Question: Which of the following is the most likely site of action of this drug in the kidney?

Context: A 30-year-old woman is brought to the emergency department because of severe headache and vomiting that started after she was hiking in the mountains at high altitude.

Choices:
A. Proximal convoluted tubule
B. Ascending loop of Henle
C. Glomerulus
D. Early distal convoluted tubule

Answer: Proximal convoluted tubule

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

2. She has severe headache and vomiting.

3. Her symptoms started after she was hiking in the mountains at high altitude.

4. She normally lives in a city that is close to sea level.

5. Therapy is initiated with a drug that alkalinizes the urine.

Emergency Medicine
Family Medicine
Internal Medicine

Neurocritical Care
Pulmonary Disease
Sports Medicine


Question: In addition to drawing her blood for viral serologies, which of the following is the most appropriate next step?

Context: A 35-year-old woman comes to employee health services 30 minutes after a work-related incident.

Context: She works as a phlebotomist and reports that blood splashed into her right eye when she was drawing blood from a 30-year-old male patient.

Context: He is an intravenous drug user and is sexually active with several male and female partners.

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

Context: Her immunizations are up-to-date.

Choices:
A. Start raltegravir, tenofovir, and emtricitabine
B. Start zidovudine
C. Start tenofovir and emtricitabine
D. Administer hepatitis B immune globulin and vaccine

Answer: Start raltegravir, tenofovir, and emtricitabine

1. A 35-year-old woman came to employee health services 30 minutes after a work-related incident.

3. Blood splashed into her right eye when she was drawing blood from a 30-year-old male patient.

4. Immediately following the incident, she flushed her eye with water for several minutes.

5. The patient from whom she drew blood was admitted for hemoptysis, weight loss, and night sweats.

7. He is sexually active with several male and female partners.

8. The phlebotomist has no history of serious illness.

11. Physical examination shows no abnormalities.


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

Context: A 65-year-old Asian woman comes to the physician for a routine health maintenance examination.

Context: On questioning, she has had occasional night sweats during the past 2 months.

Context: She has not had fevers or weight loss.

Context: Seven months ago, she had an acute myocardial infarction and was treated with percutaneous coronary intervention.

Context: She has hypertension, hyperlipidemia, and gastroesophageal reflux disease.

Context: She has smoked one pack of cigarettes daily for 37 years.

Context: Current medications include aspirin, atorvastatin, ramipril, metoprolol, and esomeprazole.

Context: She is 178 cm (5 ft 10 in) tall and weighs 89 kg (207 lbs); BMI is 29.7 kg/m2.

Context: Her temperature is 37.4°C (99.3°F), pulse is 84/min, respirations are 18/min, and blood pressure is 145/80 mm Hg.

Context: The lungs are clear to auscultation.

Context: Cardiac examination shows an S4.

Context: There is a nontender skin lesion near the right large toenail.

Context: A photograph of the lesion is shown.

Context: The remainder of the examination shows no abnormalities.

Choices:
A. Traumatic subungual hemorrhage
B. Malignant melanoma
C. Onychomycosis
D. Squamous cell carcinoma

Answer: Malignant melanoma

1. Patient is a 65-year-old Asian woman.

2. Patient has had occasional night sweats during the past 2 months.

3. Patient has not had fevers or weight loss.

4. Patient had an acute myocardial infarction 7 months ago and was treated with percutaneous coronary intervention.

5. Patient has hypertension, hyperlipidemia, and gastroesophageal reflux disease.

6. Patient has smoked one pack of cigarettes daily for 37 years.

7. Patient's current medications include aspirin, atorvastatin, ramipril, metoprolol, and esomeprazole.

8. Patient is 178 cm (5 ft 10 in) tall and weighs 89 kg (207 lbs); BMI is 29.7 kg/m2.

9. Patient's temperature is 37.4°C (99.3°F), pulse is 84/min, respirations are 18/min, and blood pressure is 145/80 mm Hg.

12. Patient has a nontender skin lesion near the right large toenail.

14. No other abnormalities found on examination.


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

Context: A 12-year-old girl brought to the clinic by her mother has a 3-day history of fever and sore throat and hematuria since this morning.

Context: The patient’s mother says she had a fever up to 39.5℃ (103.1℉) for the last 3 days and a severe sore throat, which has improved slightly.

Context: The mother states that she noticed her daughter had red urine today.

Context: The patient’s temperature is 39.3℃ (102.8℉), pulse is 89/min, respiratory rate is 25/min, and blood pressure is 109/69 mm Hg.

Context: On physical examination, her pharynx is erythematous.

Context: There is significant swelling of the tonsils bilaterally, and there is a white exudate covering them.

Context: A urine dipstick is performed and shows the following results: | Urine Dipstick | Specific Gravity 1.019 | Glucose None | Ketones None | Nitrites Negative | Leukocyte Esterase Negative | Protein None | Blood 3+ |  .

Choices:
A. Streptococcus pyogenes
B. Adenovirus
C. Escherichia coli O157:H7
D. Proteus mirabilis

Answer: Adenovirus

1. A 12-year-old girl was brought to the clinic by her mother.

2. The patient has a 3-day history of fever and sore throat.

3. The patient has had hematuria since this morning.

4. The patient's mother says the fever has been up to 39.5℃ (103.1℉) for the last 3 days.

5. The patient's mother says the sore throat has improved slightly.

6. The patient's mother noticed her daughter had red urine today.

7. The patient's temperature is 39.3℃ (102.8℉).

9. The patient's respiratory rate is 25/min.

10. The patient's blood pressure is 109/69 mm Hg.

11. On physical examination, the patient's pharynx is erythematous.

12. There is significant swelling of the tonsils bilaterally.

13. There is a white exudate covering the tonsils bilaterally.

14. Ophthalmologic examination reveals evidence of conjunctivitis bilaterally.

15. Otoscopic examination is significant for gray-white tympanic membranes bilaterally.

16. The remainder of the exam is unremarkable.

18. The urine dipstick showed a specific gravity of 1.019.

19. The urine dipstick showed no glucose.

20. The urine dipstick showed no ketones.

21. The urine dipstick showed negative nitrites.

22. The urine dipstick showed negative leukocyte esterase.

23. The urine dipstick showed no protein.

Pediatric Nephrology
Pediatric Infectious Diseases


Question: What physical finding would suggest involvement of the nerve in its course through the parotid gland?

Context: A 73-year-old woman with a past medical history of diabetes, hypertension, and hyperlipidemia presents to the emergency department with swelling in her left neck.

Context: The onset was a few months ago.

Context: She has lost 6.8 kg (15.0 lb) over the same duration.

Context: She denies any fever, night sweats or itching.

Context: Surgery is planned and the tumor is removed while trying to preserve a nerve that could be involved.

Choices:
A. Loss of taste on the left anterior 2/3 of the tongue
B. Hypersensitivity to sound in the left ear
C. Inability to smile on the left side
D. Numbness of the left cheek

Answer: Inability to smile on the left side

1. A 73-year-old woman presents to the emergency department with swelling in her left neck.

2. The onset of the swelling was a few months ago.

3. The woman has lost 6.8 kg (15.0 lb) over the same duration.

4. The woman denies any fever, night sweats or itching.

5. Physical examination reveals a painless swelling in front of her left ear.

6. There is painless lymphadenopathy below the ear.

7. Biopsy of the lymph nodes reveals mucoepidermoid carcinoma of the parotid gland.

8. Surgery is planned to remove the tumor while trying to preserve a nerve that could be involved.

9. The woman has a past medical history of diabetes, hypertension, and hyperlipidemia.


Question: Concurrent treatment with which of the following agents most likely predisposed the patient to this episode?

Context: A 43-year-old man is brought to the emergency department by his wife after a near-syncopal episode.

Context: Earlier in the day, he was started on lisinopril.

Context: On arrival, he is fully oriented.

Context: His pulse is 100/min and blood pressure is 92/60 mm Hg.

Context: Serum electrolytes are within normal limits.

Context: An ECG shows no evidence of ischemia.

Choices:
A. Ibuprofen
B. Hydrochlorothiazide
C. Lithium
D. Trimethoprim/sulfamethoxazole

Answer: Hydrochlorothiazide

1. A 43-year-old man is brought to the emergency department by his wife.

3. He was doing yard work when he began feeling dizzy and had to lie down.

4. He was started on lisinopril earlier in the day.

8. His serum electrolytes are within normal limits.

9. An ECG shows no evidence of ischemia.


Question: What additional diagnostic test would be helpful in establishing a diagnosis?

Context: A 4-year-old Caucasian girl previously diagnosed with asthma presents with recurrent sinusitis, otitis media, and clubbing of the nail bed.

Context: Family history is significant for a distant cousin with cystic fibrosis.

Context: A "sweat test" is performed and comes back normal.

Choices:
A. Nasal transepithelial potential difference
B. Skeletal survey
C. Complete blood cell count
D. Urinalysis

Answer: Nasal transepithelial potential difference

1. Patient is a 4-year-old Caucasian girl.

2. Patient has a previous diagnosis of asthma.

3. Patient presents with recurrent sinusitis.

5. Patient has clubbing of the nail bed.

6. Patient has a family history of a distant cousin with cystic fibrosis.


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

Context: She is sexually active and complains of dyspareunia.

Choices:
A. Anti-double stranded (Ds) DNA
B. HLA-B51
C. ANCA
D. HLA-B27

Answer: HLA-B51

1. A 35-year-old woman presents with a complaint of oral ulcers.

2. It is the third recurrence of ulcers in the last 8 months.

5. Examination shows the presence of a uveitis.


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

Context: A 22-year-old female software analyst presents to a medical clinic for evaluation of tingling and numbness in both hands for the past 2 months.

Context: Her symptoms are usually aggravated by the end of the work day and absent on most off days.

Context: She has been a type I diabetic for 2 years and is currently on insulin.

Context: She admits to being sexually active but has had irregular periods for the past 3 months.

Context: A urine pregnancy test is negative.

Choices:
A. Hypothyroidism
B. Acute intermittent porphyria
C. Amyotrophic lateral sclerosis
D. Multiple sclerosis

Answer: Hypothyroidism

1. A 22-year-old female software analyst presents to a medical clinic.

2. She has tingling and numbness in both hands for the past 2 months.

3. Her symptoms are usually aggravated by the end of the work day.

4. Her symptoms are absent on most off days.

5. She has been a type I diabetic for 2 years.

8. She has had irregular periods for the past 3 months.


Question: What is the normal function of the protein that is overexpressed due to the translocation seen in this patient?

Context: A 60-year-old male presents to his primary care physician complaining of fatigue.

Context: He reports a six-month history of gradually worsening tiredness.

Context: More recently, he has experienced intermittent fevers and night sweats.

Context: His temperature is 99.5°F (37.5°C), blood pressure is 115/80 mmHg, pulse is 80/min, and respirations are 18/min.

Context: A lymph node biopsy is performed and karyotypic analysis of the biopsy reveals an 11;14 translocation.

