Question: The mechanism of action of the medication given blocks cell wall synthesis, which of the following was given?

Context: A 21-year-old sexually active male complains of fever, pain during urination, and inflammation and pain in the right knee.

Context: A culture of the joint fluid shows a bacteria that does not ferment maltose and has no polysaccharide capsule.

Context: The physician orders antibiotic therapy for the patient.

Choices:
A. Gentamicin
B. Ciprofloxacin
C. Ceftriaxone
D. Trimethoprim

Answer: Ceftriaxone

4. Patient complains of pain during urination.

5. Patient complains of inflammation and pain in the right knee.

6. Culture of joint fluid shows a bacteria.

8. Bacteria has no polysaccharide capsule.

9. Physician orders antibiotic therapy for the patient.


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

Context: A 5-year-old girl is brought to the emergency department by her mother because of multiple episodes of nausea and vomiting that last about 2 hours.

Context: The vomiting was preceded by fatigue.

Context: The girl feels well between these episodes.

Context: Her immunizations are up-to-date.

Context: She appears emaciated.

Context: Examination shows dry mucous membranes.

Context: The lungs are clear to auscultation.

Choices:
A. Cyclic vomiting syndrome
B. Gastroenteritis
C. Hypertrophic pyloric stenosis
D. Gastroesophageal reflux disease

Answer: Cyclic vomiting syndrome

1. A 5-year-old girl is brought to the emergency department by her mother.

2. She has had multiple episodes of nausea and vomiting that last about 2 hours.

3. During this period, she has had 6–8 episodes of bilious vomiting and abdominal pain.

4. The vomiting was preceded by fatigue.

5. She feels well between these episodes.

6. She has missed several days of school and has been hospitalized 2 times during the past 6 months for dehydration due to similar episodes of vomiting and nausea.

7. The patient has lived with her mother since her parents divorced 8 months ago.

9. She is at the 60th percentile for height and 30th percentile for weight.

11. Her temperature is 36.8°C (98.8°F), pulse is 99/min, and blood pressure is 82/52 mm Hg.

12. Examination shows dry mucous membranes.

13. The lungs are clear to auscultation.

14. Abdominal examination shows a soft abdomen with mild diffuse tenderness with no guarding or rebound.

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


Question: Which of the following is the best course of treatment in this patient?

Context: A 40-year-old woman presents with difficulty falling asleep, diminished appetite, and tiredness for the past 6 weeks.

Context: She says that, despite going to bed early at night, she is unable to fall asleep.

Context: She denies feeling anxious or having disturbing thoughts while in bed.

Context: Even when she manages to fall asleep, she wakes up early in the morning and is unable to fall back asleep.

Context: She says she has grown increasingly irritable and feels increasingly hopeless, and her concentration and interest at work have diminished.

Context: The patient denies thoughts of suicide or death.

Context: Because of her diminished appetite, she has lost 4 kg (8.8 lb) in the last few weeks and has started drinking a glass of wine every night instead of eating dinner.

Context: She has no significant past medical history and is not on any medications.

Choices:
A. Diazepam
B. Paroxetine
C. Zolpidem
D. Trazodone

Answer: Trazodone

2. Patient has difficulty falling asleep for the past 6 weeks.

3. Patient goes to bed early at night but is unable to fall asleep.

4. Patient denies feeling anxious or having disturbing thoughts while in bed.

5. Patient wakes up early in the morning and is unable to fall back asleep.

6. Patient has grown increasingly irritable and feels increasingly hopeless.

7. Patient's concentration and interest at work have diminished.

8. Patient denies thoughts of suicide or death.

9. Patient has lost 4 kg (8.8 lb) in the last few weeks.

10. Patient has started drinking a glass of wine every night instead of eating dinner.

11. Patient has no significant past medical history.


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

Context: A 37-year-old female with a history of type II diabetes mellitus presents to the emergency department complaining of blood in her urine, left-sided flank pain, nausea, and fever.

Context: Vital signs include: temperature is 102 deg F (39.4 deg C), blood pressure is 114/82 mmHg, pulse is 96/min, respirations are 18, and oxygen saturation of 97% on room air.

Context: On physical examination, the patient appears uncomfortable and has tenderness on the left flank and left costovertebral angle.

Choices:
A. Obtain an abdominal CT scan
B. Obtain a urine analysis and urine culture
C. Begin intravenous treatment with ceftazidime
D. No treatment is necessary

Answer: Obtain a urine analysis and urine culture

1. A 37-year-old female presents to the emergency department.

2. She has a history of type II diabetes mellitus.

3. She is complaining of blood in her urine, left-sided flank pain, nausea, and fever.

4. She also states that she has pain with urination.

5. Her temperature is 102 deg F (39.4 deg C).

9. Her oxygen saturation is 97% on room air.

10. On physical examination, she appears uncomfortable.

11. She has tenderness on the left flank.

12. She has tenderness on the left costovertebral angle.


Question: Which of the following should be treated first in this patient?

Context: A 19-year-old boy presents with confusion and the inability to speak properly.

Context: The patient's mother says that, a few hours ago, she noticed a change in the way he talked and that he appeared to be in a daze.

Context: He then lost consciousness, and she managed to get him to the hospital.

Context: She is also concerned about the weight he has lost over the past few months.

Context: His blood pressure is 80/55 mm Hg, pulse is 115/min, temperature is 37.2°C (98.9°F), and respiratory rate is 18/min.

Context: On physical examination, the patient is taking rapid, deep breaths, and his breath has a fruity odor.

Context: Dry mucous membranes and dry skin are noticeable.

Context: He is unable to cooperate for a mental status examination.

Context: Results of his arterial blood gas analysis are shown. | Pco2 16 mm Hg | HCO3–  10 mEq/L | Po2 91 mm Hg | pH 7.1 | His glucose level is 450 mg/dL, and his potassium level is 4.1 mEq/L.

Choices:
A. Hypoperfusion
B. Hyperglycemia
C. Metabolic acidosis
D. Hypokalemia

Answer: Hypoperfusion

2. Patient presents with confusion and inability to speak properly.

3. Patient's mother noticed a change in the way he talked and he appeared to be in a daze a few hours ago.

4. Patient lost consciousness and mother managed to get him to the hospital.

5. Mother is concerned about weight loss over past few months.

6. Patient's blood pressure is 80/55 mm Hg.

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

9. Patient's respiratory rate is 18/min.

10. Patient is taking rapid, deep breaths.

12. Patient has dry mucous membranes and dry skin.

13. Patient is unable to cooperate for mental status examination.

18. Patient's glucose level is 450 mg/dL.

19. Patient's potassium level is 4.1 mEq/L.


Question: Which of the following represents the most likely etiology of her anemia.

Context: A 41-year-old woman presents to her primary care physician with complaints of fatigue and weakness.

Context: She denies any personal history of blood clots or bleeding problems in her past, but she says that her mother has had to be treated for breast cancer recently and is starting to wear her down.

Context: Her past medical history is significant for preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia.

Context: She currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and currently denies any illicit drug use.

Context: Her vital signs include: temperature, 36.7°C (98.0°F); blood pressure, 126/74 mm Hg; heart rate, 111/min; and respiratory, rate 23/min.

Context: On physical examination, her pulses are bounding and irregular, complexion is pale, but breath sounds remain clear.

Context: On examination, the physician finds diffuse skin pallor and orders a complete blood count.

Context: Her laboratory data demonstrate a hematocrit of 27.1%, MCV of 79 fL, and a reticulocyte count of 2.0%.

Context: The patient is diagnosed with anemia.

Choices:
A. Vitamin B12 deficiency
B. Folate deficiency
C. Iron deficiency
D. Intravascular hemolysis

Answer: Iron deficiency

2. Patient complains of fatigue and weakness.

3. Patient denies personal history of blood clots or bleeding problems.

4. Patient's mother has been treated for breast cancer recently.

5. Patient's past medical history includes preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia.

6. Patient smokes 1 pack of cigarettes per day.

7. Patient drinks 1 glass of wine per day.

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

10. Patient's blood pressure is 126/74 mm Hg.

12. Patient's respiratory rate is 23/min.

13. Patient's pulses are bounding and irregular.

16. Physician finds diffuse skin pallor.

17. Physician orders complete blood count.

20. Patient's reticulocyte count is 2.0%.


Question: Which of the following is the most likely primary mechanism underlying this woman's temporal muscle atrophy?

Context: A 59-year-old woman with stage IV lung cancer comes to the physician because of progressively worsening weakness in the past 3 months.

Context: She has had a 10.5-kg (23-lb) weight loss during this period.

Context: Her BMI is 16 kg/m2.

Context: She appears thin and has bilateral temporal wasting.

Choices:
A. Cytochrome c-mediated activation of proteases
B. Lipase-mediated degradation of triglycerides
C. TNF-α-mediated activation of caspases
D. Proteasomal degradation of ubiquitinated proteins

Answer: Proteasomal degradation of ubiquitinated proteins

1. A 59-year-old woman has stage IV lung cancer.

2. She has experienced progressively worsening weakness in the past 3 months.

3. She has lost 10.5 kg (23 lbs) in the past 3 months.


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

Context: The patient has a past medical history of dementia, diabetes, and hypertension and typically has a visiting home nurse come to administer medications.

Context: Laboratory studies are drawn as seen below. |  | Hemoglobin: 15 g/dL | Hematocrit: 45% | Leukocyte count: 4,500/mm^3 with normal differential | Platelet count: 227,000/mm^3 |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.3 mEq/L | HCO3-: 24 mEq/L | BUN: 30 mg/dL | Glucose: 97 mg/dL | Creatinine: 1.5 mg/dL | Ca2+: 10.2 mg/dL | AST: 12 U/L | ALT: 10 U/L |  | Urine: | Color: Yellow | Bacteria: Absent | Nitrites: Negative | Red blood cells: Negative |  | An initial chest radiograph is unremarkable.

Context: The patient’s mental status is at the patient’s baseline according to the son.

Choices:
A. Exertional heat stroke
B. Neuroleptic malignant syndrome
C. Non-exertional heat stroke
D. Septic shock

Answer: Non-exertional heat stroke

1. A 67-year-old man presents to the emergency department with a fever and altered mental status.

2. The patient has a history of Alzheimer dementia and is typically bed bound.

3. His son found him confused with a warm and flushed complexion thus prompting his presentation.

4. The patient has a past medical history of dementia, diabetes, and hypertension.

5. The patient typically has a visiting home nurse come to administer medications.

6. Prior to examination, he is given haloperidol and diphenhydramine as he is combative and will not allow the nurses near him.

7. His temperature is 102.9°F (39.4°C), blood pressure is 104/64 mmHg, pulse is 170/min, respirations are 22/min, and oxygen saturation is 100% on room air.

8. Physical exam is notable for dry and flushed skin and a confused man.

9. There is no skin breakdown, and flexion of the patient’s neck elicits no discomfort.

10. Laboratory studies show a hemoglobin of 15 g/dL, hematocrit of 45%, leukocyte count of 4,500/mm^3 with normal differential, and platelet count of 227,000/mm^3.

11. Serum Na+ is 139 mEq/L, Cl- is 100 mEq/L, K+ is 4.3 mEq/L, HCO3- is 24 mEq/L, BUN is 30 mg/dL, glucose is 97 mg/dL, creatinine is 1.5 mg/dL, Ca2+ is 10.2 mg/dL, AST is 12 U/L, and ALT is 10 U/L.

