Question: A 52-year-old man presents to the clinic complaining of blood in his urine. He had a mild respiratory illness 3 weeks ago. Urinalysis reveals a high red blood cell count and casts in the urine. A diagnosis of post-streptococcal glomerulonephritis is made. The physician explains that the treatment is supportive and that the patient needs to follow up with him every two weeks. Six weeks later, the patient returns to the clinic because he does not feel well; he has been experiencing malaise and fatigue. On examination, his pulse is 98/min, blood pressure is 135/85 mm Hg, temperature is 36.6°C (98.0°F), and respiratory rate is 16/min. He has a mildly distended abdomen. Blood tests reveal that the patient’s creatinine level has increased from 1.2 mg/dL to 3.0 mg/dL over the last month. He is referred to a nephrologist who diagnoses him with rapidly progressive glomerulonephritis (RPGN) and starts him on hemodialysis, as his potassium level has risen to 7 mEq/dL. The patient is advised to undergo renal transplantation. His human leukocyte antigen (HLA) genotype is A7/A5, B2/B9, C8/C3. The first allele in each locus is the maternal form; the second is paternal. Several potential donors are available for the renal graft. Which of the following would be the closest match?

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

Choices:
A. Donor B: tA5/A12, tB22/9, ttC4/C3
B. Donor A: tA7/A5, ttB8/B2, ttC3/C8
C. Donor E: tA7/A8, ttB9/B27, tC3/C4
D. Donor C: tA7/A4, ttB2/B4, ttC8/C3
E. Donor D: tA4/A7, ttB1/B8, ttC8/C3


Question: An investigator is studying determinants of childhood obesity by observing a cohort of pregnant women with obesity. After delivery, he regularly records the height and weight of the cohort's children. The results of the correlation analysis between mean childhood BMI at 4 years of age and mean maternal BMI before pregnancy are shown. Based on these findings, which of the following is the most likely correlation coefficient?

Answer: 0.45

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


Question:
A 25-year-old woman comes to the physician for a routine examination. She is a recreational runner and for the past 3 months she has been training for a marathon. Yesterday she ran 17 km (10.5 mile). Menses occur at regular 28-day intervals and last 6 days. She drinks three to five beers when going out with friends. She follows a vegan diet. She appears well. Her temperature is 36.6°C (98.0°F), blood pressure is 110/72 mm Hg, pulse is 70/min, and respirations are 14/min. Physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 9.8 g/dL
Mean corpuscular volume 91 fL
Lactate dehydrogenase 400 U/L
Platelet count 250,000/mm3
Reticulocyte count 3%
Haptoglobin 23 mg/dL (N=41–165 mg/dL)
Serum
Iron 90 μg/dL
Ferritin 170 ng/mL
Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL)
Urinalysis shows trace blood but no RBCs. Which of the following is the most likely cause of this patient's anemia?"

Answer: Intravascular hemolysis

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


Question: A 45-year-old man comes into the ED after a car accident. After waiting an hour in the waiting room, he begins to berate the receptionist and demands to be seen by a doctor. During the exam, the patient brags that he recently had to quit his job because they did not appreciate his talent and drive. After a medical student declines his invitation for a date, he becomes very angry and throws supplies across the room. The physician manages the patient's physical injuries and begins to suspect the patient has a personality disorder. Which personality disorder is most likely?

Answer: Narcissistic personality disorder

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


Question: A 61-year-old man comes to the physician because of weight loss and a non-productive cough for 4 months. He has smoked 2 packs of cigarettes daily for 42 years. A CT scan of the chest shows an irregular mass at the right hilum and axillary lymphadenopathy. A biopsy of the mass obtained on bronchoscopy confirms the diagnosis of metastatic non-small cell lung cancer. Results of a molecular diagnostic test show a microdeletion on the short arm of chromosome 7. The physician recommends chemotherapy with erlotinib. The beneficial effect of this drug is most likely due to arrest in which of the following phases of the cell cycle?

Answer: G1 phase

Choices:
A. G2 phase
B. M phase
C. G1 phase
D. G0 phase
E. S phase


Question: A 52-year-old woman comes to the physician because of a 4-day history of painful swallowing and retrosternal pain. She was diagnosed with HIV infection 2 months ago; her medications include tenofovir, emtricitabine, and raltegravir. Vital signs are within normal limits. Physical examination of the oral cavity shows no abnormalities. The patient's CD4+ T-lymphocyte count is 70/mm3 (N ≥ 500). Empiric treatment is started. Two weeks later, she reports no improvement in symptoms. Esophagogastroduodenoscopy is performed and shows multiple round superficial ulcers in the distal esophagus. Which of the following is the most likely underlying cause of this patient's symptoms?

Answer: Infection with herpes simplex virus

Choices:
A. Adverse effect of medication
B. Degeneration of ganglion cells within the myenteric plexuses
C. Eosinophilic esophageal infiltrate
D. Infection with herpes simplex virus
E. Infection with Candida species


Question:
An 18-year-old girl comes to the emergency room with abdominal pain. She states that the pain started 6 hours ago, is 8/10, and localizes to the right lower abdomen. She recalls a similar episode last month. Her older brother was hospitalized 2 years ago for perforated appendicitis. Her mother has diverticulitis. The patient got her first menstrual period at age 14. Her periods occur regularly every 28 days. Her last menstrual period was 2 weeks ago. She is sexually active with multiple partners and uses condoms inconsistently. The patient’s temperature is 99°F (37.2°C), blood pressure is 110/74 mmHg, pulse is 89/min, and respirations are 14/min with an oxygen saturation of 98% on room air. On physical exam, the patient is in moderate distress. There is lower abdominal tenderness with guarding. A pelvic examination reveals clear mucous in the vaginal introitus, a mobile uterus, and tenderness of the right adnexa. Labs are obtained, as shown below:

Leukocyte count: 10,000/mm^3 with normal differential
Hemoglobin: 13.5 g/dL
Platelet count: 200,000/mm^3
Beta-human chorionic gonadotropin: Pending

A pelvic ultrasound demonstrates a small fluid collection in the cul-de-sac posterior to the uterus. Which of the following is the most likely diagnosis?

Answer: Midcycle pain

Choices:
A. Appendicitis
B. Endometriosis
C. Midcycle pain
D. Pelvic inflammatory disease
E. Ruptured ectopic pregnancy


Question: In a suburban town in Virginia, epidemiologists are alarmed by the increasing number of squamous cell lung cancer cases. Further investigation reveals that most people in the area work in a glass factory, the region’s main source of employment. A researcher is interested in studying the role of immunosurveillance in the pathogenesis of this lung cancer. He postulates that tumor infiltration by natural killer (NK) cells has a better prognosis since they play a major role in immunosurveillance. NK cells also kill tumor cells by the perforin-mediated destruction of cancerous cells. The researcher is interested in studying tumor infiltration by NK cells in the resected specimen from patients within the cohort who have been diagnosed with stage 1 lung cancer. Which of the following cluster of differentiation markers will he need to use to identify these cells in the resected specimens?

Answer: CD56

Choices:
A. CD20
B. CD3
C. CD34
D. CD117
E. CD56


Question: A 26-year-old man presents to the office complaining of persistent back pain for the past 3 months. You saw the patient previously and prescribed NSAIDs and rest, but he has not improved. The patient states that his maternal grandfather had ‘back problems his whole life’, and he worries that he might have the same issues. An X-ray is performed and shows squaring of the vertebrae with longitudinal fibrous bands. What is the most likely diagnosis?

Answer: Ankylosing spondylitis

Choices:
A. Scoliosis
B. Ehlers-Danlos syndrome
C. Osteosarcoma
D. Ankylosing spondylitis
E. Osteopetrosis


Question: A regional hospital system has decided to institute a new task group for quality improvement and patient safety. The task group would like to begin by decreasing the number of days given for narcotic pain medication prescriptions in the emergency department to at most 7 days instead of the hospital average of 21 days per prescription. Which of the following interventions would be most successful at achieving the task group’s mission?

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

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


Question: A 57-year-old man comes to the clinic complaining of nausea and 1 episode of vomiting during the past day. He denies any precipitating event except for a headache for which he took some acetaminophen yesterday. The headache is described as bilateral, dull, and 8/10 in severity. He has never had such symptoms before. His past medical history is significant for hypertension, biliary colic, and a past hospitalization for delirium tremens when he “tried to quit alcohol cold turkey.” When asked about his current alcohol intake, the patient looks away and mutters “just a couple of drinks here and there.” The patient reports mild abdominal pain that began this morning but denies vision changes, bowel changes, fever, or weight loss. Physical examination demonstrates tenderness at the right upper quadrant (RUQ) that does not worsens with inhalation. What is the most likely explanation for this patient’s symptoms?

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

Choices:
A. Accumulation of N-acetyl-p-benzoquinone imine in the liver
B. Impaction of a gallstone in the ileus
C. Malignant overgrowth of glial cells in the brain
D. Obstruction of the cystic duct by gallstone
E. Upregulation of alpha-2 adrenergic receptors


Question:
A 48-year-old patient comes to the physician because of a 4-day history fever, headaches, loss of appetite, and myalgia. Two weeks ago, the patient went on a camping trip to Wisconsin. His temperature is 39.5°C (103.1°F). Physical examination shows no rash or joint swelling. Laboratory studies show:
Hemoglobin 14.1 g/dL
Leukocyte count 3,800/mm3
Platelet count 85,000/mm3
Serum
AST 48 U/L
ALT 52 U/L
Treatment with doxycycline is begun and the patient recovers. A paired acute and convalescent indirect fluorescent antibody test confirms that the patient had anaplasmosis. The patient's condition was most likely transmitted by which of the following vectors?"

Answer: Ixodes tick

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


Question: A 42-year-old woman comes to the clinic complaining of upper abdominal pain. Her symptoms started 1 month ago with vague abdominal discomfort following a meal at a steakhouse. Since then the pain has progressed to the point that she has more than 5 episodes a week. The pain is worse with eating but has not affected her appetite. She also reports a burning sensation in her chest when she lies down at night after dinner. She denies weight loss or dysphagia. She takes no medications except daily calcium supplements. She drinks 2 glasses of wine per week and denies tobacco use. Her blood pressure is 110/78, pulse is 72/min, and respirations are 13/min. On physical examination, the patient’s abdomen is soft and non-distended. Normal bowel sounds are appreciation. There is mild epigastric tenderness but no guarding and no rebound. Fecal occult blood is negative. Which of the following is the next best step in management?

