Question: A 45 year old male presents to clinic complaining of a ringing in his ears. The patient's vitals are: BP 120/65, RR 16, 100% on room air, HR 78 bpm and he appears to be in no acute distress. Upon obtaining a history you learn that this patient also complains that at times the "room feels like it's spinning." You also notice throughout the interview that you have to speak loudly as the patient has difficulty hearing. The patient is then lost to follow up for his current condition. The patient returns several years later with worsening symptoms and as part of this patient's workup a MRI is obtained (Image A). Which of the following chromosomes is most likely mutated in association with this patient's condition?

Answer: Chromosome 22

Choices:
A. Chromosome 13
B. Chromosome 7
C. Chromosome 17
D. Chromosome 22
E. The X chromosome


Question: A 35-year-old is brought into the emergency room after a bicycle vs motored vehicle accident. He was unconscious after hitting the side of his head on the road, but recovered consciousness after a few minutes. He started to ride his bicycle again, but then developed a severe headache with nausea and vomiting, at which time he called EMS. While in the hospital, the patient is confused and cannot provide a history. He quickly loses consciousness and his CT scan is displayed in Figure 1. What is the most likely diagnosis?

Answer: Epidural hematoma

Choices:
A. Subarachnoid hemorrhage
B. Subdural hematoma
C. Epidural hematoma
D. Subgaleal hematoma
E. Caput succedaneum


Question: A 39-year-old man comes to the physician because of a 2-month history of shortness of breath with exertion. He immigrated to the United States from Ghana 20 years ago. His pulse is 88/min, respirations are 18/min, and blood pressure is 120/80 mm Hg. Echocardiography shows thickened mitral valve leaflets with reduced motion and a narrowed mitral valve orifice diameter. Which of the following auscultation findings is most likely to correlate with the severity of this patient's valvular disease?

Answer: Decreased time between S2 and opening snap

Choices:
A. Decreased time between S2 and opening snap
B. Presence of a mid-systolic click
C. Radiation of murmur to the axilla
D. Increased intensity of the murmur
E. Absence of A2 heart sound


Question: A 6-year-old boy is brought to the physician because of worsening fatigue for the past 4 weeks. Examination of the head and neck shows conjunctival pallor, grayish-brown spots on the irises, prominent epicanthal folds, and a broad nasal bridge. He has a single transverse palmar crease, and there are scattered petechiae over the chest. An ultrasound of the abdomen shows enlargement of the liver and spleen. Analysis of the bone marrow aspirate of this patient is most likely to show which of the following findings?

Answer: CD10 positive cells

Choices:
A. Translocation t(15;17)
B. Clusters of plasma cells
C. Ringed sideroblasts
D. CD10 positive cells
E. Hypocellular bone marrow


Question: A 42-year-old female presents to the emergency department with two days of severe abdominal pain and fever. The patient has a history of gallstones, for which she was scheduled to have a cholecystectomy in two weeks. On physical exam, her abdomen is tender to palpation over the epigastrium, without rebound or guarding. The patient is noticeably jaundiced. Laboratory evaluation is notable for a leukocytosis and a total bilirubin of 6.4 mg/dL. What is the diagnosis in this patient?

Answer: Acute cholangitis

Choices:
A. Acute cholecystitis
B. Acute pancreatitis
C. Chronic pancreatitis
D. Acute cholangitis
E. Primary sclerosing cholangitis


Question: A 52-year-old woman presents to her primary care physician because she has been feeling pain in her right leg. Specifically, she says that an area on her right thigh has been feeling tender and swollen over the past few weeks. Her past medical history is significant for obesity, poorly controlled diabetes, and hypertension. She also has been taking estrogen replacement therapy and drinking alcohol to cope with her symptoms of menopause. Her family history is significant for cardiomyopathy. On physical exam, there is erythema and edema along a cord-like lesion in her thigh. This lesion feels thick and hardened on palpation and is tender to the touch. She is started on compression therapy as well as NSAIDs for pain management. Which of the following characteristics of this patient most likely increased her risk for this disorder?

Answer: Estrogen therapy

Choices:
A. Alcohol use
B. Cardiomyopathy
C. Diabetes
D. Estrogen therapy
E. Hypertension


Question: A 34-year-old woman presents to the clinic complaining of constipation and dry mouth. She had uncontrollable diarrhea for 1 day and took some medications afterwards. Patient denies any recent hospitalizations or antibiotic use. She also denies melena, hematochezia, nausea, or vomiting. Vitals are within normal limits. What medication did the patient take?

Answer: Loperamide

Choices:
A. Loperamide
B. Metronidazole
C. Oral vancomycin
D. Sulfasalazine
E. Setraline


Question: A 25-year-old arrives at a gynecology clinic for a consult as she and her husband plan to conceive a baby soon. She is currently taking no medications, doesn’t smoke, and drinks alcohol socially. Her father passed away at the age of 51 due to heart failure. Her vital signs include blood pressure 150/100 mm Hg, heart rate 67/min, respiratory rate 16/min, and temperature 36.7°C (98.0°F). Physical examination is unremarkable. When asked about her high blood pressure, the patient says that her primary care physician once told her that her blood pressure was elevated on most of her visits; the physician emphasized that she should exercise and control her diet, but she never followed up with him as she always felt good. A number of tests are run to find out the etiology of her elevated blood pressure. Everything is within the normal range except for a renal angiogram shown in the picture. What is the most likely cause of this patient’s high blood pressure?

Answer: Fibromuscular hyperplasia

Choices:
A. Atherosclerosis
B. Adult polycystic kidney disease
C. Glomerulonephritis
D. Fibromuscular hyperplasia
E. Pheochromocytoma


Question: A 73-year-old man is found to have an early stage hepatocellular carcinoma in the left lobe of his liver. He decides to undergo surgery to remove the tumor through partial liver resection. During the procedure, a ligament is found that attaches the liver to the anterior abdominal wall. Since part of this ligament lies over the part of the liver that needs to be resected, the ligament is incised to allow for removal of the tumor. The free edge of the ligament is found to have a thickening with small remnant blood vessels. Which of the following embryonic structures most likely gave rise to the thickening described here?

Answer: Left umbilical vein

Choices:
A. Ductus venosus
B. Left umbilical artery
C. Left umbilical vein
D. Right umbilical artery
E. Ductus arteriosus


Question: A researcher is conducting an experiment on the physiology of body fluids. He documents specific observations and plots some of them as a Darrow-Yannet diagram. In his study, some diagrams are normal, while most are abnormal. The abnormalities in the diagram are mostly in the form of changes in the x-axis, changes in the y-axis or changes in both axes of the diagram. Which of the following parameters are most likely to affect the x-axis in the diagram?

Answer: Fluid volume

Choices:
A. Fluid density
B. Fluid osmolality
C. Fluid surface tension
D. Fluid viscosity
E. Fluid volume


Question: An 11-year-old girl is brought to a pediatrician by her parents with recurrent wheezing for the last 3 years. After a detailed history, complete physical examination, and thorough diagnostic evaluation, the pediatrician informs the parents that the girl has mild persistent asthma, which will be most effectively treated with inhaled corticosteroids (ICS). However, her parents firmly object to the use of corticosteroids in any form, despite being told that the side effects associated with ICS are negligible. Therefore, the pediatrician suggests the regular use of a drug that does not contain a corticosteroid. The pediatrician mentions that the drug is used as prophylaxis only and will not be useful to treat acute bronchospasm. Which of the following drugs is most likely suggested by the pediatrician?

Answer: Inhaled cromolyn sodium

Choices:
A. Subcutaneous terbutaline
B. Inhaled ipratropium bromide
C. Oral theophylline
D. Inhaled cromolyn sodium
E. Oral roflumilast


Question: A team of scientists is researching the synthesis of a drug that would potentially reduce blood pressure in hypertensive patients by a novel mechanism of action. The drug A is an inactive prodrug and enters hepatocytes, reacts with reactant B, a native material in the cell, and creates products C and D. D has a blood pressure lowering effects. The reaction requires the presence of enzyme E. The researcher observes that, for the above chemical reaction, Gibbs free energy change (ΔG) is less than zero in normal hepatocytes whereas, in hepatocytes of patients with fatty liver, ΔG is more than 0 due to some unknown reason. Based on this knowledge, provided the concentration and actions of reactant B and enzyme E are same in both normal hepatocytes and hepatocytes of fatty liver patients, which of the following is the most likely possibility if drug A is administered to hypertensive patients with fatty liver?