12. Urine color is yellow, bacteria are absent, nitrites are negative, and red blood cells are negative.

13. An initial chest radiograph is unremarkable.

14. The patient is given 3 liters of Ringer's lactate and an electric fan to cool off.

15. Two hours later, his temperature is 99°F (37.2°C), blood pressure is 154/94 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 100% on room air.

16. The patient’s mental status is at the


Question: The most likely cause of this patient's symptoms is associated with which of the following enzymatic reactions?

Context: A 32-year-old man presents to a mission hospital in Cambodia because he has had difficulty walking from his village to the market.

Context: He says that he has always been healthy other than occasional infections; however, over the last year he has been having numbness in his hands and feet.

Context: Furthermore, he has noticed weakness, muscle wasting, and pain in his lower extremities.

Context: Physical exam reveals normal skin color and decreased deep tendon reflexes.

Choices:
A. Alpha-ketoglutarate dehydrogenase
B. Acyl transferases
C. Glycogen phosphorylase
D. Homocysteine methyltransferase

Answer: Alpha-ketoglutarate dehydrogenase

1. A 32-year-old man presents to a mission hospital in Cambodia.

2. He has had difficulty walking from his village to the market.

3. He has always been healthy other than occasional infections.

4. Over the last year he has been having numbness in his hands and feet.

5. He has noticed weakness, muscle wasting, and pain in his lower extremities.

6. The only change he can remember is that after having a poor harvest last year, he and his family have been subsisting on white rice.

7. Physical exam reveals normal skin color.

8. Physical exam reveals decreased deep tendon reflexes.


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

Context: She has a past medical history of hypertension and was discharged from the hospital yesterday after management of a myocardial infarction.

Context: Her temperature is 99.5°F (37.5°C), blood pressure is 147/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Context: Physical exam is within normal limits.

Choices:
A. Atenolol
B. Furosemide
C. Hydrochlorothiazide
D. Nitroglycerin

Answer: Atenolol

1. A 60-year-old woman presents to her primary care physician for a wellness checkup.

2. She has a past medical history of hypertension.

3. She was discharged from the hospital yesterday after management of a myocardial infarction.

4. She states that sometimes she experiences exertional angina.

9. Her oxygen saturation is 98% on room air.

10. Physical exam is within normal limits.


Question: When this hormone is produced by the hypothalamus, it has which of the following effects?

Context: A 42-year-old male presents to his primary care physician complaining of abdominal pain.

Context: He reports a 5-month history of epigastric pain that improves with meals.

Context: He drinks alcohol socially and has a 10 pack-year smoking history.

Context: His temperature is 98.8°F (37.1°C), blood pressure is 125/80 mmHg, pulse is 85/min, and respirations are 18/min.

Context: After further workup, the patient is started on octreotide, an analogue of an endogenously produced hormone.

Choices:
A. Decrease production of growth hormone
B. Decrease production of prolactin
C. Decrease production of gastrin
D. Decrease production of thyrotropin-releasing hormone

Answer: Decrease production of growth hormone

1. A 42-year-old male presents to his primary care physician.

3. He has a 5-month history of epigastric pain that improves with meals.

4. He has lost 15 pounds since the pain started.

5. His past medical history is significant for a prolactinoma for which he underwent transphenoidal resection.

7. He has a 10 pack-year smoking history.

8. His family history is notable for a maternal uncle with a parathyroid adenoma.

13. He is started on octreotide, an analogue of an endogenously produced hormone.


Question: What is the minimum amount of time this patient must exhibit these symptoms in order to meet the diagnostic criteria for dysthymia?

Context: A 28-year-old female reports that, for more days than not over the past 3 years, she has felt "down" and, at times, "mildly depressed." Over this period, she also endorses feeling fatigued, difficulty concentrating, and often sleeping more than in the past.

Context: The patient denies any manic or hypomanic periods and also reports that she did not have any periods of extreme worsening of her depressed mood beyond that described above.

Context: She also denies any suicidal ideation.

Choices:
A. 2 months
B. 6 months
C. 2 years
D. 5 years

Answer: 2 years

2. Patient has felt "down" and "mildly depressed" for more days than not over the past 3 years.

4. Patient endorses difficulty concentrating.

5. Patient has been sleeping more than in the past.

6. Patient denies any manic or hypomanic periods.

7. Patient denies any periods of extreme worsening of her depressed mood beyond that described above.

8. Patient denies any suicidal ideation.


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

Context: A 42-year-old man is being treated by his female family medicine physician for chronic depression.

Context: Recently, he has been scheduling more frequent office visits.

Context: He does not report any symptoms or problems with his SSRI medication during these visits.

Context: Upon further questioning, the patient confesses that he is attracted to her and says "You are the only one in the world who understands me".

Context: The physician also manages his hypertension.

Choices:
A. Re-evaluate this patient for borderline personality disorder
B. Ask closed-ended questions and use a chaperone for future visits
C. Immediately tell this patient that you can not continue to treat him and avoid any further communication
D. Increase the dosage of this patient’s SSRI

Answer: Ask closed-ended questions and use a chaperone for future visits

1. A 42-year-old man is being treated by his female family medicine physician.

3. The patient has been scheduling more frequent office visits.

4. The patient does not report any symptoms or problems with his SSRI medication during these visits.

5. Upon further questioning, the patient confesses that he is attracted to his physician.

6. The patient says "You are the only one in the world who understands me".

7. The physician also manages the patient's hypertension.


Question: What is the most likely cause of the gallstone coloring?

Context: The physician suspects she is suffering from biliary colic and recommends surgery.

Choices:
A. E. coli infection; beta-glucoronidase release
B. Shigella infection; HMG-CoA reductase release
C. Shigella infection; beta-glucoronidase release
D. Bile supersaturated with cholesterol; beta-glucoronidase release

Answer: E. coli infection; beta-glucoronidase release

1. A 51-year-old female presents with intermittent right upper quadrant discomfort.

2. The physician suspects she is suffering from biliary colic.

4. Following surgery, brown stones are removed from the gallbladder specimen.


Question: What is the most likely cause of his condition?

Context: A 56-year-old man with known coronary artery disease presents to the emergency department complaining of chest discomfort and palpitations for 2 hours.

Context: Cardiac monitoring shows the electrocardiogram (ECG) pattern in lead 2 shown below.

Choices:
A. Monomorphic ventricular tachycardia
B. Mitral regurgitation
C. Third-degree heart block
D. Acute pericarditis

Answer: Monomorphic ventricular tachycardia

1. A 56-year-old man with known coronary artery disease presents to the emergency department.

2. The patient is complaining of chest discomfort and palpitations for 2 hours.

3. On arrival, the vital signs include blood pressure 122/76 mm Hg, heart rate 180/min, respiratory rate 22/min, temperature 37.0℃ (98.6℉), and blood oxygen saturation (SpO2) 98% on room air.

4. A 12-lead electrocardiogram demonstrated ST-segment elevation in the anterolateral leads.

5. The troponin level was 0.8 ng/mL (normal 0–0.4 ng/mL).

6. The patient declined primary percutaneous intervention and was treated with antifibrinolytics in the coronary care unit.

7. After 1 hour of treatment, the patient loses consciousness and the blood pressure falls to 60/40 mm Hg.

8. Cardiac monitoring shows the electrocardiogram (ECG) pattern in lead 2.

Cardiovascular Disease
Clinical Cardiac Electrophysiology


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

Context: A 16-year-old female high school student is brought to the physician by her parents for her repeated behavioral problems at home and school during the past 10 months.

Context: Her teachers describe her behavior as uncooperative and disruptive as she persistently refuses to answer questions, insults her teachers, and annoys her classmates on a daily basis.

Context: At home, her parents try to address her frequent violations of curfew, but attempts at discussing the issue often result in their daughter losing her temper and screaming at her parents.

Context: Her grades have deteriorated over the past year.

Context: She has no history of psychiatric illness.

Context: On questioning, the patient refuses to answer and frequently disrupts the physician’s conversation with the parents.

Choices:
A. Reactive attachment disorder
B. Conduct disorder
C. Antisocial personality disorder
D. Oppositional defiant disorder

Answer: Oppositional defiant disorder

1. Patient is a 16-year-old female high school student.

2. Patient was brought to the physician by her parents.

3. Patient has had repeated behavioral problems for 10 months.

4. Patient's teachers describe her behavior as uncooperative and disruptive.

5. Patient refuses to answer questions, insults teachers, and annoys classmates on a daily basis.

6. Patient's parents have tried to address her frequent violations of curfew.

7. Attempts at discussing the issue often result in the patient losing her temper and screaming at her parents.

8. Patient's grades have deteriorated over the past year.

9. Patient has no history of psychiatric illness.

10. Patient refuses to answer and frequently disrupts the physician's conversation with the parents.


Question: Which of the following findings indicates that the cause of shock is cardiogenic?

Context: A 22-year-old man is brought to the emergency room with a penetrating stab injury to his left chest.

Context: His pulse is feeble, systolic blood pressure is 86 mm Hg, the respirations are 22/min with an oxygen saturation of 88% at room air, and the temperature is 36.6°C (98.0°F).

Context: His jugular vein is distended.

Context: Chest auscultation reveals equal breath sounds bilaterally, with muffled heart sounds.

Choices:
A. Elevated serum creatinine
B. High central venous pressure (CPV)
C. Arterial blood gas (ABG) showing base deficit and metabolic acidosis
D. White blood cell (WBC) count < 4000/mm3

Answer: High central venous pressure (CPV)

1. A 22-year-old man is brought to the emergency room.

2. He has a penetrating stab injury to his left chest.

3. He appears pale, drowsy, and diaphoretic.

5. His systolic blood pressure is 86 mm Hg.

7. His oxygen saturation is 88% at room air.

10. Chest auscultation reveals equal breath sounds bilaterally.

11. Chest auscultation reveals muffled heart sounds.

12. Immediate IV fluid resuscitation is initiated.

General Emergency Medicine
Cardiovascular Disease


Question: Which of the following characteristics best describes the most likely causal pathogen?

Context: A 56-year-old woman is brought to the physician by her husband because of a two-day history of fever, malaise, headaches, and confusion.

Context: She recently immigrated from rural China and her immunization status is unknown.

Context: Her temperature is 39.1°C (102.4°F).

Context: However, when the sheep blood agar sample is heated, numerous non-hemolytic, opaque, cream-colored colonies grow.

Choices:
A. Gram-negative coccobacillus
B. Gram-positive, lancet-shaped diplococcus
C. Gram-negative diplococcus
D. Gram-positive, facultative intracellular bacillus

Answer: Gram-negative coccobacillus

1. A 56-year-old woman is brought to the physician by her husband.

2. She has a two-day history of fever, malaise, headaches, and confusion.

3. She recently immigrated from rural China.

6. Physical examination shows nuchal rigidity and photophobia.

7. Cerebrospinal fluid analysis shows a neutrophil count of 1,500/mm3.

8. Cerebrospinal fluid cultured on Thayer-Martin agar and normal sheep blood agar shows no growth.

9. When the sheep blood agar sample is heated, numerous non-hemolytic, opaque, cream-colored colonies grow.

Infectious Disease
General Infectious Disease


Question: The pathogen associated with this patient’s condition is also known to cause which of the following?

