Question: The nerve that was most likely injured in the surgery originates from which of the following spinal roots?

Context: She has recovered well from the surgery but noticed difficulties combing her hair with her right hand.

Choices:
A. C6-C8
B. C1-C3
C. T2-T5
D. C5–C7

Answer: C5–C7

1. A 21-year-old woman comes to the physician for a follow-up examination.

2. Four months ago, she underwent posterior arthrodesis for thoracolumbar scoliosis.

3. She has recovered well from the surgery.

4. She noticed difficulties combing her hair with her right hand.

5. A photograph of the patient's back is shown.

General Neurological Surgery
General Neurology


Question: What must she have been exposed to at the party that led to such a dramatic side effect?

Context: A 45-year-old female is brought by ambulance to your emergency room after complaining of shortness of breath along with profuse sweating at a company social function.

Context: Her vitals were notable for elevated blood pressure with a normal exam and a stable electrocardiogram.

Context: She has been seeing a psychiatrist recently for her depression and was prescribed phenelzine after failing treatment with a first-line antidepressant therapy.

Choices:
A. Norepinephrine
B. Tyramine
C. Gluten
D. Dopamine

Answer: Tyramine

1. A 45-year-old female was brought to the emergency room by ambulance.

2. She was complaining of shortness of breath and profuse sweating at a company social function.

3. Her vitals showed elevated blood pressure.

6. She has been seeing a psychiatrist recently for depression.

7. She was prescribed phenelzine after failing treatment with a first-line antidepressant therapy.

General Emergency Medicine
Internal Medicine


Question: Which of the following would most likely be expected for this patient's prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time?

Context: The patient’s mother says she has been noticing bruising on her child’s arms and some blood in her diapers.

Context: The infant was born at home after the mother received normal prenatal care.

Context: The patient has been exclusively breastfed since birth and is gaining weight appropriately.

Context: The patient is lethargic with a large, full anterior fontanelle.

Choices:
A. PT normal, aPTT normal, bleeding time normal
B. PT increased, aPTT normal, bleeding time normal
C. PT normal, aPTT normal, bleeding time increased
D. PT normal, aPTT increased, bleeding time normal

Answer: PT increased, aPTT normal, bleeding time normal

1. A 3-day-old female infant is brought by her mother to the pediatrician’s office.

2. The patient’s mother says she has been noticing bruising on her child’s arms.

3. The patient’s mother says she has been noticing some blood in her diapers.

5. The mother received normal prenatal care.

6. The patient has been exclusively breastfed since birth.

7. The patient is gaining weight appropriately.

8. On exam, multiple ecchymoses are noted throughout the patient’s torso and extremities.

10. The patient has a large, full anterior fontanelle.

11. On examination of the diaper, some dried blood mixed with a small amount of stool is noted.


Question: The signal responsible for the elevated levels of these proteins was most likely secreted by which of the following cells?

Context: A 53-year-old woman comes to see her primary care physician because she has had fever and malaise for two days.

Context: She was in her usual state of health until three days ago when she began to feel tired in the evening and decided to go to bed early.

Context: She is otherwise healthy with no chronic conditions and lives by herself with two cats.

Context: She smokes one pack of cigarettes per day and drinks alcohol socially.

Context: On physical exam, she is found to have increased dullness to percussion at the lung bases and blood work is obtained showing elevated levels of C-reactive protein and hepcidin.

Choices:
A. Macrophages
B. Neutrophils
C. Regulatory T-cells
D. Type 2 helper T-cells

Answer: Macrophages

1. A 53-year-old woman comes to see her primary care physician.

2. She has had fever and malaise for two days.

3. She was in her usual state of health until three days ago.

4. She began to feel tired in the evening and decided to go to bed early.

5. The next day she developed a fever, productive cough, chills, and malaise.

6. She is otherwise healthy with no chronic conditions.

8. She smokes one pack of cigarettes per day.

10. On physical exam, she is found to have increased dullness to percussion at the lung bases.

11. Blood work is obtained showing elevated levels of C-reactive protein and hepcidin.


Question: Which of the following is the most likely causal organism?

Context: Three weeks after undergoing transurethral prostate resection for benign prostatic hyperplasia, a 70-year-old man has fever, malaise, and pain in his extremities.

Choices:
A. Enterococcus faecalis
B. Streptococcus gallolyticus
C. Cardiobacterium hominis
D. Staphylococcus epidermidis

Answer: Enterococcus faecalis

1. A 70-year-old man underwent transurethral prostate resection for benign prostatic hyperplasia three weeks ago.

2. The man has fever, malaise, and pain in his extremities.

3. Physical examination shows subungal petechiae and tender red papules on his fingers and toes.

4. A new holosystolic murmur is heard on chest auscultation.

5. A photomicrograph of a Gram stain of an isolate from blood culture is shown.

6. The organism does not cause hemolysis on blood agar.

7. Addition of pyrrolidonyl-β-naphthylamide gives the bacterial colonies a cherry red color.

In this case, the most relevant specialty would be Infectious Disease

General Infectious Disease
Infectious Disease
General Infectious Disease.


Question: What is the mechanism of action of the medication received by the patient?

Context: An 85-year-old woman is brought to her primary care provider by her son for a checkup.

Context: Past medical history is significant for hypertension, hyperlipidemia, and a urinary tract infection that was successfully treated with an extended course of oral cephalexin 3 weeks ago.

Context: Family history is noncontributory.

Context: Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 125/85 mm Hg, and temperature is 36.7°C (98.1°F).

Context: On physical exam, her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally.

Context: Further analysis reveals a prolonged PT that corrects with mixing, normal liver function tests, and a stool test that is guaiac positive.

Context: The physician administers an injection that should improve her condition and recommends further testing and a follow-up exam.

Choices:
A. γ-carboxylation of pancreatic enzymes
B. Protein C deficiency
C. Activation of 7-dehydrocholesterol by UV light
D. γ-carboxylation of liver enzymes

Answer: γ-carboxylation of liver enzymes

1. An 85-year-old woman is brought to her primary care provider by her son.

2. She is feeling well with no major complaints.

3. Her son is concerned that she has been bruising much more easily over the last week or two.

4. Past medical history is significant for hypertension, hyperlipidemia, and a urinary tract infection.

5. The urinary tract infection was successfully treated with an extended course of oral cephalexin 3 weeks ago.

8. Today, her respiratory rate is 17/min.

9. Today, her blood pressure is 125/85 mm Hg.

10. Today, her temperature is 36.7°C (98.1°F).

11. On physical exam, her heart has a regular rate and rhythm.

12. On physical exam, her lungs are clear to auscultation bilaterally.

13. She has some poorly demarcated purple-yellow bruising and areas of dark purple bruising as well.

14. Further analysis reveals a prolonged PT that corrects with mixing.

15. Further analysis reveals normal liver function tests.

16. Further analysis reveals a stool test that is guaiac positive.

17. The physician administers an injection that should improve her condition.

18. The physician recommends further testing and a follow-up exam.


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

Context: A 35-year-old man presents with loose stools and left lower quadrant abdominal pain.

Context: He says he passes 8–10 loose stools per day.

Context: The volume of each bowel movement is small and appears mucoid with occasional blood.

Context: The patient reports a 20-pack-year smoking history.

Context: He also says he recently traveled abroad about 3 weeks ago to Egypt.

Context: The vital signs include: blood pressure 120/76 mm Hg, pulse 74/min, and temperature 36.5°C (97.8°F).

Context: On physical examination, mild to moderate tenderness to palpation in the left lower quadrant with no rebound or guarding is present.

Context: Rectal examination shows the presence of perianal skin ulcers.

Choices:
A. Amebiasis
B. Crohn’s disease
C. Salmonellosis
D. Diverticulosis

Answer: Amebiasis

2. Patient has loose stools and left lower quadrant abdominal pain.

3. Patient passes 8-10 loose stools per day.

4. Volume of each bowel movement is small and appears mucoid with occasional blood.

5. Patient has a 20-pack-year smoking history.

6. Patient recently traveled abroad to Egypt about 3 weeks ago.

10. Physical examination shows mild to moderate tenderness to palpation in the left lower quadrant with no rebound or guarding.

11. Rectal examination shows presence of perianal skin ulcers.


Question: Which of the following is responsible for producing the different isoforms of HNF4a?

Context: Hepatocyte nuclear factor 4 alpha (HNF4a) is a transcription factor that is found in the liver, pancreas, kidney, and intestines.

Context: The gene is composed of 11 exons and depending on the tissue there are different isoforms of the protein being expressed.

Choices:
A. Addition of 7-methylguanosine cap
B. Addition of polyadenylated (poly-A) tail
C. Alternative splicing
D. DNA methylation

Answer: Alternative splicing

1. Hepatocyte nuclear factor 4 alpha (HNF4a) is a transcription factor.

2. HNF4a is found in the liver, pancreas, kidney, and intestines.

3. The gene for HNF4a is composed of 11 exons.

4. Different isoforms of the HNF4a protein are expressed in different tissues.

General Medical Genetics and Genomics
Clinical Genetics and Genomics


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

Context: A 50-year-old man presents for a routine examination.

Context: Past medical history is significant for cirrhosis secondary to hepatitis C virus (HCV) infection diagnosed 4 years ago and complicated by ascites.

Context: Current medications include furosemide 40 mg orally daily.

Context: Physical examination is unremarkable.

Context: Laboratory findings are significant for the following: | Laboratory test | Aspartate Aminotransferase (AST) 80 U/L | Alanine Aminotransferase (ALT) 50 U/L | Total bilirubin 2.5 mg/dL | Direct bilirubin 1.8 mg/dL | Alkaline phosphatase (ALP) 140 U/L | International normalized ratido (INR) 1.9 | Serum creatinine 1 mg/dL | Urinalysis | Sodium 200 mmol/24h | Potassium 60 mmol/24h | Protein Nil | RBCs Nil | RBC casts Nil | WBCs Nil | Urea 13 g/24h | Creatinine 6 mmol/24h |   Abdominal and renal ultrasound reveals no interval change over the past 6 months.

Context: Moderate ascites is present.

Context: Diagnostic paracentesis is performed and yields a clear liquid with an absolute polymorphonuclear neutrophil (PMN) count of 75 cells/mm3.

Choices:
A. Hepatocellular carcinoma
B. Portal hypertension
C. Spontaneous bacterial peritonitis
D. Hepatorenal syndrome

Answer: Portal hypertension

2. Patient has a past medical history of cirrhosis secondary to HCV infection diagnosed 4 years ago.

3. Patient has ascites as a complication of cirrhosis.

4. Patient is currently taking furosemide 40 mg orally daily.

5. Physical examination is unremarkable.

6. Laboratory findings are significant for AST 80 U/L, ALT 50 U/L, total bilirubin 2.5 mg/dL, direct bilirubin 1.8 mg/dL, ALP 140 U/L, INR 1.9, and serum creatinine 1 mg/dL.

7. Urinalysis reveals sodium 200 mmol/24h, potassium 60 mmol/24h, protein nil, RBCs nil, RBC casts nil, WBCs nil, urea 13 g/24h, and creatinine 6 mmol/24h.