Answer: Drug A will not decrease blood pressure, regardless of its dose or supplementation of B or E

Choices:
A. Drug A will decrease blood pressure only if reactant B is also supplemented in necessary dose
B. Drug A will decrease blood pressure only if enzyme E is also supplemented in necessary dose
C. Drug A will not decrease blood pressure, regardless of its dose or supplementation of B or E
D. Drug A will decrease blood pressure in same dose as required for patients with a healthy liver
E. Increased dose of drug A will be required to decrease blood pressure


Question: A 70-year-old man comes to the physician because of a 4-month history of progressively worsening lower back pain. He describes the pain as a constant, dull ache that interferes with his sleep and is only partially relieved with ibuprofen. Two years ago, he was diagnosed with advanced prostate cancer, for which he underwent radiation therapy of the prostate and bilateral orchiectomy. One year postoperatively, serum prostate-specific antigen (PSA) was undetectable. He missed his previous follow-up visit. Current medications include over-the-counter ibuprofen. Vital signs are within normal limits. Physical examination shows tenderness of the spinous process of the third lumbar vertebra. Digital rectal examination shows a hard, nontender prostate. The remainder of the examination shows no abnormalities. The serum PSA concentration is 16 ng/mL (N<4). A technetium-99m bone scan shows increased uptake at the second and third lumbar vertebral bodies. In addition to analgesia, which of the following is the most appropriate next step in management?

Answer: External beam radiotherapy to the lumbar vertebrae

Choices:
A. External beam radiotherapy to the lumbar vertebrae
B. Leuprolide therapy
C. Finasteride therapy
D. Observation with no further treatment
E.
Active surveillance
"


Question:
A 24-year-old woman presents complaining of a new onset vaginal odor. She reports that she is sexually active in a monogamous relationship with the same partner for two years. You perform a KOH prep, and notice an abnormal smell. On microscopy in your office, you observe the findings in figure A.

What is the most likely causative organism?

Answer: Gardnerella vaginalis

Choices:
A. Trichomonas vaginalis
B. Candida albicans
C. Escherichia coli
D. Gardnerella vaginalis
E. Neisseria gonorrhoeae


Question: A 22-year-old woman is brought to the emergency department 4 hours after the ingestion of 25 tablets of an unknown drug in an attempt to commit suicide. Her temperature is 36.7°C (98°F), pulse is 41/min, respirations are 14/min, and blood pressure is 88/55 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. She is confused and oriented only to person. The pupils are equal and reactive to light. Examination shows cold, clammy extremities. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields. The abdomen is soft. Fingerstick blood glucose concentration is 65 mg/dL. ECG shows prolonged PR intervals and narrow QRS complexes. Two large bore cannulas are inserted and intravenous normal saline, dextrose, and atropine are administered. Five minutes later, pulse is 51/min and blood pressure is 95/61 mm Hg. In addition to securing the airway, which of the following is the most appropriate next step in management?

Answer: Glucagon

Choices:
A. Glucagon
B. Activated charcoal
C. Sodium bicarbonate
D. Hemodialysis
E. Naloxone


Question: A 56-year-old patient reports a history of recurrent dental caries. The bacteria causing this patient's dental problems most likely exhibits which of the following properties?

Answer: Production of dextrans from glucose

Choices:
A. Inhibition of growth on optochin sensitivity test
B. Gram negative diplococci
C. Production of dextrans from glucose
D. Presence of catalase enzyme
E. Soluble in bile


Question:
A 40-year-old woman comes to the physician for a follow-up examination. She says she has felt fatigued for about 3 months. She does not have enough energy for her job as a physician's assistant and often has to lie down and rest during shifts. She no longer adheres to her usual exercise routine because of exhaustion. During this time, she has noticed that her stools are sometimes pale and foul smelling. She also has generalized itching. The patient does not have abdominal pain, fever, or weight loss. She takes levothyroxine for hypothyroidism. She has smoked one pack of cigarettes weekly for 20 years. Physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 14.1 g/dL
Leukocyte count 7,200/mm3
Erythrocyte sedimentation rate 26 mm/h
Serum
Thyroid-stimulating hormone 4.2 μU/ml
Bilirubin
Total 1.7 mg/dL
Direct 1.0 mg/dL
Alkaline phosphatase 370 U/L
Aspartate aminotransferase 80 U/L
Alanine aminotransferase 46 U/L
Cholesterol 320 mg/dL
Gamma-glutamyl transferase 98 U/L (N = 5–50)
Magnetic resonance cholangiopancreatography shows no gallstones and no evidence of extrahepatic biliary obstruction. Liver biopsy shows nonsuppurative destructive cholangitis with lymphocytic infiltration of portal areas and periductal granulomas. Which of the following autoantibodies is most likely to be present in this patient?"

Answer: Anti-mitochondrial antibodies

Choices:
A. Anti-liver-kidney microsomal-1 antibodies
B. Anti-mitochondrial antibodies
C. Anti-smooth muscle antibodies
D. Anti-endomysial antibodies
E. Perinuclear anti-neutrophil cytoplasmic antibodies


Question: A 73-year-old man seeks evaluation for difficulty developing and maintaining erections. He has recently made lifestyle modifications, such as losing 4.5 kg (10 lb) but his erectile symptoms have not improved. He was prescribed a drug by his physician. Inhibition of which of the following best describes this drug’s mechanism of action?

Answer: cGMP phosphodiesterase

Choices:
A. 5-alpha reductase
B. cAMP phosphodiesterase
C. cGMP phosphodiesterase
D. Estrogen receptors
E. Testosterone receptors


Question: A 65-year-old woman with hypertension comes to the emergency department because of sudden onset of a severe headache 2 hours ago. Her temperature is 35°C (95°F) and blood pressure is 189/115 mm Hg. A CT scan of the head shows a subarachnoid hemorrhage and she is started on appropriate pharmacotherapy. Which of the following regions of the brain is most likely affected?

Answer: Preoptic nucleus

Choices:
A. Anterior cingulate gyrus
B. Ventral lateral thalamic nucleus
C. Pineal gland
D. Preoptic nucleus
E. Caudate nucleus


Question: A 35-year-old woman with a one-year history of auditory hallucinations and periods of anhedonia and amotivation is being seen by her psychiatrist. She was started on haloperidol at her last visit, but she was told to stop taking the medication since she developed muscle stiffness and spasms soon after taking the drug. Today, her temperature is 97.7°F (36.5°C), blood pressure is 132/76 mmHg, pulse is 98/min, and respirations are 12/min. The patient is now started on a new medication that will seek to avoid the same side effects as her previous one; however, she will need to come in for weekly testing. Which of the following should be tested weekly?

Answer: White blood cell count

Choices:
A. Electrocardiogram
B. Electrolytes
C. Gonadotropin releasing hormone
D. Liver panel
E. White blood cell count


Question: A 9-year-old boy is brought to the emergency room by his concerned mother after he "urinated blood." The boy reports that, starting this morning, he experienced significant pain with urination and his urine appeared a bright red color. These symptoms were not present before today; however, he reports a cough, runny nose, and sore throat that started approximately 3 days ago. Vital signs are as follows: T 38.4 deg C, HR 101, BP 110/65, RR 14, SpO2 99%. Physical examination is significant for bilateral conjunctivitis, tenderness to suprapubic palpation, and a small amount of clotted blood is noted surrounding the urethral meatus. A urine sample is obtained, and urinalysis shows 3+ blood, and urine microscopy demonstrates gross blood with too many cells to count per high powered field. Which of the following is the most common viral cause of this child's condition?

Answer: Adenovirus

Choices:
A. Parvovirus B19
B. Coronavirus
C. Echovirus
D. Adenovirus
E. Coxsackie A virus


Question: A young researcher wants to develop a method of increasing oxygen delivery to the peripheral tissues. He brainstorms several ideas but is informed by his mentor that only one of his ideas will most likely help him achieve the desired result. Of the following proposed mechanisms, which one would best serve the researcher's purpose?

