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

Context: A 67-year-old man presents to his primary care physician because he has been feeling increasingly short of breath.

Context: Specifically, after retirement he has been going on daily morning walks with his wife; however, over the last year he feels that his endurance has decreased.

Context: His medical history is significant for well-controlled hypertension but is otherwise unremarkable.

Context: When asked, he reveals that he worked in a variety of industries throughout his life.

Context: Testing demonstrates decreased forced vital capacity (FVC) and a normal forced expiratory volume (FEV) to FVC ratio.

Context: Pathology demonstrates changes primarily in the upper lobes where macrophages can be seen with dark round ingested particles.

Choices:
A. Increased risk of lung cancer
B. Increased risk of tuberculosis
C. Mesothelioma
D. Lung rheumatoid nodules

Answer: Lung rheumatoid nodules

1. A 67-year-old man presents to his primary care physician.

2. He has been feeling increasingly short of breath.

3. After retirement he has been going on daily morning walks with his wife.

4. Over the last year he feels that his endurance has decreased.

5. His medical history is significant for well-controlled hypertension.

6. His medical history is otherwise unremarkable.

7. He worked in a variety of industries throughout his life.

8. Testing demonstrates decreased forced vital capacity (FVC).

9. Testing demonstrates a normal forced expiratory volume (FEV) to FVC ratio.

10. Pathology demonstrates changes primarily in the upper lobes.

11. Pathology demonstrates macrophages can be seen with dark round ingested particles.


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

Context: A 75-year-old woman is brought to the emergency department because of vomiting, abdominal pain, and constipation for the past 2 days.

Context: She has urinated frequently over the past week and has become excessively thirsty during this time.

Context: She is a 30-pack-year smoker.

Context: She appears confused.

Context: Her blood pressure is 95/70 mm Hg, pulse is 110/min, respirations are 25/min, and temperature is 37.1°C (98.8°F).

Context: She has dry oral mucosa.

Context: A computed tomography scan is shown.

Choices:
A. Adenocarcinoma
B. Bronchoalveolar carcinoma
C. Large-cell carcinoma
D. Squamous cell carcinoma

Answer: Squamous cell carcinoma

1. A 75-year-old woman is brought to the emergency department.

2. She has been vomiting, having abdominal pain, and constipated for the past 2 days.

3. She has been urinating frequently over the past week and has become excessively thirsty during this time.

4. She has no significant past medical history.

12. Lung auscultation shows rhonchi and wheezing localized to the right middle lobe area.

13. An electrocardiogram (ECG) shows a shortened QT interval.

14. A computed tomography scan is shown.


Question: The virulence factor responsible for the edema seen in this patient has a mechanism of action similar to which of the following enzymes?

Context: A 23-year-old woman comes to the physician because of a painless lesion on the arm that first appeared 5 days after she visited a petting zoo.

Context: The lesion began as a small papule and then became a blister that has since ulcerated.

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

Context: There is axillary lymphadenopathy.

Choices:
A. Adenylate cyclase
B. Catalase
C. Guanylate cyclase
D. SNARE protein

Answer: Adenylate cyclase

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

2. She has a painless lesion on her arm.

3. The lesion first appeared 5 days after she visited a petting zoo.

8. Examination shows a black eschar with edematous borders on the left upper arm.


Question: A genetic defect, in which of the following proteins is most likely responsible for this patient’s condition?

Context: A 54-year-old man with a history of hypertension presents 6 days after being admitted for new-onset atrial fibrillation with the rapid ventricular rate with a painful lesion on his left leg.

Context: He says his heart rate has been well-controlled since starting metoprolol and warfarin in the hospital but says he has developed a painful lesion on his left leg.

Context: His blood pressure is 114/78 mm Hg, the heart rate is 84/min, and the respiratory rate is 15/min.

Context: On physical examination, there is a large, dark lesion on his left leg that feels cold (see image).

Choices:
A. Factor V
B. Factor XII
C. Protein C
D. Factor VIII

Answer: Protein C

1. A 54-year-old man has a history of hypertension.

2. He was admitted 6 days ago for new-onset atrial fibrillation with a rapid ventricular rate.

3. He has been taking metoprolol and warfarin since being admitted.

4. His heart rate has been well-controlled since starting the medications.

5. He has developed a painful lesion on his left leg.

9. On physical examination, there is a large, dark lesion on his left leg.


Question: The patient’s condition is most likely caused by antibodies against which of the following compounds?

Context: A 35-year-old patient presents to the dermatologist with a new skin rash.

Context: The patient has noticed new bumps on her arm over the past 1 month.

Context: The bumps are about 0.5 cm in diameter and are filled with a clear fluid.

Context: They extend on both arms but are not in her mouth or torso.

Context: The lesions do not pop with pressure but remain tense.

Context: Her skin does not slough off with rubbing.

Context: The patient denies any other symptoms including joint pain or fever.

Context: The patient has no other medical history.

Choices:
A. Desmoglein
B. Hemidesmosomes
C. Double-stranded DNA
D. U1 ribonucleotide polypeptide

Answer: Hemidesmosomes

2. Patient presents to dermatologist with new skin rash.

3. Patient has noticed new bumps on arm over past 1 month.

4. Bumps are 0.5 cm in diameter and filled with clear fluid.

5. Bumps extend on both arms but not in mouth or torso.

6. Lesions do not pop with pressure but remain tense.

7. Skin does not slough off with rubbing.

8. Patient denies any other symptoms including joint pain or fever.

9. Patient has no other medical history.


Question: Which of the following confirmatory tests is most appropriate?

Context: A 59-year-old woman presents to the emergency department because of shortness of breath.

Context: She has been experiencing an increasing inability to breathe following strenuous activity.

Context: This includes climbing stairs and walking a few blocks down the street.

Context: During the day, her breathing becomes more pronounced when she takes her a nap or lies down to sleep at night.

Context: Another concerning symptom is the increased swelling in her legs.

Context: She has a history of few episodes of syncope.

Context: Her past medical history is otherwise unremarkable.

Context: The vital signs include: blood pressure 110/70 mm Hg, pulse 90/min, and respiratory rate 18/min.

Choices:
A. Pulmonary function test
B. Biopsy of cardiac tissue
C. Chest X-ray
D. No further testing required

Answer: Biopsy of cardiac tissue

2. Patient presents to the emergency department with shortness of breath.

3. Patient has increasing inability to breathe following strenuous activity, such as climbing stairs and walking a few blocks.

4. Patient's breathing becomes more pronounced when she takes a nap or lies down to sleep at night.

5. Patient has increased swelling in her legs.

6. Patient has a history of few episodes of syncope.

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

8. Patient's vital signs include: blood pressure 110/70 mm Hg, pulse 90/min, and respiratory rate 18/min.

9. An electrocardiogram (ECG) shows low voltage.

10. Echocardiography shows granular speckling with concentric thickening of the ventricular walls, more prominently of the right wall.


Question: What is the most likely diagnosis?

Context: A 30-year-old previously healthy male presents to your office with complaints of facial pressure and rhinorrhea for the past 3 weeks.

Context: The patient reports that several weeks prior, he had a “common cold” which resolved.

Context: However, he has since developed worsening facial pressure, especially over his cheeks and forehead.

Context: He reports over 1 week of green tinged rhinorrhea.

Context: His temperature is 100.1 deg F (37.8 deg C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min.

Choices:
A. Acute viral rhinosinusitis
B. Acute bacterial rhinosinusitis
C. Allergic rhinitis
D. Chronic rhinosinusitis

Answer: Acute bacterial rhinosinusitis

3. Patient has had complaints of facial pressure and rhinorrhea for the past 3 weeks.

4. Patient had a "common cold" several weeks prior which resolved.

5. Patient has worsening facial pressure, especially over his cheeks and forehead.

6. Patient has had over 1 week of green tinged rhinorrhea.

7. Patient's temperature is 100.1 deg F (37.8 deg C).

8. Patient's blood pressure is 120/70 mmHg.

11. Nasal exam reveals edematous turbinates and purulent discharge.


Question: Based on these findings, which of the following nerves is most likely injured in this patient?

Context: A 25-year-old man is brought to the emergency department 30 minutes after he was involved in a motorcycle collision.

Context: Physical examination shows a deep laceration on the volar surface of the distal left forearm.

Context: Neurological examination shows loss of abduction and opposition of the left thumb.

Context: The radial and ulnar pulses are palpable.

Choices:
A. Posterior interosseous nerve
B. Axillary nerve
C. Median nerve
D. Ulnar nerve

Answer: Median nerve

1. A 25-year-old man was brought to the emergency department.

2. He was involved in a motorcycle collision 30 minutes prior.

3. Physical examination revealed a deep laceration on the volar surface of the distal left forearm.

4. Neurological examination showed loss of abduction and opposition of the left thumb.

5. The radial and ulnar pulses were palpable.


Question: Which of the following is the most likely location of his intestinal bleeding?

Context: A 70-year-old man presents to the emergency department after several episodes of bloody stools that started 6 hours ago.

Context: On examination, he is pale and cachectic.

Context: The patient’s abdomen is nontender to palpation on the exam.

Context: His heart rate is 120/min and blood pressure is 80/60 mm Hg.

Context: A stool sample from the patient shows stools with bright red blood, and a hemoccult test is positive.

Choices:
A. Ascending colon
B. Sigmoid colon
C. Stomach
D. Ileum

Answer: Sigmoid colon

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

2. The patient had several episodes of bloody stools that started 6 hours ago.

3. The patient denies nausea, vomiting, or diarrhea.

4. On examination, the patient is pale and cachectic.

5. The patient's abdomen is nontender to palpation on the exam.

7. The patient's blood pressure is 80/60 mm Hg.

8. A stool sample from the patient shows stools with bright red blood.


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

Context: A 48-year-old man comes to the physician because of a 4-month history of persistent cough productive of white phlegm.

Context: He coughs consistently throughout the day, and he has not noticed any particular triggers that make it worse.

Context: He has also recently experienced some shortness of breath with exertion.

Context: He has not had any weight loss, fever, or chills.

Context: He had similar symptoms last year, which lasted about 6 months.

Context: He has hypertension, for which he takes amlodipine.

Context: He has worked in construction for the past 10 years.

Context: He has smoked a pack of cigarettes per day for 30 years.

Context: Vital signs are within normal limits.

Choices:
A. Asbestosis
B. Hypersensitivity pneumonitis
C. Asthma
D. Chronic bronchitis

Answer: Chronic bronchitis

2. Patient has had a persistent cough for 4 months.

4. Cough is consistent throughout the day.

5. Patient has not noticed any particular triggers that make it worse.

6. Patient has recently experienced shortness of breath with exertion.

7. Patient has not had any weight loss, fever, or chills.

8. Patient had similar symptoms last year, which lasted about 6 months.

9. Patient has hypertension and takes amlodipine.

10. Patient has worked in construction for the past 10 years.

11. Patient has smoked a pack of cigarettes per day for 30 years.

12. Vital signs are within normal limits.

13. Examination shows an end-expiratory wheeze throughout all lung zones.

General Pulmonary Disease
Pulmonary Disease


Question: What is the best immediate treatment for this patient?

