Question: A 50-year-old man has a kidney transplantation for end-stage renal disease in the setting of long-standing polycystic kidney disease. His postoperative course is uncomplicated. He had smoked one pack of cigarettes daily for 20 years but quit 5 years ago. He does not drink alcohol or use illicit drugs. Current medications include basiliximab, mycophenolate mofetil, and prednisone. His vital signs are within normal limits. On physical examination, the surgical incisions appear clean and intact. Prior to discharge, administration of which of the following is most appropriate in this patient?

Answer: Trimethoprim-sulfamethoxazole

Choices:
A. Azithromycin
B. Trimethoprim-sulfamethoxazole
C. Meningococcal vaccine
D. Acyclovir
E. Varicella vaccine


Question:
A 28-year-old woman, gravida 1, para 0, at 32 weeks' gestation comes to the physician for a prenatal visit. She has had no prenatal care. She emigrated from China 5 years ago and cannot recall all of her vaccinations. She appears well. Physical examination shows a uterus consistent in size with a 32-week gestation. Serum studies show:
Anti-hepatitis A IgM antibody negative
Anti-hepatitis A IgG antibody positive
Hepatitis B surface antigen negative
Anti-hepatitis B surface antibody positive
Hepatitis B core antigen negative
Anti-hepatitis B core antibody negative
Which of the following is the most appropriate next step in management?"

Answer: Plan normal vaginal delivery at term

Choices:
A. Plan normal vaginal delivery at term
B. Determine hepatitis B e antigen serum level
C. Administer hepatitis B vaccine to mother
D. Counsel on necessity to avoid breastfeeding
E. Perform liver biopsy of mother


Question: A 58-year-old woman presents to her family physician for an annual checkup. During the visit, the patient asks her physician for help quitting smoking cigarettes. She has unsuccessfully tried quitting several times previously and has also failed prior attempts with meditation and exercise. The physician prescribes a partial agonist of the nicotinic receptor to aid the patient in cessation. Which of the following is a potential side effect of this medication?

Answer: Suicidal ideation

Choices:
A. Impaired kidney function
B. Seizure
C. Sexual dysfunction
D. Suicidal ideation
E. Tachycardia


Question: A 57-year-old man with chronic obstructive pulmonary disease comes to the emergency department because of leg swelling for 2 weeks. He has smoked 2 packs of cigarettes daily for the past twenty years. His vital signs are within normal limits. Physical examination shows jugular venous distention, hepatomegaly, and pitting edema of both lower extremities. Cardiac examination shows a regular heart rate and normal heart sounds. Auscultation of the lungs shows scattered wheezing without crackles. Left ventricular ejection fraction is 60%. Which of the following is the most likely underlying cause of this patient's condition?

Answer: Chronic hypoxic vasoconstriction

Choices:
A. Excessive systemic collagen deposition
B. Left-sided systolic heart failure
C. Ventricular septal defect
D. Chronic occlusion of the pulmonary vessels
E. Chronic hypoxic vasoconstriction


Question: A young Mediterranean teen brings her 4-year-old little brother to the Emergency Room because of a high temperature. Their parents are on their way to the hospital, but, in the meantime, she provides some of the history. She explains that he has been running a fever and limping for the past week. This morning, she had trouble awakening him, and she noticed some swelling and redness around his right ankle. In terms of his past medical history, she knows he has something wrong with his blood. He had to receive extra vaccinations as an infant, and he takes an antibiotic everyday. On exam in the ED, his temperature is 102.4 deg F (39.1 deg C), blood pressure is 90/60 mmHg, pulse is 123/min, and respirations are 22/min. He is lethargic, and his exam is noteworthy for erythema and edema in an area surrounding his distal shin. What is the most likely diagnosis?

Answer: Osteomyelitis

Choices:
A. Dactylitis
B. Avascular necrosis
C. Acute vaso-occlusive episode
D. Osteomyelitis
E. Thrombophlebitis


Question:
A 47-year-old man comes to the emergency department complaining of weight gain and abdominal discomfort. He states that over the past month he has gained 10 lbs. This week he began experiencing mild, diffuse abdominal discomfort. He denies nausea, vomiting, constipation, or diarrhea. The patient has not seen a physician in years and takes no medications. He is a truck driver. He states that he drinks a 6-pack of beer per night. On physical examination, there is jaundice, hepatomegaly, and a positive fluid wave. An abdominal ultrasound reveals cirrhosis, portal vein dilation, and moderate ascites. He undergoes a paracentesis that relieves his symptoms. Fluid analysis is shown below:

Serum:
Albumin: 4.0 g/dL

Ascitic fluid:
Color: Yellow
Leukocyte count: 100/mm^3 with 50% neutrophils
Protein: 2.3 g/dL
Albumin: 1.9 g/dL

A culture is pending. He is discharged and instructed to follow-up with a gastroenterologist for an upper endoscopy. Upper endoscopy reveals multiple, small non-bleeding esophageal varices. Which of the following is the next best step in management of the patient’s condition?

Answer: Propranolol

Choices:
A. Atenolol
B. Ceftriaxone
C. Octreotide
D. Propranolol
E. Transjugular intrahepatic portosystemic shunt


Question: An 8-month-old boy is brought to the office by his mother for recurrent infections. Over the past 2 months, the boy had multiple visits to the urgent care clinic for respiratory, ear, and skin infections. His mother is concerned about the health of her child. Currently, the child had a runny nose for the last 2 days. There is no fever but the mother adds that the boy is not eating very well. His mother denies any history of infection during her pregnancy and was tested negative for HIV. The patient’s heart rate is 90/min, respiratory rate is 14/min, and temperature is 36.7°C (98.0°F). On physical exam, there are decreased lung sounds in the left lower lobe. A chest X-ray reveals an absent thymic shadow and fails to show any lung pathology. There is no history of similar symptoms in the families of either parent. What is the most likely cause of this patient’s condition?

Answer: Adenosine deaminase deficiency

Choices:
A. Adenosine deaminase deficiency
B. Hypoxanthine-guanine phosphoribosyl transferase (HGPRT) deficiency
C. HIV infection
D. Purine nucleoside phosphorylase deficiency
E. Adenosine kinase deficiency


Question: A 4-year-old girl is brought to the physician because of a nonpruritic, painless rash on her face for 5 days. She was born at term and has been healthy since. Her 62-year-old maternal grandmother has bullous pemphigoid. Her development is adequate for her age and immunizations are up-to-date. She appears healthy and well-nourished. Her temperature is 37°C (98.6°F) and pulse is 90/min. Examination shows a nontender rash on the right side of the patient's face. An image of the patient's lower face is shown. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Answer: Topical mupirocin therapy

Choices:
A. Potassium hydroxide preparation
B. Oral acyclovir therapy
C. Oral cephalexin therapy
D. Skin biopsy
E. Topical mupirocin therapy


Question: A 56-year-old man comes to the physician for a routine health maintenance examination. He has had mild pain in his left groin for 2 weeks. He was admitted to the hospital 1 month ago for myocardial infarction. Cardiac catheterization and angiography showed occlusion of the left anterior descending artery and he underwent placement of 2 stents. He has hypertension and hypercholesterolemia. There is no family history of serious illness. He has smoked 2 packs of cigarettes daily for 30 years. Current medications include aspirin, clopidogrel, rosuvastatin, and enalapril. His temperature is 36.7°C (98°F), pulse is 88/min, and blood pressure is 130/84 mm Hg. Examination shows a 3-cm (1.2-in), tender, pulsatile mass in the left thigh, below the inguinal ligament. There is mild erythema of the overlying skin. A loud murmur is heard on auscultation of the mass. Cardiopulmonary examination shows no abnormalities. There is no edema in the lower limbs. Femoral and pedal pulses are palpable bilaterally. Neurologic examination shows no focal findings. Which of the following is the most likely diagnosis?

Answer: Femoral artery pseudoaneurysm

Choices:
A. Femoral artery dissection
B. Femoral artery pseudoaneurysm
C. Femoral arteriovenous fistula
D. Femoral artery thrombosis
E. Femoral abscess


Question: A 1-year-old girl is brought to the physician because of fever and crying while passing urine for 2 days. She was born at term and has been healthy since. Three months ago, she was treated for a urinary tract infection with oral cefixime. Her temperature is 39°C (102.2°F), pulse is 144/min, and blood pressure is 85/40 mm Hg. Physical examination shows no abnormalities. Her leukocyte count is 14,000/mm3. Urine dipstick shows leukocyte esterase and nitrites; urinalysis shows WBCs and gram-negative rods. Urine culture results are pending. Renal ultrasonography shows hydronephrosis of the left kidney. Empirical antimicrobial therapy is initiated, following which the patient's symptoms improve. Which of the following is the most appropriate next step in diagnosis?

Answer: Voiding cystourethrography

Choices:
A. Cystoscopy
B. Intravenous pyelography
C. Dynamic renal scintigraphy
D. Urodynamic testing
E. Voiding cystourethrography


Question: A 69-year-old woman presents to her primary care physician complaining of a new-onset, left-sided, throbbing headache that has lasted for several days. She reports that the pain is worsened by eating. Which of the following is a complication of this condition if not treated promptly?

Answer: Monocular blindness

Choices:
A. Skin nodules
B. Intestinal ischemia
C. Monocular blindness
D. Myocardial infarction
E. Ischemic stroke


Question: A 32-year old woman presents to the office complaining of progressively worsening shortness of breath for 2 months. She was seen multiple times in the past for complications of systemic lupus erythematosus that include anemia, pericarditis, and chronic interstitial lung disease. As she does not have medical insurance, she does not regularly follow up with her physician and also is not compliant with her medications. She does not drink alcohol, smoke cigarettes, or take illicit drugs. Her family history is positive for colon cancer in her father. Her temperature is 36.5°C (97.8°F), the blood pressure is 106/70 mm Hg, the pulse is 84/min, and the respirations are 16/min. Severe clubbing of her fingernails is noted. Which of the following best describes the pathogenesis of this patient's nail findings?

Answer: Entrapment of megakaryocytes in the nail bed

Choices:
A. Septic emboli
B. Atherosclerotic emboli
C. Entrapment of megakaryocytes in the nail bed
D. Nutritional deficiency, causing nails to be brittle and convex in shape
E. Chronic hypoxemia


Question: An otherwise healthy 27-year-old woman presents to the emergency department because of worsening headaches and nosebleeds. Her blood pressure is 185/115 mm Hg, pulse is 88/min and temperature is 36.9°C (98.4°F). She denies the use of nicotine, alcohol, or illicit drugs. Family history is irrelevant. Physical examination is only positive for abdominal bruits. She is given a calcium-channel blocker and a thiazide diuretic, but her blood pressure did not respond adequately. Aldosterone-to-renin ratio is < 20. Which of the following is the most likely cause of this patient’s condition?