Answer: Increase taut form hemoglobin in muscle capillaries

Choices:
A. Decrease lactic acid production by skeletal muscle
B. Increase fetal hemoglobin concentration in circulation
C. Increase relaxed form hemoglobin in muscle capillaries
D. Increase taut form hemoglobin in muscle capillaries
E. Shift intracellular hemoglobin into plasma


Question: A 29-year-old man comes to the physician for a follow-up examination. He has had numbness and tingling of his legs for the past 10 days. Three months ago, he was diagnosed with pulmonary tuberculosis and started on antituberculosis therapy. Examination shows dry scaly lips and cracks at the corner of the mouth. Sensation to pinprick and light touch is decreased over the lower extremities. His hemoglobin concentration is 10.4 g/dL and mean corpuscular volume is 76 μm3. Administration of which of the following is most likely to have prevented this patient's current symptoms?

Answer: Pyridoxine

Choices:
A. Iron
B. Vitamin E
C. Folic acid
D. Vitamin B12
E. Pyridoxine


Question:
A 36-year-old woman presents with a 2-month history of urinary incontinence, accompanied by urgency, nocturia, and occasional hematuria. Her symptoms are present day and night and have no known triggers. She was diagnosed with grade 2 pelvic organ prolapse (cystocele) 1 year ago, which is managed with pelvic floor training exercises and a vaginal pessary. She is otherwise healthy and does not take any medications. The blood pressure is 120/80 mm Hg, the heart rate is 67/min, the respiratory rate is 14/min, and the temperature is 36.8℃ (98.2℉). The physical examination is significant for suprapubic tenderness. No costovertebral angle tenderness is present. There are no signs of vulvar inflammation, and no urethral or vaginal discharge. The vaginal mucosa is normal and there is no cervical discharge. A vaginal pessary is placed. The cervix is non-tender and mobile, the uterus is not enlarged, and the adnexa have no masses.
The urinalysis shows the following findings:
 Color:  Pale yellow
 Clarity:  Clear
 pH:  6.2
 Specific gravity:  1.023
 Glucose:  Negative
 Ketones:  Negative
 Nitrites:  Positive
 Leukocyte esterase:  Positive
 Bilirubin:  Negative
 Urinary bilirubin:  Negative
 Protein: Negative
 RBCs:  47 RBCs/hpf
 WBCs:  21 WBCs/hpf
 Epithelial cells:  27 squamous epithelial cells/hpf
 Casts:  5 hyaline casts/lpf
 Crystals:  Occasional urates
 Bacteria:  None noted
 Yeast:  None noted
The urinary culture is negative. Which investigation should be performed next in this patient?

Answer: Ultrasound examination

Choices:
A. Cystoscopy
B. Ultrasound examination
C. Cystometry
D. Cystography
E. Pelvic CT scan


Question: The incidence of red-green color blindness in males in a certain population is 1/100. Which of the following is closest to the probability of a female and a male with normal vision having a daughter with red-green color blindness?

Choices:
A. 1/100
B. 99/100
C. 1/50
D. 98/100
E. 0


Question: A 31-year-old man comes to the physician for evaluation of chronic cough, sinus pain, and nasal discharge. He has a history of frequent upper respiratory infections and recurrent sinusitis since childhood. He is also concerned about fertility, as he and his wife have been trying to conceive for 5 years unsuccessfully. Pulmonary examination shows crackles and wheezing throughout both lung fields. A CT scan of the chest is shown. The most likely cause of this patient's condition is a defect in which of the following molecular structures?

Answer: Dynein arm

Choices:
A. IL-2R gamma chain
B. NADPH oxidase
C. CFTR protein
D. Dynein arm
E. α-1 antitrypsin


Question: A 3-year-old boy is brought to the emergency department because of abdominal pain and watery diarrhea for the past 3 days. This morning he also had nausea and his stool had a red tint. Four days ago, he and his parents returned home from a vacation, during which they visited a petting zoo and consumed many new foods. He lives with his family and they have cats and dogs at home. The patient attends daycare. His immunizations are up-to-date. His temperature is 38°C (100.4°F), pulse is 140/min, and blood pressure is 80/45 mm Hg. Examination shows dry mucus membranes. The abdomen is soft, and there is tenderness to palpation of the right lower quadrant with rebound. Stool culture grows Yersinia enterocolitica. Which of the following is most likely to have prevented this patient's condition?

Answer: Avoiding the consumption of undercooked pork

Choices:
A. Hand-washing at daycare
B. Avoiding the consumption of undercooked pork
C. Avoiding the consumption of deli meats
D. Avoiding the consumption of unwashed vegetables
E. Avoiding the consumption of home-canned food


Question: A 61-year-old woman dies unexpectedly. She had not seen a physician in 10 years. Examination of the heart during autopsy shows hypertrophy of the left ventricular wall and enlargement of the left ventricular chamber. Microscopic examination shows lengthening of individual muscle fibers due to duplication of sarcomeres in series. Which of the following is the most likely underlying cause of these findings?

Answer: Increased left ventricular end diastolic volume

Choices:
A. Increased pulmonary arterial pressure
B. Decreased left ventricular contractility
C. Decreased left ventricular compliance
D. Increased systemic vascular resistance
E. Increased left ventricular end diastolic volume


Question:
A 57-year-old man with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and obstructive sleep apnea presents to your office for routine screening. He reports compliance with his medications but admits to difficulty maintaining the diet and exercise routines discussed during his last visit. He does not have any other complaints. He drinks 3-4 beers on the weekends and does not smoke cigarettes. His current medications include metformin, atorvastatin, and hydrochlorothiazide. On physical examination, his temperature is 99°F (37.2°C), blood pressure is 130/85 mmHg, pulse is 85/min, and respirations are 18/min. Laboratory results are shown below:

Serum:
Na+: 138 mEq/L
Cl-: 100 mEq/L
K+: 3.9 mEq/L
HCO3-: 23 mEq/L
BUN: 13 mg/dL
Glucose: 160 mg/dL

You decide to start the patient on a medication that triggers insulin release. What is the mechanism of action of this drug?

Answer: Close potassium channels

Choices:
A. Close potassium channels
B. Increase insulin sensitivity
C. Inhibit intestinal brush border enzymes
D. Delay gastric emptying
E. Increase ATP generation


Question: A 28-year-old woman presents to the emergency department with fever and abdominal pain for the past several days. She says she feels like she has a slight fever. She denies nausea or vomiting. Physical examination shows pain in the right upper quadrant to deep palpation with rebound tenderness and guarding. A laparoscopy is performed which shows string-like, fibrous scar tissue in the perihepatic recesses. Which of the following is the most likely organism responsible for the patient's condition?

Answer: Neisseria gonorrhoeae

Choices:
A. Giardia lamblia
B. Gardnerella vaginalis
C. Trichomonas vaginalis
D. Treponema pallidum
E. Neisseria gonorrhoeae


Question: A 30-year-old woman comes to the emergency department because of a 1-day history of sharp chest pain radiating to the left shoulder. The pain worsens when she coughs, breathes deeply, or lies down. She has had a mild fever and a cough for the past 2 days. She takes ibuprofen for hip and knee pain, which started 4 months ago. Examination shows a symmetric, erythematous rash on her nose and cheeks, and erythematous patches with scaling and plugged follicles over her hands. Cardiovascular evaluation of this patient is most likely to show which of the following findings?

Answer: Triphasic scratchy heart sound of varying intensity

Choices:
A. Increased distension of jugular veins during inspiration
B. 18 mm Hg decrease in systolic blood pressure during inspiration
C. High-pitched pericardial sound occurring slightly earlier than a third heart sound
D. Triphasic scratchy heart sound of varying intensity
E. Holosystolic blowing murmur heard best at the apex


Question: A 22-year-old man comes to the physician because he has been increasingly worried and stressed in recent weeks. He started a marketing job three months ago, which involves traveling between Washington and California several times a year. Two months ago, he was supposed to fly to Seattle, but he experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane, causing him great embarrassment. He had never been on a plane before; his parents died in a plane crash when he was younger. A week ago, he called in sick when he was supposed to go on a business trip. He worries that he will lose his job. He is otherwise well and has no history of serious illness. He takes no medications. His temperature is 37.2°C (99°F), pulse is 85/min, respirations are 12/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, he is alert and cooperative. His speech is normal and his thought process is organized. His memory, attention, and concentration are intact. Which of the following is the most appropriate next step in management of this patient's symptoms?