8. Abdominal and renal ultrasound reveals no interval change over the past 6 months and moderate ascites.

9. Upper GI endoscopy reveals esophageal varices with a hepatic venous pressure gradient measuring 14 mm Hg.

10. Diagnostic paracentesis is performed and yields a clear liquid with an absolute PMN count of 75 cells/mm3.


Question: Which of the following is the most likely causal organism?

Context: A 45-year-old man with HIV comes to the physician because of multiple lesions on his lower extremity.

Context: The lesions are increasing in size and are not painful or pruritic.

Context: He does not have lymphadenopathy.

Context: He works at a garden center.

Context: He lives in Mississippi.

Context: Medications include abacavir, dolutegravir, and lamivudine.

Context: His temperature is 37.7°C (98.8°F), pulse is 75/min, and blood pressure is 125/80 mm Hg.

Context: Examination shows multiple lesions on both heels; some are elevated.

Context: There are two similar lesions on the chest.

Context: An image of the patient's right heel is shown.

Context: His CD4+ T-lymphocyte count is 450/mm3 (normal ≥ 500/mm3).

Context: A skin biopsy shows multiple spindle-shaped cells and leukocyte infiltration.

Choices:
A. Mycobacterium avium complex
B. Human herpesvirus 8
C. Coccidioides immitis
D. Epstein-Barr virus

Answer: Human herpesvirus 8

3. Patient has multiple lesions on lower extremity.

6. Patient does not have lymphadenopathy.

9. Patient is taking abacavir, dolutegravir, and lamivudine.

10. Patient's temperature is 37.7°C (98.8°F).

12. Patient's blood pressure is 125/80 mm Hg.

13. Examination shows multiple lesions on both heels, some are elevated.

14. Examination shows two similar lesions on the chest.

15. Image of patient's right heel is shown.

16. Patient's CD4+ T-lymphocyte count is 450/mm3 (normal ≥ 500/mm3).

17. Skin biopsy shows multiple spindle-shaped cells and leukocyte infiltration.


Question: What is the next best step in management?

Context: A 32-year-old woman presents to the office complaining of pain, numbness, and discoloration of her fingers over the past 6 months.

Context: She notices that cold temperatures worsen these symptoms, turning the tip of her fingers white and sometimes blue.

Context: Her vital signs show her temperature is 37.5°C (99.5°F), blood pressure is 124/86 mm Hg, pulse is 80/min, and respirations are 10/min.

Context: On physical examination, the patient has a pale malar rash spread across her face with tender cervical and axillary lymphadenopathy.

Context: Examination of her hands reveal tenderness and shiny sclerodactyly.

Context: Antinuclear and anti-U1 ribonucleoprotein antibodies are positive.

Context: A diagnosis of mixed connective tissue disease is confirmed.

Choices:
A. Echocardiogram
B. Arthrocentesis
C. Bone marrow transplant
D. Upper GI series

Answer: Echocardiogram

2. Patient has been experiencing pain, numbness, and discoloration of her fingers for the past 6 months.

3. Patient's symptoms worsen in cold temperatures, turning the tip of her fingers white and sometimes blue.

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

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

8. Patient has a pale malar rash spread across her face.

9. Patient has tender cervical and axillary lymphadenopathy.

10. Patient has tenderness and shiny sclerodactyly on examination of her hands.

11. Patient's antinuclear and anti-U1 ribonucleoprotein antibodies are positive.

12. Patient is diagnosed with mixed connective tissue disease.


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

Context: A 58-year-old woman presents with difficulty moving her right shoulder.

Context: She underwent a right radical mastectomy with lymph node dissection 3 weeks ago.

Context: Her surgery went well with no complications.

Context: She has undergone some physical therapy which has not been effective.

Context: A few days ago, she started to notice brief periods of painful shoulder instability, especially while opening or closing doors.

Context: On physical examination, there is normal active and passive range of motion in the right shoulder.

Context: Sensation is intact.

Context: When the patient is asked to push against the wall, her right shoulder blade moves backward (see image).

Choices:
A. Axillary nerve
B. Suprascapular nerve
C. Long thoracic nerve
D. Ulnar nerve

Answer: Long thoracic nerve

2. Patient underwent right radical mastectomy with lymph node dissection 3 weeks ago.

3. Surgery went well with no complications.

4. Patient has undergone physical therapy which has not been effective.

5. Patient started to notice brief periods of painful shoulder instability, especially while opening or closing doors.

6. On physical examination, normal active and passive range of motion in the right shoulder.

7. Strength is 5 out of 5 in all muscles of the right shoulder and upper extremity.

9. When patient is asked to push against the wall, right shoulder blade moves backward (see image).


Question: Which of the following is the most likely cause of his symptoms?"

Context: A 40-year-old man comes to the physician because he is concerned about the amount of breast tissue he has recently developed.

Context: He drinks 2 beers everyday.

Context: He weighs 90 kg (198 lb) and is 175 cm (5 ft 8 in) tall; BMI is 30.1 kg/m2.

Context: Laboratory studies show: | Hematocrit 60% | Platelet count 400,000/mm3 | Serum | Na+ 135 mEq/L | Cl- 97 mEq/L | K+ 4.5 mEq/L | HCO3- 25 mEq/L | Glucose 100 mg/dL | .

Choices:
A. Anabolic steroid use
B. Normal aging
C. Erythropoietin use
D. Marijuana use

Answer: Anabolic steroid use

1. A 40-year-old man comes to the physician.

2. He is concerned about the amount of breast tissue he has recently developed.

3. His wife has noticed that he has been irritable for the past month.

4. He was recently treated for tinea capitis.

5. In preparation for an upcoming bodybuilding competition, he has been eating a lot of chicken breast.

7. He smokes marijuana 3–4 times a week but does not smoke cigarettes.

11. Physical examination shows bilateral gynecomastia and small, firm testes.

12. There is no hepatosplenomegaly or abdominal tenderness.

13. Laboratory studies show hematocrit 60%.

General Plastic Surgery
Endocrinology, Diabetes, and Metabolism


Question: Which of the following statements is correct?

Context: A 35-year-old woodsman from local forestry presents to a clinic for counseling regarding his contact with a wild fox that occurred 5 days ago.

Context: He says that the fox was not aggressive, allowed him to caress it, and even licked his forearm where he had an open wound.

Context: Two days ago, in the same forest, foresters shot a group of foxes who had attacked them, and the fox corpses were handed over to a local veterinary laboratory for testing.

Context: Two locals also reported they were attacked by foxes, so the patient became concerned about his exposure.

Context: His vital signs are as follows: the blood pressure is 125/80 mmHg, the heart rate is 81/min, the respiratory rate is 14/min, and the temperature is 36.8°C (98.2°F).

Context: Physical examination reveals 2 healing lacerations, 2 × 3 cm, with a depth of 1 mm each, and multiple scratches on the flexor surface of his right arm.

Choices:
A. The patient does not need immunoglobulin to be administered since he was not bitten by the animal.
B. Before initiating post-exposure prophylaxis, results of laboratory testing of the fox's corpses should be obtained.
C. There is no need to treat the patient’s wounds before administering post-exposure prophylaxis because the wounds are already healing; thus, they do not pose a threat to the patient’s health.
D. If rabies immunoglobulin is not available immediately, it can be administered within 7 days of the first vaccine dose.

Answer: If rabies immunoglobulin is not available immediately, it can be administered within 7 days of the first vaccine dose.

1. A 35-year-old woodsman from local forestry presents to a clinic for counseling.

2. He had contact with a wild fox 5 days ago.

3. The fox was not aggressive and allowed him to caress it.

4. The fox even licked his forearm where he had an open wound.

5. Two days ago, in the same forest, foresters shot a group of foxes who had attacked them.

6. The fox corpses were handed over to a local veterinary laboratory for testing.

7. Two locals also reported they were attacked by foxes.

8. The patient became concerned about his exposure.

9. At the time of presentation, the patient had no complaints.

14. Physical examination reveals 2 healing lacerations, 2 × 3 cm, with a depth of 1 mm each.

15. Physical examination also reveals multiple scratches on the flexor surface of his right arm.

16. The patient is unaware of his immunization status.


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

Context: A 14-year-old boy presents to his primary care physician for a general check up.

Context: The patient's parents refuse to allow the boy to join the school basketball team.

Context: The patient has attended two practices, and both times during conditioning, he has fainted.

Context: Otherwise, the child is performing well in school.

Context: The patient has a past medical history of obesity, elevated fasting blood glucose, and high blood pressure.

Context: He is not currently taking any medications.

Context: The patient's parents want the patient to be cleared medically before he goes back to playing basketball again.

Context: His temperature is 99.5°F (37.5°C), blood pressure is 130/87 mmHg, pulse is 81/min, and respirations are 11/min.

Context: Physical exam is notable for an obese child who is pleasant and conversational.

Context: Further diagnostic exams are ordered.

Choices:
A. Metformin
B. Metoprolol
C. Suggest the patient exercise more before joining a competitive team
D. Clear the patient to participate in sports

Answer: Metoprolol

2. Parents refuse to allow the boy to join the school basketball team.

4. Patient has fainted twice during conditioning.

5. Patient is performing well in school.

6. Patient has a past medical history of obesity, elevated fasting blood glucose, and high blood pressure.

7. Patient is not currently taking any medications.

8. Parents want patient to be cleared medically before returning to playing basketball.

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

10. Patient's blood pressure is 130/87 mmHg.

14. Patient is pleasant and conversational.

15. Pulmonary exam reveals lungs that are clear to auscultation bilaterally.

16. Cardiovascular exam reveals a murmur heard loudest along the left sternal border.

17. Neurological exam reveals 5/5 strength in the upper and lower extremities with 2+ reflexes.

18. Further diagnostic exams are ordered.


Question: The drug that is most likely responsible for this patient's muscle weakness inhibits which of the following?

Context: A 65-year-old man with chronic obstructive pulmonary disease is admitted to the hospital for the treatment of worsening shortness of breath and productive cough.

Context: His muscle strength is 4/5 at both hips but normal elsewhere.

Choices:
A. Adenosine receptor
B. 5-lipoxygenase
C. Myosin light-chain kinase
D. Nuclear factor-κB

Answer: Nuclear factor-κB

1. A 65-year-old man has chronic obstructive pulmonary disease.

2. He is admitted to the hospital for the treatment of worsening shortness of breath and productive cough.

3. Three days later, he complains of weakness in the lower limbs.

4. His muscle strength is 4/5 at both hips.

5. His muscle strength is normal elsewhere.


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

Context: A 64-year-old woman is brought to the emergency department after a syncopal episode 2 hours ago while grocery shopping.

Context: She has hypertension.

Context: Current medications include carvedilol.

Context: She appears diaphoretic.

Context: Her blood pressure is 102/65 mm Hg.

Context: An ECG is shown.

Choices:
A. Observation
B. Administration of dopamine
C. Placement of transcutaneous pacemaker
D.
Administration of amiodarone
"

Answer: Placement of transcutaneous pacemaker

1. A 64-year-old woman is brought to the emergency department.

2. She had a syncopal episode 2 hours ago while grocery shopping.

3. She has been feeling fatigued and lightheaded for the past couple of days.

5. Her current medications include carvedilol.

7. She is oriented to person but not to place or time.


Question: What is the most likely causative agent of this rash?