Answer: Renal artery stenosis

Choices:
A. Renal artery stenosis
B. Essential hypertension
C. Coarctation of the aorta
D. Primary aldosteronism
E. Cushing syndrome


Question: A 50-year-old farmer from Jamaica presents to his physician with a wart-like lesion on his left foot. He is a plantain farmer and often farms barefoot because of the pleasant climate. Physical examination reveals warty, cutaneous nodules that resemble the florets of cauliflower. On a KOH preparation, irregular, dark brown, yeast-like bodies with septae are noted. Culture on Sabouraud agar reveals sclerotic bodies. Which of the following is the most likely diagnosis?

Answer: Chromoblastomycosis

Choices:
A. Mycetoma
B. Sporotrichosis
C. Rhinosporidiosis
D. Entomophthoromycoses
E. Chromoblastomycosis


Question:
A 52-year-old man comes to the physician because of a 3.6-kg (8-lb) weight loss over the past 3 months and increasing fatigue. He was diagnosed with hepatitis C 6 years ago. His father died of colon cancer. He has smoked one pack of cigarettes daily for 35 years and drinks one beer daily. He used cocaine and heroin in the past but stopped 12 years ago. He is 176 cm (5 ft 8 in) tall and weighs 71 kg (156 lb); BMI is 22.9 kg/m2. His temperature is 37.0°C (98.6°F), pulse is 79/min, and blood pressure is 115/75 mm Hg. He appears weak and lethargic. Examination shows scleral icterus and scars on both cubital fossae. There is reddening of the palms bilaterally. There are several telangiectasias over the chest and back. The abdomen is soft and nontender. The liver is firm and of nodular consistency. Laboratory studies show:
Hemoglobin 11.6 g/dL
Mean corpuscular volume 88 μm3
Leukocyte count 9,600/mm3
Platelet count 223,000/mm3
Ultrasonography of the liver shows a solitary lesion. Which of the following findings is most likely in this patient?"

Answer: Elevated α-fetoprotein

Choices:
A. Positive blood cultures
B. Elevated α-fetoprotein
C. Elevated carcinoembryonic antigen
D. Exophytic tumor on colonoscopy
E. Spiculated lesion on chest CT


Question: A 63-year-old man comes to the physician for the evaluation of difficulty walking for the last 6 months. He reports weakness in his lower legs that improves with exercise and throughout the day. Three months ago, he started adding flax seeds to his breakfast because he is frequently constipated. He has hypertension and type 2 diabetes mellitus. He has smoked 2 packs of cigarettes daily for the last 45 years. His current medications include enalapril and metformin. Vital signs are within normal limits. Examination shows dry mucous membranes. Muscle strength in the lower extremities is decreased. Sensation to pinprick and light touch is normal. Deep tendon reflexes are 1+ bilaterally. Active muscle contraction or repeated muscle tapping increases reflex activity. Which of the following is most likely to confirm the diagnosis?

Answer: Autoantibodies against voltage-gated calcium channels

Choices:
A. Demyelinating plaques on a brain MRI
B. Autoantibodies against voltage-gated calcium channels
C. Decremental response following repetitive nerve stimulation
D. Fasciculations and positive sharp waves on EMG
E. Albuminocytologic dissociation in cerebrospinal fluid


Question: A 5-year-old boy is brought to the emergency department by his mother because of abdominal pain. His mother says that he has not had any fever, vomiting, diarrhea, or dysuria. His last bowel movement was 3 days ago and appeared normal. The boy is restless and clutches his abdomen. His temperature is 37.2°C (99°F), blood pressure is 108/76 mm Hg, pulse is 110/min, respirations are 20/min. The abdomen appears mildly distended. On auscultation, he has hyperactive bowel sounds. The remainder of the examination shows no abnormalities. An ultrasound of the abdomen shows no abnormalities. Which of the following is the most appropriate next step in management?

Answer: Administer polyethyelene glycol

Choices:
A. Administer polyethyelene glycol
B. Reassurance and observation
C. Administer intravenous fluids
D. Perform a barium enema
E. Start empirical antibiotic therapy


Question: A 30-year-old woman presents to the emergency department with chest pain. She states that she was making coffee this morning when she suddenly developed sharp, 8/10, mid-sternal chest pain. The pain does not radiate and is constant. She is worried because she has a marathon next week that she has been training for. Her medical history is significant for seasonal allergies. She takes no medications except a multivitamin. Her mother has asthma. She works as a lawyer. She denies sick contacts or recent travel. She has a glass of wine with dinner but denies tobacco or recreational drug use. The patient’s initial temperature is 98°F (36.7°C), blood pressure is 122/78 mmHg, pulse is 89/min, and respirations are 14/min with an oxygen saturation of 98% on room air. A physical examination is within normal limits. Labs are pending. Which of the following is the best initial step in management?

Answer: Electrocardiogram

Choices:
A. Aspirin, oxygen, nitroglycerin, and morphine
B. Computerized tomography scan
C. Electrocardiogram
D. Heparin
E. Reassurance


Question:
A 34-year-old woman, gravida 2, para 1, at 34 weeks' gestation comes to the physician because of a 10-day history of generalized pruritus and a 2-day history of jaundice, dark urine, and pale stools. She had developed pruritus at the end of her previous pregnancy, which disappeared after delivery. She has had standard prenatal care. Medications include folic acid and a multivitamin. Her blood pressure is 108/60 mm Hg. Examination shows scleral icterus, jaundice, and scratch marks on her upper and lower limbs. Pelvic examination shows a uterus consistent in size with a 30-week gestation.
Hemoglobin 11.5 g/dl
Platelet 350,000/mm3
Prothrombin time 11 seconds (INR=1)
Serum
Total bilirubin 5 mg/dl
Direct bilirubin 4.2 mg/dl
Bile acid
25 μmol/l (N= 0.3 to 10 μmol/l)
Aspartate aminotransferase 55 U/L
Alanine aminotransferase 45 U/L
There are no abnormalities on abdominopelvic ultrasonography. Which of the following is the most appropriate next step in management?"

Answer: Ursodeoxycholic acid

Choices:
A. 24-hour urine protein
B. Emergency endoscopic retrograde cholangiopancreatography and sphincterotomy
C. Immediate induction of labor
D. Laparoscopic cholecystectomy within 48 to 72 hours
E. Ursodeoxycholic acid


Question: A mother brings her 17-year-old daughter to your office because of a recent onset dull unilateral pelvic pain that started last week. In addition, the daughter also complains of constipation for which she increased her fiber intake, but the dietary changes are not helping her. She began menstruating at the age of 13, and her menstrual cycles are regular (about 28 days). On physical examination, the patient has a large, non-tender, mobile adnexal mass in the left lower quadrant. The pelvic examination is normal except for the presence of the adnexal mass. The patient is advised to have an outpatient ultrasound, and then return to the clinic next week. After 2 weeks, you learned that the patient visited the emergency department for a sudden onset of abdominal pain that required observation after an abdominal ultrasound was performed. The ultrasound showed a large simple cystic mass with increased internal echoes, having a diameter of 10 cm and hyperechogenic vascular walls on the left ovary with a small intraperitoneal collection in the pouch of Douglas. What was the most likely diagnosis of this patient?

Answer: Corpus luteum cyst

Choices:
A. Follicular cyst
B. Endometrioma
C. Tubo-ovarian abscess
D. Corpus luteum cyst
E. Dermoid cyst


Question: A 22-year-old woman comes to the clinic complaining of right anterior knee pain. She reports that the pain has been present for 3 months and has gradually worsened. She says the pain is exacerbated when climbing or descending the stairs. She also states the pain is sometimes worse with prolonged periods of sitting. She has tried over-the-counter aspirin and ibuprofen without relief. She is a soccer player and is worried that the pain is starting to affect her ability to play. She reports multiple minor lower extremity injuries due to soccer but denies significant trauma such as known fractures or torn ligaments. Her past medical history is unremarkable. She had a myringotomy in her left ear as a child. On examination, there is pain and crepitus on extension of the right knee with anterior patellar compression. Which of the following is the most appropriate management of the patient’s symptoms?

Answer: Quadriceps exercises

Choices:
A. Aspiration
B. Lidocaine injection
C. Orthopedic surgery
D. Ossicle resection
E. Quadriceps exercises


Question: A 25-year-old woman is brought to the emergency department by her husband for abdominal pain. The husband answers all questions posed to the patient by the physician. Throughout the interview, the patient makes very little eye contact with the physician. Her husband asks the physician to prescribe “something for her abdominal pain” so that they can return home. Examination of the patient shows mild bruising in the left infraorbital area and a right periorbital hematoma. When asked about her injuries, she quietly states that she fell while walking down the stairwell of her apartment complex. The husband reluctantly leaves the examination room when asked to by the physician. While alone with the physician, the patient admits that her husband is responsible for her injuries. Which of the following immediate responses by the physician is most appropriate?

Answer: """Do you feel safe leaving the emergency department?"""

Choices:
A. """May I add some information about local domestic violence agencies to your discharge records?"""
B. """Do you feel safe leaving the emergency department?"""
C. """Don't you think you should report this incident to the police?"""
D. """How often has your husband physically hurt you in the past?"""
E. “May I ask your husband to join us so we can talk about this matter together?”


Question: A 15-year-old girl comes to the physician because of a 2-month history of progressive fatigue and weakness. She also reports recurrent headaches for 2 years, which have increased in severity and frequency. Her blood pressure is 185/95 mm Hg. Serum studies show a morning renin activity of 130 ng/mL per hour (N=1–4), a morning aldosterone concentration of 60 ng/dL (N=5-30), and a potassium concentration of 2.9 mEq/L. Further evaluation is most likely to show which of the following?

Answer: Pleomorphic modified smooth muscle cells in the renal cortex

Choices:
A. ACTH-producing growth in the pituitary gland
B. Increased urinary excretion of metanephrines
C. Increased 17-hydroxyprogesterone levels
D. Pleomorphic modified smooth muscle cells in the renal cortex
E. Involution of zona glomerulosa of the adrenal gland


Question: A 15-year-old boy is brought to the emergency department by his mother because of severe left testicular pain for 1 hour. For the past week, he has also had mild testicular pain and pain on urination. He has not had nausea or vomiting. He is otherwise healthy. His temperature is 39.1°C (102.3°F), pulse is 114/min, and blood pressure is 120/76 mm Hg. Examination shows a high-riding, swollen, erythematous tender left testis; lifting the left testis relieves his pain. His hemoglobin concentration is 15.6 g/dL, leukocyte count is 14,600/mm3, and platelet count is 290,000/mm3. Testicular ultrasound shows increased blood flow to the left testicle when compared to the right and an enlarged left epididymis with decreased echogenicity. Further evaluation of this patient is most likely to show which of the following findings?

Answer: Positive nucleic acid amplification testing

Choices:
A. Reducible scrotal mass
B. Gram-negative rods in urethral swab
C. A hard testicular mass
D. Positive nucleic acid amplification testing
E. Absent cremasteric reflex


Question: A 27-year-old female presents to the emergency department with complaints of acute-onset fatigue, blurred vision, and rash earlier today. Her husband rushed her to emergency department when he noted that she was exhibiting changes in her mental status and had trouble speaking. Her vital signs are as follows: T 38.4, HR 87, BP 110/85, RR 14, and SpO2 96%. Physical examination reveals petechiae, pallor, and left upper extremity weakness. Work-up reveals Hgb 8.5 g/dL, platelets 22,000 cells/uL, normal PT/INR and PTT, absent fibrin split products, elevated fibrinogen, a negative Coombs test, 3.7 mg/dL creatinine, 3.8 mg/dL indirect bilirubin, and LDH 1000 IU/L. Which of the following would be expected on a peripheral blood smear from this patient?

