Question: Which of the following interventions would be most successful at achieving the task group’s mission?

Context: The task group would like to begin by decreasing the number of days given for narcotic pain medication prescriptions in the emergency department to at most 7 days instead of the hospital average of 21 days per prescription.

Choices:
A. Educating patients about appropriate narcotics dosing
B. Printing out and posting handouts detailing the dangers of narcotics
C. Sending an email to all providers notifying them of narcotics prescribing best practices
D. Changing the electronic medical record to only allow a maximum of 7 days per prescription

Answer: Changing the electronic medical record to only allow a maximum of 7 days per prescription

1. A regional hospital system has decided to institute a new task group for quality improvement and patient safety.

2. The task group would like to begin by decreasing the number of days given for narcotic pain medication prescriptions in the emergency department.

3. The number of days given for narcotic pain medication prescriptions in the emergency department should be at most 7 days.

4. The hospital average for narcotic pain medication prescriptions is 21 days per prescription.

Health Care Administration, Leadership, and Management


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

Context: A 57-year-old man comes to the clinic complaining of nausea and 1 episode of vomiting during the past day.

Context: He denies any precipitating event except for a headache for which he took some acetaminophen yesterday.

Context: He has never had such symptoms before.

Context: His past medical history is significant for hypertension, biliary colic, and a past hospitalization for delirium tremens when he “tried to quit alcohol cold turkey.” When asked about his current alcohol intake, the patient looks away and mutters “just a couple of drinks here and there.” The patient reports mild abdominal pain that began this morning but denies vision changes, bowel changes, fever, or weight loss.

Choices:
A. Accumulation of N-acetyl-p-benzoquinone imine in the liver
B. Impaction of a gallstone in the ileus
C. Malignant overgrowth of glial cells in the brain
D. Obstruction of the cystic duct by gallstone

Answer: Accumulation of N-acetyl-p-benzoquinone imine in the liver

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

2. He complains of nausea and 1 episode of vomiting during the past day.

3. He denies any precipitating event except for a headache.

4. The headache is described as bilateral, dull, and 8/10 in severity.

5. He has never had such symptoms before.

6. His past medical history is significant for hypertension, biliary colic, and a past hospitalization for delirium tremens.

7. He "tried to quit alcohol cold turkey" in the past.

8. When asked about his current alcohol intake, the patient looks away and mutters “just a couple of drinks here and there.”

9. The patient reports mild abdominal pain that began this morning.

10. He denies vision changes, bowel changes, fever, or weight loss.

11. Physical examination demonstrates tenderness at the right upper quadrant (RUQ) that does not worsens with inhalation.


Question: The patient's condition was most likely transmitted by which of the following vectors?"

Context: A 48-year-old patient comes to the physician because of a 4-day history fever, headaches, loss of appetite, and myalgia.

Context: His temperature is 39.5°C (103.1°F).

Context: Laboratory studies show: | Hemoglobin 14.1 g/dL | Leukocyte count 3,800/mm3 | Platelet count 85,000/mm3 | Serum | AST 48 U/L | ALT 52 U/L | Treatment with doxycycline is begun and the patient recovers.

Choices:
A. Lone star tick
B. Ixodes tick
C. Dog tick
D. Flea

Answer: Ixodes tick

1. A 48-year-old patient comes to the physician.

2. The patient has a 4-day history of fever, headaches, loss of appetite, and myalgia.

3. Two weeks ago, the patient went on a camping trip to Wisconsin.

4. The patient's temperature is 39.5°C (103.1°F).

5. Physical examination shows no rash or joint swelling.

6. Laboratory studies show a hemoglobin level of 14.1 g/dL.

7. Laboratory studies show a leukocyte count of 3,800/mm3.

8. Laboratory studies show a platelet count of 85,000/mm3.

9. Laboratory studies show an AST level of 48 U/L.

10. Laboratory studies show an ALT level of 52 U/L.

11. Treatment with doxycycline is begun.

13. A paired acute and convalescent indirect fluorescent antibody test confirms that the patient had anaplasmosis.


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

Context: She denies weight loss or dysphagia.

Context: Normal bowel sounds are appreciation.

Context: Fecal occult blood is negative.

Choices:
A. Start antibiotic therapy
B. Start omeprazole
C. Surgical fundiplication
D. Upper gastrointestinal endoscopy

Answer: Start omeprazole

1. A 42-year-old woman comes to the clinic complaining of upper abdominal pain.

2. Her symptoms started 1 month ago with vague abdominal discomfort following a meal at a steakhouse.

3. Since then the pain has progressed to the point that she has more than 5 episodes a week.

4. The pain is worse with eating but has not affected her appetite.

5. She also reports a burning sensation in her chest when she lies down at night after dinner.

7. She takes no medications except daily calcium supplements.

8. She drinks 2 glasses of wine per week and denies tobacco use.

9. Her blood pressure is 110/78, pulse is 72/min, and respirations are 13/min.

10. On physical examination, the patient’s abdomen is soft and non-distended.

11. Normal bowel sounds are appreciation.

12. There is mild epigastric tenderness but no guarding and no rebound.


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

Context: A 3-year-old boy presents to the pediatrician crying with ear pain and his temperature has been 101°F (38.3°C) for several days.

Context: His mother states that other children at his daycare center have been having similar symptoms.

Context: She further describes that he was fed formula and was not breastfed.

Context: The mother admits that she smokes cigarettes daily.

Context: On exam, the boy is irritable and crying, and frequently tugs on his left ear.

Context: Both tympanic membranes appear erythematous, and the left appears opaque and bulging with decreased mobility on pneumatic otoscopy.

Choices:
A. Amoxicillin
B. TMP-SMX
C. Tympanocentesis
D. Supportive therapy

Answer: Amoxicillin

2. Patient has been crying with ear pain.

3. Patient's temperature has been 101°F (38.3°C) for several days.

4. Patient's mother states other children at his daycare center have been having similar symptoms.

5. Patient was fed formula and was not breastfed.

6. Patient's mother smokes cigarettes daily.

7. On exam, patient is irritable and crying.

8. Patient frequently tugs on his left ear.

9. Both tympanic membranes appear erythematous.

10. Left tympanic membrane appears opaque and bulging.

11. Left tympanic membrane has decreased mobility on pneumatic otoscopy.


Question: Which of the following pathologic findings is she most likely to have?

Context: She now feels fatigued and cannot concentrate on her work or type properly on the keyboard because of an onset of tremor in her hands.

Context: The patient’s blood pressure is 124/83 mm Hg, pulse is 91/min, respirations are 17/min, and temperature is 36.7°C (98.1°F).

Context: On physical examination, there is a mild enlargement of the thyroid; the gland is minimally firm in texture and is nontender.

Choices:
A. Follicular thyroid neoplasia
B. Silent thyroiditis
C. Chronic lymphocytic thyroiditis
D. Fibrous thyroiditis

Answer: Silent thyroiditis

1. A 47-year-old G3P2 woman presents to her endocrinologist for a follow-up appointment.

2. Her last menstrual period was at the age of 35 years.

4. She cannot concentrate on her work or type properly on the keyboard because of an onset of tremor in her hands.

5. Her symptoms are taking a toll on her quality of life.

6. The patient’s blood pressure is 124/83 mm Hg.

8. The patient’s respirations are 17/min.

9. The patient’s temperature is 36.7°C (98.1°F).

10. On physical examination, there is a mild enlargement of the thyroid.

11. The gland is minimally firm in texture.

Endocrinology, Diabetes, and Metabolism
Endocrinology


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

Context: A 44-year-old woman is brought to the emergency department after she was found lying in the park mumbling to herself.

Context: She is lethargic and disoriented.

Context: She has a history of systemic lupus erythematosus but stopped taking methotrexate many years ago.

Context: Her temperature is 37.3°C (99.1°F), pulse is 89/min, and blood pressure is 154/91 mm Hg.

Context: On mental status examination, she is confused and only oriented to person, but not to place or time.

Context: Physical exam shows jugular venous distention and pitting edema in the lower extremities.

Context: Laboratory studies show: | Serum | Na+ 137 mEq/L | K+ 5.5 mEq/L | Cl- 120 mEq/L | Bicarbonate 15 mEq/L | Urea nitrogen 94 mg/dL | Creatinine 5.5 mg/dL | Glucose 92 mg/dL | .

Choices:
A. Administer lactulose
B. Hemodialysis
C. Restart methotrexate
D. Fluid restriction

Answer: Hemodialysis

1. A 44-year-old woman is brought to the emergency department.

2. She was found lying in the park mumbling to herself.

4. She has a 2-week history of increasing weakness, nausea, and vomiting.

5. She denies any recent alcohol or drug use.

6. She has a history of systemic lupus erythematosus.

7. She stopped taking methotrexate many years ago.

11. On mental status examination, she is confused and only oriented to person.

12. She is not oriented to place or time.

13. She is unable to name the days of the week backwards.

14. She exhibits moderate generalized weakness.

15. Physical exam shows jugular venous distention.

16. Physical exam shows pitting edema in the lower extremities.

17. Laboratory studies show serum Na+ 137 mEq/L.

18. Laboratory studies show serum K+ 5.5 mEq/L.

19. Laboratory studies show serum Cl- 120 mEq/L.

20. Laboratory studies show serum bicarbonate 15 mEq/L.

21. Laboratory studies show serum urea nitrogen 94 mg/dL.

22. Laboratory studies show serum creatinine 5.5 mg/dL.

23. Laboratory studies show serum glucose 92 mg/dL.


Question: The isolated hormone is most likely which of the following?

Context: An investigator is studying the secretion of gastrointestinal hormones before and after food intake.

Context: She isolates a hormone that accelerates the emptying of gastric contents into the duodenal bulb.

Choices:
A. Glucagon-like peptide
B. Gastrin
C. Cholecystokinin
D. Vasoactive intestinal peptide

Answer: Gastrin

1. An investigator is studying the secretion of gastrointestinal hormones.

2. The study is conducted before and after food intake.

4. The hormone accelerates the emptying of gastric contents.

5. The gastric contents are emptied into the duodenal bulb.


Question: What is the most likely cause of her presentation?

Context: A 45-year-old woman presents to the office with a chief complaint of a cough that has persisted for a month and a half.

Context: She also has night fevers and has lost 5 kg (11 lb) in the last 2 months.

Context: Her vitals include: heart rate 82/min, respiratory rate 17/min, temperature 38.0°C (100.4°F), and blood pressure 107/80 mm Hg.

Choices:
A. Echinococcosis
B. Tuberculosis
C. Pulmonary thromboembolism
D. Heart failure

Answer: Tuberculosis

1. A 45-year-old woman presents to the office.

2. Her chief complaint is a cough that has persisted for a month and a half.

4. She has lost 5 kg (11 lb) in the last 2 months.

5. She recently returned from a 6-month trip to Peru.

10. On auscultation, she has diminished respiratory sounds at the base of the right lung.

11. Chest radiography shows an opacity in the right apex.

Pulmonary Disease
General Pulmonary Disease


Question: What is the most likely diagnosis?

Context: Past medical records are unavailable.

Context: His temperature is 37°C (98.6°F), the respiratory rate is 15/min, the pulse is 107/min, and the blood pressure is 92/67 mm Hg.