Context: A 42-year-old morbidly obese woman presents to the emergency room for evaluation of a rash that started 3 days ago.

Context: The rash appeared under the patient’s breasts as well as in the abdominal folds, and the patient describes it as being very itchy.

Context: The rash is bright red with scaling and a few scattered purulent areas of skin breakdown.

Context: The patient is afebrile and is in no apparent distress, besides being uncomfortable from the itching.

Choices:
A. A heavily encapsulated, urease-positive yeast
B. A gram-negative rod that produces pyocyanin
C. An acid-fast bacillus
D. A commensal yeast that is catalase-positive

Answer: A commensal yeast that is catalase-positive

1. A 42-year-old morbidly obese woman presents to the emergency room.

3. The rash appeared under the patient's breasts and in the abdominal folds.

4. The patient describes the rash as being very itchy.

6. There are a few scattered purulent areas of skin breakdown.

8. The patient is in no apparent distress, besides being uncomfortable from the itching.


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

Context: He appears pale and diaphoretic.

Context: Breath sounds are normal.

Choices:
A. Papillary muscle rupture
B. Ventricular fibrillation
C. Septal wall rupture
D.
Pulmonary embolism
"

Answer: Ventricular fibrillation

1. A 47-year-old man comes to the physician because of severe retrosternal chest pain and shortness of breath for 45 minutes.

2. He has dyslipidemia, hypertension, and type 2 diabetes mellitus.

3. Current medications include hydrochlorothiazide, lisinopril, metformin, and atorvastatin.

4. He has smoked 1 pack of cigarettes daily for 20 years.

6. His temperature is 37°C (98.6°F), pulse is 115/min, and blood pressure is 140/70 mm Hg.

8. The remainder of the examination shows no abnormalities.

9. An ECG shows left ventricular hypertrophy with ST-segment elevation in leads I, aVL, and V1–V6.

10. High-dose aspirin, clopidogrel, metoprolol, sublingual nitroglycerin, and unfractionated heparin are administered.

11. As the patient awaits transport to the nearest emergency room, he collapses and becomes unresponsive.

12. His pulse and blood pressure cannot be detected.

13. Despite resuscitative efforts, the patient dies.

Interventional Cardiology
General Cardiology
Cardiovascular Disease


Question: Immunoglobulin M (IgM) antibody detection by the enzyme-linked immunoassay (ELISA) will most likely detect antibodies against which of the following pathogens?

Choices:
A. Measles virus
B. Human herpesvirus 6
C. Rubella virus
D. Parvovirus B19

Answer: Parvovirus B19

1. A 4-year-old boy presents to a clinic with intermittent fevers and a rash for 6 days.

2. According to his mother, he is also complaining of pain all over his body.

3. She adds that the rash 1st appeared on his face within 12 hours of the onset of fever, and later spread to his trunks and limbs.

4. The patient denies any itchiness over the rash.

5. There is no history of a sore throat or recent use of medication for symptom relief.

6. The temperature is 37.2°C (99.9°F) and the pulse is 88/min.

7. On examination, there is a maculopapular rash on the face and the trunk, including the limbs, but sparing the palms and soles.

8. The pediatrician reassures the mother that this is most likely a viral infection and will resolve spontaneously.

9. After 7–10 days, the boy is brought back to the clinic for a follow-up visit.

10. The areas affected by the rash appear to have a central clearing giving a lacy or reticular appearance, especially on the cheeks and it looks like someone slapped him on the cheeks.


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

Context: A 25-year-old woman comes into your office with complaints of heavy bleeding.

Context: She states that her mother also has heavy bleeding during her menstrual cycle.

Context: She has had a heavy flow as long as she can remember and had her first menstrual cycle at age 12.

Context: She states during her cycle, she has to change pads every 2 hours for at least 3 days.

Context: She also states that she gets bruised easily just like her mother.

Context: She denies any past medical history other than her heavy menstrual flow and denies taking any medications.

Context: She also denies any medical history in her father and says he is "perfectly healthy." Her vitals are HR 85, T 98.8 F, RR 13, BP 125/75.

Context: Her CBC is significant for Hgb 10.5, WBC 5.8, Plts 250, Hct 33.

Context: On coagulation studies, her PT is 14 seconds and her PTT is 43 seconds.

Context: Her INR is 1.1.

Choices:
A. Factor V Leiden
B. Von Willebrand's disease
C. Hemophilia B
D. Antiphospholipid antibody syndrome

Answer: Von Willebrand's disease

2. Patient has complaints of heavy bleeding.

3. Patient's mother also has heavy bleeding during her menstrual cycle.

4. Patient has had a heavy flow as long as she can remember.

5. Patient had her first menstrual cycle at age 12.

6. Patient has to change pads every 2 hours for at least 3 days during her cycle.

7. Patient gets bruised easily, like her mother.

8. Patient denies any past medical history other than her heavy menstrual flow.

9. Patient denies taking any medications.

10. Patient denies any medical history in her father and says he is "perfectly healthy."

11. Patient's vitals are HR 85, T 98.8 F, RR 13, BP 125/75.

12. Patient's CBC is significant for Hgb 10.5, WBC 5.8, Plts 250, Hct 33.


Question: Which of the following best describes the pathogenesis of the disease process in this patient?

Context: A 30-year-old woman comes to the physician because of numbness, fatigue, and blurry vision for 1 week.

Context: The symptoms are worse after a hot shower or bath.

Context: She had an episode of right arm weakness 2 years ago that resolved without intervention.

Context: Her temperature is 37.1°C (100°F) and blood pressure is 100/66 mm Hg.

Context: Strength is normal.

Context: There is left-sided photophobia and pupillary constriction in the left eye is decreased compared to the right eye.

Choices:
A. Spirochete protein cross-reactivity in the meninges
B. Osmotically-mediated Schwann cell damage
C. Th1 cell-mediated nerve sheath damage
D. Lymphocytic infiltrate of the endoneurium

Answer: Th1 cell-mediated nerve sheath damage

1. A 30-year-old woman comes to the physician.

2. She has had numbness, fatigue, and blurry vision for 1 week.

3. Symptoms are worse after a hot shower or bath.

4. She had an episode of right arm weakness 2 years ago.

5. The episode resolved without intervention.

6. She recently returned from a hiking trip in upstate New York.

9. Physical examination shows decreased sensation to light touch in the left hand, right thigh, and right flank.

12. Pupillary constriction in the left eye is decreased compared to the right eye.

Neurology with Special Qualification in Child Neurology


Question: Which of the following would be the best course of treatment for this patient?

Context: A 30-year-old man visits his physician with thoughts that he ‘is not real’ which occurred suddenly and have persisted for weeks.

Context: The patient states that, 3 weeks ago, he witnessed an armed robbery in which he saw a person get shot in the chest.

Context: The patient states that at the time the shot was fired, he felt as though he ‘wasn’t in the room’ and as if he was ‘floating above watching it all happen’ below him.

Context: He states that now, seemingly out of nowhere, he will have a sudden feeling that he is ‘perceiving life as a dream’.

Choices:
A. Amantadine
B. Butorphanol
C. Dextromethorphan
D. Psychotherapy

Answer: Psychotherapy

1. A 30-year-old man visits his physician.

2. He has thoughts that he ‘is not real’.

4. The thoughts have persisted for weeks.

5. Three weeks ago, he witnessed an armed robbery.

6. He saw a person get shot in the chest.

7. At the time the shot was fired, he felt as though he ‘wasn’t in the room’.

8. He felt as if he was ‘floating above watching it all happen’ below him.

9. Ever since the event, he has been having similar experiences without provocation.

10. Seemingly out of nowhere, he will have a sudden feeling that he is ‘perceiving life as a dream’.

11. He now seeks help to control these feelings of depersonalization.


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

Context: A 9-year-old boy presents with recent onset worsening performance in school and facial lesions that look like acne.

Context: Past medical history is significant for developmental delays and infantile spasm.

Context: No current medications.

Context: On physical examination, there are facial papulonodular lesions (as shown in the image), pitting of dental enamel, and multiple hypomelanotic oval macules over the torso.

Choices:
A. VHL
B. TSC
C. NF1
D. GNAQ

Answer: TSC

2. Patient has recent onset worsening performance in school.

3. Patient has facial lesions that look like acne.

4. Patient has past medical history of developmental delays and infantile spasm.

5. Patient is not currently taking any medications.

6. On physical examination, patient has facial papulonodular lesions.

7. On physical examination, patient has pitting of dental enamel.

8. On physical examination, patient has multiple hypomelanotic oval macules over the torso.


Question: Which of the following is the most likely underlying cause of this patient’s current condition?

Context: A 14-year-old girl is brought to the emergency department because of occipital headache, nausea, and vomiting for the last 2 hours.

Context: She has a multi-year history of frequent left ear infections and discharge, with poor response to antimicrobial therapy.

Context: Her blood pressure is 134/78 mm Hg, the pulse is 83/min, the respiratory rate is 16/min, and the temperature is 36.5°C (97.7°F).

Context: She is alert and oriented.

Context: Physical examination of the left ear shows perforation of the tympanic membrane, granulation tissue, and white keratinaceous debris in the posterosuperior quadrant of the tympanic membrane.

Context: An MRI shows evidence of sigmoid sinus thrombosis on the left side and a hyperintense area in the middle ear on.

Choices:
A. Acoustic neuroma
B. Cholesteatoma
C. Chronic serous otitis media
D. Chronic suppurative otitis media

Answer: Cholesteatoma

1. A 14-year-old girl is brought to the emergency department.

2. She has been experiencing occipital headache, nausea, and vomiting for the last 2 hours.

3. She has a multi-year history of frequent left ear infections and discharge.

4. She has poor response to antimicrobial therapy.

5. She has muffled hearing in the left ear.

11. Physical examination of the left ear shows perforation of the tympanic membrane.

12. Physical examination of the left ear shows granulation tissue.

13. Physical examination of the left ear shows white keratinaceous debris in the posterosuperior quadrant of the tympanic membrane.

14. An MRI shows evidence of sigmoid sinus thrombosis on the left side.

15. An MRI shows a hyperintense area in the middle ear on.


Question: In the process of embryologic development, this nodule forms as a result of the activity of which of the following?

Context: An otherwise healthy 8-year-old boy is brought to the emergency department by his mother 2 hours after the sudden onset of scrotal pain.

Context: Physical examination shows nontender testes and a tender, 5-mm, bluish nodule at the superior pole of the left testis.

Choices:
A. Leydig cells
B. Estradiol
C. Luteinizing hormone
D. Sertoli cells

Answer: Sertoli cells

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

2. His mother brought him 2 hours after the sudden onset of scrotal pain.

3. Physical examination shows nontender testes.

4. Physical examination shows a tender, 5-mm, bluish nodule at the superior pole of the left testis.

5. The patient undergoes urgent surgical exploration of the scrotum.

6. During the operation, the nodule on the superior pole of the testis is found to be necrotic.

Pediatric Emergency Medicine
Pediatric Surgery


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

Context: A 23-year-old woman comes to the physician for a 6-month history of dry cough, hoarseness, and chest pain.