Choices:
A. Promote cell growth
B. Mediate cell cycle transition to mitosis
C. Mediate cell cycle transition to G2 phase
D. Mediate cell cycle transition to S phase

Answer: Mediate cell cycle transition to S phase

1. A 60-year-old male presents to his primary care physician.

3. He has a six-month history of gradually worsening tiredness.

4. He has experienced intermittent fevers and night sweats.

9. On examination, painless cervical lymphadenopathy is noted.

11. Karyotypic analysis of the biopsy reveals an 11;14 translocation.

Medical Genetics and Genomics
Internal Medicine

Molecular Genetic Pathology
Clinical Genetics and Genomics
Hematology


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

Context: An 8-year-old boy presents with abdominal pain and constipation.

Context: The patient’s mother says that the symptoms gradually onset 2 months ago.

Context: The patient describes the pain as moderate to severe, gnawing and diffusely localized.

Context: The patient lives in a house built in the 1990s with his parents and has a sister who goes to daycare.

Context: His mother mentioned that he is a good student but has been irritable lately, and his homework has been full of careless mistakes.

Context: The vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/65 mm Hg, pulse 82/min, respiratory rate 19/min, and oxygen saturation 99% on room air.

Context: On physical examination, the patient is alert and cooperative.

Context: The abdomen is diffusely tender to palpation with no rebound or guarding.

Context: There is a left wrist drop.

Context: A nontender, flat bluish line above the gums is noted.

Context: Laboratory results are significant for the following: | Sodium 141 mEq/L | Potassium 4.1 mEq/L | Chloride 101 mEq/L | Bicarbonate 25 mEq/L | Blood urea nitrogen (BUN) 27 mg/dL | Creatinine 1.7 mg/dL | Glucose (fasting) 80 mg/dL | White blood cell (WBC) count 8,700/mm3 | Red blood cell (RBC) count 4.20 x 106/mm3 | Hematocrit 41.5% | Hemoglobin 10.3 g/dL | Platelet count 190,000/mm3 | Mean corpuscular volume (MCV) 65 mm3 | Lead 72 mcg/dL.

Choices:
A. Chelation therapy with dimercaptosuccinic acid (succimer)
B. Chelation therapy with dimercaprol
C. Chelation therapy with dimercaprol and calcium disodium edetate (EDTA)
D. Plain abdominal radiographs

Answer: Chelation therapy with dimercaprol and calcium disodium edetate (EDTA)

2. Patient presents with abdominal pain and constipation.

3. Symptoms gradually onset 2 months ago.

4. Patient describes pain as moderate to severe, gnawing and diffusely localized.

5. No significant past medical history and no current medications.

6. Patient lives in a house built in the 1990s with his parents and has a sister who goes to daycare.

7. Patient is a good student but has been irritable lately, and his homework has been full of careless mistakes.

8. Vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/65 mm Hg, pulse 82/min, respiratory rate 19/min, and oxygen saturation 99% on room air.

9. Patient is alert and cooperative on physical examination.

10. Abdomen is diffusely tender to palpation with no rebound or guarding.

12. Nontender, flat bluish line above the gums is noted.

13. Laboratory results are significant for sodium 141 mEq/L, potassium 4.1 mEq/L, chloride 101 mEq/L, bicarbonate 25 mEq/L, BUN 27 mg/dL, creatinine 1.7 mg/dL, and glucose (fasting) 80 mg/dL, White blood cell (WBC) count 8,700/mm3, Red blood cell (RBC) count 4.20 x 106/mm3, Hematocrit 41.5%, Hemoglobin 10.3 g/dL, Platelet count 190,000/mm3, Mean corpuscular volume (MCV) 65 mm3, Lead 72 mcg/dL.


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

Context: Two days after undergoing a left total hip replacement, a 68-year-old man has increasing shortness of breath and chest pain for 30 minutes.

Context: He has type 2 diabetes mellitus and bilateral osteoarthritis of the hips.

Context: Prior to admission to the hospital, his medications were metformin and naproxen.

Context: His temperature is 37.8°C (100°F), pulse is 110/min, respirations are 30/min, and blood pressure is 106/70 mm Hg.

Context: The lungs are clear to auscultation.

Context: The right lower extremity is swollen.

Context: Pedal pulses are palpable.

Context: His hematocrit is 30%.

Context: Arterial blood gas analysis on room air shows: | pH 7.48 | pCO2 27 mm Hg | pO2 68 mm Hg | HCO3- 23 mEq/L | An electrocardiogram shows sinus tachycardia and right axis deviation.

Choices:
A. Administer alteplase
B. Obtain a spiral CT angiogram
C. Obtain an x-ray of the chest
D. Perfom an echocardiography

Answer: Obtain a spiral CT angiogram

2. Patient has type 2 diabetes mellitus and bilateral osteoarthritis of the hips.

3. Patient's medications prior to admission were metformin and naproxen.

4. Patient's temperature is 37.8°C (100°F).

7. Patient's blood pressure is 106/70 mm Hg.

8. Pulse oximetry on room air shows an oxygen saturation of 89%.

10. Cardiac examination shows no abnormalities.

12. Right foot flexion in an upward direction causes pain in the right calf.

14. Supplemental oxygen and intravenous fluid resuscitation are begun.

16. Arterial blood gas analysis on room air shows: pH 7.48, pCO2 27 mm Hg, pO2 68 mm Hg, HCO3- 23 mEq/L.

17. An electrocardiogram shows sinus tachycardia and right axis deviation.

18. Patient has increasing shortness of breath and chest pain for 30 minutes, two days after undergoing a left total hip replacement.


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

Context: An 11-month-old male presents to the emergency department with his father after “passing out” at home.

Context: The patient’s temperature is 98.5°F (36.9°C), blood pressure is 86/64 mmHg, pulse is 98/min, and respirations are 26/min.

Choices:
A. Arterial blood gas
B. Echocardiogram
C. Electrocardiogram (ECG)
D. Observation and reassurance

Answer: Observation and reassurance

1. An 11-month-old male presents to the emergency department with his father.

2. His father reports that the patient started crying after his older brother took a toy away from him.

3. The patient was difficult to soothe and then suddenly stopped breathing.

4. His father reports that his lips turned slightly blue, and the patient’s entire body became limp.

5. The episode lasted a few seconds, and the patient seemed to act normally afterwards.

6. The patient’s father notes that the patient’s older brother had similar episodes as a child.

7. He denies any family history of neurological disease.

8. The patient’s temperature is 98.5°F (36.9°C).

9. The patient's blood pressure is 86/64 mmHg.

11. The patient's respirations are 26/min.

12. On physical exam, the patient is in no acute distress playing on his father’s lap.

13. The patient's neurological exam is unremarkable.


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

Choices:
A. Gonococcal arthritis
B. Parvovirus B19
C. Rheumatoid arthritis
D. Transient synovitis

Answer: Parvovirus B19

1. A 27-year-old woman presents to the emergency department for pain in multiple joints.

2. She states that she has had symmetric joint pain that started yesterday and has been worsening.

3. It is affecting her wrists, elbows, and shoulders.

4. She also endorses a subjective fever and some fatigue but denies any other symptoms.

5. The patient works as a schoolteacher and is generally healthy.

6. She is currently sexually active with 2 male partners and uses condoms occasionally.

7. Her temperature is 100°F (37.8°C), blood pressure is 122/85 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air.

8. Her laboratory values are within normal limits.

9. Physical exam is notable for joint stiffness and pain in particular of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and the wrist.

10. The patient is discharged with ibuprofen.

11. Four weeks later, the patient follows up at her primary doctor and notes that her symptoms have improved and she is no longer taking any medications for symptom control.


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

Context: A 57-year-old man with HIV and GERD comes to the emergency department because of productive cough with malodorous phlegm and night sweats for the past week.

Context: He has smoked 1 pack of cigarettes daily for 30 years and he drinks 8–10 beers daily.

Context: His temperature is 38.9°C (102.0°F).

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

Choices:
A. Bronchiectasis
B. Adenocarcinoma in situ
C. Tuberculosis
D. Aspiration pneumonia

Answer: Aspiration pneumonia

1. A 57-year-old man with HIV and GERD comes to the emergency department.

2. He has had productive cough with malodorous phlegm and night sweats for the past week.

3. He has smoked 1 pack of cigarettes daily for 30 years.

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

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

8. The CD4+ T-lymphocyte count is 280/mm3 (N ≥ 500).


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

Context: A 20-year-old woman is brought to the emergency department by her boyfriend for right arm and leg weakness, numbness, and tingling that has been resolving gradually.

Context: The symptoms started 4 hours ago after she had an argument with her boyfriend during which she slapped and kicked him.

Context: She says she has been limping and cannot use her right arm anymore.

Context: She has never had similar symptoms in the past.

Context: She has a history of genital herpes and trichotillomania.

Context: She is alert and oriented.

Context: She has 5/5 strength in all extremities and 5/5 right ankle plantar flexion when lying down.

Context: She has 4/5 strength in the right arm and leg when ambulating.

Context: She cannot stand on her toes when asked.

Context: Her deep tendon reflexes are 2+ bilaterally.

Context: She has normal proprioception, light touch sensation, and two-point discrimination in all extremities.

Context: She has a negative Spurling test.

Choices:
A. Administer alteplase
B. Provide patient education
C. Prescribe aspirin
D.
Start biofeedback therapy
"

Answer: Provide patient education

2. Patient was brought to the emergency department by her boyfriend.

3. Patient has right arm and leg weakness, numbness, and tingling.

4. Symptoms have been resolving gradually.

5. Symptoms started 4 hours ago after an argument with her boyfriend during which she slapped and kicked him.

6. Patient has been limping and cannot use her right arm.

7. Patient has never had similar symptoms in the past.

8. Patient has a history of genital herpes and trichotillomania.

10. Physical examination shows upper and lower face symmetry and normal speech.

11. Patient has 5/5 strength in all extremities and 5/5 right ankle plantar flexion when lying down.

12. Patient has 4/5 strength in the right arm and leg when ambulating.

13. Patient cannot stand on her toes when asked.

14. Patient has 2+ deep tendon reflexes bilaterally.

15. Patient has normal proprioception, light touch sensation, and two-point discrimination in all extremities.

16. Patient has a negative Spurling test.

17. CT of the head without contrast shows no abnormalities.


Question: Which of the following best describes the feelings that the psychiatrist has for the patient?

Context: A 14-year-old female presents to her psychiatrist in hopes that she can find help in dealing with the sexual abuse that occurred in her childhood.

Context: While retelling her story of the numerous encounters the patient had with her abuser, the psychiatrist begins to feel protective and parental towards the client, wishing that he could have somehow helped the young girl.

Choices:
A. Countertransference
B. Identification
C. Sublimation
D. Projection

Answer: Countertransference

1. A 14-year-old female presents to her psychiatrist.

2. The patient is seeking help in dealing with sexual abuse that occurred in her childhood.

3. The patient is retelling her story of numerous encounters with her abuser.

4. The psychiatrist begins to feel protective and parental towards the client.

5. The psychiatrist wishes he could have somehow helped the young girl.


Question: Which of the following trinucleotide DNA sequences would initiate protein translation when converted to mRNA? | Note: sequences are written 3'-->5'

Choices:
A. TAC
B. ATC
C. ATT
D. AAA

Answer: TAC

General Medical Genetics and Genomics
Molecular Genetic Pathology


Question: Which side-effect is associated with the drug of choice for the treatment of this patient’s condition?