Context: A 35-year-old male presents to his primary care physician complaining of a one-month history of progressively worsening fatigue.

Context: He sought medical attention because this has affected his ability to complete his work as a graduate student.

Context: As a child, he was hospitalized for hemolytic uremic syndrome.

Context: His past medical history is also notable for diabetes mellitus and obesity.

Context: He takes metformin and glyburide.

Context: He does not smoke and drinks alcohol occasionally.

Context: His family history is notable for chronic lymphocytic leukemia in his paternal uncle and stroke in his father.

Context: His temperature is 99.9°F (37.7°C), blood pressure is 100/70 mmHg, pulse is 110/min, and respirations are 18/min.

Context: Hematologic labs are shown below: |  | Hemoglobin: 8.9 g/dL | Hematocrit: 24% | Leukocyte count: 7,500 cells/mm^3 with normal differential | Platelet count: 180,000/mm^3 | Mean corpuscular volume: 85 µm^3 | Reticulocyte count: 0.4% |  | Head and neck imaging is negative for neck masses.

Choices:
A. Kaposi’s sarcoma
B. Erythema infectiosum
C. Mononucleosis
D. Croup

Answer: Erythema infectiosum

2. Patient has a one-month history of progressively worsening fatigue.

3. Patient sought medical attention because fatigue has affected his ability to complete his work as a graduate student.

4. Patient was hospitalized for hemolytic uremic syndrome as a child.

5. Patient has past medical history of diabetes mellitus and obesity.

6. Patient takes metformin and glyburide.

7. Patient does not smoke and drinks alcohol occasionally.

8. Patient's family history is notable for chronic lymphocytic leukemia in his paternal uncle and stroke in his father.

9. Patient's temperature is 99.9°F (37.7°C).

10. Patient's blood pressure is 100/70 mmHg.

13. Physical examination reveals diffuse pallor.

16. Leukocyte count is 7,500 cells/mm^3 with normal differential.

20. Head and neck imaging is negative for neck masses.


Question: Which of the following is the best treatment for the most likely cause for this patient’s illness?

Context: She complains that over the past week there have been 3 episodes where he has fallen asleep while speaking with her.

Context: She mentioned that these events began a few months ago and have been increasing in frequency.

Context: She also says that his snoring has gotten to the point where she has a hard time sleeping next to him.

Context: He is worried he might be “going crazy.” He has noticed that when his friends tell him a joke or he laughs at something on the TV, he drops whatever he’s holding and feels like his legs become weak.

Choices:
A. Modafinil
B. Taking longer naps
C. Continuous positive airway pressure
D. Changing bedtime to earlier in the evening

Answer: Modafinil

1. A 30-year-old man is brought to the doctor's office by his wife.

2. The wife complains that over the past week there have been 3 episodes where he has fallen asleep while speaking with her.

3. The wife mentions that these events began a few months ago and have been increasing in frequency.

4. The wife also says that his snoring has gotten to the point where she has a hard time sleeping next to him.

5. When asked, the patient says that he frequently falls asleep while reading or watching television in the afternoons and feels refreshed after a short nap.

6. The patient is worried because he sometimes hears people who aren’t in the room as he falls asleep.

7. He is worried he might be “going crazy.”

8. He has noticed that when his friends tell him a joke or he laughs at something on the TV, he drops whatever he’s holding and feels like his legs become weak.

9. These episodes self-resolve in a few seconds.

10. Examination shows a morbidly obese man in no acute distress.

Sleep Medicine
Pulmonary Disease
General Sleep Medicine


Question: Which of the following is the best next treatment for this patient?

Context: His temperature is 98.5°F (36.9°C), blood pressure is 103/61 mmHg, pulse is 120/min, respirations are 16/min, and oxygen saturation is 97% on room air.

Context: Ophthalmoplegia is noted on cranial nerve testing, and he has decreased vibration sensation in the bilateral lower extremity.

Context: An initial ECG is notable for sinus tachycardia and the patient is given 2L of Ringer lactate.

Context: Laboratory values are ordered as seen below. |  | Hemoglobin: 8.0 g/dL | Hematocrit: 30% | Leukocyte count: 3,500/mm^3 with normal differential | Platelet count: 192,000/mm^3 | MCV: 119 fL |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.3 mEq/L | HCO3-: 25 mEq/L | BUN: 20 mg/dL | Glucose: 47 mg/dL | Creatinine: 1 mg/dL | Ca2+: 9.2 mg/dL | Mg2+: 1.2 mEq/L | AST: 82 U/L | ALT: 70 U/L |  | .

Choices:
A. Folate
B. Magnesium
C. Thiamine
D. Vitamin C

Answer: Thiamine

1. A 55-year-old homeless man presents to the emergency department acutely confused.

2. The patient was found wandering the streets with an abnormal gait.

3. The patient has a past medical history of alcohol and IV drug abuse.

8. Oxygen saturation is 97% on room air.

9. Physical exam is notable for a poorly kempt man with ataxic gait.

10. Ophthalmoplegia is noted on cranial nerve testing.

11. He has decreased vibration sensation in the bilateral lower extremity.

12. Dermatologic exam reveals perifollicular hemorrhages, bleeding gums, and many bruises along the patient’s upper and lower extremities.

13. An initial ECG is notable for sinus tachycardia.

14. The patient is given 2L of Ringer lactate.

17. Leukocyte count: 3,500/mm^3 with normal differential.

General Emergency Medicine
Neurocritical Care


Question: Which of the following is the most likely initial step in the pathogenesis of this patient's coronary condition?

Context: A 61-year-old woman is brought to the emergency department because of crushing substernal chest pain at rest for the past 2 hours.

Context: She is diaphoretic.

Context: Her temperature is 37.5°C (99.5°F), pulse is 110/min, respirations are 21/min, and blood pressure is 115/65 mm Hg.

Choices:
A. Intimal monocyte infiltration
B. Platelet activation
C. Endothelial cell dysfunction
D. Fibrous plaque formation

Answer: Endothelial cell dysfunction

1. A 61-year-old woman is brought to the emergency department.

2. She has crushing substernal chest pain at rest for the past 2 hours.

8. An ECG shows ST elevation in I, aVL, and V2–V4.

9. Coronary angiography shows an 80% stenosis in the left anterior descending artery.

Cardiovascular Disease
General Cardiology


Question: What is the most likely etiology of this patient’s presentation?

Context: She states that the patient has been complaining of pain in his scrotum with swelling, abdominal pain, and nausea for the last 2 or 3 days.

Context: The patient is afebrile and all vital signs are stable.

Choices:
A. Patent processus vaginalis
B. Collection of fluid in the tunica vaginalis
C. Infection of the epididymis
D. Neoplasm of the testicle

Answer: Patent processus vaginalis

1. A 4-year-old boy presents to the office with his mother.

2. The patient has been complaining of pain in his scrotum with swelling, abdominal pain, and nausea for the last 2 or 3 days.

3. On exam, the abdomen is soft and nontender to palpation.

4. The right scrotal sac is mildly enlarged without erythema.

5. A tender mass is palpated in the right scrotal area.

6. The mass does not transilluminate when a penlight is applied.


Question: What is the most likely diagnosis?

Context: A 59-year-old man presents to his primary care physician, accompanied by his wife, who requests treatment for his “chronic pessimism.” The patient admits to feeling tired and “down” most of the time for the past several years but insists that it is “just part of getting old.” His wife believes that he has become more self-critical and less confident than he used to be.

Context: He has continued to work as a librarian at a nearby college during this time and spends time with friends on the weekends.

Context: He sleeps 7 hours per night and eats 3 meals per day.

Choices:
A. Adjustment disorder with depressive features
B. Bipolar disorder
C. Cyclothymia
D. Dysthymia

Answer: Dysthymia

1. A 59-year-old man presents to his primary care physician.

3. His wife requests treatment for his “chronic pessimism.”

4. The patient admits to feeling tired and “down” most of the time for the past several years.

5. He insists that it is “just part of getting old.”

6. His wife believes that he has become more self-critical and less confident than he used to be.

7. Neither the patient nor his wife can identify any stressors or triggering events.

8. He has continued to work as a librarian at a nearby college during this time.

9. He spends time with friends on the weekends.

12. He denies suicidal ideation or periods of elevated mood, excessive irritability, or increased energy.

13. Physical exam reveals a well-dressed, well-groomed man without apparent abnormality.

14. Basic neurocognitive testing and labs (CBC, BMP, TSH, cortisol, testosterone, and urine toxicology) are within normal limits.


Question: What is the most likely explanation for the patient’s presentation?

Context: A 17-month-old girl was brought to the emergency department by her mom following a fall.

Context: She had an uncomplicated birth history and has been meeting developmental goals except for language delay, for which she is to receive a hearing test for further evaluation next week.

Context: Physical exam reveals bruising along the left lateral thigh, knee, and elbow; all lab tests are within normal limits.

Choices:
A. Child abuse
B. Defective type 1 collagen gene
C. Low levels of phosphate
D. Low levels of vitamin D

Answer: Defective type 1 collagen gene

1. A 17-month-old girl was brought to the emergency department by her mom.

2. The mom reports that the patient was playing in the playground when she tripped and fell onto the mulch.

3. She had an uncomplicated birth history.

4. She has been meeting developmental goals except for language delay.

5. She is to receive a hearing test for further evaluation next week.

6. Physical exam reveals bruising along the left lateral thigh, knee, and elbow.

7. All lab tests are within normal limits.

8. Radiograph shows a fracture of the olecranon.

9. Serum chemistry and liver panels were within normal limits.

Child Abuse Pediatrics
Pediatric Emergency Medicine


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

Context: ِA 62-year-old man comes to the emergency department because of colicky pain in the lower abdomen and abdominal distension for the past 12 hours.

Context: His temperature is 37.1°C (98.7°F), blood pressure is 110/60 mm Hg and pulse is 85/min.

Context: On physical examination, there is diffuse abdominal distension and tenderness, and bowel sounds are faint.

Choices:
A. Infectious colitis
B. Bowel adhesions
C. Volvulus
D. Acute diverticulitis

Answer: Volvulus

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

2. He has colicky pain in the lower abdomen and abdominal distension for the past 12 hours.

3. He has chronic constipation for which he takes lactulose and senna laxatives.

7. On physical examination, there is diffuse abdominal distension and tenderness.

9. His plain abdominal radiograph is shown.


Question: The addition of this drug is most likely to increase the risk of which of the following adverse effects?"

Context: He is 180 cm (5 ft 11 in) tall and weighs 110 kg (242 lb); BMI is 34 kg/m2.

Context: Serum lipid studies show: | Cholesterol, total 302 mg/L | HDL-cholesterol 39 mg/dL | LDL-cholesterol 197 mg/dL | Triglycerides 292 mg/dL | The physician prescribes a drug that inhibits intestinal cholesterol absorption.

Choices:
A. Hepatotoxicity
B. Hyperkalemia
C. Cutaneous flushing
D. Hyperuricemia

Answer: Hepatotoxicity

1. A 73-year-old African American man comes to the physician for a routine health maintenance examination.

2. He has type 2 diabetes mellitus, hypertension, hypercholesterolemia, and coronary artery disease.

3. His current medications include metformin, hydrochlorothiazide, amlodipine, rosuvastatin, isosorbide mononitrate, aspirin, and dipyridamole.