Context: A 26-year-old female with no significant past medical history presents to the emergency department complaining of chest pain.

Context: She states that she was visiting her boyfriend in the hospital and, approximately 10 minutes ago, she developed chest pain associated with sweating, palpitations, nausea, and chills.

Choices:
A. Morphine, oxygen, nitrogylcerin, aspirin, beta blockers, ACE inhibitor, and heparin
B. Alprazolam, reassurance, encouraging patient to slow breathing
C. Albuterol breathing treatment
D. Cognitive behavioral therapy

Answer: Alprazolam, reassurance, encouraging patient to slow breathing

1. A 26-year-old female presents to the emergency department.

2. She has no significant past medical history.

3. She was visiting her boyfriend in the hospital.

4. Approximately 10 minutes ago, she developed chest pain.

5. The chest pain is associated with sweating, palpitations, nausea, and chills.

6. She appears very nervous and states that she is scared that she is dying.

7. Vital signs reveal tachycardia, hypertension, and tachypnea.

8. An EKG is obtained that is unremarkable besides tachycardia.

9. TSH and free T4 are within normal limits.

10. A urine drug screen is obtained and it is negative.

General Emergency Medicine
Cardiovascular Disease


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

Context: A 36-year-old woman is brought to the emergency department by her sister 1 hour after she was found unconscious at home.

Context: She appears lethargic.

Context: Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 5/min, and blood pressure is 120/70 mm Hg.

Context: The patient's condition improves with supportive treatment, and she is admitted for psychiatric evaluation.

Context: Three days later, a physician colleague approaches the physician who treated the patient in the lobby of the hospital and states, “I just want to know what happened.

Context: I'm her neighbor and childhood friend, and I'm worried about her.” .

Choices:
A. """Why don't you go ahead and ask her directly? She is currently in the psychiatric ward."""
B. """Her urine toxicology screening was positive for alcohol, benzodiazepines, and barbiturates."""
C. """I'm not the right person to ask. Please ask her primary care physician."""
D. """I understand your concern, but I am unable to provide information about this situation."""

Answer: """I understand your concern, but I am unable to provide information about this situation."""

1. A 36-year-old woman was brought to the emergency department by her sister 1 hour after she was found unconscious at home.

7. Urine toxicology screening is positive for alcohol, benzodiazepines, and barbiturates.

8. The patient's condition improves with supportive treatment.

9. She is admitted for psychiatric evaluation.

10. Three days later, a physician colleague approaches the physician who treated the patient in the lobby of the hospital.

11. The physician colleague is the patient's neighbor and childhood friend.

12. The physician colleague is worried about the patient.

General Emergency Medicine
Toxicology
Medical Toxicology


Question: Which of the following best describes the mechanism of rejection that happened in this patient?

Context: He was diagnosed with Wilson’s disease 20 years ago and underwent a human leukocyte antigen–matched liver transplant 15 years ago.

Context: Today he is feeling fine and has no complaints except for a new, mild jaundice that his wife noticed a few weeks ago.

Context: He denies any changes in stool or urine color and is not having any abdominal pain.

Context: On physical examination, his vital signs are within normal limits, and only mild scleral icterus is noticed.

Choices:
A. Donor allogeneic MHC molecules are taken up by recipient APCs and processed into peptides, and then the peptides are presented by recipient MHC molecules to donor T cells.
B. Donor allogeneic MHC molecules are taken up by donor APCs and processed into peptides, and then the peptides are presented by unprocessed donor allogeneic MHC molecules to recipient T cells.
C. Donor allogeneic MHC molecules are taken up by recipient APCs and processed into peptides, and then the peptides are presented by recipient MHC molecules to recipient T cells.
D. Recipient MHC molecules are taken up by donor APCs and processed into peptides, and then the peptides are presented by donor allogeneic MHC molecules to recipient T cells.

Answer: Donor allogeneic MHC molecules are taken up by recipient APCs and processed into peptides, and then the peptides are presented by recipient MHC molecules to recipient T cells.

1. A 40-year-old man presents to a clinic for a regular follow-up.

2. He was diagnosed with Wilson’s disease 20 years ago.

3. He underwent a human leukocyte antigen–matched liver transplant 15 years ago.

4. He is feeling fine and has no complaints except for a new, mild jaundice.

5. His wife noticed the jaundice a few weeks ago.

6. He denies any changes in stool or urine color.

8. On physical examination, his vital signs are within normal limits.

9. Only mild scleral icterus is noticed.

General Allergy and Immunology
Nephrology


Question: Which of the following was most likely prescribed during the previous visit?

Context: His mother is particularly disturbed because her son wakes up breathless one or 2 nights every week.

Context: Over the past few months, he has not been able to participate in any sport and is also using his inhaler more than 3 times a week.

Context: On examination, the patient appears to be in slight distress and seems pale and fatigued.

Context: A photograph of the lesion is shown.

Choices:
A. Inhaled beclomethasone
B. Inhaled ipratropium bromide
C. Nebulized theophylline
D. Inhaled salmeterol

Answer: Inhaled beclomethasone

1. A 6-year-old boy is brought to his pediatrician due to increased shortness of breath.

2. His mother reports that her son wakes up breathless one or 2 nights every week.

3. He was diagnosed with asthma 2 years ago.

4. Over the past few months, he has not been able to participate in any sport.

5. He is using his inhaler more than 3 times a week.

6. On examination, the patient appears to be in slight distress.

8. There are slight expiratory wheezes and crackles in both lungs.

9. The pediatrician starts him on a low dose of another inhaler which needs to be taken once daily.

10. She asks his mother to avoid any conditions that might aggravate her son’s symptoms and make it difficult for him to breathe.

11. Three months later, the mother is back with her son at the same pediatrician’s office.

12. She is concerned about a painless white plaque on his tongue.

13. When the physician scrapes the lesion it reveals a red base with minimal bleeding.

14. A photograph of the lesion is shown.


Question: How do you expect the venous pH, arterial pCO2, and venous pCO2 to respond?

Context: Spirometry testing, along with arterial and venous blood gases, are performed immediately before and after 15 minutes of exercising on a stationary bicycle.

Choices:
A. Venous pH decreases, arterial pCO2 decreases, venous pCO2 decreases
B. Venous pH increases, arterial pCO2 decreases, venous pCO2 increases
C. Venous pH increases, arterial pCO2 increases, venous pCO2 increases
D. Venous pH decreases, arterial pCO2 stays the same, venous pCO2 increases

Answer: Venous pH decreases, arterial pCO2 stays the same, venous pCO2 increases

1. A 25-year-old medical student enrolls in an exercise research study.

2. Spirometry testing is performed immediately before and after 15 minutes of exercising on a stationary bicycle.

3. Arterial and venous blood gases are performed immediately before and after 15 minutes of exercising on a stationary bicycle.


Question: Which of the following enzymes contributes most to maintaining a normal serum glucose level in this patient?

Context: A 38-year-old imprisoned man is brought to the physician after going on a hunger strike for 36 hours.

Choices:
A. Phosphoenolpyruvate carboxykinase
B. Hydroxymethylglutaryl-CoA lyase
C. Glycogen phosphorylase
D. Phosphofructokinase-1

Answer: Phosphoenolpyruvate carboxykinase

2. He has gone on a hunger strike for 36 hours.

3. During this time, he has only had two cups of water.

5. Physical examination shows dry mucous membranes.

6. His serum glucose concentration is 70 mg/dL.


Question: Which of the following best describes the most likely diagnosis?

Context: A 27-year-old man presents to the emergency department with a chief concern of abdominal pain and diarrhea.

Context: The patient states that for the past 4 days he has experienced abdominal pain, diarrhea, weakness and a subjective fever.

Context: He also endorses a weight loss of 11 pounds during this time.

Context: The patient has a past medical history of celiac disease, constipation, and depression.

Context: His current medications include fish oil, a multivitamin, sodium docusate, and fluoxetine.

Context: His temperature is 98.5°F (36.9°C), blood pressure is 110/75 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Context: Laboratory values are ordered as seen below: |  | Hemoglobin: 12 g/dL | Hematocrit: 36% | Leukocyte count: 8,000 cells/mm^3 with normal differential | Platelet count: 227,500/mm^3 |  | Serum: | Na+: 141 mEq/L | Cl-: 101 mEq/L | K+: 4.5 mEq/L | HCO3-: 24 mEq/L | BUN: 17 mg/dL | Glucose: 82 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: 10.1 mg/dL | AST: 12 U/L | ALT: 11 U/L |  | A stool guaiac test is performed which returns positive.

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

Choices:
A. ANCA positivity
B. ASCA positivity
C. Dilated vascular structure in the anal canal
D. Mucosal disruption

Answer: ASCA positivity

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

3. Patient has experienced abdominal pain, diarrhea, weakness and a subjective fever for the past 4 days.

4. Patient has lost 11 pounds during this time.

5. Patient has a past medical history of celiac disease, constipation, and depression.

6. Patient's current medications include fish oil, a multivitamin, sodium docusate, and fluoxetine.

7. Patient's temperature is 98.5°F (36.9°C).

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

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

12. Physical exam is notable for a young man in mild distress.

13. Cardiac and pulmonary exams are within normal limits.

14. Abdominal exam is notable for generalized tenderness and increased bowel sounds.

15. Oral exam is notable for multiple shallow painful ulcers.

18. Leukocyte count is 8,000 cells/mm^3 with normal differential.

31. Patient is started on IV fluids and morphine.


Question: Which of the following is the mechanism of action of the medication?

Context: A previously healthy 31-year-old man is rushed to the emergency department after an all-night binge that included smoking, alcohol, and cocaine.

Context: At the hospital, the blood pressure is 110/70 mm Hg and the heart rate of 160/min and regular.

Context: The electrocardiogram (ECG) is shown.

Context: The patient is given the appropriate medication that improves his heart rate and returns his ECG to normal.

Choices:
A. Gamma-aminobutyric acid receptor agonist
B. Slowing of the atrioventricular (AV) node conduction time
C. Blocking of sodium/potassium adenosine triphosphatase pump
D. Prolongation of repolarization phase of cardiac action potential

Answer: Slowing of the atrioventricular (AV) node conduction time

1. A 31-year-old man is rushed to the emergency department.

2. He had an all-night binge that included smoking, alcohol, and cocaine.

3. He complains of chest fluttering, fatigue, and lightheadedness.

4. His past medical and family history are noncontributory.

5. Social history is positive for occasional smoking and social drinking.

6. At the hospital, the blood pressure is 110/70 mm Hg.

7. The heart rate is 160/min and regular.

8. The electrocardiogram (ECG) is shown.

9. A physical maneuver involving massage of the neck is attempted without improvement.

10. The patient is given the appropriate medication.

11. The medication improves his heart rate.


Question: Which of the following drugs would most likely achieve the desired effect?

Context: In particular, she is interested in how much a novel compound that binds to both alpha-1 and beta-1 adrenergic receptors will affect blood pressure.

Context: She studies this question in non-human primates, but finds that her results are confounded by the fact that the animals' heart rates start to decrease several minutes after administration of this novel compound.