Context: A 47-year-old woman visits the emergency department due to painful, swollen fingers in both of her hands.

Context: She reports that she has lost weight in the last 2 months although there have been no changes in her diet.

Context: She also says that she generally feels fatigued all day.

Context: On examination, nodules are seen over her Achilles tendon and both wrists are erythematous, swollen, and tender to touch.

Context: Laboratory tests are presented below: | Hemoglobin: 11.0 g/dL | Hematocrit: 40.5% | Leukocyte count: 7400/mm3 | Mean corpuscular volume: 80.1 μm3 | Platelet count: 210,000/mm3 | Erythrocyte sedimentation rate: 55 mm/h | Anti-cyclic citrullinated peptide antibody: 45 (Normal reference values: < 20) | .

Choices:
A. Retinopathy
B. Arterial hypertension
C. Pneumonitis
D. Reactivation of latent tuberculosis

Answer: Pneumonitis

1. A 47-year-old woman visits the emergency department.

2. She has painful, swollen fingers in both of her hands.

3. She has worked as a bus driver for the county school system for the last 20 years.

4. Her past medical history is significant for a transient ischemic attack 5 years ago.

5. She reports that she has lost weight in the last 2 months.

6. There have been no changes in her diet.

7. She generally feels fatigued all day.

8. On examination, nodules are seen over her Achilles tendon.

9. Both wrists are erythematous, swollen, and tender to touch.

15. Erythrocyte sedimentation rate: 55 mm/h

16. Anti-cyclic citrullinated peptide antibody: 45 (Normal reference values: < 20)


Question: The patient was most likely treated with an antibiotic that binds to which of the following?

Context: Before the next dose with the same agent, the patient is given diphenhydramine and ranitidine and the antibiotic is subsequently given at a slower infusion rate without complications.

Choices:
A. Transpeptidase
B. Topoisomerase II
C. Dihydrofolate reductase
D. D-alanyl-D-alanine

Answer: D-alanyl-D-alanine

1. A 37-year-old man comes to the emergency room with fever, chills, and left lower leg pain for 2 days.

2. He was recently discharged from the hospital after arthroscopic knee surgery.

3. Physical examination shows an erythematous lesion with poorly defined margins over the left shin but no fluctuance.

4. Treatment with an intravenous antibiotic is begun.

5. Shortly after starting the infusion, the patient develops flushing, erythema, and pruritus of the upper body.

6. The symptoms resolve after discontinuation of the infusion.

7. Before the next dose with the same agent, the patient is given diphenhydramine and ranitidine.

8. The antibiotic is subsequently given at a slower infusion rate without complications.


Question: Which of the following pathologies most likely underlies this patient’s condition?

Context: A 55-year-old man presents with worsening weakness of the left hand and progressive difficulty in walking for the last 2 months.

Context: He says he was previously healthy and active, hiking every weekend, but because of his increasing weakness and incoordination while walking, he stopped his weekly hiking excursion.

Context: His past medical history is unremarkable.

Context: Current medications are a daily multivitamin and occasional acetaminophen for headaches.

Context: He has no significant family history.

Context: The patient denies smoking, recreational drug use, or drinking.

Context: His vitals include: pulse 70/min, respirations 14/min, temperature 37.0°C (98.6°F), and blood pressure 130/80 mm Hg.

Context: The left forearm shows significant atrophy, and mild lower limb muscle atrophy is also seen bilaterally.

Context: Hyporeflexia (1+) is present in the left arm, while hyperreflexia (3+) is seen in the legs bilaterally.

Context: The patient's speech is notably slow but no evidence of productive or expressive aphasia is present.

Context: The cranial nerves are intact.

Choices:
A. Demyelination of neurons in various parts of the brain
B. Degeneration of the dorsal columns of the spinal cord
C. Infarction of the posterior limb of the internal capsule
D. Loss of the pyramidal tract neurons and anterior horn cells of the spinal cord

Answer: Loss of the pyramidal tract neurons and anterior horn cells of the spinal cord

2. Patient has been experiencing worsening weakness of the left hand and progressive difficulty in walking for the last 2 months.

3. Patient was previously healthy and active, hiking every weekend.

4. Patient stopped his weekly hiking excursion due to increasing weakness and incoordination while walking.

5. Patient's past medical history is unremarkable.

6. Patient's current medications are a daily multivitamin and occasional acetaminophen for headaches.

7. Patient has no significant family history.

8. Patient denies smoking, recreational drug use, or drinking.

9. Patient's vitals include: pulse 70/min, respirations 14/min, temperature 37.0°C (98.6°F), and blood pressure 130/80 mm Hg.

10. Physical examination reveals fasciculations in the tongue and distal extremities.

11. Left forearm shows significant atrophy.

12. Mild lower limb muscle atrophy is seen bilaterally.

13. Hyporeflexia (1+) is present in the left arm.

14. Hyperreflexia (3+) is seen in the legs bilaterally.

15. Babinski’s sign is positive bilaterally.

17. No evidence of productive or expressive aphasia is present.

Degeneration of the dorsal columns of the spinal cord


Question: Which of the following best describes the likely causal virus of this patient’s symptoms?

Context: A 14-year-old male who is a recent immigrant from India visits your office complaining of difficulty walking.

Context: Physical examination reveals weakness upon right leg extension and absent right patellar tendon reflex.

Context: PCR of a stool sample and a swab of the pharynx both yield viral RNA.

Choices:
A. Non-enveloped, positive stranded, icosahedral virus
B. Enveloped, positive stranded, icosahedral virus
C. Enveloped, negative stranded, helical virus
D. Non-enveloped, negative stranded, helical virus

Answer: Non-enveloped, positive stranded, icosahedral virus

2. Patient is a recent immigrant from India.

3. Patient is visiting office complaining of difficulty walking.

4. Physical examination reveals weakness upon right leg extension.

5. Physical examination reveals absent right patellar tendon reflex.

6. PCR of a stool sample yields viral RNA.

7. PCR of a swab of the pharynx yields viral RNA.

Neurology with Special Qualification in Child Neurology


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

Context: A 21-year-old woman is brought to the emergency department because of the sudden onset of left-sided back pain with radiation to the groin that began 2 hours ago.

Context: Her pulse is 103/min.

Context: Leukocyte count is 11,000/mm3.

Context: Urine dipstick is positive for blood and a urinary cyanide nitroprusside test is positive.

Choices:
A. pH of 7.8
B. Urease-producing bacteria
C. High uric acid concentration
D. Hexagon-shaped crystals

Answer: Hexagon-shaped crystals

1. A 21-year-old woman is brought to the emergency department.

2. She has sudden onset of left-sided back pain with radiation to the groin that began 2 hours ago.

3. She has had similar episodes in the past.

5. Examination shows a soft and non-tender abdomen.

6. Left costovertebral angle tenderness is present.

8. Urine dipstick is positive for blood.

9. Urinary cyanide nitroprusside test is positive.

10. An x-ray of the abdomen shows no abnormalities.


Question: What will be most helpful in diagnosing sequelae resulting from the patient’s underlying condition?

Context: The pain is dull and constant.

Context: Over the past 2 weeks, he has also gained 3 kg (7 lb) and his shoes feel tight.

Context: He denies a history of any chronic medical conditions, recent abdominal trauma or illness, and has never noticed blood in his urine before.

Context: In the hospital, his temperature is 36.8°C (98.2°F), the heart rate is 98/min, the respiratory rate is 15/min, and the blood pressure is 135/85 mm Hg.

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

Context: He has 2+ pitting edema in both legs up to the knee and his hands appear edematous.

Choices:
A. CT angiogram with contrast
B. Non-contrast CT
C. Cystoscopy
D. Renal biopsy

Answer: CT angiogram with contrast

1. A 45-year-old man presents to the emergency department with sudden left lower back pain and bloody urine.

3. He can not localize exactly where it is.

4. Over the past 2 weeks, he has also gained 3 kg (7 lb).

6. He denies a history of any chronic medical conditions.

7. He denies a history of recent abdominal trauma or illness.

8. He has never noticed blood in his urine before.

9. In the hospital, his temperature is 36.8°C (98.2°F).

13. A review of medical records shows that his blood pressure was 115/75 mm Hg 6 months ago.

14. On physical exam, he appears distressed.

15. There are bruises on his left upper arm, chest, and right thigh.

16. The patient does not remember when he got them.

17. His heart has a regular rate and rhythm.

18. His lungs are clear to auscultation bilaterally.

19. He has 2+ pitting edema in both legs up to the knee.

21. A urine dipstick shows 3+ blood and 4+ protein.

22. Additional specimens are sent to chemistry for analysis.


Question: The difference in the level of severity of this disorder among family members in best explained by which of the following?

Context: A 21-year-old man visits his primary care provider complaining of visual disturbance in both eyes for a month and an episode of abnormal uncontrollable shaking that occurred twice last week.

Context: His mother has intermittent muscle weakness and his maternal uncle developed hemiplegia at the age of 35.

Context: Neuroimaging shows bilateral occipital lobe infarcts and a skeletal muscle biopsy reveals atypical muscle fibers that stain positive for subsarcomelar structures.

Choices:
A. Heteroplasmy
B. Mosaicism
C. Anticipation
D. Uniparental disomy

Answer: Heteroplasmy

1. A 21-year-old man visits his primary care provider.

2. He is complaining of visual disturbance in both eyes for a month.

3. He also had an episode of abnormal uncontrollable shaking that occurred twice last week.

4. He was previously healthy and did not take any medication.

5. His mother has intermittent muscle weakness.

6. His maternal uncle developed hemiplegia at the age of 35.

7. Neuroimaging shows bilateral occipital lobe infarcts.

8. A skeletal muscle biopsy reveals atypical muscle fibers that stain positive for subsarcomelar structures.

9. The physician suspects a maternally inherited genetic disorder.


Question: How would you describe the data shown below?

Context: Your hospital administrators want to provide you with a tool to analyze the usage of emergency department visits by patients in your high-risk practice.

Context: The following graph is displayed on the dashboard of your electronic medical record to show you how often your patients utilize the ED so that you can provide higher quality and more cost-effective care.

Context: The X-axis indicates the number of times a patient has been to the ED in the last year.

Context: The Y-axis indicates the number of patients who fit into that category.

Choices:
A. It is positively-skewed, with mean > median > mode.
B. It is positively-skewed, with mode > median > mean.
C. It is positively-skewed, with median > mode > mean.
D. It is negatively-skewed, with mode > median > mean.

Answer: It is positively-skewed, with mean > median > mode.

1. Hospital administrators want to provide a tool to analyze emergency department visits by patients in a high-risk practice.

