Question: The most likely cause of these findings is a fracture of which of the following bones?

Context: A 36-year-old woman comes to the emergency department because of left wrist pain and swelling that started immediately after a fall.

Context: An x-ray of the wrist 2 days later is shown.

Choices:
A. Scaphoid
B. Ulna
C. Lunate
D. Hamate

Answer: Scaphoid

1. A 36-year-old woman comes to the emergency department.

2. She has left wrist pain and swelling.

3. The pain and swelling started immediately after a fall.

4. She was walking her dog when the dog abruptly pulled away, causing her to fall forward onto both hands.

5. Physical examination shows left wrist pain with pinching and grasping, moderate swelling, and mild tenderness.

6. Her left thumb is placed in a thumb immobilization splint.

7. An x-ray of the wrist was taken 2 days later.

Surgery of the Hand
General Orthopaedic Surgery


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

Context: A 2200-g (4-lb 14-oz) newborn is delivered at term to a 37-year-old primigravid woman.

Context: Examination in the delivery room shows that he is at the 2nd percentile for head circumference and at the 10th percentile for length.

Context: He has a small jaw, small eyes, and low-set ears.

Context: He has seven fingers on each hand.

Context: Cleft lip and cleft palate are present.

Context: The heels are prominent, with convex-shaped deformity of the plantar surface of the feet.

Choices:
A. Fragile X syndrome
B. Trisomy 18
C. Fetal alcohol syndrome
D. Trisomy 13

Answer: Trisomy 13

1. A 2200-g (4-lb 14-oz) newborn is delivered at term.

2. The mother is a 37-year-old primigravid woman.

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

4. Examination in the delivery room shows the newborn is at the 2nd percentile for head circumference.

5. Examination in the delivery room shows the newborn is at the 10th percentile for length.

9. There is a keyhole-shaped defect in the iris of the left eye.

10. The newborn has seven fingers on each hand.

11. There is an opening in the roof of the mouth extending into the soft and hard palate bilaterally.

12. Cleft lip and cleft palate are present.

13. A 3/6 holosystolic murmur is heard at the left lower sternal border.

15. There is a convex-shaped deformity of the plantar surface of the feet.


Question: Which of the following changes in the oxygen-hemoglobin curve would most likely be expected in this patient?

Context: A 55-year-old woman is rushed to the emergency department after being found lying unconscious in a burning house by a firefighter.

Context: No history can be obtained.

Context: Her vital signs include pulse 130/min and respirations 16/min.

Choices:
A. The curve would be shifted left due to an increased oxygen binding affinity by hemoglobin.
B. The curve would be shifted left due to metabolic acidosis in peripheral tissues.
C. The curve would be unchanged because the partial pressure of oxygen is unchanged.
D. The curve would be shifted right due to decreased hemoglobin affinity for oxygen.

Answer: The curve would be shifted left due to an increased oxygen binding affinity by hemoglobin.

1. A 55-year-old woman is rushed to the emergency department.

2. She was found lying unconscious in a burning house by a firefighter.

6. Physical examination reveals soot all over her face.

7. Scattered wheezes can be heard on auscultation of the chest.

8. A thorough survey of the body shows no evidence of any burn injuries.

General Emergency Medicine
Critical Care Medicine
Pulmonary Disease


Question: Of the following, which medication is most likely responsible for his presentation?

Context: A 73-year-old man with a past medical history significant for high blood pressure, hypothyroidism, and diabetes presents to the outpatient clinic.

Context: He complains of joint pain, muscle pain, and fatigue that has been present for the last several weeks.

Context: On examination, you notice a butterfly-shaped rash across the bridge of his nose and cheeks.

Context: He has a blood pressure of 124/72 mm Hg and heart rate of 64/min.

Choices:
A. Verapamil
B. Clonidine
C. Hydralazine
D. Terazosin

Answer: Hydralazine

1. A 73-year-old man presents to the outpatient clinic.

2. His past medical history is significant for high blood pressure, hypothyroidism, and diabetes.

3. He complains of joint pain, muscle pain, and fatigue for the last several weeks.

4. On examination, there is a butterfly-shaped rash across the bridge of his nose and cheeks.

General Internal Medicine
Hypertension Specialist


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

Context: A 65-year-old woman with a 6-month history of acute promyelocytic leukemia managed with all-trans-retinoic acid presents with severe abdominal pain, nausea, vomiting, and bloody urine.

Context: The patient states her symptoms onset acutely a few hours ago and has not improved.

Context: She describes the pain as severe, sharp and stabbing in character, and diffusely localized to the umbilical region, accompanied by nausea and vomiting.

Context: The patient also states that she noticed blood in her urine last time she urinated.

Context: Her vitals signs include: temperature 37.0°C (98.6°F), blood pressure 95/75 mm Hg, pulse 115/min, respiratory rate 23/min, and oxygen saturation 99% on room air.

Context: On physical examination, the patient is ill-appearing and in severe distress.

Context: The cardiac exam is normal.

Context: Lungs are clear to auscultation.

Context: The abdomen is severely tender and out of proportion with physical exam findings.

Context: There are diffuse petechiae present over the entire body.

Context: Laboratory results are pending.

Context: A peripheral blood smear is shown in the exhibit.

Context: A contrast CT of the abdomen shows findings consistent with acute mesenteric ischemia.

Choices:
A. PT: ↑ | PTT ↑ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↑ | Platelet count: ↓
B. PT: ↓ | PTT ↓ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓
C. PT: ↑ | PTT ↑ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓
D. PT: ↓ | PTT ↓ | Bleeding time: ↓ | Fibrin split products: ↓ | D-dimer: ↓| Fibrinogen: ↓ | Platelet count: ↓

Answer: PT: ↑ | PTT ↑ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓

2. Patient has a 6-month history of acute promyelocytic leukemia managed with all-trans-retinoic acid.

3. Patient presents with severe abdominal pain, nausea, vomiting, and bloody urine.

4. Symptoms onset acutely a few hours ago and have not improved.

5. Pain is severe, sharp and stabbing in character, and diffusely localized to the umbilical region, accompanied by nausea and vomiting.

6. Patient noticed blood in her urine last time she urinated.

7. No additional significant past medical history.

8. Temperature 37.0°C (98.6°F), blood pressure 95/75 mm Hg, pulse 115/min, respiratory rate 23/min, and oxygen saturation 99% on room air.

9. Patient is ill-appearing and in severe distress.

12. Abdomen is severely tender and out of proportion with physical exam findings.

13. Diffuse petechiae present over the entire body.

15. Peripheral blood smear is shown in the exhibit.

16. Contrast CT of the abdomen shows findings consistent with acute mesenteric ischemia.


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

Context: A 32-year-old woman comes to the physician because of a throbbing left-sided headache that started 3 hours ago.

Context: A similar episode occurred last week.

Context: She is otherwise healthy and has recently started taking an oral contraceptive.

Context: Visual acuity is 20/20.

Choices:
A. Intranasal dihydroergotamine and subcutaneous sumatriptan
B. Oral tramadol
C. Intravenous prochlorperazine
D.
Oral ketorolac and oral ergotamine
"

Answer: Intravenous prochlorperazine

1. A 32-year-old woman comes to the physician.

2. She has a throbbing left-sided headache that started 3 hours ago.

3. Two hours ago, she took ibuprofen with no relief.

4. She has been vomiting every 20 minutes since the start of the headache.

5. She reports that she could not see very well for a few minutes this morning.

6. A similar episode occurred last week.

8. She has recently started taking an oral contraceptive.

9. Her vital signs are within normal limits.

10. Physical examination shows no abnormalities except mild sensitivity to light.


Question: Which of the following mechanisms best explains the effect of amiodarone on the coagulation profile of this patient?

Context: He has a past medical history of stroke and his current medications include warfarin.

Context: Physical examination is unremarkable.

Context: At the time of discharge, his medications include warfarin and amiodarone, and he is cautioned that his PT might be prolonged.

Choices:
A. Amiodarone induces CYP3A4 leading to a decreased effectiveness of warfarin
B. Amiodarone inhibits CYP2C9 leading to an increased risk of bleeding
C. Amiodarone causes hepatotoxicity which requires monitoring of the prothrombin time
D. Inorganic iodine from amiodarone decreases the effectiveness of warfarin

Answer: Amiodarone inhibits CYP2C9 leading to an increased risk of bleeding

1. A 66-year-old man presents with palpitation, syncope, and difficulty breathing.

2. He has a past medical history of stroke.

3. His current medications include warfarin.

4. Physical examination is unremarkable.

5. An ECG is performed and shows ventricular tachycardia.

6. The patient is treated successfully with amiodarone.

7. At the time of discharge, his medications include warfarin and amiodarone.

8. He is cautioned that his PT might be prolonged.

General Cardiology
Cardiovascular Disease


Question: What is the most appropriate initial treatment for this patient?

Context: A 55-year-old woman presents to the emergency department with recent onset confusion and photophobia.

Context: Upon questioning her husband, you discover the patient has been sick over the past week with fevers and productive sputum.

Context: Her vital signs are Temperature 102.6 Pulse 80 Respirations 18 Blood Pressure 110/70.

Context: The physical exam is significant for lethargy and nuchal rigidity.

Context: A lumbar puncture is performed and demonstrates cloudy fluid with an opening pressure of 35 cm H20, cell count of 1500 cells/uL (neutrophil predominant), protein level of 50 mg/dL and glucose of 30 mg/dL.

Choices:
A. Acyclovir
B. Ceftriaxone and dexamethasone
C. Vancomycin, ceftriaxone, ampicillin and dexamethasone
D. Vancomycin, ceftriaxone and ampicillin

Answer: Vancomycin, ceftriaxone, ampicillin and dexamethasone

2. Patient presents to the emergency department with recent onset confusion and photophobia.

3. Patient has been sick over the past week with fevers and productive sputum.

8. Patient's physical exam is significant for lethargy and nuchal rigidity.

11. Lumbar puncture opening pressure is 35 cm H20.

12. Lumbar puncture cell count is 1500 cells/uL (neutrophil predominant).

13. Lumbar puncture protein level is 50 mg/dL.

14. Lumbar puncture glucose is 30 mg/dL.

15. Computed tomography scan demonstrates no space-occupying lesions.


Question: Which of the following pathological findings is most likely to be seen on the biopsy specimen?

Context: A 58-year-old male presents to his primary care physician complaining of a painless bump on his penis.

Context: He first noticed the lesion 1 year ago but was too embarrassed to mention the issue at his last annual physical exam.

Context: The lesion has since grown in size and has recently become more erythematous.

Context: He has hypertension treated with lisinopril.

Context: At age 45, he was successfully treated for phimosis with a steroid cream.

Context: He first engaged in sexual intercourse at age 14 and has had “too many sexual partners to count” in his lifetime.

Context: He smoked one pack of cigarettes daily for 30 years but quit 10 years ago.

Context: He drinks one alcoholic beverage daily.

Context: There is no inguinal lymphadenopathy.