Context: She therefore decides to pretreat these animals with a drug that is known to prevent this decrease in heart rate.

Choices:
A. Dobutamine
B. Hexamethonium
C. Metoprolol
D. Scopolamine

Answer: Hexamethonium

1. A scientist is studying how animals regulate their blood pressure in response to various stimuli.

2. She is interested in how much a novel compound that binds to both alpha-1 and beta-1 adrenergic receptors will affect blood pressure.

3. She studies this question in non-human primates.

4. Her results are confounded by the fact that the animals' heart rates start to decrease several minutes after administration of this novel compound.

5. She decides to pretreat these animals with a drug that is known to prevent this decrease in heart rate.


Question: Based on the information provided in the drug advertisement, which of the following patients with HCC would be an appropriate treatment candidate and benefit the most from treatment with Noxbinle 100 mg in comparison to Metalimus 100 mg?

Context: A hepatologist has learned about the survival benefit of Noxbinle (tumorolimus) in hepatocellular carcinoma (HCC) patients from a fellow physician.

Context: She is looking at a list of HCC patients on her hospital's hepatology consult service and trying to identify candidates who might derive more survival benefits from Noxbinle as opposed to Metalimus.

Choices:
A. Non-cirrhotic patient with a history of hepatitis B and alcohol dependence
B. Alcoholic patient with severe cirrhosis on immunosuppressive therapy
C. Patient with severe cirrhosis, history of hepatitis C, and kidney stones
D. Patient with severe cirrhosis, history of hepatitis C, and asthma

Answer: Patient with severe cirrhosis, history of hepatitis C, and asthma

1. A hepatologist has learned about the survival benefit of Noxbinle (tumorolimus).

2. The survival benefit is for hepatocellular carcinoma (HCC) patients.

3. The hepatologist learned about the survival benefit from a fellow physician.

4. The hepatologist is looking at a list of HCC patients on her hospital's hepatology consult service.

5. The hepatologist is trying to identify candidates who might derive more survival benefits from Noxbinle as opposed to Metalimus.


Question: In this fetus, what other renal structure would be expected to be absent?

Context: It is found that the fetus lacks proper ureters, major and minor calyces, and renal pelvises.

Choices:
A. Collecting ducts
B. Ductus deferens
C. Distal convoluted tubule
D. Bowman's capsule

Answer: Collecting ducts

1. An error occurs during the embryologic development of the kidney.

2. It is found that the fetus lacks proper ureters.

3. It is found that the fetus lacks major calyces.

4. It is found that the fetus lacks minor calyces.

5. It is found that the fetus lacks renal pelvises.


Question: Which of the following is most likely to achieve this desired effect?

Context: An investigator is studying the effects of tissue hypoxia on skeletal muscles.

Context: Skeletal muscle hypoxia is induced by decreasing oxygen delivery to peripheral tissues.

Choices:
A. Decrease the serum 2,3-bisphosphoglycerate concentration
B. Increase the serum hydrogen ion concentration
C. Increase the arterial partial pressure of carbon dioxide
D. Increase the serum temperature

Answer: Decrease the serum 2,3-bisphosphoglycerate concentration

1. An investigator is studying the effects of tissue hypoxia.

2. Tissue hypoxia affects skeletal muscles.

3. Skeletal muscle hypoxia is induced by decreasing oxygen delivery.

4. Oxygen delivery is decreased to peripheral tissues.


Question: Which histological finding would place her at the highest risk of developing esophageal adenocarcinoma in the near future?

Context: A 48-year-old woman presents to the doctor’s office complaining of frequent episodes of severe heartburn and chest pain.

Context: It feels like food is getting stuck in her throat somewhere.

Context: The physician feels that the patient has acid reflux and recommends upper gastrointestinal endoscopy and a trial of omeprazole.

Context: Several biopsies are taken during the endoscopy: one from the distal esophagus, one from the gastroesophageal junction, and one from the body of the stomach.

Choices:
A. The presence of inflammatory cells in the body of the stomach
B. The presence of metaplasia at the Z line
C. The presence of goblet cells at the Z line
D. The presence of high grade dysplasia at the Z line

Answer: The presence of high grade dysplasia at the Z line

1. A 48-year-old woman presents to the doctor's office.

2. She is complaining of frequent episodes of severe heartburn and chest pain.

3. She feels like food is getting stuck in her throat somewhere.

4. She wakes up at night in fits of coughing and in pain.

5. Antacids and other over the counter remedies do not improve the discomfort.

6. The physician feels that the patient has acid reflux.

7. The physician recommends upper gastrointestinal endoscopy and a trial of omeprazole.

8. Several biopsies are taken during the endoscopy.

9. One biopsy is taken from the distal esophagus.

10. One biopsy is taken from the gastroesophageal junction.

11. One biopsy is taken from the body of the stomach.


Question: Which of the following is the most likely vector of this patient's condition?

Context: A 26-year-old man comes to the physician because of a 3-week history of malaise and recurrent fever.

Context: He has also had a 4.5-kg (10-lb) weight loss over the past 3 months.

Context: He appears ill.

Context: His temperature is 39°C (102.2°F).

Context: Physical examination shows generalized lymphadenopathy and hepatosplenomegaly.

Context: Laboratory studies show a hemoglobin concentration of 9.1 g/dL, leukocyte count of 2,900/mm3, and platelet count of 108,000/mm3.

Choices:
A. Tsetse fly
B. Sand fly
C. Freshwater snail
D. Anopheles mosquito

Answer: Sand fly

1. A 26-year-old man comes to the physician.

2. He has a 3-week history of malaise and recurrent fever.

3. He has had a 4.5-kg (10-lb) weight loss over the past 3 months.

4. He came back from his honeymoon in Kenya 6 months ago.

7. He is alert and oriented to person, time, and place.

8. Physical examination shows generalized lymphadenopathy.

9. Physical examination shows hepatosplenomegaly.

10. Laboratory studies show a hemoglobin concentration of 9.1 g/dL.

11. Laboratory studies show a leukocyte count of 2,900/mm3.

12. Laboratory studies show a platelet count of 108,000/mm3.


Question: Which best describes the principal action(s) of prazosin?

Context: A 68-year-old Caucasian male presents to your office complaining of urinary hesitancy and decreased urinary flow.

Context: His blood pressure is measured to be 168/95.

Context: You prescribe prazosin.

Choices:
A. Relaxation of urinary sphincter and reduction of peripheral vascular resistance
B. Relaxation of urinary sphincter and suppression of renin release
C. Contraction of urinary bladder wall smooth muscle and suppression of renin release
D. Contraction of urinary bladder wall smooth muscle and reduction of peripheral vascular resistance

Answer: Relaxation of urinary sphincter and reduction of peripheral vascular resistance

1. A 68-year-old Caucasian male presents to your office.

2. The patient is complaining of urinary hesitancy and decreased urinary flow.

3. The patient's blood pressure is measured to be 168/95.


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

Context: Although he has had several previous hospital admissions and received multiple courses of antibiotic therapy, he continues to get sick.

Context: The boy’s medical history is significant for neonatal sepsis and recurrent episodes of pyoderma and otitis media.

Context: The patient’s HIV status is negative and his complete blood count, T cell and B cell counts, immunoglobulin profile, and complement tests are within normal limits.

Choices:
A. CD4+ cell count
B. Bone marrow biopsy
C. Dihydrorhodamine (DHR) test
D. Adenosine deaminase levels

Answer: Dihydrorhodamine (DHR) test

1. A 4-year-old boy is referred to the infectious disease clinic for recurrent pneumonia.

2. He has had several previous hospital admissions and received multiple courses of antibiotic therapy.

4. On his most recent hospital admission, the boy presented with mild fever, right-sided chest pain, and yellow-colored sputum.

5. He had difficulty breathing and diminished breath sounds on the right side of the chest.

6. A CT scan of the thorax revealed multiple right-sided ground-glass opacities.

7. Sputum cultures grew Aspergillus galactomannan.

8. The boy’s medical history is significant for neonatal sepsis.

9. He has had recurrent episodes of pyoderma and otitis media.

10. His younger brother had recurrent purulent skin infections before he died of an otogenic brain abscess at the age of 2.

11. His mother says that skin infections are common in the male members of her family.

12. The patient’s HIV status is negative.

13. His complete blood count, T cell and B cell counts, immunoglobulin profile, and complement tests are within normal limits.


Question: Which of the following will most likely be found on physical exam?

Context: He was found on the ground by his daughter earlier today, and he was last known to be without neurological deficits two hours prior to presentation.

Context: His temperature is 99°F (37.2°C), blood pressure is 185/105 mmHg, pulse is 102/min, and respirations are 18/min.

Context: A non-contrast head CT is performed, which demonstrates a hypodense lesion affecting the left medial frontal and parietal lobe.

Choices:
A. Contralateral hemiparesis
B. Contralateral lower extremity weakness
C. Hemineglect
D. Wernicke aphasia

Answer: Contralateral lower extremity weakness

1. A 72-year-old man is being transported by emergency medical services to the emergency department for a stroke code.

2. He was found on the ground by his daughter earlier today.

3. He was last known to be without neurological deficits two hours prior to presentation.

9. The CT demonstrates a hypodense lesion affecting the left medial frontal and parietal lobe.


Question: This medication is associated with an increased risk of which of the following complications?

Context: A 33-year-old G1P0 at 39 weeks gestation is admitted to the labor and delivery floor for induction of labor.

Context: She feels well and is no acute distress.

Context: She is accompanied by her husband.

Context: Her past medical history is notable for major depressive disorder and generalized anxiety disorder.

Context: She takes sertraline.

Context: Her temperature is 99.2°F (37.3°C), blood pressure is 120/75 mmHg, pulse is 95/min, and respirations are 18/min.

Context: To initiate labor induction, the obstetrician injects the patient with a hormone that is endogenously made in the hypothalamus and released by the posterior pituitary.

Choices:
A. Placental abruption
B. Vasa previa
C. Placenta accreta
D. Preeclampsia

Answer: Placental abruption

4. Patient is admitted to labor and delivery floor for induction of labor.

5. Patient feels well and is in no acute distress.

6. Patient is accompanied by her husband.

7. Patient has past medical history of major depressive disorder and generalized anxiety disorder.

9. Patient's temperature is 99.2°F (37.3°C).

10. Patient's blood pressure is 120/75 mmHg.

13. Obstetrician injects patient with hormone endogenously made in hypothalamus and released by posterior pituitary to initiate labor induction.


Question: Which drug has been prescribed?

Context: A 57-year-old Caucasian male presents to your office with heart palpitations and shortness of breath.

Context: He fails standard pharmacologic therapy and you refer to cardiology, where he is started on an antiarrhythmic medication.

Context: The action of this agent results in a longer action potential duration, an increased effective refractory period, and a longer QT interval.

Choices:
A. Flecanide
B. Mexiletine
C. Diltiazem
D. Sotalol

Answer: Sotalol

1. A 57-year-old Caucasian male presents to office with heart palpitations and shortness of breath.

2. On exam, he is tachycardic and his rhythm is irregularly irregular.

3. He fails standard pharmacologic therapy.

5. Started on an antiarrhythmic medication.

6. Action of this agent results in a longer action potential duration.

7. Action of this agent results in an increased effective refractory period.

8. Action of this agent results in a longer QT interval.

General Cardiology
Cardiovascular Disease


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

Context: A 2-year-old girl is brought to the physician because of abdominal distention and twitching of her feet, which her mother noticed a week ago.