Context: She does not smoke and has not lost weight.

Context: A CT scan of the chest is shown.

Choices:
A. Rhabdomyosarcoma
B. Neurofibroma
C. Sarcoma
D. Aortic aneurysm

Answer: Neurofibroma

1. A 23-year-old woman comes to the physician.

2. She has a 6-month history of dry cough, hoarseness, and chest pain.

5. Laboratory studies show no abnormalities.

6. An x-ray of the chest shows a mass that projects across the right hilum.

General Pulmonary Disease
Pulmonary Disease


Question: What is the most likely organism responsible?

Context: A 4-year-old is brought into the emeregency room by his mother.

Context: The mother states the child's cough sounds like someone barking and states that he has also had mild fevers along with rhinorrhea.

Context: The patient's vitals are significant for a fever of 100.8 F, and his physical exam reveals inspiratory stridor.

Choices:
A. Parainfluenza virus
B. Respiratory syncytial virus
C. Adenovirus
D. Ebstein barr virus

Answer: Parainfluenza virus

1. A 4-year-old is brought into the emergency room by his mother.

2. The mother states that the child had a slight cough one week ago that has since worsened.

3. The mother states the child's cough sounds like someone barking.

4. The mother states the child has had mild fevers along with rhinorrhea.

5. The patient's vitals are significant for a fever of 100.8 F.

6. The patient's physical exam reveals inspiratory stridor.


Question: Which of the following correctly identifies the study design used by the researcher?

Context: A researcher interested in the relationship between vaccination and autism sends a survey to parents of children who are active patients at a large primary care practice.

Context: The survey asks several questions, including whether their children received their childhood vaccines on-time, and whether their children currently have a diagnosis of an autism spectrum disorder.

Choices:
A. Cross-sectional
B. Cohort
C. Randomized controlled trial
D. Case-control

Answer: Cross-sectional

1. A researcher is interested in the relationship between vaccination and autism.

2. The researcher sends a survey to parents of children who are active patients at a large primary care practice.

4. One of the questions is whether their children received their childhood vaccines on-time.

5. Another question is whether their children currently have a diagnosis of an autism spectrum disorder.


Question: Which of the following developmental milestones is delayed in this infant?

Context: He was born at term, and pregnancy was complicated by prolonged labor.

Context: He can sit upright without support and can roll over from the prone to the supine position.

Context: He cannot pull himself to stand.

Context: He can grasp his rattle and cannot transfer it from one hand to the other.

Context: He babbles.

Context: Vital signs are within normal limits.

Context: He is at 40th percentile for head circumference, 30th percentile for length and at 40th percentile for weight.

Choices:
A. Fine motor
B. Social
C. Gross motor
D. Cognitive

Answer: Fine motor

1. A 6-month-old boy is brought to the physician for a well-child examination.

3. Pregnancy was complicated by prolonged labor.

4. There is no family history of serious illness.

6. He can roll over from the prone to the supine position.

9. He cannot transfer it from one hand to the other.

11. He cries if anyone apart from his parents holds him or plays with him.

12. He touches his own reflection in the mirror.

13. Vital signs are within normal limits.

14. He is at 40th percentile for head circumference.

15. He is at 30th percentile for length.

16. He is at 40th percentile for weight.

17. Physical examination shows no abnormalities.


Question: Which of the following is the most likely effect of this drug?

Context: A 28-year-old woman is admitted to the hospital for treatment of a displaced fracture of the femoral neck following a high-speed motor vehicle collision.

Context: She is given pentazocine for pain relief.

Context: This drug binds to heptahelical transmembrane receptors.

Choices:
A. Release of presynaptic acetylcholine
B. Release of presynaptic norepinephrine
C. Opening of postsynaptic Na+ channels
D. Opening of postsynaptic K+ channels

Answer: Opening of postsynaptic K+ channels

1. A 28-year-old woman is admitted to the hospital.

2. The woman has a displaced fracture of the femoral neck.

3. The woman's injury was caused by a high-speed motor vehicle collision.

4. The woman is given pentazocine for pain relief.

5. Pentazocine binds to heptahelical transmembrane receptors.

General Orthopaedic Surgery
Orthopaedic Sports Medicine


Question: Which of the following is the most appropriate therapy with curative intent at this time?

Context: A 70-year-old man comes to the physician because of fatigue and intermittent epigastric pain.

Context: The symptoms began about one year ago.

Context: He appears pale.

Context: His pulse is 72/min and his blood pressure is 110/70 mm Hg.

Context: A urea breath test is positive.

Context: Biopsies of the mass show diffuse infiltrates of small lymphoid cells that are positive for CD20 antigen.

Choices:
A. Rituximab, cyclophosphamide, adriamycin, and vincristine
B. Imatinib
C. External beam radiation therapy
D. Amoxicillin, clarithromycin, and omeprazole

Answer: Amoxicillin, clarithromycin, and omeprazole

1. A 70-year-old man comes to the physician.

2. He has fatigue and intermittent epigastric pain.

3. The symptoms began about one year ago.

4. He describes the pain as diffuse and 3 out of 10 in intensity.

5. Recently, he has had unusually large black stools.

9. Physical examination shows epigastric tenderness.

11. Upper gastrointestinal endoscopy reveals an ulcerating mass in the gastric antrum.

12. Biopsies of the mass show diffuse infiltrates of small lymphoid cells.

13. The lymphoid cells are positive for CD20 antigen.

14. A CT scan of the chest and abdomen shows normal regional lymph nodes.


Question: What is the most appropriate step in this case?

Context: A 42-year-old woman approaches your office complaining of a 1-year long persistent dysuria, increasing discomfort with bladder filling and voiding, and suprapubic pain.

Context: She further comments that she has been presenting with abdominal cramps, and alternating periods of diarrhea and constipation for the past 4 months.

Context: Her family medical history is negative for malignancies and hereditary disorders.

Context: Her personal history is relevant for various visits to the general practitioners for similar complaints that resulted in multiple antimicrobial treatments for urinary tract infection.

Context: At the moment, she is not taking any medication.

Context: Physical examination shows suprapubic tenderness as well as tender areas in the pelvic floor.

Context: The vital signs include: temperature 37.0°C (98.6°F), heart rate 68/min, blood pressure 120/58 mm Hg, and respiratory rate 13/min.

Context: Vaginal examination is normal.

Context: No adnexal masses are detected and no vaginal secretions are noticed. | She brings a urinalysis and a urine culture from 1 week ago that show the following: | Test Result Normal Range | Urine culture Negative < 100,000 CFU/mL to no bacterial growth in asymptomatic patients | Urinalysis Density: 1.030; Leukocyte esterase (-); Nitrites (-); pH: 6.0, Presence of 4 RBCs per high power field.

Context: Density: 1.030 - 1.060; Leukocyte esterase (-), Nitrites (-), pH: 4.5 - 8.0 | .

Choices:
A. Self-care and behavior modification
B. Admission to the ER for intravenous antibiotic administration
C. Urinary analgesia with phenazopyridine
D. Conjugated estrogens

Answer: Self-care and behavior modification

2. Patient has been experiencing dysuria for 1 year.

3. Patient has increasing discomfort with bladder filling and voiding.

5. Patient has had abdominal cramps for 4 months.

6. Patient has had alternating periods of diarrhea and constipation for 4 months.

7. Patient's family medical history is negative for malignancies and hereditary disorders.

8. Patient has had multiple visits to the general practitioner for similar complaints.

9. Patient has had multiple antimicrobial treatments for urinary tract infection.

10. Patient is not taking any medication.

11. Physical examination shows suprapubic tenderness and tender areas in the pelvic floor.

12. Patient's vital signs include temperature 37.0°C (98.6°F), heart rate 68/min, blood pressure 120/58 mm Hg, and respiratory rate 13/min.

16. Urine culture from 1 week ago was negative < 100,000 CFU/mL to no bacterial growth in asymptomatic patients.

17. Urinalysis from 1 week ago showed density 1.030, leukocyte esterase (-), nitrites (-), pH 6.0, and 4 RBCs per high power field.


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

Context: He says he feels well, but is worried because his 32-year-old brother recently had to start hemodialysis because of kidney disease.

Context: He reports that his grandfather had ""bad kidneys” as well.

Context: He has no history of serious illness.

Choices:
A. Percutaneous aspiration
B. Reassurance
C. Abdominal CT scan
D. Partial nephrectomy

Answer: Reassurance

1. A 27-year-old man comes to the physician for a routine health maintenance examination.

3. His 32-year-old brother recently had to start hemodialysis because of kidney disease.

4. He reports that his grandfather had "bad kidneys" as well.

5. The patient does not have dysuria, hematuria, or flank pain.

6. He has no history of serious illness.

7. His vital signs are within normal limits.

8. Physical examination shows no abnormalities.

9. An ultrasound of his right kidney is shown.


Question: Which of the following best describes the mechanism of action for his blood pressure medication?

Context: A 45-year-old man is following up with his primary care doctor for follow up of his essential hypertension.

Context: This is his annual check-up, and he reports that he has been doing well since his appointment last year.

Context: His physical examination is within normal limits, and his vital signs are all within normal limits, other than his blood pressure being 142/84 mm Hg.

Choices:
A. Dihydropyridine calcium channel blockers preferentially bind to a vascular smooth muscle
B. Calcium channel blockers only bind to channels on cardiac muscles
C. Non-dihydropyridine calcium channel blockers preferentially bind to a vascular smooth muscle
D. Calcium channel blockers only bind to channels on the sarcoplasmic reticulum

Answer: Dihydropyridine calcium channel blockers preferentially bind to a vascular smooth muscle

1. A 45-year-old man is following up with his primary care doctor.

3. He reports that he has been doing well since his appointment last year.

4. He denies any negative side effects from his amlodipine or metformin.

5. His physical examination is within normal limits.

6. His vital signs are all within normal limits.

General Internal Medicine
Cardiovascular Disease
Hypertension Specialist


Question: Which of the following pairs of adjectives most likely characterize the patient’s skin lesions:

Context: A 50-year-old male visits his primary care physician with skin lesions on his knees and elbows.

Context: He reports joint pain, and physical examination reveals severe swelling of the fingers on both hands.

Choices:
A. Honey-colored, crusting
B. Irregular, depigmented
C. Silver, scaly
D. Non-blanching, hemorrhagic

Answer: Silver, scaly

1. A 50-year-old male visits his primary care physician.

2. He has skin lesions on his knees and elbows.

4. Physical examination reveals severe swelling of the fingers on both hands.

5. Tests for serum rheumatoid factor are negative.


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

Context: A 42-year-old woman comes to the physician because of a low-grade fever and generalized fatigue for a week.

Context: During this period, she has passed decreased amounts of urine.

Context: Her temperature is 37.8°C (100°F), pulse is 99/min, and blood pressure is 160/94 mm Hg.

Context: Laboratory studies show: | Hemoglobin 12.1 g/dL | Leukocyte count 6,000/mm3 | Platelet count 156,000/mm3 | Serum | Urea nitrogen 89 mg/dL | Glucose 76 mg/dL | Creatinine 3.9 mg/dL | Donor-specific antibodies negative | A biopsy of the allograft shows mononuclear infiltrates with tubulitis and arteritis.