Choices:
A. Atypical squamous cells with varying degrees of mitotic activity
B. Spirochetes on dark-field microscopy
C. Nonspecific inflammatory features with C. trachomatis amplification on PCR
D. Safety pin-shaped intracellular inclusions that appear purple on Giemsa stain

Answer: Atypical squamous cells with varying degrees of mitotic activity

2. Patient complains of a painless bump on his penis.

3. Patient first noticed the lesion 1 year ago.

4. Patient was too embarrassed to mention the issue at his last annual physical exam.

5. Lesion has grown in size and become more erythematous.

6. Patient has hypertension treated with lisinopril.

7. Patient was successfully treated for phimosis with a steroid cream at age 45.

8. Patient first engaged in sexual intercourse at age 14.

9. Patient has had "too many sexual partners to count" in his lifetime.

10. Patient smoked one pack of cigarettes daily for 30 years.

12. Patient drinks one alcoholic beverage daily.

13. Physical examination shows a nontender 5 mm x 5 mm ulcerated lesion with an erythematous base on the dorsum of the glans.

15. Excisional biopsy of the lesion is performed.


Question: His serum creatinine concentration is 1.6 mg/dL and blood urea nitrogen concentration is 20 mg/dL.This patient is at increased risk for which of the following complications?

Context: Three weeks ago he underwent emergent cardiac catheterization because of a myocardial infarction and had to stay at the hospital longer than expected because of decreased kidney function.

Context: He says his symptoms have since improved greatly and he now produces even more urine than before the procedure.

Choices:
A. Hypermagnesemia
B. Metabolic alkalosis
C. Hypernatremia
D. Hypokalemia

Answer: Hypokalemia

1. A 54-year-old man comes to the physician for a follow-up appointment.

2. Three weeks ago he underwent emergent cardiac catheterization because of a myocardial infarction.

3. He had to stay at the hospital longer than expected because of decreased kidney function.

4. He says his symptoms have since improved greatly.

5. He now produces even more urine than before the procedure.


Question: WBC 2,500/mm3 | Platelets 95,000/mm3 | What is the most likely diagnosis?

Context: A 35-year-old woman visits her primary care provider with complaints of easy fatigability, breathlessness on exertion, and altered sensations in her lower limbs.

Context: Past medical history is positive for hypertension.

Context: She takes hydrochlorothiazide and lisinopril, ethinyl estradiol-progestin, and a multivitamin every day.

Context: Family history is noncontributory.

Context: She drinks alcohol almost every day and smokes cigarettes when she drinks.

Context: Today her heart rate is 95/min, respiratory rate is 17/min, blood pressure is 130/92 mm Hg, and temperature of 37.0°C (98.6°F).

Context: Overall, she has marked pallor with slight bluing of her lips and distal fingertips.

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

Context: Additionally, she has loss of touch, and vibration sense in both of her lower limbs.

Context: Her CBC is as follows: | Hemoglobin 8.0 g/dL | MCV 112 fL | .

Choices:
A. Vitamin B12 deficiency
B. Folic acid deficiency
C. Vitamin C deficiency
D. Vitamin A deficiency

Answer: Vitamin B12 deficiency

2. Patient has complaints of easy fatigability, breathlessness on exertion, and altered sensations in her lower limbs.

3. Patient has a past medical history of hypertension.

4. Patient takes hydrochlorothiazide and lisinopril, ethinyl estradiol-progestin, and a multivitamin every day.

5. Patient's family history is noncontributory.

6. Patient drinks alcohol almost every day and smokes cigarettes when she drinks.

8. Patient's respiratory rate is 17/min.

9. Patient's blood pressure is 130/92 mm Hg.

10. Patient's temperature is 37.0°C (98.6°F).

11. Patient has marked pallor with slight bluing of her lips and distal fingertips.

12. Patient's heart has a regular rate and rhythm.

13. Patient's lungs are clear to auscultation bilaterally.

14. Patient has loss of touch, and vibration sense in both of her lower limbs.

15. Patient's CBC hemoglobin is 8.0 g/dL.


Question: The compound responsible for this patient’s clinical presentation has what mechanism of action?

Context: The patient’s blood pressure is 120/70 mmHg, respirations are 28/min, pulse is 120/min, and SaO2 is 98% on room air.

Context: The patient has no medical history and is not taking any medications.

Context: The patient has 1 alcoholic drink/week and does not use any other illicit drugs.

Choices:
A. Inhibits the electron transport chain
B. Inhibits acetylcholine esterase
C. Prevents acetylcholine release
D. DNA alkylation

Answer: Inhibits the electron transport chain

1. A 40-year-old man is brought by his wife with nausea and vomiting.

2. He had been working for four hours on repairing his car with the garage shutter closed and the car running but did not lose consciousness.

3. The patient’s blood pressure is 120/70 mmHg.

4. The patient’s respirations are 28/min.

6. The patient’s SaO2 is 98% on room air.

8. The patient is not taking any medications.

9. The patient has 1 alcoholic drink/week.

10. The patient does not use any other illicit drugs.

11. Ophthalmologic exam reveals bilateral retinal hemorrhages.

General Emergency Medicine
General Gastroenterology


Question: Which of these findings is most concerning regarding the severity of his hypovolemia?

Context: On exam, his temperature is 100.4°F (38.0°C), blood pressure is 102/80 mmHg, pulse is 95/min, and respirations are 14/min.

Context: Prior to the operation, the patient had a temperature of 98.8°F (37.1°C), blood pressure of 122/70 mmHg, and a pulse of 65/min.

Choices:
A. Decreased pulse pressure
B. Decreased systolic blood pressure
C. Increased heart rate
D. Increased temperature

Answer: Decreased systolic blood pressure

1. A 54-year-old man is hospitalized after a left hemicolectomy for colon cancer.

2. On postoperative day 1, his hemoglobin is noted on routine labs to have dropped overnight from 7.1 g/dL to 5.3 g/dL.

3. The patient does not report feeling any differently.

4. On exam, his temperature is 100.4°F (38.0°C).

5. On exam, his blood pressure is 102/80 mmHg.

7. On exam, his respirations are 14/min.

8. The patient’s urine output in his Foley bag has been 1.0 cc/kg/hr for the last 8 hours.

9. Prior to the operation, the patient had a temperature of 98.8°F (37.1°C).

10. Prior to the operation, the patient had a blood pressure of 122/70 mmHg.

11. Prior to the operation, the patient had a pulse of 65/min.


Question: Which of the following embryologic structures eventually ends up within the visualized structure?

Choices:
A. Ductus venosus
B. Umbilical artery
C. Umbilical vein
D. Vitelline duct

Answer: Umbilical vein

1. An obese 45-year-old female presents to the emergency room complaining of abdominal pain.

2. She reports a 4-hour history of severe right upper quadrant pain following a fatty meal.

3. She has a history of multiple similar episodes over the past year.

4. An ultrasound of the right upper quadrant reveals gallstones.

5. Due to the recurrent nature of her disease, she undergoes an elective laparoscopic cholecystectomy.

6. While in the operating room, the surgeons use the laparoscope to visualize a structure connecting the liver to the anterior wall of the abdominal wall.

General Obstetrics and Gynecology
General Surgery


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

Context: A 28-year-old woman presents with a recent history of severe headaches.

Context: The patient states that the headaches came on gradually about 1 week ago and have steadily worsened.

Context: She describes the headaches as severe, diffuse, and frequently causing nausea and vomiting, especially in the mornings.

Context: A review of systems is significant for fatigue and daytime sleepiness.

Context: Her temperature is 37.0°C (98.6°F), the blood pressure is 110/70 mm Hg, the pulse is 70/min, the respiratory rate is 16/min, and the oxygen saturation is 99% on room air.

Context: The cardiac exam is normal.

Context: Lungs are clear to auscultation.

Context: The neurological exam is normal.

Context: The ophthalmic exam reveals the indistinct margins of the optic disc, bilaterally.

Choices:
A. Genetics
B. Hydrocephalus
C. Intracranial mass
D. Infection

Answer: Hydrocephalus

2. Patient has a recent history of severe headaches.

3. Headaches came on gradually about 1 week ago.

5. Headaches are severe, diffuse, and frequently causing nausea and vomiting, especially in the mornings.

6. Past medical history is significant for bacterial meningitis, approx. one month ago, that was successfully treated.

7. Current medications are combined oral contraceptives and fluoxetine.

8. Review of systems is significant for fatigue and daytime sleepiness.

9. Family history is significant for her mother and aunt who suffer from migraines with aura.

14. Oxygen saturation is 99% on room air.

18. Ophthalmic exam reveals the indistinct margins of the optic disc, bilaterally.


Question: Of the following, which is the most likely cause of the patient’s symptoms:

Context: A 72-year-old presents to the Emergency Room with hemoptysis.

Context: He has smoked 1 pack of cigarettes a day for the past 30 years.

Context: Physical examination of the face is shown in Image A and is accompanied by left upper extremity edema.

Choices:
A. Pleural effusion
B. Superior sulcus tumor
C. Pulmonary embolus
D. Mass in the thoracic region of the spinal cord

Answer: Superior sulcus tumor

1. A 72-year-old presents to the Emergency Room.

2. The patient has a history of smoking 1 pack of cigarettes a day for the past 30 years.

4. Physical examination of the face is shown in Image A.

5. The patient has left upper extremity edema.

General Pulmonary Disease
General Pulmonology


Question: A recent history of which of the following conditions would discourage the use of this drug?

Context: A 59-year-old man who was recently diagnosed with renal cell carcinoma comes to the physician for a follow-up evaluation.

Context: The physician recommends starting treatment with a chemotherapeutic agent that is also used to treat neovascular age-related macular degeneration.

Choices:
A. Interstitial lung disease
B. Chronic kidney disease
C. Platinum allergy
D. Gastrointestinal bleeding

Answer: Gastrointestinal bleeding

1. A 59-year-old man has been diagnosed with renal cell carcinoma.

2. The man is coming to the physician for a follow-up evaluation.

3. The physician is recommending starting treatment with a chemotherapeutic agent.

4. The chemotherapeutic agent is also used to treat neovascular age-related macular degeneration.


Question: Which of the following statements is correct?

Context: A 36-year-old woman presents with a persistent cough productive of blood-streaked sputum, night sweats, and weight loss.

Context: No significant past medical history.

Context: She denies any history of smoking, alcohol consumption, or recreational drug use.

Context: She works as a nurse at a local hospital and lives in an apartment with her extended family.

Context: Her vital signs are a blood pressure of 100/80 mm Hg, heart rate of 94/min, respiratory rate of 17/min, and temperature of 35.9℃ (96.6℉).

Context: During the discussion regarding the required workup, the patient tells the physician about recent contact with a patient with tuberculosis.

Context: She asks the physician not to report her case because she is concerned she will lose her job.

Choices:
A. If this patient is diagnosed with active pulmonary tuberculosis, it should be reported even without the patient’s consent, and the patient should receive isolation and treatment.
B. The patient has a right to privacy, so, without her consent, the physician can not report her case even if she is diagnosed with active pulmonary tuberculosis.
C. If this patient turns out to have active pulmonary tuberculosis, her case can stay unreported only if she agrees to stay home from work and remain isolated at home for her entire treatment period.
D. Only active pulmonary tuberculosis is a reportable disease.