7. His vital signs are within normal limits.

8. His hemoglobin A1c concentration is 6.7%.

13. The physician prescribes a drug that inhibits intestinal cholesterol absorption.

Geriatric Medicine
General Internal Medicine


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

Context: A 15-year-old girl is brought to the clinic by her mother because she is worried the patient has not yet had her period.

Context: The patient’s older sister had her first period at age 14.

Context: The mother had her first period at age 13.

Context: The patient reports she is doing well in school and is on the varsity basketball team.

Context: Her medical history is significant for asthma and atopic dermatitis.

Context: Her medications include albuterol and topical triamcinolone.

Context: The patient’s temperature is 98°F (36.7°C), blood pressure is 111/72 mmHg, pulse is 65/min, and respirations are 14/min with an oxygen saturation of 99% on room air.

Context: Her body mass index (BMI) is 19 kg/m^2.

Choices:
A. CYP17 gene work-up
B. Estrogen levels
C. Gonadotrophin-releasing hormone stimulation test
D. Karotype

Answer: Karotype

2. Patient's mother brought her to the clinic.

3. Patient's mother is worried because patient has not had her period.

4. Patient's older sister had her first period at age 14.

5. Patient's mother had her first period at age 13.

6. Patient reports she is doing well in school.

7. Patient is on the varsity basketball team.

8. Patient has a medical history of asthma and atopic dermatitis.

9. Patient's medications include albuterol and topical triamcinolone.

10. Patient's temperature is 98°F (36.7°C).

11. Patient's blood pressure is 111/72 mmHg.

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

16. Physical exam shows absent breast development and external genitalia at Tanner stage 1.

17. Serum follicle stimulating hormone (FSH) level is measured to be 38 mIU/mL.

Pediatric Endocrinology
Pediatric Gynecology


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

Context: A 15-month-old girl is brought to the physician by her mother for grossly bloody diarrhea for 2 days.

Context: The girl has had a few episodes of blood-tinged stools over the past 3 weeks.

Context: She is at the 55th percentile for height and 55th percentile for weight.

Context: Examination shows conjunctival pallor.

Context: The abdomen is soft and nontender.

Context: Her hemoglobin concentration is 9.5 g/dL, mean corpuscular volume is 68 μm3, and platelet count is 300,000/mm3.

Choices:
A. Neutrophil infiltrated crypts on colonic biopsy
B. Absent ganglionic cells on rectal suction biopsy
C. Target sign on abdominal ultrasound
D. Ectopic gastric mucosa on Technetium-99m pertechnetate scan

Answer: Ectopic gastric mucosa on Technetium-99m pertechnetate scan

1. A 15-month-old girl is brought to the physician by her mother.

2. She has had grossly bloody diarrhea for 2 days.

3. She has had a few episodes of blood-tinged stools over the past 3 weeks.

4. She has not had pain, nausea, or vomiting.

5. She is at the 55th percentile for height.

6. She is at the 55th percentile for weight.

7. Examination shows conjunctival pallor.

9. There is a small amount of dark red blood in the diaper.

10. Her hemoglobin concentration is 9.5 g/dL.

11. Her mean corpuscular volume is 68 μm3.


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

Context: A 3855-g (8-lb 8-oz) newborn is examined shortly after birth.

Context: She was delivered at 40 weeks' gestation by cesarean delivery because of breech presentation.

Context: Pregnancy was otherwise uncomplicated.

Context: Physical examination shows asymmetric thigh creases.

Context: The left leg is shorter than the right leg and positioned in external rotation.

Choices:
A. Fracture of the femoral neck
B. Inflammation of the hip synovium
C. Abnormal development of the acetabulum
D. Displacement of the femoral epiphysis

Answer: Abnormal development of the acetabulum

1. A 3855-g newborn was examined shortly after birth.

2. The newborn was delivered at 40 weeks' gestation.

3. The newborn was delivered by cesarean delivery.

4. The cesarean delivery was due to breech presentation.

5. The pregnancy was otherwise uncomplicated.

6. Physical examination showed asymmetric thigh creases.

7. The left leg was shorter than the right leg.

8. The left leg was positioned in external rotation.

General Orthopaedic Surgery
Pediatric Orthopaedic Surgery


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

Context: A 27-year-old G1P0 woman at 9 weeks estimated gestational age presents for a prenatal visit.

Context: She has no current complaints and takes no medications.

Context: She is vegetarian and emigrated from Nepal 7 years ago.

Context: She does not use tobacco, alcohol or recreational drugs.

Context: The patient’s vital signs include: blood pressure 111/95 mm Hg, temperature 36.7°C (98.6°F), pulse 88/min.

Context: Laboratory results are significant for the following: | Hemoglobin 10.2 g/dL | Erythrocyte count 5.5 million/mm3 | Mean corpuscular volume 65 μm3 | Mean corpuscular hemoglobin 21 pg/cell | Red cell distribution width 13.5% (ref: 11.5–14.5%) | Serum ferritin 170 ng/mL | .

Choices:
A. Vitamin B12 deficiency
B. Zinc deficiency
C. Gestational anemia
D. Thalassemia trait

Answer: Thalassemia trait

2. Patient is at 9 weeks estimated gestational age.

6. Patient emigrated from Nepal 7 years ago.

7. Patient does not use tobacco, alcohol or recreational drugs.

8. Patient's blood pressure is 111/95 mm Hg.

9. Patient's temperature is 36.7°C (98.6°F).

12. Patient's erythrocyte count is 5.5 million/mm3.

13. Patient's mean corpuscular volume is 65 μm3.

14. Patient's mean corpuscular hemoglobin is 21 pg/cell.

15. Patient's red cell distribution width is 13.5% (ref: 11.5–14.5%).

16. Patient's serum ferritin is 170 ng/mL.

Gestational anemia
General Obstetrics and Gynecology


Question: What will be the change in the kinetics of the reaction catalyzed by carbonic anhydrase under the influence of acetazolamide?

Context: A 31-year-old woman presents to your clinic with a persistent headache.

Context: She reports she has suffered from headaches since the age of 27 when she gained 12 kg (26.4 lb) after the birth of her second child.

Context: The headache is generalized and throbbing in nature.

Context: It worsens in the morning and is aggravated with coughing, laughing, and sneezing.

Context: The patient’s blood pressure is 130/85 mm Hg, heart rate is 90/min, respiratory rate is 14/min, and the temperature is 36.6℃ (97.9℉).

Context: The patient’s weight is 101 kg (222.7 lb), height is 165 cm (5.4 ft), and BMI is 36.7 kg/m2.

Context: Examination reveals papilledema.

Context: The patient is prescribed a carbonic anhydrase inhibitor, acetazolamide, for idiopathic intracranial hypertension.

Choices:
A. Activation energy (Ea) will increase
B. Activation energy (Ea) will decrease
C. Free energy (G) of the reactants will increase
D. Increase reaction free energy change (∆G) by increasing free energy (G) of reactants and decreasing G of products

Answer: Activation energy (Ea) will increase

2. Patient has suffered from headaches since the age of 27.

3. Patient gained 12 kg (26.4 lb) after the birth of her second child.

4. Headache is generalized and throbbing in nature.

6. Headache is aggravated with coughing, laughing, and sneezing.

7. Patient's blood pressure is 130/85 mm Hg.

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

10. Patient's temperature is 36.6℃ (97.9℉).

11. Patient's weight is 101 kg (222.7 lb).

12. Patient's height is 165 cm (5.4 ft).

15. Head CT scan does not reveal any abnormalities.

16. Lumbar puncture shows an opening pressure of 32 cm H2O.

17. Patient is prescribed a carbonic anhydrase inhibitor, acetazolamide, for idiopathic intracranial hypertension.


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

Context: A 55-year-old man comes to the emergency department because of a dry cough and severe chest pain beginning that morning.

Context: Two months ago, he was diagnosed with inferior wall myocardial infarction and was treated with stent implantation of the right coronary artery.

Context: His temperature is 38.5°C (101.3°F), pulse is 92/min, respirations are 22/min, and blood pressure is 130/80 mm Hg.

Context: An ECG shows diffuse ST elevations.

Choices:
A. Cardiac tamponade
B. Constrictive pericarditis
C. Reinfarction
D. Dressler syndrome

Answer: Dressler syndrome

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

2. He has a dry cough and severe chest pain beginning that morning.

3. Two months ago, he was diagnosed with inferior wall myocardial infarction.

4. He was treated with stent implantation of the right coronary artery.

5. He has a history of hypertension and hypercholesterolemia.

6. His medications include aspirin, clopidogrel, atorvastatin, and enalapril.

11. Cardiac examination shows a high-pitched scratching sound best heard while sitting upright and during expiration.

12. The remainder of the examination shows no abnormalities.

14. Serum studies show a troponin I of 0.2 ng/mL (N < 0.01).

Pulmonary Disease
Cardiovascular Disease


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

Context: A 27-year-old man presents to the physician with concern for pain in both of his knees that he is unable to attribute to any activities that he has recently performed.

Context: He had an acute episode of diarrhea 2 weeks ago, prior to the onset of symptoms.

Context: He has also been experiencing a burning sensation during urination for the past week.

Context: When questioned about any other symptoms, he notes that he has also noticed that his eyes occasionally feel irritated and painful, leading to bouts of blurry vision.

Context: On physical examination, the patient is afebrile and has conjunctival injection surrounding the iris.

Context: A synovial fluid aspiration of the knee is performed and reveals a white blood cell count of 51,000/µL.

Choices:
A. Acetaminophen
B. Allopurinol
C. Indomethacin
D. Leflunomide

Answer: Indomethacin

3. Patient cannot attribute pain to any recent activities.

4. Patient had an acute episode of diarrhea 2 weeks ago.

5. Patient has burning sensation during urination for the past week.

6. Patient has noticed eyes occasionally feel irritated and painful.

8. Patient is afebrile on physical examination.

9. Patient has conjunctival injection surrounding the iris.

10. Synovial fluid aspiration of the knee reveals white blood cell count of 51,000/µL.


Question: Of the following organisms, infection with which one is most consistent with her symptoms?

Context: A 22-year old active duty soldier presents to your clinic with complaints of intense fatigue, fevers, abdominal pain, and a nonproductive cough.

Context: Her symptoms began a few days ago, but she returned from a tour of duty in Malawi and Mozambique four weeks ago.

Context: She endorses sleeping outside, using minimal bug spray, and swimming in rivers during her tour.

Context: On physical exam, her temperature is 101.5, and she appears exhausted.

Context: She has a hive-like rash scattered over her body.

Context: Her abdominal exam is notable for hepatosplenomegaly, and her lung exam is notable for scattered crackles.

Context: Her CBC with diff is remarkable for marked eosinophilia, and she has an elevated IgE.

Choices:
A. Plasmodium falciparum
B. Schistosoma mansoni
C. Mycobacterium tuberculosis
D. Trypanosoma brucei rhodesiense

Answer: Schistosoma mansoni

1. Patient is 22-year old active duty soldier.

2. Patient presents with complaints of intense fatigue, fevers, abdominal pain, and a nonproductive cough.

4. Patient returned from a tour of duty in Malawi and Mozambique four weeks ago.

5. Patient endorses sleeping outside, using minimal bug spray, and swimming in rivers during her tour.

6. On physical exam, patient's temperature is 101.5, and she appears exhausted.

7. Patient has a hive-like rash scattered over her body.

8. Abdominal exam is notable for hepatosplenomegaly.

9. Lung exam is notable for scattered crackles.

10. CBC with diff is remarkable for marked eosinophilia.


Question: Which of the following best describes the mechanism of action of the drug that is most likely responsible for this patient's symptoms?