Context: His condition deteriorates overnight.

Context: His blood tests show:  | Serum | Albumin 3.2 gm/dL | Alkaline phosphatase 150 U/L | Alanine aminotransferase 76 U/L | Aspartate aminotransferase 155 U/L | Gamma-glutamyl transpeptidase 202 U/L | .

Choices:
A. Alcohol-related dementia
B. Hepatic encephalopathy
C. Delirium
D. Wernicke's encephalopathy

Answer: Wernicke's encephalopathy

1. A 52-year-old homeless man is brought to the urgent care clinic with altered mental status and disorientation for the last day.

2. Past medical records are unavailable.

7. He has a flapping tremor of the wrists during attempted extension.

8. He is started on intravenous D5 1/2NS and blood is drawn for further testing.

9. His condition deteriorates overnight.

10. On re-examination the next morning, he has developed visual disturbances with a new horizontal nystagmus and a staggering gait.

11. His blood tests show: Serum Albumin 3.2 gm/dL.

12. His blood tests show: Alkaline phosphatase 150 U/L.

13. His blood tests show: Alanine aminotransferase 76 U/L.

14. His blood tests show: Aspartate aminotransferase 155 U/L.

15. His blood tests show: Gamma-glutamyl transpeptidase 202 U/L.

General Emergency Medicine
Neurocritical Care


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

Context: A 27-year-old woman comes to the emergency department at 14 weeks gestation with abdominal pain.

Context: She states she has passed a large amount of blood from her vagina in the past 2 hours.

Context: Her vitals are within normal limits and she describes her abdominal pain as a 4/10.

Context: The patient states she does not want any invasive procedures in her workup but is accepting to necessary medical interventions.

Choices:
A. Admission and external fetal monitoring
B. Dilation and curettage
C. Expectant management
D. Transvaginal ultrasound

Answer: Expectant management

1. A 27-year-old woman comes to the emergency department.

3. She has passed a large amount of blood from her vagina in the past 2 hours.

5. She describes her abdominal pain as a 4/10.

6. Physical exam is notable for a dilated cervix.

7. The patient states she does not want any invasive procedures in her workup.

8. She is accepting to necessary medical interventions.

General Obstetrics and Gynecology
Maternal


Question: Which of the following genes was most likely mutated in this fetus?

Context: A 25-year-old female is admitted to the hospital for an intrauterine fetal demise (IUFD) during her 30th gestational week.

Context: The baby is delivered via C-section and the family wishes to conduct an autopsy to understand the reason for the IUFD and to better prepare for future pregnancies.

Context: On autopsy, the fetus is discovered to have severe facial abnormalities as well as a brain lacking the normal sagittal fissure.

Choices:
A. Hox
B. Wnt-7
C. Sonic hedgehog
D. BMP

Answer: Sonic hedgehog

1. A 25-year-old female is admitted to the hospital.

2. The patient is admitted for an intrauterine fetal demise (IUFD).

3. The patient is in her 30th gestational week.

4. The patient did not receive any prenatal care or screenings.

6. The family wishes to conduct an autopsy.

7. The purpose of the autopsy is to understand the reason for the IUFD and to better prepare for future pregnancies.

8. On autopsy, the fetus is discovered to have severe facial abnormalities.

9. On autopsy, the fetus is discovered to have a brain lacking the normal sagittal fissure.


Question: The following sets of measurements are taken every 10 minutes: | Plasma concentration of substance Excretion rate of substance | Set 1 0.1 mg/mL 60 mg/min | Set 2 0.15 mg/mL 90 mg/min | Set 3 0.2 mg/mL 104 mg/min | Set 4 0.25 mg/mL 110 mg/min | Set 5 0.3 mg/mL 116 mg/min | This patient was most likely administered which of the following substances?"

Context: She is administered an intravenous substance that does not undergo tubular reabsorption.

Choices:
A. Cystatin C
B. Glucose
C. Para-aminohippurate
D. Iohexol

Answer: Para-aminohippurate

1. A healthy 32-year-old woman enrolls in a study investigating kidney function.

2. Her renal plasma flow (RPF) is 600 mL/min.

3. She is administered an intravenous substance.

4. The intravenous substance does not undergo tubular reabsorption.


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

Context: She has no history of serious illness.

Context: Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 96/52 mm Hg.

Context: Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border that radiates towards the neck.

Choices:
A. Patent ductus arteriosus
B. Venous hum
C. Coronary artery fistula
D. Aortic stenosis

Answer: Venous hum

1. A 6-year-old girl is brought to the physician for a well-child examination.

2. She has no history of serious illness.

6. Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border.

7. The murmur radiates towards the neck.

8. The murmur disappears when she flexes her neck.

9. The remainder of the examination shows no abnormalities.


Question: What is the most appropriate management of this patient’s hyponatremia?

Context: A 72-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department with three-days of fever, cough, and shortness of breath.

Context: On physical exam, temperature is 101.3 deg F (38.5 deg C), pulse is 106/min, blood pressure is 148/92 mmHg, and respiratory rate is 24/min.

Context: Sodium level is 118 mEq/L.

Choices:
A. Hypertonic saline
B. Fluid restriction
C. Salt tablets
D. Demeclocycline

Answer: Fluid restriction

1. A 72-year-old man presents to the emergency department.

2. He has a history of hypertension and hyperlipidemia.

3. He has three days of fever, cough, and shortness of breath.

4. His temperature is 101.3 deg F (38.5 deg C).

8. Crackles are auscultated on the right lower lobe.

9. Chest radiograph demonstrates right lower lobe opacities concerning for consolidation.

11. He is admitted to the hospital on empiric antibiotics.


Question: Which of the following best explains these findings?

Context: He feels tired most of the time.

Context: He has no fever or weight loss.

Context: No lymphadenopathy is palpated.

Context: The laboratory studies show the following: | Hemoglobin 8.5 g/dL | Mean corpuscular volume 105 μm3 | Leukocyte count 4,500/mm3 | Platelet 160,000/mm3 | Abdominal ultrasonography shows no organomegaly or other pathologic findings.

Context: No blasts are seen.

Context: Marrow myeloblasts are 4% in volume.

Choices:
A. Acute myeloid leukemia
B. Aplastic anemia
C. Myelodysplastic syndrome
D. Primary myelofibrosis

Answer: Myelodysplastic syndrome

1. A 75-year-old man presents to the physician for a follow-up examination.

2. Over the last several months, he reports dyspnea when walking during his daily exercise routine.

5. He has no history of severe illness and takes no medications.

6. He does not smoke, drinks alcohol, or follow a particular diet.

7. The vital signs are within normal limits.

8. The physical examination reveals pale conjunctiva.

9. The examination of the heart, lungs, abdomen, and extremities shows no abnormalities.

11. The laboratory studies show the following: Hemoglobin 8.5 g/dL, Mean corpuscular volume 105 μm3, Leukocyte count 4,500/mm3, Platelet 160,000/mm3.

12. Abdominal ultrasonography shows no organomegaly or other pathologic findings.

13. The peripheral blood smear shows large and hypogranular platelets and neutrophils with hypo-segmented or ringed nuclei.

15. Bone marrow aspiration shows hypercellularity.

16. In addition, ring sideroblasts, hypogranulation, and hyposegmentation of granulocyte precursors, and megakaryocytes with disorganized nuclei are present.

17. Marrow myeloblasts are 4% in volume.


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

Context: A 37-year-old man comes to the physician because of a 1-month history of a burning sensation in his chest.

Context: The sensation is most prominent when he is lying in bed, but it is also present after eating heavy meals.

Context: He also states his breath has an unpleasant odor in the morning.

Context: He has hypothyroidism.

Context: His father died of colon cancer and his mother has hypertension.

Context: He has smoked one pack of cigarettes daily for 15 years and drinks 2–3 beers on weekends.

Context: He is 170 cm (5 ft 7 in) tall and weighs 95 kg (210 lb); BMI is 32.9 kg/m2.

Context: Vital signs are within normal limits.

Choices:
A. Urea breath test
B. Proton-pump inhibitor
C. H2 receptor blocker
D. Barium swallow

Answer: Proton-pump inhibitor

1. A 37-year-old man comes to the physician.

2. He has a 1-month history of a burning sensation in his chest.

3. The sensation is most prominent when he is lying in bed.

4. The sensation is also present after eating heavy meals.

5. He states his breath has an unpleasant odor in the morning.

6. He has not lost any weight during this period.

10. He has smoked one pack of cigarettes daily for 15 years.

12. His medications include levothyroxine and an over-the-counter multivitamin.

16. Vital signs are within normal limits.

17. Physical examination shows no abnormalities.


Question: Which of the following histopathologic findings would most likely be seen on the liver biopsy of this patient?

Context: He is vaccinated against hepatitis A and B and denies any recent travel abroad.

Choices:
A. Small drops of fat throughout the liver parenchyma
B. Normal histologic findings
C. Mononuclear cell infiltrate and apoptotic hepatocytes
D. Onion skin fibrosis (concentric periductal fibrosis)

Answer: Onion skin fibrosis (concentric periductal fibrosis)

1. A 36-year-old man presents with right upper quadrant pain, fatigue, and pruritus.

2. His past medical history is significant for ulcerative colitis diagnosed 5 years ago, which is well-managed medically.

3. He is vaccinated against hepatitis A and B.

5. On physical examination, mild jaundice of the skin is present.

6. An abdominal examination reveals significant hepatosplenomegaly.

7. A percutaneous liver biopsy is performed.


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

Context: A 26-year-old man is brought to the emergency department because he has had abdominal pain, nausea, and vomiting for the past 2 hours.

Context: His temperature is 99.6°F (37.6°C), pulse is 80/min, respirations are 18/min, and blood pressure is 122/68 mm Hg.

Context: The lungs are clear to auscultation.

Choices:
A. Shigella dysenteriae
B. Staphylococcus aureus
C. Enterotoxigenic Escherichia coli
D. Bacillus cereus

Answer: Staphylococcus aureus

1. A 26-year-old man is brought to the emergency department.

2. He has had abdominal pain, nausea, and vomiting for the past 2 hours.

3. He ate a sandwich and coleslaw from a deli about 1 hour before the symptoms began.

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

10. Cardiac examination shows no abnormalities.

11. Abdominal examination shows diffuse mild tenderness with no rigidity, rebound, or guarding.

12. The remainder of the examination shows no abnormalities.


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

Context: A 12-year-old girl is brought to the emergency department because of severe pain and swelling of her right eye for 3 days.

Context: Over the past two weeks, she had nasal congestion and a constant, mild headache.

Context: She did not visit a doctor and instead took over-the-counter naproxen and phenylephrine.

Context: Her nasal congestion has since improved, but the headache persists.

Context: She underwent a dental procedure for caries about ten days ago.

Context: She does not recollect any recent insect bites or trauma.

Context: Her immunizations are up-to-date.

Context: She appears ill and reports occasional chills.

Context: Her temperature is 38.3°C (101°F), pulse is 89/min, and blood pressure is 110/70 mm Hg.

Context: Vision is impaired in the affected eye.

Context: Her right upper and lower eyelid are erythematous, swollen, and tender to touch.

Context: Ocular movements cause severe pain.