2. The dashboard of the electronic medical record displays a graph to show how often patients utilize the ED.

3. The X-axis of the graph indicates the number of times a patient has been to the ED in the last year.

4. The Y-axis of the graph indicates the number of patients who fit into that category.

Health Care Administration, Leadership, and Management


Question: Which of the following findings would most likely be abnormal during pregnancy?

Context: A 27-year-old G1P0000 at 17 weeks of gestation is interested in participating in a clinical trial for nausea management during pregnancy.

Context: Prior to enrolling in the trial, the investigators explain to the patient that they will be doing a full exam and some special testing to make sure she is experiencing a healthy pregnancy.

Choices:
A. Hypertension
B. Increased cardiac output
C. Increase in factor VII
D. Respiratory alkalosis

Answer: Hypertension

1. A 27-year-old G1P0000 is interested in participating in a clinical trial.

2. The clinical trial is for nausea management during pregnancy.

3. The trial will be evaluating the effects of moderate ginger consumption on nausea symptoms.

4. The patient is 17 weeks of gestation.

5. Prior to enrolling in the trial, the investigators explain to the patient that they will be doing a full exam.

6. Prior to enrolling in the trial, the investigators explain to the patient that they will be doing some special testing.

7. The special testing is to make sure the patient is experiencing a healthy pregnancy.


Question: Which of the following is most consistent with their son's symptoms?

Context: A 14-year-old Caucasian male of normal weight presents for a well-child checkup.

Context: During physical examination, his parents state that their son has been frequenting the bathroom more often than usual and his weight has decreased despite an increase in his caloric intake.

Choices:
A. Self-reactive T-cells
B. Amyloid deposits in pancreatic islet cells
C. Absence of leukocytic infiltrates in the pancreas
D. Hypoglycemia

Answer: Self-reactive T-cells

1. A 14-year-old Caucasian male is presenting for a well-child checkup.

3. His parents state he has been frequenting the bathroom more often than usual.

Pediatric Endocrinology
General Pediatrics


Question: Which of the following findings would you most likely expect to be reported in the ultrasound?

Context: A 56-year-old woman with a history of stage IIA cervical cancer presents to your office after her 5th episode of a complicated urinary tract infection.

Context: She complains of easy fatigability, weakness, and has noted that her shoes no longer fit.

Context: Given the patient’s medical history, the specialist makes a stage IIIB diagnosis; however, to confirm this, he orders abdominal and transvaginal ultrasounds and renal function tests.

Choices:
A. Bladder or rectum mucosa invasion
B. Distant metastasis
C. Parametrial invasion by cancer
D. Hydronephrosis

Answer: Hydronephrosis

1. A 56-year-old woman presents to the office.

2. She has a history of stage IIA cervical cancer.

3. She has had 5 episodes of a complicated urinary tract infection.

4. She complains of easy fatigability and weakness.

6. The physical examination is unremarkable, except for a blood pressure of 165/90 mm Hg and mild pitting lower extremity edema.

7. The rectovaginal exam revealed no masses.

8. The specialist makes a stage IIIB diagnosis.

9. To confirm this, he orders abdominal and transvaginal ultrasounds.

10. He also orders renal function tests.


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

Context: A 77-year-old man is brought to the physician because of a 2-day history of increasing shortness of breath and ankle swelling.

Context: He has type 2 diabetes mellitus, hypertension, coronary artery disease, and congestive heart failure.

Context: Current medications include lisinopril, metformin, and aspirin.

Context: He has smoked half a pack of cigarettes daily for 50 years.

Context: His temperature is 37.2°C (98.9°F), pulse is 100/min and regular, respirations are 20/min, and blood pressure is 100/65 mm Hg.

Context: There are jugular venous pulsations 5 cm above the sternal angle.

Context: Crackles are heard at both lung bases.

Context: Cardiac examination shows an S3 gallop.

Context: There is edema from the mid-tibia to the ankle bilaterally.

Context: Laboratory studies show: | Hemoglobin 14.1 g/dL | Leukocyte count 7100/mm3 | Serum | Na+ 129 mEq/L | Cl- 99 mEq/L | K+ 4.8 mEq/L | Urea nitrogen 48 mg/dL | Glucose 196 mg/dL | Creatinine 2.1 mg/dL | .

Choices:
A. Discontinue metformin therapy
B. Begin vancomycin therapy
C. Begin nitroprusside therapy
D. Begin hydrochlorothiazide therapy

Answer: Discontinue metformin therapy

2. Patient has 2-day history of increasing shortness of breath and ankle swelling.

3. Patient has type 2 diabetes mellitus, hypertension, coronary artery disease, and congestive heart failure.

4. Patient is taking lisinopril, metformin, and aspirin.

5. Patient has smoked half a pack of cigarettes daily for 50 years.

6. Patient's temperature is 37.2°C (98.9°F).

7. Patient's pulse is 100/min and regular.

9. Patient's blood pressure is 100/65 mm Hg.

10. Pulse oximetry on room air shows an oxygen saturation of 91%.

11. Jugular venous pulsations 5 cm above the sternal angle.

12. Crackles are heard at both lung bases.

13. Cardiac examination shows an S3 gallop.

14. Patient has edema from the mid-tibia to the ankle bilaterally.

15. Laboratory studies show hemoglobin 14.1 g/dL.

16. Laboratory studies show leukocyte count 7100/mm3.

17. Laboratory studies show serum Na+ 129 mEq/L.

18. Laboratory studies show Cl- 99 mEq/L.

19. Laboratory studies show K+ 4.8 mEq/L.

20. Laboratory studies show urea nitrogen 48 mg/dL.

21. Laboratory studies show glucose 196 mg/dL.

22. Laboratory studies show creatinine 2.1 mg/dL.


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

Context: A 32-year-old woman, gravida 2, para 1, at 40 weeks' gestation is admitted to the hospital 30 minutes after spontaneous rupture of membranes without labor pains.

Context: Pregnancy was complicated by hypothyroidism.

Context: Medications include levothyroxine and a multivitamin.

Context: Her pulse is 90/min, respirations are 16/min, and blood pressure is 134/76 mm Hg.

Context: A cardiotocography reading is shown.

Choices:
A. Umbilical cord compression
B. Fetal head compression
C. Uteroplacental insufficiency
D. Fetal CNS depression

Answer: Umbilical cord compression

1. A 32-year-old woman is admitted to the hospital.

4. She experienced spontaneous rupture of membranes 30 minutes prior to admission.

6. She delivered her first child vaginally at 38 weeks' gestation.

7. Her pregnancy was complicated by hypothyroidism.

8. She has no other history of serious illness.

9. Her medications include levothyroxine and a multivitamin.

13. Pelvic examination shows a uterus consistent in size with a 40 week gestation.

14. A cardiotocography reading is shown.


Question: WBC 38,000/mm3 | RBC 4.20 x 106/mm3 | Hematocrit 27.3% | Hemoglobin 8.3 g/dL | Platelet count 355,000/mm3 | A peripheral blood smear and differential shows 92% small normocytic lymphocytes. | Which of the following is the most likely diagnosis in this patient?

Context: He currently has no complaints, and his last physical and laboratory studies were unremarkable.

Context: His past medical history is significant for hypercholesterolemia, well managed with rosuvastatin, and hypertension, well managed with hydrochlorothiazide.

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

Context: Laboratory findings are significant for the following: | .

Choices:
A. Acute myelogenous leukemia
B. Chronic myelogenous leukemia
C. Chronic lymphocytic leukemia
D. Asymptomatic multiple myeloma

Answer: Chronic lymphocytic leukemia

1. A 55-year-old man presents for a routine check-up.

3. His last physical and laboratory studies were unremarkable.

4. His past medical history is significant for hypercholesterolemia.

5. Hypercholesterolemia is well managed with rosuvastatin.

6. His past medical history is also significant for hypertension.

7. Hypertension is well managed with hydrochlorothiazide.

8. His current medications also include aspirin.

10. His vital signs are within normal limits.

11. Physical examination reveals some generalized lymphadenopathy.

12. Laboratory findings are significant for the following.


Question: What is the next step in management?

Context: A 72-year-old man with a history of diabetes, dyslipidemia, and hypertension presents to the emergency department with sudden-onset right-sided facial paresthesia, word-finding difficulty, and lightheadedness.

Context: He was at a restaurant, in general good health, enjoying a dinner with friends when the 1st symptoms started.

Context: He takes atorvastatin, lisinopril, hydrochlorothiazide, and a multivitamin every day.

Context: A review of symptoms was negative.

Context: His symptoms spontaneously resolved after 5 minutes.

Context: In the emergency department, the vital signs included: blood pressure of 132/80 mm Hg, heart rate of 86/min, respiratory rate of 20/min, and oxygen saturation of 99% on room air.

Context: The laboratory results included: | Hemoglobin 11.3 g/dL | Hematocrit 33% | WBC count 9,800/mm3 | Platelet count 247,000/mm3 | International normalized ratio (INR) 1.1 | Prothrombin time (PT) 11.5 seconds | Partial thromboplastin time (PTT) 32 seconds | His electrocardiogram (ECG) and his head computed tomography (CT) scan were normal.

Context: A duplex ultrasound scan shows 70–89% stenosis in the left carotid artery and 50% in the right.

Context: A brain magnetic resonance imaging (MRI) scan was negative for areas of ischemia or intracranial hemorrhage.

Context: His symptom recurrence prompted his hospital admission for inpatient care.

Choices:
A. Enoxaparin
B. Thrombolysis
C. Carotid endarterectomy
D. Carotid artery stenting

Answer: Carotid endarterectomy

2. Patient has a history of diabetes, dyslipidemia, and hypertension.

3. Patient presented to the emergency department with sudden-onset right-sided facial paresthesia, word-finding difficulty, and lightheadedness.

4. Patient was at a restaurant, in general good health, enjoying a dinner with friends when the 1st symptoms started.

5. Patient takes atorvastatin, lisinopril, hydrochlorothiazide, and a multivitamin every day.

7. Symptoms spontaneously resolved after 5 minutes.

8. Vital signs included: blood pressure of 132/80 mm Hg, heart rate of 86/min, respiratory rate of 20/min, and oxygen saturation of 99% on room air.

9. Laboratory results included: Hemoglobin 11.3 g/dL, Hematocrit 33%, WBC count 9,800/mm3, Platelet count 247,000/mm3, International normalized ratio (INR) 1.1, Prothrombin time (PT) 11.5 seconds, Partial thromboplastin time (PTT) 32 seconds.

10. Electrocardiogram (ECG) and head computed tomography (CT) scan were normal.

11. Duplex ultrasound scan shows 70–89% stenosis in the left carotid artery and 50% in the right.

12. In the course of evaluation, his aphasia recurred for 3 minutes.

13. Brain magnetic resonance imaging (MRI) scan was negative for areas of ischemia or intracranial hemorrhage.

14. Symptom recurrence prompted his hospital admission for inpatient care.


Question: Which of the following is the best 1st step in this patient’s management?

Context: A 70-year-old woman visits her physician complaining of dry mouth and dry eyes.

Context: She states that she has recently been having difficulty wearing her dentures on account of her dry mouth.

Context: She also says that her tongue sticks to the roof of her mouth, making it difficult to speak and swallow food.