Answer: Start omeprazole

Choices:
A. Start antibiotic therapy
B. Start omeprazole
C. Stool antigen test for Helicobacter pylori
D. Surgical fundiplication
E. Upper gastrointestinal endoscopy


Question: A 3-year-old boy presents to the pediatrician crying with ear pain and his temperature has been 101°F (38.3°C) for several days. His mother states that other children at his daycare center have been having similar symptoms. She further describes that he was fed formula and was not breastfed. The mother admits that she smokes cigarettes daily. On exam, the boy is irritable and crying, and frequently tugs on his left ear. Both tympanic membranes appear erythematous, and the left appears opaque and bulging with decreased mobility on pneumatic otoscopy. Which of the following is the best next step in management?

Answer: Amoxicillin

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


Question: A 47-year-old G3P2 woman presents to her endocrinologist for a follow-up appointment. Her last menstrual period was at the age of 35 years. She now feels fatigued and cannot concentrate on her work or type properly on the keyboard because of an onset of tremor in her hands. Her symptoms are taking a toll on her quality of life. The patient’s blood pressure is 124/83 mm Hg, pulse is 91/min, respirations are 17/min, and temperature is 36.7°C (98.1°F). On physical examination, there is a mild enlargement of the thyroid; the gland is minimally firm in texture and is nontender. Which of the following pathologic findings is she most likely to have?

Answer: Silent thyroiditis

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


Question:
A 44-year-old woman is brought to the emergency department after she was found lying in the park mumbling to herself. She is lethargic and disoriented. She has a 2-week history of increasing weakness, nausea, and vomiting. She denies any recent alcohol or drug use. She has a history of systemic lupus erythematosus but stopped taking methotrexate many years ago. Her temperature is 37.3°C (99.1°F), pulse is 89/min, and blood pressure is 154/91 mm Hg. On mental status examination, she is confused and only oriented to person, but not to place or time. She is unable to name the days of the week backwards. She exhibits moderate generalized weakness. Physical exam shows jugular venous distention and pitting edema in the lower extremities. Laboratory studies show:
Serum
Na+ 137 mEq/L
K+ 5.5 mEq/L
Cl- 120 mEq/L
Bicarbonate 15 mEq/L
Urea nitrogen 94 mg/dL
Creatinine 5.5 mg/dL
Glucose 92 mg/dL
Which of the following is the most appropriate next step in management?"

Answer: Hemodialysis

Choices:
A. Administer lactulose
B. Hemodialysis
C. Restart methotrexate
D. Begin low-protein diet
E. Fluid restriction


Question: An investigator is studying the secretion of gastrointestinal hormones before and after food intake. She isolates a hormone that accelerates the emptying of gastric contents into the duodenal bulb. The isolated hormone is most likely which of the following?

Answer: Gastrin

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


Question: A 45-year-old woman presents to the office with a chief complaint of a cough that has persisted for a month and a half. She also has night fevers and has lost 5 kg (11 lb) in the last 2 months. She recently returned from a 6-month trip to Peru. Her vitals include: heart rate 82/min, respiratory rate 17/min, temperature 38.0°C (100.4°F), and blood pressure 107/80 mm Hg. On auscultation, she has diminished respiratory sounds at the base of the right lung. Chest radiography shows an opacity in the right apex. What is the most likely cause of her presentation?

Answer: Tuberculosis

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


Question:
A 52-year-old homeless man is brought to the urgent care clinic with altered mental status and disorientation for the last day. Past medical records are unavailable. His temperature is 37°C (98.6°F), the respiratory rate is 15/min, the pulse is 107/min, and the blood pressure is 92/67 mm Hg. He has a flapping tremor of the wrists during attempted extension. He is started on intravenous D5 1/2NS and blood is drawn for further testing. His condition deteriorates overnight. On re-examination the next morning, he has developed visual disturbances with a new horizontal nystagmus and a staggering gait. His blood tests show:
Serum
Albumin 3.2 gm/dL
Alkaline phosphatase 150 U/L
Alanine aminotransferase 76 U/L
Aspartate aminotransferase 155 U/L
Gamma-glutamyl transpeptidase 202 U/L
What is the most likely diagnosis?

Answer: Wernicke's encephalopathy

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


Question: A 27-year-old woman comes to the emergency department at 14 weeks gestation with abdominal pain. She states she has passed a large amount of blood from her vagina in the past 2 hours. Her vitals are within normal limits and she describes her abdominal pain as a 4/10. Physical exam is notable for a dilated cervix. The patient states she does not want any invasive procedures in her workup but is accepting to necessary medical interventions. Which of the following is the best next step in management?

Answer: Expectant management

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


Question: A 25-year-old female is admitted to the hospital for an intrauterine fetal demise (IUFD) during her 30th gestational week. The patient did not receive any prenatal care or screenings. The baby is delivered via C-section and the family wishes to conduct an autopsy to understand the reason for the IUFD and to better prepare for future pregnancies. On autopsy, the fetus is discovered to have severe facial abnormalities as well as a brain lacking the normal sagittal fissure. Which of the following genes was most likely mutated in this fetus?

Answer: Sonic hedgehog

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


Question:
A healthy 32-year-old woman enrolls in a study investigating kidney function. Her renal plasma flow (RPF) is 600 mL/min. She is administered an intravenous substance that does not undergo tubular reabsorption. The following sets of measurements are taken every 10 minutes:
Plasma concentration of substance Excretion rate of substance
Set 1 0.1 mg/mL 60 mg/min
Set 2 0.15 mg/mL 90 mg/min
Set 3 0.2 mg/mL 104 mg/min
Set 4 0.25 mg/mL 110 mg/min
Set 5 0.3 mg/mL 116 mg/min
This patient was most likely administered which of the following substances?"

Answer: Para-aminohippurate

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


Question: A 6-year-old girl is brought to the physician for a well-child examination. She has no history of serious illness. Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 96/52 mm Hg. Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border that radiates towards the neck. The murmur disappears when she flexes her neck. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

Answer: Venous hum

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


Question: A 72-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department with three-days of fever, cough, and shortness of breath. On physical exam, temperature is 101.3 deg F (38.5 deg C), pulse is 106/min, blood pressure is 148/92 mmHg, and respiratory rate is 24/min. Crackles are auscultated on the right lower lobe. Chest radiograph demonstrates right lower lobe opacities concerning for consolidation. Sodium level is 118 mEq/L. He is admitted to the hospital on empiric antibiotics. What is the most appropriate management of this patient’s hyponatremia?

Answer: Fluid restriction

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


Question:
A 75-year-old man presents to the physician for a follow-up examination. Over the last several months, he reports dyspnea when walking during his daily exercise routine. He feels tired most of the time. He has no fever or weight loss. He has no history of severe illness and takes no medications. He does not smoke, drinks alcohol, or follow a particular diet. The vital signs are within normal limits. The physical examination reveals pale conjunctiva. The examination of the heart, lungs, abdomen, and extremities shows no abnormalities. No lymphadenopathy is palpated. The laboratory studies show the following:
Hemoglobin 8.5 g/dL
Mean corpuscular volume 105 μm3
Leukocyte count 4,500/mm3
Platelet 160,000/mm3
Abdominal ultrasonography shows no organomegaly or other pathologic findings. The peripheral blood smear shows large and hypogranular platelets and neutrophils with hypo-segmented or ringed nuclei. No blasts are seen. Bone marrow aspiration shows hypercellularity. In addition, ring sideroblasts, hypogranulation, and hyposegmentation of granulocyte precursors, and megakaryocytes with disorganized nuclei are present. Marrow myeloblasts are 4% in volume. Which of the following best explains these findings?

Answer: Myelodysplastic syndrome

Choices:
A. Acute myeloid leukemia
B. Aplastic anemia
C. Myelodysplastic syndrome
D. Primary myelofibrosis
E. Vitamin B12 deficiency


Question: A 37-year-old man comes to the physician because of a 1-month history of a burning sensation in his chest. The sensation is most prominent when he is lying in bed, but it is also present after eating heavy meals. He also states his breath has an unpleasant odor in the morning. He has not lost any weight during this period. He has hypothyroidism. His father died of colon cancer and his mother has hypertension. He has smoked one pack of cigarettes daily for 15 years and drinks 2–3 beers on weekends. His medications include levothyroxine and an over-the-counter multivitamin. He is 170 cm (5 ft 7 in) tall and weighs 95 kg (210 lb); BMI is 32.9 kg/m2. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the next best step in management?

Answer: Proton-pump inhibitor

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


Question: A 36-year-old man presents with right upper quadrant pain, fatigue, and pruritus. His past medical history is significant for ulcerative colitis diagnosed 5 years ago, which is well-managed medically. He is vaccinated against hepatitis A and B and denies any recent travel abroad. On physical examination, mild jaundice of the skin is present. An abdominal examination reveals significant hepatosplenomegaly. A percutaneous liver biopsy is performed. Which of the following histopathologic findings would most likely be seen on the liver biopsy of this patient?

Answer: Onion skin fibrosis (concentric periductal fibrosis)

Choices:
A. Small drops of fat throughout the liver parenchyma
B. Normal histologic findings
C. Mononuclear cell infiltrate and apoptotic hepatocytes
D. Damage to the basement membrane of the biliary ducts and reactive hyperplasia of the epithelial duct lining
E. Onion skin fibrosis (concentric periductal fibrosis)


Question: A 26-year-old man is brought to the emergency department because he has had abdominal pain, nausea, and vomiting for the past 2 hours. He ate a sandwich and coleslaw from a deli about 1 hour before the symptoms began. He has no history of serious illness and takes no medications. His temperature is 99.6°F (37.6°C), pulse is 80/min, respirations are 18/min, and blood pressure is 122/68 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. Abdominal examination shows diffuse mild tenderness with no rigidity, rebound, or guarding. The remainder of the examination shows no abnormalities. Which of the following is the most likely causal organism?