Context: A 72-year-old man comes to the emergency room because of a 4-day history of progressively worsening pain and swelling on the right side of his face.

Context: The patient was diagnosed with multiple myeloma 8 months ago and is currently undergoing treatment.

Context: An orofacial fistula is present.

Choices:
A. Cross-linking DNA at guanine
B. Inhibition of proteosome activity
C. Stimulation of PTH receptor
D. Binding to hydroxyapatite

Answer: Binding to hydroxyapatite

1. A 72-year-old man comes to the emergency room.

2. He has a 4-day history of progressively worsening pain and swelling on the right side of his face.

3. He was diagnosed with multiple myeloma 8 months ago.

4. He is currently undergoing treatment.

5. His vital signs are within normal limits.

6. Physical exam shows erythema and swelling over the right cheek and mandible.


Question: Which of the following is the most important risk factor for the development of this condition?

Context: A 12-month-old girl is brought to the physician because she is unable to sit and has not learned how to crawl.

Context: She keeps her hips and elbows flexed and her parents have to use considerable force to passively extend her joints.

Context: She attained neck control at 4 months and could roll from front to back at 5 months of age.

Context: She does not engage in play, reach for toys, or maintain eye contact.

Context: She babbles and does not mimic sounds.

Context: She does not follow simple instructions.

Context: She has difficulty swallowing solid foods and often coughs at meal times.

Context: Her maternal cousin has Down syndrome.

Context: Her vital signs are within normal limits.

Context: She is at the 25th percentile for length and 10th percentile for weight.

Context: The ankle clonus and extensor plantar responses are present bilaterally.

Context: The Moro reflex is present.

Context: An MRI of the head shows periventricular leukomalacia.

Choices:
A. Premature birth
B. Congenital rubella infection
C. Congenital CMV infection
D. Advanced maternal age

Answer: Premature birth

2. Patient is unable to sit and has not learned how to crawl.

3. Patient keeps hips and elbows flexed and parents have to use considerable force to passively extend her joints.

4. Patient attained neck control at 4 months and could roll from front to back at 5 months of age.

5. Patient does not engage in play, reach for toys, or maintain eye contact.

6. Patient babbles and does not mimic sounds.

7. Patient does not follow simple instructions.

8. Patient has difficulty swallowing solid foods and often coughs at meal times.

9. Patient's maternal cousin has Down syndrome.

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

11. Patient is at the 25th percentile for length and 10th percentile for weight.

12. Neurological examination shows increased muscle tone in all extremities.

13. Ankle clonus and extensor plantar responses are present bilaterally.

15. MRI of the head shows periventricular leukomalacia.


Question: What is the most likely diagnosis?

Context: A 31-year-old male presents with a 2-day history of watery diarrhea that began 8 days after his arrival from Africa.

Context: He reports symptoms of malaise, anorexia, and abdominal cramps followed by watery diarrhea.

Context: He denies tenesmus, urgency, and bloody diarrhea.

Context: His temperature is 98.6°F (37°C), respiratory rate is 15/min, pulse is 107/min, and blood pressure is 90/68 mm Hg.

Context: A physical examination is performed and is within normal limits.

Context: Intravenous fluids are started, and a stool sample is sent to the lab, which comes out to be negative for any ova/parasites, blood cells, or pus cells.

Choices:
A. Giardiasis
B. Irritable bowel syndrome (IBS)
C. Traveler’s diarrhea due to Norovirus
D. Traveler’s diarrhea due to ETEC

Answer: Traveler’s diarrhea due to ETEC

2. Patient has a 2-day history of watery diarrhea.

3. Patient's diarrhea began 8 days after his arrival from Africa.

4. None of the other members of his family became ill.

5. Patient reports symptoms of malaise, anorexia, and abdominal cramps.

6. Patient denies tenesmus, urgency, and bloody diarrhea.

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

8. Patient's respiratory rate is 15/min.

10. Patient's blood pressure is 90/68 mm Hg.

11. Physical examination is within normal limits.

14. Stool sample is negative for any ova/parasites, blood cells, or pus cells.


Question: Which of the following is the primary cause of the patient’s lab results?

Context: A 46-year-old woman presents to the emergency department with progressive dyspnea and chest pain.

Context: She reports that her symptoms started 1 week ago and have gotten progressively worse.

Context: The chest pain is left-sided and is exacerbated by coughing or deep breaths.

Context: She also endorses a 6-month history of joint pains involving her knees, elbows, and digits.

Context: She does not have a significant medical or surgical history.

Context: She takes ibuprofen as needed.

Context: She works as a pre-school teacher.

Context: The patient’s temperature is 99°F (37.2°C), blood pressure is 120/78 mmHg, pulse is 89/min, and respirations are 17/min with an oxygen saturation of 93% on room air.

Context: On physical examination, a friction rub upon inspiration/expiration and crackles are appreciated at the base of the left lung.

Context: She has an erythematous rash that spans the bilateral cheeks and nose.

Context: There are also scattered ecchymoses on her arms and legs.

Context: A chest radiograph shows a small left-sided pleural effusion.

Context: A complete blood count is obtained, as shown below: |  | Hemoglobin: 9 g/dL | Hematocrit: 28% | Leukocyte count: 1,500/mm^3 with normal differential | Platelet count: 80,000/mm^3 |  | A urinalysis shows elevated protein levels.

Context: Serologic antibodies are pending.

Choices:
A. Hematologic malignancy
B. Immune-mediated destruction
C. Mechanical shearing
D. Viral infection

Answer: Immune-mediated destruction

2. Patient presents to the emergency department with progressive dyspnea and chest pain.

3. Symptoms started 1 week ago and have gotten progressively worse.

4. Chest pain is left-sided and is exacerbated by coughing or deep breaths.

5. Patient has a 6-month history of joint pains involving her knees, elbows, and digits.

6. Patient does not have a significant medical or surgical history.

8. Patient works as a pre-school teacher.

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

10. Patient's blood pressure is 120/78 mmHg.

12. Patient's respirations are 17/min with an oxygen saturation of 93% on room air.

13. Physical examination reveals a friction rub upon inspiration/expiration and crackles at the base of the left lung.

14. Patient has an erythematous rash that spans the bilateral cheeks and nose.

15. Patient has scattered ecchymoses on her arms and legs.

16. Chest radiograph shows a small left-sided pleural effusion.

17. Complete blood count shows hemoglobin of 9 g/dL, hematocrit of 28%, leukocyte count of 1,500/mm^3 with normal differential, and platelet count of 80,000/mm^3.

18. Urinalysis shows elevated protein levels.

Pulmonary Disease
General Pulmonary Disease


Question: The cell type responsible for the regeneration of the patient's alveolar epithelium is also functions in:

Context: A 48-year-old patient is recovering from acute lung injury following a diffuse pulmonary viral infection.

Choices:
A. Protease release
B. Phagocytosis
C. Surfactant secretion
D. Recruitment of neutrophils

Answer: Surfactant secretion

2. Patient is recovering from acute lung injury.

3. Patient had a diffuse pulmonary viral infection.


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

Context: She has generalized itching.

Context: Laboratory studies show: | Hemoglobin 13.2 g/dL | Leukocyte count 8,300/mm3 | Platelet count 280,000/mm3 | ESR 32 mm/h | Serum | Glucose 89 mg/dL | Creatinine 0.7 mg/dL | TSH 4.8 μU/ml | Bilirubin | Total 1.4 mg/dL | Direct 0.9 mg/dL | Alkaline phosphatase 480 U/L | Aspartate aminotransferase 62 U/L | Alanine aminotransferase 32 U/L | Total cholesterol 288 mg/dL | HDL-cholesterol 57 mg/dL | LDL-cholesterol 189 mg/dL | Triglycerides 212 mg/dL | γ-Glutamyl transferase 92 U/L (N = 5–50) | Antimitochondrial antibody (AMA) positive | Antinuclear antibody (ANA) positive | Urinalysis shows no abnormalities.

Choices:
A. Liver biopsy
B. Atorvastatin
C. Cholestyramine
D. Ursodeoxycholic acid

Answer: Ursodeoxycholic acid

1. A 36-year-old woman comes to the physician because of fatigue for 4 months.

2. She is unable to do her chores and complains of excessive sleepiness during the day.

4. She has not had abdominal pain, fever, or weight loss.

5. She has had chronic low back pain for 6 years.

6. Her current medications include acetaminophen and vitamin supplements.

7. Examination shows scratch marks over the trunk.

8. The remainder of the examination shows no abnormalities.

9. Laboratory studies show: Hemoglobin 13.2 g/dL.

10. Laboratory studies show: Leukocyte count 8,300/mm3.

11. Laboratory studies show: Platelet count 280,000/mm3.

12. Laboratory studies show: ESR 32 mm/h.

13. Laboratory studies show: Serum Glucose 89 mg/dL.

14. Laboratory studies show: Creatinine 0.7 mg/dL.

15. Laboratory studies show: TSH 4.8 μU/ml.

16. Laboratory studies show: Bilirubin Total 1.4 mg/dL.

17. Laboratory studies show: Direct 0.9 mg/dL.

18. Laboratory studies show: Alkaline phosphatase 480 U/L.

19. Laboratory studies show: Aspartate aminotransferase 62 U/L.

20. Laboratory studies show: Alanine aminotransferase 32 U/L.

21. Laboratory studies show: Total cholesterol 288 mg/dL.

22. Laboratory studies show: HDL-cholesterol 57 mg/dL.

23. Laboratory studies show: LDL-cholesterol 189 mg/dL.

24. Laboratory studies show: Triglycerides 212 mg/dL.

25. Laboratory studies show: γ-Glutamyl transferase 92 U/L (N = 5–50).

26. Laboratory studies show: Antimitochondrial antibody (AMA) positive.

27. Laboratory studies show: Antinuclear antibody (ANA) positive.

29. Ultrasound of the abdomen shows gallbladder sludge.


Question: Which of the following arterial blood findings for the partial pressure of oxygen (PaO2), oxygen saturation (SaO2), and oxygen concentration (CaO2) are expected in this patient?

Context: A 40-year-old woman presents to the physician with complaints of frequent headaches and fatigue for a month.

Context: Her headaches are mild and occur at random times.

Context: They are relieved by over the counter analgesics.

Context: Furthermore, she feels tired most of the time and sometimes gets short of breath with exertion.

Context: She denies low mood, loss of interest, inability to concentrate, sleep disturbance, or suicidal ideation.

Context: She was diagnosed with Crohn’s disease 20 years ago for which she currently takes methotrexate.

Context: Additionally, she takes a folic acid-containing multivitamin daily.

Context: Her medical history is otherwise insignificant and she does not smoke, drink, or use recreational drugs.

Context: She has a pulse rate of 110/min, respiratory rate of 20/min, and temperature of 37.0°C (98.6°F).

Context: Physical examination reveals pallor in her palms and lower palpebral conjunctiva.