Context: C4d staining is negative.

Context: Oral fluconazole is administered.

Choices:
A. Intravenous immunoglobulin therapy
B. Methylprednisolone therapy
C. Removal of graft
D. Plasmapheresis

Answer: Methylprednisolone therapy

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

2. She has a low-grade fever and generalized fatigue for a week.

3. She has passed decreased amounts of urine.

4. Two months ago, she underwent a renal allograft transplant because of reflux nephropathy.

5. There is no family history of serious illness.

6. Her current medications include prednisone, cyclosporine, and azathioprine.

10. Examination shows several white patches within the oral cavity.

11. There is a well-healed surgical incision over the right lower abdomen.

12. The remainder of the examination shows no abnormalities.

13. Laboratory studies show: Hemoglobin 12.1 g/dL.

14. Laboratory studies show: Leukocyte count 6,000/mm3.

15. Laboratory studies show: Platelet count 156,000/mm3.

16. Laboratory studies show: Serum urea nitrogen 89 mg/dL.

17. Laboratory studies show: Glucose 76 mg/dL.

18. Laboratory studies show: Creatinine 3.9 mg/dL.

19. Laboratory studies show: Donor-specific antibodies negative.

20. A biopsy of the allograft shows mononuclear infiltrates with tubulitis and arteritis.


Question: Which of the following lesions is the patient at risk to develop?

Context: A 55-year-old woman is brought to your office for evaluation of 6 months of anal discomfort, vaginal pruritus, and soreness that worsened in the last several months.

Context: The physical examination is unremarkable, except for the presence of white, atrophic papules merging into an ulcerated plaque, with some of the white lesions extending and surrounding the anus (see image).

Context: You order biopsies of the lesions and a follow-up appointment.

Context: 2 weeks later, the histology evaluation reports hyperkeratosis, significant epidermal thinning, and plugging of infundibular follicles.

Choices:
A. Basal cell carcinoma (BCC)
B. Vulvar low-grade squamous intraepithelial lesion (LSIL)
C. Differentiated squamous cell carcinoma (SCC)
D. Vulvar high-grade squamous intraepithelial lesion (HSIL)

Answer: Differentiated squamous cell carcinoma (SCC)

1. A 55-year-old woman is brought to the office for evaluation.

2. The symptoms are 6 months of anal discomfort, vaginal pruritus, and soreness that worsened in the last several months.

3. The past medical history is significant for hypertension and smoking.

4. The family history is negative for malignancies.

5. The physical examination is unremarkable, except for the presence of white, atrophic papules merging into an ulcerated plaque.

6. Some of the white lesions extend and surround the anus.

7. Biopsies of the lesions and a follow-up appointment are ordered.

8. 2 weeks later, the histology evaluation reports hyperkeratosis.

9. The histology evaluation also reports significant epidermal thinning.

10. The histology evaluation also reports plugging of infundibular follicles.

General Dermatology
Gynecologic Oncology


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

Context: A 32-year-old male presents to his primary care physician with complaints of chronic headaches that have developed and increased in frequency and severity over the last several months.

Context: Additionally, the patient has noted he has been less coordinated over the last few weeks, stumbling and tripping often when he is walking.

Context: Physical examination is significant for notably reduced hand grip strength bilaterally as well as decreased pain and temperature sensation along the upper back and down both arms to the hands.

Context: A referral to the appropriate specialist is made, and an MRI of the brain and neck is obtained.

Context: Results of the MRI are show in Figures A and B.

Choices:
A. Arnold-Chiari malformation type 1
B. Arnold-Chiari malformation type 2
C. Arnold-Chiari malformation type 3
D. Arnold-Chiari malformation type 4

Answer: Arnold-Chiari malformation type 1

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

2. The patient has been experiencing chronic headaches for several months.

3. The headaches have been increasing in frequency and severity.

4. The patient has been less coordinated over the last few weeks, stumbling and tripping often when he is walking.

5. Physical examination is significant for notably reduced hand grip strength bilaterally.

6. Physical examination is also significant for decreased pain and temperature sensation along the upper back and down both arms to the hands.

7. A referral to the appropriate specialist is made.

8. An MRI of the brain and neck is obtained.

9. Results of the MRI are shown in Figures A and B.


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

Context: After hospitalization for urgent chemotherapy to treat Burkitt’s lymphoma, a 7-year-old boy develops paresthesias of the fingers, toes, and face.

Context: Laboratory studies show the following: | Hemoglobin 15 g/dL | Leukocyte count 6,000/mm3 with a normal differential serum | K+ 6.5 mEq/L | Ca+ 6.6 mg/dL | Phosphorus 5.4 mg/dL | HCO3− 15 mEq/L | Uric acid 12 mg/dL | Urea nitrogen 54 mg/dL | Creatinine 3.4 mg/dL | Arterial blood gas analysis on room air: | pH 7.30 | PCO2 30 mm Hg | O2 saturation 95% | Febuxostat is initiated.

Choices:
A. Hemodialysis
B. Intravenous 0.9% saline
C. Sodium bicarbonate
D. Orotracheal intubation

Answer: Hemodialysis

1. A 7-year-old boy develops paresthesias of the fingers, toes, and face after hospitalization for urgent chemotherapy to treat Burkitt’s lymphoma.

2. Blood pressure is 100/65 mm Hg, respirations are 28/min, pulse is 100/min, and temperature is 36.2°C (97.2°F).

3. Inflating a blood pressure cuff on the boy’s arm produces carpal spasm.

4. He has excreted 20 mL urine in the past 6 hours.

5. Laboratory studies show hemoglobin 15 g/dL.

6. Laboratory studies show leukocyte count 6,000/mm3 with a normal differential serum.

7. Laboratory studies show K+ 6.5 mEq/L.

8. Laboratory studies show Ca+ 6.6 mg/dL.

9. Laboratory studies show phosphorus 5.4 mg/dL.

10. Laboratory studies show HCO3− 15 mEq/L.

11. Laboratory studies show uric acid 12 mg/dL.

12. Laboratory studies show urea nitrogen 54 mg/dL.

13. Laboratory studies show creatinine 3.4 mg/dL.

14. Arterial blood gas analysis on room air shows pH 7.30.

15. Arterial blood gas analysis on room air shows PCO2 30 mm Hg.

16. Arterial blood gas analysis on room air shows O2 saturation 95%.

Pediatric Hematology
Neuromuscular Medicine
Pediatric Neurology


Question: Which of the following is most likely to be present on this patient's urine culture?"

Context: An 84-year-old woman with an indwelling urinary catheter and a history of recurrent nephrolithiasis is brought to the emergency department from her nursing home because of increasing confusion over the past day.

Context: Her temperature is 38.3°C (100.9°F).

Context: Examination shows dry mucous membranes.

Context: Urine studies show: | pH 8.3 | WBC 40/hpf | Bacteria moderate | Nitrites positive | The urine has an ammonia odor.

Choices:
A. Gram-negative, oxidase-positive rods
B. Gram-positive, novobiocin-resistant cocci
C. Gram-positive, gamma-hemolytic cocci
D. Gram-negative, oxidase-negative rods

Answer: Gram-negative, oxidase-negative rods

1. An 84-year-old woman has an indwelling urinary catheter and a history of recurrent nephrolithiasis.

2. She was brought to the emergency department from her nursing home because of increasing confusion over the past day.

3. On arrival, she is oriented only to person.

5. Examination shows dry mucous membranes.

8. Urine studies show bacteria present in moderate amounts.

9. Urine studies show nitrites are positive.


Question: Which of the following ego defenses is this patient most closely exhibiting?

Context: A 28-year-old woman who was recently hired at a new company feels intense physical attraction towards her supervisor.

Context: She feels he is exceptionally kind to her and finds herself fantasizing about him during work.

Context: While talking to her co-workers, she ardently raises complaints about her supervisor and declares that she finds him to be extremely repulsive, rude, and arrogant.

Choices:
A. Denial
B. Isolation of affect
C. Reaction formation
D. Repression

Answer: Reaction formation

1. A 28-year-old woman was recently hired at a new company.

2. She feels intense physical attraction towards her supervisor.

3. She feels he is exceptionally kind to her.

4. She finds herself fantasizing about him during work.

5. She ardently raises complaints about her supervisor while talking to her co-workers.

6. She declares that she finds her supervisor to be extremely repulsive, rude, and arrogant.

General Psychiatry
C: "Reaction formation"
Clinical Neurophysiology
Reaction Formation


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

Context: An 11-year-old boy presents to his pediatrician with his mother for a sore throat.

Context: His symptoms began approximately a few days ago after attending a birthday party with his friends.

Context: His symptoms are accompanied by nausea, vomiting, and a mild headache.

Context: He also has mild discomfort in his throat when eating food or drinking water.

Context: The patient denies rhinorrhea, conjunctivitis, cough, myalgias, or a rash.

Context: His mother said his temperature last night was 101°F (38.3°C).

Context: On physical exam, the patient has tender and enlarged anterior cervical lymph nodes.

Choices:
A. Azithromycin
B. Observation
C. Penicillin V
D. Rapid antigen detection test

Answer: Rapid antigen detection test

2. Patient is presenting to his pediatrician with his mother.

4. Symptoms began a few days ago after attending a birthday party with friends.

5. Symptoms include nausea, vomiting, and a mild headache.

6. Patient has mild discomfort in throat when eating food or drinking water.

7. Patient denies rhinorrhea, conjunctivitis, cough, myalgias, or a rash.

8. Mother reported patient's temperature last night was 101°F (38.3°C).

9. On physical exam, patient has tender and enlarged anterior cervical lymph nodes.

10. Upon oral inspection, there is pharyngeal inflammation and exudates with petechial lesions on the soft palate.

General Pediatrics
Pediatric Infectious Diseases


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

Context: A 52-year-old male with follicular non-Hodgkin lymphoma undergoes chemotherapy.

Context: He develops suprapubic pain and hematuria.

Choices:
A. Cyclophosphamide
B. Mesna
C. Bleomycin
D. Carmustine

Answer: Cyclophosphamide

1. A 52-year-old male has follicular non-Hodgkin lymphoma.

Medical Oncology
General Medical Oncology


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

Context: A 68-year-old man comes to the physician because of a 1-week history of difficulty with urination.

Context: Two weeks ago, he was hospitalized for treatment of a cerebrovascular accident; his symptoms began after he was discharged.

Choices:
A. Muscarinic agonist
B. Muscarinic antagonist
C. Alpha-1 receptor agonist
D. 5-alpha-reductase inhibitor

Answer: Muscarinic agonist

1. A 68-year-old man comes to the physician.

2. He has a 1-week history of difficulty with urination.

3. Two weeks ago, he was hospitalized for treatment of a cerebrovascular accident.

4. His symptoms began after he was discharged.

5. His vital signs are within normal limits.

6. Neurologic examination shows mild dysarthria, right facial droop, and right hemiparesis.

7. Rectal examination shows a normal prostate.

8. The patient produces 70 mL of urine for a sample.

9. Placement of a Foley catheter yields an additional 500 mL of urine.


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

Context: A 61-year-old woman presents with painless vaginal bleeding.