Context: Her headache is worsened by leaning forward and improves when the patient is lying on her back.

Choices:
A. Cavernous sinus thrombosis
B. Suppurative spread of dacrocystitis
C. Bacterial infection from sphenoid sinus
D. Bacterial infection from ethmoidal sinus

Answer: Bacterial infection from ethmoidal sinus

2. Patient has had severe pain and swelling of her right eye for 3 days.

3. Patient had nasal congestion and a constant, mild headache for two weeks.

4. Patient took over-the-counter naproxen and phenylephrine for her symptoms.

5. Nasal congestion has improved, but headache persists.

6. Patient underwent a dental procedure for caries about ten days ago.

7. Patient does not recollect any recent insect bites or trauma.

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

9. Patient appears ill and reports occasional chills.

10. Patient's temperature is 38.3°C (101°F).

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

13. Examination shows proptosis of the right eye.

14. Vision is impaired in the affected eye.

15. Right upper and lower eyelid are erythematous, swollen, and tender to touch.

17. Patient's headache is worsened by leaning forward and improves when the patient is lying on her back.


Question: Which of the following laboratory findings would best represent your suspected diagnosis?

Context: He recently had a middle ear infection.

Context: In addition, he reports that his headache increases after rotating his head horizontally.

Choices:
A. Glucose: ↑, Proteins: ↑, Cells: 10% lymphocytes, Lactic Acid (mmol/l): 3.0
B. Glucose: ↓, Proteins: normal, Cells: 10% lymphocytes, Lactic Acid (mmol/l): 2.8
C. Glucose: ↑, Proteins: ↓, Cells: 90% neutrophils , Lactic Acid (mmol/l): 4.3
D. Glucose: ↓, Proteins: ↑, Cells: 90% neutrophils, Lactic Acid (mmol/l): 4.5

Answer: Glucose: ↓, Proteins: ↑, Cells: 90% neutrophils, Lactic Acid (mmol/l): 4.5

1. A 45-year-old man presents to the emergency room with fever and headache.

2. He recently had a middle ear infection.

3. On physical examination, when the head is passively flexed towards the chest, then flexion of the knee is observed.

4. He reports that his headache increases after rotating his head horizontally.

5. Lumbar puncture and CSF analysis were done.


Question: Infection of a healthy adult with the pathogen affecting this infant would most likely present with which of the following clinical conditions?

Context: A 6-day-old female infant is brought to the emergency department because of poor feeding and irritability for two days.

Context: She was born at 39 weeks' gestation, and the pregnancy and delivery were uncomplicated.

Context: Her temperature is 39.2°C (102.6°F).

Context: She appears lethargic and makes occasional twitching movements in both upper extremities.

Context: A lumbar puncture is performed and analysis of the cerebrospinal fluid shows increased protein and decreased glucose.

Choices:
A. Cystitis
B. Pelvic inflammatory disease
C. Meningitis
D. Gastroenteritis

Answer: Gastroenteritis

1. A 6-day-old female infant is brought to the emergency department.

2. The infant has been poor feeding and irritable for two days.

3. The infant was born at 39 weeks' gestation.

4. The pregnancy and delivery were uncomplicated.

5. The infant's temperature is 39.2°C (102.6°F).

6. The infant appears lethargic and makes occasional twitching movements in both upper extremities.

7. The anterior fontanelle is soft and full.

9. Analysis of the cerebrospinal fluid shows increased protein and decreased glucose.

10. Cerebrospinal fluid culture shows gram-positive, intracellular rods with tumbling motility.


Question: What is the most likely infectious agent responsible for this patient’s condition?

Context: A 64-year-old man has complaints of scrotal pain and swelling for the past 2 weeks.

Context: The pain is so severe that he is now unable to even sit comfortably for more than 5 minutes.

Context: Additionally, he complains of an inability to hold urine when he has an urge to urinate and of mild discomfort during urination.

Context: His medical history is significant for hypertension that is well-controlled with losartan.

Context: He smokes 1 pack of cigarettes every day and has been doing so for the past 25 years.

Context: On physical examination, swelling and erythema of the right hemiscrotal sac are evident, accompanied by intense tenderness with palpation of an indurated epididymis.

Choices:
A. Chlamydia trachomatis
B. Neisseria gonorrhoeae
C. Mumps virus
D. Escherichia coli

Answer: Escherichia coli

2. Patient has had scrotal pain and swelling for 2 weeks.

3. Patient has severe pain that prevents him from sitting for more than 5 minutes.

4. Patient has difficulty holding urine when he has an urge to urinate.

5. Patient has mild discomfort during urination.

6. Patient has a history of hypertension, which is well-controlled with losartan.

7. Patient smokes 1 pack of cigarettes every day for the past 25 years.

8. On physical examination, swelling and erythema of the right hemiscrotal sac are evident.

9. On physical examination, intense tenderness is present with palpation of an indurated epididymis.


Question: Which of the following is an expected side effect of this medication?

Context: After a lumpectomy with a negative axillary lymph node dissection and subsequent radiation therapy, the patient is started on adjuvant chemotherapy with anastrozole.

Choices:
A. Increased risk for endometrial carcinoma
B. Decreased LDL and increased HDL levels
C. Increased risk for osteoporosis
D. Excessive weight loss

Answer: Increased risk for osteoporosis

1. A 65-year-old female is diagnosed with invasive ductal carcinoma of the breast.

3. Axillary lymph node dissection is negative.

4. The patient receives radiation therapy.

5. The patient is started on adjuvant chemotherapy with anastrozole.


Question: Which of the following is the most likely mode of inheritance for this patient's condition?

Context: An 18-year-old man comes to the physician because of fatigue, back pain, and dark-colored urine for two days.

Context: He has no history of serious illness.

Context: He recently sprained his ankle playing basketball and has been taking ibuprofen as needed for pain.

Context: Laboratory studies show a hemoglobin concentration of 9.2 g/dL and serum lactate dehydrogenase concentration of 254 U/L.

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

Answer:
X-linked recessive
"

1. An 18-year-old man comes to the physician.

2. He has fatigue, back pain, and dark-colored urine for two days.

3. He has no history of serious illness.

4. He recently sprained his ankle playing basketball.

5. He has been taking ibuprofen as needed for pain.

6. Physical examination shows scleral icterus.

7. Laboratory studies show a hemoglobin concentration of 9.2 g/dL.

8. Laboratory studies show a serum lactate dehydrogenase concentration of 254 U/L.

9. A photomicrograph of a peripheral blood smear with Wright's stain is shown.


Question: Which of the following tests is most likely to yield an accurate diagnosis?

Context: A detailed developmental history reveals that he was born to a couple who had a non-consanguineous marriage.

Context: He was born by normal delivery at 39 weeks of gestation and his neonatal period was uneventful.

Context: His birth weight was 2.9 kg (6.3 lb) and he is exclusively breastfed.

Context: His parents also report that he has had 25–30 episodes of loose stools per day since his seventh day of life.

Context: His temperature is 38.6ºC (101.4°F), pulse is 110/min, and respiratory rate is 35/min.

Context: On physical examination, erythema and induration are noted around the umbilicus and mild hepatosplenomegaly is present.

Context: His laboratory studies show: | Hemoglobin 12.9 gm/dL | Leukocyte count 73,000/mm3 | Platelet count 170,000/mm3 | Peripheral smear Hypersegmented polymorphs, toxic granules | Stool pH 6 | .

Choices:
A. Ultrasonography of the abdomen and pelvis
B. Flow cytometry
C. Magnetic resonance imaging
D. Complete blood count

Answer: Flow cytometry

1. A 32-day-old boy is brought to the pediatrician with complaints of purulent discharge from the umbilicus and perianal ulceration for the past few days.

2. The boy's parents had a non-consanguineous marriage.

3. He was born by normal delivery at 39 weeks of gestation.

5. His birth weight was 2.9 kg (6.3 lb).

7. His parents report that he has had 25–30 episodes of loose stools per day since his seventh day of life.

8. His umbilical cord fell off on the 25th day of life.

12. On physical examination, erythema and induration are noted around the umbilicus.

17. His peripheral smear shows hypersegmented polymorphs and toxic granules.


Question: The abdominal defect is immediately covered in sterile saline dressings, and an orogastric tube and two peripheral intravenous lines are placed. |  | This condition is associated with which of the following additional cardiac defects?

Context: A 1-hour-old newborn male is evaluated in the delivery room.

Context: The infant was born at 37 weeks gestation to a 39-year-old G3.

Context: The mother initially labored at home with a midwife but was transferred to the hospital for failure to progress.

Context: The infant was eventually delivered via Caesarean section.

Context: The mother declined all prenatal screening during this pregnancy.

Context: Upon delivery, the infant is found to have a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of bowel.

Context: His Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.

Context: His weight is 3.0 kg (6.6 lb), and his height and head circumference are in the 30th and 40th percentiles, respectively.

Choices:
A. No cardiac defects
B. Bicuspid aortic valve
C. Tetralogy of Fallot
D. Ventricular septal defect

Answer: No cardiac defects

3. Infant was born at 37 weeks gestation.

6. Mother initially labored at home with a midwife.

7. Mother was transferred to the hospital for failure to progress.

8. Infant was delivered via Caesarean section.

9. Mother declined all prenatal screening during this pregnancy.

10. Infant has a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of bowel.

11. Infant's Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.

13. Infant's height is in the 30th percentile.

14. Infant's head circumference is in the 40th percentile.


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

Context: She is worried about gaining weight.

Context: She attends high school and plays field hockey on the school team.

Context: She is at the 25th percentile for height, 12th percentile for weight, and 17th percentile for BMI.

Choices:
A. Major depressive disorder
B. Bulimia nervosa
C. Body dysmorphic disorder
D.
Anorexia nervosa
"

Answer: Bulimia nervosa

1. A 17-year-old girl is brought to the physician for a well-child examination.

3. She frequents buffet restaurants but feels guilty soon after.

4. She has a history of burning her extremities with cigarettes.

5. Her last menstrual period was 3 weeks ago.

7. She plays field hockey on the school team.

8. She is at the 25th percentile for height.

9. She is at the 12th percentile for weight.

10. She is at the 17th percentile for BMI.

11. Examination shows bilateral parotid gland enlargement.

12. Oropharyngeal examination shows perimolysis.

13. The remainder of the examination shows no abnormalities.


Question: What would be the expected findings on brain MRI?

Context: A 37-year-old man with a history of depression has a two-year history of slowly worsening movement abnormalities characterized by rapid, involuntary, nonrepetitive movements involving his face, trunk, and limbs presents to clinic.

Context: He has also noted worsening of his depression, along with symptoms of increased anxiety and irritability.

Context: During the interview, his wife explains that he has suffered cognitive decline, most notably in the realm of executive function.

Context: On family history, you discover that his father suffered from a similar illness before dying at the age of 44.