Answer: If this patient is diagnosed with active pulmonary tuberculosis, it should be reported even without the patient’s consent, and the patient should receive isolation and treatment.

2. Patient has a persistent cough productive of blood-streaked sputum, night sweats, and weight loss.

3. Patient has no significant past medical history.

4. Patient denies any history of smoking, alcohol consumption, or recreational drug use.

5. Patient works as a nurse at a local hospital.

6. Patient lives in an apartment with her extended family.

7. Patient's blood pressure is 100/80 mm Hg.

9. Patient's respiratory rate is 17/min.

10. Patient's temperature is 35.9℃ (96.6℉).

11. Physical examination reveals dullness to percussion and diminished breath sounds over the upper lobe of the left lung.

12. Patient recently had contact with a patient with tuberculosis.

13. Patient is concerned she will lose her job if her case is reported.


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

Context: A 33-year-old woman gravida 2, para 1, at 35 weeks gestation is admitted to the hospital with fever and active labor.

Context: She reports a 2-day history of fluid leakage from the vagina without pain or vaginal bleeding.

Context: She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise.

Context: The patient reports a 10-pack-year history of smoking before pregnancy and smoked 4 cigarettes daily during pregnancy.

Context: At the hospital, her temperature is 39.6°C (103.3°F), blood pressure is 108/60 mm Hg, and pulse is 125/min.

Context: Her BMI is 18.2 kg/m2.

Context: Uterine palpation reveals tenderness.

Context: Her lungs are clear to auscultation.

Choices:
A. Amnioinfusion
B. Ampicillin and gentamicin
C. Intravenous betamethasone
D. Ritodrine hydrochloride

Answer: Ampicillin and gentamicin

1. A 33-year-old woman is admitted to the hospital.

2. She is gravida 2, para 1, at 35 weeks gestation.

3. She has a 2-day history of fluid leakage from the vagina without pain or vaginal bleeding.

4. Her pregnancy has otherwise been uncomplicated.

5. She has attended many prenatal appointments.

6. She followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise.

7. Her previous pregnancy was complicated by a preterm delivery at 34 weeks gestation.

8. She has a 10-pack-year history of smoking before pregnancy.

9. She smoked 4 cigarettes daily during pregnancy.

10. Her temperature is 39.6°C (103.3°F).

14. Uterine palpation reveals tenderness.

15. Cervical examination indicates 100% effacement and 10 cm dilation.

16. Her lungs are clear to auscultation.

17. The baseline fetal heart rate is 180/min.

Maternal
General Obstetrics and Gynecology


Question: Which of the following tests is comparatively less useful in assessing the function of the organ involved in this condition?

Context: A 49-year-old man, with a history of alcohol abuse over the last 2 decades, presents with a complaint of epigastric pain for about a year.

Context: He previously had one episode of acute pancreatitis for which he was hospitalized.

Context: He continued to drink 4–5 beers/day after he was discharged.

Context: His appetite is good, but he has a history of weight loss.

Context: He also complains of oily and bulky stools.

Context: He takes aluminum hydroxide gel and ranitidine for partial pain relief.

Context: Vital signs are stable.

Context: Abdominal CT scan is shown below.

Choices:
A. Secretin stimulation test
B. Serum amylase and lipase levels
C. Fecal elastase level
D. Magnetic resonance cholangiopancreatography (MRCP)

Answer: Serum amylase and lipase levels

2. Patient has a history of alcohol abuse for the last 2 decades.

3. Patient presents with a complaint of epigastric pain for about a year.

4. Patient had one episode of acute pancreatitis for which he was hospitalized.

5. Patient continued to drink 4–5 beers/day after he was discharged.

7. Patient has a history of weight loss.

8. Patient complains of oily and bulky stools.

9. Patient takes aluminum hydroxide gel and ranitidine for partial pain relief.

11. Routine physical exam and blood work are normal except for mild hypocalcemia.


Question: Which of the following diagnostic tests would be the most appropriate?

Context: A 34-year-old woman presents to the office due to a pulmonary embolism confirmed by computed tomography (CT) chest angiogram, which she was recently hospitalized for.

Context: She does not have any recent surgical trauma or travel history.

Context: She complains of having episodes where her fingers become white and then blue, and they are usually accompanied by pain in the same region.

Context: These episodes tend to happen more frequently during winter and have been ongoing for about 2 years now.

Context: She also had a spontaneous abortion at 12 weeks of gestation last year.

Context: She does not have a family history of venous thromboembolic disease.

Context: The vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg.

Context: The complete blood count (CBC) results are as follows: | Hemoglobin 14.2 g/dL | Hematocrit 39% | Leukocyte count 4,950/mm3 | Neutrophils 59% | Bands 3% | Eosinophils 1% | Basophils 0% | Lymphocytes 31% | Monocytes 4% | Platelet count 120,000/mm3 | The coagulation test results are as follows: | Partial thromboplastin time (activated) 56 seconds | Prothrombin time 15 seconds | Reticulocyte count 1.0% | Thrombin time < 2 seconds deviation from control | .

Choices:
A. Protein C
B. Factor-V-Leiden
C. Lupus anticoagulant
D. Protein S

Answer: Lupus anticoagulant

2. Patient was recently hospitalized for a pulmonary embolism confirmed by CT chest angiogram.

3. Patient does not have any recent surgical trauma or travel history.

4. Patient complains of episodes where her fingers become white and then blue, accompanied by pain in the same region.

5. Episodes tend to happen more frequently during winter and have been ongoing for about 2 years.

6. Patient had a spontaneous abortion at 12 weeks of gestation last year.

7. Patient does not have a family history of venous thromboembolic disease.

8. Vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg.

9. Physical examination is non-contributory.

10. CBC results: Hemoglobin 14.2 g/dL, Hematocrit 39%, Leukocyte count 4,950/mm3, Neutrophils 59%, Bands 3%, Eosinophils 1%, Basophils 0%, Lymphocytes 31%, Monocytes 4%, Platelet count 120,000/mm3.

11. Coagulation test results: Partial thromboplastin time (activated) 56 seconds, Prothrombin time 15 seconds, Reticulocyte count 1.0%, Thrombin time < 2 seconds deviation from control.


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

Context: A 36-year-old woman, gravida 3, para 2, at 34 weeks' gestation is brought to the emergency department for the evaluation of continuous, dark, vaginal bleeding that started one hour ago.

Context: She also reports severe lower abdominal pain.

Context: Her current pregnancy was complicated by preeclampsia.

Context: Her first two children were delivered vaginally.

Context: Her pulse is 100/min, respirations are 16/min, and blood pressure is 90/60 mm Hg.

Context: The abdomen is tender, and hypertonic contractions are felt.

Context: There is blood on the vulva and on the medial aspect of both thighs bilaterally.

Context: The fetus is in a cephalic presentation.

Context: The fetal heart rate is 170/min with several decelerations.

Choices:
A. Emergency cesarean delivery
B. Elective cesarean delivery
C. Administration of terbutaline
D. Administration of oxytocin and normal vaginal birth

Answer: Emergency cesarean delivery

4. Brought to the emergency department for evaluation of continuous, dark, vaginal bleeding that started one hour ago.

6. Pregnancy complicated by preeclampsia.

7. First two children delivered vaginally.

8. Current medications include methyldopa and a multivitamin.

14. Blood on the vulva and on the medial aspect of both thighs bilaterally.

16. Fetal heart rate is 170/min with several decelerations.

General Obstetrics and Gynecology
Maternal


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

Context: A 16-year-old boy is brought to the emergency department because of severe left flank pain and nausea for 3 hours.

Context: His temperature is 37.1°C (98.8°F), pulse is 103/min, and blood pressure is 108/72 mm Hg.

Choices:
A. Rhomboid crystals on urinalysis
B. Urinary pH of 7.8
C. Serum anti-Saccharomyces cerevisiae antibodies
D. Hexagon-shaped crystals on urinalysis

Answer: Hexagon-shaped crystals on urinalysis

1. A 16-year-old boy is brought to the emergency department.

2. He has severe left flank pain and nausea for 3 hours.

3. The pain is colicky and radiates towards his groin.

4. He drinks multiple glasses of iced tea every day.

5. He has had similar episodes of abdominal pain in the past.

6. His maternal uncle has a similar history of abdominal pain.

10. Examination shows a soft and nontender abdomen.

11. Left costovertebral angle tenderness is present.

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

13. A urinary cyanide nitroprusside test is positive.


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

Context: A 57-year-old woman comes to the emergency department because of severe dyspnea, cough, and pleuritic chest pain for 20 minutes.

Context: The patient appears distressed.

Context: Her pulse is 112/min, respirations are 24/min, and blood pressure is 88/55 mm Hg.

Context: A CT scan of the chest is shown.

Choices:
A. Endovascular stent-grafting
B. Alteplase
C. Coronary angioplasty
D. Pericardiocentesis

Answer: Alteplase

1. A 57-year-old woman comes to the emergency department.

2. She has severe dyspnea, cough, and pleuritic chest pain for 20 minutes.

3. Three weeks ago, she underwent surgery for a total right knee replacement.

8. Examination shows jugular venous distention.

9. There is a mildly tender surgical scar on her right knee.

Pulmonary Disease
General Emergency Medicine


Question: What type of study has been used by the researchers in this example?

Context: From the hospital database, they identify 19,000 patients over the age of 20 with newly diagnosed pulmonary tuberculosis, as well as 72,000 patients without pulmonary tuberculosis for comparison purposes.

Choices:
A. Cohort study
B. Case-control study
C. Ecological study
D. Intervention study

Answer: Case-control study

1. A group of multidisciplinary researchers from a tertiary hospital decides to investigate whether there is an association between splenectomy and pulmonary tuberculosis.

2. From the hospital database, they identify 19,000 patients over the age of 20 with newly diagnosed pulmonary tuberculosis.

3. From the hospital database, they identify 72,000 patients without pulmonary tuberculosis for comparison purposes.

4. Both of these groups are matched for age, gender, and an index year when the condition was initially diagnosed.

5. The odds of pulmonary tuberculosis development associated with splenectomy and other comorbidities is estimated.

6. After controlling for all relevant confounders, the results show that splenectomy is associated with a two-fold higher incidence of pulmonary tuberculosis development.

7. There is also a synergistic effect between splenectomy and other comorbid conditions in the development of pulmonary tuberculosis.


Question: What is the best next step in evaluating this patient?

Context: She has gained 10 pounds over the past month but attributes it to her menopause.

Context: Past medical history is significant for asthma and seasonal allergies, and medications include a rescue inhaler and cetirizine as need.

Context: Review of systems is negative except for cold intolerance and constipation.

