temperature is 38.5°C (100.5°F), pulse is 120/min, respirations are 33/min, blood pressure is 101/54 mm Hg, and oxygen saturation is 96% on room air.

Context: The boy looks unwell with mild difficulty breathing and a nonproductive cough multiple times followed by a “whoop” sound during the inhalation.

Context: He has scattered petechiae on his face.

Choices:
A. Ceftriaxone
B. Cefotaxime
C. Erythromycin
D. Ampicillin

Answer: Erythromycin

1. A 2-year-old boy is brought to see the pediatrician by his mother.

2. The mother reports that he has been coughing so hard that he threw up on several occasions.

3. He is adopted and the mother does not know his vaccination history.

9. His oxygen saturation is 96% on room air.

10. The boy looks unwell with mild difficulty breathing.

11. He has a nonproductive cough multiple times followed by a “whoop” sound during the inhalation.

12. He has scattered petechiae on his face.

13. A nasopharyngeal swab is sent for culture and PCR.


Question: What is the mechanism by which this organism causes diarrhea?

Context: A 19-year-old man returns from travel in South America.

Context: You suspect the causative organism to be Enterotoxigenic E.coli.

Choices:
A. Blocks the release of inhibitory neurotransmitters GABA and glycine
B. Blocks the presynaptic release of acetylcholine at the neuromuscular junction
C. Stimulates release of cytokines
D. Stimulates adenylate cyclase (increasing cAMP)

Answer: Stimulates adenylate cyclase (increasing cAMP)

1. A 19-year-old man returns from travel.

2. He presents complaining of profuse, watery diarrhea.

3. You suspect the causative organism to be Enterotoxigenic E. coli.


Question: What histopathological findings would you expect to find in this patient?

Context: A 38-year-old man presents to the clinic for complaints of abdominal pain and diarrhea.

Context: He reports a long-standing history of the symptoms except for the time when he attempted a carbohydrate-free diet 5 years ago.

Context: The pain is described as stabbing, diffuse, 8/10, and is especially worse following food intake.

Context: Recently, he noticed some numbness and tingling of his feet but denies any bloody stool, nausea, vomiting, fevers, weight loss, or focal neurological deficits.

Choices:
A. Blunting of the intestinal villi at the ileum
B. Crypt abscesses at the descending colon
C. Noncaseating granulomas at the ileum
D. Normal gastric mucosa at the jejunum

Answer: Blunting of the intestinal villi at the ileum

1. A 38-year-old man presents to the clinic.

3. He has had these symptoms for a long time.

4. Five years ago, he attempted a carbohydrate-free diet.

5. The pain is described as stabbing, diffuse, 8/10.

6. The pain is worse following food intake.

7. He has noticed some numbness and tingling of his feet.

13. He denies any focal neurological deficits.