Answer: Schistocytes

Choices:
A. Ovalocytes
B. Spherocytes
C. Atypical lymphocytes
D. Schistocytes
E. Rouleaux formation


Question: A 67-year-old African American male presents to his primary care physician for routine follow-up. He has a history of poorly controlled hypertension, despite being on lisinopril, hydrochlorothiazide, amlodipine and metoprolol, which he takes regularly. His blood pressure during the visit is 170/80. He does not have kidney disease. His primary care physician decides to start him on methyldopa. What is the mechanism of action of methyldopa?

Answer: Centrally acting alpha2 adrenergic receptor agonist

Choices:
A. Direct vascular smooth muscle relaxation
B. Dopamine receptor agonist
C. Inhibition of angiotensin converting enzyme
D. Centrally acting alpha2 adrenergic receptor agonist
E. Inhibition of alpha1 adrenergic receptors


Question: A 2800-g (6-lb 3-oz), 3-day-old newborn is in the intensive care unit for fever, vomiting, tremors, cyanotic episodes, and seizures. She was born at 36 weeks to a 25-year-old primigravid woman. Spontaneous vaginal delivery was complicated by maternal fever and chorioamnionitis. Apgar scores were 6 at 1 minute and 7 at 5 minutes, respectively. Shortly after delivery, the child had seizures and high-grade fever with poor feeding and hypotonia. She was intubated for respiratory distress. Her temperature is 39°C (102.3°F), pulse is 180/min, and respirations are 60/min. Physical exam shows grunting breath sounds, an enlarged liver palpable 3 cm below the right costal margin, and lethargy. A CT scan of the chest, abdomen, and pelvis shows multiple pulmonary and hepatic granulomas. Which of the following would most likely have prevented this complication?

Answer: Avoiding unpasteurized milk products

Choices:
A. Avoiding unpasteurized milk products
B. Measles, mumps, rubella vaccination before pregnancy
C. Prophylactic penicillin
D. Prophylactic acyclovir
E. Delivery via cesarean section


Question: A 45-year-old woman presents to her primary care practitioner requesting a routine checkup for a job application. Her family history is negative for malignancies and inheritable diseases. She has been married for 15 years and has 2 healthy children. Her past medical history is negative for surgical procedures and cardiovascular disease; however, she used to work as a radiology technician. Her only complaints at the moment are neck pain and hoarseness. Physical examination is unremarkable except for a painless nodule in the right lobe of the thyroid gland with no inflammatory signs. In a follow-up appointment, the patient brings the results of her thyroid function tests, which are normal. She also brings the results of a fine-needle aspiration biopsy that report the pathology of the nodule as follicular neoplasia. After some discussion, the patient opts for surgical treatment. With a surgical pathology report that describes vascular invasion, which of the following additional features would you expect to find for this thyroid nodule?

Answer: Capsular invasion

Choices:
A. Capsular invasion
B. Cystic nature
C. Psammoma bodies
D. Eosinophil and macrophage invasion
E. Pleomorphic cells without follicle development


Question: A 65-year-old man comes to the physician because of progressive shortness of breath and a worsening cough for the past month. He also reports occasional bloody sputum. He has lost about 7 kg (15.4 lb) of weight over the past 4 months despite having no change in appetite. He has smoked 2 packs of cigarettes daily for 15 years but stopped smoking at the age of 55. Physical examination shows reduced breath sounds throughout both lungs. An x-ray of the chest is shown. Which of the following is the most likely cause of the patient's symptoms?

Answer: Pulmonary metastases

Choices:
A. Squamous cell lung carcinoma
B. Small cell lung cancer
C. Lung adenocarcinoma
D. Pulmonary metastases
E. Pleural mesothelioma


Question: A 67-year-old man comes to the physician due to exertional dyspnea and lower extremity swelling for the last 4 weeks. The patient has been a smoker for the last 45 years and has been diagnosed with COPD. He has no history of diabetes mellitus or ischemic heart disease. He is non-compliant with his medications for COPD. The patient is a retired social worker and spends most of his time at home. His temperature is 37.2°C (98.9°F), blood pressure is 135/115 mm Hg, pulse is 90/min, and respirations are 22/min. Oxygen saturation on room air is 92%. Physical examination reveals a barrel-shaped chest, distension of neck veins, and 3+ bilateral pitting edema of his lower extremities. The liver is palpated 6 cm below the costal margin and is tender to palpation. Application of pressure on the upper abdomen causes persistent distension of jugular veins. Lungs are clear to auscultation. Chest X-ray shows enlarged main pulmonary arteries. ECG shows right bundle branch block and right ventricular hypertrophy. Which of the following is the gold standard test for diagnosing this patient’s condition?

Answer: Right heart catheterization

Choices:
A. Pulmonary capillary wedge pressure
B. Right heart catheterization
C. Coronary angiography
D. Abdominal paracentesis
E. Ultrasound of liver


Question: A 13-year-old African-American girl is brought to the physician for right shoulder pain that has worsened over the past month. She has had many episodes of joint and bone pain and recurrent painful swelling in her hands and feet. Physical examination shows tenderness of the right anterior humerus without swelling or skin changes. Active and passive range of motion of the right shoulder is decreased and there is pain with movement. The leukocyte count is 4600/mm3. An x-ray of the right shoulder shows subchondral lucency of the humeral head with sclerosis and joint space narrowing. Which of the following is the most likely underlying cause of this patient's shoulder pain?

Answer: Infarction of the bone trabeculae

Choices:
A. Infection of the joint space
B. Crystal deposition within the joint
C. Loss of bone mineral density
D. Infarction of the bone trabeculae
E. Infection of the bone


Question: A 4-month-old male presents to the emergency department with severe cough, wheezing, and cyanosis. You suspect bronchiolitis of viral etiology and you administer an anti-viral medication. This drug is often used to treat which one of these other infections?

Answer: Hepatitis C

Choices:
A. HIV
B. Hepatitis B
C. Hepatitis C
D. Rhinovirus
E. HSV


Question: A 43-year-old woman presents to the clinic complaining of “spotting.” She states that over the past 5 months she has had intermenstrual bleeding. Additionally, her menses last more than a week with the first 4 days consisting of heavy bleeding. She denies abdominal pain but reports feeling an increasing “pressure-like" discomfort. She denies dysuria, dyspareunia, or dyschezia. Prior to 5 months ago, her menstrual periods were only 4 days long and consisted of moderate bleeding. Her periods normally occur every 28 days. She is frustrated because she feels like she needs to wear a pad all the time. The patient delivered 3 healthy children vaginally without complications, followed by a tubal ligation. Her last menstrual period was 1 week ago. She is sexually active with her husband and denies a history of sexually transmitted diseases. She has never had an abnormal pap smear. Her last pap smear and test for human papillomavirus was 4 years ago. The patient has hypothyroidism treated with levothyroxine. On physical examination, the thyroid is normal in size without masses or tenderness. Pelvic examination reveals a firm, mobile, enlarged, irregularly-shaped uterus without adnexal tenderness. Speculum exam is unremarkable. Which of the following is the most likely diagnosis?

Answer: Leiomyoma

Choices:
A. Adenomyosis
B. Cervical cancer
C. Endometriosis
D. Hypothyroidism
E. Leiomyoma


Question: A 19-year-old woman comes to the physician because of a 1-week history of fatigue and yellow discoloration of her eyes. Four weeks ago, she had a sore throat and was diagnosed with a viral infection that self-resolved. She has no history of serious medical illness. Her only medication is an oral contraceptive. She appears tired. Her pulse is 94/min, and blood pressure is 125/75 mm Hg. Physical examination shows scleral icterus. The liver edge is palpable 2 cm below the right costal margin and the spleen tip is palpable 4 cm below the left costal margin. Skin examination shows no rashes. Her hemoglobin concentration is 9.5 g/dL, and the direct antiglobulin test is positive. Which of the following additional laboratory findings is most likely in this case?

Answer: Decreased haptoglobin level

Choices:
A. Increased serum C3 complement concentration
B. Increased direct bilirubin level
C. Decreased haptoglobin level
D. Decreased mean corpuscular volume
E. Increased bleeding time


Question: A 67-year-old female is admitted to the hospital with enterococcus endocarditis and is treated with penicillin and gentamicin. During her admission, she develops worsening pulmonary edema secondary to valvular insufficiency and requires therapy with IV furosemide. This patient is most likely to experience which of the following adverse reactions to her current pharmacological treatment:

Answer: Ringing in the ears and impaired hearing

Choices:
A. Ringing in the ears and impaired hearing
B. Hyperkalemia leading to possible cardiac arrhythmia
C. Anemia and chronic fatigue
D. Diffuse flushing and redness over body surface
E. Pseudomembranous colitis and diarrhea


Question: A 75-year-old male is brought to the emergency room by his daughter due to slurred speech and a drooping eyelid on the right side. This morning, he had difficulty eating his breakfast and immediately called his daughter for help. She says that his voice also seems different. His temperature is 99°F (37.2°C), blood pressure is 120/78 mmHg, pulse is 90/min, respirations are 21/min, and pulse oximetry is 98% on room air. On physical exam, he is oriented to time and place. There is right-sided nystagmus and he has difficulty with point-to-point movement. Where is the lesion responsible for his symptoms most likely located?

Answer: Posterior inferior cerebellar artery

Choices:
A. Anterior spinal artery
B. Posterior inferior cerebellar artery
C. Anterior cerebral artery
D. Anterior inferior cerebellar artery
E. Basilar artery


Question: You are conducting an experiment on a cell line in your laboratory. You introduce a molecule into the tissue culture dish containing the cell line that binds to a transmembrane protein. As a result, the affected cell initiates a process characterized by karyorrhexis, membrane blebbing, and pyknosis. What was the molecule that you introduced into the culture?

Answer: FAS-ligand

Choices:
A. Perforin
B. Granzyme B
C. FAS-ligand
D. IL-2
E. BCL-2


Question: A 45-year-old woman comes to the physician because of a 6-month history of progressive irritability, palpitations, heat intolerance, frequent bowel movements, and a 6.8-kg (15-lb) weight loss. She also has a smooth, uniformly enlarged mass at the front of her neck and protuberant eyes with lid retraction. Laboratory investigations show undetectable levels of thyroid stimulating hormone, elevated levels of free T3 and T4, and a raised titer of TSH receptor autoantibodies (TRAbs). Therapy is initiated with radioactive iodine-131. This patient is at greatest risk for which of the following complications?