Choices:
A. Beta-hCG levels
B. FSH levels
C. Thyroid peroxidase antibody titer
D. TSH levels

Answer: TSH levels

1. A 53-year-old woman presents to the clinic with complaints of fatigue.

2. She reports that over the past several months she has been lethargic and tired.

3. She has gained 10 pounds over the past month.

4. She attributes her weight gain to her menopause.

5. Her last menstrual period (LMP) was 1 year ago.

6. Past medical history is significant for asthma.

7. Past medical history is significant for seasonal allergies.

8. Medications include a rescue inhaler.

9. Medications include cetirizine as needed.

10. Review of systems is negative except for cold intolerance.

11. Review of systems is negative except for constipation.

Internal Medicine
Endocrinology, Diabetes, and Metabolism

Endocrinology, Diabetes, and Metabolism
General Endocrinology


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

Context: A 33-year-old man presents to his primary care physician for fatigue, weight loss, and diffuse pruritus.

Context: The patient has a past medical history of multiple admissions for severe abdominal pain and bloody diarrhea as well as several episodes of ascending cholangitis which were successfully treated.

Context: He is currently a member of Alcoholics Anonymous.

Context: His temperature is 98.2°F (36.8°C), blood pressure is 124/75 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 99% on room air.

Context: A rectal exam reveals pale stool and grossly visible blood.

Context: Physical exam is otherwise notable for pruritis, jaundice, and scleral icterus.

Choices:
A. Ascending cholangitis
B. Cholangiocarcinoma
C. Cirrhosis
D. Colon cancer

Answer: Cholangiocarcinoma

2. Patient presents with fatigue, weight loss, and diffuse pruritus.

3. Patient has past medical history of multiple admissions for severe abdominal pain and bloody diarrhea.

4. Patient has past medical history of several episodes of ascending cholangitis.

5. Patient is currently a member of Alcoholics Anonymous.

6. Patient's temperature is 98.2°F (36.8°C).

7. Patient's blood pressure is 124/75 mmHg.

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

11. Urinalysis is notable only for a dark urine sample with no red blood cells present.

12. Rectal exam reveals pale stool and grossly visible blood.

13. Physical exam is notable for pruritis, jaundice, and scleral icterus.


Question: Which of the following must be done before beginning treatment with a TNF inhibitor?

Context: She undergoes subsequent testing, and is found to have anti-citrullinated protein antibodies.

Context: Her physician is concerned for rheumatoid arthritis, and discusses treatment with a biologic disease-modifying anti-rheumatic agent. |  | .

Choices:
A. Confirm diagnosis with a test for rheumatoid factor
B. Confirm diagnosis with elevated ESR and CRP
C. Test for latent mycobacterial infection
D. Obtain a radiograph demonstrating osteophytes

Answer: Test for latent mycobacterial infection

1. A 43-year-old female presents with several years of pain and stiffness in her wrists and hands.

2. Her symptoms have been getting progressively worse.

3. She reports that her hands feel stiff for an hour or more after awaking in the morning.

5. She is found to have anti-citrullinated protein antibodies.

6. Her physician is concerned for rheumatoid arthritis.

7. Her physician discusses treatment with a biologic disease-modifying anti-rheumatic agent.


Question: Which of the following is the most crucial in the development of this patient’s condition?

Context: A 65-year-old man is brought to the emergency department with a complaint of right-sided numbness for 5 hours.

Context: The numbness started in the right-side of the face and has progressed to the same side arm and leg within 30 minutes.

Context: He denies limb weakness, walking difficulty, vision problem, or vertigo.

Context: He had similar symptoms 5 months ago that were resolved within 10 minutes.

Context: The past medical history includes type 2 diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia.

Context: The medication list includes allopurinol, amlodipine, aspirin, glimepiride, lisinopril, and rosuvastatin.

Context: The blood pressure is 165/102 mm Hg, and the rest of the vital signs are within normal limits.

Context: On examination, there are no facial droop and slurring of the speech noted.

Context: The muscle strength is normal in all 4 limbs with a normal tone and deep tendon reflexes.

Context: There is a decreased pinprick sensation and proprioception on the right arm and leg.

Context: The gait is normal.

Context: The blood sugar is 221 mg/dL.

Context: The CT scan of the head is normal.

Context: The MRI of the head with diffusion-weighted imaging reveals a 15 mm diffusion restriction in the left thalamus.

Choices:
A. Emboli from deep leg veins with a patent foramen ovale
B. Leakage of blood from intracranial vessel due to uncontrolled hypertension
C. Lipohyalinosis of small penetrating arteries due to chronic hypertension
D. Significant stenosis of the left carotid artery

Answer: Lipohyalinosis of small penetrating arteries due to chronic hypertension

2. Patient has right-sided numbness for 5 hours.

3. Numbness started in right-side of face and progressed to same side arm and leg within 30 minutes.

4. Patient denies limb weakness, walking difficulty, vision problem, or vertigo.

5. Patient had similar symptoms 5 months ago that were resolved within 10 minutes.

6. Past medical history includes type 2 diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia.

7. Medication list includes allopurinol, amlodipine, aspirin, glimepiride, lisinopril, and rosuvastatin.

9. Other vital signs are within normal limits.

10. No facial droop or slurring of speech noted on examination.

11. Muscle strength is normal in all 4 limbs with normal tone and deep tendon reflexes.

12. Decreased pinprick sensation and proprioception on right arm and leg.

16. MRI of head with diffusion-weighted imaging reveals 15 mm diffusion restriction in left thalamus.


Question: Which of the following physiologic changes will occur when the patient takes this medication?

Context: He reports that he recently started a new job that involves regular public speaking and is very stressed before every public speaking event.

Context: He does not smoke or drink alcohol.

Context: His temperature is 98.6°F (37°C), blood pressure is 110/65 mmHg, pulse is 85/min, and respirations are 17/min.

Context: He is alert and fully oriented.

Choices:
A. Decreased cardiac output and decreased peripheral resistance
B. Decreased cardiac output and increased peripheral resistance
C. Increased cardiac output and decreased peripheral resistance
D. Increased cardiac output and increased peripheral resistance

Answer: Decreased cardiac output and increased peripheral resistance

1. A 23-year-old man presents to a psychiatrist for evaluation of situational anxiety.

2. He reports that he recently started a new job that involves regular public speaking.

3. He is very stressed before every public speaking event.

4. He describes developing a rapid heart rate and diaphoresis that interferes with his ability to speak well.

5. He has no past medical history and takes no medications.

11. On exam, he is well-appearing and appropriately conversational.

13. The patient is prescribed propranolol to take before major public speaking events.


Question: Which of the following is the best initial step in the management of this patient's condition?

Context: A 69-year-old woman is brought into the emergency room by family members after they noted that she had become increasingly lethargic over the past 3 days.

Context: Her temperature is 39.5°C (103.1°F), the blood pressure is 75/40 mm Hg, the heart rate 130/min, the respiratory rate 24/min, and the oxygen saturation is 89% on room air.

Context: Her skin is warm to the touch.

Context: White blood cell count is 15,000/mm3 and her urinalysis is positive for nitrites and leukocyte esterase.

Choices:
A. Intramuscular adrenaline
B. Intravenous hydrocortisone
C. Assessment of airway, breathing, and circulation
D. Intravenous noradrenaline

Answer: Assessment of airway, breathing, and circulation

1. A 69-year-old woman is brought into the emergency room by family members.

2. She had become increasingly lethargic over the past 3 days.

7. Her oxygen saturation is 89% on room air.

8. On examination, she is severely ill, drowsy, and unable to speak.

10. Her white blood cell count is 15,000/mm3.

11. Her urinalysis is positive for nitrites and leukocyte esterase.


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

Context: A 28-year-old G2P1 woman at 29 weeks gestation presents to the obstetrician after noticing red spots on her undergarments over the past week.

Context: Her vaginal bleeding has not been painful; however, she is concerned that it has persisted.

Context: Her previous child was born by cesarean section and she is currently taking folate and a multivitamin.

Context: She endorses feeling fetal movements.

Context: Her temperature is 98.9°F (37.2°C), blood pressure is 120/84 mmHg, pulse is 88/min, respirations are 17/min, and oxygen saturation is 99% on room air.

Choices:
A. Placenta percreta
B. Placenta previa
C. Placental abruption
D. Uterine rupture

Answer: Placenta previa

3. Patient has noticed red spots on her undergarments over the past week.

4. Patient's vaginal bleeding has not been painful.

5. Patient's previous child was born by cesarean section.

6. Patient is currently taking folate and a multivitamin.

7. Patient endorses feeling fetal movements.

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

9. Patient's blood pressure is 120/84 mmHg.

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

13. Physical exam is notable for a gravid uterus and non-tender abdomen.

14. Speculum exam reveals a closed cervical os and a small amount of blood.


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

Context: She has hypertension.

Context: Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 16/min, and blood pressure is 134/88 mm Hg.

Context: Her speech is clear.

Choices:
A. Cerebellar lesion
B. Inferior frontal gyrus lesion
C. Upper motor neuron lesion
D. Thalamus lesion

Answer: Upper motor neuron lesion

1. A 57-year-old woman comes to the emergency department 1 hour after experiencing a distressing 10-minute episode of stuttering during a business meeting.

3. She has smoked 2 packs of cigarettes daily for 30 years.

4. Current medications include fosinopril and hydrochlorothiazide.

9. She is oriented to person, place, and time.

11. When she is asked to hold both arms fully extended at shoulder level with palms upwards and eyes closed, her right palm turns inwards and downwards.


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

Context: A 40-year-old man comes to the physician because of a 5-kg (11-lb) weight loss over the past month and easy bruising.

Context: He also noticed that his arms now bruise more easily.

Context: He appears pale.

Context: His pulse is 70/min, his blood pressure is 125/75 mm Hg, and his temperature is 38°C (100.4°F).

Context: His liver is enlarged.

Context: Laboratory results show: | Leukocytes 10,500/mm3 | Hemoglobin 10.2 g/dL | Platelets 52,000/mm3 | Fibrinogen 110 mg/dL (Reference: 150-400 mg/dL) | Cytogenetic analysis shows leukocytes with a reciprocal translocation of chromosomes 15 and 17.

Choices:
A. Cyclophosphamide
B. All-trans retinoic acid
C. Cryoprecipitate transfusion
D. Imatinib

Answer: All-trans retinoic acid

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

2. He has experienced a 5-kg (11-lb) weight loss over the past month.

4. He has not changed his diet significantly.

5. He has noticed that his arms now bruise more easily.

10. Examination shows a palm-sized hematoma on his right arm.

11. His spleen is palpable 5 cm below the costal margin.

13. Laboratory results show leukocytes 10,500/mm3.

14. Laboratory results show hemoglobin 10.2 g/dL.

15. Laboratory results show platelets 52,000/mm3.

16. Laboratory results show fibrinogen 110 mg/dL (Reference: 150-400 mg/dL).

17. Laboratory results show cytogenetic analysis with leukocytes with a reciprocal translocation of chromosomes 15 and 17.


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

Context: At a routine exam, a 68-year-old female patient is discovered to have a serum calcium level of 11.5 mg/dL.