Context: Her eyes have also been burning, and she has had to use over the counter eye drops much more often.

Context: On physical exam, mild bilateral enlargement of the parotid glands was noted, and an intraoral examination revealed a red, dry, and smooth mucosal surface on the dorsum of the tongue and buccal mucosa.

Context: The patient has a history of hypertension, for which she takes lisinopril.

Choices:
A. Administer prednisone
B. Obtain an electrocardiogram (ECG)
C. Perform a Schirmer test and obtain anti-Ro/anti-La titers
D. Perform a parotid gland biopsy

Answer: Perform a Schirmer test and obtain anti-Ro/anti-La titers

1. A 70-year-old woman visits her physician.

2. She is complaining of dry mouth and dry eyes.

3. She has difficulty wearing her dentures due to her dry mouth.

4. Her tongue sticks to the roof of her mouth, making it difficult to speak and swallow food.

5. Her eyes have been burning and she has been using over the counter eye drops more often.

6. These symptoms have persisted for several months.

7. On physical exam, mild bilateral enlargement of the parotid glands was noted.

8. An intraoral examination revealed a red, dry, and smooth mucosal surface on the dorsum of the tongue and buccal mucosa.

9. The patient has a history of hypertension.

10. She takes lisinopril for her hypertension.


Question: This patient most likely has elevated levels of which of the following?

Context: A 61-year old obese nulliparous female presents to your office with right lower quadrant abdominal pain.

Context: Her medical history is significant for breast cancer and past use of postmenopausal estrogen replacement therapy.

Choices:
A. hCG
B. AFP
C. CA 19-9
D. CA 125

Answer: CA 125

1. A 61-year old female presents to your office.

4. The female has right lower quadrant abdominal pain.

5. The female has a medical history of breast cancer.

6. The female has a history of past use of postmenopausal estrogen replacement therapy.

General Obstetrics and Gynecology
General Surgery


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

Context: A 28-year-old man comes to the physician because of a swollen, tender left knee for the past 4 days.

Context: During this period, the patient has had pain with urination.

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

Context: He is sexually active with two male partners and they use condoms inconsistently.

Context: His older sister has systemic lupus erythematosus.

Context: He is 180 cm (5 ft 11 in) tall and weighs 98 kg (216 lb); BMI is 30.1 kg/m2.

Context: His temperature is 37°C (98.6°F), pulse is 83/min, and blood pressure is 140/75 mm Hg.

Context: Examination shows conjunctivitis bilaterally.

Context: The left knee is warm, erythematous, and tender to touch; range of motion is limited.

Context: Urinanalysis shows WBCs.

Choices:
A. HLA-B27 positive genotype
B. Hiking trip two months ago
C. Positive anti-dsDNA antibodies
D. Intravenous drug use

Answer: HLA-B27 positive genotype

2. Patient has had a swollen, tender left knee for the past 4 days.

3. Patient has had pain with urination during this period.

4. Patient has no history of serious illness and takes no medications.

5. Patient is sexually active with two male partners and they use condoms inconsistently.

6. Patient's older sister has systemic lupus erythematosus.

8. Patient weighs 98 kg (216 lb); BMI is 30.1 kg/m2.

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

11. Patient's blood pressure is 140/75 mm Hg.

12. Patient has conjunctivitis bilaterally.

13. Patient's left knee is warm, erythematous, and tender to touch.

14. Patient's range of motion is limited.

15. Laboratory studies show an erythrocyte sedimentation rate of 62 mm/h.


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

Context: He says, “My teammates never understand how important it is to do things the right way.” Ever since high school, he has used the majority of his time to plan out assignments and does not have time to regularly participate in social activities.

Choices:
A. Obsessive-compulsive personality disorder
B. Obsessive-compulsive disorder
C. Schizoid personality disorder
D.
Adjustment disorder with mixed anxiety and depressed mood
"

Answer: Obsessive-compulsive personality disorder

1. A 21-year-old man comes to the physician because of nervousness and difficulty sleeping over the past 2 weeks.

2. Three months ago, he started a new team project at his job.

3. He says that he has trouble falling asleep at night because he thinks about the project.

4. He insists on checking the work of his teammates and spends several hours each week making elaborate lists and schedules.

5. He refuses to let others take on more tasks because he thinks that only he can complete them satisfactorily.

6. The project deadline has already been postponed once.

7. He says, “My teammates never understand how important it is to do things the right way.”

8. Ever since high school, he has used the majority of his time to plan out assignments.

9. He does not have time to regularly participate in social activities.


Question: Which of the following drugs is most likely to be effective as a preventive therapy in this patient?

Context: He says the episodes are short-lived (usually lasting for a few seconds to 3-4 minutes), and he describes them as a severe throbbing orbital headache, accompanied by ipsilateral conjunctival injection and lacrimation.

Context: He says that often the episodes seem to be triggered by a cutaneous stimulus touching the face or while chewing food.

Context: Sometimes, he says he experiences countless attacks during a single day.

Context: The headaches do not respond to indomethacin and any other non-steroidal anti-inflammatory drug (NSAID).

Choices:
A. Ibuprofen
B. Acetaminophen
C. Lamotrigine
D. Amitriptyline

Answer: Lamotrigine

1. A 52-years-old man presents with a history of recurrent episodes of unilateral headaches.

2. The episodes are short-lived, usually lasting for a few seconds to 3-4 minutes.

3. He describes them as a severe throbbing orbital headache.

4. The headaches are accompanied by ipsilateral conjunctival injection and lacrimation.

5. The episodes seem to be triggered by a cutaneous stimulus touching the face or while chewing food.

6. Sometimes, he experiences countless attacks during a single day.

7. The headaches do not respond to indomethacin.

8. The headaches do not respond to any other non-steroidal anti-inflammatory drug (NSAID).


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

Context: A 55-year-old obese man presents to the emergency department with abdominal pain.

Context: His temperature is 101.0°F (38.3°C), blood pressure is 157/98 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Context: Physical exam is notable for left lower quadrant abdominal tenderness and rectal exam is unremarkable.

Context: A CT scan is performed demonstrating inflamed outpouchings of the colonic mucosa with a 4-cm abscess.

Choices:
A. Ciprofloxacin and gentamicin
B. CT-guided percutaneous drainage
C. Laparoscopy and drainage
D. Piperacillin-tazobactam and vancomycin

Answer: CT-guided percutaneous drainage

1. A 55-year-old man presents to the emergency department with abdominal pain.

2. His pain started 2 days ago and has been worsening steadily.

3. His only current medication is allopurinol.

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

9. Physical exam is notable for left lower quadrant abdominal tenderness.

12. CT scan demonstrates inflamed outpouchings of the colonic mucosa.

13. CT scan demonstrates a 4-cm abscess.


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

Context: A 32-year-old G2P2 woman gives birth to a boy at 39 weeks gestation.

Context: The mother recently immigrated from Somalia and had no prenatal care.

Context: She refused all intrapartum medications.

Context: The boy’s Apgar scores were 7 and 9 at 1 and 5 minutes, respectively.

Context: His height and weight were in the 20th and 15th percentiles, respectively.

Context: However, 7 days later, the mother presents to the pediatrician because she noticed redness and discharge in her baby's eyes.

Context: His temperature is 98.8°F (37.1°C), blood pressure is 105/65 mmHg, pulse is 120/min, and respirations are 22/min.

Context: On exam, the boy has scant non-purulent mucoid bilateral eye discharge and conjunctival hyperemia.

Choices:
A. Intravenous acyclovir
B. Oral and topical erythromycin
C. Sterile lubricant with artificial tear preparation
D. Topical bacitracin

Answer: Oral and topical erythromycin

1. A 32-year-old G2P2 woman gave birth to a boy.

3. The mother recently immigrated from Somalia.

5. The mother refused all intrapartum medications.

6. The boy's Apgar scores were 7 and 9 at 1 and 5 minutes, respectively.

7. The boy's height was in the 20th percentile.

8. The boy's weight was in the 15th percentile.

9. Mother and child were discharged the day after birth.

10. Seven days later, the mother presented to the pediatrician.

11. The mother noticed redness and discharge in her baby's eyes.

12. The boy's temperature was 98.8°F (37.1°C).

13. The boy's blood pressure was 105/65 mmHg.

16. On exam, the boy had scant non-purulent mucoid bilateral eye discharge and conjunctival hyperemia.

General Obstetrics and Gynecology
Maternal


Question: Inhibition of which of the following processes is the best explanation for such adverse effects?

Context: A 21-year-old woman presents to her physician for a regular follow-up visit.

Context: She was diagnosed with relapsing-remitting multiple sclerosis 2 months ago when she suffered a second episode of optic neuritis.

Context: She was successfully treated with methylprednisolone pulse therapy and discharged.

Context: Today, she only complains of slight fatigue with upper and lower extremity weakness.

Context: Her blood pressure is 120/80 mm Hg, her heart rate is 63/min, her respiratory rate is 14/min, and her temperature is 36.7°C (98.0°F).

Context: Neurological examination reveals brisk deep reflexes (3+ equal) and decreased strength (4/4) in the upper limbs.

Context: The patient is prescribed a drug that is an inhibitor of ɑ4-integrin (CD49d) for the prevention of relapses.

Context: She is concerned about the side effects of this drug, among which is increased susceptibility to the upper respiratory tract and urinary tract infections.

Choices:
A. Tight adhesion of leukocytes to the endothelial cells
B. Expression of selectins on the surface of endothelial cells
C. Formation of tight bounds between leukocytes and endothelial selectins
D. Inhibition of interaction between platelet endothelial cell adhesion molecules (PECAMs) on the surfaces of leukocytes and endothelial cells

Answer: Tight adhesion of leukocytes to the endothelial cells

2. Patient was diagnosed with relapsing-remitting multiple sclerosis 2 months ago.

3. Patient suffered a second episode of optic neuritis.

4. Patient was successfully treated with methylprednisolone pulse therapy and discharged.

5. Patient only complains of slight fatigue with upper and lower extremity weakness.

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

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

9. Patient's temperature is 36.7°C (98.0°F).

10. Neurological examination reveals brisk deep reflexes (3+ equal).

11. Neurological examination reveals decreased strength (4/4) in the upper limbs.

12. The rest of the examination is unremarkable.

13. Patient is prescribed a drug that is an inhibitor of ɑ4-integrin (CD49d) for the prevention of relapses.

14. Patient is concerned about the side effects of this drug, among which is increased susceptibility to the upper respiratory tract and urinary tract infections.


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

Context: A 64-year-old man presents to the clinic complaining of low back pain.

Context: He was diagnosed with benign prostatic hypertrophy several years ago, which worsened last year.

Context: A hard nodule was felt on a digital rectal exam, which led to a prostate biopsy that revealed high-grade adenocarcinoma.

Context: A bone scan at that time showed small, focal abnormalities in the lumbar spine.

Context: He subsequently underwent radiation therapy to his prostate and pelvic lymph nodes.

Context: He was then placed on leuprolide and an anti-androgen.