Answer: Worsening exophthalomos

Choices:
A. Radiation thyroiditis
B. Worsening exophthalomos
C. Agranulocytosis
D. Vocal cord paralysis
E.
Thyroid carcinoma
"


Question: A 56-year-old woman comes to the emergency department because of severe abdominal pain associated with nausea and vomiting for 12 hours. The pain extends from the epigastrium to the right upper quadrant and radiates to the right scapula. The patient has gastroesophageal reflux disease. She underwent total thyroidectomy for papillary thyroid carcinoma 3 years ago. She has smoked one pack of cigarettes daily for 35 years. Current medications include levothyroxine, omeprazole, and a multivitamin. The patient appears uncomfortable. Her temperature is 38.1°C (100.6°F), pulse is 93/min, and blood pressure is 140/85 mm Hg. Abdominal examination shows tenderness to deep palpation in the right upper quadrant. The patient's leukocyte count is 10,300/mm3. Abdominal ultrasonography shows thickening of the gallbladder wall, without dilatation of the intra- and extrahepatic bile ducts. Laparoscopic cholecystectomy is performed. Pathological examination shows acute cholecystitis. There is an ulcerated 1 x 1.5-cm mass in the fundus of the gallbladder with invasion of the gallbladder wall and lymphatic vessels. Which of the following is the most likely underlying condition?

Answer: Cutaneous malignant melanoma

Choices:
A. Adenocarcinoma of the sigmoid colon
B. Cutaneous malignant melanoma
C. Recurrence of papillary thyroid carcinoma
D. Multiple endocrine neoplasia
E.
Squamous cell carcinoma of the esophagus
"


Question: You are on your first day of a pathology rotation and the attending pathologist gives you a biopsy specimen to examine. She says it is from the antrum of the stomach of a 32-year-old man who has been complaining of abdominal pain for the past 6 months. The patient states the pain gets worse when eating. On endoscopy, there was a single ulcerated lesion with a 'punched out' appearance. What are the most likely histologic findings in this biopsy specimen?

Answer: A urease-positive organism

Choices:
A. Signet ring cells
B. An abundance of self reactive T cells
C. A urease-positive organism
D. Absence or evidence of destruction of parietal cells
E. The presence of a large amount of neutrophils with limited macrophages


Question: A 40-year-old man is brought into the emergency department by his wife complaining of intense lower right abdominal pain. An abdominal CT scan was performed which noted a dilated appendix with a thickened wall and the accumulation of extraluminal fluid. A quick history is taken while the OR is prepped for surgery. Past medical history is noncontributory and the patient takes no medications. Social history reveals a sedentary lifestyle. The patient admits to regularly drinking several beers and several shots of vodka every night. He had to stop drinking 2 days ago due to the intense abdominal pain. The patient is brought into the OR and the inflamed and necrotic appendix is removed. He is admitted to the hospital for overnight monitoring. Later that night, the patient begins to hallucinate. Which type of hallucination is this patient likely to experience?

Answer: Tactile hallucination

Choices:
A. Proprioceptive hallucinations
B. Olfactory hallucination
C. Gustatory hallucination
D. Hypnagogic hallucination
E. Tactile hallucination


Question:
A 34-year-old woman presents with sudden onset flank pain for the past day. She describes the pain as intermittent and radiating to her groin. She denies any similar symptoms in the past. No significant past medical history. The patient currently does not take any medications. Family history is significant for her mother who died of a pancreatic tumor at the age of 53. Laboratory analysis reveals:
Serum calcium 12 mg/dL
Serum phosphorus 2.2 mg/dL
Serum parathyroid hormone 105 pg/mL
Which of the following mutated gene products is most likely causing this patient’s symptoms?

Answer: Menin

Choices:
A. Receptor tyrosine kinase
B. Cytokine receptor
C. Antiapoptotic molecule
D. Threonine kinase
E. Menin


Question: As a public health practitioner, you are charged with choosing which blood test to use for the screening of a new infectious disease. You want to ensure that as many cases of this disease as possible are picked up by this initial screening test. Which of the following is the highest priority characteristic of this new test?

Answer: Highly sensitive test

Choices:
A. Highly sensitive test
B. Highly specific test
C. Low false positive rate
D. High true positive rate
E. Low negative predictive value


Question: A 25-year-old man is brought into the hospital by his family because they are concerned that he has post-traumatic stress disorder. The patient is a marine and was deployed to Afghanistan 2 years ago. He was able to successfully reintegrate with society upon his return; however, for the last 2 weeks, he has been having recurrent nightmares and avoiding news coverage on the war. He has become more and more detached from his family and friends and, on the few times he does interact with them, he has angry outbursts. The patient is afebrile, and his vital signs are within normal limits. Physical examination is unremarkable. Which of the following findings is most important in correctly diagnosing this patient’s condition?

Answer: Duration of symptoms

Choices:
A. Duration of symptoms
B. Flashbacks
C. State of hyperarousal
D. Avoidance of triggers
E. Negative Mood


Question: A 4-year-old girl is brought to the pediatrician because of throat pain for 2 days. She had frequent episodes of oral thrush as a baby and has been treated for vaginal yeast infection twice in the past year. Physical examination shows white patches on the tongue and palate. Scraping off the patches reveals erythematous oral mucosa with pinpoint bleeding. Leukocyte count is within normal range. Exposure to nitroblue tetrazolium turns the patient's neutrophils dark blue. A deficiency in which of the following enzymes is the most likely cause of this patient's recurrent infections?

Answer: Myeloperoxidase

Choices:
A. Adenosine deaminase
B. Pyruvate kinase
C. Glucose-6-phosphate dehydrogenase
D. NADPH oxidase
E. Myeloperoxidase


Question: A 55-year-old male with chronic dyspnea is intubated and started on mechanical ventilation for respiratory failure. Pressure-volume scalars on the ventilator show decreased change in volume for each unit change in pressure as compared to normal values. Of the following options, which is the most likely cause of his respiratory failure?

Answer: Pulmonary fibrosis

Choices:
A. Amyotrophic lateral sclerosis
B. Asthma
C. Centriacinar emphysema
D. Pulmonary fibrosis
E. Alpha-1-antitrypsin deficiency


Question: A 6-year-old African-American boy presents with severe pain and swelling of both his hands and wrists. His symptoms onset 2 days ago and have not improved. He also has had diarrhea for the last 2 days and looks dehydrated. This patient has had two similar episodes of severe pain in the past. Physical examination reveals pallor, jaundice, dry mucous membranes, and sunken eyes. Which of the following mutations is most consistent with this patient’s clinical condition?

Answer: Missense

Choices:
A. Chromosomal deletion
B. Nonsense
C. Silent
D. Missense
E. Frame shift


Question: A 45-year-old woman presents to her primary care physician with complaints of weight loss and anxiety. She says that over the past 6 months she has lost 10 pounds even though she has had an increased appetite. In addition, she describes 3 episodes where it felt like her heart was "pounding out of her chest." Her temperature is 99.3°F (37.4°C), pulse is 106/min and regular, blood pressure is 141/80 mmHg, and respirations are 18/min. Physical exam is significant for mild bilateral proptosis and 3+ deep tendon reflexes bilaterally. Which of the following is the best initial therapy for the patient's condition?

Answer: Propranolol

Choices:
A. Adenosine
B. Methimazole
C. Potassium iodide
D. Propranolol
E. Thyroidectomy


Question:
A 58-year-old woman is brought to the emergency department by her husband because of increasing confusion and generalized fatigue over the past week. During this period, she has had muscle cramps, headaches, nausea, and vomiting. Six days ago, she underwent resection of a parasagittal meningioma. She tolerated the procedure well without complications and was discharged two days ago. She has hypercholesterolemia and hypertension. Current medications include oxycodone, acetaminophen, atorvastatin, and hydrochlorothiazide. She is oriented only to person and place. Her temperature is 37°C (98.6°F), pulse is 89/min, respiratory rate is 14/min, and blood pressure is 142/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The remainder of the examination shows no abnormalities. Serum studies show:
Serum
Na+ 126 mEq/L
K+ 3.6 mEq/L
Cl- 107 mEq/L
Urea nitrogen 16 mg/dL
Glucose 87 mg/dL
Creatinine 0.9 mg/dL
Osmolality 255 mOsmol/kg H2O
Urine
Osmolality 523 mOsmol/kg H2O
Sodium 44 mEq/L
Which of the following is the most likely cause of this patient's symptoms?"

Answer: Syndrome of inappropriate antidiuretic hormone

Choices:
A. Cerebral salt wasting syndrome
B. Hydrochlorothiazide
C. Syndrome of inappropriate antidiuretic hormone
D. Primary polydipsia
E. Mineralocorticoid deficiency


Question: A 55-year-old man comes to the emergency department because of left arm pain after falling from a ladder. Physical examination shows tenderness along the proximal left humerus. An x-ray of the left arm and shoulder shows a nondisplaced proximal humerus fracture. Which of the following cytokines is most likely to be involved in normal bone healing in this patient?

Answer: Macrophage colony-stimulating factor

Choices:
A. Interleukin-4
B. Interleukin-2
C. Interferon-α
D. Granulocyte colony-stimulating factor
E. Macrophage colony-stimulating factor


Question: A 62-year-old African American man is admitted to the emergency department with a 24-hour history of intense epigastric pain that radiates to the back with nausea and vomiting. His medical history is relevant for hypertension, heart failure (HF), chronic obstructive pulmonary disease (COPD), and radicular pain, all under control with amlodipine, furosemide, ipratropium, and gabapentin. He drinks occasionally at family gatherings and has never smoked cigarettes. His vital signs are recorded as follows: blood pressure of 130/80 mm Hg, a heart rate of 78/min, a respiratory rate of 18/min, and a body temperature of 36.6°C (97.9°F). Abdominal examination shows edema and bruising of periumbilical subcutaneous tissue and intense pain to touch but no signs of peritoneal irritation. Which of the following is the most likely responsible for this patient’s condition?

Answer: Furosemide

Choices:
A. Amlodipine
B. Furosemide
C. Ipratropium
D. Gabapentin
E. Alcohol consumption


Question: A 62-year-old woman presents to the emergency department complaining of intense pain in her right knee that started 12 hours ago. Her past medical history is significant for hemochromatosis, managed with biweekly phlebotomy. Her vitals include: blood pressure of 130/70 mm Hg, pulse of 82/min, respiratory rate of 18/min, and temperature of 36.5°C (97.7°F). Physical examination reveals an erythematous, warm, and severely tender right knee with a restricted range of motion. An arthrocentesis is performed, and synovial fluid analysis is significant for a neutrophil count of 3,200 cells/μL, a negative Gram stain, and the following result under polarized light microscopy (see image). Which of the following additional findings would you also expect to observe in this patient?

Answer: Chondrocalcinosis

Choices:
A. Chondrocalcinosis
B. Lipohemarthrosis
C. Urate tophi
D. Heberden's nodes
E. Rheumatoid nodules


Question: A 52-year-old man with a history of mild chronic obstructive pulmonary disease (COPD) has been using albuterol as needed to manage his COPD without any other maintenance medications. Recently, he has been experiencing a greater degree of shortness of breath, wheezing, and a productive cough. He denies any recent changes to his activities of daily living, exercise, or recent upper respiratory illnesses. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. His physical examination shows decreased breath sounds bilateral, and expiratory wheezes, a barrel-shaped chest, and a holosystolic murmur heard best at the 2nd intercostal space on the left. Pulmonary function tests demonstrate a forced expiratory volume-1 (FEV-1) which is 60% of the predicted value. What is the next best step for the management of his COPD?