Context: The patient has also had a low-grade fever for 5 days.

Context: She has not had a bowel movement in 3 days.

Context: She was born at term and has been healthy since.

Context: She is at the 40th percentile for height and 20th percentile for weight.

Context: Her temperature is 38.1°C (100.6°F), pulse is 128/min, and blood pressure is 135/82 mm Hg.

Context: The liver is palpated 3 cm below the right costal margin.

Context: A 24-hour urine collection shows elevated homovanillic acid and vanillylmandelic acid levels.

Choices:
A. Hodgkin lymphoma
B. Hepatoblastoma
C. Nephroblastoma
D. Neuroblastoma

Answer: Neuroblastoma

2. Mother noticed abdominal distention and twitching of feet a week ago.

3. Patient has had a low-grade fever for 5 days.

4. Patient has not had a bowel movement in 3 days.

5. Patient was born at term and has been healthy since.

6. Patient is at the 40th percentile for height and 20th percentile for weight.

7. Patient's temperature is 38.1°C (100.6°F).

9. Patient's blood pressure is 135/82 mm Hg.

10. Examination shows an irregular palpable mass that crosses the midline of the abdomen.

11. Liver is palpated 3 cm below the right costal margin.

12. There are erratic movements of the eyes.

13. 24-hour urine collection shows elevated homovanillic acid and vanillylmandelic acid levels.


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

Context: A 53-year-old man is brought to the emergency department by his wife after the sudden onset of dizziness, nausea, and left-sided weakness.

Context: His blood pressure is 165/95 mm Hg.

Context: A CT scan of the head shows a small lesion in the left lateral pons that involves the nucleus of a cranial nerve that exits the brain at the middle cerebellar peduncle.

Choices:
A. Ptosis and inability to look up with the right eye
B. Winging of the left scapula and weakness turning the head to the right
C. Difficulty chewing and deviation of the jaw to the left
D. Inability to smell vanilla or coffee

Answer: Difficulty chewing and deviation of the jaw to the left

1. A 53-year-old man is brought to the emergency department by his wife.

2. The man has sudden onset of dizziness, nausea, and left-sided weakness.

4. Neurological examination shows decreased muscle tone and hyperreflexia in the right upper and lower extremities.

5. His gait is unsteady, and he falls to the left when attempting to walk.

6. Finger-to-nose testing shows dysmetria on the left side.

7. A CT scan of the head shows a small lesion in the left lateral pons.

8. The lesion involves the nucleus of a cranial nerve.

9. The cranial nerve exits the brain at the middle cerebellar peduncle.


Question: Which of the following would you expect to see upon chest X-ray:

Context: A 38-year-old African American female presents to her primary care physician with uveitis, cough, and arthralgias in her ankles and legs.

Context: Bloodwork reveals elevated angiotensin converting enzyme levels, and skin PPD testing shows no observable induration after 48 hours.

Context: The patient demonstrates reduced FEV1 and FVC upon spirometry.

Context: FEV1/FVC is 85%.

Choices:
A. Enlarged hilar lymph nodes
B. Kerley B Lines
C. Bilateral diaphragmatic elevation.
D. Fluid in alveolar walls

Answer: Enlarged hilar lymph nodes

4. Patient presents to primary care physician with uveitis, cough, and arthralgias in ankles and legs.

5. Bloodwork reveals elevated angiotensin converting enzyme levels.

6. Skin PPD testing shows no observable induration after 48 hours.

7. Patient demonstrates reduced FEV1 and FVC upon spirometry.


Question: A mutation of which of the following genes is most likely responsible for this patient's condition?

Context: A previously healthy 41-year-old man comes to the physician for evaluation of a 1-month history of painless, intermittent bleeding on defecation, which he discovered while wiping.

Context: His younger sister was recently diagnosed with endometrial cancer, and his mother was diagnosed with gastric cancer at 58 years of age.

Choices:
A. MLH1
B. TP53
C. DCC
D. KRAS

Answer: MLH1

1. A 41-year-old man comes to the physician for evaluation of a 1-month history of painless, intermittent bleeding on defecation.

2. He discovered the bleeding while wiping.

3. His younger sister was recently diagnosed with endometrial cancer.

4. His mother was diagnosed with gastric cancer at 58 years of age.

5. Physical examination shows no abnormalities.

6. Test of the stool for occult blood is positive.

7. Colonoscopy shows a tumor in the ascending colon.

8. Histopathologic examination of the tumor shows a mucinous, poorly-differentiated adenocarcinoma.

Colon and Rectal Surgery
Colorectal Surgery

General Colon and Rectal Surgery
General Colorectal Surgery


Question: This medication has which of the following mechanisms of action?

Context: A 49-year-old woman presents to her pulmonologist for a follow-up visit.

Context: She reports a longstanding history of chronic dyspnea and fatigue.

Context: Her past medical history is notable for asthma.

Context: She has a known mutation in the BMPR2 gene.

Context: She was recently trialed on nifedipine but stopped due to severe lower extremity edema.

Context: She does not smoke and does not drink alcohol.

Context: Her temperature is 99.4°F (37.4°C), blood pressure is 135/80 mmHg, pulse is 80/min, and respirations are 20/min.

Context: Physical examination reveals an increased P2 on cardiac auscultation.

Context: Her physician recommends starting a medication to slow the patient’s clinical worsening that requires regular monitoring of liver function tests.

Choices:
A. Endothelin-1 receptor antagonist
B. Beta-2-adrenergic receptor agonist
C. Phospholipase A2 antagonist
D. Phosphodiesterase type 5 antagonist

Answer: Endothelin-1 receptor antagonist

2. Patient has longstanding history of chronic dyspnea and fatigue.

3. Patient has past medical history of asthma.

4. Patient has known mutation in BMPR2 gene.

5. Patient was recently trialed on nifedipine but stopped due to severe lower extremity edema.

8. Patient's temperature is 99.4°F (37.4°C).

9. Patient's blood pressure is 135/80 mmHg.

12. Physical examination reveals increased P2 on cardiac auscultation.

13. Physician recommends starting medication to slow patient's clinical worsening.

14. Medication requires regular monitoring of liver function tests.


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

Context: A 14-year-old girl is brought to the physician by her mother for the evaluation of recurrent episodes of nose bleeding for several months.

Context: Menses occur at regular 27-day intervals with heavy flow.

Context: Vital signs are within normal limits.

Context: Laboratory studies show: | Hemoglobin 11 g/dL | Hematocrit 34% | Leukocyte count 7,000/mm3 | Platelet count 180,000/mm3 | Prothrombin time 13 sec | Partial thromboplastin time 45 sec | Fibrin split products negative | The bleeding time is 10 minutes.

Choices:
A. Oral prednisone
B. Intravenous immunoglobulins
C. Tranexamic acid
D. Desmopressin

Answer: Desmopressin

1. A 14-year-old girl is brought to the physician by her mother.

2. The girl has had recurrent episodes of nose bleeding for several months.

3. The episodes occur unexpectedly and stop after a few minutes by elevating the upper body and bending the head forward.

4. The girl's menses occur at regular 27-day intervals with heavy flow.

5. Her last menstrual period was 3 weeks ago.

6. Vital signs are within normal limits.

7. Physical examination shows no abnormalities.

8. Laboratory studies show a hemoglobin level of 11 g/dL.

9. Laboratory studies show a hematocrit level of 34%.

10. Laboratory studies show a leukocyte count of 7,000/mm3.

11. Laboratory studies show a platelet count of 180,000/mm3.

12. Laboratory studies show a prothrombin time of 13 sec.

13. Laboratory studies show a partial thromboplastin time of 45 sec.

14. Laboratory studies show fibrin split products are negative.

15. Laboratory studies show a bleeding time of 10 minutes.


Question: Which of the following is the most probable cause of the newborn’s condition?

Context: A 29-year-old G3P2 undergoes a cesarean section at 38 weeks gestation and delivers a boy weighing 4570 g with Apgar scores of 5 and 8 at 1 and 5 minutes, respectively.

Context: The current pregnancy was complicated by gestational diabetes with poor glycemic control.

Context: The newborn’s heart rate is 122/min, the respiratory rate is 31/min, and the temperature 36.4℃ (97.5℉).

Context: On examination, the newborn is pale, lethargic, diaphoretic, and has poor muscular tone.

Context: The liver is 2 cm below the right costal margin.

Choices:
A. Microangiopathy
B. Hyperinsulinemia
C. Hyperglycemia
D. Polycythemia

Answer: Hyperinsulinemia

3. Patient underwent cesarean section at 38 weeks gestation.

6. Apgar scores at 1 and 5 minutes were 5 and 8, respectively.

7. Current pregnancy was complicated by gestational diabetes with poor glycemic control.

9. Newborn's respiratory rate is 31/min.

10. Newborn's temperature is 36.4℃ (97.5℉).

11. On examination, newborn is pale, lethargic, diaphoretic, and has poor muscular tone.

12. Liver is 2 cm below the right costal margin.


Question: What medication is the patient most likely taking?

Context: A 19-year-old woman is brought to the emergency department by ambulance after experiencing a first-time seizure.

Context: She as preparing for an exam at her college’s library, in her normal state of health and collapsed.

Context: Past medical history is significant for major depressive disorder.

Context: Family medical history is insignificant for neurological disorders.

Context: Instead, for the past 10 days, she has been taking her roommate’s antidepressant medication instead.

Context: Today her blood pressure is 100/80 mm Hg, pulse 102/min, respirations 12/min and he BMI is 15 kg/m2.

Choices:
A. Bupropion
B. Gabapentin
C. Selegiline
D. Amitriptyline

Answer: Bupropion

1. A 19-year-old woman was brought to the emergency department by ambulance.

2. She was in her normal state of health and collapsed while preparing for an exam at her college’s library.

3. When she regained consciousness she was surrounded by students and staff.

4. The emergency personnel assessed her condition and brought her in.

5. Her past medical history is significant for major depressive disorder.

6. Her primary care physician prescribed a medication for her depression, but she has not taken it for several days because she was concerned about weight gain.

7. Her family medical history is insignificant for neurological disorders.

8. For the past 10 days, she has been taking her roommate’s antidepressant medication instead.

9. Her blood pressure is 100/80 mm Hg, pulse 102/min, respirations 12/min and BMI is 15 kg/m2.

10. Physical examination reveals pale and dry mucosa and conjunctiva, and lanugo on her arms and legs.


Question: Which of the following intracellular changes is most likely to occur in renal vascular smooth muscle as a result of this drug?

Context: A 59-year-old man with long-standing hypertension is brought to the emergency department because of vomiting and headache for 2 hours.

Context: He reports that he has been unable to refill the prescription for his antihypertensive medications.

Context: His blood pressure is 210/120 mm Hg.