Context: He was doing well until 2 months ago when he developed low back pain, which has worsened since then.

Context: He reports that the pain is 8/10 and nearly constant.

Context: He states that the pain not only affects his ability to fall asleep but also wakes him up at night.

Context: The pain is mildly alleviated by ibuprofen.

Context: In addition to prostate cancer, his medical history is significant for hypertension, hyperlipidemia, recurrent nephrolithiasis, and gastroesophageal reflux disease.

Context: He takes aspirin, lisinopril, rosuvastatin, and pantoprazole.

Context: Upon physical examination, there is midline tenderness within the lumbar region.

Context: Magnetic resonance imaging of the spine is obtained, which shows bony metastasis to the L2 and L3 spine without evidence of fracture or spinal cord compression.

Context: His prostate-specific antigen is 17.5 ng/mL.

Choices:
A. Calcium and vitamin D supplementation
B. External radiation therapy
C. Flutamide
D. Kyphoplasty

Answer: External radiation therapy

3. Patient was diagnosed with benign prostatic hypertrophy several years ago.

4. Benign prostatic hypertrophy worsened last year.

5. Digital rectal exam revealed a hard nodule.

6. Prostate biopsy revealed high-grade adenocarcinoma.

7. Bone scan showed small, focal abnormalities in the lumbar spine.

8. Patient underwent radiation therapy to prostate and pelvic lymph nodes.

9. Patient was placed on leuprolide and an anti-androgen.

10. Patient was doing well until 2 months ago.

11. Low back pain has worsened since then.

13. Pain affects patient's ability to fall asleep and wakes him up at night.

14. Pain is mildly alleviated by ibuprofen.

15. Patient's medical history is significant for hypertension, hyperlipidemia, recurrent nephrolithiasis, and gastroesophageal reflux disease.

16. Patient takes aspirin, lisinopril, rosuvastatin, and pantoprazole.

17. Physical examination reveals midline tenderness within the lumbar region.

18. Magnetic resonance imaging of the spine shows bony metastasis to the L2 and L3 spine without evidence of fracture or spinal cord compression.

19. Patient's prostate-specific antigen is 17.5 ng/mL.


Question: Which of the following is the most likely cause of her current condition?

Context: Two days after undergoing internal fixation of a displaced right femoral fracture sustained during a motor vehicle accident, a 34-year-old woman develops sudden shortness of breath.

Context: Her temperature is 38.3°C (100.9°F), pulse is 122/min, respiratory rate is 31/min, and blood pressure is 152/90 mm Hg.

Context: Her hemoglobin concentration is 10.3 g/dL, leukocyte count is 9,500/mm3, and platelet count is 140,000/mm3.

Choices:
A. Fat globules entering the circulation
B. Rupture of a coronary plaque
C. Damage to the alveolar capillary endothelium
D. Bacterial invasion of the pulmonary parenchyma

Answer: Fat globules entering the circulation

1. A 34-year-old woman developed sudden shortness of breath two days after undergoing internal fixation of a displaced right femoral fracture sustained during a motor vehicle accident.

2. On examination, she is oriented only to person.

7. Pulse oximetry on room air shows an oxygen saturation of 83%.

8. There are several scattered petechiae on the anterior chest wall.

9. Her hemoglobin concentration is 10.3 g/dL.


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

Context: A 15-year-old girl comes to the physician for the evaluation of a painless swelling under the left lower jaw for 5 months.

Context: Her 18-year-old sister has a history of acute lymphoblastic leukemia that has been in remission for 11 years.

Context: The patient's temperature is 37°C (98.6°F) Physical examination shows a 3 × 2 cm swelling on the left side, 4 cm below the base of the mandible and anterior to the sternocleidomastoid muscle.

Context: The swelling is soft and fluctuant.

Context: It does not move with swallowing, and forced exhalation against a closed glottis does not increase the size of the swelling.

Choices:
A. Lymphadenopathy
B. Branchial cleft cyst
C. Laryngocele
D. Infantile hemangioma

Answer: Branchial cleft cyst

2. Patient has a painless swelling under the left lower jaw for 5 months.

3. Patient's 18-year-old sister has a history of acute lymphoblastic leukemia in remission for 11 years.

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

5. Physical examination shows a 3 × 2 cm swelling on the left side, 4 cm below the base of the mandible and anterior to the sternocleidomastoid muscle.

7. Swelling does not move with swallowing.

8. Forced exhalation against a closed glottis does not increase the size of the swelling.

9. Ultrasound shows a round mass with uniform low echogenicity and no internal septations.


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

Context: A 70-year-old man is brought to the emergency department by staff of the group home where he resides because of fever, a productive cough, and blood-tinged sputum for 2 days.

Context: The staff report that he developed myalgia, headache, and rhinorrhea 7 days ago, which improved initially before worsening again.

Context: Current medications include enalapril and donepezil.

Context: On arrival, he is obtunded.

Context: His temperature is 39.8°C (103.6°F), pulse is 120/min, respirations are 22/min and shallow, and blood pressure is 100/60 mm Hg.

Context: An x-ray of the chest shows bilateral lung opacities and multiple small, thin-walled cystic spaces within the basal pulmonary parenchyma.

Choices:
A. Infection with Staphylococcus aureus
B. Infection with Aspergillus fumigatus
C. Foreign body aspiration
D. Granulomatosis with polyangiitis

Answer: Infection with Staphylococcus aureus

1. A 70-year-old man is brought to the emergency department.

3. He has fever, a productive cough, and blood-tinged sputum for 2 days.

4. He developed myalgia, headache, and rhinorrhea 7 days ago.

5. His symptoms initially improved before worsening again.

6. He has hypertension and Alzheimer disease.

7. His current medications include enalapril and donepezil.

11. His respirations are 22/min and shallow.

13. Pulse oximetry on 10 L/min of oxygen via nasal cannula shows an oxygen saturation of 92%.

14. Examination shows scattered crackles and rhonchi throughout both lung fields.

15. An x-ray of the chest shows bilateral lung opacities.

16. An x-ray of the chest shows multiple small, thin-walled cystic spaces within the basal pulmonary parenchyma.

Pulmonary Disease
General Pulmonary Disease


Question: Which of the following is the most likely infectious agent?

Context: A 55-year-old man presents to his primary care physician with ear pain.

Context: The patient states he has had worsening ear pain for the past 2 days.

Context: He describes his pain as 9/10.

Context: The patient has a past medical history of diabetes, obesity, and hypertension.

Context: His current medications include insulin, metformin, lisinopril, aspirin, and atorvastatin.

Context: His temperature is 100.5°F (38.1°C), blood pressure is 177/99 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Context: Physical exam reveals a purulent drainage from the ear canal.

Context: Manipulation of the ear causes severe pain.

Choices:
A. Haemophilus influenzae
B. Moraxella catarrhalis
C. Pseudomonas aeruginosa
D. Staphylococcus aureus

Answer: Pseudomonas aeruginosa

4. Patient has past medical history of diabetes, obesity, and hypertension.

5. Patient is taking insulin, metformin, lisinopril, aspirin, and atorvastatin.

6. Patient's temperature is 100.5°F (38.1°C).

7. Patient's blood pressure is 177/99 mmHg.

10. Patient's oxygen saturation is 98% on room air.

11. Physical exam reveals purulent drainage from ear canal.

12. Manipulation of ear causes severe pain.


Question: How do you respond?

Context: He is afebrile, with a blood pressure of 128/60 mmHg, pulse of 100/min, respirations at 25/min, and SpO2 of 95% on room air.

Context: He exhibits no tremors or myoclonus.

Context: His basic metabolic panel is displayed below: |  | Serum: | Na+: 138 mEq/L | Cl-: 90 mEq/L | K+: 4.0 mEq/L | HCO3-: 20 mEq/L | BUN: 30 mg/dL | Glucose: 100 mg/dL | Creatinine: 0.8 mg/dL |  | An arterial blood gas reveals the following: |  | pH: 7.32 | pCO2: 34 mmHg | pO2: 89 mmHg |  | The girlfriend is concerned that the patient's breathing appears uncomfortable.

Choices:
A. His breathing is concerning for hepatic encephalopathy
B. His breathing suggests that he needs some fluids
C. His breathing suggests that he has major depression disorder
D. You are not his healthcare proxy and I cannot speak to you

Answer: His breathing suggests that he needs some fluids

1. A 19-year-old male college student with no significant medical history presents to the emergency department with altered mental status.

2. His girlfriend said that he drank multiple shots of vodka and gin throughout the weekend and was found slumped on the couch with some vomit on his shirt.

8. His pupils are equal and reactive to light bilaterally.

10. The remainder of the physical exam is unremarkable.

21. The girlfriend is concerned that the patient's breathing appears uncomfortable.


Question: Which of the following explains these findings?

Context: He takes metformin and insulin NPH.

Context: Today, his blood pressure is 130/80 mm Hg, pulse is 76/min, respiratory rate is 18/min, and temperature is 36.5°C (97.7°F).

Context: On physical exam, he appears obese.

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

Context: A urinalysis reveals  glucose (++), and protein (+++).

Choices:
A. Glomerular hyperfiltration
B. Renal artery stenosis
C. Subendothelial immune-complex deposits
D. Interstitial atrophy

Answer: Glomerular hyperfiltration

1. A 56-year-old man presents to his primary care provider for a check-up.

2. His past medical history is significant for type 2 diabetes mellitus for 20 years and insomnia.

4. Both of his parents died in a car accident several years ago.

5. He smokes a half of a pack of cigarettes every day and drinks 1-2 beers a day and more on the weekends.

6. Today, his blood pressure is 130/80 mm Hg.

8. Today, his respiratory rate is 18/min.

9. Today, his temperature is 36.5°C (97.7°F).

11. His heart has a regular rate and rhythm.

12. His lungs are clear to auscultation bilaterally.

13. A foot exam is performed and is unremarkable.


Question: Treatment with which of the following drugs was most likely initiated in this patient?

Context: A 64-year-old man comes to the physician because of a 1-month history of progressively worsening back pain that wakes him up at night.

Context: Initially, there is an increase in serum testosterone and dihydrotestosterone levels, followed by a sustained decrease in both serum hormone levels.

Choices:
A. Leuprolide
B. Finasteride
C. Ketoconazole
D. Cyproterone acetate

Answer: Leuprolide

1. A 64-year-old man comes to the physician.

2. He has a 1-month history of progressively worsening back pain that wakes him up at night.

3. He also reports symptoms of urinary urgency and a weak urine stream.

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

5. Rectal examination shows an enlarged and hardened prostate with a nodular surface.

6. After further evaluation and confirmation of the diagnosis, he is started on a new drug.

7. Initially, there is an increase in serum testosterone and dihydrotestosterone levels.

8. This is followed by a sustained decrease in both serum hormone levels.

General Orthopaedic Surgery
Orthopaedic Sports Medicine


Question: The toxin responsible for this clinical presentation has a mechanism of action that is most similar to which other toxin?

Context: A 46-year-old man presents to a physician three days after arriving in Morocco.

Context: He endorses acute onset of painless, profuse watery diarrhea that appears white and cloudy.

