Question: Which medication is most likely responsible for this complication?

Context: A 54-year-old male is involved in a high speed motor vehicle collision and is brought to the emergency department.

Context: On arrival, his vitals are temperature 98.6 °F (37 °C), blood pressure 110/70 mmHg, pulse 100/min, and respirations are 20/min.

Context: Physical exam is notable for a rapid and thready pulse, and a rigid and distended abdomen with positive rebound tenderness.

Context: Two large bore IV's are started and the patient is given a 1L bolus of normal saline.

Context: The patient’s mental status rapidly deteriorates and he becomes unresponsive.

Context: The patient is started on a medication while additional fluids are administered.

Context: Subsequently his vitals, his pulse is 80/minute and blood pressure is 120/80 mmHg.

Context: While the patient is being taken to the operating room, he develops pain in all four distal extremities.

Choices:
A. Epinephrine
B. Norepinephrine
C. Vasopressin
D. Ephedrine

Answer: Norepinephrine

1. A 54-year-old male is involved in a high speed motor vehicle collision.

2. He is brought to the emergency department.

3. On arrival, his temperature is 98.6 °F (37 °C).

7. His Glasgow Coma Score (GCS) is 13 (eye opening 3, verbal response 5, and motor response 5).

8. Physical exam is notable for a rapid and thready pulse.

9. His abdomen is rigid and distended with positive rebound tenderness.

10. FAST exam reveals a large hypoechoic stripe in the hepatorenal recess.

12. He is given a 1L bolus of normal saline.

13. His mental status rapidly deteriorates and he becomes unresponsive.

14. His pulse is 149/min and blood pressure is 70/40 mmHg.

17. His pulse is 80/minute and blood pressure is 120/80 mmHg.

18. While being taken to the operating room, he develops pain in all four distal extremities.

19. His digits appear blue and are cool to the touch.


Question: Serum level of which of the following coagulation factors is likely abnormal in this patient?

Context: A 20-year-old man with a history of cystic fibrosis presents to his pulmonologist for a regular checkup.

Context: He generally feels well but noticed that he has had an increase in stool frequency.

Context: He describes his stools as loose and “greasy”, often staining the toilet bowl.

Context: He regularly uses albuterol and budesonide inhalers and has chest physical therapy several times a month.

Context: Physical exam is unremarkable.

Choices:
A. II
B. V
C. VIII
D. XI

Answer: II

1. A 20-year-old man presents to his pulmonologist for a regular checkup.

4. He has had an increase in stool frequency.

5. He describes his stools as loose and “greasy”.

6. His stools often stain the toilet bowl.

7. He regularly uses albuterol and budesonide inhalers.

8. He has chest physical therapy several times a month.


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

Context: His father has similar skin findings.

Context: His mother has epilepsy and glaucoma.

Context: Vital signs are within normal limits.

Context: Examination of his skin shows eight brownish macules and numerous soft, non-tender, pedunculated lesions on the back, chest, and abdomen.

Choices:
A. MRI of the brain
B. Electroencephalogram
C. B-scan ultrasound
D. Gonioscopy

Answer: MRI of the brain

1. A 6-year-old boy is brought to the physician by his father for an annual health maintenance examination.

2. His father notes that he has several pigmented areas on his skin and a few fleshy bumps.

3. He has also had some blurred vision in his left eye.

4. He has no history of serious medical illness.

5. He lives at home with both parents and is up-to-date on all his immunizations.

6. His father has similar skin findings.

7. His mother has epilepsy and glaucoma.

8. Vital signs are within normal limits.

9. Visual acuity testing shows 20/50 in the left eye and 20/20 in the right eye.

10. Slit-lamp examination shows pigmented iris nodules.

11. Examination of his skin shows eight brownish macules.

12. Examination of his skin shows numerous soft, non-tender, pedunculated lesions on the back, chest, and abdomen.

General Pediatrics
Neurodevelopmental Disabilities


Question: This patient is most likely to experience which of the following adverse effects?

Context: A 43-year-old man is brought to the emergency department because of a fever, cough, pleuritic chest pain, and dyspnea.

Choices:
A. Hypomagnesemia
B. Histamine release
C. Leukopenia
D. Cytochrome P450 induction

Answer: Hypomagnesemia

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

2. He has a fever, cough, pleuritic chest pain, and dyspnea.

3. Two days ago, he returned from a construction site along the Mississippi River.

4. Abdominal examination shows a palpable spleen.

5. An x-ray of the chest shows diffuse reticulonodular infiltrates.

6. Therapy with a drug that binds ergosterol is initiated.


Question: Which of the following is the primary underlying cause of this patient’s presentation?

Context: A 49-year-old African man presents to the physician with a 3-month history of fatigue, shortness of breath, and abdominal distention.

Context: He immigrated to the US approximately 6 months ago.

Context: He has no other medical problems and is currently not on medication.

Context: He previously worked as a farmer but stopped due to his inability to keep up with the work.

Context: His blood pressure is 112/58 mm Hg, pulse is 90/min, respiratory rate is 19/min, and temperature is 37.8°C (100.0°F).

Context: Physical examination reveals bilateral pedal edema up to the knees, jugular venous distention, and abdominal distention with free fluid.

Context: Chest auscultation reveals the following sound.

Choices:
A. Coxsackie A virus
B. Tuberculosis
C. Protozoan infection
D. Tricuspid endocarditis

Answer: Tuberculosis

1. Patient is a 49-year-old African man.

2. Patient has a 3-month history of fatigue, shortness of breath, and abdominal distention.

3. Patient immigrated to the US approximately 6 months ago.

4. Patient has no other medical problems and is currently not on medication.

5. Patient previously worked as a farmer but stopped due to his inability to keep up with the work.

6. Patient's blood pressure is 112/58 mm Hg.

8. Patient's respiratory rate is 19/min.

9. Patient's temperature is 37.8°C (100.0°F).

10. Physical examination reveals bilateral pedal edema up to the knees.

11. Physical examination reveals jugular venous distention.

12. Physical examination reveals abdominal distention with free fluid.

13. Chest auscultation reveals a specific sound.

14. Jugular venous pressure tracing reveals prominent ‘x’ and ‘y’ descents.

15. Radial pulse is absent during inspiration bilaterally.


Question: Which of the following options describes the  proper management in this patient assuming that no deterioration occurs up to the time of delivery?

Context: A 25-year-old primigravida is admitted to the hospital at 35 weeks gestation with lower leg edema.

Context: She denies any other symptoms.

Context: Prior to admission, the antepartum course was unremarkable and she was compliant with recommended  prenatal care.

Context: The vital signs were as follows: blood pressure, 155/90 mm Hg; heart rate, 84/min; respiratory rate, 16/min; and temperature, 36.6℃ (97.9℉).

Context: The fetal heart rate was 142/min.

Context: The physical examination shows 2+ pitting edema.

Context: A 24-hour urine assessment showed proteinuria (1.2 g).

Context: An ultrasound examination showed a normally developing fetus without structural abnormalities.

Context: The placental margin was located 3 cm away from the internal os.

Choices:
A. Induction of vaginal delivery at 37 weeks’ pregnancy if not begin spontaneously earlier
B. Cesarean delivery after a course of a corticosteroid treatment
C. Vaginal delivery induction after a course of corticosteroid treatment
D. Watch for a spontaneous vaginal delivery at any term from the moment of presentation

Answer: Induction of vaginal delivery at 37 weeks’ pregnancy if not begin spontaneously earlier

1. Patient is a 25-year-old primigravida.

2. Patient is admitted to the hospital at 35 weeks gestation.

6. Patient was compliant with recommended prenatal care.

12. Physical examination shows 2+ pitting edema.

13. 24-hour urine assessment showed proteinuria (1.2 g).

14. Ultrasound examination showed a normally developing fetus without structural abnormalities.

15. Placental margin is located 3 cm away from the internal os.


Question: What is the most likely primary metabolic disturbance?

Context: A 12-year-old female presents to the emergency room difficult to arouse and occasionally vomiting.

Context: On physical exam, her oral mucosa looks dry, her breath has a fruity odor, and her breathing is slow, deep and labored.

Choices:
A. Anion gap metabolic acidosis
B. Non-anion gap metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis

Answer: Anion gap metabolic acidosis

1. A 12-year-old female presents to the emergency room.

4. On physical exam, her oral mucosa looks dry.

6. Her breathing is slow, deep and labored.


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

Context: A 36-year-old man presents to the emergency room with subacute worsening of chronic chest pain and shortness of breath with exertion.

Context: The patient is generally healthy, lifts weights regularly, and does not smoke.

Context: His temperature is 97.8°F (36.6°C), blood pressure is 122/83 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Context: An ECG shows left axis deviation and meets criteria for left ventricular hypertrophy.

Context: An initial troponin is < 0.01 ng/mL.

Choices:
A. Bacterial endocarditis
B. Bicuspid aortic valve
C. Cardiac myxoma
D. Senile calcific changes

Answer: Bicuspid aortic valve

1. A 36-year-old man presents to the emergency room.

2. Patient has subacute worsening of chronic chest pain and shortness of breath with exertion.

3. Patient is generally healthy and lifts weights regularly.

5. Patient's temperature is 97.8°F (36.6°C).

6. Patient's blood pressure is 122/83 mm Hg.

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

10. Cardiac auscultation reveals a crescendo-decrescendo murmur heard right of the upper sternal border with radiation into the carotids.

11. ECG shows left axis deviation and meets criteria for left ventricular hypertrophy.


Question: Which of the following characteristics of norepinephrine best explains this choice in this patient?

Context: A 66-year-old man is admitted to the intensive care unit for management of laboratory-confirmed septic shock.

Context: After the administration of adequate intravenous isotonic fluids, his temperature is 37.2°C (99.0°F), the pulse rate is 120/min, the blood pressure is 90/50 mm Hg, and the respiratory rate is 22/min.

Context: His extremities are warm and capillary refill time is normal.

Context: The patient is started on vasopressor therapy, and norepinephrine is chosen over epinephrine.

Choices:
A. Norepinephrine has less α1-adrenergic effects compared to epinephrine
B. Norepinephrine has more β2-adrenergic activity compared to epinephrine
C. Norepinephrine has similar α1-adrenergic effects compared to epinephrine
D. Norepinephrine has more α1-adrenergic effects compared to epinephrine

Answer: Norepinephrine has more α1-adrenergic effects compared to epinephrine

1. A 66-year-old man is admitted to the intensive care unit.

2. He has laboratory-confirmed septic shock.

3. His current plan includes appropriate management of airway and breathing, intravenous antibiotics, fluid resuscitation, and supportive care.

4. After the administration of adequate intravenous isotonic fluids, his temperature is 37.2°C (99.0°F).

10. He is started on vasopressor therapy.

11. Norepinephrine is chosen over epinephrine.


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

Context: A 67-year-old man comes to the physician because of a worsening tremor that began one year ago.

Context: The tremor affects his left hand and improves when he uses his hand to complete a task.

Context: He also reports feeling stiffer throughout the day, and he has fallen twice in the past year.