Answer: Staphylococcus aureus

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


Question: A 12-year-old girl is brought to the emergency department because of severe pain and swelling of her right eye for 3 days. Over the past two weeks, she had nasal congestion and a constant, mild headache. She did not visit a doctor and instead took over-the-counter naproxen and phenylephrine. Her nasal congestion has since improved, but the headache persists. She underwent a dental procedure for caries about ten days ago. She does not recollect any recent insect bites or trauma. Her immunizations are up-to-date. She appears ill and reports occasional chills. Her temperature is 38.3°C (101°F), pulse is 89/min, and blood pressure is 110/70 mm Hg. Examination shows proptosis of the right eye. Vision is impaired in the affected eye. Her right upper and lower eyelid are erythematous, swollen, and tender to touch. Ocular movements cause severe pain. Her headache is worsened by leaning forward and improves when the patient is lying on her back. Which of the following is the most likely cause of the patient's symptoms?

Answer: Bacterial infection from ethmoidal sinus

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


Question: A 45-year-old man presents to the emergency room with fever and headache. He recently had a middle ear infection. On physical examination, when the head is passively flexed towards the chest, then flexion of the knee is observed. In addition, he reports that his headache increases after rotating his head horizontally. Lumbar puncture and CSF analysis were done. Which of the following laboratory findings would best represent your suspected diagnosis?

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

Choices:
A. Glucose: ↑, Proteins: ↑, Cells: 10% lymphocytes, Lactic Acid (mmol/l): 3.0
B. Glucose: ↓, Proteins: normal, Cells: 10% lymphocytes, Lactic Acid (mmol/l): 2.8
C. Glucose: ↑, Proteins: ↓, Cells: 90% neutrophils , Lactic Acid (mmol/l): 4.3
D. Glucose: normal, Proteins: normal, Cells: 90% neutrophils , Lactic Acid (mmol/l): 3.3
E. Glucose: ↓, Proteins: ↑, Cells: 90% neutrophils, Lactic Acid (mmol/l): 4.5


Question: A 6-day-old female infant is brought to the emergency department because of poor feeding and irritability for two days. She was born at 39 weeks' gestation, and the pregnancy and delivery were uncomplicated. Her temperature is 39.2°C (102.6°F). She appears lethargic and makes occasional twitching movements in both upper extremities. The anterior fontanelle is soft and full. A lumbar puncture is performed and analysis of the cerebrospinal fluid shows increased protein and decreased glucose. Cerebrospinal fluid culture shows gram-positive, intracellular rods with tumbling motility. Infection of a healthy adult with the pathogen affecting this infant would most likely present with which of the following clinical conditions?

Answer: Gastroenteritis

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


Question: A 64-year-old man has complaints of scrotal pain and swelling for the past 2 weeks. The pain is so severe that he is now unable to even sit comfortably for more than 5 minutes. Additionally, he complains of an inability to hold urine when he has an urge to urinate and of mild discomfort during urination. His medical history is significant for hypertension that is well-controlled with losartan. He smokes 1 pack of cigarettes every day and has been doing so for the past 25 years. On physical examination, swelling and erythema of the right hemiscrotal sac are evident, accompanied by intense tenderness with palpation of an indurated epididymis. What is the most likely infectious agent responsible for this patient’s condition?

Answer: Escherichia coli

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


Question: A 65-year-old female is diagnosed with invasive ductal carcinoma of the breast. After a lumpectomy with a negative axillary lymph node dissection and subsequent radiation therapy, the patient is started on adjuvant chemotherapy with anastrozole. Which of the following is an expected side effect of this medication?

Answer: Increased risk for osteoporosis

Choices:
A. Increased risk for endometrial carcinoma
B. Decreased LDL and increased HDL levels
C. Mental confusion progressing to more severe dementia
D. Increased risk for osteoporosis
E. Excessive weight loss


Question: An 18-year-old man comes to the physician because of fatigue, back pain, and dark-colored urine for two days. He has no history of serious illness. He recently sprained his ankle playing basketball and has been taking ibuprofen as needed for pain. Physical examination shows scleral icterus. Laboratory studies show a hemoglobin concentration of 9.2 g/dL and serum lactate dehydrogenase concentration of 254 U/L. A photomicrograph of a peripheral blood smear with Wright's stain is shown. Which of the following is the most likely mode of inheritance for this patient's condition?

Answer:
X-linked recessive
"

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


Question:
A 32-day-old boy is brought to the pediatrician with complaints of purulent discharge from the umbilicus and perianal ulceration for the past few days. A detailed developmental history reveals that he was born to a couple who had a non-consanguineous marriage. He was born by normal delivery at 39 weeks of gestation and his neonatal period was uneventful. His birth weight was 2.9 kg (6.3 lb) and he is exclusively breastfed. His parents also report that he has had 25–30 episodes of loose stools per day since his seventh day of life. His umbilical cord fell off on the 25th day of life. His temperature is 38.6ºC (101.4°F), pulse is 110/min, and respiratory rate is 35/min. On physical examination, erythema and induration are noted around the umbilicus and mild hepatosplenomegaly is present. His laboratory studies show:
Hemoglobin 12.9 gm/dL
Leukocyte count 73,000/mm3
Platelet count 170,000/mm3
Peripheral smear Hypersegmented polymorphs, toxic granules
Stool pH 6
Which of the following tests is most likely to yield an accurate diagnosis?

Answer: Flow cytometry

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


Question:
A 1-hour-old newborn male is evaluated in the delivery room. The infant was born at 37 weeks gestation to a 39-year-old G3. The mother initially labored at home with a midwife but was transferred to the hospital for failure to progress. The infant was eventually delivered via Caesarean section. The mother declined all prenatal screening during this pregnancy. Upon delivery, the infant is found to have a 3 cm full-thickness defect in the abdominal wall to the right of the umbilicus with evisceration of a loop of bowel. His Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. His weight is 3.0 kg (6.6 lb), and his height and head circumference are in the 30th and 40th percentiles, respectively. The abdominal defect is immediately covered in sterile saline dressings, and an orogastric tube and two peripheral intravenous lines are placed.

This condition is associated with which of the following additional cardiac defects?

Answer: No cardiac defects

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


Question: A 17-year-old girl is brought to the physician for a well-child examination. She is worried about gaining weight. She frequents buffet restaurants but feels guilty soon after. She has a history of burning her extremities with cigarettes. Her last menstrual period was 3 weeks ago. She attends high school and plays field hockey on the school team. She is at the 25th percentile for height, 12th percentile for weight, and 17th percentile for BMI. Examination shows bilateral parotid gland enlargement. Oropharyngeal examination shows perimolysis. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

Answer: Bulimia nervosa

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


Question: A 37-year-old man with a history of depression has a two-year history of slowly worsening movement abnormalities characterized by rapid, involuntary, nonrepetitive movements involving his face, trunk, and limbs presents to clinic. He has also noted worsening of his depression, along with symptoms of increased anxiety and irritability. During the interview, his wife explains that he has suffered cognitive decline, most notably in the realm of executive function. On family history, you discover that his father suffered from a similar illness before dying at the age of 44. What would be the expected findings on brain MRI?

Answer: Atrophy of the caudate nucleus

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


Question: A 55-year-old man with a history of diabetes and hypertension presents to the emergency department when he found half of his face paralyzed this morning. The patient was last seen normal the night before by his wife and woke up with these symptoms. He has a past medical history of diabetes and hypertension and is not currently taking any medications for these conditions. His temperature is 98.5°F (36.9°C), blood pressure is 177/118 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for an inability for the patient to move any part of his face on the right side. The rest of his neurological exam is within normal limits. Which of the following is the next best step in management for the most likely diagnosis?

Answer: Topical lubricants and discharge

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


Question: A newborn boy develops excessive bilious vomiting 4 hours after delivery. The infant was born vaginally to a 29-year-old mother (gravida 2, para 1) at 38 weeks gestation. History was significant for polyhydramnios detected at 32 weeks and monitored for the duration of gestation. He was put to the breast right after birth and sucked actively. He still has not passed meconium. The patient’s vital signs include: blood pressure 77/50 mm Hg, heart rate 128/min, respiratory rate 37/min, and temperature 36.4℃ (97.5℉). On physical examination, the newborn appears fussy and mildly dehydrated. His abdomen appears rounded, soft and nontender on palpation, with no palpable organomegaly or masses. What is the most probable site of obstruction?

Answer: Duodenum, distal to Vater’s papilla

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


Question:
The patient is counselled about her risk of thyroid malignancy. Serum studies show:
Na+ 138 mEq/L
K+ 4.1 mEq/L
Cl- 101 mEq/L
TSH 0.03 μU/mL
Calcium 9 mg/dL
Which of the following is the most appropriate next step in management?"

Answer: Thyroid scintigraphy scan

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


Question: An 18-month-old girl is brought to her pediatrician because of swelling in her hands and feet. Her mother is concerned because she has been inconsolable for the last 8 hours. The mother adds that the girl has been getting tired easily recently. The vital signs include: temperature 38.0°C (100.4°F), blood pressure 90/55 mm Hg, and pulse 122/min. Gentle palpation of the metacarpal and metatarsal bones causes the infant to scream. The laboratory evaluation is remarkable for mild anemia, leukocytosis, and increased reticulocyte count. Her peripheral blood smear is shown in the picture. Which of the following best represents the etiology of this infant condition?

Answer: Abnormal globin chain structure

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


Question:
A 34-year-old gravida-1 at 8 weeks gestation seeks evaluation for a fever and sore throat for 3 days. She also reports generalized body pain and fatigue over this period. She was diagnosed with Graves’ disease 6 months ago. Before conception, methimazole was switched to propylthiouracil. She appears ill. The vital signs include: axillary temperature 38.0℃ (100.4℉), pulse 88/min, respiratory rate 12/min, and blood pressure 120/80 mm Hg. A 1 × 1 cm ulcer is seen on the side of the tongue. The ulcer is tender with surrounding erythema. Examination of the neck, lungs, heart, and abdomen shows no abnormalities. The laboratory studies show the following:
Hemoglobin 13.5 g/dL
Mean corpuscular volume 90 μm3
Leukocyte count 2,500/mm3
Segmented neutrophils 5%
Lymphocytes 88%
Platelet count 240,000/mm3
Alanine aminotransferase 18 U/L
Aspartate transaminase 16 U/L
Which of the following is the most appropriate next step in management?