Answer: Add tiotropium to treatment regimen

Choices:
A. Add budesonide to treatment regimen
B. Add rofilumast to treatment regimen
C. Add tiotropium to treatment regimen
D. Add tiotropium plus fluticasone to treatment regimen
E. Add carbocysteine to treatment regimen


Question: A 24 year-old male presented to his physician with a homogenous, painless testicular swelling that he noticed for the past two weeks. After ultrasound and blood tests, he subsequently underwent a radical inguinal orchiectomy and pathology was consistent with seminoma. Which of the following would you expect to see in a tissue sample from the patient’s orchiectomy?

Answer: Lobules of large cells with prominent nuclei and watery cytoplasm

Choices:
A. Lobules of large cells with prominent nuclei and watery cytoplasm
B. Schiller-Duval bodies
C. Reinke crystals
D. Tubular papillary architecture with necrosis
E. Mature derivatives of endoderm, mesoderm, and ectoderm


Question: A 31-year-old man comes to the physician because of diarrhea, bloating, nausea, and vomiting for the past week. He describes his stool as greasy, frothy, and soft; it is not red or darkened. The patient went on a hiking trip in Brazil 3 weeks ago. He has no history of serious illness and takes no medications. The patient appears dehydrated. His vital signs are normal. Examination shows dry mucous membranes and diffuse abdominal tenderness. Microscopy of the stool reveals egg-shaped cysts with prominent two-layered cell wall and multiple nuclei. Which of the following is the most appropriate treatment?

Answer: Metronidazole therapy

Choices:
A. Supportive treatment only
B. Vancomycin therapy
C. Trimethoprim-sulfamethoxazole therapy
D. Metronidazole therapy
E. Octreotide therapy


Question: A 48-year-old man presents to the clinic feeling depressed after a string of failed business projects. His team noticed that he seems less engaged than he once used to be and this is reflecting in his work. He has no previous psychiatric history and symptoms of depressed mood have been ongoing for the past 6 months. A patient health questionnaire 9 (PHQ-9) was administered and the patient scored 10. The patient is started on venlafaxine. The alteration in the normal functioning of which of the following is the mechanism of action for this therapy?

Answer: Serotonin, norepinephrine, and dopamine

Choices:
A. Serotonin, norepinephrine, and dopamine
B. Norepinephrine and dopamine
C. Serotonin only
D. Serotonin receptor antagonism
E. Alpha-2 receptor antagonism


Question: A researcher is performing an experiment where she is using bacteria to clone copies of a mutated gene that she plans on introducing to cells. In order to perform this, she has created a small, circular segment of double-stranded DNA that includes the gene of interest as well as a gene for antibiotic resistance. After introducing this segment of DNA to competent bacteria, she plates the bacteria on media containing the antibiotic. Which of the following processes was necessary in order for the bacteria to survive on the plate and contain copies of the gene of interest?

Answer: Transformation

Choices:
A. Conjugation
B. Transduction
C. Transfection
D. Transformation
E. Transposition


Question:
A 27-year-old woman presents to the emergency department with altered mental status. Her parents found her in her room surrounded by pill bottles, alcohol, and illicit drugs 10 minutes ago and promptly brought her in. She was unconscious with lacerations on her wrists. The patient has a past medical history of depression, fibromyalgia, and multiple suicide attempts. Physical exam is notable for a somnolent young woman who responds to questions but is non-compliant in describing the history. She is currently vomiting and her gait seems ataxic. Initial laboratory values are unremarkable. An arterial blood gas analysis reveals the following findings.

Arterial blood gas
pH: 7.50
pO2: 105 mmHg
pCO2: 20 mmHg
Bicarbonate: 24 mEq/L

Which of the following is the most likely intoxication in this patient?

Answer: Aspirin

Choices:
A. Acetaminophen
B. Alcohol
C. Amitriptyline
D. Aspirin
E. Ethylene glycol


Question: A 33-year-old Asian American man presents to his primary care provider in February with pain in his fingers. His symptoms started 2 years ago and have gradually progressed. He initially attributed his symptoms to stress at work as a social worker. He has tried using ibuprofen, acetaminophen, and naproxen, but these medications did not improve his pain. He also reports that there have been at least 3 instances in the past 2 months in which his fingers became extremely painful and turned white before turning pale blue. These instances occurred when the patient was walking outside. His past medical history is notable for gastroesophageal reflux disease and gout. He takes omeprazole and allopurinol. His temperature is 99°F (37.2°C), blood pressure is 120/78 mmHg, pulse is 90/min, and respirations are 18/min. Physical examination reveals loss of skin fold wrinkles and indurated skin on the palmar side of the digits. Finger range of motion is limited. Which of the following medications is most appropriate to address this patient's concerns?

Answer: Amlodipine

Choices:
A. Ambrisentan
B. Amlodipine
C. Cilostazol
D. Lisinopril
E. Verapamil


Question: A 3-year-old boy is brought to the physician because of a 1-day history of abdominal pain and frequent urination. His mother reports that the patient has wet his bed overnight and that his urine smelled odd this morning. He has been toilet trained for 4 months and has had very few accidents since then. His last bowel movement was 3 days ago. He was born at term after a normal gestation and has reached all developmental milestones. His parents divorced 4 months ago and the patient's father has moved away. The patient began preschool 6 weeks ago. During this period, he has had two upper respiratory infections that resolved without treatment. His 12-year-old brother has type 1 diabetes mellitus. Vital signs are within normal limits. Physical examination of the abdomen shows mild suprapubic tenderness. Urine dipstick is positive for leukocyte esterase, nitrite, and blood; urinalysis shows white blood cells and gram-negative rods. Which of the following is the most likely predisposing factor for this patient's condition?

Answer: Constipation

Choices:
A. Social stressors
B. Constipation
C. Posterior urethral valves
D. Respiratory tract infection
E. Family history of diabetes mellitus


Question: A 37-year-old male presents with difficulty eating solids and drinking water; which has been progressively worse over the past year. He has noticed that he is regurgitating food that appears undigested and has also been having difficulty belching. He said that lifting his neck seems to help him keep his food down. He is currently on omeprazole for his acid reflux; however, his heartburn still persists. An esophagogastroduodenoscopy (EGD) is performed that shows no evidence of mechanical obstruction or esophageal inflammation. If esophageal manometry is performed, which of the following will most likely be present in this patient?

Answer: Aperistalsis in the distal two-thirds of the esophagus with incomplete lower esophageal relaxation

Choices:
A. Hypomotility of the esophagus with lower esophageal sphincter incompetence
B. Aperistalsis in the distal two-thirds of the esophagus with incomplete lower esophageal relaxation
C. Normal amplitude, uncoordiated, simultaneous esophageal contractions
D. Excessive amplitude or duration of coordinated esophageal contractions
E. Hypotensive peristaltic contractions


Question: A 56-year-old man comes to the emergency department for chest pain that started 1 hour ago. He has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. He appears diaphoretic and distressed. An ECG shows P waves independent of QRS complexes. The QRS interval is 0.11 seconds with normal morphology. Which of the following is the most likely trigger of this patient's ventricular contractions?

Answer: Bundle of His

Choices:
A. Sinoatrial node
B. Bachmann bundle
C. Bundle of His
D. Purkinje fibers
E.
Ectopic atrial focus
"


Question: A 29-year-old pregnant woman is brought to the emergency department complaining of the sudden onset of severe, sharp pelvic pain. She is at 6 weeks’ gestation. The patient is bleeding heavily from the vagina and feels very dizzy. Substantial pain is noted in the lower right quadrant, which intensified towards the end of the physical exam. On examination, there is evidence of abdominal and cervical motion tenderness. Her blood pressure is 71/37 mm Hg, respiratory rate is 21/min, pulse is 117/min, and temperature is 38.4°C (101.1°F). Which of the following is the most appropriate definitive step in the management of this patient?

Answer: Surgery

Choices:
A. Surgery
B. Methotrexate
C. Transvaginal ultrasound
D. Abdominal ultrasound
E. Serial hCG


Question: A 24-year-old man presents to his primary care physician with heel pain that has been persistent for 3 weeks now. He is bothered by the feeling of significant pressure and swelling in his ankle. He is also having difficulty walking due to pain in his hip. Upon physical examination, there is evidence of swelling and warmth over his Achilles tendon. Imaging of his sacroiliac joint reveals soft tissue involvement and narrowing of the joint spaces. This patient also appears to have a low to moderate kyphosis of his spine. He has no family history of any bone or rheumatological diseases. This patient most likely presents with clinical features of which disease?

Answer: Ankylosing spondylitis

Choices:
A. Osteoarthritis
B. Ankylosing spondylitis
C. Reactive arthritis
D. Osteoma
E. Fibromyalgia


Question: A 51-year-old man comes to his physician with chronic sinusitis and rhinorrhea for which he uses mometasone nasal spray. He is seeking a refill on this prescription, noting that, although it has not fully relieved his nasal symptoms over the past 2 years, it has helped minimize the severity of those symptoms. On auscultation, there are faint crackles in the bilateral lung fields and an indentation at the nasal bridge. The patient also notes occasional hemoptysis and hematuria. He has no significant medical history and takes no other medications. Family history is significant for rheumatoid arthritis. The physician is suspicious for granulomatosis with polyangiitis and a nasal mucosal biopsy is obtained which confirms the diagnosis. The patient is started immediately on prednisone and cyclophosphamide. Which of the following should also be added to this patient’s therapeutic regimen?

Answer: Trimethoprim/sulfamethoxazole

Choices:
A. Azithromycin
B. Daptomycin
C. Ganciclovir
D. Doxycycline
E. Trimethoprim/sulfamethoxazole


Question:
A 28-year-old man presents to a clinic for a health check-up. He says that he feels great and has not seen a physician for approximately 10 years. He is concerned about his health because his 3 older brothers have recently developed cardiac problems. His medical history is significant for an appendectomy 16 years ago. He works out twice a week and eats a low-salt, well-balanced diet. He drinks alcohol socially on the weekend, but does not use tobacco or drugs. The pulse is 80/min, respirations are 14/min, and the blood pressure is 129/80 mm Hg. The physical examination is unremarkable. Laboratory testing shows the following:
Serum Glucose (fasting) 100 mg/dL
  Sodium 142 mEq/L
  Potassium 3.9 mEq/L
  Chloride 101 mEq/L
Serum Creatinine 0.8 mg/dL
Blood Urea Nitrogen 10 mg/dL
Cholesterol, total 250 mg/dL
  HDL-cholesterol 34 mg/dL
  LDL-cholesterol 210 mg/dL
Triglycerides 160 mg/dL
The patient is most likely started on a medication which acts by which of the following mechanism?