Context: Follow-up laboratory tests show a high parathyroid hormone with low phosphorus and mildly elevated alkaline phosphatase.

Context: Review of symptoms includes complaints of fatigue, constipation, and diffuse bone pain for which she takes vitamin D.

Context: Past medical history is significant for type 2 diabetes mellitus for 25 years and essential hypertension for 15 years.

Context: The patient has a history of kidney stones.

Context: Family history is irrelevant.

Choices:
A. Vitamin D intoxication
B. Familial hypocalciuric hypercalcaemia
C. Solitary parathyroid adenoma
D. Thyrotoxicosis

Answer: Solitary parathyroid adenoma

3. Follow-up laboratory tests show high parathyroid hormone with low phosphorus and mildly elevated alkaline phosphatase.

4. 24-hour urine calcium level is elevated.

5. Patient has complaints of fatigue, constipation, and diffuse bone pain.

7. Patient has past medical history of type 2 diabetes mellitus for 25 years and essential hypertension for 15 years.

8. Patient has history of kidney stones.

Endocrinology, Diabetes, and Metabolism
Internal Medicine

General Endocrinology
Endocrinology, Diabetes, and Metabolism


Question: Which of the following is associated with the pathophysiology underlying this patient's disorder?

Context: A 27-year-old man and his wife present to an infertility clinic for evaluation after they tried unsuccessfully to conceive for 2 years.

Context: In addition, he has testicular atrophy and very little body hair, which is distributed primarily in the pubic region.

Context: Further analysis reveals azoospermia, and appropriate tests confirming the diagnosis are performed.

Context: The couple is told about the cause of their inability to conceive and given further options to pursue.

Choices:
A. Abnormal signaling through androgen receptors
B. Abnormal conversion of testosterone
C. Increased aromatase activity
D. Increased production of prolactin

Answer: Increased aromatase activity

1. A 27-year-old man and his wife present to an infertility clinic for evaluation.

2. They have been trying unsuccessfully to conceive for 2 years.

3. He has no prior medical history and does not currently take any medications.

4. On evaluation, he is found to have long extremities and gynecomastia.

5. He also has testicular atrophy and very little body hair, which is distributed primarily in the pubic region.

6. Further analysis reveals azoospermia.

7. Appropriate tests confirming the diagnosis are performed.

8. The couple is told about the cause of their inability to conceive.

9. The couple is given further options to pursue.

Reproductive Endocrinology and Infertility


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

Context: A 32-year-old GP2 presents to an outpatient clinic for a routine gynecologic examination.

Context: The patient appears well, although she mentions that during the past 6 months she has noticed small amounts of vaginal bleeding in the middle of her menstrual cycles.

Context: Her last pregnancy was 3 years ago.

Context: Her subsequent menstrual cycles have been regular, lasting about 2–3 days.

Context: She mentions that she is up to date with her Pap smear; all of her Pap smears have been normal.

Context: She denies any recent travel or history of trauma.

Context: The patient is sexually active with her husband and they use condoms consistently.

Context: She does not smoke, drinks alcohol occasionally, and has never used illicit drugs.

Context: The physical examination is essentially normal.

Context: An ultrasound reveals a fleshy mass with a pedunculated stalk deep in the cervical canal.

Context: The uterine lining measures 5 mm in thickness and is homogeneous.

Context: The patient is otherwise asymptomatic and has no other complaints.

Context: The rest of the physical examination is unremarkable.

Choices:
A. No further intervention with follow-up in 6 months
B. Electrocautery and cryofreezing
C. Cervical brush biopsy
D. Removal of the lesion with a ring forceps

Answer: Removal of the lesion with a ring forceps

3. Patient is presenting to an outpatient clinic for a routine gynecologic examination.

4. Patient has noticed small amounts of vaginal bleeding in the middle of her menstrual cycles for the past 6 months.

5. Patient's last pregnancy was 3 years ago.

6. Patient's menstrual cycles have been regular, lasting about 2–3 days.

7. Patient is up to date with her Pap smear.

8. All of patient's Pap smears have been normal.

9. Patient denies any recent travel or history of trauma.

10. Patient is sexually active with her husband and they use condoms consistently.

12. Patient drinks alcohol occasionally.

13. Patient has never used illicit drugs.

14. Physical examination is essentially normal.

15. Ultrasound reveals a fleshy mass with a pedunculated stalk deep in the cervical canal.

16. Uterine lining measures 5 mm in thickness and is homogeneous.

17. Multiple small leiomyomas are also observed.

18. Patient is otherwise asymptomatic and has no other complaints.

19. Rest of the physical examination is unremarkable.


Question: Which of the following is the most likely underlying pathology?

Context: An 11-year-old girl presents to her pediatrician with complaints of headache and rapid leg fatigue with exercise.

Context: Her vital signs are: HR 77, BP in left arm 155/100, RR 14, SpO2 100%, T 37.0 C.

Choices:
A. Peripheral arterial disease
B. Vasospasm
C. Coarctation of the aorta
D. Tetralogy of Fallot

Answer: Coarctation of the aorta

1. An 11-year-old girl presents to her pediatrician.

2. She has complaints of headache and rapid leg fatigue with exercise.

8. On palpation, her left dorsalis pedis pulse is delayed as compared to her left radial pulse.

9. Her lower extremities feel slightly cool.

10. Blood pressure obtained on the left lower extremity is 120/80.


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

Context: A 34-year-old woman comes to the gynecologist complaining of vaginal swelling and discomfort.

Context: She states that over the past 2 weeks she has noticed swelling of her right labia.

Context: The swelling continued to grow in size and now causes her discomfort when walking.

Context: She denies any history of known trauma.

Context: On physical exam, there is a fluctuant, swelling of the right labia, most prominently at the posterior vestibule.

Choices:
A. Bartholin gland cyst
B. Folliculitis
C. Granuloma inguinale
D. Vulvar cancer

Answer: Bartholin gland cyst

1. A 34-year-old woman comes to the gynecologist.

2. She is complaining of vaginal swelling and discomfort.

3. She has noticed swelling of her right labia over the past 2 weeks.

4. The swelling has continued to grow in size.

5. The swelling causes her discomfort when walking.

6. She denies abnormal discharge or bleeding from the swelling or from the vulva.

7. She normally shaves the area, but with the recent pain, she has been unable to.

8. She denies any history of known trauma.

9. The patient is relatively healthy and takes only a multivitamin.

10. She never received the vaccine for human papillomavirus (HPV).

11. On physical exam, there is a fluctuant, swelling of the right labia.

12. The swelling is most prominently at the posterior vestibule.


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

Context: A 4-month-old boy is brought to the physician because of noisy breathing for 2 months that has progressively become louder.

Context: The noisy breathing improves when he is in the prone position.

Context: It is worse when he is agitated, feeding, or lying on his back.

Context: His temperature is 37.1°C (98.8°F), pulse is 120/min, and respirations are 50/min.

Context: Examination shows inspiratory stridor.

Choices:
A. Observation
B. Surgical division
C. Ceftriaxone therapy
D. Supraglottoplasty

Answer: Observation

1. A 4-month-old boy is brought to the physician.

2. Noisy breathing has been present for 2 months and has progressively become louder.

3. Noisy breathing improves when he is in the prone position.

4. Noisy breathing is worse when he is agitated, feeding, or lying on his back.

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

9. Pulse oximetry on room air shows an oxygen saturation of 98%.

10. Examination shows inspiratory stridor.


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

Context: A 16-year-old girl comes to the physician with a 4-day history of painful vulvar lesions, generalized fatigue, and malaise.

Context: During this period, she has also had dysuria.

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

Context: Her immunizations are up-to-date; she completed the vaccination course for human papilloma virus 2 months ago.

Context: Her temperature is 38.1°C (100.6°F), pulse is 100/min, respirations are 12/min, and blood pressure is 110/70 mm Hg.

Context: There is bilateral, tender inguinal lymphadenopathy.

Choices:
A. Acyclovir therapy
B. Azithromycin therapy
C. Doxycycline therapy
D. Penicillin therapy

Answer: Acyclovir therapy

2. Patient has a 4-day history of painful vulvar lesions, generalized fatigue, and malaise.

3. Patient has had dysuria during this period.

4. Patient is sexually active with 2 male partners.

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

7. Patient completed the vaccination course for human papilloma virus 2 months ago.

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

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

12. Pelvic examination shows several shallow ulcers on an erythematous base over the labia majora and minora.

13. Patient has bilateral, tender inguinal lymphadenopathy.

Pediatrics
Obstetrics and Gynecology
Dermatology

Pediatric Infectious Diseases
General Obstetrics and Gynecology
General Dermatology


Question: These cells most likely originated from which of the following structures?

Context: A 57-year-old man comes to the physician because of progressively worsening epigastric pain and 6.8-kg (15-lb) weight loss for the past 2 months.

Context: He appears thin.

Choices:
A. Lymphoid tissue in the terminal ileum
B. Mature hepatocytes in the liver
C. Exocrine ducts in the body of the pancreas
D. Squamous epithelium in the proximal esophagus

Answer: Exocrine ducts in the body of the pancreas

1. A 57-year-old man comes to the physician.

2. He has experienced progressively worsening epigastric pain for the past 2 months.

3. He has lost 6.8 kg (15 lb) in the past 2 months.

4. Two weeks ago, he noticed painful, red blotches on the medial aspect of his right calf.

5. He has smoked one pack of cigarettes daily for the last 35 years.

7. Physical examination shows tender erythematous nodules on the right ankle and left antecubital fossa.

8. Endoscopy shows a large mass in the antrum of the stomach.

9. A biopsy specimen of the gastric mass shows disorganized mucin-secreting cells with surrounding fibrosis.


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

Context: A 62-year-old woman comes to the emergency department because of painful and difficult swallowing.

Context: Her voice has also become muffled.

Context: She has been well until last night and reports having intermittent fevers at home.

Context: The patient has smoked a pack of cigarettes a day since age 19 but is otherwise healthy.

Context: Her temperature is 39°C (102.2°F), blood pressure is 142/93 Hg/mm, heart rate is 109/min, and respiratory rate is 18/min.

Context: On examination, the patient's head is extended and she appears anxious.

Context: Her voice is muffled and there is inspiratory stridor.

Context: There is tender bilateral cervical lymphadenopathy and pain upon palpation of the hyoid.

Context: Laboratory studies show a leukocyte count of 18,000/mm3 with 83% neutrophils.

Choices:
A. Pseudomonas aeruginosa
B. Corynebacterium diphtheriae
C. Parainfluenza virus
D. Haemophilus influenzae type b

Answer: Haemophilus influenzae type b

1. A 62-year-old woman comes to the emergency department.

2. She has painful and difficult swallowing.

5. She reports having intermittent fevers at home.

6. She has smoked a pack of cigarettes a day since age 19.

12. On examination, her head is extended.

16. There is tender bilateral cervical lymphadenopathy.

17. There is pain upon palpation of the hyoid.

18. The remainder of the examination shows no abnormalities.

19. Laboratory studies show a leukocyte count of 18,000/mm3.

20. 83% of the leukocytes are neutrophils.