Answer: Cognitive behavioral therapy

Choices:
A. Oral paroxetine
B. Oral alprazolam
C. Oral propranolol
D. Observation
E. Cognitive behavioral therapy


Question: A 52-year-old man presents to the office complaining of a 2-week history of fatigue, progressively worsening shortness of breath, and swelling of his lower legs and feet. His past medical history is only significant for slightly elevated blood pressure. The patient denies tobacco use although he does admit to drinking 8-10 beers, daily, for the past 10 years. He takes a low dose of aspirin daily, ever since he had an anterior myocardial infarction 2 years ago. The patient works as a financial consultant and frequently travels for work. The current temperature is 36.8°C (98.3°F), the pulse rate is 68/min, the blood pressure is 152/84 mm Hg, and the respiratory rate is 16/min. His weight is 102 kg (224 lb) and height 180 cm (5 ft 9 in). Echocardiography demonstrates an ejection fraction of 35% and a thin left ventricular wall. What is the appropriate medication for this patient’s condition?

Answer: Spironolactone

Choices:
A. Nifedipine
B. Atorvastatin
C. Procainamide
D. Ibuprofen
E. Spironolactone


Question: A 70-year-old man comes to the physician for a follow-up evaluation. Eight months ago, he presented with a 6-month history of increased urinary frequency, difficulty to initiate urination, and straining to maintain the urinary stream. Digital rectal examination showed symmetrically enlarged, nontender prostate with rubbery texture. Laboratory studies showed a prostate-specific antigen (PSA) level of 2 ng/mL. Abdominal ultrasound showed a post-void residual urine volume of 250 ml and bladder wall thickening. The patient received appropriate treatment. His vital signs are within normal limits. Laboratory studies now show a PSA level of 1 ng/mL. Which of the following medications was most likely used to treat this patient's symptoms?

Answer: Dutasteride

Choices:
A. Oxybutynin
B. Dutasteride
C. Terazosin
D. Flutamide
E. Tadalafil


Question: A 53-year-old man presents to the office complaining of persistent abdominal pain. He states that he has gained 4.5 kg (10.0 lb) because the pain is only relieved by eating. The patient also admits that he has had numerous loose, foul-smelling stools over the last few weeks with associated nausea. He has taken some over the counter antacids without relief or change in symptoms. His blood pressure is 132/76 mm Hg, respiratory rate is 14/min, and heart rate is 75/min. Physical examination reveals mild tenderness to palpation of the upper abdomen. Which of the following is the most likely diagnosis?

Answer: Zollinger-Ellison syndrome

Choices:
A. Whipple disease
B. H. pylori infection
C. Intestinal type gastric adenocarcinoma
D. NSAID induced peptic ulcer disease
E. Zollinger-Ellison syndrome


Question: A 68-year-old man with advanced dementia is brought to the preoperative unit prior to an elective cholecystectomy for biliary colic. He says he does not want the surgery anymore. He begins yelling at unit staff and requests to leave. His designated medical power of attorney, who had previously signed the surgery consent forms, is present. Which of the following is the most appropriate next step in management?

Answer: Ask the patient about his concerns and try to address them

Choices:
A. Consult psychiatry for capacity evaluation
B. Cancel the surgery and allow the patient to leave
C. Ask the patient about his concerns and try to address them
D. Call family members and schedule a family meeting
E. Perform cognitive screening evaluation


Question: A 67-year-old man presents to his physician’s office with a progressive cough. It has been increasing in intensity over the past week. He has also been noticing an increase in the amount of sputum he usually produces, which is thick and yellow. He also complains of increased difficulty in breathing, more so than he previously experienced. He was diagnosed with chronic obstructive lung disease (COPD) about 3 years ago and has been on treatment for it since then. He doesn’t report any fever, chills, or night sweats. He has observed a foul smell to his sputum. His blood pressure is 100/65 mm Hg, the respirations are 23/min and the pulse is about 110/min. Currently, his FEV1 is around 48% of the normal predicted value. He is currently receiving a yearly influenza shot and has taken the pneumococcal vaccination at the time of his diagnosis. In spite of this, he has had acute exacerbations of his symptoms 4 times over the last year. His last episode was 2 months ago, for which he was treated with a short course of antibiotics. He is also currently receiving treatment for diabetes. Which of the following pathogens should be considered before initiating treatment for the current episode?

Answer: P. aeruginosa

Choices:
A. S. pneumonia
B. H. influenzae
C. P. aeruginosa
D. M. catarrhalis
E. Syncytial virus


Question: A 27-year-old man who was involved in a motor vehicle collision is brought into the emergency room with a fractured skull. The paramedics report that the patient was conscious and lucid on the way to the hospital but now is unresponsive. His vitals are a blood pressure of 122/78 mm Hg, temperature of 37.0°C (98.6°F), pulse rate of 88/min, and respiratory rate of 14/min. A noncontrast CT scan of the head shows an epidural hematoma. Which of the following structures is involved in the development of an epidural hematoma?

Answer: Middle meningeal artery

Choices:
A. Middle meningeal artery
B. Bridging cortical veins
C. Arteriovenous malformation
D. Saccular aneurysm
E. Lenticulostriate vessels


Question: A 54-year-old woman presents to the emergency department due to recent onset of a high fever, accompanied by severe headache and neck stiffness. Her past medical history is significant for rapidly progressive glomerulonephritis. She is currently on immunosuppressants after a kidney transplant performed 6 months ago. On presentation, her temperature is 102.2°F (39°C), blood pressure is 112/71 mmHg, pulse is 107/min, and respirations are 22/min. Physical exam reveals severe pain with neck flexion and reciprocal knee flexion. Laboratory tests reveal a gram-positive organism with endotoxin. Which of the following characteristics is true of the most likely cause of this patient's disorder?

Answer: Tumbling motility in broth

Choices:
A. Anaerobic spore forming rods
B. Catalase-negative
C. Coagulase-positive
D. Tumbling motility in broth
E. V formation of club-shaped rods


Question: A 2-year-old boy is brought to see the pediatrician by his mother due to a “bad” cough. The mother reports that he has been coughing so hard that he threw up on several occasions. He is adopted and the mother does not know his vaccination history. He has no known allergies. His temperature is 38.5°C (100.5°F), pulse is 120/min, respirations are 33/min, blood pressure is 101/54 mm Hg, and oxygen saturation is 96% on room air. The boy looks unwell with mild difficulty breathing and a nonproductive cough multiple times followed by a “whoop” sound during the inhalation. He has scattered petechiae on his face. A nasopharyngeal swab is sent for culture and PCR. Which of the following antibiotics is recommended for this patient?

Answer: Erythromycin

Choices:
A. Ciprofloxacin
B. Ceftriaxone
C. Cefotaxime
D. Erythromycin
E. Ampicillin


Question: A 19-year-old man returns from travel in South America. He presents complaining of profuse, watery diarrhea. You suspect the causative organism to be Enterotoxigenic E. coli. What is the mechanism by which this organism causes diarrhea?

Answer: Stimulates adenylate cyclase (increasing cAMP)

Choices:
A. Blocks the release of inhibitory neurotransmitters GABA and glycine
B. Blocks the presynaptic release of acetylcholine at the neuromuscular junction
C. Inactivates mammalian 60S ribosomal subunit
D. Stimulates release of cytokines
E. Stimulates adenylate cyclase (increasing cAMP)


Question: A 38-year-old man presents to the clinic for complaints of abdominal pain and diarrhea. He reports a long-standing history of the symptoms except for the time when he attempted a carbohydrate-free diet 5 years ago. The pain is described as stabbing, diffuse, 8/10, and is especially worse following food intake. Recently, he noticed some numbness and tingling of his feet but denies any bloody stool, nausea, vomiting, fevers, weight loss, or focal neurological deficits. What histopathological findings would you expect to find in this patient?