Context: Past medical history is significant for diabetes mellitus type 2 and hypertension, both managed medically.

Context: Current medications are atorvastatin, lisinopril, hydrochlorothiazide, and metformin.

Context: Menopause occurred 8 years ago, and she denies taking hormone replacement therapy or estrogen-containing oral contraceptives.

Context: Her last Pap smear 1 year ago was normal.

Context: Vital signs are temperature 37.0℃ (98.6℉), blood pressure 130/85 mm Hg, pulse 82/min, respiratory rate 13/min, and oxygen saturation 99% on room air.

Context: BMI is 33.8 kg/m2.

Context: Cardiac exam is normal.

Context: Lungs are clear to auscultation.

Context: The cervix is movable and non-tender.

Context: The uterus is not enlarged but softened on palpation.

Context: Adnexa is non-palpable.

Choices:
A. Hysteroscopy
B. Pap test
C. Endometrial biopsy
D. Pelvic MRI

Answer: Endometrial biopsy

2. Patient presents with painless vaginal bleeding.

3. Patient says the bleeding has been occurring occasionally for the past 3 years.

4. Patient has a past medical history of diabetes mellitus type 2 and hypertension, both managed medically.

5. Patient's current medications are atorvastatin, lisinopril, hydrochlorothiazide, and metformin.

6. Patient has not been sexually active since the death of her husband 9 years ago.

7. Patient's menopause occurred 8 years ago.

8. Patient denies taking hormone replacement therapy or estrogen-containing oral contraceptives.

9. Patient's last Pap smear 1 year ago was normal.

10. Patient's vital signs are temperature 37.0℃ (98.6℉), blood pressure 130/85 mm Hg, pulse 82/min, respiratory rate 13/min, and oxygen saturation 99% on room air.

12. On physical examination, patient is alert and cooperative.

15. Abdomen is soft and non-tender with no masses or hepatosplenomegaly.

16. Examination of the perineum shows pale, atrophic vaginal mucosa.

17. Speculum examination shows no vaginal or cervical lesions.

19. There is trace blood in the vaginal vault and mild bleeding from the cervical os.

20. Uterus is not enlarged but softened on palpation.


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

Context: A 20-year-old African American woman presents to the clinic after missing her last 2 periods.

Context: Her cycles are usually regular, occurring at 28–32 day intervals with moderate bleeding and some abdominal discomfort.

Context: She also complains of occasional diffuse and generalized headaches.

Context: She is a college student and works part-time as a bartender.

Context: The past medical history is benign.

Context: The blood pressure is 110/70 mm Hg, the pulse is 80/min, the respiratory rate is 14/min, and the temperature is 36.5°C (97.7°F).

Context: The physical examination is significant for mild breast tenderness and secretions from the nipple area.

Context: A urine pregnancy test is negative.

Choices:
A. MRI of the brain
B. Serum prolactin levels
C. LH:FSH ratio
D. Dopamine agonists

Answer: Serum prolactin levels

1. Patient is a 20-year-old African American woman.

2. Patient has missed her last 2 periods.

3. Patient's cycles are usually regular, occurring at 28–32 day intervals with moderate bleeding and some abdominal discomfort.

4. Patient complains of occasional diffuse and generalized headaches.

5. Patient is a college student and works part-time as a bartender.

6. Patient's past medical history is benign.

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

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

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

11. Physical examination is significant for mild breast tenderness and secretions from the nipple area.

Reproductive Endocrinology and Infertility


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

Context: A 50-year-old man comes to the physician because of an 8-month history of intermittent watery diarrhea and abdominal pain.

Context: He has also had episodic pain of the ankle, wrist, and knee joints during the past 5 years.

Context: Histopathologic examination of a tissue specimen shows foamy macrophages in the lamina propria with periodic acid-Schiff (PAS)-positive inclusions.

Choices:
A. Anti-tissue transglutaminase antibodies
B. Anti-cyclic citrullinated peptide antibody
C. Intracellular, gram-positive bacilli
D. Low serum TSH and high free T4 concentrations

Answer: Intracellular, gram-positive bacilli

1. A 50-year-old man comes to the physician.

2. He has had an 8-month history of intermittent watery diarrhea and abdominal pain.

3. He has had a 12-kg (26-lb) weight loss during this period.

4. He has had episodic pain of the ankle, wrist, and knee joints during the past 5 years.

5. An endoscopy with small bowel biopsy is performed.

6. Histopathologic examination of a tissue specimen shows foamy macrophages in the lamina propria.

7. The foamy macrophages are periodic acid-Schiff (PAS)-positive inclusions.


Question: The drug that most specifically targets this patient's tumor is also used in the treatment of which of the following conditions?

Context: A 49-year-old woman comes to the physician because of a growing lump in the right breast that she first noticed 1 month ago.

Context: Immunohistochemical analysis of a biopsy specimen from the mass shows malignant cells that stain negative for estrogen and progesterone receptors and positive for human epidermal growth factor receptor 2.

Choices:
A. Multiple sclerosis
B. Gastric cancer
C. Osteoporosis
D. Rheumatoid arthritis

Answer: Gastric cancer

1. A 49-year-old woman comes to the physician.

2. She noticed a growing lump in the right breast 1 month ago.

3. Physical examination of the right breast shows a 3.5-cm firm, fixed mass in the right upper quadrant.

4. There is dimpling of the overlying skin.

5. A mammogram shows a mass with poorly-defined margins and microcalcifications.

6. Immunohistochemical analysis of a biopsy specimen from the mass shows malignant cells.

7. The malignant cells stain negative for estrogen and progesterone receptors.

8. The malignant cells stain positive for human epidermal growth factor receptor 2.


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

Context: A 17-year-old girl is brought to the physician because her mother is concerned about her lack of appetite.

Context: She has had a 4-kg (8.8-lb) weight loss over the past 4 months.

Context: The patient states that she does not “feel like eating so much”.

Context: Over the last year her academic performance in school has decreased and she has had a lot of disputes with her parents concerning her future.

Context: Her mother says that she has also become more nervous and restless.

Context: Her grandmother had a problem with her thyroid.

Context: She is sexually active with two male partners and uses condoms inconsistently.

Context: She is at 60th percentile for height and at 15th percentile for weight.

Context: She appears thin.

Context: Her temperature is 37°C (98.6°F), pulse is 104/min, and blood pressure is 135/80 mm Hg.

Context: The pupils are 9 mm large, round and minimally reactive to light.

Context: Deep tendon reflexes are 2+ bilaterally.

Context: There is fine tremor of her hands.

Choices:
A. Measure serum electrolytes
B. Perform abdominal ultrasound
C. Obtain toxicology screening
D. Obtain HIV screening test

Answer: Obtain toxicology screening

2. Patient has had a 4-kg (8.8-lb) weight loss over the past 4 months.

3. Patient states that she does not “feel like eating so much”.

4. Patient's academic performance in school has decreased over the last year.

5. Patient has had a lot of disputes with her parents concerning her future.

6. Patient's mother says that she has also become more nervous and restless.

7. Patient's grandmother had a problem with her thyroid.

8. Patient is sexually active with two male partners and uses condoms inconsistently.

9. Patient is at 60th percentile for height and at 15th percentile for weight.

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

13. Patient's blood pressure is 135/80 mm Hg.

14. Patient's pupils are 9 mm large, round and minimally reactive to light.

15. Patient's deep tendon reflexes are 2+ bilaterally.

16. Patient has fine tremor of her hands.

17. The remainder of the examination shows no abnormalities.


Question: Which of the following additional findings is most likely to be found in this patient’s history?

Context: An 11-year-old male presents to the pediatrician to be evaluated for learning difficulties.

Context: His parents report that the patient’s grades have been falling since he started middle school this year.

Context: The patient previously attended a smaller elementary school that focused more on the arts and creative play.

Context: His parents report that at home the patient bathes and dresses himself independently but requires help with more difficult tasks, such as packing his backpack and making a schedule for homework.

Context: He enjoys reading comic books and playing video games.

Context: The patient’s parents report that he said his first word at 19 months and walked at 21 months.

Context: His mother notes that she herself struggled to pay attention in her classes and completed college in six years after taking a reduced course load.

Context: On physical exam, the patient has a long, narrow face with large ears.

Context: His testicles are larger than expected for his age.

Choices:
A. Compulsive completion of rituals
B. Cruelty to animals or fire-setting
C. Difficulty seeing the board at school
D. Poor reciprocal emotional behavior

Answer: Poor reciprocal emotional behavior

2. Patient presents to pediatrician to be evaluated for learning difficulties.

3. Patient's grades have been falling since he started middle school this year.

4. Patient previously attended a smaller elementary school that focused more on the arts and creative play.

5. Patient bathes and dresses himself independently.

6. Patient requires help with more difficult tasks, such as packing his backpack and making a schedule for homework.

7. Patient enjoys reading comic books and playing video games.

8. Patient said his first word at 19 months.

10. Patient's mother struggled to pay attention in her classes and completed college in six years after taking a reduced course load.

11. On physical exam, patient has a long, narrow face with large ears.

12. Patient's testicles are larger than expected for his age.

Developmental
Child and Adolescent Psychiatry


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

Context: A 17-year-old girl comes to the primary care clinic with her father complaining of right knee pain.

Context: She reports that the pain started about a month ago, and since then it has gotten progressively worse.

Context: The knee pain is not constant but becomes most noticeable when going up or down the stairs.

Context: She also endorses that her knee becomes uncomfortable towards the end of class.

Context: Her father is worried because the pain is affecting her ability to play basketball, and she has college scouts coming to watch her play.

Context: The patient has no chronic medical conditions.

Context: She had a tonsillectomy as a child.

Context: She takes a multivitamin and uses ibuprofen as needed for the pain.

Context: On physical examination, there is tenderness at the inferior pole of the patella, without swelling or overlying skin changes.

Choices:
A. Osgood-Schlatter disease
B. Patellar stress fracture
C. Patellar tendonitis
D. Patellofemoral syndrome

Answer: Patellar tendonitis

2. Patient is accompanied by her father.

3. Patient complains of right knee pain.

7. Pain is most noticeable when going up or down stairs.

8. Pain becomes uncomfortable towards the end of class.

9. Father is worried because pain is affecting her ability to play basketball.

10. College scouts are coming to watch her play.

11. Patient has no chronic medical conditions.

12. Patient had a tonsillectomy as a child.

14. Patient uses ibuprofen as needed for the pain.

15. Physical examination reveals tenderness at the inferior pole of the patella.

16. No swelling or overlying skin changes noted.


Question: Which of the following pathological type of polyp does this patient most likely have that also puts him at higher risk of malignancy?

Context: He has hypertension and dyslipidemia.