Context: He has not noticed any changes in his cognition or mood.

Context: He has not had difficulty sleeping, but his wife says that he would kick and punch while dreaming for almost a decade.

Context: He drinks two cans of beer daily.

Context: He takes no medications.

Context: He appears healthy and well nourished.

Context: His vital signs are within normal limits.

Context: He maintains a blank stare throughout the visit.

Choices:
A. Reduced amplitude on foot tapping
B. Extensor plantar response
C. Choreiform movements
D.
No abnormalities
"

Answer: Reduced amplitude on foot tapping

2. Patient has worsening tremor that began one year ago.

4. Tremor improves when patient uses hand to complete a task.

5. Patient reports feeling stiffer throughout the day.

6. Patient has fallen twice in the past year.

7. Patient has not noticed any changes in cognition or mood.

8. Patient has not had difficulty sleeping.

9. Patient's wife says he has been kicking and punching while dreaming for almost a decade.

10. Patient drinks two cans of beer daily.

12. Patient appears healthy and well nourished.

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

14. Patient maintains a blank stare throughout the visit.

Neurology with Special Qualification in Child Neurology


Question: Which finding would you most likely expect with this patient?

Context: A 25-year-old African American man comes to the emergency department for “red urine.” Patient reports that he just returned from a skiing trip in the Rocky Mountains and developed the reddish urine today.

Context: He denies upper respiratory infection symptoms, chest pain, fever, or chills but does endorse some right flank pain that developed 3 days ago.

Context: Laboratory findings are as follows: |  | Serum: | Na+: 137 mEq/L | K+: 4.9 mEq/L | Cl-: 100 mEq/L | HCO3-: 25 mEq/L | Osmolality: 275 Osm/kg |  | Urine: | Color: Red | Protein: 3+ | RBC: 4 cells/hpf | Osmolality: 214 Osm/kg | Specific gravity: 1.004 |  | .

Choices:
A. Cystic mass of the right kidney on CT abdomen/pelvis
B. HbS on hemoglobin electrophoresis
C. Renal stones on CT abdomen/pelvis
D. Segmental sclerosis and hyalinosis of renal glomeruli on light microscopy

Answer: HbS on hemoglobin electrophoresis

1. A 25-year-old African American man comes to the emergency department for “red urine.”

2. Patient reports that he just returned from a skiing trip in the Rocky Mountains and developed the reddish urine today.

3. He denies upper respiratory infection symptoms, chest pain, fever, or chills.

4. He endorses some right flank pain that developed 3 days ago.

5. Physical examination was unremarkable except for some tenderness upon palpation at the right flank.


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

Context: A 62-year-old man presents to his primary care physician because of lower back pain and radiating leg pain.

Context: He says that the pain is searing and goes from the buttock into the posterior thigh and lateral leg.

Context: It is moderate in intensity and he has noticed that it worsens with sitting and improves with standing.

Context: His past medical history is significant for well controlled hypertension, but he has otherwise been healthy.

Context: He works as a laborer loading packages in a warehouse and is concerned because the pain does not allow him to work.

Context: On physical exam, he is found to have pain and paresthesia while performing a straight leg raise.

Context: Radiographs show loss of disk height and MRI shows significant degeneration and posterolateral herniation of the disk in between the L5 and S1 vertebrae.

Choices:
A. Weak ankle dorsiflexion and diminished Achilles reflex
B. Weak ankle dorsiflexion and hallucis extension
C. Weak ankle plantarflexion and diminished Achilles reflex
D. Weak ankle plantarflexion and diminished patellar reflex

Answer: Weak ankle plantarflexion and diminished Achilles reflex

1. A 62-year-old man presents to his primary care physician.

2. He has lower back pain and radiating leg pain.

3. The pain is searing and goes from the buttock into the posterior thigh and lateral leg.

5. The pain worsens with sitting and improves with standing.

6. His past medical history is significant for well controlled hypertension.

7. He works as a laborer loading packages in a warehouse.

8. He is concerned because the pain does not allow him to work.

9. On physical exam, he has pain and paresthesia while performing a straight leg raise.

10. Radiographs show loss of disk height.

11. MRI shows significant degeneration and posterolateral herniation of the disk in between the L5 and S1 vertebrae.

12. Adjacent disks appear to be relatively normal without notable herniation.


Question: Which of the following medications is first-line therapy to slow disease progression?

Context: It seems to subsides later in the day.

Context: The blood tests show the following findings: | Red blood cell count 3.3 million/mm3 | Hb 12.1 mg/dL | Leukocyte count 10,101/mm3 | ESR 48 mm/h | C-reactive protein 3.9 mg/L | Anti-cyclic citrullinated peptide 45 μ/mL | .

Choices:
A. Intra-articular corticosteroid injections
B. Methotrexate
C. Meloxicam
D. Etanercept

Answer: Methotrexate

1. A 46-year-old woman presents to her primary care provider with pain in both of his hands and wrists.

2. She notes that it is hard for her to prepare breakfast or wash dishes in the morning due to stiffness.

3. It seems to subsides later in the day.

4. She also complains of a constant fatigue and unintentional weight loss during the last few months.

5. The past medical history is significant for hypertension.

6. She takes captopril and aspirin daily, and occasional ibuprofen for the pain in her hands.

7. Her mother developed similar symptoms in her hands resulting in hand deformity.

8. The blood pressure is 140/90 mm Hg, heart rate is 67/min, respiratory rate is 13/min, and temperature is 37.0°C (98.6°F).

9. Physical examination shows redness, edema, and tenderness on palpation at the metacarpophalangeal and proximal interphalangeal joints of both hands.

10. The blood tests show the following findings:

11. Red blood cell count 3.3 million/mm3

16. Anti-cyclic citrullinated peptide 45 μ/mL.


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

Context: A 27-year-old woman presents to her primary care physician’s office complaining of trouble sleeping.

Context: She reports that for the past 10 months she has experienced difficulty falling asleep due constant worrying.

Context: The content of her worry include items such as whether or not her child will feel lonely in day care and the health of her parents.

Context: She states that she has trouble concentrating at work as well and describes her heart as "racing" during these episodes.

Choices:
A. Acetylcholine
B. Dopamine
C. GABA
D. Norepinephrine

Answer: GABA

1. A 27-year-old woman presents to her primary care physician's office.

2. She is complaining of trouble sleeping.

3. She has experienced difficulty falling asleep for the past 10 months.

4. The content of her worry includes items such as whether or not her child will feel lonely in day care and the health of her parents.

5. These worrying episodes typically begin toward the end of the day and last for several hours.

6. She has trouble concentrating at work.

7. She describes her heart as "racing" during these episodes.

8. She denies any alcohol or illicit drug use.


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

Context: A 10-year-old boy is brought to the physician because of fever and bloody diarrhea for the past few days.

Context: His parents report that he has become increasingly lethargic and irritable.

Context: His temperature is 38.6°C (101.4°F), pulse is 102/min, and respirations are 22/min.

Context: He has no significant past medical history.

Context: His parents say that he mostly only eats a diet of chicken, hamburgers, fries, cheese, and milk.

Context: His laboratory studies show: | Hemoglobin 8.9 gm/dL | Leukocyte count 9,300/mm3 | Platelet count 67,000/mm3 | Blood urea nitrogen 43 mg/dL | Serum creatinine 2.46 mg/dL | Coombs test Negative | .

Choices:
A. Thrombotic thrombocytopenic purpura
B. Genetic form of hemolytic uremic syndrome
C. Hemolytic uremic syndrome associated with systemic disease
D. Escherichia-induced hemolytic uremic syndrome

Answer: Escherichia-induced hemolytic uremic syndrome

2. Patient has had fever and bloody diarrhea for the past few days.

3. Patient has become increasingly lethargic and irritable.

4. Patient's temperature is 38.6°C (101.4°F).

7. Patient has no significant past medical history.

8. Patient's diet consists mostly of chicken, hamburgers, fries, cheese, and milk.

9. On physical examination, pallor and edema in both legs are present.

11. Patient's leukocyte count is 9,300/mm3.

12. Patient's platelet count is 67,000/mm3.

13. Patient's blood urea nitrogen is 43 mg/dL.

14. Patient's serum creatinine is 2.46 mg/dL.


Question: Which structure has he most likely injured?

Context: A 50-year-old white male who works in construction comes to your office because of pain in his upper arm.

Context: He states that over the last few months, he has been having pain in his upper arm that worsens with raising objects overhead.

Context: He states that he also recently fell on his outstretched hand and that seemed to worsen his pain.

Context: He also had no pain with the lift off test, but does have significant pain with the empty can test and the arm drop test.

Choices:
A. Pectoralis major tendon
B. Deltoid muscle
C. Supraspinatus tendon
D. Subscapularis tendon

Answer: Supraspinatus tendon

1. A 50-year-old white male comes to the office.

4. The pain has been worsening over the last few months.

5. He recently fell on his outstretched hand.

6. His vital signs are within normal limits.

7. He has no pain on internal or external rotation.

8. He has no pain with the lift off test.

9. He has significant pain with the empty can test.

10. He has significant pain with the arm drop test.


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

Context: A 76-year-old man presents to the physician with a severe, pruritic rash as shown in the image.

Context: He has not noticed any insect bites.

Context: He is not experiencing any pain.

Choices:
A. Cimex lectularius
B. Dermatobia hominis
C. Varicella zoster
D. Sarcoptes scabiei

Answer: Cimex lectularius

1. A 76-year-old man presents to the physician with a severe, pruritic rash.

2. He has lost sleep over the past week because of itchiness and discomfort.

5. He currently lives in an elderly home where several other residents are experiencing a similar problem.

6. He has no history of a serious illness and does not take any medications.

7. His vital signs are within normal limits.

8. A similar rash is seen on his face and below the knees on both sides.

9. The skin of the groin, genital and perianal area, buttocks, and thighs show no abnormalities.

10. The remainder of the physical examination is unremarkable.


Question: Which of the following enzymes is deficient in this patient?

Context: A 6-month-old girl is brought to the hospital by her parents for evaluation due to poor feeding for the last month.

Context: Her parents say that she has not been eating well over the last two months, yet her abdomen has grown larger.

Context: Physical exam shows a thin female infant with an enlarged liver and palpable spleen.

Context: She has an intact muscle tone and reflexes.

Choices:
A. Hexosaminidase A
B. α-galactosidase A
C. Sphingomyelinase
D. Galactocerebrosidase

Answer: Sphingomyelinase

1. A 6-month-old girl is brought to the hospital by her parents.

2. Her parents say that she has not been eating well over the last two months.

4. Physical exam shows a thin female infant.

5. Physical exam reveals an enlarged liver.

6. Physical exam reveals a palpable spleen.

7. Eye exam reveals a red spot on the retina.

Pediatrics
Medical Genetics and Genomics

Pediatric Neurology
Pediatric Hematology
General Medical Genetics and Genomics


Question: This patient's presentation can be best explained by intoxication with a substance that acts at which of the following receptors?