Choices:
A. Normal brain MRI
B. Atrophy of the caudate nucleus
C. Periventricular high-signal intensity lesions on FLAIR sequence
D. Atrophy of the hippocampi

Answer: Atrophy of the caudate nucleus

1. A 37-year-old man has a two-year history of slowly worsening movement abnormalities.

2. The movement abnormalities involve his face, trunk, and limbs.

4. The man has worsening of his depression, along with symptoms of increased anxiety and irritability.

5. The man's wife explains that he has suffered cognitive decline, most notably in the realm of executive function.

6. The man's father suffered from a similar illness.

7. The man's father died at the age of 44.

Neurology with Special Qualification in Child Neurology


Question: Which of the following is the next best step in management for the most likely diagnosis?

Context: A 55-year-old man with a history of diabetes and hypertension presents to the emergency department when he found half of his face paralyzed this morning.

Context: The patient was last seen normal the night before by his wife and woke up with these symptoms.

Context: He has a past medical history of diabetes and hypertension and is not currently taking any medications for these conditions.

Context: His temperature is 98.5°F (36.9°C), blood pressure is 177/118 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air.

Context: Physical exam is notable for an inability for the patient to move any part of his face on the right side.

Context: The rest of his neurological exam is within normal limits.

Choices:
A. Elevation of the head of the bed and intubation
B. MRI of the head
C. Tissue plasminogen activator
D. Topical lubricants and discharge

Answer: Topical lubricants and discharge

2. Patient has a history of diabetes and hypertension.

3. Patient was last seen normal the night before by his wife.

4. Patient woke up with half of his face paralyzed.

5. Patient is not currently taking any medications for diabetes or hypertension.

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

7. Patient's blood pressure is 177/118 mmHg.

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

11. Patient is unable to move any part of his face on the right side.

12. Patient's neurological exam is within normal limits.


Question: What is the most probable site of obstruction?

Context: A newborn boy develops excessive bilious vomiting 4 hours after delivery.

Context: The infant was born vaginally to a 29-year-old mother (gravida 2, para 1) at 38 weeks gestation.

Context: History was significant for polyhydramnios detected at 32 weeks and monitored for the duration of gestation.

Context: He was put to the breast right after birth and sucked actively.

Context: He still has not passed meconium.

Context: The patient’s vital signs include: blood pressure 77/50 mm Hg, heart rate 128/min, respiratory rate 37/min, and temperature 36.4℃ (97.5℉).

Context: His abdomen appears rounded, soft and nontender on palpation, with no palpable organomegaly or masses.

Choices:
A. Esophagus
B. Gastric pylorus
C. Duodenum, distal to Vater’s papilla
D. Sigmoid colon

Answer: Duodenum, distal to Vater’s papilla

5. The infant was born at 38 weeks gestation.

6. Polyhydramnios was detected at 32 weeks gestation.

7. The infant was put to the breast right after birth.

10. The infant developed excessive bilious vomiting 4 hours after delivery.

15. On physical examination, the newborn appears fussy and mildly dehydrated.

16. His abdomen appears rounded, soft and nontender on palpation.

17. There is no palpable organomegaly or masses.


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

Context: Serum studies show: | Na+ 138 mEq/L | K+ 4.1 mEq/L | Cl- 101 mEq/L | TSH 0.03 μU/mL | Calcium 9 mg/dL | .

Choices:
A. Free T4 and T3 levels
B. Fine-needle aspiration biopsy
C. Open biopsy
D. Thyroid scintigraphy scan

Answer: Thyroid scintigraphy scan

1. The patient is counselled about her risk of thyroid malignancy.

Endocrinology, Diabetes, and Metabolism
Internal Medicine

General Endocrinology
Endocrinology, Diabetes, and Metabolism


Question: Which of the following best represents the etiology of this infant condition?

Context: An 18-month-old girl is brought to her pediatrician because of swelling in her hands and feet.

Context: Her mother is concerned because she has been inconsolable for the last 8 hours.

Context: The mother adds that the girl has been getting tired easily recently.

Context: The vital signs include: temperature 38.0°C (100.4°F), blood pressure 90/55 mm Hg, and pulse 122/min.

Context: The laboratory evaluation is remarkable for mild anemia, leukocytosis, and increased reticulocyte count.

Context: Her peripheral blood smear is shown in the picture.

Choices:
A. Red cell enzymatic deficiency
B. Abnormal heme synthesis
C. Abnormal globin chain structure
D. Abnormal globin chain synthesis

Answer: Abnormal globin chain structure

1. An 18-month-old girl is brought to her pediatrician.

2. The girl has swelling in her hands and feet.

3. The girl has been inconsolable for the last 8 hours.

4. The girl has been getting tired easily recently.

5. The girl's temperature is 38.0°C (100.4°F).

6. The girl's blood pressure is 90/55 mm Hg.

8. Gentle palpation of the metacarpal and metatarsal bones causes the infant to scream.

9. The laboratory evaluation is remarkable for mild anemia.

10. The laboratory evaluation is remarkable for leukocytosis.

11. The laboratory evaluation is remarkable for increased reticulocyte count.

12. The peripheral blood smear is shown in the picture.


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

Context: A 34-year-old gravida-1 at 8 weeks gestation seeks evaluation for a fever and sore throat for 3 days.

Context: She also reports generalized body pain and fatigue over this period.

Context: She was diagnosed with Graves’ disease 6 months ago.

Context: She appears ill.

Context: The vital signs include: axillary temperature 38.0℃ (100.4℉), pulse 88/min, respiratory rate 12/min, and blood pressure 120/80 mm Hg.

Context: The laboratory studies show the following: | Hemoglobin 13.5 g/dL | Mean corpuscular volume 90 μm3 | Leukocyte count 2,500/mm3 | Segmented neutrophils 5% | Lymphocytes 88% | Platelet count 240,000/mm3 | Alanine aminotransferase 18 U/L | Aspartate transaminase 16 U/L | .

Choices:
A. Acetaminophen for fever control
B. Discontinuation of propylthiouracil
C. Oral ampicillin
D. Rectal temperature measurement

Answer: Discontinuation of propylthiouracil

1. Patient is a 34-year-old gravida-1 at 8 weeks gestation.

2. Patient has had a fever and sore throat for 3 days.

3. Patient also reports generalized body pain and fatigue over this period.

4. Patient was diagnosed with Graves’ disease 6 months ago.

5. Before conception, methimazole was switched to propylthiouracil.

7. Vital signs include axillary temperature 38.0℃ (100.4℉), pulse 88/min, respiratory rate 12/min, and blood pressure 120/80 mm Hg.

8. Examination of the neck, lungs, heart, and abdomen shows no abnormalities.

9. A 1 × 1 cm ulcer is seen on the side of the tongue.

10. The ulcer is tender with surrounding erythema.

11. Laboratory studies show hemoglobin 13.5 g/dL.

12. Laboratory studies show mean corpuscular volume 90 μm3.

13. Laboratory studies show leukocyte count 2,500/mm3.

14. Laboratory studies show segmented neutrophils 5%.

15. Laboratory studies show lymphocytes 88%.

16. Laboratory studies show platelet count 240,000/mm3.

17. Laboratory studies show alanine aminotransferase 18 U/L.

18. Laboratory studies show aspartate transaminase 16 U/L.

Infectious Disease
General Pediatrics
Pediatric Infectious Diseases


Question: This patient's findings indicate damage to which of the following structures?

Context: A 27-year-old man comes to the physician because of a 1-week history of fever and pain with urination.

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

Choices:
A. Urethra
B. Ureter
C. Renal interstitium
D. Glomerulus

Answer: Renal interstitium

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

2. He has a 1-week history of fever and pain with urination.

4. Physical examination shows no abnormalities.

5. A photomicrograph of a urine sample is shown.


Question: Administration of which of the following drugs is the most appropriate next step in management?

Context: Twelve hours after undergoing uncomplicated total knee replacement, a 55-year-old man develops increasing anxiety, agitation, hand tremor, and nausea.

Context: He drinks 7 cans of beer daily.

Context: He is diaphoretic.

Context: His temperature is 37.6°C (99.7°F), pulse is 118/min, respirations are 18/min, and blood pressure is 146/92 mm Hg.

Choices:
A. Chlordiazepoxide
B. Lorazepam
C. Dantrolene
D. Carbamazepine

Answer: Lorazepam

1. A 55-year-old man underwent uncomplicated total knee replacement 12 hours ago.

2. He has developed increasing anxiety, agitation, hand tremor, and nausea.

3. He told the nurse he saw a bear in his room.

4. His pain has been controlled with intravenous morphine.

5. He has a history of advanced liver disease.


Question: The nerve involved in this patient’s clinical presentation exits the skull through which of the following brain structures?

Context: A 45-year-old woman comes to the physician’s office with complaints of jaw pain.

Context: These episodes last about 30 seconds and have recurred about 10 times per day for the last month.

Context: She finds these episodes extremely distressing and comes to the physician’s office in hope of finding a treatment.

Choices:
A. Superior orbital fissure
B. Foramen ovale
C. Foramen spinosum
D. Jugular foramen

Answer: Foramen ovale

1. A 45-year-old woman comes to the physician's office with complaints of jaw pain.

2. When she eats, yawns, or rubs her jaw, she gets intense, shooting pains down the left side of her jaw, including her lower lip and chin.

3. These episodes last about 30 seconds.

4. These episodes have recurred about 10 times per day for the last month.

5. She finds these episodes extremely distressing and comes to the physician's office in hope of finding a treatment.

6. The patient denies any locking of her jaw.

7. Physical exam is not notable for any tenderness to palpation over the jaw.

8. She has no crepitus in her temporomandibular joint.

9. The patient is able to open and close her jaw without pain.


Question: In addition to adequate intravenous hydration, which of the following if given would have most likely prevented the patient’s symptoms?

Context: An arthrocentesis is performed that reveals negatively birefringent needle-shaped crystals under polarized light.

Choices:
A. Acetazolamide
B. Allopurinol
C. Colchicine
D. Corticosteroids

Answer: Allopurinol

1. A 64-year-old woman presents to the hospital for chemotherapy.

2. She has newly diagnosed acute myeloid leukemia.

3. She is due to receive treatment with bendamustine for 2 days.

4. On day 2 of her treatment, the patient complains of intense pain in her right great toe.

5. On physical exam, the metatarsophalangeal joint of the 1st toe is warm, erythematous, swollen, and tender to both movement and palpation.

7. Negatively birefringent needle-shaped crystals are seen under polarized light.

8. A Gram stain of the synovial fluid is negative.


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

Context: A 29-year-old woman comes to the physician with complaints of fever, headache, and rash, which have gradually worsened over the past 6 days.

Context: The rash started at the wrists and ankles and then gradually spread to the trunk, palms, and soles.

Context: On examination, the physician notes a maculopapular rash as shown in the image below.

Context: Vital signs show a temperature of 39.4°C (103.0°F), a blood pressure of 110/70 mm Hg, and a pulse rate of 86/min.

Choices:
A. Endemic typhus
B. Lyme disease
C. Rocky Mountain spotted fever
D. Q fever

Answer: Rocky Mountain spotted fever

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

2. She has complaints of fever, headache, and rash.

3. The symptoms have gradually worsened over the past 6 days.

4. The patient informs the physician that the rash appeared after 2 days of fever.

5. The rash started at the wrists and ankles.

6. The rash then gradually spread to the trunk, palms, and soles.

7. On examination, the physician notes a maculopapular rash.

8. Vital signs show a temperature of 39.4°C (103.0°F).

9. Vital signs show a blood pressure of 110/70 mm Hg.

10. Vital signs show a pulse rate of 86/min.

Internal Medicine
Pediatrics
Infectious Disease

Infectious Disease
Pediatric Infectious Diseases
General Infectious Disease


Question: Which of the following was most likely ingested by the patient?