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

Context: An MRI of the brain shows a central mass; surgical resection is planned.

Context: One day before the surgery, the patient has another generalized seizure and, despite resuscitative efforts, she dies.

Choices:
A. Oligodendroglioma
B. Glioblastoma
C. Schwannoma
D. Meningioma

Answer: Glioblastoma

1. A 56-year-old woman is brought to the emergency department by her husband 30 minutes after a generalized tonic-clonic seizure.

2. Over the past 3 months, she has had recurrent headaches and worsening early-morning vomiting.

3. She has no personal or family history of a seizure disorder.

4. An MRI of the brain shows a central mass.

6. One day before the surgery, the patient has another generalized seizure.

7. Despite resuscitative efforts, she dies.

8. Gross examination of the brain at autopsy is shown.


Question: Which of the following laboratory values should be assessed next in this patient?

Context: A 29-year-old woman (gravida 2, para 1) presents at 32 weeks gestation for routine follow-up care.

Context: Her previous pregnancy was complicated with preeclampsia, and she delivered at 35 weeks via cesarean delivery.

Context: Four years ago, she was diagnosed with arterial hypertension.

Context: Prior to pregnancy, she took amlodipine and hydrochlorothiazide; after she found out she was pregnant, she switched to methyldopa.

Context: The course of her current pregnancy has been unremarkable with normal laboratory values at each checkup.

Context: According to her blood pressure diary, her systolic blood pressure varies between 120 and 130 mm Hg, and her diastolic blood pressure is usually normal.

Context: At presentation, the blood pressure is 140/80 mm Hg, heart rate is 76/min, respiratory rate is 15/min, and temperature is 36.9°C (98.4°F).

Context: The fetal heart rate is 143/min.

Context: Examination shows a 1+ pitting lower leg edema.

Context: Dipstick test shows 2+ protein.

Choices:
A. Coagulogram
B. Liver transaminases
C. Total bilirubin
D. Urinalysis

Answer: Liver transaminases

4. Patient's previous pregnancy was complicated with preeclampsia.

5. Patient delivered at 35 weeks via cesarean delivery.

6. Patient was diagnosed with arterial hypertension four years ago.

7. Patient took amlodipine and hydrochlorothiazide prior to pregnancy.

8. Patient switched to methyldopa after finding out she was pregnant.

9. Course of current pregnancy has been unremarkable.

10. Normal laboratory values at each checkup.

11. Systolic blood pressure varies between 120 and 130 mm Hg.

12. Diastolic blood pressure is usually normal.

13. Blood pressure at presentation is 140/80 mm Hg.

14. Heart rate at presentation is 76/min.

15. Respiratory rate at presentation is 15/min.

16. Temperature at presentation is 36.9°C (98.4°F).

18. Examination shows 1+ pitting lower leg edema.

20. 24-hour urine assessment demonstrates urinary protein excretion of 1 g/L.


Question: Which of the following best describes this approach to the prevention of medical errors?

Context: Following a colonoscopy performed on a 63-year-old man, the gastroenterologist identifies a firm tumor approx.

Context: 80 cm (31.4 in) from the entry site.

Context: He also performs an endoscopic polypectomy and tattooing at 50 cm (19.6 in) from the entry site.

Context: A pathologic report shows a benign polyp.

Context: One week later, the surgeon in the operating room is erroneously preparing to perform partial colectomy of the tattooed site.

Context: After confirming the patient’s name and before surgery, the surgical team reviews the patient’s history and medical documents orally based on institutional protocols.

Context: The surgery resident points out that the resected polyp is benign and the tumor lies 30 cm (11.8 in) distal to the tattooed area.

Context: The attending surgeon performs a partial colectomy on the correct site.

Choices:
A. Closed-loop communication
B. Preoperative time-out
C. Primordial prevention
D. Sentinel event

Answer: Preoperative time-out

1. A colonoscopy was performed on a 63-year-old man.

2. An endoscopic polypectomy and tattooing was performed at 50 cm (19.6 in) from the entry site.

3. A pathologic report showed a benign polyp.

4. One week later, the surgeon was erroneously preparing to perform partial colectomy of the tattooed site.

5. The surgical team reviewed the patient’s history and medical documents orally based on institutional protocols.

6. The surgery resident pointed out that the resected polyp was benign and the tumor lies 30 cm (11.8 in) distal to the tattooed area.

7. The attending surgeon performed a partial colectomy on the correct site.

Internal Medicine
Surgery
General Surgery


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

Context: She has a history of type I diabetes controlled by insulin and delivered 1 child by normal spontaneous vaginal delivery 2 years ago.

Context: Urinalysis each time confirmed a urinary tract infection, and both urine cultures isolated organisms sensitive to nitrofurantoin.

Context: She has no complaints today.

Choices:
A. Admit to the hospital and treat with intravenous ceftriaxone
B. Treat with oral trimethroprim-sulfamethoxazole for 10 days then continue for prophylaxis until delivery
C. Treat with oral nitrofurantion for 10 days
D. Treat with oral nitrofurantion for 10 days then continue for prophylaxis until delivery

Answer: Treat with oral nitrofurantion for 10 days then continue for prophylaxis until delivery

1. A 28-year-old G2P1001 presents for a routine obstetric visit in her 36th week of pregnancy.

2. She has a history of type I diabetes controlled by insulin.

3. She delivered 1 child by normal spontaneous vaginal delivery 2 years ago.

4. Earlier in this pregnancy, she had 2 episodes of burning with urination and frequent urination.

5. Urinalysis each time confirmed a urinary tract infection.

6. Both urine cultures isolated organisms sensitive to nitrofurantoin.

7. Her symptoms resolved with 10-day courses of nitrofurantoin.

9. Urinalysis is positive for leukocyte esterase and nitrites.


Question: Analysis of a left calf biopsy specimen from this patient is most likely to show which of the following?

Context: A 3-year-old boy is brought to the physician by his parents because of clumsiness and multiple falls over the past 4 months.

Context: He started walking at the age of 18 months and could walk up steps by the time he was 27 months old but now struggles to walk at all without assistance.

Context: There is bilateral calf enlargement.

Choices:
A. Proliferation of mitochondria within muscle fibers
B. Degeneration of muscle fibers with fibrofatty replacement
C. Atrophic muscle fibers interspersed among hypertrophic muscle fibers
D. Necrotic muscle fibers with lymphocytic infiltrate

Answer: Degeneration of muscle fibers with fibrofatty replacement

1. A 3-year-old boy is brought to the physician by his parents.

2. The boy has experienced clumsiness and multiple falls over the past 4 months.

3. The boy started walking at the age of 18 months.

4. The boy could walk up steps by the time he was 27 months old.

5. The boy now struggles to walk at all without assistance.

6. When standing up from a lying position, he crawls onto his knees and slowly walks himself up with his hands.


Question: What is the most likely diagnosis for the lesions seen in endoscopy?

Context: He has a history of hepatitis B.

Context: He was diagnosed with hepatocellular carcinoma and initially received radiotherapy while on the transplant list to prevent local expansion of his malignancy.

Context: He received a blood transfusion.

Choices:
A. Intrinsic apoptotic pathway
B. Coagulative necrosis
C. Overexpression of BcL-2 gene
D. Cytotoxic CD8 T cells pathway

Answer: Intrinsic apoptotic pathway

1. A 60-year-old man presented to the hospital with right upper quadrant abdominal pain.

3. He underwent a CT of his abdomen which revealed a large mass (11.3 cm x 7.2 cm in diameter) with a metastatic retroperitoneal lymph node.

4. He was diagnosed with hepatocellular carcinoma.

5. He initially received radiotherapy while on the transplant list to prevent local expansion of his malignancy.

6. 3 months after radiotherapy, the patient experienced hematemesis and melena.

7. He was admitted to the emergency department for evaluation.

8. His vitals were: blood pressure 84/56 mmHg, heart rate 92/min, and respiratory rate 20/min.

9. Laboratory evaluation revealed severe anemia with a hemoglobin level of 5.7 g/dL, INR 1.8 and platelets of 68,000 cells/mm3.

11. An endoscopic examination demonstrated diffuse edematous hyperemic mucosa and multiple hemorrhagic patches with active oozing in the antrum.


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

Context: Her mother and father have hypertension and her father had myocardial infarction at the age of 68 years.

Context: She drinks 3 glasses of wine a week.

Choices:
A. Liver function tests
B. Urine microalbumin
C. Hemoglobin A1C
D. Blood glucose

Answer: Blood glucose

1. A 49-year-old Caucasian woman presents to your office for elevated blood pressure.

2. She is a nurse and checks her blood pressure regularly while working in the wards.

3. She presents with readings ranging between 163/101 and 156/94 mm Hg.

4. After some research she conducted on her own, she has been exercising and following a low-fat, low-salt diet for the past 3 months.

5. Her past medical history includes laparoscopic cholecystectomy for acute cholecystitis 2 years previously.

6. Her mother and father have hypertension.

7. Her father had myocardial infarction at the age of 68 years.

8. She takes no medications and denies smoking.

10. Her blood pressure in the office after more than 10 minutes of rest was 153/89 mm Hg in her left arm and 145/90 mm Hg in her right arm.

11. A review of her medical record reveals that her blood pressure was 142/92 mm Hg at her visit 1 year ago.


Question: Which of the following is most likely to be seen in this patient?

Context: He does not experience pain when cycling but notices the pain when standing or walking.

Context: He is requesting pain medication and a doctor's note to take off work for the week as his symptoms are disrupting his life.

Choices:
A. Bamboo appearance of the spine on radiography
B. Muscular tenderness with perispinal palpation
C. Multiple doctors visits for other unrelated problems
D. Narrowing of the lumbar spinal canal on MRI

Answer: Narrowing of the lumbar spinal canal on MRI

1. A 55-year-old man presents to his primary care physician for back pain.

2. The patient states that his back pain is worse in the morning and improves with certain activities.

3. He does not experience pain when cycling.

4. He notices the pain when standing or walking.

5. 2 months prior to presentation he was lifting heavy boxes and furniture into his daughter's new home.

7. He is requesting a doctor's note to take off work for the week.

8. His symptoms are disrupting his life.

Orthopaedic Sports Medicine
General Orthopaedic Surgery


Question: WBC 15.2 x  10°/L | Hemoglobin 13.4 g/dL | Platelets 185 x 109/L | Prostate-specific antigen (PSA) 10 ng/mL | What is the most likely cause of the patient’s symptoms?

Context: A 75-year-old man presents to the emergency department from his doctor’s office with a 2-day history of urinary hesitancy, fever, and chills.

Context: He additionally notes that he has been getting up frequently during the night to urinate.

Context: For the last 2 years, it has taken him longer than usual to initiate urination and his stream has gotten weaker.

Context: He has a history of hypertension for which he takes losartan.

Context: His blood pressure is 128/84 mm Hg, heart rate is 84/min, respiratory rate is 14/min, and temperature is 38.2°C (100.8°F).