Answer: Inhibition of HMG-CoA reductase

Choices:
A. Blockage of beta-adrenergic receptors
B. Blockage of the angiotensin receptors
C. Increase loss of bile acids in the feces
D. Inhibition of angiotensin converting enzyme
E. Inhibition of HMG-CoA reductase


Question: A 17-year-old boy presents for a psychotherapy session after finding out that his girlfriend has been carrying on another relationship with someone else. He expresses rage and complains of difficulty focusing on his upcoming high school comedy club routines and upcoming track meet. His therapist, while explaining the concept of defense mechanisms, describes some hypothetical examples related to the situation. Which of the following potential actions by this patient would be an example of sublimation?

Answer: Channeling his anger about the situation into training for his track meet

Choices:
A. Channeling his anger about the situation into training for his track meet
B. Instigating a physical fight with his girlfriend’s other partner
C. Making jokes about the situation and incorporating them into his comedy routine
D. Not thinking about the upsetting situation now or in the future
E. Not thinking about the upsetting situation until after his track meet, then confronting and processing his feelings about it


Question:
A 39-year-old woman is brought to the emergency room by her fiancé for severe abdominal pain for the past 5 hours. She was watching TV after dinner when she felt a sudden, sharp, 10/10 pain at the epigastric region that did not go away. Ibuprofen also did not help. She reports recurrent abdominal pain that would self-resolve in the past but states that “this one is way worse.” Her past medical history is significant for diabetes and an appendectomy 2 years ago. The patient endorses nausea and 1 episode of emesis, but denies fevers, chills, chest pain, shortness of breath, diarrhea, constipation, urinary symptoms, paresthesia, or weakness. She used to smoke marijuana in college and drinks about 2 beers a week. A physical examination demonstrates an overweight woman in acute distress with diffuse abdominal tenderness. Her vitals are within normal limits. Laboratory values are shown below:

Hemoglobin: 12 g/dL
Hematocrit: 34%
Leukocyte count: 4,900/mm^3 with normal differential
Platelet count: 160,000/mm^3

Serum:
Na+: 138 mEq/L
Cl-: 98 mEq/L
K+: 4.8 mEq/L
HCO3-: 25 mEq/L
Glucose: 123 mg/dL
Ca2+:  6.9 mg/dL
AST: 387 U/L
ALT: 297 U/L
ALP: 168 U/L
Lipase: 650 U/L (Normal 0 – 160 U/L)

What is the best next step in the workup of this patient?

Answer: Abdominal ultrasound

Choices:
A. Abdominal computed tomography with IV contrast
B. Abdominal computed tomography without IV contrast
C. Abdominal magnetic resonance imaging
D. Abdominal ultrasound
E. Upright chest and abdominal radiograph


Question: A 50-year-old man is evaluated for a 2-year history of intermittent, nonproductive, chronic cough, as well as mild dyspnea with exertion. He has a 20-pack-year history of smoking and is a current smoker. His medical history is significant for hypertension and type 2 diabetes mellitus, which he has controlled with diet and exercise. He also takes lisinopril. On physical examination, blood pressure is 125/76 mm Hg, pulse rate is 78/min, respiratory rate is 15/min, oxygen saturation is 98% (breathing room air), and his BMI is 25 kg/m2. There is no jugular venous distention. Heart sounds are normal, and there is no murmur. Auscultation of the lungs reveals faint, bilateral wheezing. No peripheral edema is noted. The remainder of the examination is normal. Which of the following is most likely to confirm the diagnosis for this patient?

Answer: Spirometry

Choices:
A. Chest CT scan
B. Measurement of protease inhibitor
C. Arterial blood gases (ABG)
D. Spirometry
E. Cardiac catheterization


Question: A 51-year-old woman presents with bilateral hand tremors. She has had these tremors for several years, and her symptoms have gradually worsened over time. The tremors are restricted to her hands and are most prominent when she is holding a cup of tea or a pen. The tremors get worse when she is under stress or exhausted, and they are starting to disrupt her work routine. She denies walking difficulties, speech problems, and weakness. Her past medical history is significant for a recent hospitalization for an asthma exacerbation. Current medications include salmeterol, medium-dose fluticasone, and a daily multivitamin. The patient denies smoking but drinks alcohol socially. The patient is afebrile and her vital signs are within normal limits. On physical examination, her hands have a noticeable tremor when in use and remain still while resting in her lap. Which of the following is the best course of treatment for this patient?

Answer: Primidone

Choices:
A. Baclofen
B. Levodopa-carbidopa
C. Primidone
D. Propranolol
E. Sodium valproate


Question: A 39-year-old female was involved in a head-on collision motor vehicle accident. If she was found to have a traumatic rupture of the aorta, where along the path of the aorta is the most common site of injury?

Answer: Aortic isthmus

Choices:
A. Ascending aorta
B. Site of attachment of ligamentum arteriosum
C. Aortic isthmus
D. Descending aorta - Thoracic aorta
E. Abdominal aorta


Question: A previously healthy 2-month-old boy is brought to the physician because of a 10-day history of poor feeding. He used to feed for 20 minutes but now needs 40 minutes. He struggles to breathe and sweats while feeding. He was born at 38 weeks' gestation. He is at the 20th percentile for length and 10th percentile for weight. His vital signs are within normal limits. Pulse oximetry on room air shows an oxygen saturation of 98%. A grade 3/6 holosystolic murmur is heard at the left lower sternal border. An ECG shows left-axis deviation. An x-ray of the chest shows an enlarged left atrium and ventricle and increased pulmonary vascular markings. Doppler echocardiography confirms the presence of an intracardiac shunt. Which of the following is the most likely explanation for the direction of flow of blood across this shunt?

Answer: Decrease in pulmonary vascular resistance

Choices:
A. Closure of the ductus arteriosus
B. Communication between the right and left atria
C. Right ventricular outflow tract obstruction
D. Increase in pulmonary vascular resistance
E. Decrease in pulmonary vascular resistance


Question: A 14-year-old boy is brought to the physician for a follow-up examination. He has allergic rhinitis and his only medication is cetirizine. He is at the 60th percentile for height and above the 95th percentile for weight and BMI. Vital signs are within the normal limits. Examination shows a slightly tender, firm, 1-cm subareolar mass in the left breast. There are no changes in the skin or nipple. The right breast is unremarkable. There is no palpable axillary lymphadenopathy. Axillary and pubic hair is present. Examination of the penis and testis shows no abnormalities. Neurologic examination shows no focal findings. Which of the following is the most likely cause of this patient's findings?

Answer: Physiological development

Choices:
A. Adverse drug reaction
B. Leydig cell tumor
C. Hyperthyroidism
D. Ductal ectasia
E. Physiological development


Question: A 54-year-old woman presents to her primary care physician complaining of a lump in her right breast. She first noticed it 1 month ago. Now she is worried that it may have grown. She claims that the lump is not painful or itchy, and she denies any abnormal nipple bleeding or discharge. She has a family history of breast cancer, including both her mother and older sister. Physical examination reveals a firm, immobile lump in the upper right breast. A mammogram is performed, which identifies an irregular mass with a fibrotically stranded border. A biopsy is performed that is positive for invasive ductal carcinoma. The patient is started on radiation induction therapy and scheduled for a modified radical mastectomy. Following tumor gene testing, the patient is found to be positive or the HER-2/neu oncogene. Which of the following should be started post-mastectomy to improve the patient’s prognosis?

Answer: Trastuzumab

Choices:
A. Anastrozole
B. Corticosteroids
C. Leuprolide
D. Tamoxifen
E. Trastuzumab


Question: A 48-year-old man presents to his primary care physician concerned about his weight. He states he has been gaining weight though does not feel he has changed his diet. The patient also states he has felt fatigued lately and not himself. He denies taking any medications or using any illicit substances at baseline. His temperature is 99.2°F (37.3°C), blood pressure is 177/108 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man with striae on his abdomen. A 24-hour urine free cortisol is collected and demonstrates an elevated cortisol level; however, a high dose of dexamethasone when administered results in no attenuation of cortisol release. A CT scan of the abdomen is within normal limits. Which of the following is associated with the most likely diagnosis?

Answer: History of smoking

Choices:
A. Adrenal adenoma
B. Decreased ACTH level
C. Enlargement of the facial bones
D. History of smoking
E. Increased personal stress and poor sleep habits


Question: Advances in molecular biology have identified important factors and sequences required for transcription and translation of mRNA as well as multiple diseases associated with mutations. The Kozak sequence is one such finding from this research. What is the Kozak consensus sequence?

Answer: An initiator of translation proximal to the start codon

Choices:
A. A sequence box that binds to NF-1
B. A 25-base upstream promoter of transcription
C. An untranslated region downstream of the the stop codon
D. An initiator of translation proximal to the start codon
E. A site to which the 50S ribosome binds


Question: A 3-week-old male infant is brought to the physician by his parents because they noticed that his head has been tilted to the left since birth. Physical examination shows the head turned toward the left side and the chin rotated toward the right. He cries during an attempt to rotate the head to the right. There is a firm, well-circumscribed mass on the left lower side of the neck. Which of the following is the strongest predisposing factor for this patient's condition?

Answer: Fetal macrosomia

Choices:
A. Fetal macrosomia
B. Cesarean delivery
C. Intrauterine exposure to haloperidol
D. Polyhydramnios
E. Preterm birth


Question: A 13-month-old boy was brought to the clinic due to failure-to-thrive and mental impairment. Retinal findings are shown in the picture. The parents are healthy, but they previously had a child who died at 14 months of age. What is the most likely cause for the underlying abnormalities?

Answer: Lysosomal enzyme mutation

Choices:
A. Structural protein mutation
B. Genomic imprinting
C. Lysosomal enzyme mutation
D. Robertsonian translocation
E. Mitochondrial gene mutation


Question: A 24-year-old woman who is 16 weeks pregnant comes to your office requesting a referral for an abortion. Upon questioning she states that she is scared that her baby will be "deformed" because on routine screening she was found to have an elevated level of alpha-fetoprotein. What is the most likely cause of this lab abnormality in this patient?

Answer: Inaccurate gestational age

Choices:
A. Trisomy 13
B. Trisomy 18
C. Trisomy 21
D. Neural tube defect
E. Inaccurate gestational age


Question: A previously healthy 45-year-old man is brought to the emergency department after being found by a search and rescue team in the mountains. He has been without food or water for 30 hours. His temperature is 37°C (98.6°F), pulse is 123/min, respirations are 20/min, and blood pressure is 90/55 mm Hg. Physical examination shows decreased skin turgor and dry mucous membranes. Evaluation of this patient's urine before treatment is initiated is most likely to show which of the following?

Answer: Low urine sodium with hyaline casts

Choices:
A. High urine urea with granular casts
B. Low urine sodium and low urine osmolality
C. Low urine sodium with hyaline casts
D. High urine protein with fatty casts
E. Low urine osmolality with RBC casts


Question: A 14-year-old Caucasian male presents with painful erythematous and honey-colored crusted lesions around his mouth. Culture of the lesions reveals gram-positive cocci in clusters. Further analysis reveals bacteria that are beta-hemolytic, coagulase positive, catalase positive, and appear golden on the blood agar plate. Which of the following helps the bacterium in this infection bind to immunoglobulin and prevent phagocytosis when invading its host?