Context: A 25-year-old man presents to the emergency department after paramedics picked him up from an electronic music festival.

Context: His temperature is 103°F (39.4°C), blood pressure is 167/105 mmHg, and pulse is 122/min.

Context: On physical exam, the patient is highly alert, agitated, and diaphoretic.

Context: Laboratory testing is significant for a serum sodium concentration of 130 mEq/L.

Choices:
A. Heroin
B. Ketamine
C. 3,4-methylenedioxymethamphetamine
D. Lysergic acid diethylamide

Answer: 3,4-methylenedioxymethamphetamine

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

2. Paramedics picked him up from an electronic music festival.

6. On physical exam, the patient was highly alert, agitated, and diaphoretic.

7. Laboratory testing was significant for a serum sodium concentration of 130 mEq/L.


Question: What is the most likely diagnosis?

Context: A 1-day-old male is seen in the neonatal intensive care unit for respiratory distress.

Context: He was born at 37 weeks to a 24-year-old G3P11011 Rh- mother who had no prenatal care.

Context: On physical examination, temperature is 99°F (37.2°C), blood pressure is 120/85 mmHg, pulse is 120/min, respirations are 26/min, and pulse oximetry is 92% on room air.

Context: There is abdominal distention with a positive fluid wave.

Context: Laboratory results are as follows: |  | Serum: | Alkaline phosphatase: 80 U/L | ALT: 33 U/L | AST: 32 U/L | Bilirubin (total): 10 mg/dL | Bilirubin (conjugated): 0.2 mg/dL | Amylase: 76 U/L |  | Leukocyte count: 5,000/mm^3 with normal differential | Hemoglobin: 8 g/dL | Platelet count: 200,000/mm^3 | Mean corpuscular volume: 80 µm^3 | Reticulocyte count: 3% |  | .

Choices:
A. Dubin-Johnson syndrome
B. Gilbert syndrome
C. Breast feeding jaundice
D. Erythroblastosis fetalis

Answer: Erythroblastosis fetalis

2. Patient is in the neonatal intensive care unit for respiratory distress.

6. Patient's mother had no prenatal care.

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

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

11. Patient's pulse oximetry is 92% on room air.

12. Patient has abdominal distention with a positive fluid wave.

13. Patient's serum alkaline phosphatase is 80 U/L.

16. Patient's total bilirubin is 10 mg/dL.

17. Patient's conjugated bilirubin is 0.2 mg/dL.

19. Patient's leukocyte count is 5,000/mm^3 with normal differential.

21. Patient's platelet count is 200,000/mm^3.

22. Patient's mean corpuscular volume is 80 µm^3.


Question: Which of the following most likely explains the difference between these 2 studies?

Context: The authors of Study X retrospectively reviewed patients' reported coffee consumption and found that drinking greater than 6 cups of coffee per day was associated with an increased risk of developing lung cancer.

Context: The same study in lab mice; however, did not come to a similar conclusion.

Choices:
A. Confounding
B. Lead time bias
C. Observer bias
D. Selection bias

Answer: Confounding

1. Study X examined the relationship between coffee consumption and lung cancer.

2. The authors of Study X retrospectively reviewed patients' reported coffee consumption.

3. Drinking greater than 6 cups of coffee per day was associated with an increased risk of developing lung cancer.

4. The same study in lab mice did not come to a similar conclusion.


Question: What is the most likely mechanism underlying this patient’s findings?

Context: A 2-day-old boy was born at 38 weeks gestation to a 37-year-old woman by vaginal delivery.

Context: Since birth, the boy has had difficulty latching onto the breast but has not vomited or passed meconium.

Context: Examination reveals a flat facial profile with epicanthal eyelids, low-set earlobes, and a transverse crease on each palm.

Context: The abdomen is distended with absent breath sounds in the hypogastric region.

Context: A digital rectal examination shows a patent anal canal and is followed by a projected expulsion of gas and stool.

Choices:
A. Hypertrophic pylorus causing retrograde flow of gastric contents
B. Inspissated meconium causing intestinal obstruction
C. Failure of neural crest cell migration during embryologic development
D. Telescoping of 2 parts of the intestine into each other

Answer: Failure of neural crest cell migration during embryologic development

1. A 2-day-old boy was born at 38 weeks gestation.

4. The boy has difficulty latching onto the breast.

5. The boy has not vomited or passed meconium.

6. Examination reveals a flat facial profile with epicanthal eyelids.

7. Examination reveals low-set earlobes.

8. Examination reveals a transverse crease on each palm.

10. Breath sounds are absent in the hypogastric region.

11. A digital rectal examination shows a patent anal canal.

12. Gas and stool are projected after the digital rectal examination.


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

Context: An otherwise healthy 23-year-old newly-married woman comes to the physician because of a 6-day history of discomfort in her vaginal area during and after sexual intercourse.

Context: Her last menstrual period was 3 weeks ago.

Context: Two years ago, she was diagnosed with genital herpes which was treated with acyclovir.

Context: She has been in a monogamous relationship for the past year and has been using an intrauterine device for contraception for the past month.

Choices:
A. Obstructed orifice of the Bartholin duct
B. Reactivation of the genital herpes
C. Squamous cell carcinoma of the vulva
D. Allergic reaction to the intrauterine device

Answer: Obstructed orifice of the Bartholin duct

1. Patient is a 23-year-old newly-married woman.

2. Patient has a 6-day history of discomfort in her vaginal area during and after sexual intercourse.

3. Patient's last menstrual period was 3 weeks ago.

4. Patient was diagnosed with genital herpes two years ago and was treated with acyclovir.

5. Patient has been in a monogamous relationship for the past year.

6. Patient has been using an intrauterine device for contraception for the past month.

7. Examination shows a 4-cm, mildly tender mass in the inferior aspect of the left labium minus with no signs of inflammation.

8. Speculum examination causes her discomfort but shows no abnormalities.


Question: Which biopsy findings are most likely to be present in this patient?

Context: She additionally notes that she frequently has bumps and bruises from playing softball, but she has no injuries today.

Context: The patient's blood pressure is 110/70 mm Hg, heart rate is 78/min, and respiratory rate is 15/min.

Context: A biopsy of the mass is performed.

Choices:
A. Chronic inflammation with plasma cells
B. Necrotic fat with calcifications and giant cells
C. Leaf-like projections
D. Abundant extracellular mucin

Answer: Necrotic fat with calcifications and giant cells

1. A 22-year-old professional softball player is undergoing an annual check-up.

2. Her medical history is significant for hallux valgus and scoliosis.

3. She additionally notes that she frequently has bumps and bruises from playing softball.

5. Her family history is significant for heart disease.

6. The patient's blood pressure is 110/70 mm Hg.

8. The patient's respiratory rate is 15/min.

9. A physical examination is unremarkable except for an indurated palpable mass on her left breast.


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

Context: A 5-month-old male infant is brought to the physician by his parents for the evaluation of a progressive enlargement of his head circumference.

Context: His parents report that he has been healthy except for an episode of tonsillitis 3 months ago treated with penicillin.

Context: The patient was born at term by a lower segment transverse cesarean section because of a transverse lie.

Context: He has met all developmental milestones.

Context: His immunizations are up-to-date.

Context: The patient is at the 50th percentile for length, 50th percentile for weight, and 95th percentile for head circumference.

Context: He appears well-nourished.

Context: His temperature is 37°C (98.6°F), pulse is 120/min, and blood pressure is 90/60 mm Hg.

Context: The eyes deviate inferiorly and the eyelids are retracted.

Choices:
A. Serial lumbar punctures
B. CT scan of the head
C. Place a CSF shunt
D. Ultrasound of the head

Answer: Ultrasound of the head

1. Patient is a 5-month-old male infant.

2. Parents brought him to the physician for evaluation of progressive enlargement of head circumference.

3. Patient had an episode of tonsillitis 3 months ago, treated with penicillin.

4. Patient was born at term by lower segment transverse cesarean section because of transverse lie.

5. Patient has met all developmental milestones.

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

7. Patient is at 50th percentile for length.

8. Patient is at 50th percentile for weight.

9. Patient is at 95th percentile for head circumference.

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

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

14. Physical examination shows a tense anterior fontanelle.


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

Context: A 37-year-old G1P1001 delivers a male infant at 9 pounds 6 ounces after a C-section for preeclampsia with severe features.

Context: The mother has a history of type II diabetes with a hemoglobin A1c of 12.8% at her first obstetric visit.

Context: Before this pregnancy, she was taking metformin, and during this pregnancy, she was started on insulin.

Context: At her routine visits, her glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL.

Context: In addition, her routine third trimester culture for group B Streptococcus was positive.

Context: At 38 weeks and 4 days gestation, she was found to have a blood pressure of 176/103 mmHg and reported a severe headache during a routine obstetric visit.

Context: She denied rupture of membranes or vaginal bleeding.

Context: Her physician sent her to the obstetric triage unit, and after failure of several intravenous doses of labetalol to lower her blood pressure and relieve her headache, a C-section was performed without complication.

Context: After one hour, the infant is found to be jittery; the infant's temperature is 96.1°F (35.6°C), blood pressure is 80/50 mmHg, pulse is 110/min, and respirations are 60/min.

Choices:
A. ß-cell hyperplasia
B. Neonatal sepsis
C. Inborn error of metabolism
D. Neonatal encephalopathy

Answer: ß-cell hyperplasia

2. Patient delivers a male infant at 9 pounds 6 ounces.

3. Delivery is via C-section for preeclampsia with severe features.

4. Patient has a history of type II diabetes.

5. Patient's hemoglobin A1c at first obstetric visit is 12.8%.

6. Patient was taking metformin before this pregnancy.

7. Patient was started on insulin during this pregnancy.

8. Patient's glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL.

9. Patient's routine third trimester culture for group B Streptococcus was positive.

10. Patient's blood pressure at 38 weeks and 4 days gestation is 176/103 mmHg.

11. Patient reported a severe headache during a routine obstetric visit.

12. Patient denied rupture of membranes or vaginal bleeding.

13. Patient's physician sent her to the obstetric triage unit.

14. After failure of several intravenous doses of labetalol to lower her blood pressure and relieve her headache, a C-section was performed without complication.

15. Fetal heart rate tracing had been reassuring throughout her admission.

16. Apgar scores at 1 and 5 minutes were 7 and 10.

17. After one hour, the infant is found to be jittery.

18. Infant's temperature is 96.1°F (35.6°C).

19. Infant's blood pressure is 80/50 mmHg.

22. When the first feeding is attempted, he does not latch and begins to shake his arms and legs.

23. After 20 seconds, the episode ends and the infant becomes lethargic.


Question: What is the most likely diagnosis?

Context: A 65-year-old male presents to his cardiologist to discuss increasing episodes of dyspnea after climbing stairs.

Context: He also now needs three pillows at night to sleep.

Context: Physical examination reveals an early diastolic murmur best appreciated at the left sternal border with bounding peripheral pulses.