Choices:
A. Increased activity of protein kinase C
B. Increased activity of guanylate cyclase
C. Increased production of cyclic adenosine monophosphate
D. Increased intracellular concentration of calcium

Answer: Increased production of cyclic adenosine monophosphate

1. A 59-year-old man is brought to the emergency department.

3. He has been vomiting and has had a headache for 2 hours.

4. He has been unable to refill the prescription for his antihypertensive medications.

6. Fundoscopy shows bilateral optic disc swelling.

7. An ECG shows left ventricular hypertrophy.

8. Treatment with intravenous fenoldopam is begun.


Question: Of the following options, which underlying condition could cause this reaction?

Context: A 4-year-old boy is referred to the transfusion clinic with malaise, fever, bilateral conjunctivitis, erythema of the oral mucosa, macular rash of the trunk, and inguinal lymphadenopathy following several days of loose stool.

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

Context: He is rushed to the emergency department where his blood pressure is 85/48 mm Hg, heart rate is 120/min, respiratory rate is 26/min, and temperature is 37.0°C (98.6°F).

Context: A complete blood count is normal.

Choices:
A. Bruton's agammaglobulinemia
B. IgA deficiency
C. Hyper-IgM syndrome
D. Hyper-IgD syndrome

Answer: IgA deficiency

1. A 4-year-old boy is referred to the transfusion clinic.

2. He has malaise, fever, bilateral conjunctivitis, erythema of the oral mucosa, macular rash of the trunk, and inguinal lymphadenopathy.

3. He had several days of loose stool prior to referral.

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

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

6. Kawasaki’s disease is suspected and therapy with intravenous immunoglobulin and aspirin is initiated.

7. Later that day, the patient develops trouble breathing, facial flushing, and rapidly evolving pruritic abdominal rash.

8. He is rushed to the emergency department.

9. His blood pressure is 85/48 mm Hg, heart rate is 120/min, respiratory rate is 26/min, and temperature is 37.0°C (98.6°F).

10. On physical examination, the patient has severe facial edema and severe stridor, which can be heard without a stethoscope.


Question: What is the mode of inheritance for this patient's disease?

Context: He takes no medications.

Context: His blood pressure is 125/92 mm Hg, pulse is 90/min, respiratory rate 12/min, and temperature is 36.6°C (97.9°F).

Context: Laboratory testing shows: | Hematocrit 23% | Erythrocyte count 2.2 million/mm3 | Thrombocyte count  25,000/mm3 | A bone marrow biopsy shows decreased trilineage hematopoiesis and macrophages with a crinkled tissue-paper appearance.

Choices:
A. Autosomal dominant
B. X-linked recessive
C. Autosomal recessive
D. X-linked dominant

Answer: Autosomal recessive

1. A 19-year-old man presents to the physician due to progressively worsening weakness.

2. He also notes that he has been getting tired easily and frequently feels short of breath.

3. Additionally, he notes a protuberant belly that he cannot seem to reduce with diet and exercise.

4. His past medical history is significant for easy bruising since he was very young, requiring at least one transfusion when he was younger.

10. Physical examination reveals hepatomegaly and splenomegaly.

11. Several bruises can be seen on the inside of his arms and legs.

12. Laboratory testing shows a hematocrit of 23%.

13. Laboratory testing shows an erythrocyte count of 2.2 million/mm3.

14. Laboratory testing shows a thrombocyte count of 25,000/mm3.

15. A bone marrow biopsy shows decreased trilineage hematopoiesis and macrophages with a crinkled tissue-paper appearance.

Pediatrics
Medical Genetics and Genomics

General Medical Genetics and Genomics
Neuromuscular Medicine
General Pediatrics


Question: What is the best next step in terms of managing this patient?

Context: A 1-day-old boy is brought to the emergency room by his parents for difficulty breathing.

Context: The mom received minimal prenatal care as she wanted the most natural process for her child.

Context: The mom reports that he has been relatively healthy expect for when he feeds he gets a little fussy.

Context: However, these episodes self-resolve after he curls up his legs.

Context: A physical examination demonstrates a baby in acute distress with subcostal retractions and cyanosis at the distal extremities.

Choices:
A. Administer warming blankets
B. Give prostaglandin E1
C. Immediate surgical repair
D. Obtain lumbar puncture for CSF analysis

Answer: Give prostaglandin E1

1. A 1-day-old boy is brought to the emergency room by his parents.

2. He was delivered at home via vaginal birth with no complications.

3. The mom received minimal prenatal care.

4. The mom wanted the most natural process for her child.

5. The mom reports that he has been relatively healthy.

6. He gets a little fussy when he feeds.

7. These episodes self-resolve after he curls up his legs.

8. A physical examination demonstrates a baby in acute distress.

9. Subcostal retractions and cyanosis at the distal extremities are present.

10. A 5/6 systolic ejection murmur is heard at the left upper sternal border.


Question: Which medication would most likely further improve her lipid profile?

Context: Lab tests show the following: | Serum glucose (fasting) 95 mg/dL |     Serum electrolytes: | Sodium 140 mEq/L | Potassium 3.8 mEq/L | Chloride 101 mEq/L | Serum creatinine 0.8 mg/dL | Blood urea nitrogen 10 mg/dL | Cholesterol, total 180 mg/dL | HDL-cholesterol 42 mg/dL | LDL-cholesterol 70 mg/dL | Triglycerides 365 mg/dL |     Urinalysis:   | Glucose negative | Ketones negative | Leucocytes negative | Nitrites negative | RBC negative | Casts negative | .

Choices:
A. Niacin
B. Orlistat
C. Fenofibrate
D. Ezetimibe

Answer: Fenofibrate

1. A 40-year-old woman schedules an appointment for a routine medical check-up.

2. She admits to being careless about her health, but is motivated to improve.

3. She is working with a personal trainer at the gym and is following a weight reduction diet plan.

4. Despite a 20 kg (44 lb) weight loss over the last year, she still feels that she is fat.

5. She was a frequent binge drinker, but now she has reduced her alcohol consumption to a single glass of wine with dinner and an occasional beer on the weekend.

6. She also has a 15 pack-year smoking history, but quit 6 months ago after she developed a cough and shortness of breath that later improved.

7. She admits to trying various recreational drugs in the past.

8. On her last visit, she was started on rosuvastatin for an elevated cholesterol level.

9. She is sexually active with her partner and they have 2 children.

10. She is uncertain about her family history as she was raised in foster care.

11. The vital signs include: pulse 80/min, respirations 16/min, and blood pressure 122/80 mm Hg.

12. The physical examination reveals a visibly overweight woman with a body mass index (BMI) of 34 kg/m2.

13. The remainder of the examination yields no significant findings.

14. An electrocardiogram (ECG) and chest X-ray are both normal.

15. Lab tests show the following: Serum glucose (fasting) 95 mg/dL.

16. Serum electrolytes: Sodium 140 mEq/L.

17. Serum electrolytes: Potassium 3.8 mEq/L.

18. Serum electrolytes: Chloride 101 mEq/L.

Lipidology
Endocrinology, Diabetes, and Metabolism


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

Context: His past medical history is notable for an ST elevation myocardial infarction (STEMI) treated 1 year ago, an abdominal aortic aneurysm (AAA) treated 1 week ago, chronic obstructive pulmonary disease (COPD), asthma, obesity, hypertension, stroke treated 5 years ago, an atrial arrhythmia, diabetes, constipation, and post-traumatic stress disorder (PTSD).

Context: His temperature is 102.0°F (39°C), blood pressure is 197/128 mmHg, pulse is 135/min, respirations are 22/min, and oxygen saturation is 92% on room air.

Context: Laboratory values are ordered as seen below. |  | Hemoglobin: 14 g/dL | Hematocrit: 42% | Leukocyte count: 15,500/mm^3 with normal differential | Platelet count: 199,000/mm^3 |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.4 mEq/L | HCO3-: 22 mEq/L | BUN: 32 mg/dL | Glucose: 189 mg/dL | Creatinine: 1.9 mg/dL | Ca2+: 10.2 mg/dL | Lactate: 4.5 mg/dL | AST: 12 U/L | ALT: 10 U/L |  | .

Choices:
A. Abdominal aortic aneurysm repair complication
B. Atrial fibrillation
C. Obstruction of the small bowel
D. Ruptured appendix

Answer: Abdominal aortic aneurysm repair complication

1. A 59-year-old man presents to the emergency department with abdominal pain.

2. He states that it seemed to come on abruptly, though he does endorse feeling pain the past several days.

3. He has been experiencing bloody diarrhea as well as a subjective fever.

4. His past medical history is notable for an ST elevation myocardial infarction (STEMI) treated 1 year ago.

5. His past medical history is also notable for an abdominal aortic aneurysm (AAA) treated 1 week ago.

6. His past medical history is further notable for chronic obstructive pulmonary disease (COPD), asthma, obesity, hypertension, stroke treated 5 years ago, an atrial arrhythmia, diabetes, constipation, and post-traumatic stress disorder (PTSD).

11. His oxygen saturation is 92% on room air.

12. On physical exam, you note an obese man in distress.

13. Cardiopulmonary exam is notable for bilateral wheezes and a systolic murmur.

14. There is bilateral lower extremity pitting edema and venous stasis ulcers.

15. Abdominal exam reveals diffuse tenderness which the patient describes as 10/10 in severity.

16. Laboratory values show a hemoglobin of 14 g/dL.

17. Laboratory values show a hematocrit of 42%.

18. Laboratory values show a leukocyte count of 15,500/mm^3 with normal differential.

19. Laboratory values show a platelet count of 199,000/mm^3.

20. Laboratory values show a serum Na+ of 139 mEq/L.

21. Laboratory values show a serum Cl- of 100 mEq/L.

22. Laboratory values show a serum K+ of 4.4 mEq/L.

23. Laboratory values show a serum HCO3- of 22 mEq/L.

24. Laboratory values show a serum BUN of 32 mg/dL.

25. Laboratory values show a serum glucose of 189 mg/dL.


Question: Which of the following processes is most likely targeted by this drug?

Context: An investigator is studying an experimental treatment for HIV infection that inhibits the maturation of new HIV virions.

Context: Patients who are taking the drug are observed for several years and side effects are recorded.

Context: In addition, a significant portion of the patients who take the drug for several years shows increased fat accumulation in the neck with loss of subcutaneous fat in the face and extremities.

Choices:
A. Viral entry into host cell
B. Viral polypeptide cleavage
C. Viral budding from host cells
D. Reverse transcription of viral RNA

Answer: Viral polypeptide cleavage

1. An investigator is studying an experimental treatment for HIV infection.

2. The treatment inhibits the maturation of new HIV virions.

3. Patients who are taking the drug are observed for several years.

5. A correlation is established between the drug and the development of impaired glucose tolerance.

6. A significant portion of the patients who take the drug for several years shows increased fat accumulation in the neck.

7. There is loss of subcutaneous fat in the face and extremities.


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

Context: A 30-year-old G1P1 woman gives birth to a healthy infant at 39 weeks gestation.

Context: The mother attended all her prenatal visits and took all her appropriate prenatal vitamins.

Context: Her past medical history is notable for diabetes mellitus, for which she takes metformin.