Answer: Discontinuation of propylthiouracil

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


Question: A 27-year-old man comes to the physician because of a 1-week history of fever and pain with urination. His temperature is 39°C (102.2°F). Physical examination shows no abnormalities. A photomicrograph of a urine sample is shown. This patient's findings indicate damage to which of the following structures?

Answer: Renal interstitium

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


Question: Twelve hours after undergoing uncomplicated total knee replacement, a 55-year-old man develops increasing anxiety, agitation, hand tremor, and nausea. He told the nurse he saw a bear in his room. His pain has been controlled with intravenous morphine. He has a history of advanced liver disease. He drinks 7 cans of beer daily. He is diaphoretic. His temperature is 37.6°C (99.7°F), pulse is 118/min, respirations are 18/min, and blood pressure is 146/92 mm Hg. Administration of which of the following drugs is the most appropriate next step in management?

Answer: Lorazepam

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


Question: A 45-year-old woman comes to the physician’s office with complaints of jaw pain. When she eats, yawns, or rubs her jaw, she gets intense, shooting pains down the left side of her jaw, including her lower lip and chin. These episodes last about 30 seconds and have recurred about 10 times per day for the last month. She finds these episodes extremely distressing and comes to the physician’s office in hope of finding a treatment. The patient denies any locking of her jaw. Physical exam is not notable for any tenderness to palpation over the jaw. She has no crepitus in her temporomandibular joint. The patient is able to open and close her jaw without pain. The nerve involved in this patient’s clinical presentation exits the skull through which of the following brain structures?

Answer: Foramen ovale

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


Question: A 64-year-old woman presents to the hospital for chemotherapy. She has newly diagnosed acute myeloid leukemia. She is due to receive treatment with bendamustine for 2 days. On day 2 of her treatment, the patient complains of intense pain in her right great toe. On physical exam, the metatarsophalangeal joint of the 1st toe is warm, erythematous, swollen, and tender to both movement and palpation. An arthrocentesis is performed that reveals negatively birefringent needle-shaped crystals under polarized light. A Gram stain of the synovial fluid is negative. In addition to adequate intravenous hydration, which of the following if given would have most likely prevented the patient’s symptoms?

Answer: Allopurinol

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


Question: A 29-year-old woman comes to the physician with complaints of fever, headache, and rash, which have gradually worsened over the past 6 days. The patient informs the physician that the rash appeared after 2 days of fever. The rash started at the wrists and ankles and then gradually spread to the trunk, palms, and soles. On examination, the physician notes a maculopapular rash as shown in the image below. Vital signs show a temperature of 39.4°C (103.0°F), a blood pressure of 110/70 mm Hg, and a pulse rate of 86/min. Which of the following is the most likely diagnosis?

Answer: Rocky Mountain spotted fever

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


Question: A 25-year-old man presents to the emergency department after paramedics picked him up from an electronic music festival. His temperature is 103°F (39.4°C), blood pressure is 167/105 mmHg, and pulse is 122/min. On physical exam, the patient is highly alert, agitated, and diaphoretic. Laboratory testing is significant for a serum sodium concentration of 130 mEq/L. Which of the following was most likely ingested by the patient?

Answer: 3,4-methylenedioxymethamphetamine

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


Question:
A 1-day-old male is seen in the neonatal intensive care unit for respiratory distress. He was born at 37 weeks to a 24-year-old G3P11011 Rh- mother who had no prenatal care. On physical examination, temperature is 99°F (37.2°C), blood pressure is 120/85 mmHg, pulse is 120/min, respirations are 26/min, and pulse oximetry is 92% on room air. There is abdominal distention with a positive fluid wave. Laboratory results are as follows:

Serum:
Alkaline phosphatase: 80 U/L
ALT: 33 U/L
AST: 32 U/L
Bilirubin (total): 10 mg/dL
Bilirubin (conjugated): 0.2 mg/dL
Amylase: 76 U/L

Leukocyte count: 5,000/mm^3 with normal differential
Hemoglobin: 8 g/dL
Platelet count: 200,000/mm^3
Mean corpuscular volume: 80 µm^3
Reticulocyte count: 3%

What is the most likely diagnosis?

Answer: Erythroblastosis fetalis

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


Question: Study X examined the relationship between coffee consumption and lung cancer. The authors of Study X retrospectively reviewed patients' reported coffee consumption and found that drinking greater than 6 cups of coffee per day was associated with an increased risk of developing lung cancer. The same study in lab mice; however, did not come to a similar conclusion. Which of the following most likely explains the difference between these 2 studies?

Answer: Confounding

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


Question: A 2-day-old boy was born at 38 weeks gestation to a 37-year-old woman by vaginal delivery. Since birth, the boy has had difficulty latching onto the breast but has not vomited or passed meconium. Examination reveals a flat facial profile with epicanthal eyelids, low-set earlobes, and a transverse crease on each palm. The abdomen is distended with absent breath sounds in the hypogastric region. A digital rectal examination shows a patent anal canal and is followed by a projected expulsion of gas and stool. What is the most likely mechanism underlying this patient’s findings?

Answer: Failure of neural crest cell migration during embryologic development

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


Question: An otherwise healthy 23-year-old newly-married woman comes to the physician because of a 6-day history of discomfort in her vaginal area during and after sexual intercourse. Her last menstrual period was 3 weeks ago. Two years ago, she was diagnosed with genital herpes which was treated with acyclovir. She has been in a monogamous relationship for the past year and has been using an intrauterine device for contraception for the past month. Examination shows a 4-cm, mildly tender mass in the inferior aspect of the left labium minus with no signs of inflammation. Speculum examination causes her discomfort but shows no abnormalities. Which of the following is the most likely cause of these findings?

Answer: Obstructed orifice of the Bartholin duct

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


Question: A 22-year-old professional softball player is undergoing an annual check-up. Her medical history is significant for hallux valgus and scoliosis. She additionally notes that she frequently has bumps and bruises from playing softball, but she has no injuries today. Her family history is significant for heart disease. The patient's blood pressure is 110/70 mm Hg, heart rate is 78/min, and respiratory rate is 15/min. A physical examination is unremarkable except for an indurated palpable mass on her left breast. A biopsy of the mass is performed. Which biopsy findings are most likely to be present in this patient?

Answer: Necrotic fat with calcifications and giant cells

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


Question: A 5-month-old male infant is brought to the physician by his parents for the evaluation of a progressive enlargement of his head circumference. His parents report that he has been healthy except for an episode of tonsillitis 3 months ago treated with penicillin. The patient was born at term by a lower segment transverse cesarean section because of a transverse lie. He has met all developmental milestones. His immunizations are up-to-date. The patient is at the 50th percentile for length, 50th percentile for weight, and 95th percentile for head circumference. He appears well-nourished. His temperature is 37°C (98.6°F), pulse is 120/min, and blood pressure is 90/60 mm Hg. Physical examination shows a tense anterior fontanelle. The eyes deviate inferiorly and the eyelids are retracted. Which of the following is the most appropriate next step in the management of this patient?

Answer: Ultrasound of the head

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


Question: A 37-year-old G1P1001 delivers a male infant at 9 pounds 6 ounces after a C-section for preeclampsia with severe features. The mother has a history of type II diabetes with a hemoglobin A1c of 12.8% at her first obstetric visit. Before this pregnancy, she was taking metformin, and during this pregnancy, she was started on insulin. At her routine visits, her glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL. In addition, her routine third trimester culture for group B Streptococcus was positive. At 38 weeks and 4 days gestation, she was found to have a blood pressure of 176/103 mmHg and reported a severe headache during a routine obstetric visit. She denied rupture of membranes or vaginal bleeding. Her physician sent her to the obstetric triage unit, and after failure of several intravenous doses of labetalol to lower her blood pressure and relieve her headache, a C-section was performed without complication. Fetal heart rate tracing had been reassuring throughout her admission. Apgar scores at 1 and 5 minutes were 7 and 10. After one hour, the infant is found to be jittery; the infant's temperature is 96.1°F (35.6°C), blood pressure is 80/50 mmHg, pulse is 110/min, and respirations are 60/min. When the first feeding is attempted, he does not latch and begins to shake his arms and legs. After 20 seconds, the episode ends and the infant becomes lethargic. Which of the following is the most likely cause of this infant’s presentation?

Answer: ß-cell hyperplasia

Choices:
A. Transplacental action of maternal insulin
B. ß-cell hyperplasia
C. Neonatal sepsis
D. Inborn error of metabolism
E. Neonatal encephalopathy


Question: A 65-year-old male presents to his cardiologist to discuss increasing episodes of dyspnea after climbing stairs. He also now needs three pillows at night to sleep. Physical examination reveals an early diastolic murmur best appreciated at the left sternal border with bounding peripheral pulses. The cardiologist is very concerned and immediately refers the patient for a surgical workup. What is the most likely diagnosis?

Answer: Aortic regurgitation

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


Question: A 42-year-old overweight restaurant waiter develops excruciating pain in the heel of his right foot. Symptoms are most intense after getting out of bed but get better after walking. On physical examination, both feet have a flat medial arch. There is tenderness to palpation along the inner aspect of the right heel bone, minimal active dorsiflexion, and pain at passive dorsiflexion. X-ray films reveal a bone spur at the level of the attachment of the right plantar fascia. The spur is also present in the comparison film of the left foot. He is diagnosed with plantar fasciitis and is told to lose weight, rest, use ice, and take anti-inflammatory medications. Which of the following is most accurate?

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

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


Question: A 7-year-old boy is brought to the physician because of decreased vision, hearing, and speaking over the past 3 months. During this time, he has also had difficulty walking, concentrating, drawing, and feeding himself. His maternal male cousin had similar complaints and died at the age of 5 years. Examination shows hyperpigmented skin and nails. His speech is dysarthric. Neurologic examination shows an ataxic gait, spasticity, and decreased muscle strength in all extremities. Fundoscopy shows optic atrophy. Which of the following is the most likely cause of this patient's symptoms?