Context: The cardiologist is very concerned and immediately refers the patient for a surgical workup.

Choices:
A. Mitral valve insufficiency
B. Aortic regurgitation
C. Mitral stenosis
D. Aortic stenosis

Answer: Aortic regurgitation

1. A 65-year-old male presents to his cardiologist.

2. The patient has increasing episodes of dyspnea after climbing stairs.

3. The patient now needs three pillows at night to sleep.

4. Physical examination reveals an early diastolic murmur.

5. The murmur is best appreciated at the left sternal border.

6. The patient has bounding peripheral pulses.

8. The cardiologist immediately refers the patient for a surgical workup.

General Cardiology
Cardiovascular Disease


Question: Which of the following is most accurate?

Context: A 42-year-old overweight restaurant waiter develops excruciating pain in the heel of his right foot.

Context: There is tenderness to palpation along the inner aspect of the right heel bone, minimal active dorsiflexion, and pain at passive dorsiflexion.

Context: He is diagnosed with plantar fasciitis and is told to lose weight, rest, use ice, and take anti-inflammatory medications.

Choices:
A. The central fascicle is the thinnest and the most likely to rupture.
B. The patient's windlass mechanism remains intact.
C. This was caused by excessive strain on the medial fascicle.
D. The pain in the right foot is caused by the bone spur.

Answer: This was caused by excessive strain on the medial fascicle.

1. A 42-year-old restaurant waiter is overweight.

2. He has excruciating pain in the heel of his right foot.

3. Symptoms are most intense after getting out of bed but get better after walking.

4. On physical examination, both feet have a flat medial arch.

5. There is tenderness to palpation along the inner aspect of the right heel bone.

6. There is minimal active dorsiflexion and pain at passive dorsiflexion.

7. X-ray films reveal a bone spur at the level of the attachment of the right plantar fascia.

8. The spur is also present in the comparison film of the left foot.

9. He is diagnosed with plantar fasciitis.

10. He is told to lose weight, rest, use ice, and take anti-inflammatory medications.


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

Context: A 7-year-old boy is brought to the physician because of decreased vision, hearing, and speaking over the past 3 months.

Context: During this time, he has also had difficulty walking, concentrating, drawing, and feeding himself.

Context: His speech is dysarthric.

Context: Fundoscopy shows optic atrophy.

Choices:
A. Deficiency of β-glucocerebrosidase
B. Dysfunction of ATP-binding cassette transporter
C. Deficiency of arylsulfatase A
D. Deficiency of lysosomal galactocerebrosidase

Answer: Dysfunction of ATP-binding cassette transporter

1. A 7-year-old boy is brought to the physician.

2. The boy has had decreased vision, hearing, and speaking over the past 3 months.

3. The boy has also had difficulty walking, concentrating, drawing, and feeding himself.

4. His maternal male cousin had similar complaints and died at the age of 5 years.

5. Examination shows hyperpigmented skin and nails.

7. Neurologic examination shows an ataxic gait, spasticity, and decreased muscle strength in all extremities.

Pediatric Neurology
Neurodevelopmental Disabilities


Question: Based on this information, what is the probability that this patient does not have prostate cancer if his PSA is 4.3 ng/mL?

Context: He has no history of serious illness.

Context: He takes no medication.

Context: In patients without urinary retention, hematuria, back pain, or incontinence, the positive predictive value for PSA > 4 ng/mL is estimated at 30% and the negative predictive value for PSA ≤ 4 ng/mL at 85%.

Choices:
A. 79%
B. 15%
C. 70%
D. 9%

Answer: 70%

1. A 55-year-old man comes to the physician because of a 4-month history of nocturia.

2. He wakes up twice each night to urinate.

3. He has no history of serious illness.

5. His younger brother was diagnosed with testicular cancer at the age of 35 years.

6. Rectal examination shows a smooth, symmetrical prostate without nodules.

7. The physician offers to discuss the advantages and limitations of the prostate specific antigen (PSA) test in diagnosing prostate cancer.

8. He mentions that a a serum PSA of 4 ng/mL is generally used as a cutoff value.

9. At this cutoff, the test has a sensitivity of 21% for detecting any prostate cancer and 51% for detecting high-risk prostate cancer, with a specificity of 91%.

10. In patients without urinary retention, hematuria, back pain, or incontinence, the positive predictive value for PSA > 4 ng/mL is estimated at 30%.

11. The negative predictive value for PSA ≤ 4 ng/mL at 85%.


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

Context: A 23-year-old woman presents to the emergency department for vomiting and abdominal pain.

Context: The patient states that she has been unable to eat or drink for the past 24 hours without vomiting.

Context: She also complains of worsening abdominal pain that started 3 days ago.

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

Context: She is not on any current medications.

Context: Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Context: On physical exam, tenderness is elicited when the right lower quadrant of her abdomen is palpated.

Context: Laboratory studies are ordered as seen below. |  | Hemoglobin: 12 g/dL | Hematocrit: 36% | Leukocyte count: 11,500/mm^3 with normal differential | Platelet count: 197,000/mm^3 |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.3 mEq/L | HCO3-: 27 mEq/L | BUN: 20 mg/dL | Glucose: 67 mg/dL | Creatinine: 1.1 mg/dL | Ca2+: 10.2 mg/dL | AST: 12 U/L | ALT: 15 U/L |  | Urine: | Cocaine: positive | Amphetamines: positive | ß-hCG: positive | Marijuana: positive | Heroin: negative | PCP: negative | MDMA: positive | Glucose: negative | Ketones: negative |  | .

Choices:
A. Chest radiograph
B. Abdominal CT
C. Ultrasound
D. Colonoscopy

Answer: Ultrasound

2. Patient presents to the emergency department for vomiting and abdominal pain.

3. Patient states she has been unable to eat or drink for the past 24 hours without vomiting.

4. Patient complains of worsening abdominal pain that started 3 days ago.

5. Patient has a past medical history of IV drug abuse and alcohol abuse.

6. Patient is not on any current medications.

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

8. Patient's blood pressure is 127/68 mmHg.

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

12. Tenderness is elicited when the right lower quadrant of her abdomen is palpated.

13. Deep palpation and release of the left lower quadrant of her abdomen also causes severe pain.

14. Rectal exam reveals normal tone and stool is Guiac negative.

15. Laboratory studies show hemoglobin of 12 g/dL, hematocrit of 36%, leukocyte count of 11,500/mm^3 with normal differential, and platelet count of 197,000/mm^3.

16. Serum Na+ is 139 mEq/L, Cl- is 100 mEq/L, K+ is 4.3 mEq/L, HCO3- is 27 mEq/L, BUN is 20 mg/dL, glucose is 67 mg/dL, creatinine is 1.1 mg/dL, and Ca2+ is 10.2 mg/dL.

17. Serum AST is 12 U/L and ALT is 15 U/L.

18. Urine cocaine is positive, amphetamines is positive, ß-hCG is positive, marijuana is positive, heroin is negative, PCP is negative, MDMA is positive, glucose is negative, and ketones are negative.


Question: Which of the following is the most likely pathology for this presentation?

Context: A 75-year-old man was brought in by his daughter since he was having increased incidences of forgetting things.

Context: His daughter said that he becomes increasingly frustrated searching for his glasses and keys most of the time.

Context: He recently lost his driving license when he was spotted by the cops driving in the wrong direction on the interstate.

Choices:
A. Prion infection
B. α-synuclein defect
C. Depigmented substantia nigra and locus cerulus
D. Abnormal cleavage of amyloid precursor protein

Answer: Abnormal cleavage of amyloid precursor protein

1. A 75-year-old man was brought in by his daughter.

2. He was having increased incidences of forgetting things.

3. His daughter said he becomes increasingly frustrated searching for his glasses and keys most of the time.

4. He was helped out a couple of times in the supermarket for forgetting the way out.

5. He recently lost his driving license.

6. He was spotted by the cops driving in the wrong direction on the interstate.


Question: What is the most likely organism responsible?

Context: A 7-month-old male child is brought into your office for recent rhinorrhea and cough.

Context: The mother states that the child has had mild fevers of up to 100.7 F over the last three days along with clear nasal discharge, and a nonproductive cough, but the child has been working harder to breathe over the last day.

Context: His vitals are significant for a temperature of 100.9F and his physical exam is significant for intercostal retractions along with expiratory wheezing.

Choices:
A. Parainfluenza virus
B. Adenovirus
C. Respiratory syncytial virus
D. Echovirus

Answer: Respiratory syncytial virus

1. A 7-month-old male child is brought into your office.

2. The mother states the child has had mild fevers of up to 100.7 F over the last three days.

3. The child has clear nasal discharge and a nonproductive cough.

4. The child has been working harder to breathe over the last day.

5. The mother states the child was vaccinated for the flu one month ago.

6. The child's vitals are significant for a temperature of 100.9F.

7. The child's physical exam is significant for intercostal retractions.

8. The child's physical exam is significant for expiratory wheezing.

Pediatric Infectious Diseases
General Pediatrics


Question: Which of the following interventions most likely would have prevented this patient's condition?"

Context: He also has had a 5.4 kg (12 lb) weight loss over the past 6 months.

Context: He has smoked one pack of cigarettes daily for 32 years and drinks one alcoholic beverage per week.

Context: The abdomen is soft and nontender.

Context: Laboratory studies show: | Hemoglobin 12.6 g/dL | Mean corpuscular volume 86 μm3 | Leukocyte count 8800/mm3 | Platelet count 282,000/mm3 | Hemoglobin A1C 6.3 % | Serum | Glucose 113 mg/dL | Creatinine 1.1 mg/dL | Albumin 4.1 mg/dL | Total bilirubin 1.1 mg/dL | Alkaline phosphatase 66 U/L | AST 100 U/L | ALT 69 U/L | Ferritin 180 ng/mL | α-fetoprotein | 410 ng/mL (N < 10 ng/mL) | CT scan of the abdomen shows a 3.5 x 2 x 1.5 cm mass in segment 6 of the liver.

Choices:
A. Regular phlebotomies
B. Hepatitis B vaccination
C. Penicillamine therapy
D. Antitrypsin replacement therapy

Answer: Hepatitis B vaccination

1. A 56-year-old man comes to the physician because of increasing generalized fatigue for 1 month.

2. He has had a 5.4 kg (12 lb) weight loss over the past 6 months.

3. He has hypertension and type 1 diabetes mellitus.

4. His father died of colon cancer at the age of 65 years.

5. He has smoked one pack of cigarettes daily for 32 years.

6. He drinks one alcoholic beverage per week.

7. He has numerous tattoos, several of which were acquired when he went backpacking through Southeast Asia as a young man.

8. Current medications include enalapril and insulin.

9. He is 180 cm (5 ft 11 in) tall and weighs 78 kg (172 lb); BMI is 24.1 kg/m2.

10. His temperature is 37.0°C (98.6°F), pulse is 86/min, and blood pressure is 140/90 mm Hg.

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

13. Laboratory studies show: Hemoglobin 12.6 g/dL, Mean corpuscular volume 86 μm3, Leukocyte count 8800/mm3, Platelet count 282,000/mm3, Hemoglobin A1C 6.3 %, Serum Glucose 113 mg/dL, Creatinine 1.1 mg/dL, Albumin 4.1 mg/dL, Total bilirubin 1.1 mg/dL, Alkaline phosphatase 66 U/L, AST 100 U/L, ALT 69 U/L, Ferritin 180 ng/mL, α-fetoprotein 410 ng/mL (N < 10 ng/mL).