Context: A 24-year-old female is brought to the ED from a nearby nightclub by the local police due to aggressive and violent behavior over the past hour.

Context: A friend accompanying the patient reports that the patient smoked marijuana that "seemed different" approximately one hour ago.

Context: The patient has never had this kind of reaction to marijuana use in the past.

Context: On examination, the patient is combative with slurred speech and active visual hallucinations; eye examination shows prominent vertical nystagmus.

Choices:
A. Serotonin
B. Cannabinoid
C. NMDA
D. Norepinephrine

Answer: NMDA

1. A 24-year-old female was brought to the ED from a nearby nightclub by the local police.

2. The patient had been exhibiting aggressive and violent behavior for the past hour.

3. A friend accompanying the patient reported that the patient had smoked marijuana approximately one hour ago.

4. The friend reported that the marijuana "seemed different".

5. The patient had never had this kind of reaction to marijuana use in the past.

6. On examination, the patient was combative with slurred speech and active visual hallucinations.

7. Eye examination showed prominent vertical nystagmus.


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

Context: He is his mother’s first-born boy.

Context: She was in Mexico during the delivery and says that she had a regular 39-week gestation.

Context: His pulse is 130/min, respiratory rate is 43/min, temperature is 37.2°C (99.0°F), and blood pressure is 90/60 mm Hg.

Choices:
A. Branched-chain alpha-ketoacid dehydrogenase
B. Cystathionine synthase deficiency
C. Phenylalanine hydroxylase
D. Propionyl-CoA carboxylase

Answer: Branched-chain alpha-ketoacid dehydrogenase

1. A 2-month-old infant comes to the clinic because of progressive weakness and fatigue over the past 4 weeks.

3. She was in Mexico during the delivery.

4. She says that she had a regular 39-week gestation.

5. She took folic acid during her pregnancy.

6. The infant was born through vaginal delivery with no complications.

7. Apgar scores were 10 and 9 at 1 and 5 minutes, respectively.

8. The neonate did not go through a newborn screening process.

13. Physical examination shows lethargy, hypotonia, and a weak response to primitive reflexes.

14. There is a “honey-like” odor around his diaper which the mother says has been present since birth.

Metabolic Genetics
Pediatric Metabolic Medicine


Question: Which of the following psychological defense mechanisms is this individual demonstrating?

Context: A 35-year-old engineer is told by his boss that his team will need to work extra evening hours in the coming week in order to meet a project deadline.

Context: This frustrates the engineer, who already feels he is working too many hours.

Context: Instead of discussing this directly with his boss, the engineer calls in sick and leaves his work for his boss to finish.

Choices:
A. Displacement
B. Acting out
C. Passive aggression
D. Blocking

Answer: Passive aggression

1. A 35-year-old engineer is told by his boss that his team will need to work extra evening hours in the coming week.

2. The extra evening hours are in order to meet a project deadline.

3. The engineer already feels he is working too many hours.

4. The engineer does not discuss this directly with his boss.

5. The engineer calls in sick and leaves his work for his boss to finish.


Question: Which of the following is the most likely underlying mechanism of this condition?

Context: A 29-year-old woman comes to the physician because of a 4-month history of fever, progressive shortness of breath, and a dry cough.

Context: During this time, she has also had a 5-kg (11-lb) weight loss.

Choices:
A. Necrotizing inflammation
B. Granulomatous inflammation
C. Monoclonal plasma cell production
D.
Neoplastic transformation
"

Answer: Granulomatous inflammation

1. A 29-year-old woman comes to the physician.

2. She has had a 4-month history of fever, progressive shortness of breath, and a dry cough.

3. She has had a 5-kg (11-lb) weight loss.

4. Two months ago, she was in Kenya for several weeks to visit her family.

5. Physical examination shows fine crackles and wheezing over both lung fields.

6. Her serum calcium concentration is 11.8 mg/dL.

7. An x-ray of the chest shows reticular opacities in both lungs and bilateral hilar lymphadenopathy.


Question: Which of the following agents is most strongly associated with this phenomenon described above?

Context: A 58-year-old man undergoes coronary angiography that demonstrates a 90% stenosis of the left anterior descending coronary artery.

Context: The circumflex branch of the left coronary artery is not significantly obstructed.

Context: Prior to the angiogram, he underwent a pharmacologic cardiac stress test.

Context: When administered, the pharmacologic agent caused the left circumflex artery to vasodilate, with resulting increased blood supply to its supplied myocardium that was already well-perfused at baseline.

Context: This increased flow through the circumflex artery shunted blood flow away from the myocardium supplied by the stenosed left anterior descending artery, resulting in ischemia that manifested as a perfusion defect on radionuclide imaging.

Choices:
A. Metoprolol
B. Verapamil
C. Diltiazem
D. Dipyridamole

Answer: Dipyridamole

1. A 58-year-old man underwent coronary angiography.

2. The angiography demonstrated a 90% stenosis of the left anterior descending coronary artery.

3. The circumflex branch of the left coronary artery was not significantly obstructed.

4. The man underwent a pharmacologic cardiac stress test prior to the angiogram.

5. The pharmacologic agent caused the left circumflex artery to vasodilate.

6. This increased blood supply to its supplied myocardium that was already well-perfused at baseline.

7. This increased flow through the circumflex artery shunted blood flow away from the myocardium supplied by the stenosed left anterior descending artery.

8. This resulted in ischemia that manifested as a perfusion defect on radionuclide imaging.


Question: Maintaining the patient on this medication to prevent recurrence of her current illness will also prevent infection with which of the following pathogens?

Context: A 51-year-old woman comes to the physician because of a 3-week history of fatigue, non-productive cough, and worsening shortness of breath while walking.

Context: She takes no medications because she does not feel like she needs them.

Context: She occasionally uses intravenous illicit drugs and has smoked a pack of cigarettes daily for 35 years.

Context: She appears ill.

Context: Her temperature is 38.4°C (101.1°F), respiratory rate is 25/min, pulse is 116/min, and blood pressure is 115/70 mm Hg.

Context: Laboratory studies show a CD4 count of 67/mm3 (N ≥ 500/mm3) and an elevated HIV viral load.

Context: In addition to starting antiretroviral therapy, the appropriate treatment for her current illness is initiated.

Choices:
A. Varicella zoster virus
B. Toxoplasmosa gondii
C. Cryptococcus neoformans
D. Candida albicans

Answer: Toxoplasmosa gondii

1. A 51-year-old woman comes to the physician.

2. She has a 3-week history of fatigue, non-productive cough, and worsening shortness of breath while walking.

3. She was diagnosed with HIV 11 years ago.

4. Two years ago, she was treated for esophageal thrush with fluconazole.

6. She occasionally uses intravenous illicit drugs.

7. She has smoked a pack of cigarettes daily for 35 years.

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

14. Inspiratory crackles are heard over bilateral lung fields.

15. Cardiac examination shows no abnormalities.

16. Laboratory studies show a CD4 count of 67/mm3 (N ≥ 500/mm3).

17. Laboratory studies show an elevated HIV viral load.

18. An x-ray of the chest shows diffuse interstitial infiltrates bilaterally.

19. The appropriate treatment for her current illness is initiated in addition to starting antiretroviral therapy.

General Pulmonary Disease
Pulmonary Disease


Question: Which of the following is the most likely mechanism giving rise to this patient’s condition?

Context: A 37-year-old man presents with right lower extremity weakness and low back pain.

Context: The patient states that he has had chronic mild to moderate low back pain for several years, but, 3 days ago after lifting a box, the pain increased in intensity and spread to his right leg.

Context: He describes the pain as severe, electrical in character, and descending from his right gluteal region along his right posterior thigh and leg to his right lateral ankle and foot.

Context: The patient also says that he has been having difficulty walking due to stumbling over his right foot.

Context: His temperature is 37.0℃ (98.6℉), the blood pressure is 125/80 mm Hg, the pulse is 72/min, the respiratory rate is 16/min, and the oxygen saturation is 98% on room air.

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

Context: Musculoskeletal examination of the lower extremities shows the following results: | Functional Muscle Group/DTR Tested Right Side Left Side |                Strength | Hip extension 5/5 5/5 | Hip abduction 4/5  5/5 | Hip adduction  5/5  5/5 | Hip flexion 5/5 5/5 | Knee flexion 5/5 5/5 | Knee extension 5/5 5/5 | Foot plantar flexion 5/5 5/5 | Foot dorsiflexion 4/5 5/5 | Foot inversion 4/5 5/5 | Foot eversion 4/5 5/5 | Toe extension 3/5 5/5 |               Reflexes | Knee 3+ 3+ | Achilles 1+ 3+ | Plantar 2+ 3+ |                Sensory | Sensation Decreased on the lateral aspect of the lower leg and dorsum of the foot Normal over all the surface | Lassegue test Positive at 30 deg.

Context: Negative | .

Choices:
A. Protrusion of the L4/L5 intervertebral disk
B. Entrapment of the femoral nerve in the femoral canal
C. Inflammation of the S2-3 spinal roots
D. Herniation of the L2/3 intervertebral disk

Answer: Protrusion of the L4/L5 intervertebral disk

2. Patient presents with right lower extremity weakness and low back pain.

3. Patient has had chronic mild to moderate low back pain for several years.

4. Pain increased in intensity and spread to right leg 3 days ago after lifting a box.

5. Patient describes pain as severe, electrical in character, and descending from right gluteal region along right posterior thigh and leg to right lateral ankle and foot.

6. Patient has been having difficulty walking due to stumbling over right foot.

11. Oxygen saturation is 98% on room air.

12. Patient is alert and cooperative on physical examination.

13. Strength of hip extension is 5/5 on right side and 5/5 on left side.

14. Strength of hip abduction is 4/5 on right side and 5/5 on left side.

15. Strength of hip adduction is 5/5 on right side and 5/5 on left side.

16. Strength of hip flexion is 5/5 on right side and 5/5 on left side.

17. Strength of knee flexion is 5/5 on right side and 5/5 on left side.

18. Strength of knee extension is 5/5 on right side and 5/5 on left side.

19. Strength of foot plantar flexion is 5/5 on right side and 5/5 on left side.

20. Strength of foot dorsiflexion is 4/5 on right side and 5/5 on left side.

21. Strength of foot inversion is 4/5 on right side and 5/5 on left side.

22. Strength of foot eversion is 4/5 on right side and 5/5 on left side.

23. Strength of toe extension is 3/5 on right side and 5/5 on left side.

24. Knee reflex is 3+ on right side and 3+ on left side.

25. Achilles reflex is 1+ on right side and 3+ on left side.

26. Plantar reflex is 2+ on right side and 3+ on left


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

Context: A 21-year-old woman comes to the physician because of a 5-day history of pain with urination and vaginal itching.

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

Context: Pelvic examination shows erythema of the vulva and vaginal mucosa, punctate hemorrhages on the cervix, and green-yellow, malodorous discharge.