Answer: Dysfunction of ATP-binding cassette transporter

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


Question: A 55-year-old man comes to the physician because of a 4-month history of nocturia. He wakes up twice each night to urinate. He has no history of serious illness. He takes no medication. His younger brother was diagnosed with testicular cancer at the age of 35 years. Rectal examination shows a smooth, symmetrical prostate without nodules. The physician offers to discuss the advantages and limitations of the prostate specific antigen (PSA) test in diagnosing prostate cancer. He mentions that a a serum PSA of 4 ng/mL is generally used as a cutoff value. At this cutoff, the test has a sensitivity of 21% for detecting any prostate cancer and 51% for detecting high-risk prostate cancer, with a specificity of 91%. In patients without urinary retention, hematuria, back pain, or incontinence, the positive predictive value for PSA > 4 ng/mL is estimated at 30% and the negative predictive value for PSA ≤ 4 ng/mL at 85%. Based on this information, what is the probability that this patient does not have prostate cancer if his PSA is 4.3 ng/mL?

Answer: 70%

Choices:
A. 79%
B. 15%
C. 30%
D. 70%
E. 9%


Question:
A 23-year-old woman presents to the emergency department for vomiting and abdominal pain. The patient states that she has been unable to eat or drink for the past 24 hours without vomiting. She also complains of worsening abdominal pain that started 3 days ago. The patient has a past medical history of IV drug abuse and alcohol abuse. She is not on any current medications. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, tenderness is elicited when the right lower quadrant of her abdomen is palpated. Deep palpation and release of the left lower quadrant of her abdomen also causes severe pain. Rectal exam reveals normal tone and stool is Guiac negative. Laboratory studies are ordered as seen below.

Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 11,500/mm^3 with normal differential
Platelet count: 197,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 27 mEq/L
BUN: 20 mg/dL
Glucose: 67 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
AST: 12 U/L
ALT: 15 U/L

Urine:
Cocaine: positive
Amphetamines: positive
ß-hCG: positive
Marijuana: positive
Heroin: negative
PCP: negative
MDMA: positive
Glucose: negative
Ketones: negative

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

Answer: Ultrasound

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


Question: A 75-year-old man was brought in by his daughter since he was having increased incidences of forgetting things. His daughter said that he becomes increasingly frustrated searching for his glasses and keys most of the time. He was helped out a couple of times in the supermarket for forgetting the way out. He recently lost his driving license when he was spotted by the cops driving in the wrong direction on the interstate. Which of the following is the most likely pathology for this presentation?

Answer: Abnormal cleavage of amyloid precursor protein

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


Question: A 7-month-old male child is brought into your office for recent rhinorrhea and cough. The mother states that the child has had mild fevers of up to 100.7 F over the last three days along with clear nasal discharge, and a nonproductive cough, but the child has been working harder to breathe over the last day. The mother states the child was vaccinated for the flu one month ago. His vitals are significant for a temperature of 100.9F and his physical exam is significant for intercostal retractions along with expiratory wheezing. What is the most likely organism responsible?

Answer: Respiratory syncytial virus

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


Question:
A 56-year-old man comes to the physician because of increasing generalized fatigue for 1 month. He also has had a 5.4 kg (12 lb) weight loss over the past 6 months. He has hypertension and type 1 diabetes mellitus. His father died of colon cancer at the age of 65 years. He has smoked one pack of cigarettes daily for 32 years and drinks one alcoholic beverage per week. He has numerous tattoos, several of which were acquired when he went backpacking through Southeast Asia as a young man. Current medications include enalapril and insulin. He is 180 cm (5 ft 11 in) tall and weighs 78 kg (172 lb); BMI is 24.1 kg/m2. His temperature is 37.0°C (98.6°F), pulse is 86/min, and blood pressure is 140/90 mm Hg. The abdomen is soft and nontender. The liver is palpated 3 cm below the right costal margin. Laboratory studies show:
Hemoglobin 12.6 g/dL
Mean corpuscular volume 86 μm3
Leukocyte count 8800/mm3
Platelet count 282,000/mm3
Hemoglobin A1C 6.3 %
Serum
Glucose 113 mg/dL
Creatinine 1.1 mg/dL
Albumin 4.1 mg/dL
Total bilirubin 1.1 mg/dL
Alkaline phosphatase 66 U/L
AST 100 U/L
ALT 69 U/L
Ferritin 180 ng/mL
α-fetoprotein
410 ng/mL (N < 10 ng/mL)
CT scan of the abdomen shows a 3.5 x 2 x 1.5 cm mass in segment 6 of the liver. Which of the following interventions most likely would have prevented this patient's condition?"

Answer: Hepatitis B vaccination

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


Question: A 6-year-old girl with polycystic kidney disease is started on a new medication after receiving a kidney transplant from a matched, unrelated donor. Two days after starting the medication, laboratory studies show a leukocyte count of 17,500/mm3 (90% segmented neutrophils, 4% bands, 1% eosinophils, 3% lymphocytes, and 1% monocytes). Which of the following drugs is the most likely cause of these laboratory findings?

Answer: Methylprednisolone

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


Question: A clinical trial is conducted to investigate the efficiency of a new glucagon receptor antagonist in the treatment of type 2 diabetes mellitus. After 12 weeks of treatment with this drug, all participants in the study achieved statistically significant reductions in fasting and postprandial serum glucose. Three individuals reported symptoms of hypoglycemia while exercising. The activity of which of the following cellular enzymes is most likely to be decreased in response to treatment with this drug?

Answer: Protein kinase A

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


Question: A 19-year-old man is admitted to the medical intensive care unit with suspected sepsis. Blood cultures grow Gram-negative cocci containing lipooligosaccharide in their cell wall. Which of the following would you expect to find on a detailed history and physical examination of this patient?

Answer: Petechial rash

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


Question: A 25-year-old male rugby player presents to the emergency room complaining of a severe headache. He is accompanied by his teammate who reports that he had a head-to-head collision with another player and briefly passed out before regaining consciousness. His past medical history is significant for a pilocytic astrocytoma as a child treated successfully with surgery. His family history is notable for stroke in his father. His temperature is 98.9°F (37.2°C), blood pressure is 160/90 mmHg, pulse is 60/min, and respirations are 20/min. On examination, he is lethargic but oriented to person, place, and time. The affected vessel in this patient directly branches from which of the following vessels?

Answer: Maxillary artery

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


Question: A 4-year-old boy presents with 3 days of fever, crampy abdominal pain, vomiting, and loose, bloody bowel movements containing mucus. The patient’s mother says that other children from his daycare class have also developed similar symptoms. The patient’s temperature is 39.0°C (102.2°F). On physical examination, the patient is irritable and inconsolable, and his abdomen is distended. Intravenous fluid resuscitation is initiated. Histopathologic analysis of his stool reveals numerous red and white blood cells. Which of the following is characteristic of the most likely microorganism responsible for this patient’s symptoms?

Answer: Inactivation of the 60S ribosome subunit

Choices:
A. Inactivation of elongation factor EF-2
B. Inactivation of the 60S ribosome subunit
C. Permanent activation of Gs alpha subunit
D. Overactivation of guanylate cyclase
E. Disabling Gi alpha subunit


Question: A 23-year-old man develops a seizure on the medical floor. He was admitted 2 days ago with high-grade fever and severe headache. At the time of admission, he had photophobia, neck rigidity, and the following vital signs: temperature 39.5°C (103.1°F), blood pressure 130/70 mm Hg, and heart rate 120/min. A cerebral spinal fluid analysis was ordered, and he was started on intravenous antibiotics. The patient’s seizure terminates without any medication or intervention. An MRI is performed which reveals dilation of all the ventricles of the brain. Which of the following is the most likely cause of his abnormal radiologic findings?

Answer: Arachnoid granulation adhesions

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


Question: A 27-year-old unconscious man is brought to the ED by EMS. He was found face down in the middle of the sidewalk at 2AM. The patient is disheveled and smells of alcohol. Physical exam reveals bruising and ecchymosis at the right temple and 1-mm pupils bilaterally. His temperature 97.1°F (36.3°C), blood pressure is 84/58 mmHg, pulse is 71/min, respirations are 8/min. Following initial stabilization and respiratory support, what is the best next step for this patient?

Answer: Naloxone

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


Question:
A 43-year-old man presents to the clinic for pain with swallowing for a month. He says that the pain has gotten worse over the past few weeks. His past medical history is significant for AIDS. He states that he has not been able to afford his highly active antiretroviral therapy, so he is not currently taking any medications. His temperature is 98.6°F (37°C), respirations are 15/min, pulse is 70/min, and blood pressure is 100/84 mm Hg. Physical examination reveals no mucosal lesions. Evaluation of the blood reveals:
Hb%: 11 gm/dL
Total count (WBC): 2,400 /mm3
Differential count:
Neutrophils: 70%
Lymphocytes: 25%
Monocytes: 5%
CD4+ cell count: 51/mm3
What is the best pharmacotherapy for this patient's current symptom?

Answer: Oral fluconazole

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


Question: A 25-year-old man is brought by his roommate to the emergency department with chest pain, which began 90 minutes ago. His roommate says that he has not slept within the past 24 hours and has been taking pills to help him study longer for his upcoming national dental board exam. On examination, he is diaphoretic, extremely agitated, and attempts to remove his IV lines and ECG leads. His temperature is 38.9°C (102.2°F), pulse is 115/min, and blood pressure is 160/102 mmHg. His pupil size is 7 mm bilaterally. The lungs are clear to auscultation. The most appropriate next step in management is administration of which of the following?

Answer: Lorazepam

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


Question: A 65-year-old female presents to her primary care physician for a routine check-up. She reports feeling well but has noticed occasional weakness and constipation over the past few months. A complete blood count is within normal limits. Serum calcium is 11.9 mg/dL and serum phosphate is 2.4 mg/dL. Urine calcium output is 400 mg/24 h. A sestamibi scan demonstrates increased uptake near the inferior left pole of the thyroid gland. Which of the following mechanisms is most likely involved in this patient’s symptoms?

Answer: Increased RANK-L expression

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


Question: A 35-year-old male presents to his physician with a small mass that he found in the anterior of his neck a few days ago. The mass is not painful and does not affect his swallowing. He noticed no change in his weight. His history is significant for radiation exposure for treating his neuroblastoma at the age of 15. On examination, a nodule around the size of 2.2 cm is palpated in the right thyroid lobule; the nodule is firm and non-tender. There is cervical lymphadenopathy. His blood pressure is 118/75 mm Hg, respirations are 17/min, pulse is 67/min, and temperature is 37.5°C (99.5°F). Laboratory findings include serum Na+ of 136 mmol/L, K+ of 4.2 mmol/L, Cl– of 90 mmol/L, and bicarbonate of 24 mmol/L. Which of the following factors will most likely make the prognosis worse in this patient?