Answer: Protein A

Choices:
A. Protein A
B. Staphylokinase
C. Exfoliatin A
D. Protein M
E. Neurotoxin


Question: A 70-year-old man comes to the physician for the evaluation of abdominal pain over the past month. The patient describes epigastric pain that radiates to the back. He also reports a 10-kg (22-lb) weight loss over the past 6 months. He has a history of untreated type 2 diabetes mellitus. He has not seen a doctor in 15 years. He is retired and spends most of his time at home watching TV. He rarely cooks and mainly eats fast food. He has smoked one pack of cigarettes daily for the past 50 years. He drinks 2–3 cans of beer per day. He appears pale. His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 150/90 mm Hg. Physical examination shows jaundice of the conjunctivae and the skin. The abdomen is soft, with no rebound or guarding. Laboratory studies show a serum glucose concentration of 260 mg/dL. Abdominal sonography shows enlargement of the gallbladder. Which of the following is most likely to have contributed to this patient's condition?

Answer: Smoking history

Choices:
A. Smoking history
B. Lack of physical activity
C. Poor dietary habits
D. History of alcohol use
E. Diabetes mellitus


Question: A 63-year-old African American man with a history of hypertension and dyslipidemia presents to the emergency department with facial swelling and difficulty breathing. Symptoms began suddenly that morning and continued to worsen. He started taking lisinopril several weeks ago. His blood pressure is 110/74 mm Hg, heart rate is 94/min, and respiratory rate is 20/min. Physical examination is notable for swelling of his lips and inspiratory stridor. Clinical lab results suggest a normal C1 esterase inhibitor level. Of the following options, which is the most likely diagnosis?

Answer: Drug-induced angioedema

Choices:
A. Scleredema
B. Erysipelas
C. Facial lymphedema
D. Drug-induced angioedema
E. Contact dermatitis


Question: A 21-year-old female college student comes to the physician because of a two-week history of vaginal itching and burning. She also noticed white vaginal discharge despite cleaning her genital area daily using a ""soap-free, natural"" vaginal douche. She is worried that she might have contracted a sexually transmitted disease after meeting her new boyfriend around one month ago. She has type 1 diabetes mellitus. The patient swims for the college swimming team. She had an intrauterine device implanted 3 months ago and does not use barrier protection. She smokes one pack of cigarettes per day and does not drink alcohol. Speculum examination shows an erythematous vagina covered in copious white discharge. Her vaginal pH is 4.4 and the microscopic image of a KOH preparation shows multiple pseudohyphae. Which of the following is the greatest predisposing factor for this patient's condition?"

Answer: Diabetes mellitus

Choices:
A. Smoking history
B. Frequent vaginal douching
C. Unprotected sexual intercourse
D. Intrauterine device
E. Diabetes mellitus


Question: A 72-year-old female recently fractured her hip in a fall. She suffers from regular joint pain in her fingers, and hip X-rays reveal low bone mineral density. She has a history of diabetes mellitus and was diagnosed 2 years ago with end-stage renal disease. Serum phosphate levels are markedly elevated. Which of the following likely contributes to her orthopedic problems?

Answer: Increased serum parathyroid hormone

Choices:
A. Decreased serum aldosterone
B. Increased serum parathyroid hormone
C. Increased serum glucose
D. Chronic hypertension
E. Chronic hypovolemia


Question: A 52-year-old man presents to his primary care physician for his annual check-up. He says that he has no health concerns; however, his wife is concerned that he has become increasingly forgetful. For example, he has become forgetful during his daily activities and recently has been getting lost during errands like shopping. She says that these symptoms have been occurring for about a year. She says that she became alarmed when he started forgetting the names of their children. Finally, over the last month he has become more irritable, which has led to several confrontations at work. Based on the age of onset for his disease, the patient is referred for genetic testing. Which of the following chromosomes contain genes that may be mutated in this patient's disease?

Choices:
A. 1
B. 4
C. 6
D. 18
E. 20


Question: A 23-year-old woman, gravida 2, para 1, at 13 weeks gestation, comes to the physician because of a 2-day history of burning pain during urination. She has been sexually active with different male partners during the pregnancy and did not use condoms. She has not had any fever, chills, or pelvic pain. Physical examination shows thick, purulent discharge from the urethra. Urine dipstick shows leukocyte esterase, urinalysis shows 10 WBCs/hpf, and Gram stain of the urethral swab shows polymorphonuclear leukocytes with intracellular gram-negative diplococci. Pelvic ultrasound shows a viable intrauterine pregnancy. Which of the following is the most appropriate treatment?

Answer:
Intramuscular ceftriaxone and oral azithromycin
"

Choices:
A. Oral levofloxacin
B. Oral cefixime and oral doxycycline
C. Intramuscular ceftriaxone
D. Oral erythromycin
E.
Intramuscular ceftriaxone and oral azithromycin
"


Question: A 20-year-old college student is brought to his primary care physician by his parents over the New Years holiday because they are concerned about his behavior since right after high school graduation in May the spring before. Prior to this year, he was generally an outgoing and social young man, who now reportedly has been spending the majority of his time alone in his dorm room and room at home, where his mother and father have overheard him talking to other people when he has no guests. When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove that will soon takeover the student union building by setting the trees on fire for all to see. On exam, his appears to be otherwise healthy and his urine toxicology screen is negative. What is the most likely diagnosis?

Answer: Schizophrenia

Choices:
A. Schizoaffective disorder
B. Major depression
C. Schizophrenia
D. Schizophreniform disorder
E. Malingering


Question: A 58-year-old man comes to the physician for evaluation of an increasing left-sided cheek swelling and recurrent oral ulcers for 1 year. He has smoked a pack of cigarettes daily for 25 years. Examination shows a mild, nontender swelling above the angle of the left jaw. An ultrasound-guided biopsy of the mass confirms the diagnosis of parotid adenoid cystic carcinoma. A left-sided total parotidectomy is performed. This patient is at greatest risk for which of the following complications?

Answer: Inability to wrinkle the left side of the forehead

Choices:
A. Hyperesthesia of the left ear lobe
B. Impaired taste of the posterior 1/3 of the tongue
C. Flushing of the right cheek while eating
D. Inability to wrinkle the left side of the forehead
E. Hyperacusis of the left ear


Question: A 34-year-old man comes to the physician for a routine health maintenance examination required for his occupation as a school bus driver. He feels well and healthy. Upon questioning, he reports that he has smoked 2 joints of marijuana every night after work for the past year for recreational purposes. He typically smokes 5 joints or more on weekends. Which of the following responses by the physician is the most appropriate?

Answer: """Have you ever experienced a situation in which you wished you smoked less marijuana?"""

Choices:
A. """Let me know when you are ready to stop smoking marijuana. We can talk about specific strategies to help you quit at that time."""
B. """Have you ever experienced a situation in which you wished you smoked less marijuana?"""
C. """When did you start being dependent on marijuana consumption?"""
D. """We have a great program to help patients with substance use disorder issues. Let me give you more information about specific details."""
E. """You should stop smoking marijuana because it is not good for your health."""


Question: A 6-year-old girl of Moroccan descent is brought to the pediatrician by her father who is concerned about the child developing a body odor. He reports that she has started to smell “like a teenage boy” especially after physical activity. The child has had limited medical follow-up since being born in Morocco and immigrating to the United States at 3 years of age. Her temperature is 99°F (37.2°C), blood pressure is 150/90 mmHg, pulse is 85/min, and respirations are 18/min. On exam, she has hair in her axillary and pubic regions. Genital examination demonstrates clitoral enlargement and labioscrotal fusion. Which of the following metabolites is most likely elevated in this patient?

Answer: 11-deoxycorticosterone

Choices:
A. Aldosterone
B. Corticosterone
C. Cortisol
D. 11-deoxycorticosterone
E. Leutenizing hormone


Question: A 25-year-old woman presents to the clinic for burning with urination. She is a newlywed and reports 3 similar episodes within the past 4 months. She claims that since yesterday she has noticed a burning sensation whenever she urinates, an increase in urinary frequency, and some clear vaginal discharge. She denies fever, chills, back pain, or chest pain. Her past medical history is significant for chlamydia that was adequately treated 3 years ago. She is currently sexually active with her husband and has an IUD. She is subsequently prescribed a course of nitrofurantoin for her symptoms. While getting up to leave, the patient asks “why is it that I always get these symptoms but my husband is fine?” What is the most appropriate answer to this patient’s question?

Answer: The female urethra is shorter

Choices:
A. Her partner is an asymptomatic carrier
B. Inadequate treatment of her prior episodes
C. The female urethra is shorter
D. The patient is experiencing recurrence of her past chlamydial infection
E. There is no explanation


Question: A 17-year-old boy comes to the physician 1 week after noticing a lesion on his penis. There is no history of itching or pain associated with the lesion. He is sexually active with two female partners and uses condoms inconsistently. Five weeks ago, he returned from a trip to the Caribbean with some of his football teammates. He takes no medications. He has recently started an intense exercise program. His vital signs are within normal limits. Physical examination shows multiple enlarged, nontender lymph nodes in the inguinal area bilaterally. A photograph of the lesion is shown. Which of the following is the most likely pathogen?

Answer: Treponema pallidum

Choices:
A. Trichophyton rubrum
B. Mycoplasma genitalium
C. Human papillomavirus
D. Treponema pallidum
E. Herpes simplex virus type 2


Question: A 36-year-old man presents to a physician for a post-transplant medical evaluation. He has been taking prednisone and azathioprine for the last 6 months after receiving a cadaveric renal transplant. He complains of fever, cough, and anorexia for the last 6-7 days. His cough is productive of thick sputum. His temperature is 38.5°C (101.5°F). The physical examination is significant for diminished breath sounds over the left lower lung with dullness on percussion and increased vocal resonance. A left lower lobe nodule, 5 cm (2 in) in diameter with eccentric central cavitation, is visible on the chest X-ray. A sputum analysis reveals branched, irregular, gram-positive filamentous rods. Which of the following constitutes the first-line therapy in this patient?

Answer: Sulfisoxazole

Choices:
A. Erythromycin
B. Ceftazidime
C. Penicillin
D. Sulfisoxazole
E. Tobramycin


Question: A 54-year-old woman presents to her gynecologist complaining of incontinence. She reports leakage of a small amount of urine when she coughs or laughs as well as occasionally when she is exercising. She denies any pain with urination. She underwent menopause 2 years ago and noted that this problem has increased in frequency since that time. Her history is significant only for three uncomplicated pregnancies with vaginal births. Urinalysis, post-void residual, and cystometrogram are conducted and all show normal results. The patient's vital signs are as follows: T 37.5 C, HR 80, BP 128/67, RR 12, and SpO2 99%. Physical examination is significant for pelvic organ prolapse on pelvic exam. Which of the following is a reasonable first step in the management of this patient's condition?

Answer: Kegel exercises

Choices:
A. Kegel exercises
B. Imipramine
C. Bethanechol
D. Urethropexy
E. Tension-free vaginal tape


Question: Researchers from a public health institute located in the United States conducted a multicenter cohort study on a large number of elderly individuals in order to evaluate the protective effect of the new vaccine for herpes zoster (commonly known as shingles) reactivation. After a long follow-up period, the data shows that shingles developed in 15% of study participants who received the new vaccine compared to 20% of diseased study participants in the control group that did not receive the vaccine. If the new vaccine showed identical efficacy in groups with higher and lower risks of herpes zoster reactivation (e.g., 40% and 10% risk), the calculated protective proportion of 25% would be maintained, regardless of the different baseline risk for shingles development. What is this metric also known as?