14. CT scan of the abdomen shows a 3.5 x 2 x 1.5 cm mass in segment 6 of the liver.


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

Context: A 6-year-old girl with polycystic kidney disease is started on a new medication after receiving a kidney transplant from a matched, unrelated donor.

Context: Two days after starting the medication, laboratory studies show a leukocyte count of 17,500/mm3 (90% segmented neutrophils, 4% bands, 1% eosinophils, 3% lymphocytes, and 1% monocytes).

Choices:
A. Methylprednisolone
B. Abciximab
C. Erythropoietin
D. Tacrolimus

Answer: Methylprednisolone

1. A 6-year-old girl has polycystic kidney disease.

2. She received a kidney transplant from a matched, unrelated donor.

4. Two days after starting the medication, laboratory studies showed a leukocyte count of 17,500/mm3.

5. 90% of the leukocytes were segmented neutrophils.

7. 1% of the leukocytes were eosinophils.

8. 3% of the leukocytes were lymphocytes.


Question: The activity of which of the following cellular enzymes is most likely to be decreased in response to treatment with this drug?

Choices:
A. Mitogen-activated protein kinase
B. Guanylate cyclase
C. Protein kinase A
D. Phospholipase C

Answer: Protein kinase A

1. A clinical trial is conducted to investigate the efficiency of a new glucagon receptor antagonist in the treatment of type 2 diabetes mellitus.

2. After 12 weeks of treatment with this drug, all participants in the study achieved statistically significant reductions in fasting and postprandial serum glucose.

3. Three individuals reported symptoms of hypoglycemia while exercising.

Internal Medicine
Endocrinology, Diabetes, and Metabolism

Endocrinology, Diabetes, and Metabolism
General Endocrinology


Question: Which of the following would you expect to find on a detailed history and physical examination of this patient?

Context: A 19-year-old man is admitted to the medical intensive care unit with suspected sepsis.

Context: Blood cultures grow Gram-negative cocci containing lipooligosaccharide in their cell wall.

Choices:
A. Petechial rash
B. Ascending paralysis
C. History of exposure to rabbit hides
D. Rice water stools

Answer: Petechial rash

1. A 19-year-old man is admitted to the medical intensive care unit.

2. The man is suspected of having sepsis.

3. Blood cultures grow Gram-negative cocci.

4. The Gram-negative cocci contain lipooligosaccharide in their cell wall.


Question: The affected vessel in this patient directly branches from which of the following vessels?

Context: A 25-year-old male rugby player presents to the emergency room complaining of a severe headache.

Context: He is accompanied by his teammate who reports that he had a head-to-head collision with another player and briefly passed out before regaining consciousness.

Context: His past medical history is significant for a pilocytic astrocytoma as a child treated successfully with surgery.

Context: His family history is notable for stroke in his father.

Context: His temperature is 98.9°F (37.2°C), blood pressure is 160/90 mmHg, pulse is 60/min, and respirations are 20/min.

Context: On examination, he is lethargic but oriented to person, place, and time.

Choices:
A. Maxillary artery
B. Internal carotid artery
C. Superficial temporal artery
D. Anterior cerebral artery

Answer: Maxillary artery

1. Patient is a 25-year-old male rugby player.

2. Patient presents to the emergency room complaining of a severe headache.

3. Patient is accompanied by his teammate.

4. Patient had a head-to-head collision with another player and briefly passed out before regaining consciousness.

5. Patient's past medical history is significant for a pilocytic astrocytoma as a child treated successfully with surgery.

6. Patient's family history is notable for stroke in his father.

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

8. Patient's blood pressure is 160/90 mmHg.

11. On examination, patient is lethargic but oriented to person, place, and time.


Question: Which of the following is characteristic of the most likely microorganism responsible for this patient’s symptoms?

Context: The patient’s mother says that other children from his daycare class have also developed similar symptoms.

Context: The patient’s temperature is 39.0°C (102.2°F).

Choices:
A. Inactivation of the 60S ribosome subunit
B. Permanent activation of Gs alpha subunit
C. Overactivation of guanylate cyclase
D. Disabling Gi alpha subunit

Answer: Inactivation of the 60S ribosome subunit

1. A 4-year-old boy presents with 3 days of fever, crampy abdominal pain, vomiting, and loose, bloody bowel movements containing mucus.

2. The patient's mother says that other children from his daycare class have also developed similar symptoms.

3. The patient's temperature is 39.0°C (102.2°F).

4. On physical examination, the patient is irritable and inconsolable, and his abdomen is distended.

5. Intravenous fluid resuscitation is initiated.

6. Histopathologic analysis of his stool reveals numerous red and white blood cells.


Question: Which of the following is the most likely cause of his abnormal radiologic findings?

Context: At the time of admission, he had photophobia, neck rigidity, and the following vital signs: temperature 39.5°C (103.1°F), blood pressure 130/70 mm Hg, and heart rate 120/min.

Context: A cerebral spinal fluid analysis was ordered, and he was started on intravenous antibiotics.

Context: An MRI is performed which reveals dilation of all the ventricles of the brain.

Choices:
A. Blood clot in the foramen of 3rd ventricle
B. Aqueductal stenosis
C. Arachnoid granulation adhesions
D. Mega cisterna magna

Answer: Arachnoid granulation adhesions

1. A 23-year-old man develops a seizure on the medical floor.

2. He was admitted 2 days ago with high-grade fever and severe headache.

3. At the time of admission, he had photophobia, neck rigidity.

4. Temperature at admission was 39.5°C (103.1°F).

5. Blood pressure at admission was 130/70 mm Hg.

7. A cerebral spinal fluid analysis was ordered.

8. He was started on intravenous antibiotics.

9. The patient’s seizure terminates without any medication or intervention.

11. MRI reveals dilation of all the ventricles of the brain.


Question: Following initial stabilization and respiratory support, what is the best next step for this patient?

Context: A 27-year-old unconscious man is brought to the ED by EMS.

Context: Physical exam reveals bruising and ecchymosis at the right temple and 1-mm pupils bilaterally.

Context: His temperature 97.1°F (36.3°C), blood pressure is 84/58 mmHg, pulse is 71/min, respirations are 8/min.

Choices:
A. Flumazenil
B. Glucose
C. Naloxone
D. Warming blankets

Answer: Naloxone

1. A 27-year-old man was brought to the ED by EMS.

2. He was found face down in the middle of the sidewalk at 2AM.

3. The patient is disheveled and smells of alcohol.

4. Physical exam reveals bruising and ecchymosis at the right temple.


Question: WBC): 2,400 /mm3 | Differential count: | Neutrophils: 70% | Lymphocytes: 25% | Monocytes: 5% | CD4+ cell count: 51/mm3 | What is the best pharmacotherapy for this patient's current symptom?

Context: A 43-year-old man presents to the clinic for pain with swallowing for a month.

Context: He says that the pain has gotten worse over the past few weeks.

Context: His past medical history is significant for AIDS.

Context: He states that he has not been able to afford his highly active antiretroviral therapy, so he is not currently taking any medications.

Context: His temperature is 98.6°F (37°C), respirations are 15/min, pulse is 70/min, and blood pressure is 100/84 mm Hg.

Context: Evaluation of the blood reveals: | Hb%: 11 gm/dL | Total count (.

Choices:
A. Oral fluconazole
B. Oral nystatin liquid suspension
C. Intravenous amphotericin B
D. Oral acyclovir

Answer: Oral fluconazole

2. Patient presents to clinic with pain with swallowing for one month.

3. Pain has gotten worse over past few weeks.

4. Patient has past medical history of AIDS.

5. Patient is not currently taking any medications due to inability to afford highly active antiretroviral therapy.

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

9. Patient's blood pressure is 100/84 mm Hg.

10. Physical examination reveals no mucosal lesions.

11. Evaluation of blood reveals Hb%: 11 gm/dL.

12. Evaluation of blood reveals total count.


Question: The most appropriate next step in management is administration of which of the following?

Context: A 25-year-old man is brought by his roommate to the emergency department with chest pain, which began 90 minutes ago.

Context: His roommate says that he has not slept within the past 24 hours and has been taking pills to help him study longer for his upcoming national dental board exam.

Context: His temperature is 38.9°C (102.2°F), pulse is 115/min, and blood pressure is 160/102 mmHg.

Context: His pupil size is 7 mm bilaterally.

Context: The lungs are clear to auscultation.

Choices:
A. Lorazepam
B. Dantrolene
C. Ketamine
D.
Haloperidol
"

Answer: Lorazepam

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

3. His roommate says he has not slept within the past 24 hours.

4. He has been taking pills to help him study longer for his upcoming national dental board exam.

5. On examination, he is diaphoretic, extremely agitated, and attempts to remove his IV lines and ECG leads.

10. The lungs are clear to auscultation.


Question: Which of the following mechanisms is most likely involved in this patient’s symptoms?

Context: Serum calcium is 11.9 mg/dL and serum phosphate is 2.4 mg/dL.

Context: Urine calcium output is 400 mg/24 h.

Choices:
A. Increased osteoprotegerin expression
B. Decreased RANK-L expression
C. Increased RANK-L expression
D. Increased ß-adrenergic receptor synthesis

Answer: Increased RANK-L expression

1. A 65-year-old female presents to her primary care physician for a routine check-up.

2. She reports feeling well but has noticed occasional weakness and constipation over the past few months.

3. A complete blood count is within normal limits.

7. A sestamibi scan demonstrates increased uptake near the inferior left pole of the thyroid gland.


Question: Which of the following factors will most likely make the prognosis worse in this patient?

Context: A 35-year-old male presents to his physician with a small mass that he found in the anterior of his neck a few days ago.

Context: The mass is not painful and does not affect his swallowing.

Context: He noticed no change in his weight.

Context: His history is significant for radiation exposure for treating his neuroblastoma at the age of 15.

Context: On examination, a nodule around the size of 2.2 cm is palpated in the right thyroid lobule; the nodule is firm and non-tender.

Context: There is cervical lymphadenopathy.

Context: His blood pressure is 118/75 mm Hg, respirations are 17/min, pulse is 67/min, and temperature is 37.5°C (99.5°F).

Context: Laboratory findings include serum Na+ of 136 mmol/L, K+ of 4.2 mmol/L, Cl– of 90 mmol/L, and bicarbonate of 24 mmol/L.

Choices:
A. Age
B. Bone metastases
C. Follicular histological variant
D. Hurthle cell variant

Answer: Bone metastases

2. Patient found a small mass in the anterior of his neck a few days ago.

3. Mass is not painful and does not affect his swallowing.

4. Patient noticed no change in his weight.

5. Patient has a history of radiation exposure for treating his neuroblastoma at the age of 15.

6. On examination, a nodule around the size of 2.2 cm is palpated in the right thyroid lobule.

Internal Medicine
Otolaryngology
Endocrinology

Endocrinology, Diabetes, and Metabolism
General Endocrinology
General Otolaryngology


Question: Which of the following patterns of abnormal brain activity would most likely be present in this patient?