Answer: Blunting of the intestinal villi at the ileum

Choices:
A. Blunting of the intestinal villi at the ileum
B. Crypt abscesses at the descending colon
C. Noncaseating granulomas at the ileum
D. Normal gastric mucosa at the jejunum
E. PAS-positive foamy macrophages at the jejunum


Question: A 25-year-old male presents for a new primary-care visit. He has never been seen by a physician and reports that he has been in good health. You note a very tall, very thin male whose arm span is greater than his height. The patient reports that his father had a similar build but passed away suddenly in his 40s. You suspect a genetic disorder characterized by a defect in fibrillin-1. What is the histopathology of the most common large-artery complication of this disease?

Answer: Cystic medial degeneration

Choices:
A. Focal granulomatous inflammation with mural lymphocytes, macrophages, giant cells
B. Eosinophilic vasculitis
C. Predominant neutrophilic infiltration with fibrinoid necrosis
D. Fibrinoid necrosis of blood vessel walls, endothelial swelling, and neutrophilic infiltrate in skin lesions
E. Cystic medial degeneration


Question: A group of investigators is evaluating the efficacy of intranasal ketamine in decreasing acute suicidality in teenagers admitted to inpatient psychiatric units. They conducted a pilot study in which 15 participants were randomized to receive intranasal ketamine while 15 participants were randomized to receive placebo. The investigators ultimately found no statistically significant difference in suicidality after 30 days of follow up with the level of significance fixed at 5%. They suspect inadequate statistical power. Assuming the investigators intend to keep the level of significance at 5%, which of the following changes would be most effective to increase the statistical power?

Answer: Decrease the type II error rate

Choices:
A. Decrease alpha
B. Decrease the sample size
C. Decrease the type II error rate
D. Increase beta
E. Increase the type I error rate


Question: A 56-year-old man presents with severe back pain for the past hour. He says the pain started about 1 hour ago and has not improved. The patient describes the pain as sharp, 10/10, and located between his scapula. Past medical history is significant for hypertension, which he is noncompliant with medication. His vital signs are a blood pressure of 180/95 mm Hg and a pulse of 108/min. On physical examination, there is a loss of pain and temperature sensation in the lower trunk and extremities bilaterally. Strength is 4 out of 5 in all muscle groups in the lower extremities bilaterally. A contrast CT of the chest reveals findings consistent with a type B aortic dissection. Which of the following etiologies is the most likely cause of this patient’s neurologic findings?

Answer: Anterior cord syndrome

Choices:
A. Central cord syndrome
B. Brown-Séquard syndrome
C. Spinal cord compression
D. Anterior cord syndrome
E. Spinal epidural hematoma


Question: A 7-year-old girl is brought to the physician by her mother because of a 6-month history of worsening fatigue and frequent upper respiratory tract infections. She is at the 2nd percentile for height and 10th percentile for weight. Physical examination shows pallor, diffuse hyperpigmented macules, absence of the radial bones, and hypoplastic thumbs. Her hemoglobin concentration of 8.7 g/dL, leukocyte count is 2,500/mm3, and platelet count is 30,000/mm3. This patient's condition is most likely caused by a defect in a gene encoding a protein that is normally involved in which of the following processes?

Answer: DNA interstrand crosslink repair

Choices:
A. Excision of pyrimidine dimers
B. Hydrolysis of glucocerebroside
C. DNA interstrand crosslink repair
D. Maturation of erythroid progenitor cells
E. Ras signal transduction pathway


Question:
A 36-year-old woman is brought to the emergency department because of loss of consciousness. Her husband says that she complained of vomiting and dizziness for 2 days, but did not seek medical care. She has a history of acral vitiligo. Her blood pressure is 90/60 mm Hg, temperature is 35.9°C (96.6°F), and pulse is 90/min. On physical examination, she is obtunded, skin turgor is reduced, and her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks. Lab results are shown:
Random plasma glucose 40 mg/dL
Serum osmolarity 275 mOsm/kg H₂O
Serum sodium 130 mEq/L
Serum potassium 6 mEq/L
Urine sodium level 30 mEq/L
ECG shows normal sinus rhythm without ST-T wave changes. Dextrose 5% is given and random plasma glucose becomes 60 mg/dL, but her blood pressure is still the same. Which of the following is the best next step in the management of this patient condition?

Answer: Normal saline and intravenous dexamethasone

Choices:
A. Intravenous calcium gluconate
B. ACTH stimulation test
C. Subcutaneous octreotide
D. Oral dehydroepiandrosterone (DHEA)
E. Normal saline and intravenous dexamethasone


Question: A 4-year-old girl is seen by her pediatrician for developmental delay. One year prior, the patient was able to ride a tricycle, stack 3 blocks, and speak in short sentences. Now, she is unable to feed herself and has recently started to point to objects she wants rather than asking. Physical exam reveals a well nourished child sitting in a stroller wringing her hands. Vital signs are normal. The patient's mother reports that her 7-year-old son is doing well, and that they have no family history of mental retardation or other cognitive disorders. What is the most likely diagnosis?

Answer: Rett syndrome

Choices:
A. Angelman syndrome
B. Rett syndrome
C. Beckwith–Wiedemann syndrome
D. Prader-Willi syndrome
E. McCune-Albright syndrome


Question: A 49-year-old woman visits the emergency department with the acute onset of severe shortness of breath. She also reports right-sided calf pain that developed after a 22-hour flight from Beijing to Los Angeles, and that, several hours after she felt pain in her calf, she began to have trouble breathing. Currently, her shortness of breath is so severe that she is unable to speak clearly or quickly, but she manages to deny any recent surgery or history of recent bleeding. The vital signs include: blood pressure 111/69 mm Hg, pulse 142/min, and respiratory rate 33/min. On observation, she is using accessory muscles to breathe. On auscultation, her lungs are clear and her heart rate is rapid but regular. Her right calf is swollen, warm, and tender. The arterial blood gas test result reveals a pH of 7.5, partial pressure of carbon dioxide (PCO2) 22 mm Hg, and a partial pressure of oxygen (PaO2) 47 mm Hg on 6 L of oxygen by nasal cannula. Which of the following is the most appropriate next step in the management of this patient?

Answer: Streptokinase

Choices:
A. Unfractionated heparin
B. Streptokinase
C. Low molecular-weight heparin
D. Warfarin
E. Embolectomy


Question: A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor. She has had no prenatal care. Her three children were delivered by lower segment transverse cesarean section. The patient appears in acute distress. Her pulse is 98/min, respirations are 15/min, and blood pressure is 130/80 mm Hg. The abdomen is nontender and contractions are felt. The fetus is in a cephalic presentation. The fetal heart rate is reactive with no decelerations. One hour following vaginal delivery, the placenta is not delivered. Manual separation of the placenta leads to profuse vaginal bleeding. A firm, nontender uterine fundus is palpated at the level of the umbilicus. Which of the following is the most likely diagnosis?

Answer: Placenta accreta

Choices:
A. Ruptured vasa previa
B. Uterine rupture
C. Placenta previa
D. Placenta accreta
E.
Abruptio placentae
"


Question: A 40-year-old man is brought to the clinic by his wife with a complaint of behavioral changes for the past few months. He is irritable and gets angry with trivial matters. He sometimes screams in the middle of the night and remains restless. His wife has recently noticed that he is forgetting things and repeats the same question multiple times. For the past few weeks, he is also having abnormal movements of his body, more prominent in the arms and hands. The past medical history is unremarkable. His father died at the age of 28 years old in a road traffic accident. His grandmother had similar symptoms after her retirement. He does not smoke, drinks alcohol, or uses illicit drugs. The physical examination reveals a restless ill-groomed man. He is having intermittent involuntary dance-like movements. The slit-lamp ophthalmic examination is normal. His mini-mental state examination (MMSE) score is 22/30. The complete blood count, basic metabolic profile, thyroid profile, liver profile, serum vitamin B12, and ceruloplasmin levels are within normal range. An MRI of the brain will reveal an atrophy of which of the following structure?