Answer: Relative risk reduction

Choices:
A. Event rate
B. Risk difference
C. Attributable difference
D. Relative risk reduction
E. Absolute risk reduction


Question: A 55-year-old gentleman has been working in a sand blasting factory for over 25 years. He presents to his primary care physician with what he describes as increasing shortness of breath. PFTs are performed describing a restrictive lung process. Which of the following has most likely been the long-term mechanism of his disease development?

Answer: Phagocytosis of silica

Choices:
A. Eosinophilic reaction
B. Phagocytosis of silica
C. Tuberculosis
D. Primary lung cancer
E. Defective mucociliary transport


Question: A 37-year-old man presents to the emergency department with acute loss of vision, slurred speech, and agitation. Past medical history is significant for HIV and hepatitis C, diagnosed 10 years ago for which he is non-compliant with medication. A T1 MRI of the brain shows asymmetric, hypointense white matter lesions. Which of the following pathogens is most likely responsible for this patient’s opportunistic infection?

Answer: JC virus

Choices:
A. Mycobacterium avium complex
B. Herpes virus 8
C. Candida albicans
D. JC virus
E. Pneumocystis jirovecii


Question: A 4-year-old girl is brought to the physician for evaluation of a rash that her mother noticed 5 months ago. The rash is not painful or itchy but she notices that her daughter sometimes picks at the “spots.” The girl's 2-year-old brother has also started developing similar skin lesions over the past month. The patient has no history of serious illness and takes no medications. She is in the 75th percentile for height and 50th percentile for weight. A photograph of the patient's rash is shown. Which of the following infectious agents is the most likely cause of this patient's skin condition?

Answer: Poxvirus

Choices:
A. Human herpesvirus 8
B. Human papillomavirus
C. Herpes simplex virus 1
D. Poxvirus
E. Varicella-zoster virus


Question: A 51-year-old police officer is brought to the emergency room after being shot in the abdomen. His wound was packed and bandaged by emergency medical services before he was transported to the hospital. His past medical history is notable for hypertension and diabetes. He takes metformin and lisinopril. He has a 20-pack-year smoking history and does not drink alcohol. His temperature is 98.6°F (37°C), blood pressure is 142/86 mmHg, pulse is 120/min, and respirations are 24/min. On exam, he appears uncomfortable but is able to answer questions appropriately. He has a 1 cm x 1 cm wound in the left upper quadrant. There is an exit wound in the left lower back. After undergoing the appropriate laboratory and imaging tests, he undergoes a diagnostic laparotomy. No involvement of the colon or small intestine is noted intraoperatively. He is placed on the appropriate antibiotic and pain control regimens. Three days later, he experiences several episodes of non-bloody diarrhea. His temperature is 101°F (38.3°C). Sigmoidoscopy reveals multiple pseudomembranous plaques in the sigmoid and descending colon. This patient's symptoms are most likely due to taking an antibiotic that inhibits which of the following enzymes?

Answer: 50S ribosomal subunit

Choices:
A. 30S ribosomal subunit
B. 50S ribosomal subunit
C. Dihydropteroate synthetase
D. DNA-dependent RNA polymerase
E. DNA gyrase


Question: A 3-year-old girl is brought to the physician by her parents for the evaluation of vaginal discharge for one month. The discharge is foul-smelling and contains some blood. The patient sometimes has pain with urination. She has not had increased urinary frequency or abdominal pain. Topical vaginal cream application did not improve the patient's symptoms. There is no personal or family history of serious illness. She lives with her parents and attends a local daycare center. Vital signs are within normal limits. Examination of the vulva and vaginal entrance shows an intact hymen, vaginal erythema with blood-tinged, foul-smelling discharge, and the tip of a white object. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

Answer: Vaginal irrigation with warm saline

Choices:
A. Vaginal irrigation with warm saline
B. Colposcopy
C. Vacuum suction
D. Alert Child Protective Services
E. Administration of oral metronidazole


Question: A 60-year-old man comes to the physician because of a 3-month history of a slowly enlarging painless ulcer on his lower lip. One year ago he had a painful rash near his upper lip that resolved completely with acyclovir therapy. He has a 10-year history of type 2 diabetes mellitus treated with metformin. He has worked in construction for the past 33 years. He has smoked one pack of cigarettes daily for 35 years. Examination shows a 0.5 x 0.5 cm nontender ulcer with everted edges on the midline of his lower lip. The erythematous ulcer bleeds upon palpation. He has numerous moles of varying sizes all over his body. There are no palpable cervical lymph nodes. Which of the following is the most likely diagnosis?

Answer: Squamous cell carcinoma

Choices:
A. Squamous cell carcinoma
B. Aphthous stomatitis
C. Psoriasis
D. Seborrheic keratosis
E.
Actinic keratosis
"


Question: A 3-year-old girl is brought to the pediatrician by her father for fever and cough. The patient’s father states that she had a sore throat and runny nose 2 weeks ago. Then last night she developed a productive cough and a fever. The father is worried that this is pneumonia again, and reports that she has been hospitalized 5 times already with pneumonia. Her medical history is also significant for chronic diarrhea. The father reports that the patient has 2 older brothers who are both healthy. The patient’s temperature is 102°F (38.9°C), blood pressure is 102/60 mmHg, pulse is 110/min, and respirations are 28/min with an oxygen saturation of 94% on room air. On physical examination, decreased breath sounds are appreciated on the right. A chest radiography shows consolidation in the right upper lobe, consistent with pneumonia. An antibody panel and flow cytometry are obtained in the setting of the patient’s recurrent infections. The results show a normal lymphocyte count with low levels of IgA, IgG, and IgE and elevated levels of IgM. Which of the following is the patient most at risk for developing?

Answer: Blurry vision

Choices:
A. Ataxia
B. Atopic dermatitis
C. Blurry vision
D. Lymphoma
E. Scant tonsils


Question: A 72-year-old man presents with urinary frequency resulting in frequent awakening to urinate at night. He is a retired elite runner and does not have a history of any chronic medical conditions. The patient denies weight loss, bone pain, or pain with urination. The patient is not in distress. Vitals show: temperature 36.8°C (98.2°F), heart rate 98/min, respiratory rate 15/min, and blood pressure 100/75 mm Hg. Physical exam is significant for a smooth, non-tender, uniformly enlarged prostate on digital rectal exam. There is no CVA tenderness. CBC, CMP, urinalysis, and abdominal ultrasound are ordered. Significant findings include: bilateral hydronephrosis on ultrasound, BUN/creatinine > 20:1, specific gravity > 1,020, FENa < 1%, urine Na < 20, and urine osmolality > 450 mOsm/kg. Furthermore, post-void residual volume is > 100 mL. Which type of patient would least likely have these same diagnostic findings?

Answer: A 35-year-old woman with severe colicky pain radiating to the left flank

Choices:
A. A 55-year-old Egyptian man with painless hematuria, 18.1 kg (40 lb) incidental weight loss and confirmed Schistosoma hematobium infection
B. A 27-year-old woman with waxing and waning internuclear ophthalmoplegia, scanning speech, and optic neuritis
C. An ICU patient with a kinked Foley catheter
D. A multiparous obese woman presenting with urinary incontinence, pelvic fullness, and a vaginal bulge
E. A 35-year-old woman with severe colicky pain radiating to the left flank


Question: An 82-year-old man with Alzheimer disease is brought to the physician by his daughter because of extensive bruising on his arms. He lives in an assisted living facility. Physical examination shows large ecchymoses across both forearms and upper arms in varied stages of healing. His hemoglobin concentration is 11.7 g/dL, mean corpuscular volume is 78 μm3, and platelet count is 180,000/mm3. Coagulation studies are within normal limits. Which of the following is the most likely etiology of his bruises?

Answer: Nonaccidental trauma

Choices:
A. Platelet aggregation inhibition
B. Intravascular coagulation with fibrinolysis
C. Increased activity of epidermal melanocytes
D. Nonaccidental trauma
E. Vitamin K deficiency


Question:
A 23-year-old woman presents to her gynecologist for a routine visit. She is nulliparous, does not report any gynecologic or systemic diseases, and has no complaints. She is sexually active with one partner and uses oral contraceptive pills. Her vital signs are as follows: blood pressure 125/70 mm Hg, heart rate 81/min, respiratory rate 12/min, and temperature 36.6℃ (97.9℉). The physical examination is within normal limits. The breast examination is normal. No pathology is noted in the external genitalia and a speculum examination reveals a normal cervix with a closed external os and no discharge. A specimen is obtained from the cervical portion for a Pap smear. On bimanual examination, the uterus is normal size, non-tender, and mobile adnexa is non-palpable.
The pap smear result is as follows:
The pap smear result is as follows:
Specimen adequacy: satisfactory for evaluation
Interpretation: negative for intraepithelial lesion or malignancy
Notes: absent transformation zone component
How should we proceed with the management of this patient?

Answer: Repeat Pap test in 3 years as a usual screening schedule suggests

Choices:
A. Repeat Pap test in 3 years as a usual screening schedule suggests
B. Repeat Pap test within 2 weeks and ensure proper sampling from the transformation zone
C. Perform a screening test for high-risk human papillomavirus (HPV)
D. Recommend genotyping for HPV types 16 and 18
E. Perform a HPV testing and Pap smear in one year


Question: A 57-year-old woman presents to the emergency department with acute pain in the left lower abdomen associated with nausea and vomiting for the past 24 hours. Prior to this episode, the patient did not have any significant gastrointestinal (GI) problems except for occasional constipation and indigestion after heavy meals. She has had hypertension and hypercholesterolemia for the past 7 years. Her family history is negative for GI disorders. Vital signs include a temperature of 38.0°C (100.4°F), blood pressure of 120/80 mm Hg, and pulse of 85/min. On physical examination, there is tenderness in the left lower abdominal quadrant. Abdominal CT scan shows thickening of the bowel wall and streaky mesenteric fat. Which of the following best describe the primary disorder in this patient?

Answer: Herniation of mucosa and submucosa through the muscular layer of the colon

Choices:
A. Obstruction of the lumen of the appendix
B. Decreased blood flow to the GI tract
C. Inflammation of the renal parenchyma, calyces and pelvis
D. Herniation of mucosa and submucosa through the muscular layer of the colon
E. Inflammation of the upper genital tract


Question: A 35-year-old woman comes to the emergency department because of a 3-day history of pain in the left cheek. The pain occurs every few hours, lasts 30–60 seconds, and is aggravated by chewing and brushing. She has a history of pain with a vesicular rash in the right axillary area one year ago. She had an upper respiratory infection 2 weeks ago. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

Answer: Trigeminal neuralgia

Choices:
A. Cluster headache
B. Trigeminal neuralgia
C. Postherpetic neuralgia
D. Sinus headache
E. Temporal arteritis