Choices:
A. Normal PaO2, normal SaO2, normal CaO2
B. Low PaO2, low SaO2, low CaO2
C. Low PaO2, normal SaO2, normal CaO2
D. Normal PaO2, normal SaO2, low CaO2

Answer: Normal PaO2, normal SaO2, low CaO2

2. Patient has been experiencing frequent headaches and fatigue for a month.

3. Headaches are mild and occur at random times.

4. Headaches are relieved by over the counter analgesics.

5. Patient feels tired most of the time.

6. Patient sometimes gets short of breath with exertion.

7. Patient denies low mood, loss of interest, inability to concentrate, sleep disturbance, or suicidal ideation.

8. Patient was diagnosed with Crohn’s disease 20 years ago.

9. Patient currently takes methotrexate.

10. Patient takes a folic acid-containing multivitamin daily.

11. Patient's medical history is otherwise insignificant.

12. Patient does not smoke, drink, or use recreational drugs.

13. Patient has a pulse rate of 110/min.

14. Patient has a respiratory rate of 20/min.

15. Patient has a temperature of 37.0°C (98.6°F).

16. Physical examination reveals pallor in patient's palms and lower palpebral conjunctiva.


Question: What is the most logical diagnostic test for this patient?

Context: A 25-year-old woman complains of dyspnea and mild chest pain on exertion, which increases gradually with continued exertion.

Context: She had similar symptoms last year and her medical record included the following arterial blood gas findings: | pH 7.51 | pO2 77 mm Hg | pCO2  32 mm Hg | An ECG last year demonstrated a right axis deviation.

Context: The current chest X-ray showed enlarged pulmonary arteries but no parenchymal inﬁltrates.

Context: A lung perfusion scan revealed a low probability for pulmonary thromboembolism.

Context: The current ECG showed right heart strain but no evidence of primary cardiac disease.

Choices:
A. Echocardiography
B. Holter monitoring
C. Lung biopsy
D. Transbronchial biopsy

Answer: Echocardiography

2. Patient complains of dyspnea and mild chest pain on exertion, which increases gradually with continued exertion.

3. Patient had similar symptoms last year.

4. Medical record included arterial blood gas findings of pH 7.51, pO2 77 mm Hg, and pCO2 32 mm Hg.

5. ECG last year demonstrated right axis deviation.

6. Chest X-ray showed enlarged pulmonary arteries but no parenchymal infiltrates.

7. Lung perfusion scan revealed low probability for pulmonary thromboembolism.

8. Current ECG showed right heart strain but no evidence of primary cardiac disease.

Pulmonary Disease
General Cardiology
Adult Congenital Heart Disease
Echocardiography


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

Context: A 4-year-old boy is brought to the physician because of a progressive rash for 2 days.

Context: The rash started behind the ears and now involves the trunk and extremities.

Context: Over the past 4 days, he has had mild sore throat, red, itchy eyes, and headache.

Context: He was born at term and has been healthy except for recurrent episodes of tonsillitis and occasional asthma attacks.

Context: Two weeks ago, he was treated for tonsillitis that resolved with penicillin therapy.

Context: He immigrated with his family from Brazil 3 weeks ago.

Context: His immunization status is unknown.

Context: The patient appears weak and lethargic.

Context: His temperature is 38°C (100.4°F), pulse is 100/min, and blood pressure is 100/60 mm Hg.

Context: There is a non-confluent, pink maculopapular rash over the torso and extremities.

Context: His palms and soles show no abnormalities.

Choices:
A. Rubella
B. Allergic drug reaction
C. Scarlet fever
D. Erythema infectiosum

Answer: Rubella

2. Patient has had a progressive rash for 2 days.

3. Rash started behind the ears and now involves the trunk and extremities.

4. Patient has had mild sore throat, red, itchy eyes, and headache for 4 days.

5. Patient was born at term and has had recurrent episodes of tonsillitis and occasional asthma attacks.

6. Patient was treated for tonsillitis 2 weeks ago and it resolved with penicillin therapy.

7. Patient immigrated with his family from Brazil 3 weeks ago.

8. Patient's immunization status is unknown.

10. Patient's temperature is 38°C (100.4°F).

12. Patient's blood pressure is 100/60 mm Hg.

13. Examination shows postauricular and suboccipital lymphadenopathy.

14. Patient has a non-confluent, pink maculopapular rash over the torso and extremities.

15. Patient's palms and soles show no abnormalities.

General Pediatrics
Pediatric Dermatology


Question: Which of the following should be monitored as the patient continues treatment?

Context: He denies chest pain or palpitations.

Context: The patient is found to be anemic.

Context: A fecal occult blood test is positive, and a colonoscopy is obtained.

Context: He undergoes a partial colectomy and is started on 5-fluorouracil as adjuvant chemotherapy.

Choices:
A. Creatinine
B. Fecal leukocytes
C. Neutrophil count
D. Peak flow

Answer: Neutrophil count

1. A 66-year-old man presents to the office complaining of fatigue.

2. He reports that for the past year he has been experiencing a progressive decrease in energy.

3. This week he began having some difficulty breathing while climbing the stairs.

4. He denies chest pain or palpitations.

5. He has no other chronic medical conditions and has had no prior surgeries.

7. A fecal occult blood test is positive.

9. The patient is subsequently diagnosed with colorectal cancer.

11. He is started on 5-fluorouracil as adjuvant chemotherapy.


Question: The molecular structure of the drug most likely recommended by the physician closely resembles a drug used to treat which of the following conditions?

Context: She has multiple erythematous pustules and nodules over her face, for which she has received erythromycin and topical benzoyl peroxide.

Context: The physician recommends a drug on the condition that the patient agrees to use oral contraceptives.

Choices:
A. EGFR-positive non-small cell lung cancer
B. Acute promyelocytic leukemia
C. BRAF-positive metastatic melanoma
D. Choriocarcinoma

Answer: Acute promyelocytic leukemia

1. A 15-year-old girl comes to the physician for a follow-up evaluation.

2. She has multiple erythematous pustules and nodules over her face.

3. She has received erythromycin and topical benzoyl peroxide.

4. She is concerned that the therapy is ineffective.

6. The patient must agree to use oral contraceptives in order to receive the drug.


Question: A biopsy of one of this lesion would most likely reveal which of the following?

Context: A 62-year-old female presents to her primary care provider complaining of a mass near her right jaw.

Context: She reports that the mass is painless and has grown very slowly over the past six months.

Context: She initially did not see a physician due to being very busy at her work as a lawyer.

Context: However, she reports that she noticed some right-sided facial weakness in the past week which prompted her to visit the physician.

Context: Her past medical history is notable for Hodgkins lymphoma as a child which required radiation therapy to the neck.

Context: She has a 20 pack-year smoking history and drinks alcohol socially.

Context: Her temperature is 98.6°F (37°C), blood pressure is 120/85 mmHg, pulse is 85/min, and respirations are 18/min.

Context: There is also a small palpable firm mass beneath the floor of the mouth.

Context: A right facial droop along with an inability to elevate her right eyebrow is noted.

Choices:
A. Cystic configurations of anaplastic squamous and mucoid cells
B. Non-infiltrative clusters of epithelial and mesenchymal cells
C. Epithelial cells with dense lymphoid stroma and germinal centers
D. Uniform spindle cells with scant cytoplasm and cigar-shaped nuclei

Answer: Cystic configurations of anaplastic squamous and mucoid cells

2. Patient presents with a mass near her right jaw.

3. Mass is painless and has grown slowly over the past six months.

4. Patient initially did not see a physician due to being very busy at her work as a lawyer.

5. Patient noticed some right-sided facial weakness in the past week which prompted her to visit the physician.

6. Patient's past medical history is notable for Hodgkins lymphoma as a child which required radiation therapy to the neck.

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

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

10. Patient's blood pressure is 120/85 mmHg.

13. Physical examination reveals a painless firm mass at the angle of the right jaw.

14. Physical examination reveals a small palpable firm mass beneath the floor of the mouth.

15. Physical examination reveals a right facial droop along with an inability to elevate her right eyebrow.


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

Context: A 29-year-old woman presents with low-grade fever, rash, and joint pain.

Context: She says her symptoms started gradually about 3 months ago and have progressively worsened.

Context: The patient describes her rash as pruritic, flat, and localized to her face.

Context: She reports a different type of rash on her shoulders and arms that are aggravated by exposure to sunlight.

Context: She describes her joint pain as moderate, dull and aching in character, and present mainly in the small bones of her wrists and hands, worse on the right than the left.

Context: She has no other relevant medical history and takes no current medications.

Context: Her family history is notable for her maternal grandmother, who had an unknown autoimmune condition.

Context: The patient denies any smoking history, alcohol use, or recreational drug use.

Context: Her temperature is 38.0℃ (100.3℉), pulse is 59/min, respiratory rate is 19/min, and blood pressure is 129/84 mm Hg.

Context: On physical examination, there is a macular, erythematous rash that involves both cheeks and the bridge of her nose, sparing the nasolabial folds.

Context: There is also a mild macular rash on the sun-exposed areas of her upper extremities and shoulders.

Context: She has moderate to severe point tenderness in the small joints of her wrists and hands, worse on the right, with minimal erythema and swelling.

Choices:
A. Swelling and proliferation of endothelial and mesangial cells in portions of each glomerulus with neutrophil infiltration
B. Immunologically mediated destruction of the salivary glands
C. Abnormal accumulation of fibrous tissue in the skin and multiple organs
D. Amyloid deposits within the myocardium between the muscle fibers

Answer: Swelling and proliferation of endothelial and mesangial cells in portions of each glomerulus with neutrophil infiltration

2. Patient has low-grade fever, rash, and joint pain.

3. Symptoms started gradually about 3 months ago and have progressively worsened.

4. Rash is pruritic, flat, and localized to her face.

5. Different type of rash on her shoulders and arms that are aggravated by exposure to sunlight.

6. Joint pain is moderate, dull and aching in character, and present mainly in the small bones of her wrists and hands, worse on the right than the left.

7. No other relevant medical history and takes no current medications.

8. Family history is notable for her maternal grandmother, who had an unknown autoimmune condition.

9. Patient denies any smoking history, alcohol use, or recreational drug use.

14. Physical examination reveals macular, erythematous rash that involves both cheeks and the bridge of her nose, sparing the nasolabial folds.

15. Mild macular rash on the sun-exposed areas of her upper extremities and shoulders.

16. Moderate to severe point tenderness in the small joints of her wrists and hands, worse on the right, with minimal erythema and swelling.

17. Multiple painless ulcers are present on the soft and hard palate.


Question: The child likely has:

Context: A 3-year-old Cuban-American male has a history of recurrent Pseudomonas and Candida infections.

Context: Examination of his serum shows decreased levels of IgG and CT scan reveals the absence of a thymus.

Choices:
A. Severe combined immunodeficiency syndrome
B. DiGeorge syndrome
C. Isolated IgA deficiency
D. Common variable immunodeficiency

Answer: Severe combined immunodeficiency syndrome

1. Patient is a 3-year-old Cuban-American male.

2. Patient has a history of recurrent Pseudomonas and Candida infections.

3. Laboratory analysis reveals no electrolyte abnormalities.

4. Examination of patient's serum shows decreased levels of IgG.

5. CT scan reveals the absence of a thymus.

Immunology
Immunology and Allergy
General Allergy and Immunology


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

Context: Her pulse is 89/min and blood pressure is 117/92 mm Hg.