Answer: Bone metastases

Choices:
A. Age
B. Bone metastases
C. Palpable lymph nodes
D. Follicular histological variant
E. Hurthle cell variant


Question: An 18-year-old man is referred to a psychiatrist for evaluation after a recent suicide attempt. On questioning him, he says that he did it because he got fed up with life and feels that he is worthless. The patient’s father informs the doctor that his son has been gloomy most of the time over the last 2 months, and his academic performance has declined significantly. His father further adds that his son’s appetite has decreased significantly over the last 3 months, leading to a 5.0 kg (11.0 lb) weight loss.  The patient denies any history of manic or hypomanic episodes. Physical examination is unremarkable. Routine laboratory tests, including thyroid hormone and cortisol levels, are within normal limits. Which of the following patterns of abnormal brain activity would most likely be present in this patient?

Answer: Decreased norepinephrine levels in the cortical and limbic areas

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


Question: A 10-year-old girl is evaluated for a suspected primary deficiency. She is the first child in a consanguineous marriage. She was born vaginally at full term after an uncomplicated pregnancy and was breastfed for 9 months. The patient has had an episode of meningococcal meningitis, recurrent bronchiolitis, and multiple bouts of pneumococcal pneumonia over the past 5 years. She has also suffered from chronic otitis media since the age of 5. After a thorough examination, the child is found to have a partial CD19 deficiency. Which of the following proteins is heavily involved with this pathogenesis?

Answer: CD21

Choices:
A. CD155
B. CD8
C. CD16
D. CD21
E. CD25


Question: A 24-year old woman is brought to the emergency department after a motor vehicle collision. She was a restrained passenger at the time of impact. On examination, the patient is pale and in moderate distress. She complains of a sharp pain in the posterior aspect of the left shoulder. Vitals include temperature is 37.0°C (98.6°F), right arm blood pressure is 94/63 mm Hg, left arm blood pressure is 90/61 mm Hg, pulse is 122/min, and respirations are 24/min. Cardiopulmonary auscultation reveals normal heart sounds and clear lungs. Neck veins are not distended. Several, large ecchymoses are visible over the chest and abdomen in a seatbelt pattern. Her abdomen is tender on superficial palpation with mild rebound tenderness and rigidity. Her range of motion is normal with 5/5 motor strength in all extremities. Wrist drop is absent. A FAST scan is pending. Based on the patient’s current presentation, which organ is most likely affected?

Answer: Spleen

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


Question:
A 68-year-old woman presents to her primary care physician with complaints of fatigue, difficulty breathing upon exertion, and crampy lower abdominal pain. She also notices that her stools are dark. She has had essential hypertension for 20 years for which she takes bisoprolol. Her family history is positive for type 2 diabetes mellitus. On physical examination, she looks pale. Complete blood count shows the following:
Hemoglobin 10 g/dL
Mean corpuscular volume (MCV) 70 fL
Mean corpuscular hemoglobin (MCH) 25 pg/cell
Mean corpuscular hemoglobin concentration (MCHC) 27 g/dL
Red cell distribution width 16%
Platelet count 350,000/mm3
Serum ferritin is 9 ng/mL. The patient is referred to a gastroenterologist and conventional colonoscopy reveals a polypoid mass in the ascending colon. Biopsy shows poorly differentiated adenocarcinoma. A preoperative staging is performed and a laparoscopic cancer resection with postoperative chemotherapy are planned. Which of the following tests can be used for postoperative follow up of this patient?

Answer: Carcinoembryonic antigen (CEA)

Choices:
A. Liver biochemistry
B. Carcinoembryonic antigen (CEA)
C. Pelvic magnetic resonance imaging (MRI)
D. Transrectal endoscopic ultrasound (TRUS)
E. Cancer antigen 125 (CA 125)


Question: A 34-year-old man comes to the physician because of a 2-day history of progressively blurred vision. He also reports seeing flashing lights in his visual field. He does not have any pain. The patient has not been examined by a physician in several years. He appears emaciated. Examination shows right conjunctival injection. Visual acuity is 20/20 in the left eye and 20/100 in the right eye. Fundoscopic examination of the right eye is shown. His CD4+ T-lymphocyte count is 46/mm3. Which of the following is the most appropriate pharmacotherapy for this patient's eye condition?

Answer: Valganciclovir

Choices:
A. Valganciclovir
B. Penicillin G
C. Famciclovir
D. Sulfadiazine and pyrimethamine
E. Trimethoprim-sulfamethoxazole


Question: A 42-year-old man comes to the physician because of several episodes of rectal bleeding over 2 weeks. He has had pain around the anal area for the past month. Six months ago, he was diagnosed with esophageal candidiasis and was treated with oral fluconazole. He is HIV-positive. He has had 9 male sexual partners over his lifetime and uses condoms inconsistently. The patient's current medications include dolutegravir, tenofovir, and emtricitabine. He is 179 cm (5 ft 10 in) and weighs 66 kg (146 lb); BMI is 20.9 kg/m2. Vital signs are within normal limits. Digital rectal examination and anoscopy show a hard 2-cm mass palpable 0.5 cm above the anal verge that bleeds on contact. There is no inguinal lymphadenopathy. The abdomen is soft and nontender. The CD4+ T-lymphocyte count is 95/mm3(N ≥ 500/mm3). A biopsy confirms the diagnosis. This patient is most likely to benefit from which of the following interventions?

Answer: Radiochemotherapy

Choices:
A. Radiochemotherapy
B. Local 5-fluorouracil therapy
C. Total mesorectal excision
D. Injection sclerotherapy
E.
Submucosal hemorrhoidectomy
"


Question: A 19-month-old boy comes into the emergency department with his parents. He has burns on his buttocks and perineal area. The patient’s mother says she was at home with the patient when she heard him screaming from the kitchen. She says she ran to the room to find that the patient had pulled down a container of hot water on himself. Which of the following burn patterns would be most indicative of child abuse in this patient?

Answer: Circular burns of equal depth restricted to the buttocks, with sparing of the hands and feet

Choices:
A. Burns to flexor and anterior surfaces
B. Burns with irregular borders, uneven depth of burns, and splash pattern
C. Burns with some areas blistering but with others not blistering
D. Circular burns of equal depth restricted to the buttocks, with sparing of the hands and feet
E. Non-circumferential burns


Question: A 44-year-old woman presents to the physician for evaluation of recurrent episodes of pounding headache, palpitations, excessive sweating, anxiety, tremors, and pallor, with occasional vomiting for the last 2 weeks. She has presented to the same physician with similar complaints in the past; however, she is frustrated with the lack of proper diagnosis and now insists on a detailed workup. She does not take any medications. She has a history of progressively increasing thyroid swelling as well as multiple bone pain for the past 2 months. On physical examination, she is very lean and appears anxious and apprehensive. She has clammy and moist hands. Her temperature is 37.1°C (98.9°F), the pulse is 110/min, the blood pressure is 176/94 mm Hg, and the respiratory rate is 27/min. Her weight is 43 kg (94.8 lb), height is 145 cm (4 ft 7 in), and body mass index (BMI) is 20.4 kg/m2. A firm thyroid nodule is palpable in the right lobe. Physical examination is otherwise normal. What is the most appropriate initial management for this patient?

Answer: 24-h urine catecholamine by-products (vanillylmandelic acid (VMA), metanephrine, and normetanephrine)

Choices:
A. Serum epinephrine and norepinephrine
B. Clonidine test
C. CT scan/MRI of the abdomen
D. 24-h urine catecholamine by-products (vanillylmandelic acid (VMA), metanephrine, and normetanephrine)
E. Serum calcium and PTH


Question: A 54-year-old male is involved in a high speed motor vehicle collision and is brought to the emergency department. On arrival, his vitals are temperature 98.6 °F (37 °C), blood pressure 110/70 mmHg, pulse 100/min, and respirations are 20/min. His Glasgow Coma Score (GCS) is 13 (eye opening 3, verbal response 5, and motor response 5). Physical exam is notable for a rapid and thready pulse, and a rigid and distended abdomen with positive rebound tenderness. FAST exam reveals a large hypoechoic stripe in the hepatorenal recess. Two large bore IV's are started and the patient is given a 1L bolus of normal saline. The patient’s mental status rapidly deteriorates and he becomes unresponsive. His pulse is 149/min and blood pressure is 70/40 mmHg. The patient is started on a medication while additional fluids are administered. Subsequently his vitals, his pulse is 80/minute and blood pressure is 120/80 mmHg. While the patient is being taken to the operating room, he develops pain in all four distal extremities. His digits appear blue and are cool to the touch. Which medication is most likely responsible for this complication?

Answer: Norepinephrine

Choices:
A. Epinephrine
B. Dobutamine
C. Norepinephrine
D. Vasopressin
E. Ephedrine


Question: A 20-year-old man with a history of cystic fibrosis presents to his pulmonologist for a regular checkup. He generally feels well but noticed that he has had an increase in stool frequency. He describes his stools as loose and “greasy”, often staining the toilet bowl. He regularly uses albuterol and budesonide inhalers and has chest physical therapy several times a month. Physical exam is unremarkable. Serum level of which of the following coagulation factors is likely abnormal in this patient?

Answer: II

Choices:
A. II
B. V
C. VIII
D. XI
E. XII


Question: A 6-year-old boy is brought to the physician by his father for an annual health maintenance examination. His father notes that he has several pigmented areas on his skin and a few fleshy bumps. He has also had some blurred vision in his left eye. He has no history of serious medical illness. He lives at home with both parents and is up-to-date on all his immunizations. His father has similar skin findings. His mother has epilepsy and glaucoma. Vital signs are within normal limits. Visual acuity testing shows 20/50 in the left eye and 20/20 in the right eye. Slit-lamp examination shows pigmented iris nodules. Examination of his skin shows eight brownish macules and numerous soft, non-tender, pedunculated lesions on the back, chest, and abdomen. Which of the following is the most appropriate next step in management?