Choices:
A. Hamartomatous polyps
B. Villous adenomatous polyps
C. Tubular adenomatous polyps
D. Hyperplastic polyps

Answer: Villous adenomatous polyps

1. A 60-year-old man presents to the physician for his 10-year colonoscopy screening.

2. He has no complaints except for occasional diarrhea and dribbling of urine.

3. He says that he is on a healthy diet and exercises 3 days a week.

4. He quit smoking 5 years ago after smoking 1 pack of cigarettes per day for 20 years.

5. He has hypertension and dyslipidemia.

6. He has benign prostatic hyperplasia that was diagnosed last year.

7. On physical examination, his abdomen is lax with no tenderness or rigidity.

8. Rectal examination reveals no blood in the rectal vault.

9. Colonoscopy reveals a 4 x 3 cm polyp in the sigmoid colon.

10. Multiple biopsies are obtained and sent for pathologic examination.

11. Genetic testing reveals a mutation in the KRAS gene.


Question: Which of the following could be the mechanism of action of the administered drug?

Context: The medical history is unremarkable and she takes no medications.

Context: She denies smoking, drinking, and drug use.

Context: The family history is unremarkable.

Context: A drug which is known to selectively act on a segment of the renal vasculature is administered and the glomerular filtration rate (GFR) and filtration fraction (FF) both increase.

Choices:
A. Efferent arteriole constriction
B. Renal artery constriction
C. Increased peritubular capillary permeability
D. Afferent arteriole constriction

Answer: Efferent arteriole constriction

1. A 20-year-old healthy female volunteer is enrolled in a study involving renal perfusion.

8. The physical examination reveals no abnormal findings.

10. The drug is known to selectively act on a segment of the renal vasculature.

11. The glomerular filtration rate (GFR) increases.

12. The filtration fraction (FF) increases.


Question: This patient most likely has a deficiency in which of the following factors?

Context: A 3-year-old male is brought to the emergency room by his mother for a rash and fever.

Context: The mother reports that the child first developed a cough and malaise three days ago.

Context: Over the last 24 hours, a rash developed and the patient had a temperature up to 101.4°F (38.6°C) the night prior to presentation.

Context: The child’s medical history is notable for a prior hospitalization at the age of 2 for fever, vomiting, and lethargy.

Context: During that hospitalization, a cerebrospinal fluid sample demonstrated gram-negative diplococci.

Context: His current temperature is 100.9°F (38.3°C), blood pressure is 130/85 mmHg, pulse is 115/min, and respirations are 22/min.

Choices:
A. C1q
B. C3
C. C4
D. C5

Answer: C5

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

4. Patient had a cough and malaise three days ago.

5. Patient had a temperature up to 101.4°F (38.6°C) the night prior to presentation.

6. Patient had a prior hospitalization at the age of 2 for fever, vomiting, and lethargy.

7. During prior hospitalization, a cerebrospinal fluid sample demonstrated gram-negative diplococci.

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

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

12. Physical examination reveals a lethargic male child with a diffuse petechial skin rash that is most prominent on the trunk and legs.

Pediatric Infectious Diseases
Pediatric Rheumatology
General Pediatrics


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

Context: His immunizations are up-to-date.

Context: Laboratory studies show: | Hemoglobin 9.4 g/dL | Leukocyte count 11,500/mm3 | Platelet count 30,000/mm3 | Prothrombin time 14 sec | Partial thromboplastin time 33 sec | .

Choices:
A. Chronic granulomatous disease
B. DiGeorge syndrome
C. Chediak-Higashi syndrome
D. Wiskott-Aldrich syndrome

Answer: Wiskott-Aldrich syndrome

1. A 13-month-old boy is brought to the physician for the evaluation of rectal bleeding that occurred earlier that morning.

2. The patient has also had several itchy and red skin lesions that started on his scalp and spread downwards.

3. The parents report that their son has had six episodes of bilateral otitis media since birth.

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

6. His vital signs are within normal limits.

7. Examination shows several eczematous lesions over the scalp, neck, and upper and lower extremities, as well as multiple red spots that do not blanch on pressure.

8. The remainder of the physical examination shows no abnormalities.

9. Laboratory studies show: Hemoglobin 9.4 g/dL

10. Laboratory studies show: Leukocyte count 11,500/mm3

11. Laboratory studies show: Platelet count 30,000/mm3

12. Laboratory studies show: Prothrombin time 14 sec

13. Laboratory studies show: Partial thromboplastin time 33 sec.


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

Context: A 28-year-old woman, gravida 3, para 2, at 34 weeks' gestation comes to the physician because of a 1-day history of dyspnea, dry cough, and chest pain.

Context: Her pulse is 112/min, respirations are 24/min, and blood pressure is 108/78 mm Hg.

Context: Examination shows jugular venous distention and bilateral pitting edema below the knees that is worse on the right side.

Choices:
A. Pulmonary embolism
B. Panic attack
C. Bacterial pneumonia
D. Acute pericarditis

Answer: Pulmonary embolism

1. A 28-year-old woman comes to the physician.

4. She has a 1-day history of dyspnea, dry cough, and chest pain.

8. Pulse oximetry on room air shows an oxygen saturation of 90%.

9. Examination shows jugular venous distention.

10. Examination shows bilateral pitting edema below the knees.

11. The edema is worse on the right side.

12. There is dullness to percussion over the right lung base.


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

Context: He appears pale.

Context: Temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 155/90 mm Hg.

Context: Laboratory studies show: | Hemoglobin 10 g/dL | Leukocyte count 2,500/mm3 | Platelet count 80,000/mm3 | Serum | Urea nitrogen 30 mg/dL | Glucose 150 mg/dL | .

Choices:
A. Tacrolimus
B. Daclizumab
C. Mycophenolate mofetil
D. Azathioprine

Answer: Mycophenolate mofetil

1. A 55-year-old man comes to the physician for a follow-up examination.

2. One month ago, he underwent a right-sided kidney transplantation due to severe polycystic kidney disease.

3. Following the procedure, he was started on transplant rejection prophylaxis.

4. He has had some chest and back pain as well as frequent coughing.

5. He has also had 5–6 bowel movements per day of loose stool and occasional vomiting.

10. Physical examination shows lower extremity pitting edema.

11. Laboratory studies show hemoglobin 10 g/dL.


Question: This patient is at increased risk for recurrent infections with which of the following pathogens?

Context: A 2-year-old boy with a history of multiple hospitalizations for fever and infection undergoes immunologic evaluation.

Context: Serum CH50 assay shows inappropriately low erythrocyte lysis and further workup confirms C8 deficiency.

Choices:
A. Neisseria species
B. Giardia species
C. Pneumocystis species
D.
Mycobacterium species
"

Answer: Neisseria species

1. A 2-year-old boy has a history of multiple hospitalizations for fever and infection.

2. Serum CH50 assay shows inappropriately low erythrocyte lysis.

3. Further workup confirms C8 deficiency.

Pediatric Infectious Diseases
Immunology and Allergy


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

Context: A 55-year-old man is brought to the emergency department because of cough and poor appetite for the past week.

Context: Since it began, he has been coughing up small amounts of malodorous phlegm.

Context: During the past two nights, he has also had night sweats.

Context: He drinks 8–10 beers daily.

Context: His temperature is 38.9°C (102.0°F), pulse is 101/min, respirations are 25/min and blood pressure is 145/92 mm Hg.

Context: The patient appears intoxicated.

Choices:
A. Pneumocystis pneumonia
B. Aspiration pneumonia
C. Mitral valve regurgitation
D.
Pharyngoesophageal diverticulum
"

Answer: Aspiration pneumonia

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

2. He has had a cough and poor appetite for the past week.

3. He has been coughing up small amounts of malodorous phlegm.

4. He has had night sweats for the past two nights.

5. He was diagnosed with HIV infection 5 years ago.

6. He has hypertension, type 2 diabetes mellitus, and severe heartburn.

7. The patient is homeless and does not take any medication.

8. He has smoked a pack of cigarettes daily for 30 years.

10. His temperature is 38.9°C (102.0°F).

15. Physical examination shows crackles and dullness to percussion at the right lung base.

16. Scattered expiratory wheezing is heard throughout both lung fields.

17. A grade 2/6 mid-systolic ejection murmur is heard along the upper right sternal border.

18. His CD4+T-lymphocyte count is 280/mm3 (Normal ≥ 500).

19. An x-ray of the chest shows a hazy infiltrate in the right lower lung field.


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

Context: Some are healing and some are fresh.

Choices:
A. To report to Child Protective Services
B. To order patch testing for allergic contact dermatitis
C. To obtain skin scrapings for examination by light microscopy
D. Mupirocin cream

Answer: To report to Child Protective Services

1. A 2-year-old boy is brought in to his pediatrician for his annual exam, flu vaccination, and to evaluate a diaper rash.

2. The itchy pink rash has been bothering the boy for about 1 week and over the counter, remedies are not helping.

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

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

5. During the discussion, his parents are frustrated by his behavior and inability to follow directions.

6. Today, his vital signs are stable and normal for his age.

7. On physical examination, the boy appears uncomfortable.

8. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally.

9. There is a pink-red, raised rash in the anogenital region and medial thighs.

10. Additionally, there are multiple bruises on the boy’s buttocks and the back of his thighs.

11. Some are healing and some are fresh.

12. When questioned about the bruising, the parents become evasive and end the discussion.


Question: The patient's therapy increases her risk of which of the following conditions?

Context: A 62-year-old woman comes to the physician for the evaluation of a palpable mass in the left breast that she noticed 3 weeks ago.

Context: She has no children.

Context: The patient's menopause occurred at 57 years of age.

Context: The patient had smoked one pack of cigarettes daily for 30 years but quit 15 years ago.

Context: She does not drink alcohol.

Context: She appears well.

Context: The patient undergoes lumpectomy of the left breast and treatment with tamoxifen is started.

Choices:
A. Myelosuppression
B. Osteoporosis
C. Endometrial cancer
D. Ovarian cancer

Answer: Endometrial cancer

1. A 62-year-old woman comes to the physician for the evaluation of a palpable mass in the left breast.

3. During this period, she has also had some left-sided blood-tinged discharge.

4. She has hypertension, type 2 diabetes mellitus, and hypercholesterolemia.

6. Her menopause occurred at 57 years of age.

7. Her mother died of colon cancer at the age of 65 years.

8. She smoked one pack of cigarettes daily for 30 years.

11. Her current medications include enalapril, metformin, atorvastatin, and a multivitamin.

12. She is 165 cm (5 ft 5 in) tall and weighs 84 kg (187 lb); BMI is 30.9 kg/m2.

14. Her temperature is 37°C (98.6°F), pulse is 78/min, and blood pressure is 135/80 mm Hg.

15. Examination of the breasts shows a left-sided single, nontender, firm mass with poorly defined margins in the upper outer quadrant.

16. Biopsy of the mass confirms the diagnosis of pleomorphic lobular carcinoma in situ (LCIS) that is estrogen-receptor (ER) positive.

17. The patient undergoes lumpectomy of the left breast.

18. Treatment with tamoxifen is started.


Question: Which of the following is the most likely risk factor contributing to this patient's underlying diagnosis?

Context: A confused and disoriented 32-year-old man is brought to the emergency department by his wife.

Context: He was in his usual state of health until yesterday, when he started complaining of fever and headache.

Context: This morning he was complaining of worsened headache and was acting odd, prompting his wife to bring him to the hospital.

Context: At the hospital, his temperature is 39.2°C (102.5°F), pulse is 116/min, and blood pressure is 96/64 mm Hg.