Context: The patient declines rectal examination.

Context: Significant laboratory results are as follows: | .

Choices:
A. Prostate cancer
B. Pyelonephritis
C. Nephrolithiasis
D. Prostatitis

Answer: Prostatitis

2. Patient has a 2-day history of urinary hesitancy, fever, and chills.

3. Patient has been getting up frequently during the night to urinate.

4. Patient has a history of hypertension for which he takes losartan.

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

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

8. Patient's temperature is 38.2°C (100.8°F).

9. No costovertebral angle tenderness is present on physical examination.

10. Patient declines rectal examination.

11. Significant laboratory results are present.


Question: This patient's skin lesions are most likely associated with which of the following?

Context: A 6-year-old boy is brought to the physician for evaluation of bilateral erythematous skin lesions on the flexures of the elbows and knees.

Context: He has been scratching the areas frequently.

Context: He has had similar lesions intermittently for the last 2 years.

Choices:
A. Reversible decrease in FEV1/FVC ratio
B. IgA anti-tissue transglutaminase antibodies
C. Hepatocyte infection with hepatitis C virus
D. Pencil-in-cup deformity of the fingers

Answer: Reversible decrease in FEV1/FVC ratio

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

2. The evaluation is for bilateral erythematous skin lesions on the flexures of the elbows and knees.

3. The boy has been scratching the areas frequently.

4. The boy has had similar lesions intermittently for the last 2 years.

5. A photograph of the lesions on the back of the knees is shown.

General Dermatology
Pediatric Dermatology


Question: Which of the following molecules is responsible for this reaction?

Context: An important step in the formation of thyroid hormones is the formation of I2 via oxidation of I-.

Choices:
A. Thyroid deiodinase
B. Thyroid peroxidase
C. Perchlorate
D. Propylthiouracil

Answer: Thyroid peroxidase

1. An important step in the formation of thyroid hormones.


Question: This patient’s history is most consistent with which of the following conditions?

Context: A 29-year-old woman presents to her primary care provider for a normal check-up at the prompting of her mother.

Context: A review of her medical record indicates that she has endured several episodes of verbal and physical abuse from her prior relationships which she suggested “were all her fault.” She has had 4 prior serious relationships and reports that she has not been single for more than a few days in the last 10 years.

Choices:
A. Avoidant personality disorder
B. Dependent personality disorder
C. Histrionic personality disorder
D. Paranoid personality disorder

Answer: Dependent personality disorder

1. A 29-year-old woman presents to her primary care provider for a normal check-up.

2. Her mother prompted her to go for the check-up.

3. When asked how she is doing, she replies that she feels depressed.

4. Upon further questioning, she states that she feels “worthless” now that her ex-boyfriend left her 2 days ago.

5. She has been sitting in his bed all day trying to call him but he is not answering her calls.

6. She says that she will never find another man like him and feels like she should just “disappear” rather than continue living without him.

7. She also reports that she can hear his voice when he’s not around, especially at night before she goes to bed.

8. She denies having any other friends and has some social anxiety, particularly in large groups of people.

9. A review of her medical record indicates that she has endured several episodes of verbal and physical abuse from her prior relationships.

10. She suggested that the abuse was “all her fault.”

11. She has had 4 prior serious relationships.

12. She reports that she has not been single for more than a few days in the last 10 years.

13. On exam, she is unkempt with poor self-care.


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

Context: The patient’s laboratory studies are ordered as seen below. |  | Serum: | Na+: 140 mEq/L | Cl-: 103 mEq/L | K+: 5.3 mEq/L | HCO3-: 25 mEq/L | BUN: 33 mg/dL | Glucose: 168 mg/dL | Creatinine: 1.8 mg/dL | Ca2+: 10.0 mg/dL | Troponin: < 0.05 mcg/L |  | A chest CT angiogram, an echocardiogram (ECG), and a second troponin are ordered and are all unremarkable.

Context: A lumbar puncture is performed and based on the results the patient is subsequently started on acyclovir.

Choices:
A. Bolus of IV fluids
B. Calcium gluconate
C. Hemodialysis
D. No further interventions needed

Answer: Bolus of IV fluids

1. A 65-year-old man presents to the emergency department with confusion and chest pain.

2. He states his symptoms started after he landed on a return flight from Brazil.

3. Since then, the patient states that he feels anxious, short of breath, and has pleuritic chest pain.

4. The patient has a past medical history of diabetes and chronic kidney disease.

5. His medications include insulin, lisinopril, aspirin, and atorvastatin.

6. His temperature is 101°F (38.3°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 96% on room air.

7. Physical exam is notable for a confused man.

17. A chest CT angiogram, an echocardiogram (ECG), and a second troponin are ordered and are all unremarkable.

18. The patient’s chest pain resolves with diazepam.

20. Based on the results of the lumbar puncture, the patient is subsequently started on acyclovir.

Neurocritical Care
General Emergency Medicine
Neurology


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

Context: A 52-year-old homosexual man presents to the emergency department because of sudden right loin pain accompanied by nausea and vomiting.

Context: His temperature is 36.9°C (98.4°F), the blood pressure is 137/92 mm Hg, and the pulse is 95/min.

Context: Physical examination reveals right flank tenderness and 2+ edema of both legs up to the knees.

Context: Laboratory results are shown: | Serum creatinine 2.2 mg/dL | Urine dipstick 4+ protein | Urine analysis 20–25 red cells/high power field | .

Choices:
A. Acute pyelonephritis
B. Hypertensive kidney disease
C. Membranous nephropathy
D. Penile cancer

Answer: Membranous nephropathy

1. A 52-year-old homosexual man presents to the emergency department.

2. He has sudden right loin pain accompanied by nausea and vomiting.

3. He has essential hypertension for 3 years for which he takes bisoprolol.

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

8. Physical examination reveals right flank tenderness.

9. Physical examination reveals 2+ edema of both legs up to the knees.

10. Doppler ultrasonography shows an enlarged, echogenic right kidney with the absent venous signal.

13. Urine analysis shows 20–25 red cells/high power field.


Question: Angiography would most likely show a dissection in which of the following vessels?

Context: A 53-year-old woman is brought to the emergency department for a 2-hour history of balance problems.

Context: She was gardening when she suddenly felt very dizzy and she quickly called for her husband.

Context: When she tried to stand up they found she was very unsteady and unbalanced, so her husband carried her to the car.

Context: In the emergency department, while lying in bed, she complains of a room-spinning sensation; when she sits up, she sways to the right.

Context: She has a past medical history of hypertension, polycystic ovarian syndrome, and type 2 diabetes mellitus.

Choices:
A. Anterior cerebral artery
B. Middle cerebral artery
C. Vertebral artery
D. Anterior spinal artery

Answer: Vertebral artery

1. A 53-year-old woman is brought to the emergency department.

2. She has a 2-hour history of balance problems.

3. She was gardening when she suddenly felt very dizzy.

5. When he arrived, she was sitting on the ground, swaying back and forth but overall leaning to the right.

6. When she tried to stand up they found she was very unsteady and unbalanced.

8. In the emergency department, while lying in bed, she complains of a room-spinning sensation.

9. When she sits up, she sways to the right.

10. She is unable to walk more than 3 steps without falling.

11. Finger-nose-finger and heel-knee-shin testing are abnormal.

12. She has a past medical history of hypertension.

13. She has a past medical history of polycystic ovarian syndrome.

14. She has a past medical history of type 2 diabetes mellitus.

15. All of her vital signs are all within normal limits.


Question: Which of the following best describes this cause of the patients symptoms after treatment?

Context: A 65-year-old man with squamous cell carcinoma of the lung presents with a sodium of 118 and an altered mental status.

Context: He is started on 3% normal saline over the next several hours.

Context: The patient’s mental status improves and and a repeat sodium six hours later is 129.

Context: Three days after treatment he demonstrates quadriparesis and dysarthria.

Choices:
A. Lateral medullary syndrome
B. Medial medullary syndrome
C. Osmotic demyelination syndrome
D. Hypercalcemia

Answer: Osmotic demyelination syndrome

1. A 65-year-old man has squamous cell carcinoma of the lung.

6. His sodium level is 129 six hours later.

7. Three days after treatment he has quadriparesis and dysarthria.


Question: Which of the following is the most likely trigger for her current episode?

Context: A 27-year-old woman presents to the emergency department with severe wheezing, which started an hour ago.

Context: She informs the doctor that she has had mild persistent asthma for the last 2 years and is on inhaled corticosteroids, and uses them regularly.

Context: She has not experienced asthma symptoms for the last 2 months and there is no history of non-compliance.

Context: She mentions that her present symptoms came on about 20 minutes after her last meal.

Context: When the doctor makes specific inquiries, she recollects items in her lunch, which included canned milk product, commercially available roasted peanuts, homemade celery salad, and wine.

Context: She also mentions that she took a tablet of acetaminophen immediately after the meal because her legs were aching since morning, which she attributes to her morning walk at 6 am the same day.

Context: She has never developed respiratory symptoms in response to milk protein, peanuts, or acetaminophen until now.

Choices:
A. Ara-h-1 protein
B. Food additive
C. Acetaminophen
D. Exercise

Answer: Food additive

2. Patient presents to the emergency department with severe wheezing.

4. Patient has had mild persistent asthma for the last 2 years.

5. Patient is on inhaled corticosteroids.

6. Patient uses inhaled corticosteroids regularly.

7. Patient has not experienced asthma symptoms for the last 2 months.

9. Symptoms came on about 20 minutes after last meal.

10. Last meal included canned milk product, commercially available roasted peanuts, homemade celery salad, and wine.

11. Patient took a tablet of acetaminophen immediately after the meal.

12. Patient's legs were aching since morning.

13. Patient attributes aching legs to morning walk at 6 am the same day.

14. Patient has never developed respiratory symptoms in response to milk protein, peanuts, or acetaminophen until now.

15. Skin prick testing for food allergens, performed a month back, was negative for all the common food allergens, including milk and peanuts.


Question: What is the chance the offspring will be a child WITHOUT sickle cell anemia?

Context: She states that both she and her husband have family histories of sickle cell disease.

Context: Based on previous genetic testing, they both also have a copy of the sickle cell gene from their parents, but neither of them has ever manifested symptoms associated with the disease.

Context: They want to conceive and are concerned about the chances that their child might have the disease.

Choices:
A. 1/2
B. 3/4
C. 1/4
D. 2/3

Answer: 3/4

1. A 30-year old African-American woman comes into your office for pregnancy counseling with her husband.

2. She has a family history of sickle cell disease.

3. Her husband has a family history of sickle cell disease.

4. She has a copy of the sickle cell gene from her parents.

5. Her husband has a copy of the sickle cell gene from his parents.

6. Neither of them has ever manifested symptoms associated with the disease.

8. They are concerned about the chances that their child might have the disease.

Pediatrics
Medical Genetics and Genomics

Clinical Genetics and Genomics
Pediatric Genetics and Genomics
Pediatric Genetics


Question: Which of the following would be the closest match?

Context: He has a mildly distended abdomen.