Choices:
A. Neisseria gonorrhoeae
B. Treponema pallidum
C. Candida albicans
D. Trichomonas vaginalis

Answer: Trichomonas vaginalis

1. A 21-year-old woman comes to the physician.

2. She has a 5-day history of pain with urination and vaginal itching.

3. She is sexually active with multiple partners.

5. Pelvic examination shows erythema of the vulva and vaginal mucosa.

6. Pelvic examination shows punctate hemorrhages on the cervix.

7. Pelvic examination shows green-yellow, malodorous discharge.

8. A photomicrograph of the discharge is shown.


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

Context: A 9-year-old girl has recently begun having daily staring-spells in which she becomes unresponsive for several seconds.

Context: Following these episodes, she rapidly returns to normal with no recollection of the event.

Context: The child's pediatrician refers her to a pediatric neurologist, and, after an appropriate neurological work-up, the child is diagnosed with absence seizures.

Context: Her neurologist recommends initiating an anti-seizure medication, but the patient adamantly refuses due to fear of side effects and her belief that the condition is not affecting her quality of life.

Choices:
A. Prescribe a long acting depot medication
B. Discuss the patient's school performance with her teachers
C. Obtain consent from one parent before initiating therapy
D. Obtain consent from both parents before initiating therapy

Answer: Obtain consent from one parent before initiating therapy

1. A 9-year-old girl has recently begun having daily staring-spells.

2. During these episodes, she becomes unresponsive for several seconds.

3. Following the episodes, she rapidly returns to normal with no recollection of the event.

4. Her performance in school has begun to deteriorate.

5. The child's pediatrician refers her to a pediatric neurologist.

6. After an appropriate neurological work-up, the child is diagnosed with absence seizures.

7. Her neurologist recommends initiating an anti-seizure medication.

8. The patient adamantly refuses due to fear of side effects.

9. The patient also refuses due to her belief that the condition is not affecting her quality of life.


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

Context: A 44-year-old woman comes to the physician because of pain and swelling below her left eye for 3 days.

Context: She has also had excessive watering from her eyes during this period.

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

Context: Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 110/70 mm Hg.

Context: The discharge is sent for cultures.

Choices:
A. Topical ciprofloxacin
B. Irrigation of lacrimal cannaliculi
C. Oral amoxicillin-clavulanate therapy
D.
CT scan of the orbit
"

Answer: Oral amoxicillin-clavulanate therapy

1. A 44-year-old woman comes to the physician.

2. She has pain and swelling below her left eye for 3 days.

3. She has had excessive watering from her eyes during this period.

4. She has no history of serious illness.

9. Examination shows erythema, tenderness, warmth, and swelling below the medial canthus of the left eye.

10. There is purulent discharge from the lower lacrimal punctum on palpation of the swelling.

11. The remainder of the examination shows no abnormalities.


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

Context: A 40-year-old man comes to the physician because of decreased sexual arousal and erectile dysfunction that has put strain on his marriage for the last year.

Context: He has also had fatigue and generalized weakness for the past 9 months.

Context: He looks fatigued.

Context: He is 168 cm (5 ft 6 in) tall and weighs 89 kg (196 lb); BMI is 31.6 kg/m2.

Context: His temperature is 36.5°C (97.7°F), pulse is 50/min, and blood pressure is 125/90 mm Hg.

Context: Laboratory studies show: | Hemoglobin 11.0 g/dL | Platelet count 380,000/mm3 | Serum | Na+ 130 mEq/L | Cl- 97 mEq/L | K+ 4.5 mEq/L | HCO3- 25 mEq/L | Glucose 95 mg/dL | TSH 0.2 μU/mL | .

Choices:
A. Hemochromatosis
B. Pituitary adenoma
C. Graves disease
D. Hashimoto thyroiditis

Answer: Pituitary adenoma

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

2. He has decreased sexual arousal and erectile dysfunction.

3. This has put strain on his marriage for the last year.

4. He has had fatigue and generalized weakness for the past 9 months.

5. He has noticed his bowel movements have not been as frequent as usual.

6. He has occasional dry coughing and back pain.

7. He has not had fever, headache, or changes in vision.

8. One year ago, he traveled to South Africa with his wife.

16. Physical examination shows dry skin and a distended abdomen.

17. Neurological examination reveals delayed deep tendon reflexes.

18. Laboratory studies show: Hemoglobin 11.0 g/dL.

19. Laboratory studies show: Platelet count 380,000/mm3.

20. Laboratory studies show: Serum Na+ 130 mEq/L.

21. Laboratory studies show: Cl- 97 mEq/L.

22. Laboratory studies show: K+ 4.5 mEq/L.

23. Laboratory studies show: HCO3- 25 mEq/L.

24. Laboratory studies show: Glucose 95 mg/dL.

25. Laboratory studies show: TSH 0.2 μU/mL.


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

Context: A 52-year-old man with limited, unresectable small cell lung cancer comes to the emergency department because of fever for the past 2 days.

Context: His temperature is 38.5°C (101.3°F), blood pressure is 100/60 mm Hg, and pulse is 115/min.

Context: The lungs are clear to auscultation.

Context: Examination shows a soft, nontender abdomen.

Context: Laboratory studies show: | Hemoglobin 10.2 g/dL | Leukocyte count 4,000/mm3 | Total neutrophils 8% | Eosinophils 2% | Lymphocytes 80% | Monocytes 10% | Urinalysis shows no abnormalities.

Context: Blood culture samples are obtained.

Choices:
A. Cefepime
B. Piperacillin
C. Clindamycin
D. High-resolution chest CT

Answer: Cefepime

1. A 52-year-old man has limited, unresectable small cell lung cancer.

2. He has been on numerous chemotherapy regimens.

3. His last round of treatment was with cisplatin and etoposide and ended 10 days ago.

4. He has had fever for the past 2 days.

5. He feels fatigued but has not had nausea or vomiting.

16. His urinalysis shows no abnormalities.


Question: Which of the following findings are most likely?

Context: Auscultation of the lungs reveals bilateral crepitations and a friction rub.

Context: Lab findings show pancytopenia, proteinuria, and a false-positive test for syphilis.

Choices:
A. Photosensitivity
B. Urethritis
C. Xerostomia
D. Esophageal dysmotility

Answer: Photosensitivity

1. A 28-year-old woman presents in respiratory distress.

2. Auscultation of the lungs reveals bilateral crepitations.

3. Auscultation of the lungs reveals a friction rub.

6. Lab findings show a false-positive test for syphilis.

7. A chest X-ray shows bilateral pleural effusions.


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

Context: A 2-month-old infant is brought in by his mother for runny nose and cough.

Context: She reports he had an ear infection 2 weeks ago, and since then he has had a productive cough and nasal congestion.

Context: The mother reports that the infant has a good appetite but has had intermittent, non-bloody diarrhea.

Context: On physical examination, the patient has widespread, dry, erythematous patches, mucopurulent nasal drip, and crusting of the nares.

Context: Labs are drawn, as shown below: |  | Hemoglobin: 12.8 g/dL | Platelets: 280,000/mm^3 | Leukocytes: 7,500/mm^3 | Neutrophils: 5,500/mm^3 | Lymphocytes: 2,000/mm^3 |  | Serum: | Na+: 138 mEq/L | Cl-: 96 mEq/L | K+: 4.3 mEq/L | HCO3-: 23 mEq/L | Urea nitrogen: 18 mg/dL | Glucose: 90 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: : 9.2 mg/dL |  | .

Choices:
A. 22q11.2 deletion
B. Adenosine deaminase deficiency
C. Defective leukocyte adhesion
D. WAS gene mutation

Answer: Adenosine deaminase deficiency

1. A 2-month-old infant is brought in by his mother.

2. The infant has a runny nose and cough.

3. The mother reports he had an ear infection 2 weeks ago.

4. Since then he has had a productive cough and nasal congestion.

5. His medical history is significant for multiple ear infections and eczematous dermatitis.

6. He has also been hospitalized for 2 episodes of severe viral bronchiolitis.

7. The mother reports that the infant has a good appetite.

8. The infant has intermittent, non-bloody diarrhea.

9. The patient is at the 20th percentile for weight.

10. On physical examination, the patient has widespread, dry, erythematous patches.

11. The patient has mucopurulent nasal drip and crusting of the nares.

12. His tongue is coated by a thick white film which is easily scraped off.

13. Crackles are heard at the left lung base.


Question: Which of the following is the most appropriate response in this patient’s case?

Context: A 51-year-old inmate was released from prison 1 month ago and visits his general practitioner for evaluation of a positive HIV diagnosis he received from a local free clinic a week ago.

Context: The patient states that he had spent the last 2 years in prison and that, during that time, he had engaged in multiple unprotected sexual acts with fellow male inmates.

Context: When he was released from prison recently, he decided to get tested for HIV and was diagnosed positive.

Context: He is currently married with 2 children and has been paroled back to the home he shares with them.

Context: He has not told either his wife or his children of his diagnosis.

Context: He adamantly states that he is not homosexual, but that his wife would assume that he is if she found out he had contracted HIV while in prison.

Context: He states that he is terrified his wife will leave him or possibly keep his children from seeing him if she finds out about his HIV status.

Context: He insists that he will use the proper precautions to ensure his wife and children don’t contract HIV from him and reiterates the importance of keeping his diagnosis a secret.

Context: He continues and states that “they are all I have.

Context: If they leave me, I have no one.” .

Choices:
A. Honor the patient’s wishes and treat him without telling his wife or reporting him to the Department of Health
B. Tell the patient you will honor his wishes, but report him to the Department of Health so they can tell his wife
C. Consult an ethics committee to determine whether or not to report him to the Department of Health
D. Advise the patient the positive diagnosis will be reported to the public health office, but you would also encourage him to have a discussion with his family.

Answer: Advise the patient the positive diagnosis will be reported to the public health office, but you would also encourage him to have a discussion with his family.

1. A 51-year-old inmate was released from prison 1 month ago.

2. He visits his general practitioner for evaluation of a positive HIV diagnosis he received from a local free clinic a week ago.

3. He had spent the last 2 years in prison.

4. During that time, he had engaged in multiple unprotected sexual acts with fellow male inmates.

5. He is currently married with 2 children.

6. He has been paroled back to the home he shares with them.

7. He has not told either his wife or his children of his HIV diagnosis.

8. He adamantly states that he is not homosexual.

9. He is terrified his wife will leave him or possibly keep his children from seeing him if she finds out about his HIV status.

10. He wants to be treated without the threat of his wife finding out.

11. He insists that he will use the proper precautions to ensure his wife and children don’t contract HIV from him.

12. He reiterates the importance of keeping his diagnosis a secret.

13. He states that “they are all I have. If they leave me, I have no one.”


Question: Which of the following adverse events is associated with the use of this agent?

Context: A 62-year-old man with end-stage renal disease is brought to the emergency department because of fever, severe abdominal pain, and shaking chills for 4 hours.

Context: His last hemodialysis was 2 days ago.