Answer: MRI of the brain

Choices:
A. CT scan of the brain
B. MRI of the brain
C. Electroencephalogram
D. B-scan ultrasound
E. Gonioscopy


Question: A 43-year-old man is brought to the emergency department because of a fever, cough, pleuritic chest pain, and dyspnea. Two days ago, he returned from a construction site along the Mississippi River. Abdominal examination shows a palpable spleen. An x-ray of the chest shows diffuse reticulonodular infiltrates. Therapy with a drug that binds ergosterol is initiated. This patient is most likely to experience which of the following adverse effects?

Answer: Hypomagnesemia

Choices:
A. Hypomagnesemia
B. Histamine release
C. Leukopenia
D. Dysgeusia
E. Cytochrome P450 induction


Question: A 49-year-old African man presents to the physician with a 3-month history of fatigue, shortness of breath, and abdominal distention. He immigrated to the US approximately 6 months ago. He has no other medical problems and is currently not on medication. He previously worked as a farmer but stopped due to his inability to keep up with the work. His blood pressure is 112/58 mm Hg, pulse is 90/min, respiratory rate is 19/min, and temperature is 37.8°C (100.0°F). Physical examination reveals bilateral pedal edema up to the knees, jugular venous distention, and abdominal distention with free fluid. Chest auscultation reveals the following sound. Jugular venous pressure tracing reveals prominent ‘x’ and ‘y’ descents. Radial pulse is absent during inspiration bilaterally. Which of the following is the primary underlying cause of this patient’s presentation?

Answer: Tuberculosis

Choices:
A. Coxsackie A virus
B. Tuberculosis
C. Cor pulmonale
D. Protozoan infection
E. Tricuspid endocarditis


Question: A 25-year-old primigravida is admitted to the hospital at 35 weeks gestation with lower leg edema. She denies any other symptoms. Prior to admission, the antepartum course was unremarkable and she was compliant with recommended  prenatal care. The vital signs were as follows: blood pressure, 155/90 mm Hg; heart rate, 84/min; respiratory rate, 16/min; and temperature, 36.6℃ (97.9℉). The fetal heart rate was 142/min. The physical examination shows 2+ pitting edema. A 24-hour urine assessment showed proteinuria (1.2 g). An ultrasound examination showed a normally developing fetus without structural abnormalities. The placental margin was located 3 cm away from the internal os. Which of the following options describes the  proper management in this patient assuming that no deterioration occurs up to the time of delivery?

Answer: Induction of vaginal delivery at 37 weeks’ pregnancy if not begin spontaneously earlier

Choices:
A. Induction of vaginal delivery at 37 weeks’ pregnancy if not begin spontaneously earlier
B. Cesarean delivery after a course of a corticosteroid treatment
C. Vaginal delivery induction after a course of corticosteroid treatment
D. Cesarean delivery at 37 weeks’ pregnancy or urgently after beginning of spontaneous delivery if it is earlier
E. Watch for a spontaneous vaginal delivery at any term from the moment of presentation


Question: A 12-year-old female presents to the emergency room difficult to arouse and occasionally vomiting. On physical exam, her oral mucosa looks dry, her breath has a fruity odor, and her breathing is slow, deep and labored. What is the most likely primary metabolic disturbance?

Answer: Anion gap metabolic acidosis

Choices:
A. Anion gap metabolic acidosis
B. Non-anion gap metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
E. Respiratory acidosis


Question: A 36-year-old man presents to the emergency room with subacute worsening of chronic chest pain and shortness of breath with exertion. The patient is generally healthy, lifts weights regularly, and does not smoke. His temperature is 97.8°F (36.6°C), blood pressure is 122/83 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Cardiac auscultation reveals a crescendo-decrescendo murmur heard right of the upper sternal border with radiation into the carotids. An ECG shows left axis deviation and meets criteria for left ventricular hypertrophy. An initial troponin is < 0.01 ng/mL. Which of the following is the most likely diagnosis?

Answer: Bicuspid aortic valve

Choices:
A. Bacterial endocarditis
B. Bicuspid aortic valve
C. Cardiac myxoma
D. Mitral insufficiency
E. Senile calcific changes


Question: A 66-year-old man is admitted to the intensive care unit for management of laboratory-confirmed septic shock. His current plan includes appropriate management of airway and breathing, intravenous antibiotics, fluid resuscitation, and supportive care. After the administration of adequate intravenous isotonic fluids, his temperature is 37.2°C (99.0°F), the pulse rate is 120/min, the blood pressure is 90/50 mm Hg, and the respiratory rate is 22/min. His extremities are warm and capillary refill time is normal. The patient is started on vasopressor therapy, and norepinephrine is chosen over epinephrine. Which of the following characteristics of norepinephrine best explains this choice in this patient?

Answer: Norepinephrine has more α1-adrenergic effects compared to epinephrine

Choices:
A. Norepinephrine has less α1-adrenergic effects compared to epinephrine
B. Norepinephrine has more β2-adrenergic activity compared to epinephrine
C. Norepinephrine has similar effects on β2 adrenergic receptors compared to epinephrine
D. Norepinephrine has similar α1-adrenergic effects compared to epinephrine
E. Norepinephrine has more α1-adrenergic effects compared to epinephrine


Question: A 67-year-old man comes to the physician because of a worsening tremor that began one year ago. The tremor affects his left hand and improves when he uses his hand to complete a task. He also reports feeling stiffer throughout the day, and he has fallen twice in the past year. He has not noticed any changes in his cognition or mood. He has not had difficulty sleeping, but his wife says that he would kick and punch while dreaming for almost a decade. He drinks two cans of beer daily. He takes no medications. He appears healthy and well nourished. His vital signs are within normal limits. He maintains a blank stare throughout the visit. Further evaluation is most likely to show which of the following?

Answer: Reduced amplitude on foot tapping

Choices:
A. Reduced amplitude on foot tapping
B. Startle myoclonus
C. Extensor plantar response
D. Choreiform movements
E.
No abnormalities
"


Question:
A 25-year-old African American man comes to the emergency department for “red urine.” Patient reports that he just returned from a skiing trip in the Rocky Mountains and developed the reddish urine today. He denies upper respiratory infection symptoms, chest pain, fever, or chills but does endorse some right flank pain that developed 3 days ago. Physical examination was unremarkable except for some tenderness upon palpation at the right flank. Laboratory findings are as follows:

Serum:
Na+: 137 mEq/L
K+: 4.9 mEq/L
Cl-: 100 mEq/L
HCO3-: 25 mEq/L
Osmolality: 275 Osm/kg

Urine:
Color: Red
Protein: 3+
RBC: 4 cells/hpf
Osmolality: 214 Osm/kg
Specific gravity: 1.004

Which finding would you most likely expect with this patient?

Answer: HbS on hemoglobin electrophoresis

Choices:
A. Cystic mass of the right kidney on CT abdomen/pelvis
B. HbS on hemoglobin electrophoresis
C. Linear deposition of IgG antibodies on renal electron microscopy
D. Renal stones on CT abdomen/pelvis
E. Segmental sclerosis and hyalinosis of renal glomeruli on light microscopy


Question: A 62-year-old man presents to his primary care physician because of lower back pain and radiating leg pain. He says that the pain is searing and goes from the buttock into the posterior thigh and lateral leg. It is moderate in intensity and he has noticed that it worsens with sitting and improves with standing. His past medical history is significant for well controlled hypertension, but he has otherwise been healthy. He works as a laborer loading packages in a warehouse and is concerned because the pain does not allow him to work. On physical exam, he is found to have pain and paresthesia while performing a straight leg raise. Radiographs show loss of disk height and MRI shows significant degeneration and posterolateral herniation of the disk in between the L5 and S1 vertebrae. Adjacent disks appear to be relatively normal without notable herniation. Which of the following sets of findings would most likely be seen in this patient?

Answer: Weak ankle plantarflexion and diminished Achilles reflex

Choices:
A. Weak ankle dorsiflexion and diminished Achilles reflex
B. Weak ankle dorsiflexion and hallucis extension
C. Weak ankle plantarflexion and diminished Achilles reflex
D. Weak ankle plantarflexion and diminished patellar reflex
E. Weak ankle plantarflexion and hallucis extension


Question:
A 46-year-old woman presents to her primary care provider with pain in both of his hands and wrists. She notes that it is hard for her to prepare breakfast or wash dishes in the morning due to stiffness. It seems to subsides later in the day. She also complains of a constant fatigue and unintentional weight loss during the last few months. The past medical history is significant for hypertension. She takes captopril and aspirin daily, and occasional ibuprofen for the pain in her hands. Her mother developed similar symptoms in her hands resulting in hand deformity. The blood pressure is 140/90 mm Hg, heart rate is 67/min, respiratory rate is 13/min, and temperature is 37.0°C (98.6°F). Physical examination shows redness, edema, and tenderness on palpation at the metacarpophalangeal and proximal interphalangeal joints of both hands. The blood tests show the following findings:
Red blood cell count 3.3 million/mm3
Hb 12.1 mg/dL
Leukocyte count 10,101/mm3
ESR 48 mm/h
C-reactive protein 3.9 mg/L
Anti-cyclic citrullinated peptide 45 μ/mL
Which of the following medications is first-line therapy to slow disease progression?

Answer: Methotrexate

Choices:
A. Intra-articular corticosteroid injections
B. Methotrexate
C. Azathioprine
D. Meloxicam
E. Etanercept


Question: A 27-year-old woman presents to her primary care physician’s office complaining of trouble sleeping. She reports that for the past 10 months she has experienced difficulty falling asleep due constant worrying. The content of her worry include items such as whether or not her child will feel lonely in day care and the health of her parents. These worrying episodes typically begin toward the end of the day and last for several hours. She states that she has trouble concentrating at work as well and describes her heart as "racing" during these episodes. She denies any alcohol or illicit drug use. Which of the following neurotransmitters is most likely decreased in this patient?