Answer: Caudate nucleus

Choices:
A. Caudate nucleus
B. Cerebellum
C. Diffuse cortex
D. Frontal and temporal lobes
E. Substantia nigra


Question: A researcher is studying the association between hemoglobin levels and BMI. He divides volunteers who wish to participate into 2 groups based on their BMI, a normal weight group and an overweight group. He then measures the hemoglobin level of all of the volunteers. His null hypothesis is that there is no association between hemoglobin levels and body weight. The mean hemoglobin level for the normal weight group is 13.4 g/dL and 13.8 g/dL for the overweight group. He obtains a mean difference of 0.4 g/dL between the 2 groups. He does an unpaired t-test and gets a p-value of 0.10. Which of the following statements best describes the study?

Answer: If the null hypothesis is true, there is a 10% probability to get this difference of 0.4 g/dL or higher due to chance.

Choices:
A. If the null hypothesis is not true, 10% or more of the volunteers would not show any association between hemoglobin level and weight.
B. If the null hypothesis is not true, there is still a 10% probability to not get this difference of 0.4 g/dL or higher due to chance.
C. If the null hypothesis is true, there is still a 10% probability of not getting this difference of 0.4 g/dL or higher due to chance.
D. If the null hypothesis is true, there is a 10% probability to get this difference of 0.4 g/dL due to chance.
E. If the null hypothesis is true, there is a 10% probability to get this difference of 0.4 g/dL or higher due to chance.


Question: A 51-year-old female with a history of papillary thyroid carcinoma who is two weeks status-post thyroidectomy presents to her surgeon complaining of difficulty with her voice. Following the operation, she developed immediate hoarseness and difficulty speaking. The hoarseness has not improved since the operation. Her past medical history is notable for hypertension and obesity. Her temperature is 99°F (37.2°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 16/min. Physical examination reveals a healing surgical scar without evidence of infection or dehiscence. Which of the following embryologic structures most likely gave rise to the structure that was damaged in this patient?

Answer: Sixth branchial arch

Choices:
A. First branchial arch
B. Second branchial arch
C. Third branchial arch
D. Fourth branchial arch
E. Sixth branchial arch


Question: Six days after admission to the hospital for treatment of infective endocarditis, a 64-year-old woman develops persistent ringing in both ears, lightheadedness, and nausea. When she turns her head, she sees the light on the ceiling swinging from side to side. She has congestive heart disease, hypertension, and coronary artery disease. She was treated for a cerebrovascular accident 7 years ago and has no residual deficits. Current medications include intravenous vancomycin and gentamicin, as well as oral aspirin, atenolol, furosemide, and lisinopril. Her vital signs are within normal limits. Cardiac examination shows a grade 3/6 holosystolic murmur along the left lower sternal border. While the patient fixates on a target, administration of brisk, horizontal head rotations to both sides results in corrective saccades to refixate back to the target. She has an unsteady gait. Muscle strength and sensation are normal. Which of the following is the most likely cause of this patient's current symptoms?

Answer: Medication toxicity

Choices:
A. Decreased endolymph resorption
B. Dislodged otoliths
C. Suppurative labyrinthitis
D. Medication toxicity
E. Delirium


Question: A patient with congestive heart failure with viral myocarditis due to coxsackievirus infection presents to a local hospital for treatment and then returns home. Which of the following cardiac conditions are the most likely long-term consequence of the patient’s clinical presentation and hospitalization?

Answer: Dilated cardiomyopathy

Choices:
A. Concentric hypertrophy
B. Dilated cardiomyopathy
C. Endarteritis obliterans
D. Hypertrophic cardiomyopathy
E. Restrictive cardiomyopathy


Question: A 5-year-old male presents to the pediatrician with his mother for a well child visit. His mother has no complaints. The patient is doing well in preschool and appears to be ready for kindergarten. He can begin to sound out letters and write out his first name. He has many friends at school and enjoys playing with his older siblings. The patient’s past medical history is notable for birth weight in the 99th percentile and unexplained hypoglycemia in the first week of life. The patient’s mother denies any family history of genetic syndromes or malignancy. The patient’s height and weight are in the 99th percentile. On physical exam, the patient has an enlarged tongue with no other dysmorphic features. He also has the physical exam findings seen in Figures A and B. This patient should be screened for abnormalities in which of the following organs?

Answer: Kidneys

Choices:
A. Adrenal glands
B. Bone
C. Eyes
D. Kidneys
E. Thyroid gland


Question: A first-year medical student undergoes a surgical procedure involving a midline laporotomy incision. The patient presents back to the surgeon approximately 3 months later and asks the surgeon: "What type of tissue is causing the scar to form on my abdomen?" The physician promptly answers:

Answer: Type 1 collagen

Choices:
A. Keratin
B. Type 1 collagen
C. Type 2 collagen
D. Type 3 collagen
E. Type 4 collagen


Question: A 40-year-old female complains of muscle weakness. Her blood pressure is 180/140 mm Hg, and serum potassium is 3.2 mEq/L. Plasma renin levels are abnormally low. A CT scan of her abdomen reveals a 3 cm lesion in her right adrenal gland. The patient’s lesion is likely composed of functional cells from which of the following regions:

Answer: Zona glomerulosa

Choices:
A. Zona glomerulosa
B. Zona fasciculata
C. Zona reticularis
D. Adrenal medulla
E. Posterior pituitary


Question: A 75-year-old woman is brought to the physician by her daughter because of a 1-month history of fatigue and a 3.5-kg (7-lb) weight loss. The patient has a history of hypertension, hyperlipidemia, and Alzheimer's dementia. She lives with her daughter and requires assistance with all of her banking and meal preparation. Her daughter has hypothyroidism but there is no other history of serious illness in the family. She does not remember the names of her medications but says she takes them every day. Her pulse is 114/min and blood pressure is 148/101 mm Hg. Physical examination shows warm skin and a tremor. The thyroid gland is not palpable. The serum thyroid stimulating hormone level is undetectable. Histological examination of a thyroid biopsy shows follicular atrophy. Which of the following is the most likely underlying cause of this patient's symptoms?

Answer: Exogenous levothyroxine use

Choices:
A. Graves disease
B. Exogenous levothyroxine use
C. Granulomatous thyroiditis
D. Iodine exposure
E.
Medullary thyroid cancer
"


Question: A 42-year-old man is brought to the emergency department by EMS from the scene of an automobile accident, where he appeared to be an unrestrained passenger. The patient is confused and unable to answer questions. His temperature is 98.6°F (37°C), pulse is 120/min, blood pressure is 75/44 mmHg, and respiratory rate is 22/min. On physical exam, there is bruising over his sternum and left chest, with tenderness to palpation. Cardiac auscultation reveals normal heart sounds with no murmurs, rubs, or gallops. He has marked jugular venous distention and bibasilar crackles on pulmonary auscultation with equal air entry bilaterally. Abdominal and cranial nerve exams are within normal limits. His extremities are cool with prolonged capillary refill, and he is diaphoretic. The patient is admitted to the intensive care unit and hemodynamic monitoring is established, which reveals a pulmonary capillary wedge pressure (PCWP) of 22 mmHg (normal range 8-12 mmHg), central venous pressure (CVP) of 12 cmH2O (normal range 4-12 cmH2O), cardiac output (CO) of 2.2 L/min (normal range 4-8 L/min), and systemic vascular resistance (SVR) of 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5). Which of the following types of shock best describes this patient's condition?

Answer: Cardiogenic

Choices:
A. Hypovolemic
B. Cardiogenic
C. Anaphylactic
D. Neurogenic
E. Obstructive


Question: A 23-year-old man comes to the emergency department complaining of 10/10 abdominal pain. He describes the pain as sharp, stabbing, intermittent, and concentrated at the left lower quadrant. It started about 3 hours ago with no obvious precipitating factor. He reports multiple similar episodes in the past but they have all resolved within 1 hour or so. He denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes but endorses “red-colored urine” for the past day. He just returned from an extensive hiking trip in Colorado. A radiograph of the abdomen was unremarkable. What is the most likely explanation for this patient’s presentation?