Choices:
A. Photosensitivity
B. Rhabdomyolysis
C. Ototoxicity
D. QT prolongation

Answer: Rhabdomyolysis

1. A 62-year-old man with end-stage renal disease is brought to the emergency department.

2. He has fever, severe abdominal pain, and shaking chills for 4 hours.

3. His last hemodialysis was 2 days ago.

4. On arrival, he appears ill and is poorly responsive.

5. Blood cultures grow gram-positive, catalase-positive cocci that express mecA.

6. Intravenous antibiotic therapy is begun with an agent that disrupts cell membranes by creating transmembrane channels.


Question: Which of the following is the most likely origin of the injured muscles?

Context: A 25-year-old woman comes to the physician because of pain and weakness in her left leg that started 2 days ago while running a marathon.

Context: Physical examination shows impaired flexion of the left knee joint and impaired extension of the left hip joint.

Context: An MRI of the left lower extremity shows injury to the long head of the biceps femoris muscle and the semitendinosus muscle.

Choices:
A. Ischial tuberosity
B. Anterior superior iliac spine
C. Greater trochanter
D. Linea aspera

Answer: Ischial tuberosity

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

2. She has pain and weakness in her left leg.

3. The pain and weakness started 2 days ago.

4. She was running a marathon when the pain and weakness started.

5. Physical examination shows impaired flexion of the left knee joint.

6. Physical examination shows impaired extension of the left hip joint.

7. An MRI of the left lower extremity shows injury to the long head of the biceps femoris muscle.

8. An MRI of the left lower extremity shows injury to the semitendinosus muscle.


Question: Which of the following is most likely to improve the patient's ability to conceive?

Context: A 32-year-old man and his 29-year-old wife come to the physician because they have been unable to conceive despite regular unprotected sexual intercourse for 13 months.

Context: The man works in construction and his wife is a secretary for a law firm.

Context: The right scrotum appears normal.

Choices:
A. Ligation of dilated pampiniform venous plexus
B. Conservative management with scrotal support
C. Surgical excision of the hydrocele sac
D. Administration of ceftriaxone and doxycycline

Answer: Ligation of dilated pampiniform venous plexus

1. A 32-year-old man and a 29-year-old wife come to the physician.

2. They have been unable to conceive despite regular unprotected sexual intercourse for 13 months.

3. The woman reports regular menstrual cycles since the age of 13.

4. Menses occur at regular 28-day intervals and last 5–7 days.

5. Ovulation predictor kits consistently turn positive around day 14.

6. The man has a negative history of mumps.

7. They each smoked one pack of cigarettes per day until one year ago.

9. The wife is a secretary for a law firm.

10. Examination of the scrotum in a standing position shows soft bands palpated in the upper pole of the left scrotum with an intact left testicle.

11. Following Valsalva maneuver, the patient reports a dull, aching pain in his left hemiscrotum.

12. A light held behind the scrotum does not shine through.

14. Semen studies show normal sperm count with moderately decreased motility and abnormal morphology.

Reproductive Endocrinology and Infertility


Question: Which of the following personality disorders best characterizes this patient?

Context: A 29-year-old man comes into his primary care physician's office with a chief complaint of a cough.

Context: The patient states that the cough started yesterday and he is asking if he needs antibiotics.

Context: While conversing with the patient, you note that he seems cold, mistrustful, and does not display much emotion.

Context: The patient worked for a software company but recently took a different position that allows him to work from home.

Context: The patient states that he switched positions because while at the office he made a mistake during a presentation.

Context: He felt that afterwards, his fellow workers thought less of him and he was embarrassed to show his face around the office.

Context: The patient wishes he could have related better to his coworkers.

Context: He currently lives in a barn on the outskirts of town with his many cats.

Context: On physical exam you note a healthy young man, adorned in overalls and denim shoes.

Context: His physical exam is notable for erythema of the posterior pharynx.

Context: The patient is informed that he has a viral upper respiratory infection and is sent home with instructions to rest and hydrate himself.

Choices:
A. Avoidant
B. Schizoid
C. Schizotypal
D. Paranoid

Answer: Avoidant

4. Patient is cold, mistrustful, and does not display much emotion.

5. Patient worked for a software company.

6. Patient recently took a different position that allows him to work from home.

7. Patient switched positions because of a mistake during a presentation.

8. Patient felt his coworkers thought less of him after the mistake.

9. Patient wishes he could have related better to his coworkers.

10. Patient currently lives in a barn on the outskirts of town with his many cats.

11. On physical exam patient is healthy and adorned in overalls and denim shoes.

12. Physical exam is notable for erythema of the posterior pharynx.

13. Patient has a viral upper respiratory infection.

14. Patient is sent home with instructions to rest and hydrate himself.


Question: Which of the following is true about informed consent in this case?

Context: A 49-year-old man is undergoing an elective hernia repair.

Context: No significant past medical history or current medications.

Context: The patient has been working as a cardiovascular surgeon in the same hospital for the past 15 years.

Context: In obtaining informed consent, the patient’s doctor has described all the available options for the procedure with their pros and cons, has offered different materials for the hernioplasty, and described the exact procedure.

Context: He has not focused too much on the possible complications and the risks and benefits of not performing the operation, because the patient insists he already knows everything that can happen since he is a surgeon himself.

Context: The patient has given his consent, but on the day of the operation, he changes his mind regarding the material of the synthetic mesh to be used for the hernioplasty.

Choices:
A. The informed consent obtained from this patient in this hospital is invalid because he works in the hospital.
B. There is no need to receive an informed consent from a patient who is a doctor himself.
C. The patient’s doctor should have included possible complications of the given operation and risks and benefits of not performing it, regardless of the patient’s education or prior experience.
D. Even though the patient has changed his mind about the type of mesh material, since the basic procedure is still the same, informed consent does not need to be obtained from the patient again.

Answer: The patient’s doctor should have included possible complications of the given operation and risks and benefits of not performing it, regardless of the patient’s education or prior experience.

2. Patient has no significant past medical history or current medications.

3. Patient has been working as a cardiovascular surgeon in the same hospital for the past 15 years.

4. Doctor has described all the available options for the procedure with their pros and cons.

5. Doctor has offered different materials for the hernioplasty.

6. Doctor has described the exact procedure.

7. Doctor has not focused too much on the possible complications and the risks and benefits of not performing the operation.

9. On the day of the operation, patient changes his mind regarding the material of the synthetic mesh to be used for the hernioplasty.


Question: What is the mechanism of action of the drug most likely responsible for the patient’s complaints?

Context: A 55-year-old man presents to his primary care provider complaining of blood clots in his urine.

Context: On further questioning, he also reports suprapubic discomfort and a feeling of bladder fullness with difficulty voiding.

Context: Vital signs are within normal limits.

Choices:
A. Alkylating agent
B. Intercalating agent
C. Reverse transcriptase inhibitor
D. Microtubule inhibitor

Answer: Alkylating agent

1. A 55-year-old man presents to his primary care provider.

2. He is complaining of blood clots in his urine.

3. On further questioning, he also reports suprapubic discomfort.

4. He also reports a feeling of bladder fullness with difficulty voiding.

5. The patient reports recently starting treatment for a newly diagnosed non-Hodgkin lymphoma.

6. Vital signs are within normal limits.

7. Physical exam reveals pain on palpation of the suprapubic region.


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

Context: A 25-year-old man presents to his primary care physician with lower back pain.

Context: He states that he has had the pain for the past two years.

Context: The patient works as a butcher, and recently was moving heavy meat carcasses.

Context: The patient states that his pain is worse in the morning and that nothing improves it aside from swimming.

Context: The patient has a past medical history of anabolic steroid abuse, acne, hypertension and obesity.

Context: His current medications are hydrochlorothiazide, ibuprofen, topical benzoyl peroxide, and acetaminophen.

Context: On physical exam there is no tenderness upon palpation of the spine.

Context: There is limited range of motion of the spine in all 4 directions.

Choices:
A. Radiograph of the spine
B. The straight leg test and the clinical presentation
C. MRI of the sacroiliac joint
D. HLA typing

Answer: MRI of the sacroiliac joint

2. Patient has lower back pain for two years.

4. Patient recently moved heavy meat carcasses.

5. Patient's pain is worse in the morning.

6. Nothing improves patient's pain aside from swimming.

7. Patient has past medical history of anabolic steroid abuse, acne, hypertension, and obesity.

8. Patient's current medications are hydrochlorothiazide, ibuprofen, topical benzoyl peroxide, and acetaminophen.

9. On physical exam, there is no tenderness upon palpation of the spine.

10. On physical exam, there is limited range of motion of the spine in all 4 directions.


Question: Which of the following may be associated with this patient’s condition?

Context: A 42-year-old African American female presents to your clinic complaining of excessive thirst and urination.

Context: She reports that these symptoms began one week ago, and they have been affecting her ability to work as a schoolteacher.

Context: Labs are drawn and are listed below. |  | Serum: | Na+: 145 mEq/L | Cl-: 101 mEq/L | K+: 4.4 mEq/L | HCO3-: 25 mEq/L | Urea nitrogen: 24 mg/dL | Glucose: 115 mg/dL | Creatinine: 0.7 mg/dL | Hemoglobin: 10.5 g/dL | Hematocrit: 25% | Leukocyte count: 11,000/mm^3 | Platelets: 200,000/mm^3 |  | Urine: | Specific gravity: 1.006 | Epithelial cells: 5/hpf | Glucose: negative | Protein: 20 mg/dL | RBC: 6/hpf | WBC: 1/hpf | Leukocyte esterase: negative | Nitrites: negative | Bacterial: none |  | A water deprivation test is performed with the following results: |  | Serum osmolality: 305 mOsm/kg | Urine osmolality: 400 mOsm/kg | Urine specific gravity: 1.007 |  | Desmopressin is administered, and the patient's urine osmolality increases to 490 mOsm/kg.

Context: The patient's antidiuretic hormone is measured and is within normal limits.

Choices:
A. Coarse tremor
B. Auditory hallucinations
C. Amenorrhea
D. Dactylitis

Answer: Dactylitis

1. Patient is a 42-year-old African American female.

2. Patient is complaining of excessive thirst and urination.

4. Symptoms are affecting patient's ability to work as a schoolteacher.

25. Serum osmolality after water deprivation test: 305 mOsm/kg

26. Urine osmolality after water deprivation test: 400 mOsm/kg

27. Urine specific gravity after water deprivation test: 1.007

28. Urine osmolality after desmopressin administration: 490 mOsm/kg

29. Patient's antidiuretic hormone is within normal limits.


Question: This patient has most likely been treated with which of the following medications?

Context: A 42-year-old male with a history of schizophrenia presents to his psychiatrist for a normal follow-up visit.

Context: He is accompanied by his case manager.

Context: The patient was diagnosed with schizophrenia at the age of 27.

Context: After being trialed on two different medications, he was deemed to be stable on a third medication which he has been taking for the past 10 years.

Context: He reports that he occasionally hears voices.

Context: He lives in supportive housing, and his caretakers report that he prefers to be alone but is not disruptive.

Context: His temperature is 99°F (37.2°C), blood pressure is 130/90 mmHg, pulse is 105/min, and respirations are 18/min.

Context: On exam, he demonstrates a flattened affect and disorganized speech.