Context: Laboratory studies show: | Platelet count 100,000/mm3 | Prothrombin time 12 seconds | Partial thromboplastin time 33 seconds | Bleeding time 13 minutes | A peripheral blood smear shows enlarged platelets.

Choices:
A. Glycoprotein Ib deficiency
B. Vitamin K deficiency
C. Von Willebrand factor deficiency
D. ADAMTS13 deficiency

Answer: Glycoprotein Ib deficiency

1. A 7-year-old girl is brought to the physician for evaluation of recurrent epistaxis.

2. Her mother reports that she bruises easily while playing.

5. Examination shows multiple bruises in the upper and lower extremities.

6. Laboratory studies show a platelet count of 100,000/mm3.

8. Partial thromboplastin time is 33 seconds.

10. A peripheral blood smear shows enlarged platelets.

11. Ristocetin assay shows no platelet aggregation.


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

Context: A 38-year-old woman comes to the emergency department because of progressive headache, blurry vision, and nausea for 1 day.

Context: She appears lethargic.

Context: Her temperature is 39.1°C (102.3°F), and blood pressure is 148/95 mm Hg.

Choices:
A. Cerebral venous thrombosis
B. Hypertensive emergency
C. Subarachnoid hemorrhage
D. Viral meningitis

Answer: Cerebral venous thrombosis

1. A 38-year-old woman comes to the emergency department.

2. She has progressive headache, blurry vision, and nausea for 1 day.

3. Four days ago, she was diagnosed with a right middle ear infection.

7. Ophthalmologic examination shows bilateral swelling of the optic disc.

8. The corneal reflex in the right eye is absent.

9. Sensation to touch is reduced on the upper right side of the face.

10. Serum studies show increased concentrations of fibrin degradation products.

Neurology with Special Qualification in Child Neurology


Question: Which of the following features are not associated of Waardenburg’s syndrome?

Context: She informs you that she is pregnant, and that the father of her child has Waardenburg’s syndrome.

Context: She asks you about common findings in Waardenburg’s syndrome.

Choices:
A. Heterochromia
B. Conductive hearing loss
C. Lateral displacement of inner canthi
D. Broad nasal root

Answer: Conductive hearing loss

1. A 35-year-old female presents to your office for a routine physical.

2. She informs you that she is pregnant.

3. The father of her child has Waardenburg's syndrome.

4. She asks you about common findings in Waardenburg's syndrome.

General Pediatrics
Clinical Genetics and Genomics


Question: Which of the following is the most likely underlying mechanism of this patient's fall?

Context: Examination shows a mildly swollen right ankle with no tenderness over the medial or lateral malleolus; range of motion is full with mild pain.

Choices:
A. Loss of the ATM protein
B. Absence of dystrophin protein
C. Arylsulfatase A deficiency
D. SMN1 gene defect

Answer: Absence of dystrophin protein

1. A 4-year-old boy is brought to the emergency department for evaluation after falling.

2. He has fallen multiple times in the last year.

3. His parents report that he did not walk until he was 18 months old.

4. Examination shows a mildly swollen right ankle with no tenderness over the medial or lateral malleolus.

5. Range of motion is full with mild pain.

6. He has marked enlargement of both calves.

7. When standing up, the patient uses his hands against his knees and thighs to slowly push himself up into a standing position.

General Pediatrics
Pediatric Emergency Medicine


Question: Administering succinylcholine during this procedure would most likely result in which of the following complications?

Context: A 25-year-old man is brought to the emergency department with second- and third-degree burns covering 30% of the surface area of his body.

Context: He is alert and active.

Context: His temperature is 36.5°C (97.7°F), pulse is 62/min, respirations are 18/min, and blood pressure is 105/70 mm Hg.

Context: Respirations are 30/min.

Context: There is an inspiratory stridor.

Choices:
A. Prolonged muscle weakness
B. Malignant hyperthermia
C. Cardiac arrhythmia
D. Respiratory depression

Answer: Cardiac arrhythmia

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

2. He has second- and third-degree burns covering 30% of the surface area of his body.

4. He has no personal or family history of serious illness.

9. Pulse oximetry on 2 liters by nasal cannula shows an oxygen saturation of 98%.

10. Intravenous fluids, intravenous and topical antibiotics, and intravenous pain medications are administered in the intensive care unit.

11. Twenty-four hours later, the patient develops respiratory distress.

14. The patient requires rapid sequence intubation.


Question: What ausculatory finding would explain the mechanism by which her more recent complaint occurred?

Context: A 32-year-old woman presents to the emergency department with 2 hours of left-sided weakness.

Context: Her husband reports that she had been complaining of pain and swelling in her right calf for several weeks prior to this event.

Choices:
A. Holosystolic murmur radiating to the axilla
B. Wide, fixed splitting of S2
C. Crescendo-decrescendo murmur heard loudest at the right second intercostal space
D. An S2 that splits during expiration

Answer: Wide, fixed splitting of S2

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

2. She has had left-sided weakness for 2 hours.

3. Her husband reports she had been complaining of pain and swelling in her right calf for several weeks prior to this event.

4. The couple had recently returned from a vacation in Europe.


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

Context: A 41-year-old woman presents with pain in her abdomen for the last couple of hours.

Context: She says pain is intermittent and localized to the right hypochondriac region.

Context: She admits to eating fatty foods this morning before the pain started.

Context: She also complains of nausea but has not vomited yet.

Context: She describes episodes with similar symptoms in the past after a fatty meal but were less severe.

Context: Past medical history is irrelevant.

Context: The vital signs include: heart rate 85/min, respiratory rate 16/min, temperature 37.6°C (99.6°F), and blood pressure 120/80 mm Hg.

Context: Physical examination is within normal limits.

Context: An abdominal ultrasound is pending.

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

Answer: Cholecystokinin

2. Patient has been experiencing pain in her abdomen for the last couple of hours.

3. Pain is intermittent and localized to the right hypochondriac region.

4. Patient admits to eating fatty foods this morning before the pain started.

5. Patient also complains of nausea but has not vomited yet.

6. Patient has had episodes with similar symptoms in the past after a fatty meal but were less severe.

7. Patient's past medical history is irrelevant.

9. Patient's respiratory rate is 16/min.

10. Patient's temperature is 37.6°C (99.6°F).

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

12. Patient's physical examination is within normal limits.


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

Context: A 53-year-old man comes to the physician because of a 1-day history of fever and chills, severe malaise, and cough with yellow-green sputum.

Context: Current medications include metoprolol and warfarin.

Context: His temperature is 38.5°C (101.3°F), pulse is 96/min, respirations are 26/min, and blood pressure is 98/62 mm Hg.

Choices:
A. Pseudomonas aeruginosa
B. Streptococcus pyogenes
C. Haemophilus influenzae
D. Streptococcus pneumoniae

Answer: Streptococcus pneumoniae

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

2. He has a 1-day history of fever and chills, severe malaise, and cough with yellow-green sputum.

3. He works as a commercial fisherman on Lake Superior.

4. His current medications include metoprolol and warfarin.

9. Examination shows increased fremitus and bronchial breath sounds over the right middle lung field.

10. An x-ray of the chest shows consolidation of the right upper lobe.


Question: Which of the following is the most appropriate antibiotic to pair with the tamsulosin?

Context: A 46-year-old man presents to his physician because of persistent pelvic and scrotal pain for the past month.

Context: He also has had occasional fevers, chills, dysuria, and increased urinary frequency over the last few months.

Context: He was prescribed trimethoprim and sulfamethoxazole for the urinary symptoms, but he is still having symptoms currently.

Context: He is sexually active with multiple male and female partners and uses condoms inconsistently.

Context: The patient has hypertension and takes lisinopril.

Context: He also takes PrEP (Truvada, which contains tenofovir and emtricitabine).

Context: On physical exam, his temperature is 36.7℃ (98.1℉), the blood pressure is 115/70 mm Hg, the pulse is 74/min, and the respirations are 14/min.

Context: A digital rectal exam reveals a mildly tender and mildly enlarged prostate.

Context: Urine specimens are sent for culture and sensitivity testing.

Context: A urine sample taken after prostate massage shows a 10-fold increase in bacteria counts.

Context: The test results for antimicrobial sensitivity include ampicillin, cefepime, gentamicin, levofloxacin, and meropenem.

Context: The patient is prescribed tamsulosin.

Choices:
A. Cefepime
B. Gentamicin
C. Levofloxacin
D. Trimethoprim and sulfamethoxazole

Answer: Levofloxacin

2. Patient has persistent pelvic and scrotal pain for the past month.

3. Patient has occasional fevers, chills, dysuria, and increased urinary frequency over the last few months.

4. Patient was prescribed trimethoprim and sulfamethoxazole for the urinary symptoms, but still having symptoms.

5. Patient is sexually active with multiple male and female partners and uses condoms inconsistently.

6. Patient has hypertension and takes lisinopril.

7. Patient takes PrEP (Truvada, which contains tenofovir and emtricitabine).

8. Patient's temperature is 36.7℃ (98.1℉).

9. Patient's blood pressure is 115/70 mm Hg.

12. Digital rectal exam reveals a mildly tender and mildly enlarged prostate.

13. Urine specimens sent for culture and sensitivity testing.

14. Urine sample taken after prostate massage shows a 10-fold increase in bacteria counts.

15. Test results for antimicrobial sensitivity include ampicillin, cefepime, gentamicin, levofloxacin, and meropenem.


Question: This drug is most likely to result in which of the following laboratory changes?

Context: A 29-year-old woman comes to the emergency department because of progressive numbness and weakness in her right arm and right leg for 1 day.

Context: She does not smoke or drink alcohol.

Context: Her temperature is 37°C (98.6°F), pulse is 78/min, respirations are 14/min, and blood pressure is 115/71 mm Hg.

Context: Muscle strength is 3/5 in the right arm and leg and 5/5 on the left side.

Choices:
A. Monocytosis
B. Lymphocytosis
C. Eosinopenia
D. Granulocytopenia

Answer: Eosinopenia

1. A 29-year-old woman comes to the emergency department.

2. She has progressive numbness and weakness in her right arm and right leg for 1 day.

3. Two months ago, she had blurry vision and headache for a week, which resolved without treatment.

9. Muscle strength is 3/5 in the right arm and leg.

10. Muscle strength is 5/5 on the left side.

11. MRI of the brain shows gadolinium-enhancing lesions in the left central sulcus, cervical spinal cord, and optic nerve.

12. Intravenous methylprednisolone therapy is started.


Question: Which of the following disorders does this patient potentially suffer from?

Context: A 30-year-old male biology graduate student was dismissed from his PhD program after 8 years because he was not able to produce a thesis, claiming that his data was never exactly how he wanted it.

Context: He has had similar problems in his undergraduate courses, often failing to complete his assignments on time because he had to revise them until they were perfect.

Choices:
A. Schizoid personality disorder
B. Narcissistic personality disorder
C. Obsessive compulsive personality disorder
D. Paranoid personality disorder

Answer: Obsessive compulsive personality disorder

1. A 30-year-old male biology graduate student was dismissed from his PhD program after 8 years.

2. He was not able to produce a thesis, claiming that his data was never exactly how he wanted it.

3. He would spend weeks planning out a simple experiment, since everything had to be just right.

4. For many experiments, he would start over because he felt he went out of order in adding the reagents to his media for his cells.