Answer: Hereditary defect of amino acid transporter in the kidney

Choices:
A. Dehydration leading to a build up of uric acid in the urine
B. Hereditary defect of amino acid transporter in the kidney
C. Infection with urease positive bacteria
D. Presence of antibodies to the glomerular basement membrane
E. Thinning and splitting of the glomerular basement membrane


Question: A 33-year-old African American woman presents to the emergency department due to diffuse pain and fatigue. The woman states that she feels like her bones and muscles diffusely hurt. She also has experienced some abdominal pain as well and states that she has trouble focusing. The patient has a past medical history of sickle cell disease for which she takes hydroxyurea. Her temperature is 98.1°F (36.7°C), blood pressure is 119/59 mmHg, pulse is 130/min, respirations are 16/min, and oxygen saturation is 98% on room air. Laboratory values are ordered and are currently pending. Which of the following is a side-effect of definitive treatment for this patient?

Answer: Tetany

Choices:
A. Dilute urine
B. Hyperglycemia
C. Peaked T-waves on ECG
D. QT shortening on ECG
E. Tetany


Question: A 40-year-old man with psoriatic arthritis comes to the physician because of progressively worsening pain and stiffness in both of his hands and feet for the past 3 weeks. His psoriatic arthritis had been well-controlled with adalimumab for several years prior to this. His only other medication is omeprazole. Physical examination shows scaly plaques on both elbows and limited range of motion of most of the larger joints. Which of the following is the most likely underlying mechanism of the recurrence of this patient's symptoms?

Answer: Formation of antidrug antibodies

Choices:
A. Suppression of the bone marrow
B. Decreased ionization by the glomeruli
C. Formation of antidrug antibodies
D. Increased acetylation by the liver
E. Inhibition of cytochrome P450 activity


Question: A 35-year-old African American female presents to the emergency department with a three day history of cough, chest pain, and fever. Upon presenting to the emergency department, her temperature is 101.4 °F (38.5 °C), blood pressure is 110/80 mmHg, pulse is 95/min, and respirations are 24/min. Lung auscultation reveals crackles over the left lung base. Chest radiograph reveals a dense consolidation in the left lower lung. The patient undergoes lab tests in the emergency department that demonstrate an elevated level of C-reactive protein. This abnormal lab finding was most likely caused by increased activity of which of the following mediators?

Answer: IL-6

Choices:
A. TNF-alpha
B. IL-12
C. IL-8
D. IL-6
E. IL-2


Question: A 50-year-old man comes to the physician after a fall on a flight of stairs earlier that day. He slipped, causing him to fall and hit the handrail with the lateral part of his chest. He has no shortness of breath. He returned from a 10-day trip to South Africa 4 weeks ago. He smoked one pack of cigarettes daily for 10 years but stopped 18 years ago. He drinks 1–2 beers a week. His temperature is 37.1°C (98.8°F), pulse is 78/min, and blood pressure is 126/72 mm Hg. Examination shows normal breath sounds bilaterally. The left lateral chest wall is tender to palpation. An x-ray of the chest shows no fracture; there is a 5-mm lesion in the right upper lung field. There are no previous x-rays of the patient available. Which of the following is the most appropriate next step in management?

Answer: CT scan of the chest

Choices:
A. Follow-up x-ray of the chest in 12 months
B. Follow-up x-ray of the chest in 6 months
C. Positron emission tomography
D. CT scan of the chest
E. Reassurance


Question:
A 62-year-old woman presents to a clinic with complaints of a worsening rash on her back, fevers with chills, and rigor for 2 days. She denies any headaches, nausea, or vomiting. She is currently on chemotherapy for multiple myeloma, which was diagnosed last year. On examination, there were multiple punched-out ulcers covered in crusts surrounded by raised, violaceous margins on her back. Some of the lesions have black necrotic centers. The vital signs include: temperature 38.8°C (102.0°F), respirations 24/min, pulse 110/min, and blood pressure 100/90 mm Hg. Laboratory studies show:
Hemoglobin 8.4 g/dL
White blood cell (WBC) count  1,500/mm3
Platelets 300,000/mm3
Which of the following organisms is most likely responsible for this patient’s condition?

Answer: Pseudomonas aeruginosa

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


Question: An 8-year-old boy developed nausea, abdominal pain, and watery diarrhea 6 hours after consuming homemade mushroom soup. The boy is rushed to the emergency department. He is severely dehydrated and his blood pressure is 60/40 mm Hg. He is managed with intravenous fluids and other supportive treatment. The mushrooms in the soup had been picked from his family's backyard, and samples of mushrooms were sent to the lab for analysis. The lab reports confirmed that the mushrooms contained some kind of toxin. Which of the following enzymes is most likely inhibited by this toxin?

Answer: RNA polymerase II

Choices:
A. Topoisomerase II
B. DNA gyrase
C. RNA polymerase II
D. RNA polymerase I
E. RNA polymerase III


Question:
A 6-year-old girl is brought to the physician because of generalized fatigue and dark urine for 4 days. Four weeks ago, she was treated with cephalexin for a skin infection. Her temperature is 37°C (98.6°F) and blood pressure is 132/89 mm Hg. Physical examination shows 1+ pretibial edema bilaterally. Her serum creatinine is 1.7 mg/dL. Urine studies show:
Blood 2+
Protein 2+
RBC 12–14/hpf with dysmorphic features
RBC casts numerous
Which of the following is the most likely cause of these findings?"

Answer: Granular subepithelial immune complex deposition

Choices:
A. Granular subepithelial immune complex deposition
B. Systemic amyloid protein aggregation
C. Defective circulating IgA antibodies
D. Anti-type IV collagen antibody formation
E. DNA-anti-DNA antibody immune complex formation


Question: A 7-year-old girl is brought to the physician by her mother for a 6-month history of irritability. She has no history of significant illness and is up-to-date on her immunizations. She appears markedly lethargic. Her vital signs are within normal limits. Physical examination shows subconjunctival pallor. Her hemoglobin concentration is 9.2 g/dL and mean corpuscular volume is 76 μm3. A photomicrograph of a wet stool mount is shown. Which of the following infectious agents is the most likely cause of these findings?

Answer: Necator americanus

Choices:
A. Necator americanus
B. Ascaris lumbricoides
C. Enterobius vermicularis
D. Trichuris trichiura
E. Taenia solium


Question: A 15-year-old girl is brought to the physician by her mother because of a 3-day history of lower abdominal pain. Over the past 9 months, she has had multiple similar episodes of abdominal pain, each lasting for 4–5 days. Menarche has not yet occurred. Examination shows suprapubic tenderness to palpation. Pubic hair and breast development are Tanner stage 4. Pelvic examination shows bulging, bluish tissue 1 cm inside the vaginal introitus. Which of the following is the most likely diagnosis?

Answer: Imperforate hymen

Choices:
A. Labial adhesions
B. Androgen insensitivity
C. Endometriosis
D. Imperforate hymen
E. Müllerian agenesis


Question: A 6-year-old boy presents with high fever, sore throat, and cough for the past day. The patient’s mother also says he is complaining of generalized muscle aches and chills. Past medical history is significant for childhood asthma, managed with inhaled mometasone furoate. The patient’s temperature is 39.1°C (102.3°F), pulse is 120/min, and respiratory rate is 20/min. On physical examination, his oropharynx is erythematous with mild swelling of the pharyngeal tonsils. Chest auscultation reveals crepitus over the lung bases bilaterally. There are no signs of respiratory distress. Rapid diagnostic testing for influenza B infection in this patient is positive. In addition to symptomatic treatment, which of the following antiviral drugs would most likely benefit this patient?

Answer: Oseltamivir

Choices:
A. Amantadine
B. Ribavirin
C. Rimantadine
D. Oseltamivir
E. Zanamivir


Question: A 38-year-old woman presents to the emergency department with nausea and progressive right upper quadrant abdominal pain for the past day. For the past year, she has had occasional pain in her right upper quadrant which is often relieved on its own after a few hours. She was recently diagnosed with multiple gallstones for which she underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago. Past medical history is otherwise unremarkable. On physical examination, there is tenderness over the epigastrium with no guarding or rebound. Vital signs include blood pressure 110/68 mm Hg, pulse 98/min, temperature 36.2°C (97.2°F), and respiratory rate 11/min. Laboratory tests are pending. An imaging study of the abdomen confirms the most likely diagnosis. Which of the following is most likely to be below the normal range in her blood due to her current condition?