Context: A funduscopic examination reveals pigmented plaques at the retinal periphery.

Context: No deposits are seen in the cornea or anterior lens.

Choices:
A. Fluphenazine
B. Olanzapine
C. Chlorpromazine
D. Thioridazine

Answer: Thioridazine

2. Patient has a history of schizophrenia.

3. Patient was diagnosed with schizophrenia at age 27.

4. Patient was trialed on two different medications.

5. Patient is stable on third medication for 10 years.

8. Caretakers report patient prefers to be alone.

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

10. Patient's blood pressure is 130/90 mmHg.

13. Patient demonstrates flattened affect and disorganized speech.

14. Funduscopic examination reveals pigmented plaques at retinal periphery.

15. No deposits seen in cornea or anterior lens.


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

Context: A 6-month-old girl is brought to the emergency department because her lips turned blue for several minutes earlier during feeding.

Context: Her father reports that the patient had similar episodes while playing that resolved quickly.

Context: During the examination, she sits calmly in her father's lap.

Context: When her ears are examined, the patient begins to cry and her lips and fingers begin to turn blue.

Choices:
A. Diminutive left ventricle on echocardiogram
B. Decreased blood pressure in both lower extremities
C. Pulmonary vascular congestion on chest x-ray
D. Right axis deviation on ECG

Answer: Right axis deviation on ECG

1. A 6-month-old girl was brought to the emergency department.

2. Her lips had turned blue for several minutes earlier during feeding.

3. Her father reported similar episodes while playing that resolved quickly.

4. During the examination, she was sitting calmly in her father's lap.

5. When her ears were examined, the patient began to cry.

6. Her lips and fingers began to turn blue.


Question: Which of the following mechanisms is responsible for the patient’s current condition?

Context: A 52-year-old female presents to clinic complaining of sudden onset of flank tenderness that was fluctuating and radiating into her groin.

Context: Laboratory analysis reveals a serum calcium of 12.4 (normal 8.4-10.2) and a serum phosphorous of 2.5 (normal 2.7-4.5) and a chloride:phosphorous ratio >33.

Choices:
A. PTH binding to receptors on osteoclasts
B. Parafollicular, or C-cell, synthesis of calcitonin
C. Increased RANK-L production
D. Decreased M-CSF production

Answer: Increased RANK-L production

1. A 52-year-old female presents to clinic.

2. Complaining of sudden onset of flank tenderness.

3. Flank tenderness was fluctuating and radiating into her groin.

4. Laboratory analysis reveals a serum calcium of 12.4.

5. Normal range for serum calcium is 8.4-10.2.

6. Laboratory analysis reveals a serum phosphorous of 2.5.

7. Normal range for serum phosphorous is 2.7-4.5.

8. Laboratory analysis reveals a chloride:phosphorous ratio >33.

9. You suspect primary hyperparathyroidism.


Question: Further histological examination of the liver biopsy specimen is most likely to show which of the following findings?

Context: A 53-year-old man comes to the physician because of a 2-week history of fatigue, generalized itching, and yellowing of the eyes and skin.

Context: He underwent a liver transplantation because of acute liver failure following α-amanitin poisoning 1 year ago.

Choices:
A. Graft vessel vasculitis
B. Fibrinoid necrosis
C. Interstitial fibrosis
D.
Viral inclusions
"

Answer: Interstitial fibrosis

1. A 53-year-old man comes to the physician.

2. He has a 2-week history of fatigue, generalized itching, and yellowing of the eyes and skin.

3. He underwent a liver transplantation 1 year ago due to acute liver failure following α-amanitin poisoning.

4. Physical examination shows scleral icterus and abdominal distention with shifting dullness.

5. A liver biopsy specimen shows decreased hepatic duct density.

General Gastroenterology
General Hepatology
Hepatology


Question: Which of the following echocardiographic findings is most likely in this patient?"

Context: A 23-year-old man comes to the emergency department because of a 5-day history of progressively worsening dyspnea.

Context: His temperature is 36.8°C (98.2°F), pulse is 113/min, and blood pressure is 100/70 mm Hg.

Context: Cardiac examination shows an S3 gallop.

Context: Laboratory studies show: | Hemoglobin 14.8 g/dL | Leukocyte count 9200/mm3 | Platelet count 230,000/mm3 | ESR 41 mm/hr | Serum | Creatinine 1.1 mg/dL | Glucose 92 mg/dL | LDH 120 U/L | Troponin I 0.204 ng/mL (N< 0.1 ng/mL) | An x-ray of the chest shows an enlarged cardiac silhouette and prominent vascular markings in both lung fields.

Context: An ECG shows diffuse T-wave inversions.

Choices:
A. Swinging heart with compression of the left heart chambers
B. Mitral valve stenosis with left atrial enlargement
C. Left ventricular dilation and global hypokinesis
D. Vegetations on the mitral valve

Answer: Left ventricular dilation and global hypokinesis

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

2. He has had a 5-day history of progressively worsening dyspnea.

3. He has had intermittent episodes of chest pain, which was 4/10 in intensity and increased on inspiration.

4. He does triathlons and has not been able to train because of the discomfort.

5. He has had no fever or syncopal episodes.

6. He had an upper respiratory tract infection 3 weeks ago.

7. His father died of heart disease at the age of 55 years.

11. Examination shows jugular venous distention.

12. Inspiratory crackles are heard throughout the thorax.

13. Cardiac examination shows an S3 gallop.

14. Laboratory studies show: Hemoglobin 14.8 g/dL.

15. Laboratory studies show: Leukocyte count 9200/mm3.

16. Laboratory studies show: Platelet count 230,000/mm3.

17. Laboratory studies show: ESR 41 mm/hr.

18. Laboratory studies show: Serum Creatinine 1.1 mg/dL.

19. Laboratory studies show: Glucose 92 mg/dL.

20. Laboratory studies show: LDH 120 U/L.

21. Laboratory studies show: Troponin I 0.204 ng/mL (N< 0.1 ng/mL).

22. An x-ray of the chest shows an enlarged cardiac silhouette and prominent vascular markings in both lung fields.

23. An ECG shows diffuse T-wave inversions.


Question: The obstruction in this patient is most likely caused by which of the following structures?

Context: Two days after undergoing abdominal surgery for lysis of adhesions, a 52-year-old man has nausea and one episode of bilious vomiting.

Choices:
A. Superior mesenteric artery
B. Common bile duct
C. Portal vein
D. Inferior vena cava

Answer: Superior mesenteric artery

1. A 52-year-old man underwent abdominal surgery for lysis of adhesions two days ago.

2. The patient has nausea and one episode of bilious vomiting.

3. The patient's nausea is somewhat alleviated in the prone position.

4. The patient has had a 70-kg (154-lb) weight loss since undergoing bariatric surgery 1 year ago.

5. Physical examination shows abdominal distention.

6. Sudden movement of the patient elicits a sloshing sound on auscultation of the abdomen.

7. An upper gastrointestinal series of the abdomen with oral contrast shows no passage of contrast past the third segment of the duodenum.


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

Context: A 16-year-old girl is brought to the physician because her mother is concerned about her lack of appetite and poor weight gain.

Context: She has had a 7-kg (15-lb) weight loss over the past 3 months.

Context: The patient states that she should try to lose more weight because she does not want to be overweight anymore.

Context: She maintains a diary of her daily calorie intake.

Context: Menarche was at the age of 13 years, and her last menstrual period was 3 months ago.

Context: She is on the high school track team.

Context: She is sexually active with 2 male partners and uses condoms inconsistently.

Context: She is at 50th percentile for height and below the 5th percentile for weight and BMI.

Context: Her temperature is 37°C (98.6°F), pulse is 58/min and blood pressure is 96/60 mm Hg.

Choices:
A. HIV infection
B. Type 1 diabetes mellitus
C. Hyperthyroidism
D. Anorexia nervosa

Answer: Anorexia nervosa

2. Patient has had a 7-kg (15-lb) weight loss over the past 3 months.

3. Patient states she should try to lose more weight.

4. Patient maintains a diary of her daily calorie intake.

5. Patient's menarche was at the age of 13 years.

6. Patient's last menstrual period was 3 months ago.

7. Patient is on the high school track team.

8. Patient is sexually active with 2 male partners.

10. Patient is at 50th percentile for height.

11. Patient is below the 5th percentile for weight and BMI.

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

14. Patient's blood pressure is 96/60 mm Hg.

15. Examination shows fine hair over the trunk and extremities.

Pediatric Endocrinology
Pediatric Gastroenterology


Question: What is the most likely diagnosis in this patient?

Context: A 25-year-old male presents with progressively worsening headaches over the past two months.

Context: He also feels that he has been losing his balance more often over the past week, but he denies any motor weakness or sensory impairment.

Context: His neurological exam reveals impaired upward gaze, pupils that constrict poorly to light but react to accommodation, and bilateral upper eyelid retraction.

Context: On tandem walking, he tends to fall on both sides.

Context: The remainder of the physical examination is unremarkable.

Choices:
A. Multiple sclerosis
B. Pituitary mass
C. Pineal tumor
D. Craniopharyngioma

Answer: Pineal tumor

3. Patient has had progressively worsening headaches for two months.

4. Patient has been losing balance more often over the past week.

5. Patient denies motor weakness or sensory impairment.

6. Neurological exam reveals impaired upward gaze.

7. Neurological exam reveals pupils constrict poorly to light but react to accommodation.

8. Neurological exam reveals bilateral upper eyelid retraction.

9. Patient tends to fall on both sides when tandem walking.

10. Remainder of physical examination is unremarkable.


Question: What is the next best step in management?

Context: A 32-year-old woman presents to an urgent care facility after having sustained a deep cut 8 hours ago while hiking in the Appalachian mountains.

Context: She immigrated to the United States at age 20 and was unvaccinated upon arrival.

Context: Her medical records indicate that she has since received one dose of Tdap and one Td booster 3 years ago.

Context: She is afebrile, well appearing, and her wound appears clean without signs of infection at this time.

Choices:
A. Tetanus immunoglobulin only
B. Tetanus titers and if negative, tetanus toxoid and immunoglobulin within 48 hours
C. Tetanus toxoid and tetanus immunoglobulin
D. Tetanus toxoid and tetanus immunoglobulin today; tetanus toxoid again on days 3, 7, and 14 after exposure

Answer: Tetanus toxoid and tetanus immunoglobulin

1. A 32-year-old woman presented to an urgent care facility.

2. She sustained a deep cut 8 hours ago while hiking in the Appalachian mountains.

3. Immediately after she sustained the injury she rinsed out the dirt with a bottle of saline from her first aid kit.

4. She immigrated to the United States at age 20.

6. Her medical records indicate that she has since received one dose of Tdap.

7. She has also received one Td booster 3 years ago.

10. Her wound appears clean without signs of infection at this time.


Question: Which of the following is associated with this patient's most likely diagnosis?

Context: A 39-year-old woman presents to the emergency department with a chief concern of abdominal pain.

Context: She states that her symptoms occurred shortly after she began eating dinner that evening.