Choices:
A. Donor B: tA5/A12, tB22/9, ttC4/C3
B. Donor A: tA7/A5, ttB8/B2, ttC3/C8
C. Donor E: tA7/A8, ttB9/B27, tC3/C4
D. Donor D: tA4/A7, ttB1/B8, ttC8/C3

Answer: Donor A: tA7/A5, ttB8/B2, ttC3/C8

1. A 52-year-old man presents to the clinic complaining of blood in his urine.

2. He had a mild respiratory illness 3 weeks ago.

3. Urinalysis reveals a high red blood cell count and casts in the urine.

4. A diagnosis of post-streptococcal glomerulonephritis is made.

5. The physician explains that the treatment is supportive and that the patient needs to follow up with him every two weeks.

6. Six weeks later, the patient returns to the clinic because he does not feel well; he has been experiencing malaise and fatigue.

7. On examination, his pulse is 98/min, blood pressure is 135/85 mm Hg, temperature is 36.6°C (98.0°F), and respiratory rate is 16/min.

9. Blood tests reveal that the patient’s creatinine level has increased from 1.2 mg/dL to 3.0 mg/dL over the last month.

10. He is referred to a nephrologist who diagnoses him with rapidly progressive glomerulonephritis (RPGN) and starts him on hemodialysis, as his potassium level has risen to 7 mEq/dL.

11. The patient is advised to undergo renal transplantation.

12. His human leukocyte antigen (HLA) genotype is A7/A5, B2/B9, C8/C3.

13. The first allele in each locus is the maternal form; the second is paternal.

14. Several potential donors are available for the renal graft.


Question: Based on these findings, which of the following is the most likely correlation coefficient?

Context: An investigator is studying determinants of childhood obesity by observing a cohort of pregnant women with obesity.

Context: After delivery, he regularly records the height and weight of the cohort's children.

Context: The results of the correlation analysis between mean childhood BMI at 4 years of age and mean maternal BMI before pregnancy are shown.

Choices:
A. -0.45
B. 0.45
C. 0
D. -1.80

Answer: 0.45

1. An investigator is studying determinants of childhood obesity.

2. The investigator is observing a cohort of pregnant women with obesity.

3. The investigator regularly records the height and weight of the cohort's children after delivery.

4. The investigator is conducting a correlation analysis between mean childhood BMI at 4 years of age and mean maternal BMI before pregnancy.

5. The results of the correlation analysis are shown.

Pediatric Endocrinology
Maternal
Neonatal


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

Context: Yesterday she ran 17 km (10.5 mile).

Context: She follows a vegan diet.

Context: She appears well.

Context: Her temperature is 36.6°C (98.0°F), blood pressure is 110/72 mm Hg, pulse is 70/min, and respirations are 14/min.

Context: Laboratory studies show: | Hemoglobin 9.8 g/dL | Mean corpuscular volume 91 fL | Lactate dehydrogenase 400 U/L | Platelet count 250,000/mm3 | Reticulocyte count 3% | Haptoglobin 23 mg/dL (N=41–165 mg/dL) | Serum | Iron 90 μg/dL | Ferritin 170 ng/mL | Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL) | Urinalysis shows trace blood but no RBCs.

Choices:
A. Extravascular hemolysis
B. Vitamin B12 deficiency
C. Intravascular hemolysis
D. Impaired heme synthesis

Answer: Intravascular hemolysis

1. A 25-year-old woman comes to the physician for a routine examination.

2. She is a recreational runner and for the past 3 months she has been training for a marathon.

4. Menses occur at regular 28-day intervals and last 6 days.

5. She drinks three to five beers when going out with friends.

12. Physical examination shows no abnormalities.

13. Laboratory studies show hemoglobin 9.8 g/dL.

18. Haptoglobin 23 mg/dL (N=41–165 mg/dL).

21. Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL).

22. Urinalysis shows trace blood but no RBCs.


Question: Which personality disorder is most likely?

Context: After waiting an hour in the waiting room, he begins to berate the receptionist and demands to be seen by a doctor.

Context: During the exam, the patient brags that he recently had to quit his job because they did not appreciate his talent and drive.

Context: After a medical student declines his invitation for a date, he becomes very angry and throws supplies across the room.

Context: The physician manages the patient's physical injuries and begins to suspect the patient has a personality disorder.

Choices:
A. Narcissistic personality disorder
B. Avoidant personality disorder
C. Histrionic personality disorder
D. Obsessive-compulsive personality disorder

Answer: Narcissistic personality disorder

1. A 45-year-old man comes into the ED after a car accident.

2. He waits an hour in the waiting room.

3. He berates the receptionist and demands to be seen by a doctor.

4. He brags that he recently had to quit his job because they did not appreciate his talent and drive.

5. A medical student declines his invitation for a date.

6. He becomes very angry and throws supplies across the room.

7. The physician manages the patient's physical injuries.

8. The physician begins to suspect the patient has a personality disorder.

General Psychiatry
General Emergency Medicine


Question: The beneficial effect of this drug is most likely due to arrest in which of the following phases of the cell cycle?

Context: A 61-year-old man comes to the physician because of weight loss and a non-productive cough for 4 months.

Choices:
A. G2 phase
B. G1 phase
C. G0 phase
D. S phase

Answer: G1 phase

1. A 61-year-old man comes to the physician.

2. He has a non-productive cough for 4 months.

3. He has smoked 2 packs of cigarettes daily for 42 years.

4. A CT scan of the chest shows an irregular mass at the right hilum and axillary lymphadenopathy.

5. A biopsy of the mass obtained on bronchoscopy confirms the diagnosis of metastatic non-small cell lung cancer.

6. Results of a molecular diagnostic test show a microdeletion on the short arm of chromosome 7.

7. The physician recommends chemotherapy with erlotinib.


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

Context: A 52-year-old woman comes to the physician because of a 4-day history of painful swallowing and retrosternal pain.

Context: She was diagnosed with HIV infection 2 months ago; her medications include tenofovir, emtricitabine, and raltegravir.

Context: Vital signs are within normal limits.

Context: Empiric treatment is started.

Context: Esophagogastroduodenoscopy is performed and shows multiple round superficial ulcers in the distal esophagus.

Choices:
A. Adverse effect of medication
B. Degeneration of ganglion cells within the myenteric plexuses
C. Infection with herpes simplex virus
D. Infection with Candida species

Answer: Infection with herpes simplex virus

1. A 52-year-old woman comes to the physician.

2. She has a 4-day history of painful swallowing and retrosternal pain.

3. She was diagnosed with HIV infection 2 months ago.

4. Her medications include tenofovir, emtricitabine, and raltegravir.

5. Vital signs are within normal limits.

6. Physical examination of the oral cavity shows no abnormalities.

7. The patient's CD4+ T-lymphocyte count is 70/mm3 (N ≥ 500).

9. Two weeks later, she reports no improvement in symptoms.

10. Esophagogastroduodenoscopy is performed.

11. Esophagogastroduodenoscopy shows multiple round superficial ulcers in the distal esophagus.


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

Context: Her mother has diverticulitis.

Context: The patient’s temperature is 99°F (37.2°C), blood pressure is 110/74 mmHg, pulse is 89/min, and respirations are 14/min with an oxygen saturation of 98% on room air.

Context: Labs are obtained, as shown below: |  | Leukocyte count: 10,000/mm^3 with normal differential | Hemoglobin: 13.5 g/dL | Platelet count: 200,000/mm^3 | Beta-human chorionic gonadotropin: Pending |  | A pelvic ultrasound demonstrates a small fluid collection in the cul-de-sac posterior to the uterus.

Choices:
A. Appendicitis
B. Endometriosis
C. Midcycle pain
D. Ruptured ectopic pregnancy

Answer: Midcycle pain

1. An 18-year-old girl comes to the emergency room with abdominal pain.

2. She states that the pain started 6 hours ago, is 8/10, and localizes to the right lower abdomen.

3. She recalls a similar episode last month.

4. Her older brother was hospitalized 2 years ago for perforated appendicitis.

6. The patient got her first menstrual period at age 14.

7. Her periods occur regularly every 28 days.

8. Her last menstrual period was 2 weeks ago.

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

10. The patient’s temperature is 99°F (37.2°C).

11. The patient’s blood pressure is 110/74 mmHg.

13. The patient’s respirations are 14/min with an oxygen saturation of 98% on room air.

14. On physical exam, the patient is in moderate distress.

15. There is lower abdominal tenderness with guarding.

16. A pelvic examination reveals clear mucous in the vaginal introitus, a mobile uterus, and tenderness of the right adnexa.

17. Labs are obtained, as shown below: Leukocyte count: 10,000/mm^3 with normal differential.

18. Labs are obtained, as shown below: Hemoglobin: 13.5 g/dL.

19. Labs are obtained, as shown below: Platelet count: 200,000/mm^3.

20. Labs are obtained, as shown below: Beta-human chorionic gonadotropin: Pending.

21. A pelvic ultrasound demonstrates a small fluid collection in the cul-de-sac posterior to the uterus.

Emergency Medicine
Pediatrics
Obstetrics and Gynecology
General Surgery

General Emergency Medicine
General Pediatrics
General Surgery
General Obstetrics and Gynecology


Question: Which of the following cluster of differentiation markers will he need to use to identify these cells in the resected specimens?

Context: Further investigation reveals that most people in the area work in a glass factory, the region’s main source of employment.

Choices:
A. CD20
B. CD3
C. CD34
D. CD56

Answer: CD56

1. In a suburban town in Virginia, epidemiologists are alarmed by the increasing number of squamous cell lung cancer cases.

2. Most people in the area work in a glass factory, the region’s main source of employment.

3. A researcher is interested in studying the role of immunosurveillance in the pathogenesis of this lung cancer.

4. He postulates that tumor infiltration by natural killer (NK) cells has a better prognosis since they play a major role in immunosurveillance.

5. NK cells also kill tumor cells by the perforin-mediated destruction of cancerous cells.

6. The researcher is interested in studying tumor infiltration by NK cells in the resected specimen from patients within the cohort who have been diagnosed with stage 1 lung cancer.


Question: What is the most likely diagnosis?

Context: A 26-year-old man presents to the office complaining of persistent back pain for the past 3 months.

Context: You saw the patient previously and prescribed NSAIDs and rest, but he has not improved.

Context: The patient states that his maternal grandfather had ‘back problems his whole life’, and he worries that he might have the same issues.

Context: An X-ray is performed and shows squaring of the vertebrae with longitudinal fibrous bands.

Choices:
A. Ehlers-Danlos syndrome
B. Osteosarcoma
C. Ankylosing spondylitis
D. Osteopetrosis

Answer: Ankylosing spondylitis

1. A 26-year-old man presents to the office.

2. He has been complaining of persistent back pain for the past 3 months.

3. The patient was previously prescribed NSAIDs and rest, but has not improved.

4. The patient's maternal grandfather had "back problems his whole life".

5. The patient worries that he might have the same issues.

7. The X-ray shows squaring of the vertebrae with longitudinal fibrous bands.