Context: The infant's temperature is 99.2°F (37.3°C), blood pressure is 65/40 mmHg, pulse is 110/min, and respirations are 22/min.

Choices:
A. Decreased androgen receptor responsiveness
B. Impaired sense of smell
C. Long extremities
D. Testosterone-to-dihydrotestosterone ratio > 20

Answer: Testosterone-to-dihydrotestosterone ratio > 20

1. A 30-year-old G1P1 woman gave birth to a healthy infant at 39 weeks gestation.

2. The mother attended all her prenatal visits.

3. The mother took all her appropriate prenatal vitamins.

4. The mother's past medical history is notable for diabetes mellitus.

5. The mother takes metformin for her diabetes mellitus.

6. The infant's Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.

7. The infant's temperature is 99.2°F (37.3°C).

8. The infant's blood pressure is 65/40 mmHg.

10. The infant's respirations are 22/min.

11. On exam, the child has ambiguous genitalia.

12. A karyotype analysis demonstrates the presence of a Y chromosome.

13. Further workup reveals internal testes with normal levels of serum luteinizing hormone and testosterone.


Question: Which of the following statements best describes the properties of drug A when compared to drug B?"

Context: An investigator is studying the pharmacokinetic properties of two novel inhalational anesthetics and reports the following findings. | Blood-gas partition coefficient Minimum alveolar concentration | Drug A 0.42 3.20% | Drug B 2.31 7.45% | .

Choices:
A. More blood soluble and faster induction of anesthesia
B. More potent and slower recovery from anesthesia
C. More lipid-soluble and faster recovery from anesthesia
D. Less potent and faster induction of anesthesia

Answer: More lipid-soluble and faster recovery from anesthesia

1. An investigator is studying the pharmacokinetic properties of two novel inhalational anesthetics.

2. The investigator reports the following findings.

3. The blood-gas partition coefficient for Drug A is 0.42.

4. The minimum alveolar concentration for Drug A is 3.20%.

5. The blood-gas partition coefficient for Drug B is 2.31.

6. The minimum alveolar concentration for Drug B is 7.45%.


Question: Which of the following best describes the mechanism of development of these skin lesions in this patient?

Context: A 56-year-old man presents to an initial visit to his primary care physician complaining of excessive fatigue, weight loss, and increased abdominal girth.

Context: He drinks about 2–4 glasses of wine with dinner and recalls having abnormal liver enzymes in the past.

Context: The skin lesion in this photo is present in on the face, arms, and upper trunk of the patient.

Choices:
A. Anastomoses between portal vein tributaries and the arterial system
B. Hormonal imbalance
C. Coagulation defects
D. Increase in serum ammonia

Answer: Hormonal imbalance

1. A 56-year-old man presents to an initial visit to his primary care physician.

2. He is complaining of excessive fatigue, weight loss, and increased abdominal girth.

3. He drinks about 2–4 glasses of wine with dinner.

4. He recalls having abnormal liver enzymes in the past.

5. He has a remote history of intravenous drug use.

6. Physical examination reveals shifting dullness, firm liver, and splenomegaly.

7. There is a skin lesion present on the face, arms, and upper trunk of the patient.


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

Context: A 44-year-old man presents to the emergency department due to sudden chest pain and difficulty breathing for the past 3 hours.

Context: The pain is felt in the retrosternal area and radiates up to his left shoulder and arm; it worsens on inspiration, and is relieved when he is leaning forward.

Context: An ECG is performed.

Choices:
A. Acute pericarditis
B. Aortic stenosis
C. Infective endocarditis
D. Myocardial infarction

Answer: Acute pericarditis

1. A 44-year-old man presents to the emergency department.

2. He has had sudden chest pain and difficulty breathing for the past 3 hours.

3. The pain is felt in the retrosternal area and radiates up to his left shoulder and arm.

4. The pain worsens on inspiration and is relieved when he is leaning forward.

5. His heart rate is 61/min, respiratory rate is 16/min, temperature is 36.5°C (97.7°F), and blood pressure is 115/78 mm Hg.

6. Physical examination shows no abnormalities.

7. Pericardial friction rub is heard on auscultation.

8. Laboratory results show elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels.

Cardiovascular Disease
General Emergency Medicine


Question: The bacteriostatic effect of this drug is most likely due to which of the following mechanisms?

Context: A 27-year-old woman comes to the physician because of a rash and headache.

Context: Her temperature is 38.2°C (100.8°F).

Context: A drug is prescribed that can cause fatal aplastic anemia.

Choices:
A. Inhibition of initiation complex formation at the 30S ribosomal subunit
B. Inactivation of prokaryotic topoisomerase II and IV
C. Inhibition of tRNA binding site at the 30S ribosomal subunit
D. Inactivation of bacterial peptidyltransferase at the 50S ribosomal subunit

Answer: Inactivation of bacterial peptidyltransferase at the 50S ribosomal subunit

1. A 27-year-old woman comes to the physician.

2. She recently returned from a camping trip in North Carolina.

3. She has a severe allergy to doxycycline.

5. Physical examination shows a blanching erythematous rash and petechiae over both ankles and the soles of her feet.

7. The drug can cause fatal aplastic anemia.


Question: Which of these benefits can the physician ethically accept?

Context: The research of an academic physician helps to discover a novel small molecule that improves outcomes after myocardial infarction in animal models due to decreasing the severity of reperfusion injury.

Context: A pharmaceutical company then approached the university of this physician in order to sign an agreement allowing the molecule to proceed to clinical trials.

Context: After several years of work, the physician has obtained a wealth of new data from human trials and has published several high profile papers. |  | A major national conference then invites this physician to give a keynote presentation on his work with the novel small molecule.

Context: In order to prepare for this speech, the pharmaceutical company offers: | 1.

Context: A speaking honorarium | 2.

Context: Compensation for travel expenses | 3.

Context: Help with preparing slides for the speech |  | .

Choices:
A. 1 only
B. 1 and 2
C. 1 and 3
D. 1, 2, and 3

Answer: 1 and 2

1. An academic physician conducted research that discovered a novel small molecule that improves outcomes after myocardial infarction in animal models due to decreasing the severity of reperfusion injury.

2. A pharmaceutical company approached the university of this physician in order to sign an agreement allowing the molecule to proceed to clinical trials.

3. After several years of work, the physician has obtained a wealth of new data from human trials and has published several high profile papers.

4. A major national conference invited this physician to give a keynote presentation on his work with the novel small molecule.

5. The pharmaceutical company offered a speaking honorarium, compensation for travel expenses, and help with preparing slides for the speech.


Question: Which of the following options best describes the pathogenesis of edema in this patient?

Context: His temperature is 36.9°C (98.4°F), pulse rate is 88/min, blood pressure is 98/70 mm Hg, and respiratory rate is 20/min.

Context: Laboratory studies show: | Serum creatinine 0.8 mg/dL | Serum albumin 1.5 g/dL | Serum cholesterol 260 mg/dL | Serum C3 and C4 Normal | Urine protein/creatinine ratio 3.1 mg/mg | The patient is diagnosed with minimal change disease.

Choices:
A. Increased capillary hydrostatic pressure
B. Increased capillary permeability
C. Increased interstitial oncotic pressure
D. Decreased oncotic pressure gradient across capillary

Answer: Decreased oncotic pressure gradient across capillary

1. A 6-year-old boy is brought to the pediatrician with swelling around the eyes, lower extremity edema, and abdominal distension for the past 3 days.

2. There is no history of hematuria or decreased urine output.

7. On physical examination, 2+ pitting edema is present in the lower limbs and the periorbital region.

8. The abdomen is distended with a positive fluid wave.

9. Laboratory studies show serum creatinine 0.8 mg/dL.

10. Laboratory studies show serum albumin 1.5 g/dL.

11. Laboratory studies show serum cholesterol 260 mg/dL.

12. Laboratory studies show serum C3 and C4 Normal.

13. Laboratory studies show urine protein/creatinine ratio 3.1 mg/mg.

14. The patient is diagnosed with minimal change disease.


Question: This patient's condition is most likely associated with decreased production of which of the following substances?

Context: A 73-year-old woman is brought to the physician by her son because of a 2-year history of increasing forgetfulness.

Context: She does not remember her children's names; she cannot go outside the house unaccompanied because she forgets where she is and what she is supposed to do.

Context: Her son reports that over the past year, she has withdrawn herself from social gatherings and avoids making conversation.

Context: She is oriented only to person.

Context: Her abstract reasoning is impaired.

Context: She appears indifferent about her memory lapses and says this is normal for someone her age.

Choices:
A. Gamma-aminobutyric acid
B. Acetylcholine
C. Norepinephrine
D. Dopamine

Answer: Acetylcholine

1. A 73-year-old woman is brought to the physician by her son.

2. She has a 2-year history of increasing forgetfulness.

3. She does not remember her children's names.

4. She cannot go outside the house unaccompanied.

5. She forgets where she is and what she is supposed to do.

6. Her son reports that over the past year, she has withdrawn herself from social gatherings.

8. Mental status examination shows both impaired short- and long-term memory.

11. She appears indifferent about her memory lapses.

12. She says this is normal for someone her age.

Neurology with Special Qualification in Child Neurology


Question: What type of medication would be best long-term for our patient?

Context: During an emergency room shift, you encounter a disheveled looking man claiming that he is President Kennedy’s love child and the FBI is out to get him.

Context: He also endorses that the aliens are responsible for his fathers death and that the aliens implanted a chip in his head to constantly speak to him.

Choices:
A. Quetiapine
B. Lithium
C. Fluoxetine
D. Chlorpromazine

Answer: Quetiapine

1. During an emergency room shift, you encounter a disheveled looking man.

2. The man claims that he is President Kennedy’s love child.

3. The man claims that the FBI is out to get him.

4. The man endorses that the aliens are responsible for his father's death.

5. The man claims that the aliens implanted a chip in his head to constantly speak to him.

6. Upon review of his medical record, you notice that he made a previous visit to the ER for a similar episode about 8 months ago.

7. Besides his eccentric demeanor and disorganized speech, his vitals and physical exam are all within in normal range.

8. No illicit substances were identified following a urinary toxicology screening.


Question: What is the most likely pathological process seen in this type of infection?

Context: A 20-year-old man presents to an outpatient clinic with complaints of fever and sweating for 2 months.

Context: He says that he does not have the same appetite as before.

Context: He lost 2.7 kg (6.0 lb) in the last 2 months.

Context: He also complains of pleuritic chest pain and difficulty breathing, which is not nocturnal and is unrelated to position.

Context: He has had a mild cough for several months.

Context: On examination, the patient is afebrile with normal auscultatory findings.

Context: A chest X-ray reveals a right upper lobe homogeneous density.

Choices:
A. Caseous necrosis
B. Liquefactive necrosis
C. Fat necrosis
D. Fibrinoid necrosis

Answer: Caseous necrosis

2. Patient has had fever and sweating for 2 months.

4. Patient has lost 2.7 kg (6.0 lb) in the last 2 months.

5. Patient has pleuritic chest pain and difficulty breathing.

6. Patient's chest pain and difficulty breathing is not nocturnal and is unrelated to position.

7. Patient has had a mild cough for several months.

8. Patient is afebrile with normal auscultatory findings on examination.

9. Chest X-ray reveals a right upper lobe homogeneous density.

10. Ziehl-Neelsen staining of sputum shows Mycobacterium tuberculosis.


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

Context: A 19-year-old man presents with a 10-day history of progressive lower back pain and leg weakness, followed by severe lower abdominal pain for the past 12-hours.