Context: Physical examination is notable for neck stiffness and a large scar across his abdomen that his wife says is from a splenectomy operation following a car accident a few years ago.

Context: A lumbar puncture shows elevated protein, low glucose, and 1,200 WBCs with 95% polymorphonuclear cells; gram staining shows gram-positive diplococci.

Choices:
A. Congenital humoral immunodeficiency
B. Dysfunction of a single organ
C. Dysfunction of multiple organs
D. Undiagnosed viral infection

Answer: Dysfunction of a single organ

1. A 32-year-old man is brought to the emergency department by his wife.

2. He was in his usual state of health until yesterday.

3. Yesterday he started complaining of fever and headache.

4. This morning he was complaining of worsened headache and was acting odd.

5. His past medical history is unremarkable.

6. At the hospital, his temperature is 39.2°C (102.5°F).

9. Physical examination is notable for neck stiffness.

10. He has a large scar across his abdomen from a splenectomy operation following a car accident a few years ago.

11. He has not seen a doctor since that time.

12. A lumbar puncture shows elevated protein.

13. A lumbar puncture shows low glucose.

14. A lumbar puncture shows 1,200 WBCs with 95% polymorphonuclear cells.

15. Gram staining shows gram-positive diplococci.


Question: What does the letter ‘a’ represent in this process?

Context: A group of scientists is verifying previous research on DNA replication.

Context: The diagram illustrates the theoretical DNA replication process in bacteria such as Escherichia coli.

Choices:
A. RNA Primers
B. Okazaki fragments
C. The leading strand
D. Replication fork

Answer: Okazaki fragments

1. A group of scientists is verifying previous research.

3. A diagram illustrates the theoretical DNA replication process.

4. The DNA replication process is in bacteria such as Escherichia coli.


Question: Which of the following is acceptable for the physician to accept?: | A) Compensation for travel expenses | B) An honorarium for speaking | C) Assistance with preparing her presentations

Context: The company invites her to give a lecture series for other physicians on new therapies in her field of expertise at a retreat center in the Caribbean.

Choices:
A. A only
B. B only
C. C only
D. A and B

Answer: A and B

1. A physician is involved in a research collaboration with a pharmaceutical company.

2. The pharmaceutical company invites the physician to give a lecture series.

3. The lecture series is for other physicians.

4. The lecture series is about new therapies in the physician's field of expertise.

5. The lecture series will be held at a retreat center in the Caribbean.

Health Care Administration, Leadership, and Management


Question: Which of the following set of findings were most likely found during the physical exam?

Context: They are concerned about his performance at school and have received several letters from his school noting that the adolescent has difficulty with reading and writing compared to his classmates and often misbehaves during class.

Context: After a careful review of all findings the pediatrician suspects the teenager may have a numerical chromosomal disorder and orders karyotype (see image).

Choices:
A. Arachnodactyly, scoliosis and aortic root dilation
B. Short stature, broad chest and thick skin folds in neck
C. Short stature, hypotonia and obesity
D. Tall Stature and gynecomastia

Answer: Tall Stature and gynecomastia

1. A 15-year-old teenager is brought to a pediatrician by his parents.

2. His parents are concerned about his performance at school.

3. The adolescent has difficulty with reading and writing compared to his classmates.

5. A physical exam reveals some atypical findings.

6. A Wechsler Intelligence Scale for Children (WISC) shows that the boy has a mild intellectual disability with an IQ of 84.

7. Complete blood count and serum TSH levels are normal.

8. The pediatrician suspects the teenager may have a numerical chromosomal disorder.

9. The pediatrician orders karyotype (see image).

Pediatric Endocrinology
Pediatric Cardiology


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

Context: He was born at 32 weeks' gestation.

Context: His temperature is 37°C (98.6°F), pulse is 145/min, respirations are 65/min, and blood pressure is 78/55 mm Hg.

Context: The lungs are clear to auscultation.

Context: His hemoglobin concentration is 13.0 g/dL, leukocyte count is 10,900/mm3, and platelet count is 90,000/mm3.

Context: Arterial blood gas analysis on room air shows: | pH 7.31 | PCO2 30 mm Hg | PO2 80 mm Hg | O2 saturation 98% | An x-ray of the abdomen is shown.

Choices:
A. Nasogastric tube gut decompression
B. Exploratory laparotomy
C. Administration of ampicillin, gentamicin, and metronidazole
D.
Barium enema
"

Answer: Exploratory laparotomy

1. Ten days after delivery, a 1500-g (3.3-lb) male newborn is feeding poorly.

3. He has had frequent episodes of vomiting for the past 2 days.

4. He has no fever, diarrhea, or hematemesis.

5. He appears lethargic and is difficult to arouse.

10. The lungs are clear to auscultation.

11. The abdomen is hard with rebound tenderness.

12. The patient is responsive only to painful stimuli.

13. His hemoglobin concentration is 13.0 g/dL.

16. Arterial blood gas analysis on room air shows pH 7.31, PCO2 30 mm Hg, PO2 80 mm Hg, and O2 saturation 98%.


Question: What is the most likely diagnosis?

Context: A 45-year-old man who underwent liver transplantation 3 months ago for chronic liver failure presents to the physician because of a backache following a fall from sitting.

Context: He is currently on immunosuppressive therapy with glucocorticoids and cyclosporine.

Context: He has no comorbidities.

Context: On physical examination, his vitals are within normal limits.

Context: He has tenderness over his lumbar spine.

Context: An X-ray of the lumbar spine shows a wedge compression fracture of the L1 vertebra.

Context: His serum testosterone and serum creatinine levels are normal.

Context: Bone mineral densitometry shows a T-score of –3.0.

Choices:
A. Renal osteodystrophy
B. Osteopenia
C. Osteomalacia
D. Transplantation-related osteoporosis

Answer: Transplantation-related osteoporosis

2. Patient underwent liver transplantation 3 months ago for chronic liver failure.

3. Patient presents to physician due to backache following a fall from sitting.

4. Patient is on immunosuppressive therapy with glucocorticoids and cyclosporine.

6. Patient's vitals are within normal limits.

7. Patient has tenderness over lumbar spine.

8. X-ray of lumbar spine shows wedge compression fracture of L1 vertebra.

9. Patient's serum testosterone level is normal.

10. Patient's serum creatinine level is normal.

11. Bone mineral densitometry shows T-score of -3.0.


Question: Which of the following is the best initial diagnostic test for her current complaint?

Context: A 56-year-old woman presents to the emergency department with acute onset of pain and redness of the skin of her right arm for the past 3 days.

Context: She has had type 2 diabetes mellitus for the past 22 years, but she is not compliant with her medications.

Context: Her temperature is 38.0°C (100.4°F), pulse is 105/min, and blood pressure is 116/74 mm Hg.

Context: She is diagnosed with acute cellulitis, and intravenous clindamycin is started.

Context: On the 6th day of antibiotic therapy, the patient complains of severe watery diarrhea, fever, and abdominal tenderness without rigidity.

Choices:
A. Complete blood count with differential
B. Sigmoidoscopy or colonoscopy
C. Fecal occult blood test
D. Polymerase chain reaction

Answer: Polymerase chain reaction

1. A 56-year-old woman presents to the emergency department.

2. She has had type 2 diabetes mellitus for the past 22 years.

3. She is not compliant with her medications.

7. On physical examination, her forearm is tender and erythematous.

8. She is diagnosed with acute cellulitis.

10. On the 6th day of antibiotic therapy, the patient complains of severe watery diarrhea.

12. She also complains of abdominal tenderness without rigidity.


Question: Which of the following correlates with the estimated standard error of the mean for this population?

Context: A group of researchers attempts to determine the mean fasting triglyceride levels in patients between the ages of 30 and 60 in a suburb of Tampa, FL.

Context: Over the course of several years, the team manages to obtain the blood levels of a random sample of 10,000 volunteers who fit their inclusion criteria.

Context: The blood levels are measured and demonstrate a standard deviation of 5.

Choices:
A. 0.02
B. 0.05
C. 0.10
D. 0.15

Answer: 0.05

1. A group of researchers attempts to determine the mean fasting triglyceride levels in patients.

2. The patients are between the ages of 30 and 60.

3. The research is conducted in a suburb of Tampa, FL.

4. The team manages to obtain the blood levels of a random sample of 10,000 volunteers.

5. The volunteers fit the inclusion criteria.

7. The blood levels demonstrate a standard deviation of 5.


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

Context: A 14-year-old girl is brought to the physician by her mother for evaluation of several bruises on her lower extremities.

Context: She has had these bruises for about 6 weeks, and the mother is concerned that she might be bullied at school.

Context: The patient has had increasing fatigue and paleness over the past several days.

Context: She has a history of recurrent generalized tonic-clonic seizures treated with carbamazepine.

Context: She appears pale and ill.

Context: Her temperature is 37.8°C (100.1°F), pulse is 115/min, and blood pressure is 100/60 mm Hg.

Context: The lungs are clear to auscultation.

Context: There are several subcutaneous purple spots on her legs bilaterally.

Context: Her hemoglobin concentration is 8.4 g/dL, leukocyte count is 2,600/mm3, platelet count is 18,000/mm3, and reticulocyte count is 0.3%.

Choices:
A. Immune thrombocytopenic purpura
B. Sickle cell disease
C. Systemic lupus erythematosus
D. Adverse effect of medication

Answer: Adverse effect of medication

2. Patient has several bruises on her lower extremities for 6 weeks.

3. Mother is concerned that patient might be bullied at school.

4. Patient has increasing fatigue and paleness over the past several days.

5. Patient has a history of recurrent generalized tonic-clonic seizures treated with carbamazepine.

7. Patient's temperature is 37.8°C (100.1°F).

9. Patient's blood pressure is 100/60 mm Hg.

11. Examination shows a soft, nontender abdomen with no organomegaly.

12. Patient has several subcutaneous purple spots on her legs bilaterally.

13. Patient's hemoglobin concentration is 8.4 g/dL.

14. Patient's leukocyte count is 2,600/mm3.

15. Patient's platelet count is 18,000/mm3.

16. Patient's reticulocyte count is 0.3%.

17. Serum electrolyte concentrations are within normal limits.


Question: Histopathologic examination of these macules is most likely to show which of the following?

Context: A 51-year-old man comes to the emergency department because of a 3-day history of shortness of breath, fever, and chills.

Context: He has no history of serious illness.

Context: His temperature is 39.5°C (103.1°F).

Context: Physical examination shows a grade 4/6, holosystolic, blowing murmur over the apex that radiates to the axilla.

Choices:
A. Microabscesses with neutrophil infiltration of capillaries
B. Epithelioid cells with surrounding multinucleated giant cells
C. Cleft-like vacuoles within the arterioles
D. Spiral-shaped bacteria with axial filaments in the epidermis

Answer: Microabscesses with neutrophil infiltration of capillaries

1. A 51-year-old man comes to the emergency department.

2. He has a 3-day history of shortness of breath, fever, and chills.

3. He has no history of serious illness.

5. Physical examination shows a grade 4/6, holosystolic, blowing murmur over the apex.

7. Crackles are heard in both lower lung fields.

8. Examination of the extremities shows several non-tender, non-blanching, erythematous macules on the palms and soles.