Context: Vital signs are T 98.6, HR 120, RR 17, and BP 85/50.

Context: On physical exam, the patient has dry mouth, decreased skin turgor, and cold clammy skin.

Choices:
A. Diphtheria toxin
B. Exotoxin A
C. Edema toxin
D. Shiga-like toxin

Answer: Edema toxin

1. A 46-year-old man presents to a physician.

2. He arrived in Morocco three days ago.

3. He has acute onset of painless, profuse watery diarrhea.

4. The diarrhea appears white and cloudy.

5. The patient denies bloody stool, vomiting, or subjective fevers.

13. His peripheral pulse is rapid and thready.


Question: What test will most likely be positive?

Context: A 25-year-old woman presents to the urgent care center with a one month history of intermittent chest pain that occurs about 2-3 times per week in the early mornings.

Context: She does not smoke and has never suffered from chest pain before.

Context: She has no family history of early MI.

Choices:
A. Ergonovine
B. Immediately repeat ECG
C. Exercise stress test
D. Kehr's sign

Answer: Ergonovine

1. A 25-year-old woman presents to the urgent care center.

2. She has a one month history of intermittent chest pain.

3. The chest pain occurs about 2-3 times per week in the early mornings.

5. She has never suffered from chest pain before.

6. She has no family history of early MI.

7. A 12 lead ECG does not show any abnormalities.

8. Creatine kinase and troponin I enzymes are within normal limits.


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

Context: In the operating room, he is placed on continuous hemodynamic monitoring and anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace.

Context: His temperature is 37.1°C (98.8°F), pulse is 38/min, respirations are 24/min, and palpable systolic blood pressure is 58 mmHg.

Context: The skin is diaphoretic and flushed.

Context: The lungs are clear to auscultation.

Context: Heart sounds are not audible.

Choices:
A. Loss of sympathetic vascular tone
B. Obstructive thrombus in the pulmonary artery
C. Intravascular volume depletion
D. Type I hypersensitivity reaction

Answer: Loss of sympathetic vascular tone

1. A 28-year-old man is scheduled for skin grafting of the right leg.

2. Four weeks earlier, he underwent open reduction and internal fixation of an open right tibial fracture.

3. The postoperative period at that time was complicated by necrosis of the overlying skin.

4. In the operating room, he is placed on continuous hemodynamic monitoring.

5. Anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace.

6. Thirty minutes later, he has severe shortness of breath and lightheadedness and loses consciousness.

10. Palpable systolic blood pressure is 58 mmHg.

11. The skin is diaphoretic and flushed.

12. He withdraws the upper extremities to painful stimuli above the navel.

13. The lungs are clear to auscultation.

General Plastic Surgery
Micrographic Dermatologic Surgery


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

Context: A 42-year-old man with no significant medical history presents to the emergency department with complaints of headache, nausea, and dizziness.

Context: He states that he was at home working on his car when he started to feel dizzy and experienced a headache.

Context: This progressed to him feeling nauseous.

Context: The patient states he went inside and drank some water and felt better; however, when he started working on his car again his symptoms returned.

Context: Upon presentation, he states his symptoms have mostly improved except for a persistent headache.

Context: His temperature is 98.1°F (36.7°C), blood pressure is 125/84 mmHg, pulse is 87/min, respirations are 18/min, and oxygen saturation is 98% on room air.

Context: Neurologic exam is unremarkable.

Choices:
A. 100% oxygen
B. CT
C. Hydroxocobalamin
D. Ibuprofen and acetaminophen

Answer: 100% oxygen

2. Patient has no significant medical history.

3. Patient presented to the emergency department with complaints of headache, nausea, and dizziness.

4. Patient was at home working on his car when he started to feel dizzy and experienced a headache.

5. Symptoms progressed to feeling nauseous.

6. Patient went inside and drank some water and felt better.

7. Symptoms returned when patient started working on his car again.

8. Upon presentation, patient states his symptoms have mostly improved except for a persistent headache.

9. Patient's temperature is 98.1°F (36.7°C).

10. Patient's blood pressure is 125/84 mmHg.

13. Patient's oxygen saturation is 98% on room air.


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

Context: A 19-year-old woman comes to the physician because of severe headaches for the past 3 months.

Context: The headaches are pulsating in nature and she describes the pain as 8 out of 10 in intensity.

Context: She has visited the emergency department for headaches twice in the past month; during both visits, her blood pressure was elevated.

Context: She has polycystic ovarian disease.

Context: Her medications include metformin and an oral contraceptive pill.

Context: She is 162 cm (5 ft 4 in) tall and weighs 86 kg (190 lb); BMI is 32.8 kg/m2.

Context: Her temperature is 37°C (98.6°F), pulse is 99/min, and blood pressure is 168/98 mm Hg.

Context: Examination shows hirsutism.

Context: The abdomen is soft and nontender.

Context: An abdominal bruit is heard on the left side.

Context: A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.

Context: An abdominal ultrasound shows an increased peak systolic velocity in the distal portion of the left renal artery.

Context: A contrast-enhanced CT scan of the abdomen shows alternating stenosis and dilation in an 8-mm distal segment of the left renal artery with approximately 75% reduction in the diameter of the vessel.

Context: A CT scan of the brain shows no abnormalities.

Choices:
A. Combination therapy with captopril and valsartan
B. Percutaneous transluminal angioplasty without stent placement
C. Ramipril and percutaneous transluminal angioplasty without stent placement
D. Enalapril and aortorenal bypass with a vein graft

Answer: Ramipril and percutaneous transluminal angioplasty without stent placement

2. Patient has had severe headaches for 3 months.

4. Patient describes pain as 8 out of 10 in intensity.

5. Patient has visited the emergency department twice in the past month.

6. Both visits showed elevated blood pressure.

7. Patient has polycystic ovarian disease.

8. Medications include metformin and an oral contraceptive pill.

9. Patient is 162 cm tall and weighs 86 kg.

15. Cardiopulmonary examination shows no abnormalities.

17. Abdominal bruit is heard on the left side.

18. Neurologic examination shows no focal findings.

19. Complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.

20. Plasma free metanephrines are within the reference range.

21. Abdominal ultrasound shows increased peak systolic velocity in the distal portion of the left renal artery.

22. Contrast-enhanced CT scan of the abdomen shows alternating stenosis and dilation in an 8-mm distal segment of the left renal artery with approximately 75% reduction in the diameter of the vessel.

23. CT scan of the brain shows no abnormalities.


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

Context: A 28-year-old male is found to have 93% HbA, 2% HbF, and 5% HbA2 on hemoglobin electrophoresis.

Choices:
A. Alpha thalassemia major with Hb Bart's
B. Beta-thalassemia minor
C. Beta-thalassemia major
D. Diabetes mellitus

Answer: Beta-thalassemia minor

3. Hemoglobin electrophoresis reveals 93% HbA.

4. Hemoglobin electrophoresis reveals 2% HbF.

5. Hemoglobin electrophoresis reveals 5% HbA2.


Question: Which of the following is the best assessment of the patient’s capacity to make healthcare decisions?

Context: A 76-year-old female is brought to the emergency department for altered mental status.

Context: She is accompanied by a nurse from her nursing home.

Context: The nurse says that usually the patient is interactive even though she is sometimes forgetful.

Context: In the last two days, the patient has been increasingly lethargic and doesn’t respond to the staff’s questions.

Context: She also has not been able to get up and use the restroom so the staff has had to change multiple soiled sheets.

Context: Her temperature is 102.1°F (38.9°C), blood pressure is 100/74 mmHg, pulse is 120/min, and respirations are 24/min.

Context: The patient is combative on arrival but can be subdued with reorientation by the care team.

Context: She is not oriented to person, place, or time.

Context: Urine culture grows >100,000 CFU of E.

Context: coli.

Context: The physician team would like to consent this patient for a Foley catheter.

Choices:
A. The patient does not have capacity to make decisions
B. The patient does have capacity to make decisions
C. The hospital ethics board should be consulted
D. Capacity cannot be determined at this time

Answer: Capacity cannot be determined at this time

3. Patient is accompanied by a nurse from her nursing home.

4. Patient is usually interactive, but sometimes forgetful.

5. Patient has been increasingly lethargic in the last two days.

6. Patient does not respond to staff's questions.

7. Patient has not been able to get up and use the restroom.

8. Staff has had to change multiple soiled sheets.

9. Patient's temperature is 102.1°F (38.9°C).

10. Patient's blood pressure is 100/74 mmHg.

14. Patient can be subdued with reorientation by the care team.

15. Patient is not oriented to person, place, or time.

16. Urinalysis shows positive leukocyte esterase and nitrites.

17. Urine culture grows >100,000 CFU of E. coli.

18. Physician team would like to consent this patient for a Foley catheter.


Question: While the physician empathizes with the family, which of the following is the most appropriate response?

Context: She has no history of serious illness.

Context: Her Glasgow Coma Scale (GCS) is 3.

Context: Her father is shocked at the suggestion of organ donation and says that “life is still circulating in her body because it is warm, and she has a normal heartbeat!” .

Choices:
A. “Only after your consent will her organs be removed.”
B. “Brain death is considered legal death just as if her heart was not beating.”
C. “She is very unlikely to recover.”
D. “She will be dead once she is disconnected from advanced life-support.”

Answer: “Brain death is considered legal death just as if her heart was not beating.”

1. A 19-year-old woman is brought to the emergency department by ambulance 1 hour after a motor vehicle accident.

2. She has no history of serious illness.

3. She is on mechanical ventilation without any sedation.

4. Her vital signs are within a normal range.

6. Examination by the attending trauma surgeon and neurologist shows brain death.

7. Laboratory studies show no abnormalities.

8. A search on the state donor registry shows that she has registered as an organ donor.

9. Her father is shocked at the suggestion of organ donation.

10. He says that “life is still circulating in her body because it is warm, and she has a normal heartbeat!”


Question: Which of the following ego defenses best characterizes this gentleman's behavior?

Choices:
A. Altruism
B. Displacement
C. Sublimation
D. Atonement

Answer: Altruism

1. A 58-year-old male has had long-term involvement in the world of organized crime.

2. He very recently retired from his post within this organization.

3. This former mafia boss has now suddenly started making large contributions to several local charities.


Question: The patient's pulmonary function tests would be similar to that seen in a patient with:

Context: A 45-year-old man presents with a chronic productive cough that he has had for the past few years.

Context: He admits to having smoked 1 pack of cigarettes a day for the past 25 years.