Answer: GABA

Choices:
A. Acetylcholine
B. Dopamine
C. GABA
D. Norepinephrine
E. Glutamate


Question:
A 10-year-old boy is brought to the physician because of fever and bloody diarrhea for the past few days. His parents report that he has become increasingly lethargic and irritable. His temperature is 38.6°C (101.4°F), pulse is 102/min, and respirations are 22/min. He has no significant past medical history. His parents say that he mostly only eats a diet of chicken, hamburgers, fries, cheese, and milk. On physical examination, pallor and edema in both legs are present. His laboratory studies show:
Hemoglobin 8.9 gm/dL
Leukocyte count 9,300/mm3
Platelet count 67,000/mm3
Blood urea nitrogen 43 mg/dL
Serum creatinine 2.46 mg/dL
Coombs test Negative
Which of the following is the most likely diagnosis?

Answer: Escherichia-induced hemolytic uremic syndrome

Choices:
A. Thrombotic thrombocytopenic purpura
B. Genetic form of hemolytic uremic syndrome
C. Hemolytic uremic syndrome associated with systemic disease
D. Escherichia-induced hemolytic uremic syndrome
E. Pneumococci-induced hemolytic uremic syndrome


Question: A 50-year-old white male who works in construction comes to your office because of pain in his upper arm. He states that over the last few months, he has been having pain in his upper arm that worsens with raising objects overhead. He states that he also recently fell on his outstretched hand and that seemed to worsen his pain. His vital signs are within normal limits. He has no pain on internal or external rotation. He also had no pain with the lift off test, but does have significant pain with the empty can test and the arm drop test. Which structure has he most likely injured?

Answer: Supraspinatus tendon

Choices:
A. Pectoralis major tendon
B. Deltoid muscle
C. Supraspinatus tendon
D. Infraspinatus tendon
E. Subscapularis tendon


Question: A 76-year-old man presents to the physician with a severe, pruritic rash as shown in the image. He has lost sleep over the past week because of itchiness and discomfort. He has not noticed any insect bites. He is not experiencing any pain. He currently lives in an elderly home where several other residents are experiencing a similar problem. He has no history of a serious illness and does not take any medications. His vital signs are within normal limits. A similar rash is seen on his face and below the knees on both sides. The skin of the groin, genital and perianal area, buttocks, and thighs show no abnormalities. The remainder of the physical examination is unremarkable. Which of the following pathogens is the most likely cause of this patient’s condition?

Answer: Cimex lectularius

Choices:
A. Cimex lectularius
B. Dermatobia hominis
C. Varicella zoster
D. Lice
E. Sarcoptes scabiei


Question: A 6-month-old girl is brought to the hospital by her parents for evaluation due to poor feeding for the last month. Her parents say that she has not been eating well over the last two months, yet her abdomen has grown larger. Physical exam shows a thin female infant with an enlarged liver and palpable spleen. Eye exam reveals a red spot on the retina. She has an intact muscle tone and reflexes. Which of the following enzymes is deficient in this patient?

Answer: Sphingomyelinase

Choices:
A. Hexosaminidase A
B. α-galactosidase A
C. Glucocerebrosidase
D. Sphingomyelinase
E. Galactocerebrosidase


Question: A 24-year-old female is brought to the ED from a nearby nightclub by the local police due to aggressive and violent behavior over the past hour. A friend accompanying the patient reports that the patient smoked marijuana that "seemed different" approximately one hour ago. The patient has never had this kind of reaction to marijuana use in the past. On examination, the patient is combative with slurred speech and active visual hallucinations; eye examination shows prominent vertical nystagmus. This patient's presentation can be best explained by intoxication with a substance that acts at which of the following receptors?

Answer: NMDA

Choices:
A. Serotonin
B. Cannabinoid
C. GABA
D. NMDA
E. Norepinephrine


Question: A 2-month-old infant comes to the clinic because of progressive weakness and fatigue over the past 4 weeks. He is his mother’s first-born boy. She was in Mexico during the delivery and says that she had a regular 39-week gestation. She took folic acid during her pregnancy. The infant was born through vaginal delivery with no complications. Apgar scores were 10 and 9 at 1 and 5 minutes, respectively. The neonate did not go through a newborn screening process. His pulse is 130/min, respiratory rate is 43/min, temperature is 37.2°C (99.0°F), and blood pressure is 90/60 mm Hg. Physical examination shows lethargy, hypotonia, and a weak response to primitive reflexes. There is a “honey-like” odor around his diaper which the mother says has been present since birth. Which of the following enzymes is most likely deficient in this patient?

Answer: Branched-chain alpha-ketoacid dehydrogenase

Choices:
A. Branched-chain alpha-ketoacid dehydrogenase
B. Cystathionine synthase deficiency
C. Homogentisic acid oxidase
D. Phenylalanine hydroxylase
E. Propionyl-CoA carboxylase


Question: A 35-year-old engineer is told by his boss that his team will need to work extra evening hours in the coming week in order to meet a project deadline. This frustrates the engineer, who already feels he is working too many hours. Instead of discussing this directly with his boss, the engineer calls in sick and leaves his work for his boss to finish. Which of the following psychological defense mechanisms is this individual demonstrating?

Answer: Passive aggression

Choices:
A. Anticipation
B. Displacement
C. Acting out
D. Passive aggression
E. Blocking


Question: A 29-year-old woman comes to the physician because of a 4-month history of fever, progressive shortness of breath, and a dry cough. During this time, she has also had a 5-kg (11-lb) weight loss. Two months ago, she was in Kenya for several weeks to visit her family. Physical examination shows fine crackles and wheezing over both lung fields. Her serum calcium concentration is 11.8 mg/dL. An x-ray of the chest shows reticular opacities in both lungs and bilateral hilar lymphadenopathy. Which of the following is the most likely underlying mechanism of this condition?

Answer: Granulomatous inflammation

Choices:
A. Necrotizing inflammation
B. Granulomatous inflammation
C. Viral infection
D. Monoclonal plasma cell production
E.
Neoplastic transformation
"


Question: A 58-year-old man undergoes coronary angiography that demonstrates a 90% stenosis of the left anterior descending coronary artery. The circumflex branch of the left coronary artery is not significantly obstructed. Prior to the angiogram, he underwent a pharmacologic cardiac stress test. When administered, the pharmacologic agent caused the left circumflex artery to vasodilate, with resulting increased blood supply to its supplied myocardium that was already well-perfused at baseline. This increased flow through the circumflex artery shunted blood flow away from the myocardium supplied by the stenosed left anterior descending artery, resulting in ischemia that manifested as a perfusion defect on radionuclide imaging. Which of the following agents is most strongly associated with this phenomenon described above?

Answer: Dipyridamole

Choices:
A. Metoprolol
B. Verapamil
C. Diltiazem
D. Carvedilol
E. Dipyridamole


Question: A 51-year-old woman comes to the physician because of a 3-week history of fatigue, non-productive cough, and worsening shortness of breath while walking. She was diagnosed with HIV 11 years ago. Two years ago, she was treated for esophageal thrush with fluconazole. She takes no medications because she does not feel like she needs them. She occasionally uses intravenous illicit drugs and has smoked a pack of cigarettes daily for 35 years. She appears ill. Her temperature is 38.4°C (101.1°F), respiratory rate is 25/min, pulse is 116/min, and blood pressure is 115/70 mm Hg. Pulse oximetry shows an oxygen saturation of 89% on room air. Inspiratory crackles are heard over bilateral lung fields. Cardiac examination shows no abnormalities. Laboratory studies show a CD4 count of 67/mm3 (N ≥ 500/mm3) and an elevated HIV viral load. An x-ray of the chest shows diffuse interstitial infiltrates bilaterally. In addition to starting antiretroviral therapy, the appropriate treatment for her current illness is initiated. Maintaining the patient on this medication to prevent recurrence of her current illness will also prevent infection with which of the following pathogens?

Answer: Toxoplasmosa gondii

Choices:
A. Varicella zoster virus
B. Toxoplasmosa gondii
C. Cryptococcus neoformans
D. Cytomegalovirus
E. Candida albicans


Question:
A 37-year-old man presents with right lower extremity weakness and low back pain. The patient states that he has had chronic mild to moderate low back pain for several years, but, 3 days ago after lifting a box, the pain increased in intensity and spread to his right leg. He describes the pain as severe, electrical in character, and descending from his right gluteal region along his right posterior thigh and leg to his right lateral ankle and foot. The patient also says that he has been having difficulty walking due to stumbling over his right foot. His temperature is 37.0℃ (98.6℉), the blood pressure is 125/80 mm Hg, the pulse is 72/min, the respiratory rate is 16/min, and the oxygen saturation is 98% on room air. On physical examination, the patient is alert and cooperative. Musculoskeletal examination of the lower extremities shows the following results:
Functional Muscle Group/DTR Tested Right Side Left Side
               Strength
Hip extension 5/5 5/5
Hip abduction 4/5  5/5
Hip adduction  5/5  5/5
Hip flexion 5/5 5/5
Knee flexion 5/5 5/5
Knee extension 5/5 5/5
Foot plantar flexion 5/5 5/5
Foot dorsiflexion 4/5 5/5
Foot inversion 4/5 5/5
Foot eversion 4/5 5/5
Toe extension 3/5 5/5
              Reflexes
Knee 3+ 3+
Achilles 1+ 3+
Plantar 2+ 3+
               Sensory
Sensation Decreased on the lateral aspect of the lower leg and dorsum of the foot Normal over all the surface
Lassegue test Positive at 30 deg. Negative
Which of the following is the most likely mechanism giving rise to this patient’s condition?

Answer: Protrusion of the L4/L5 intervertebral disk

Choices:
A. Protrusion of the L4/L5 intervertebral disk
B. Entrapment of the femoral nerve in the femoral canal
C. Compression of the sciatic nerve by piriform muscle
D. Inflammation of the S2-3 spinal roots
E. Herniation of the L2/3 intervertebral disk


Question: A 21-year-old woman comes to the physician because of a 5-day history of pain with urination and vaginal itching. She is sexually active with multiple partners and uses condoms inconsistently. Pelvic examination shows erythema of the vulva and vaginal mucosa, punctate hemorrhages on the cervix, and green-yellow, malodorous discharge. A photomicrograph of the discharge is shown. Which of the following is the most likely causal organism?

Answer: Trichomonas vaginalis

Choices:
A. Neisseria gonorrhoeae
B. Treponema pallidum
C. Chlamydia trachomatis
D. Candida albicans
E. Trichomonas vaginalis