Context: He describes the back pain as moderate in intensity which radiates to both legs.

Context: The weakness has progressively increased, and he cannot ambulate without support.

Context: He is also complaining of fever but never checks it.

Context: He is a captain of the college basketball team and the back pain and lower limb weakness is preventing him from participating in practices or games.

Context: Past medical history is significant for schizophrenia and a suicide attempt.

Context: His vital signs include: blood pressure 128/84 mm Hg, temperature 38.8°C (101.8°F).

Context: A mass is palpable in the lower abdomen.

Context: Strength is 5 out of 5 in the upper limbs bilaterally and 3 out of 5 in the lower limbs bilaterally.

Context: Deep tendon reflexes are 2+ in the upper limbs while they are reduced in the lower limbs.

Choices:
A. Nerve conduction studies
B. Psychiatric consultation
C. Spinal magnetic resonance imaging (MRI)
D. Ultrasound of kidneys, ureters, and bladder

Answer: Spinal magnetic resonance imaging (MRI)

2. Patient has 10-day history of progressive lower back pain and leg weakness.

3. Patient has severe lower abdominal pain for the past 12-hours.

4. Patient describes back pain as moderate in intensity which radiates to both legs.

5. Patient's weakness has progressively increased.

6. Patient cannot ambulate without support.

7. Patient is complaining of fever but never checks it.

8. Patient is captain of college basketball team.

9. Back pain and lower limb weakness is preventing patient from participating in practices or games.

10. Patient has past medical history of schizophrenia and a suicide attempt.

11. Patient's blood pressure is 128/84 mm Hg.

12. Patient's temperature is 38.8°C (101.8°F).

14. Strength is 5 out of 5 in upper limbs bilaterally and 3 out of 5 in lower limbs bilaterally.

15. Deep tendon reflexes are 2+ in upper limbs and reduced in lower limbs.

16. Sensitivity to pinprick is absent from below the umbilicus.

17. 1270 mL of urine is collected after placing a Foley catheter.


Question: Which of the following deposits would most likely be detected on the renal biopsy in this patient?

Context: His blood work shows mild anemia and urinalysis detects proteinuria at a level of 670 mg/24 h.

Context: A kidney biopsy is performed.

Choices:
A. Аβ amyloid
B. Calcitonin
C. AL amyloid
D. Mutated transthyretin

Answer: AL amyloid

1. A 72-year-old man is diagnosed with multiple myeloma.

3. Urinalysis detects proteinuria at a level of 670 mg/24 h.


Question: Which of the following options would be most appropriate for the management of this patient?

Context: A 29-year-old woman, gravida 1, para 0 at 11 weeks' gestation, comes to the physician because of a 2-day history of left lower-extremity pain and swelling.

Context: Her temperature is 37.9°C (100.2°F).

Context: She denies any trauma but says she has not been ambulating due to swelling and the pain in her lower extremities.

Choices:
A. Aspirin
B. Dipyridamole
C. Heparin
D. Warfarin

Answer: Heparin

1. A 29-year-old woman is gravida 1, para 0 at 11 weeks' gestation.

2. She has a 2-day history of left lower-extremity pain and swelling.

5. She has not been ambulating due to swelling and the pain in her lower extremities.

6. Physical examination shows diffuse pain on palpation and swelling of the left leg, as well as warmth and tenderness.

7. Compression ultrasound shows poor compressibility of the femoral vein.

General Obstetrics and Gynecology
Maternal


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

Context: A 65-year-old woman presents to the emergency department with a new-onset seizure.

Context: The patient works as a gardener is often dehydrated but drinks large volumes of water to compensate for her work.

Context: She does not wear protective gear or sunscreen while working.

Context: She has smoked 1.5 packs of cigarettes per day for the past 40 years.

Context: She drinks liquor before bed every night.

Context: The patient has a past medical history of hypertension and diabetes and recently lost 9 pounds.

Context: Physical exam is within normal limits.

Choices:
A. Glioblastoma multiforme
B. Infiltrating ductal carcinoma of the breast
C. Primary seizure disorder
D. Small cell carcinoma of the lung

Answer: Small cell carcinoma of the lung

1. A 65-year-old woman presented to the emergency department with a new-onset seizure.

2. The patient was at home watching television when she suddenly began jerking her limbs and not responding according to her partner.

4. The patient is often dehydrated but drinks large volumes of water to compensate for her work.

5. The patient does not wear protective gear or sunscreen while working.

6. The patient has smoked 1.5 packs of cigarettes per day for the past 40 years.

7. The patient drinks liquor before bed every night.

8. The patient has a past medical history of hypertension and diabetes.

10. Physical exam is within normal limits.


Question: What is inoculation of the tetanus vaccine able to stimulate the production of?

Context: A 32-year-old man presents to the emergency department after puncturing his foot while working on his garage last week.

Context: On examination, the patient’s jaw seems rigid, and his temperature is 38.3°C (100.9°F).

Choices:
A. Anti-tetanus antibodies
B. Allotype antibodies
C. Hypersensitive reaction type III
D. Idiotype antibodies

Answer: Allotype antibodies

1. A 32-year-old man presents to the emergency department.

2. He punctured his foot while working on his garage last week.

3. His past medical history is significant for bronchial asthma and seasonal allergies.

4. On examination, the patient's jaw seems rigid.

6. The puncture on the sole of his foot is 2 cm deep and 0.5 cm long.

7. The patient is immediately given tetanus immunoglobulin.

General Emergency Medicine
Infectious Disease


Question: Which of the following explains these findings?

Context: She has lost 20 kg (44 lb).

Context: A physical examination indicates that the body temperature is 37.8°C (100.0°F), the heart rate is 120/min, and the blood pressure is 130/80 mm Hg.

Context: She was agitated and experienced a fine tremor with warm moist palms; she also had increased deep tendon reflexes.

Context: No exophthalmos was noted.

Context: The laboratory tests revealed TSH < 0.01 mIU/L (normal: 0.5–4.0 mIU/L), T4: 57 pmol/L (normal: 10–25 pmol/L), T3: 24 pmol/L (normal 3.1–5.4 pmol/L).

Context: Complete blood count was normal.

Choices:
A. Exogenous thyroxine intake
B. Graves’ disease
C. Hashimoto’s thyroiditis
D. Pregnancy

Answer: Graves’ disease

1. A 28-year-old woman presents to the clinic with 2 months of palpitations, tremor, heat intolerance, insomnia, and loose bowel movements.

3. A physical examination indicates that the body temperature is 37.8°C (100.0°F).

6. The examination also reveals that a moderately-sized diffuse goiter and a bruit were present.

7. She was agitated and experienced a fine tremor with warm moist palms.

8. She also had increased deep tendon reflexes.

10. The laboratory tests revealed TSH < 0.01 mIU/L (normal: 0.5–4.0 mIU/L).

11. T4: 57 pmol/L (normal: 10–25 pmol/L).

12. T3: 24 pmol/L (normal 3.1–5.4 pmol/L).

14. A thyroid scan demonstrated diffusely increased uptake.

15. A high level of thyroid-stimulating immunoglobulin antibodies was detected.

Internal Medicine
Endocrinology, Diabetes, and Metabolism

Endocrinology, Diabetes, and Metabolism
General Endocrinology


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

Context: A 45-year-old woman comes to the physician because of fatigue and irregular menstrual cycles for the past year.

Context: She also complains of recurrent sinus infections.

Context: During the past 6 months, she has had increased urinary frequency and swelling of her feet.

Context: She has also had difficulty lifting her 3-year-old niece for the past 3 weeks.

Context: She was recently diagnosed with depression.

Context: She works as a medical assistant.

Context: The patient has smoked one half-pack of cigarettes daily for 25 years and drinks four beers on the weekends.

Context: Her only medication is escitalopram.

Context: She is 160 cm (5 ft 3 in) tall and weighs 79 kg (175 lb); BMI is 31 kg/m2.

Context: She appears tired.

Context: Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 18/min, and blood pressure is 140/82 mm Hg.

Context: Laboratory studies show: | Serum | Na+ 150 mEq/L | K+ 3.0 mEq/L | Cl- 103 mEq/L | HCO3- 30 mEq/L | Urea nitrogen 19 mg/dL | Creatinine 0.9 mg/dL | Glucose 136 mg/dL | A 1 mg overnight dexamethasone suppression test shows a serum cortisol of 167 nmol/L (N < 50) and a 24-hour urinary cortisol is 425 μg (N < 300 μg).

Context: Serum ACTH is 169 pg/mL (N = 7–50).

Context: Subsequently, a high-dose dexamethasone suppression test shows a serum cortisol level of 164 nmol/L (N < 50).

Choices:
A. Adrenal carcinoma
B. Hypothyroidism
C. Small cell lung cancer
D. Adrenal adenoma

Answer: Small cell lung cancer

2. Patient has been experiencing fatigue and irregular menstrual cycles for the past year.

3. Patient has had recurrent sinus infections.

4. Patient has had increased urinary frequency and swelling of her feet for the past 6 months.

5. Patient has had difficulty lifting her 3-year-old niece for the past 3 weeks.

6. Patient was recently diagnosed with depression.

7. Patient works as a medical assistant.

8. Patient has smoked one half-pack of cigarettes daily for 25 years.

9. Patient drinks four beers on the weekends.

10. Patient's only medication is escitalopram.

12. Patient weighs 79 kg (175 lb); BMI is 31 kg/m2.

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

17. Patient's blood pressure is 140/82 mm Hg.

18. Physical examinations shows neck obesity and an enlarged abdomen.

19. Examination of the skin shows multiple bruises on her arms and legs.

20. There is generalized weakness and atrophy of the proximal muscles.

28. A 1 mg overnight dexamethasone suppression test shows a serum cortisol of 167 nmol/L (N < 50).

29. 24-hour urinary cortisol is 425 μg (N < 300 μg).

31. High-dose dexamethasone suppression test shows a serum cortisol level of 164 nmol/L (N < 50).


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

Context: A 39-year-old woman, gravida 3, para 2, at 39 weeks' gestation is admitted to the hospital with leakage of fluid and contractions.

Context: She noticed the fluid leak about an hour ago and has no associated bleeding.

Context: Contractions have been about 20 minutes apart.

Context: On admission, she is dilated 2 cm, 50% effaced, and at -2 station.

Context: Spontaneous rupture of membranes is confirmed and she is monitored by external tocodynamometer.

Context: Repeat evaluation after 2 hours shows dilation of 6 cm , 70% effacement, and -1 station.

Context: Four hours later, her pelvic exam shows no changes and she has 4 strong contractions every 10 minutes.

Context: The fetal heart rate is 120/min, with moderate accelerations and no late or variable decelerations.