Context: She states that the pain is in the right side of her abdomen and travels to her right shoulder.

Context: She has a past medical history of polycystic ovarian syndrome, obesity, type II diabetes mellitus, and hypertension.

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

Context: Her temperature is 99.5°F (37.5°C), blood pressure is 110/75 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 99% on room air.

Context: On abdominal exam, the patient demonstrates tenderness in the right upper quadrant.

Context: The patient is started on IV fluids and morphine.

Context: Four hours later, she states that the pain has abated.

Choices:
A. Acetylcholine
B. Cholecystokinin
C. Gastrin
D. Secretin

Answer: Cholecystokinin

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

3. Symptoms began shortly after eating dinner.

4. Pain is in the right side of the abdomen and travels to the right shoulder.

5. Patient has a past medical history of polycystic ovarian syndrome, obesity, type II diabetes mellitus, and hypertension.

6. Patient's current medications include metformin, insulin, atorvastatin, aspirin, and lisinopril.

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

8. Patient's blood pressure is 110/75 mmHg.

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

12. Abdominal exam demonstrates tenderness in the right upper quadrant.

13. Patient is started on IV fluids and morphine.

14. Four hours later, patient states that the pain has abated.


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

Context: A 12-year-old girl is brought to the primary physician because of severe ear pain and yellow discharge from her left ear for the past 2 days.

Context: It is also mildly pruritic.

Context: The pain started during her last day of summer camp, where she spent a lot of time outdoors hiking, horseback riding, and swimming.

Context: Her temperature is 37°C (98.6°F), pulse is 76/min, and blood pressure is 110/75 mm Hg.

Context: Examination shows tragal tenderness and a red and edematous external auditory canal.

Context: A diagnostic tuning fork is placed in the middle of the patient's forehead.

Context: The patient reports hearing the sound more loudly in the left ear.

Context: To complete the workup, the tuning fork is placed on the mastoid process of the left ear.

Context: Once she can no longer hear the sound, the tuning fork is placed in front of the auricle, and she reports no longer hearing the sound.

Context: On the right side, once the sound from the mastoid process subsides and the tuning fork is placed in front of the right ear, she reports hearing the sound again.

Choices:
A. Infection with Aspergillus species
B. Abnormal squamous epithelial growth
C. Infection with Pseudomonas aeruginosa
D.
Pleomorphic replacement of normal bone
"

Answer: Infection with Pseudomonas aeruginosa

2. Patient has severe ear pain and yellow discharge from left ear for 2 days.

4. Patient's pain started during last day of summer camp.

5. Patient spent time outdoors hiking, horseback riding, and swimming.

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

8. Patient's blood pressure is 110/75 mm Hg.

9. Examination shows tragal tenderness and red and edematous external auditory canal.

10. Diagnostic tuning fork is placed in middle of patient's forehead.

11. Patient reports hearing sound more loudly in left ear.

12. Tuning fork is placed on mastoid process of left ear.

13. Patient can no longer hear sound when tuning fork is placed in front of auricle.

14. On right side, sound from mastoid process subsides and patient reports no longer hearing sound when tuning fork is placed in front of right ear.


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

Context: A 50-year-old man comes to the emergency department because of severe lower chest pain for the past hour.

Context: The pain radiates to the back and is associated with nausea.

Context: He has had two episodes of non-bloody vomiting since the pain started.

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

Context: He has smoked one pack of cigarettes daily for 30 years.

Context: He drinks five to six beers per day.

Context: His medications include enalapril and metformin.

Context: His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 90/60 mm Hg.

Context: The lungs are clear to auscultation.

Context: Examination shows a distended abdomen with epigastric tenderness and guarding but no rebound; bowel sounds are decreased.

Context: Laboratory studies show: | Hemoglobin 14.5 g/dL | Leukocyte count 5,100/mm3 | Platelet count 280,000/mm3 | Serum | Na+ 133 mEq/L | K+ 3.5 mEq/L | Cl- 98 mEq/L | Total bilirubin 1.0 mg/dL | Amylase 160 U/L | Lipase 880 U/L (N = 14–280) | An ECG shows sinus tachycardia.

Choices:
A. Acute mesenteric ischemia
B. Peptic ulcer disease
C. Myocardial infarction
D. Acute pancreatitis

Answer: Acute pancreatitis

2. Patient has severe lower chest pain for the past hour that radiates to the back and is associated with nausea.

3. Patient has had two episodes of non-bloody vomiting since the pain started.

4. Patient has a history of hypertension and type 2 diabetes mellitus.

5. Patient smokes one pack of cigarettes daily for 30 years.

6. Patient drinks five to six beers per day.

7. Patient's medications include enalapril and metformin.

8. Patient's temperature is 38.5°C (101.3°F).

10. Patient's blood pressure is 90/60 mm Hg.

11. Patient's lungs are clear to auscultation.

12. Patient's abdomen is distended with epigastric tenderness and guarding but no rebound; bowel sounds are decreased.

14. Patient's leukocyte count is 5,100/mm3.

15. Patient's platelet count is 280,000/mm3.

19. Patient's total bilirubin is 1.0 mg/dL.

21. Patient's lipase is 880 U/L (N = 14–280).


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

Context: A 29-year-old woman presents to the physician’s office complaining of swollen hands for the past 3 weeks.

Context: The patient’s medical history is significant for hypothyroidism that is managed with levothyroxine.

Context: She has no recent travel history.

Context: Vital signs are normal.

Context: On examination, the patient has a butterfly-shaped, non-blanching rash on her face with mild cervical lymphadenopathy.

Choices:
A. Anti-double-stranded-DNA antibody
B. Anti-U1 ribonucleoprotein antibody
C. Antinuclear antibody
D. Anti-histone antibody

Answer: Antinuclear antibody

1. A 29-year-old woman presents to the physician's office.

2. She is complaining of swollen hands for the past 3 weeks.

3. It is associated with stiffness in the morning, which lasts about 10 minutes.

4. The patient's medical history is significant for hypothyroidism.

8. On examination, the patient has a butterfly-shaped, non-blanching rash on her face.

9. She has mild cervical lymphadenopathy.

10. The metacarpophalangeal and proximal interphalangeal joints are tender and appear swollen.

11. Cardiopulmonary examination reveals a grade 2/6 holosystolic murmur heard best at the apex.


Question: The structural changes in this patient's heart are most likely associated with which of the following?

Context: A 61-year-old male dies in a motor vehicle accident.

Context: Autopsy of the heart reveals dilatation of the left atrium and expansion of the left ventricular cavity with associated eccentric hypertrophy.

Choices:
A. Pulmonic stenosis
B. Mitral insufficiency
C. Chronic hypertension
D. Congenital atrial septal defect

Answer: Mitral insufficiency

2. The cause of death was a motor vehicle accident.

3. An autopsy of the heart was performed.

5. The left ventricular cavity was expanded.

6. Eccentric hypertrophy was associated with the expansion.

Adult Congenital Heart Disease
Congenital Cardiac Surgery
General Internal Medicine
General Cardiology


Question: Which of the following changes best describes the direct effect of the prescribed medication on his cardiovascular physiology in the cardiac output/venous return versus right atrial pressure graph?

Context: A 52-year-old business executive presents to his physician with complaints of intermittent chest pain which started 2 months ago.

Context: The pain radiates to his left arm and jaw, occurs only when he climbs the stairs or runs on a treadmill, and is relieved by rest.

Context: He has been hypertensive and diabetic for the last 10 years and has been compliant with his medications.

Choices:
A. i
B. iii
C. iv
D. vi

Answer: iv

1. A 52-year-old business executive presents to his physician.

2. He has intermittent chest pain which started 2 months ago.

3. He describes his pain as crushing, centrally located, and typically lasting about 5 minutes but never more than 10 minutes.

4. The pain radiates to his left arm and jaw.

5. The pain occurs only when he climbs the stairs or runs on a treadmill.

7. He has been hypertensive and diabetic for the last 10 years.

8. He has been compliant with his medications.

9. His physical exam findings are within normal limits.

10. Lab tests are normal except for a significantly elevated LDL-cholesterol level.

11. A stress ECG shows ST-segment depression in the anterior chest leads when his heart rate and blood pressure increase to over 40% from their baseline values.

12. The physician decides to initiate a medication to relieve his symptoms.

General Cardiology
Cardiovascular Disease


Question: Mutations in which of the following genes are most likely responsible for these findings?

Context: He was diagnosed with HIV 6 years ago and has been on highly active antiretroviral therapy with emtricitabine, tenofovir, and darunavir.

Context: His last CD4+ T-lymphocyte count was 520/mm3 (N > 500) and HIV viral load was undetectable.

Context: Today, his CD4+ T-lymphocyte count is 410/mm3 and his HIV viral load is 240 copies/mL.

Choices:
A. tat
B. pol
C. rev
D. env

Answer: pol

1. A 34-year-old man comes to the physician for a follow-up appointment.

2. He was diagnosed with HIV 6 years ago.

3. He has been on highly active antiretroviral therapy with emtricitabine, tenofovir, and darunavir.

4. He reports that he has been compliant with his medication regimen.

5. His last CD4+ T-lymphocyte count was 520/mm3 (N > 500).

6. His last HIV viral load was undetectable.

7. Today, his CD4+ T-lymphocyte count is 410/mm3.

8. Today, his HIV viral load is 240 copies/mL.

9. Further evaluation shows resistance to emtricitabine and tenofovir.


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

Context: A 61-year-old woman with a history of stage IV pancreatic cancer comes to the emergency department with insomnia due to intractable midepigastric pain.

Context: The pain had been constant for months but has worsened over the past few weeks despite the fact that she is already taking hydrocodone 10 mg and ibuprofen 400 mg.

Context: She has a past medical history of chronic pain and major depressive disorder.

Context: In the past month, she has been taking her pain medications with increasing frequency, going from twice a day to four times a day.

Context: Her other medications include venlafaxine and eszopiclone.

Context: She describes her mood as low, but states she does not have any suicidal thoughts.

Context: She appears fatigued and slightly cachectic.

Context: Her temperature is 36°C (96.8°F), pulse is 100/min, and blood pressure is 128/65 mm Hg.

Choices:
A. Discontinue hydrocodone and ibuprofen, and start IV ketorolac
B. Switch from hydrocodone to hydromorphone
C. Switch from eszopiclone to zolpidem
D.
Allow the patient to take hydrocodone and ibuprofen up to every four hours
"

Answer: Switch from hydrocodone to hydromorphone

2. Patient has a history of stage IV pancreatic cancer.

3. Patient presents to the emergency department with insomnia due to intractable midepigastric pain.

4. Pain has been constant for months but has worsened over the past few weeks.

5. Patient is already taking hydrocodone 10 mg and ibuprofen 400 mg.

6. Patient has a past medical history of chronic pain and major depressive disorder.

7. Patient has been taking her pain medications with increasing frequency, going from twice a day to four times a day.

8. Patient's other medications include venlafaxine and eszopiclone.

9. Patient describes her mood as low, but states she does not have any suicidal thoughts.

10. Patient appears fatigued and slightly cachectic.

11. Patient's temperature is 36°C (96.8°F).

13. Patient's blood pressure is 128/65 mm Hg.

14. Physical examination shows a mass in the midepigastric region.


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

Context: Two days into hospitalization for pyelonephritis and sepsis, a 48-year-old woman develops severe sudden-onset dyspnea.