Choices:
A. Asymptomatic asthma
B. Silicosis
C. Emphysema
D. Coal worker's pneumonitis

Answer: Emphysema

1. A 45-year-old man presents with a chronic productive cough.

2. The cough has been present for the past few years.

3. The man has smoked 1 pack of cigarettes a day for the past 25 years.

4. A chest radiograph reveals an enlarged heart.


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

Choices:
A. Decreased orexin
B. Decreased melatonin
C. Increased dopamine
D. Increased acetylcholine

Answer: Decreased melatonin

1. A 69-year-old gentleman presents to his primary care physician for a general checkup.

2. He states that overall he is doing well.

3. Ever since he retired, he has been working on projects at home, and taking time to exercise every day.

4. He eats a balanced diet, and has been spending time with his wife every evening.

5. Despite this, the patient claims that he feels less well rested when he awakes in the morning.

6. The patient states that he used to sleep nine hours a night in his youth and felt excellent.

7. Now he sleeps seven hours a night and doesn’t feel as well rested as he used to.

8. The patient’s wife states that he seems to sleep peacefully.

9. On physical exam the patient’s neurological exam is within normal limits.

10. The patient is muscular and has a healthy weight and has a pleasant demeanor.

11. He denies feeling fatigued or tired currently.


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

Context: A 7-year-old boy with sickle cell disease is brought into the clinic by his mother for knee and hip pain.

Context: The child has been admitted several times in the past for pain crises managed with fluids and hydromorphone.

Context: He started complaining of worsening hip pain over the last several days and now walks with a limp.

Context: His temperature is 97.9°F (36.6°C), blood pressure is 84/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 99% on room air.

Context: On physical exam, the hip appears normal and is cool to the touch.

Context: There is decreased range of motion at the hip and pain with ambulation.

Choices:
A. CT
B. Ibuprofen and acetaminophen
C. MRI
D. Radiograph

Answer: Radiograph

3. Patient is brought into the clinic by his mother.

5. Patient has been admitted several times in the past for pain crises.

6. Patient's pain crises were managed with fluids and hydromorphone.

7. Patient has been complaining of worsening hip pain over the last several days.

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

10. Patient's blood pressure is 84/54 mmHg.

13. Patient's oxygen saturation is 99% on room air.

14. On physical exam, the hip appears normal.

15. On physical exam, the hip is cool to the touch.

16. On physical exam, there is decreased range of motion at the hip.

17. On physical exam, there is pain with ambulation.


Question: Which of the following is a risk factor for this patient condition?

Context: A 65-year-old asian man presents to his primary care physician because of abdominal distension, right upper quadrant (RUQ) abdominal pain, decreased appetite, and weight loss for several weeks.

Context: His temperature is 37.1°C (98.7°F), blood pressure is 120/80 mm Hg, and pulse is 85/min.

Context: Alpha fetoprotein (AFP) is 500 μg/L.

Choices:
A. Exposure to nitrosamines
B. Cyclophosphamide use
C. Clonorchis sinensis infection
D. Chronic hepatitis C infection

Answer: Chronic hepatitis C infection

1. A 65-year-old Asian man presents to his primary care physician.

2. He has abdominal distension, right upper quadrant (RUQ) abdominal pain, decreased appetite, and weight loss for several weeks.

3. He denies smoking or excess alcohol intake.

7. Physical examination reveals a cachectic man with jaundice, palmar erythema, ascites, and a palpable mass in the RUQ.

8. Abdominal ultrasound shows a 3 cm hypoechoic mass in the right lobe of the liver.


Question: What should the physician do in this situation?

Context: A 71-year-old man from Puerto Rico presents to the emergency department with a 2-week history of abdominal pain.

Context: He does not speak much English so his family explains that he has been complaining of intermittent pain that is not associated with any particular actions.

Context: Furthermore, his family is concerned because he has been having weight loss and blood in his stool for 3 months.

Context: The physician explains that there is a concern for colon cancer and that a colonoscopy is required to evaluate his condition further.

Context: The family is afraid that the news will upset the patient so they ask that they be allowed to make healthcare decisions on the patient's behalf.

Choices:
A. Ask the family to translate the plan for the patient and ask for questions
B. Call for a Spanish-speaking interpreter to speak with the patient
C. Respect the family's cultural wishes and not discuss the plan with the patient
D. Speak directly with the patient in English to ascertain their wishes

Answer: Call for a Spanish-speaking interpreter to speak with the patient

1. A 71-year-old man from Puerto Rico presents to the emergency department.

2. He has a 2-week history of abdominal pain.

4. His family explains that he has been complaining of intermittent pain that is not associated with any particular actions.

5. His family is concerned because he has been having weight loss and blood in his stool for 3 months.

6. The physician explains that there is a concern for colon cancer.

7. A colonoscopy is required to evaluate his condition further.

8. The family is afraid that the news will upset the patient.

9. They ask that they be allowed to make healthcare decisions on the patient's behalf.

10. They explain that this is the way that their culture handles medical decisions.


Question: Which of the following ion channels is dysfunctional in this patient?

Context: A 45-year-old man presents to a physician with recurrent episodes of palpitations over the last 3 months.

Context: The episodes are self-limiting but cause significant distress and discomfort to the patient.

Context: After a detailed electrophysiological workup, the physician concludes that the symptoms occur mainly due to abnormal function of the cardiac ion channels, which primarily produce the plateau phase of the action potential in cardiac myocytes in healthy patients.

Choices:
A. Fast sodium channels
B. L-type voltage-gated calcium channels
C. T-type voltage-gated calcium channels
D. Inward rectifier IK1 channels

Answer: L-type voltage-gated calcium channels

1. A 45-year-old man presents to a physician.

2. The patient has had recurrent episodes of palpitations over the last 3 months.

4. The episodes cause significant distress and discomfort to the patient.

5. The physician performs a detailed electrophysiological workup.

6. The physician concludes that the symptoms occur mainly due to abnormal function of the cardiac ion channels.

7. The cardiac ion channels primarily produce the plateau phase of the action potential in cardiac myocytes in healthy patients.


Question: An analysis of this patient's cerebral spinal fluid is most likely to show which of the following findings?

Context: A 23-year-old man comes to the physician because of severe daytime sleepiness and random episodes of falling asleep during the day for short periods of time.

Context: He sleeps 6–7 hours at night.

Context: Last week, he suddenly “lost control” of his legs and neck for about 30 seconds after his classmate had told him a joke.

Choices:
A. Decreased orexin-A
B. Increased neuron-specific enolase
C. Increased 14-3-3 protein
D. Anti-ganglioside antibodies

Answer: Decreased orexin-A

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

3. He has random episodes of falling asleep during the day for short periods of time.

4. When he wakes up from these episodes, he feels refreshed.

6. He reports that sometimes he is unable to move for a few minutes when he first wakes up in the morning.

7. Last week, he suddenly “lost control” of his legs and neck for about 30 seconds.

8. This happened after his classmate had told him a joke.


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

Context: A 73-year-old man is brought to the emergency department 30 minutes after he lost consciousness for 5 minutes while watching a game of summer league football in a seat from the stands in the afternoon.

Context: His temperature is 41.5 °C (106.7 °F), pulse is 106/min, respirations are 26/min, and blood pressure is 128/70 mm Hg.

Context: Examination shows hot, dry skin.

Context: His abdomen is soft and nontender.

Context: An ECG shows a normal sinus rhythm.

Choices:
A. Inadequate hypothalamic response
B. Metabolic acidosis with ketosis
C. Elevation of serum thyroxine levels
D. Central dopamine receptor blockade

Answer: Inadequate hypothalamic response

1. A 73-year-old man was brought to the emergency department.

2. He lost consciousness for 5 minutes while watching a game of summer league football in a seat from the stands in the afternoon.

3. On arrival, he is lethargic and oriented only to person.

4. Three weeks ago, he was treated for hepatitis A.

5. He has type 2 diabetes mellitus and hypothyroidism.

6. Current medications include metformin and levothyroxine.

7. His temperature is 41.5 °C (106.7 °F).

12. The pupils are equal and reactive to light.

13. Neurologic examination shows no focal findings.

14. Fundoscopy shows proliferative diabetic retinopathy.

15. Cardiopulmonary examination shows no abnormalities.

17. There is no costovertebral angle tenderness.

18. His serum glucose concentration is 160 mg/dL.


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

Context: A 3-year-old boy is brought to the physician for a well-child examination.

Context: He feels well.

Context: He was born at 38 weeks' gestation and weighed 2766 g (6 lb 2 oz).

Context: He now weighs 14 kg (31 lbs).

Context: There is no personal or family history of serious illness.

Context: His immunizations are up-to-date.

Context: He is at 60th percentile for height and 55th percentile for weight.

Context: Vital signs are within normal limits.

Context: The lungs are clear to auscultation.

Context: A grade 3/6 systolic ejection murmur is heard along the upper left sternal border.

Context: There is a grade 2/6 mid-diastolic murmur along the lower left sternal border.

Context: The abdomen is soft and nontender; there is no organomegaly.

Choices:
A. Patent ductus arteriosus
B. Benign heart murmur
C. Atrial septal defect
D. Pulmonary valve stenosis

Answer: Atrial septal defect

3. Patient was born at 38 weeks' gestation.

4. Patient weighed 2766 g (6 lb 2 oz) at birth.

6. No personal or family history of serious illness.

8. Patient is at 60th percentile for height.

9. Patient is at 55th percentile for weight.

10. Vital signs are within normal limits.

12. Grade 3/6 systolic ejection murmur heard along upper left sternal border.

13. S2 is widely split and does not vary with respiration.

14. Grade 2/6 mid-diastolic murmur heard along lower left sternal border.


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

Context: A 30-year-old man presents to the emergency department after being attacked by 2 men a few minutes ago.

Context: He is in apparent distress.

Context: His temperature is 36.8°C (98.2°F), the blood pressure is 100/60 mm Hg, the pulse is 110/min, the respirations are 28/min, and the SaO2 is 85% on 4 L oxygen by nasal cannula.

Context: The respiratory exam shows severe tenderness in the right chest, decreased inspiration in the right lung, and tracheal deviation to the left.

Choices:
A. Pericardiocentesis
B. Intravenous fluids
C. Dobutamine
D. Needle thoracostomy

Answer: Needle thoracostomy

1. A 30-year-old man presents to the emergency department.

2. He was attacked by 2 men a few minutes ago.

3. He was suddenly approached by 2 men holding knives while he was walking on the street nearby.

4. While trying to escape, he was stabbed once in the neck.

5. He is complaining of difficulty breathing and chest pain.

11. The SaO2 is 85% on 4 L oxygen by nasal cannula.

12. Examination of the neck reveals a deep penetrating injury on the right side and distended neck veins.

13. The respiratory exam shows severe tenderness in the right chest.

14. The respiratory exam shows decreased inspiration in the right lung.

15. The respiratory exam shows tracheal deviation to the left.


Question: Which of the following is characteristic of this patient’s diagnosis?

Context: An 8-month-old male presents to your office with a 5-day history of blood in his stool.

Context: Abdominal pain is notably absent on history obtained from his parents.

Choices:
A. It may affect neonates but is more common in adolescents.
B. It is rare, affecting less than 1% of the population.
C. Both males and females are equally affected.
D. Diagnostic studies localize ectopic gastric tissue.

Answer: Diagnostic studies localize ectopic gastric tissue.

1. An 8-month-old male presents to your office.

2. He has a 5-day history of blood in his stool.

3. Abdominal pain is absent on history obtained from his parents.

4. Past medical history and physical exam findings are not remarkable.

5. Laboratory findings are significant for mild iron deficiency.