Choices:
A. Cesarean delivery
B. Assisted vaginal delivery
C. Amnioinfusion
D.
Intrauterine pressure catheter
"

Answer: Cesarean delivery

4. Patient has leakage of fluid and contractions.

5. Patient noticed fluid leak about an hour ago.

7. Contractions are about 20 minutes apart.

8. On admission, patient is dilated 2 cm, 50% effaced, and at -2 station.

9. Spontaneous rupture of membranes is confirmed.

10. Patient is monitored by external tocodynamometer.

11. Repeat evaluation after 2 hours shows dilation of 6 cm, 70% effacement, and -1 station.

12. Four hours later, pelvic exam shows no changes.

13. Patient has 4 strong contractions every 10 minutes.

15. Fetal heart rate has moderate accelerations.

16. Fetal heart rate has no late or variable decelerations.


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

Context: A 32-year-old homeless man presents to the emergency department with dyspnea, left-sided chest pain, chills, and a productive cough over the last week or so.

Context: He does not have medical insurance and has not seen a doctor for many years.

Context: His chest pain increases with inspiration.

Context: The pain does not radiate or worsen with movement.

Context: He states that has a productive cough with yellow sputum with flecks of blood.

Context: He drinks 6 beers a night and does not smoke or take illicit drugs.

Context: Temperature is 37.8°C (100.0°F), blood pressure is 124/90 mm Hg, pulse is 92/min, and respiration rate is 16/min.

Context: On physical examination, tactile fremitus is increased and there is a dullness to percussion over the lower part of the left lung.

Context: No murmurs are heard.

Choices:
A. Supplemental oxygen
B. IV antibiotics and thoracentesis
C. Inhaled bronchodilators
D. Upper endoscopy

Answer: IV antibiotics and thoracentesis

3. Patient presents with dyspnea, left-sided chest pain, chills, and a productive cough over the last week or so.

4. Patient has not had medical insurance and has not seen a doctor for many years.

5. Patient's chest pain increases with inspiration.

6. Patient's chest pain does not radiate or worsen with movement.

7. Patient has a productive cough with yellow sputum with flecks of blood.

9. Patient does not smoke or take illicit drugs.

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

11. Patient's blood pressure is 124/90 mm Hg.

13. Patient's respiration rate is 16/min.

14. On physical examination, tactile fremitus is increased.

15. On physical examination, there is a dullness to percussion over the lower part of the left lung.

16. On physical examination, no murmurs are heard.

17. Oral examination reveals poor dentition.

18. Chest X-ray reveals a large left lobar opacification with extensive pleural effusion.

General Emergency Medicine
Pulmonary Disease


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

Context: A 43-year-old woman presents with left calf pain.

Context: She denies any previous episodes of such pain.

Context: Past medical history is significant for cervical carcinoma treated with cryosurgery with no evidence of recurrence.

Context: Current medications are an estrogen-containing oral contraceptive and a multivitamin.

Context: The patient reports a 40-pack-year smoking history, but no alcohol or recreational drug use.

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

Context: A D-dimer level is positive.

Choices:
A. Fibromyalgia
B. Oral contraceptives
C. Protein C deficiency
D. Protein S deficiency

Answer: Oral contraceptives

2. Patient presents with left calf pain.

3. Patient denies any previous episodes of such pain.

4. Patient has past medical history of cervical carcinoma treated with cryosurgery with no evidence of recurrence.

5. Patient is currently taking an estrogen-containing oral contraceptive and a multivitamin.

6. Patient has a 40-pack-year smoking history, but no alcohol or recreational drug use.

7. Patient is afebrile and her vital signs are within normal limits.

8. On physical examination, her left calf is swollen, erythematous, and tender to palpation.

Orthopaedic Sports Medicine
General Internal Medicine
Vascular Medicine


Question: Assuming all other parameters remain constant, which of the following is most likely to decrease the volume of retrograde blood flow in this patient?

Context: A 53-year-old woman with hypertension and hyperlipidemia comes to the physician because of a 3-month history of progressively worsening shortness of breath.

Context: Her pulse is 92/min, respirations are 22/min, and blood pressure is 110/70 mm Hg.

Context: Cardiac examination shows a grade 3/6 holosystolic murmur at the apex that radiates to the axilla and an extra heart sound during early diastole.

Choices:
A. Increase in atrioventricular orifice size
B. Increase in left ventricular inotropy
C. Decrease in systemic vascular resistance
D. Increase in left ventricular end-diastolic pressure

Answer: Decrease in systemic vascular resistance

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

2. She has hypertension and hyperlipidemia.

3. She has a 3-month history of progressively worsening shortness of breath.

7. Cardiac examination shows a grade 3/6 holosystolic murmur at the apex.

9. There is an extra heart sound during early diastole.


Question: What is the most likely cause of his symptoms?

Context: A 66-year-old man presents to his primary care physician with abdominal pain in the setting of progressively worsening constipation.

Context: He complains of epigastric pain that waxes and wanes, and expressed concern that he has not defecated for the past 5 days.

Context: Upon further questioning, he relates that he has been taking three of his wife's multivitamins each day for the past three weeks to "combat a cold." Vital signs are within normal limits.

Context: Physical exam reveals an abdomen with nonspecific tenderness to deep palpation without rebound tenderness, hyperpercussion, or flank tenderness.

Choices:
A. Magnesium overdose
B. Iron overdose
C. Potassium overdose
D. Folic acid overdose

Answer: Iron overdose

1. A 66-year-old man presents to his primary care physician with abdominal pain.

2. The abdominal pain is in the setting of progressively worsening constipation.

3. He complains of epigastric pain that waxes and wanes.

4. He has not defecated for the past 5 days.

5. He has been taking three of his wife's multivitamins each day for the past three weeks.

6. Vital signs are within normal limits.

7. Physical exam reveals an abdomen with nonspecific tenderness to deep palpation.

8. There is no rebound tenderness, hyperpercussion, or flank tenderness.


Question: Which of the following findings in the nephron best describes the tubular osmolality, compared with serum, in this patient?

Context: Two days after undergoing transsphenoidal removal of a pituitary macroadenoma, a 35-year-old woman reports increased thirst and frequent urination.

Context: The surgery was uncomplicated.

Context: Neurologic examination shows no abnormalities.

Context: Her serum sodium concentration is 153 mEq/L and serum glucose concentration is 92 mg/dL.

Choices:
A. Distal ascending loop of Henle is hypertonic
B. Proximal convoluted tubule is hypertonic
C. Collecting duct is hypotonic
D. Distal convoluted tubule is hypertonic

Answer: Collecting duct is hypotonic

1. A 35-year-old woman underwent transsphenoidal removal of a pituitary macroadenoma.

2. Two days after the surgery, the woman reported increased thirst and frequent urination.

4. Neurologic examination showed no abnormalities.

5. The woman's serum sodium concentration was 153 mEq/L.

6. The woman's serum glucose concentration was 92 mg/dL.


Question: This patient's symptoms are most likely caused by obstruction at which of the following locations?

Context: A 67-year-old woman comes to the physician because of a 5-day history of episodic abdominal pain, nausea, and vomiting.

Context: She is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); her BMI is 34 kg/m2.

Context: Her temperature is 38.1°C (100.6°F).

Context: Physical examination shows dry mucous membranes, abdominal distension, and hyperactive bowel sounds.

Choices:
A. Third part of the duodenum
B. Distal ileum
C. Proximal jejunum
D. Pancreatic duct

Answer: Distal ileum

1. A 67-year-old woman comes to the physician.

2. She has a 5-day history of episodic abdominal pain, nausea, and vomiting.

3. She has coronary artery disease and type 2 diabetes mellitus.

4. She takes aspirin, metoprolol, and metformin.

9. Physical examination shows dry mucous membranes.

10. Physical examination shows abdominal distension.

11. Physical examination shows hyperactive bowel sounds.

12. Ultrasonography of the abdomen shows air in the biliary tract.


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

Context: A 47-year-old man presents to his ophthalmologist for abnormal vision.

Context: The patient was discharged from the hospital 2 weeks ago after a motor vehicle accident where he was given 1L of blood.

Context: He also underwent several surgical procedures including enucleation of the right globe and exploratory abdominal laparotomy to stop internal bleeding.

Context: Currently, he states that he has noticed decreased vision in his left eye.

Context: The patient has a past medical history of poorly controlled diabetes, asthma, and atopic dermatitis.

Context: His temperature is 98.9°F (37.2°C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 97% on room air.

Context: Physical exam is notable for 20/200 vision in the patient's left eye, which is worse than usual.

Context: The patient's left eye appears red and irritated.

Choices:
A. Anterior uveitis
B. Normal post-operative visual adaptations
C. Seasonal allergies
D. Sympathetic ophthalmia

Answer: Sympathetic ophthalmia

2. Patient was discharged from hospital 2 weeks ago after motor vehicle accident.

4. Patient underwent enucleation of right globe and exploratory abdominal laparotomy.

5. Patient has noticed decreased vision in left eye.

6. Patient has past medical history of poorly controlled diabetes, asthma, and atopic dermatitis.

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

8. Patient's blood pressure is 167/108 mmHg.

11. Patient's oxygen saturation is 97% on room air.

12. Patient's vision in left eye is 20/200.

13. Patient's left eye appears red and irritated.


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

Context: A 26-year-old female presents to her primary care physician with several months of mood swings, which she feels are affecting her work and personal relationships.

Context: She states that on roughly a quarter of days each month, she feels highly irritable, sensitive to criticism and rejection, and easily saddened.

Context: She also feels that her appetite varies greatly, and on the days when she is particularly emotional, she also feels especially hungry.

Context: As a result of these symptoms, her performance at work has suffered, and her boyfriend has been complaining that she is difficult to live with.

Context: She is anxious that she cannot “get my mood under control.” The patient has no past medical history, regular periods every 28 days, and no obstetric history.

Context: She uses condoms for contraception.

Context: Her mother has major depressive disorder, and her father has hypertension and coronary artery disease.

Context: At this visit, the patient’s temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 130/76 mmHg, and respirations are 13/min.

Context: She appears slightly anxious but has overall normal affect and is pleasantly conversational.

Context: Physical exam is unremarkable.

Choices:
A. Selective serotonin reuptake inhibitor
B. Combined oral contraceptive therapy
C. Serotonin-norepinephrine reuptake inhibitor
D. Cognitive behavioral therapy

Answer: Selective serotonin reuptake inhibitor

2. Patient has been experiencing mood swings for several months.

3. Patient feels highly irritable, sensitive to criticism and rejection, and easily saddened on roughly a quarter of days each month.

4. Patient's appetite varies greatly on days when she is particularly emotional.

5. Patient's performance at work has suffered.

6. Patient's boyfriend has been complaining that she is difficult to live with.

7. Patient is anxious that she cannot "get my mood under control."

9. Patient has regular periods every 28 days.

11. Patient uses condoms for contraception.

12. Patient's mother has major depressive disorder.

13. Patient's father has hypertension and coronary artery disease.

14. Patient's temperature is 98.4°F (36.9°C).

16. Patient's blood pressure is 130/76 mmHg.

18. Patient appears slightly anxious but has overall normal affect.

19. Patient is pleasantly conversational.

20. Patient's physical exam is unremarkable.