Context: The patient’s father informs the doctor that his son has been gloomy most of the time over the last 2 months, and his academic performance has declined significantly.

Context: His father further adds that his son’s appetite has decreased significantly over the last 3 months, leading to a 5.0 kg (11.0 lb) weight loss.

Context: Physical examination is unremarkable.

Choices:
A. Increased dopaminergic activity in the limbic system
B. Increased glutamatergic activity in the subthalamic nucleus
C. Decreased norepinephrine levels in the cortical and limbic areas
D. Decreased cholinergic activity in the hippocampus and amygdala

Answer: Decreased norepinephrine levels in the cortical and limbic areas

1. An 18-year-old man is referred to a psychiatrist for evaluation after a recent suicide attempt.

2. On questioning him, he says that he did it because he got fed up with life and feels that he is worthless.

3. The patient's father informs the doctor that his son has been gloomy most of the time over the last 2 months.

4. The patient's father further adds that his son's academic performance has declined significantly.

5. The patient's father further adds that his son's appetite has decreased significantly over the last 3 months.

6. The patient's father further adds that his son has experienced a 5.0 kg (11.0 lb) weight loss.

7. The patient denies any history of manic or hypomanic episodes.

8. Physical examination is unremarkable.

9. Routine laboratory tests, including thyroid hormone and cortisol levels, are within normal limits.


Question: Which of the following proteins is heavily involved with this pathogenesis?

Context: She was born vaginally at full term after an uncomplicated pregnancy and was breastfed for 9 months.

Context: The patient has had an episode of meningococcal meningitis, recurrent bronchiolitis, and multiple bouts of pneumococcal pneumonia over the past 5 years.

Context: She has also suffered from chronic otitis media since the age of 5.

Choices:
A. CD8
B. CD16
C. CD21
D. CD25

Answer: CD21

1. A 10-year-old girl is evaluated for a suspected primary deficiency.

2. She is the first child in a consanguineous marriage.

3. She was born vaginally at full term after an uncomplicated pregnancy.

5. The patient has had an episode of meningococcal meningitis.

6. The patient has had recurrent bronchiolitis.

7. The patient has had multiple bouts of pneumococcal pneumonia over the past 5 years.

8. The patient has suffered from chronic otitis media since the age of 5.

9. After a thorough examination, the child is found to have a partial CD19 deficiency.


Question: Based on the patient’s current presentation, which organ is most likely affected?

Context: Vitals include temperature is 37.0°C (98.6°F), right arm blood pressure is 94/63 mm Hg, left arm blood pressure is 90/61 mm Hg, pulse is 122/min, and respirations are 24/min.

Context: Neck veins are not distended.

Context: Her abdomen is tender on superficial palpation with mild rebound tenderness and rigidity.

Context: Her range of motion is normal with 5/5 motor strength in all extremities.

Context: Wrist drop is absent.

Context: A FAST scan is pending.

Choices:
A. Pancreas
B. Heart
C. Spleen
D. Appendix

Answer: Spleen

1. A 24-year old woman is brought to the emergency department after a motor vehicle collision.

2. She was a restrained passenger at the time of impact.

3. On examination, the patient is pale and in moderate distress.

4. She complains of a sharp pain in the posterior aspect of the left shoulder.

6. Right arm blood pressure is 94/63 mm Hg.

7. Left arm blood pressure is 90/61 mm Hg.

10. Cardiopulmonary auscultation reveals normal heart sounds and clear lungs.

12. Several, large ecchymoses are visible over the chest and abdomen in a seatbelt pattern.

13. Abdomen is tender on superficial palpation with mild rebound tenderness and rigidity.

14. Range of motion is normal with 5/5 motor strength in all extremities.

Emergency Medicine
Surgery
General Surgery

General Emergency Medicine
Surgical Critical Care


Question: Which of the following tests can be used for postoperative follow up of this patient?

Context: Complete blood count shows the following: | Hemoglobin 10 g/dL | Mean corpuscular volume (MCV) 70 fL | Mean corpuscular hemoglobin (MCH) 25 pg/cell | Mean corpuscular hemoglobin concentration (MCHC) 27 g/dL | Red cell distribution width 16% | Platelet count 350,000/mm3 | Serum ferritin is 9 ng/mL.

Context: The patient is referred to a gastroenterologist and conventional colonoscopy reveals a polypoid mass in the ascending colon.

Context: A preoperative staging is performed and a laparoscopic cancer resection with postoperative chemotherapy are planned.

Choices:
A. Carcinoembryonic antigen (CEA)
B. Pelvic magnetic resonance imaging (MRI)
C. Transrectal endoscopic ultrasound (TRUS)
D. Cancer antigen 125 (CA 125)

Answer: Carcinoembryonic antigen (CEA)

1. A 68-year-old woman presents to her primary care physician with complaints of fatigue, difficulty breathing upon exertion, and crampy lower abdominal pain.

2. She also notices that her stools are dark.

3. She has had essential hypertension for 20 years for which she takes bisoprolol.

4. Her family history is positive for type 2 diabetes mellitus.

5. On physical examination, she looks pale.

6. Complete blood count shows a hemoglobin of 10 g/dL.

7. Complete blood count shows a mean corpuscular volume (MCV) of 70 fL.

8. Complete blood count shows a mean corpuscular hemoglobin (MCH) of 25 pg/cell.

9. Complete blood count shows a mean corpuscular hemoglobin concentration (MCHC) of 27 g/dL.

10. Complete blood count shows a red cell distribution width of 16%.

11. Complete blood count shows a platelet count of 350,000/mm3.

13. The patient is referred to a gastroenterologist.

14. Conventional colonoscopy reveals a polypoid mass in the ascending colon.

15. Biopsy shows poorly differentiated adenocarcinoma.

16. A preoperative staging is performed.

17. A laparoscopic cancer resection with postoperative chemotherapy are planned.


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

Context: A 34-year-old man comes to the physician because of a 2-day history of progressively blurred vision.

Context: He also reports seeing flashing lights in his visual field.

Context: He does not have any pain.

Context: The patient has not been examined by a physician in several years.

Context: He appears emaciated.

Context: His CD4+ T-lymphocyte count is 46/mm3.

Choices:
A. Valganciclovir
B. Penicillin G
C. Sulfadiazine and pyrimethamine
D. Trimethoprim-sulfamethoxazole

Answer: Valganciclovir

1. A 34-year-old man comes to the physician.

2. He has a 2-day history of progressively blurred vision.

3. He reports seeing flashing lights in his visual field.

5. He has not been examined by a physician in several years.

7. Examination shows right conjunctival injection.

8. Visual acuity is 20/20 in the left eye and 20/100 in the right eye.

9. Fundoscopic examination of the right eye is shown.

10. His CD4+ T-lymphocyte count is 46/mm3.


Question: This patient is most likely to benefit from which of the following interventions?

Context: He is HIV-positive.

Context: Vital signs are within normal limits.

Context: There is no inguinal lymphadenopathy.

Context: The abdomen is soft and nontender.

Context: A biopsy confirms the diagnosis.

Choices:
A. Radiochemotherapy
B. Local 5-fluorouracil therapy
C. Injection sclerotherapy
D.
Submucosal hemorrhoidectomy
"

Answer: Radiochemotherapy

1. A 42-year-old man comes to the physician because of several episodes of rectal bleeding over 2 weeks.

2. He has had pain around the anal area for the past month.

3. Six months ago, he was diagnosed with esophageal candidiasis and was treated with oral fluconazole.

5. He has had 9 male sexual partners over his lifetime and uses condoms inconsistently.

6. The patient's current medications include dolutegravir, tenofovir, and emtricitabine.

7. He is 179 cm (5 ft 10 in) and weighs 66 kg (146 lb); BMI is 20.9 kg/m2.

8. Vital signs are within normal limits.

9. Digital rectal examination and anoscopy show a hard 2-cm mass palpable 0.5 cm above the anal verge that bleeds on contact.

10. There is no inguinal lymphadenopathy.

12. The CD4+ T-lymphocyte count is 95/mm3(N ≥ 500/mm3).


Question: Which of the following burn patterns would be most indicative of child abuse in this patient?

Context: The patient’s mother says she was at home with the patient when she heard him screaming from the kitchen.

Context: She says she ran to the room to find that the patient had pulled down a container of hot water on himself.

Choices:
A. Burns to flexor and anterior surfaces
B. Burns with irregular borders, uneven depth of burns, and splash pattern
C. Burns with some areas blistering but with others not blistering
D. Circular burns of equal depth restricted to the buttocks, with sparing of the hands and feet

Answer: Circular burns of equal depth restricted to the buttocks, with sparing of the hands and feet

1. A 19-month-old boy comes into the emergency department with his parents.

2. He has burns on his buttocks and perineal area.

3. The patient's mother was at home with the patient when she heard him screaming from the kitchen.

4. She ran to the room to find that the patient had pulled down a container of hot water on himself.


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

Context: A 44-year-old woman presents to the physician for evaluation of recurrent episodes of pounding headache, palpitations, excessive sweating, anxiety, tremors, and pallor, with occasional vomiting for the last 2 weeks.

Context: She has presented to the same physician with similar complaints in the past; however, she is frustrated with the lack of proper diagnosis and now insists on a detailed workup.

Context: She does not take any medications.

Context: She has a history of progressively increasing thyroid swelling as well as multiple bone pain for the past 2 months.

Context: On physical examination, she is very lean and appears anxious and apprehensive.

Context: She has clammy and moist hands.

Context: Her temperature is 37.1°C (98.9°F), the pulse is 110/min, the blood pressure is 176/94 mm Hg, and the respiratory rate is 27/min.

Context: Her weight is 43 kg (94.8 lb), height is 145 cm (4 ft 7 in), and body mass index (BMI) is 20.4 kg/m2.

Choices:
A. Serum epinephrine and norepinephrine
B. Clonidine test
C. 24-h urine catecholamine by-products (vanillylmandelic acid (VMA), metanephrine, and normetanephrine)
D. Serum calcium and PTH

Answer: 24-h urine catecholamine by-products (vanillylmandelic acid (VMA), metanephrine, and normetanephrine)

2. Patient has recurrent episodes of pounding headache, palpitations, excessive sweating, anxiety, tremors, and pallor, with occasional vomiting for the last 2 weeks.

3. Patient has presented to the same physician with similar complaints in the past.

4. Patient is frustrated with the lack of proper diagnosis and now insists on a detailed workup.

5. Patient does not take any medications.

6. Patient has a history of progressively increasing thyroid swelling for the past 2 months.

7. Patient has multiple bone pain for the past 2 months.

8. Patient appears anxious and apprehensive.

10. Patient's temperature is 37.1°C (98.9°F).

12. Patient's blood pressure is 176/94 mm Hg.

13. Patient's respiratory rate is 27/min.

14. Patient's weight is 43 kg (94.8 lb).

15. Patient's height is 145 cm (4 ft 7 in).

16. Patient's body mass index (BMI) is 20.4 kg/m2.

17. A firm thyroid nodule is palpable in the right lobe.

18. Physical examination is otherwise normal.