Context: She is fatigued and pale.

Context: Her blood pressure is 115/65 mm Hg, the pulse is 120/min, the respiratory rate is 36/min, and the temperature is 39.7°C (103.5°F).

Context: Cardiac examination shows no murmurs.

Context: A chest X-ray, taken before orotracheal intubation, is shown.

Choices:
A. Broad-spectrum antibiotics
B. High-dose glucocorticoids
C. Intravenous fluids
D. Low tidal volume ventilation

Answer: Low tidal volume ventilation

1. A 48-year-old woman is hospitalized for pyelonephritis and sepsis.

2. Two days into hospitalization, she develops severe sudden-onset dyspnea.

3. She has no history of serious cardiopulmonary disease.

9. Her oxygen saturation is 80% on 60% FiO2.

10. She has severe nasal flaring, supraclavicular and intercostal respiratory retractions, and paradoxical abdominal movements.

11. Inspiratory crackles are heard over both lung fields.

12. Cardiac examination shows no murmurs.

13. A chest X-ray is taken before orotracheal intubation.

Pulmonary Disease
General Pulmonary Disease


Question: In such a situation, which of the following vaccines should definitely be recommended to this patient?

Context: The FEV1/FVC ratio is 0.66.

Choices:
A. 23-valent pneumococcal polysaccharide vaccine
B. Haemophilus influenzae type b vaccine
C. Influenza vaccine
D. Pertussis vaccine

Answer: Influenza vaccine

1. A 48-year-old man presents to the physician with a cough with expectoration and breathlessness on exertion for the last 4 years.

2. There is no history of any other medical conditions.

3. He has been a smoker for the last 10 years.

4. He recently immigrated from a developing country and his immunization status is unknown.

5. After a complete physical examination of the patient, the physician orders a chest radiogram which shows increased bronchovascular markings and flattening of the diaphragm.

6. His spirometry findings include an FEV1 of 82% of predicted, which increases to 88% of predicted at 15 minutes after the administration of inhaled albuterol.

8. The physician explains the diagnosis to the patient and emphasizes the importance of smoking cessation.

9. He also offers him specific vaccinations.

10. However, the patient mentions that he does not have medical insurance and due to his poor financial situation, he can afford only 1 of the suggested vaccines.


Question: Which of the following cardiac abnormalities is associated with this condition?

Context: A five-year-old female presents to the pediatrician for a well visit.

Context: The patient’s parents report that she recently entered kindergarten and her teacher expressed concern that the patient is not meeting developmental milestones.

Context: She struggles to name colors and has not expressed any interest in learning to read.

Context: The patient’s parents have also noticed that the patient is not completing tasks that her older siblings were doing by this age, including dressing herself independently and going to the bathroom by herself.

Context: The patient rolled over at 9 months, sat without support at 12 months, and walked at 20 months.

Context: Her parents also report that the patient is very social, and that adults frequently comment on her friendly personality.

Context: The patient is in the 15th percentile for weight and 5th percentile for height.

Context: On physical exam, the patient has a broad forehead, flat nasal bridge, long philtrum, and a wide mouth.

Context: She has a strabismus on neurological exam, and her cardiac exam is significant for a heart murmur.

Context: Laboratory testing is below: |  | Serum: | Na+: 145 mEq/L | K+: 3.9 mEq/L | Cl-: 100 mEq/L | HCO3-: 24 mEq/ | Urea nitrogen: 11 mg/dL | Glucose: 76 mg/dL | Creatinine: 0.9 mg/dL | Ca2+: 11.9 mg/dL |  | .

Choices:
A. Bicuspid aortic valve
B. Coarctation of the aorta
C. Supravalvular aortic stenosis
D. Tetralogy of Fallot

Answer: Supravalvular aortic stenosis

2. Patient recently entered kindergarten.

3. Teacher expressed concern that patient is not meeting developmental milestones.

5. Patient has not expressed any interest in learning to read.

6. Patient is not completing tasks that her older siblings were doing by this age.

8. Patient sat without support at 12 months.

11. Adults frequently comment on patient's friendly personality.

12. Patient is in the 15th percentile for weight.

13. Patient is in the 5th percentile for height.

18. Patient has a strabismus on neurological exam.

19. Patient has a heart murmur on cardiac exam.


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

Context: A 20-year-old male comes to the physician because of a 1-week-history of a painless ulceration on his penis.

Context: The patient is sexually active with multiple partners and does not use barrier protection.

Context: Physical examination shows a shallow, firm ulcer with a smooth base along the shaft of the penis and nontender bilateral inguinal adenopathy.

Choices:
A. Tzanck preparation
B. Culture swab
C. Dark field microscopy
D. Serologic detection of antibodies

Answer: Dark field microscopy

1. A 20-year-old male comes to the physician.

2. The patient has a 1-week-history of a painless ulceration on his penis.

3. The patient is sexually active with multiple partners.

4. The patient does not use barrier protection.

5. Physical examination shows a shallow, firm ulcer with a smooth base along the shaft of the penis.

6. Physical examination shows nontender bilateral inguinal adenopathy.


Question: What additional finding is most likely to be present in this patient on physical examination?

Context: A 31-year-old man presents to the clinic as a follow-up visit after recently being diagnosed with medullary thyroid cancer.

Context: Last year, he was diagnosed with a pheochromocytoma that was successfully resected.

Context: His family history is positive for medullary thyroid cancer in his father and paternal grandmother with a mucosal neuroma in his brother.

Choices:
A. Ash leaf spot
B. Pituitary adenoma
C. Neurofibromas
D. Marfanoid habitus

Answer: Marfanoid habitus

1. A 31-year-old man presents to the clinic as a follow-up visit.

2. He was recently diagnosed with medullary thyroid cancer.

3. Last year, he was diagnosed with a pheochromocytoma.

4. The pheochromocytoma was successfully resected.

5. His family history is positive for medullary thyroid cancer in his father.

6. His family history is positive for medullary thyroid cancer in his paternal grandmother.


Question: Resection of which of the following segments of the gastrointestinal tract would prevent the absorption of these digested lipids?

Context: Digestion begins in the mouth by breaking food up into smaller particles through mastication and mixing it with saliva containing amylase.

Context: Food then enters the stomach, where gastric acid and pepsin initiate protein digestion.

Context: The resulting chyme is then expelled into the duodenum where pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids.

Context: These digested lipids are then ready for absorption across the gastrointestinal mucosa.

Choices:
A. Jejunum
B. Ileum
C. Descending colon
D. Rectum

Answer: Jejunum

2. Food is broken up into smaller particles through mastication.

3. Food is mixed with saliva containing amylase.

5. Gastric acid and pepsin initiate protein digestion in the stomach.

6. The resulting chyme is expelled into the duodenum.

7. Pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids in the duodenum.

8. Digested lipids are ready for absorption across the gastrointestinal mucosa.


Question: Increased atrial stretch would most likely lead to which of the following changes?

Context: A group of investigators is studying hemodynamic regulatory mechanisms in a human volunteer subject.

Context: The volunteer is administered a stimulant drug, and a sudden increase in blood pressure is observed.

Choices:
A. Vasodilation and decreased platelet aggregation
B. Decreased reabsorption of sodium
C. Increased reabsorption of solute-free water
D. Vasoconstriction and stimulation of thirst

Answer: Decreased reabsorption of sodium

1. A group of investigators is studying hemodynamic regulatory mechanisms.

2. The study involves a human volunteer subject.

3. The volunteer is administered a stimulant drug.

4. A sudden increase in blood pressure is observed.

5. It is hypothesized that the increase in blood pressure causes stretching of the atria.


Question: Which of the following would be the definitive treatment of this patient’s condition?

Context: A 26-month-old boy is presented to the outpatient clinic by his parents complaining of a productive cough for the last 5 days.

Context: On examination, there are purpuric eruptions over the extremities as well as eczematous patches on the flexural surfaces of his elbows and knees.

Context: With a suspicion of a congenital immunodeficiency, flow cytometry is ordered which reveals a Wiskott-Aldrich syndrome protein (WASP) mutation.

Choices:
A. Early hematopoietic stem cell transplantation (HSCT)
B. Intravenous immunoglobulin (IVIG)
C. Rituximab
D. Chemotherapy

Answer: Early hematopoietic stem cell transplantation (HSCT)

1. A 26-month-old boy is presented to the outpatient clinic by his parents.

2. His parents are complaining of a productive cough for the last 5 days.

3. His mother reports a history of recurrent chest infections during the past year.

4. He also has a history of chronic bloody diarrhea and pronounced bleeding after his circumcision.

5. The vital signs are as follows: blood pressure 100/60 mm Hg, pulse 100/min, temperature 38.0°C (100.4°F), and respiratory rate 27/min.

6. On examination, there are purpuric eruptions over the extremities.

7. On examination, there are also eczematous patches on the flexural surfaces of his elbows and knees.

8. Chest auscultation reveals crepitus over the base of the right lung.

9. Chest radiography is suggestive of consolidation in the right lower lobe.

10. Blood test results show anemia, thrombocytopenia with small platelets, and leukopenia.

11. With a suspicion of a congenital immunodeficiency, flow cytometry is ordered.

12. Flow cytometry reveals a Wiskott-Aldrich syndrome protein (WASP) mutation.


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

Context: Four hours after undergoing an open emergency surgery under general anesthesia for a bleeding abdominal aortic aneurysm, a 55-year-old man is unable to move both his legs.

Context: During the surgery, he had prolonged hypotension, which was corrected with IV fluids and vasopressors.

Context: He has a history of hypertension and hyperlipidemia.

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

Context: Prior to admission, his medications were hydrochlorothiazide and atorvastatin.

Context: The patient is conscious and oriented to place and person.

Context: His temperature is 37.7°C (99°F), pulse is 74/min, and blood pressure is 100/70 mm Hg.

Context: Examination shows muscle strength of 1/5 in the lower extremities.

Choices:
A. Babinski's sign present bilaterally
B. Normal bulbocavernosus reflex
C. Bilaterally increased knee and ankle jerk
D.
Normal proprioception in the extremities
"

Answer:
Normal proprioception in the extremities
"

2. Patient underwent open emergency surgery under general anesthesia for a bleeding abdominal aortic aneurysm four hours ago.

3. Patient is unable to move both his legs.

4. Patient had prolonged hypotension during surgery, which was corrected with IV fluids and vasopressors.

5. Patient has a history of hypertension and hyperlipidemia.

6. Patient has smoked one pack of cigarettes daily for 35 years.

7. Patient's medications prior to admission were hydrochlorothiazide and atorvastatin.

8. Patient is conscious and oriented to place and person.

9. Patient's temperature is 37.7°C (99°F).

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

12. Patient's muscle strength in lower extremities is 1/5.