5. He has had similar problems in his undergraduate courses.

6. He often failed to complete his assignments on time because he had to revise them until they were perfect.

Obsessive compulsive personality disorder


Question: Which of the following serum markers is most strongly associated with this patient’s condition?

Context: A 62-year-old male presents to his primary care physician complaining of an unintended 10-pound weight loss over the last 4 months.

Context: He also reports vague abdominal discomfort, weakness, and occasional yellowing of his skin and eyes.

Context: Physical exam demonstrates hepatomegaly and abdominal distention.

Choices:
A. Carcinoembryonic antigen (CEA)
B. Cancer antigen 19-9 (CA 19-9)
C. Alpha-fetoprotein (AFP)
D. Beta-human chorionic gonadotropin (ß-HCG)

Answer: Alpha-fetoprotein (AFP)

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

2. He has experienced an unintended 10-pound weight loss over the last 4 months.

3. He reports vague abdominal discomfort, weakness, and occasional yellowing of his skin and eyes.

4. He has a history of cirrhosis secondary to alcohol abuse and hepatitis C infection.

5. Physical exam demonstrates hepatomegaly.

6. Physical exam demonstrates abdominal distention.


Question: This study is best described as which of the following?

Context: The investigators examined the total number of cases of syphilis and genitourinary chlamydia in the United States using a national health survey of a nationally representative sample of US citizens conducted in 2012.

Choices:
A. Single-blind clinical trial
B. Double-blind clinical trial
C. Cross-sectional study
D. Case-control study

Answer: Cross-sectional study

1. A research group designed a study to investigate the epidemiology of syphilis in the United States.

2. The investigators examined the total number of cases of syphilis and genitourinary chlamydia in the United States.

3. The investigators used a national health survey of a nationally representative sample of US citizens conducted in 2012.

4. The investigators ultimately found that a history of genitourinary chlamydia infection is associated with syphilis.

Infectious Disease
Medical Microbiology Pathology


Question: Which of the following is the best treatment for this patient’s condition while waiting for the ascitic fluid culture results?

Context: A 56-year-old African American male presents with altered mental status, abdominal pain, and a fever of 100.4F.

Context: His past medical history is significant for alcohol use and cirrhosis of the liver.

Context: Shifting dullness is noted on physical exam.

Context: Paracentesis demonstrates serum ascites albumen gradient of 1.3 g/dL, and the ascitic fluid polymorphonuclear cell count is 280 cells/mm^3.

Choices:
A. Nadolol
B. Cefotaxime
C. Penicillin
D. Gentamicin

Answer: Cefotaxime

1. Patient is 56-year-old African American male.

2. Patient presents with altered mental status, abdominal pain, and fever of 100.4F.

3. Patient has past medical history of alcohol use and cirrhosis of the liver.

4. Physical exam reveals shifting dullness.

5. Paracentesis demonstrates serum ascites albumen gradient of 1.3 g/dL.

6. Ascitic fluid polymorphonuclear cell count is 280 cells/mm^3.


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

Context: A 4-year-old boy who recently emigrated from Ghana is brought to the physician because of a 5-day history of pain and swelling in his hands.

Context: The patient appears distressed.

Context: His temperature is 38.1°C (100.5°F).

Context: Physical examination shows pallor.

Context: The dorsum of his hands and fingers are swollen, warm, and tender to palpation.

Choices:
A. Coronary artery aneurysm
B. Hyperuricemia
C. Thickened heart valves
D. Microhematuria

Answer: Microhematuria

1. A 4-year-old boy recently emigrated from Ghana.

2. He has a 5-day history of pain and swelling in his hands.

3. He has had similar episodes in the past.

7. The dorsum of his hands and fingers are swollen.

8. The dorsum of his hands and fingers are warm.

9. The dorsum of his hands and fingers are tender to palpation.


Question: Which of the following is the most likely explanation for the laboratory findings in this patient?

Context: A 47-year-old woman is admitted to the hospital because of a 2-week history of low-grade fever, fatigue, and a 3-kg (6.6-lb) weight loss.

Context: Her temperature is 38°C (100.4°F).

Context: Her serum creatinine is 1.8 mg/dL.

Choices:
A. Occlusion of renal arteries by cholesterol crystals
B. Deposition of antigen-antibody complexes
C. Intravascular fragmentation of red blood cells
D. Hypersensitivity to penicillin haptens

Answer: Deposition of antigen-antibody complexes

1. A 47-year-old woman is admitted to the hospital.

2. She has a 2-week history of low-grade fever, fatigue, and a 3-kg (6.6-lb) weight loss.

4. Physical examination shows pallor and a cardiac murmur.

6. Urinalysis shows red cell casts and 2+ protein.

7. A CT scan of the abdomen with contrast shows no abnormalities.

8. Despite appropriate medical therapy, the patient dies.

9. A photograph of the heart taken during autopsy is shown.

Infectious Disease
General Internal Medicine
Rheumatology


Question: Which of the following nerve roots is most likely to be affected in this patient?

Context: A 36-year-old woman comes to the physician because of a 2-month history of progressively worsening lower back pain and weakness in the lower extremities.

Context: She was diagnosed with pulmonary tuberculosis 6 months ago and is currently taking isoniazid and rifampin.

Context: Strength is 2/5 with right-sided dorsiflexion and the patellar reflex is absent.

Choices:
A. S2
B. S1
C. L3
D. L4

Answer: L4

1. A 36-year-old woman comes to the physician.

2. She has a 2-month history of progressively worsening lower back pain and weakness in the lower extremities.

3. The pain is worse with movement and improves with lying down on a flat surface.

4. She was diagnosed with pulmonary tuberculosis 6 months ago.

5. She is currently taking isoniazid and rifampin.

6. Physical examination shows sensory loss over the lateral aspect of the mid-thigh, patella, and medial aspect of the right lower leg.

7. Strength is 2/5 with right-sided dorsiflexion.

9. An x-ray of the spine shows a paravertebral opacity with anterior wedging of the vertebral body.


Question: Arterial blood gas analysis on room air shows: | pH 7.56 | PCO2 40 mm Hg | PO2 94 mm Hg | HCO3- 30 mEq/L | Measurement of which of the following is the most appropriate next step in diagnosis?"

Context: A 24-year-old primigravid woman at 8 weeks' gestation is brought to the emergency department because of a 5-day history of nausea and vomiting.

Context: She has not been able to tolerate much food or drink.

Context: Her symptoms are worse in the morning.

Context: She has tried multiple oral antiemetics with limited relief.

Context: She has not had fevers, chills, abdominal pain, urinary symptoms, or diarrhea.

Context: She appears tired.

Context: Her temperature is 37°C (98.6°F), pulse is 105/min, and blood pressure is 108/60 mm Hg.

Context: Examination shows dry mucous membranes and cool extremities, with delayed capillary refill time.

Choices:
A. Serum osmolal gap
B. Serum anion gap
C. Urine albumin to urine creatinine ratio
D. Urine chloride concentration

Answer: Urine chloride concentration

1. Patient is a 24-year-old primigravid woman.

3. Patient has a 5-day history of nausea and vomiting.

4. Patient has not been able to tolerate much food or drink.

6. Patient has tried multiple oral antiemetics with limited relief.

7. Patient has not had fevers, chills, abdominal pain, urinary symptoms, or diarrhea.

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

11. Patient's blood pressure is 108/60 mm Hg.

12. Examination shows dry mucous membranes.

14. Examination shows delayed capillary refill time.


Question: Which of the following is the most appropriate recommendation at this time?

Context: A 34-year-old pregnant woman, gravida 2, para 0, at 28 weeks of gestation presents to the physician for a prenatal visit.

Context: She has not had regular prenatal care.

Context: Her most recent abdominal ultrasound was at 20 weeks of gestation, and it confirmed accurate fetal dates and appropriate fetal development.

Context: She appears well.

Choices:
A. Hepatitis A vaccination
B. Plan to formula feed the newborn
C. Start combination therapy with interferon α and ribavirin
D. Undergo liver biopsy

Answer: Hepatitis A vaccination

1. A 34-year-old pregnant woman presents to the physician for a prenatal visit.

2. She is gravida 2, para 0, and 28 weeks of gestation.

3. She has not had regular prenatal care.

4. Her most recent abdominal ultrasound was at 20 weeks of gestation.

5. The ultrasound confirmed accurate fetal dates and appropriate fetal development.

6. She takes levothyroxine for hypothyroidism.

7. She used to work as a nurse before she emigrated from Brazil 13 years ago.

8. She lost her immunization records during the move and cannot recall all of her vaccinations.

10. Her vital signs are within normal limits.

11. The physical examination reveals a fundal height of 26 cm.

12. No abnormalities are found during the physical exam.

13. An ELISA test conducted for HIV is negative.

14. Serology test results for hepatitis B surface antibody and hepatitis C antibody are positive for both.

15. The laboratory test results for hepatitis B core antibody, hepatitis B surface antigen, and hepatitis A antibody are negative.

16. The polymerase chain reaction analysis of hepatitis C RNA is positive for genotype 1.


Question: Which of the following does this screening test detect?

Context: A 36-year-old man presents with a 3-week history of fever, enlarged lymph nodes, fatigue, and a dry cough.

Context: The patient’s wife says she has noticed that he lost a lot of weight over the last 6 months and seems very pale.

Context: Over the last week, he has noticed a worsening non-productive cough and night sweats.

Context: His blood count shows anemia and low lymphocyte count.

Context: He tells the physician that he had multiple unprotected sexual relationships with women other than his wife about 6 years ago and is fearful this may be related to his current health concerns.

Context: A test is performed which screens for the cause of this patient's immunodeficiency.

Choices:
A. Anti-HCV antigen
B. Lactic dehydrogenase
C. p24 antigen
D. CCR5 mutation

Answer: p24 antigen

2. Patient has a 3-week history of fever, enlarged lymph nodes, fatigue, and a dry cough.

3. Patient's wife has noticed weight loss and paleness over the last 6 months.

4. Patient has a worsening non-productive cough and night sweats over the last week.

5. Patient's blood count shows anemia and low lymphocyte count.

6. Patient had multiple unprotected sexual relationships with women other than his wife about 6 years ago.

7. Patient is fearful this may be related to his current health concerns.

8. Test is performed to screen for cause of patient's immunodeficiency.


Question: Laboratory studies show: | Hemoglobin 9 g/dL | Leukocyte count 1,500/mm3 | Percent segmented neutrophils 50% | Platelet count 85,000/mm3 | To reduce the likelihood of complications, it is most appropriate to administer which of the following?

Context: Seven days after initiation of induction chemotherapy for acute myeloid leukemia, a 56-year-old man develops leukopenia.

Context: He feels well.

Context: His temperature is 36.7°C (98.1°F), blood pressure is 110/65 mm Hg, pulse is 72/min, and respiratory rate is 14/min.

Choices:
A. Ciprofloxacin
B. Granulocyte colony-stimulating factor
C. Vancomycin
D. No pharmaco-prophylaxis at this time

Answer: Ciprofloxacin

1. A 56-year-old man developed leukopenia seven days after initiation of induction chemotherapy for acute myeloid leukemia.

3. He has no history of serious cardiopulmonary disease.

8. Examination of the skin, head and neck, heart, lungs, abdomen, and perirectal area reveals no abnormalities.