Answer: Calcium

Choices:
A. Trypsinogen
B. C-reactive protein
C. Lipase
D. Glucose
E. Calcium


Question: A 42-year-old woman comes to the emergency department because of hematuria and pain in both flanks. She has a history of recurrent urinary tract infections. She also complains of swelling of both feet and facial puffiness. She has passed urinary stones twice before. Her mother also has a history of urinary stone and underwent a kidney transplant. Her temperature is 38.0°C (100.4°F), pulse is 110/min, and blood pressure is 150/98 mm Hg. Abdominal examination shows palpable, bilateral flank masses. Results of a complete blood count are within the reference range. Her serum creatinine concentration is 2.7 mg/dL. Which of the following additional findings is most likely to be seen in this patient?

Answer: Multiple hepatic cysts

Choices:
A. Osteolytic bone lesions
B. Multiple hepatic cysts
C. Mitral valve stenosis
D. Popliteal aneurysm
E. Vesicoureteral reflux


Question: A 51-year-old man with a past medical history of peptic ulcer disease currently treated via outpatient triple therapy presents to the urgent care center complaining of acute abdominal pain which began suddenly less than 2 hours ago. The physical examination shows his abdomen to be mildly distended, diffusely tender to palpation, and positive for rebound tenderness. Physical exam is unremarkable. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 96/54 mm Hg, heart rate 112/min, and respiratory rate 19/min. Given the following options, what is the next best step in patient management?

Answer: CT abdomen and pelvis

Choices:
A. Abdominal radiographs
B. CT abdomen and pelvis
C. Upper endoscopy
D. H. pylori testing
E. Serum gastrin level


Question: A 10-month-old boy is brought to the physician because of fever and a cough for 3 days. He was treated for otitis media 3 and 4 months ago. He was also treated for pneumococcal pneumonia and H. influenzae meningitis this past month. He was delivered at term. Pregnancy and neonatal period were uncomplicated. He was breast-fed until 6 months of age. He has a maternal uncle who died of recurrent respiratory tract infections at 28 years of age. He is at the 20th percentile for height and the 10th percentile for weight. His temperature is 39°C (102.2°F), pulse is 122/min, and respirations are 44/min. Examination shows crackles at the left lung base. Palatine tonsils are absent. An x-ray shows an infiltrate in the left lower lung lobe. Flow cytometry shows absence of B-cells. Which of the following is mostly responsible for this patient's late onset of symptoms?

Answer: Maternal IgG decreases by 6 months

Choices:
A. Breastfeeding until 6 months
B. Reduced T-cell receptor excision circles by 6 months
C. Involution of the thymus begins at 6 months
D. Splenic dysfunction occurs by 6 months
E. Maternal IgG decreases by 6 months


Question: A 55-year-old right-handed woman is being evaluated for a long history of numbness and tingling in both of her hands, particularly in the third digits, that is worse at night. She works as a medical office assistant in a local travel medicine clinic. Her past medical history is significant for hypothyroidism, managed medically with thyroxine. Physical examination showed thenar eminence atrophy, decreased sensation in the 3 first digits of both hands that extends proximally, and weakness on thumb abduction and thumb opposition; deep tendon reflexes are normal. Phalen and Tinel tests are positive. Which of the following is the most inclusive list of spinal roots that contribute to the affected nerve in this patient?

Answer: C5, C6, C7, C8, T1

Choices:
A. C5, C6, C7
B. C4, C5
C. C6, C7, C8
D. C3, C4, C5
E. C5, C6, C7, C8, T1


Question: A 7-year-old girl is referred to a pediatric cardiologist after a heart murmur was auscultated during a routine school health examination. The patient has not experienced any symptoms of shortness of breath, fatigue, chest pain, or palpitations. She is healthy, does not have any significant medical history, and had an uneventful birth without any complications. Her vital signs are as follows: T 37.2 C, HR 92, BP 104/62, RR 24, SpO2 99%. Physical examination is significant for a midsystolic ejection murmur heard best at the 2nd intercostal space near the left sternal border, a loud S1 heart sound, a widely fixed split S2 heart sound, and no evidence of cyanosis or clubbing. An echocardiogram is conducted and reveals a left-to-right shunt across the interatrial septum. Surgical correction of this patient's condition will most likely prevent which of the following from developing later in life?

Answer: Pulmonary hypertension

Choices:
A. Arteriovenous fistula
B. Pulmonary stenosis
C. Coronary artery disease
D. Pulmonary hypertension
E. Aortic root dilation


Question:
A 21-year-old man is brought to the emergency department by the police because of altered mental status. The police found him covering his ears and shouting near a highway rest area. Upon questioning, he was unable to look directly at the police and answer coherently. On the way to the hospital, he reported feeling nauseous and vomited twice. His temperature is 38.2°C (100.8°F), pulse is 100/min, respirations are 28/min, and blood pressure is 110/77 mm Hg. He is admitted to the hospital for evaluation. Three hours after admission, he has a tonic-clonic seizure. Laboratory studies show:
Serum
Na+ 140 mEq/L
Cl- 102 mEq/L
Arterial blood gas analysis on room air:
On admission Three hours later
pH 7.47 7.39
PaCO2 24 mm Hg 31 mm Hg
PO2 84 mm Hg 82 mm Hg
HCO3- 20 mEq/L 18 mEq/L
Which of the following is the most likely explanation of the patient's laboratory findings?"

Answer: Salicylate toxicity

Choices:
A. Opioid overdose
B. Salicylate toxicity
C. Diabetic ketoacidosis
D. Recurrent vomiting
E. Adrenal insufficiency


Question:
A 58-year-old man makes an appointment with his nephrologist because he has been feeling weak and increasingly fatigued over the last month. Specifically, he has not been able to do activities of daily living independently because he feels short of breath after several minutes of activity. His past medical history is significant for rapidly progressive glomerulonephritis that led to kidney failure. He has been on hemodialysis for the last 6 months and has been compliant with attending every dialysis session. Physical exam reveals conjunctival pallor. Laboratory tests are obtained and results are shown below:

Hemoglobin: 8.9 g/dL (normal: 13.5-17.5 g/dL)
Platelet count: 198,000/mm^3 (normal: 150,000-400,000/mm^3)
Mean corpuscular volume: 87 µm^3 (normal: 80-100 µm^3)
Reticulocyte count: 0.1% (normal: 0.5-1.5%)

Based on these findings, the patient is given appropriate treatment to address his symptoms. Which of the following is the most likely mechanism of action for this treatment?

Answer: Activation of receptors on erythroid progenitor cells

Choices:
A. Activation of receptors on erythroid progenitor cells
B. Chelation of heavy metals
C. Provision of finished blood products
D. Removal of red blood cell clearing organ
E. Transplantation of new cells


Question: A 33-year-old African American woman comes to the physician because of a 4-month history of progressive fatigue, shortness of breath, constipation, and a nonproductive cough. She returned from a trip to Nigeria 6 months ago. Physical examination is unremarkable. Serum calcium concentration is 11.7 mg/dL. An x-ray of the chest shows bilateral hilar lymphadenopathy with coarse, nodular opacities in both lower lobes. A photomicrograph of a biopsy specimen of the affected area of the lungs is shown. Which of the following best describes the pathogenesis of this patient's histopathological findings?

Answer: TNF-α secretion by CD4+ T cells

Choices:
A. MHC I binding to CD8+ T cells
B. Antigen binding to IgM
C. TGF-β secretion by regulatory T cells
D. TNF-α secretion by CD4+ T cells
E. IL-5 secretion by Th2 cells


Question: A 15-day-old female newborn is brought to the physician for evaluation of red eyes with discharge for 3 days. She was born at 37 weeks' gestation to a 26-year-old woman. Pregnancy and delivery were uncomplicated. The mother received irregular prenatal care during the 3rd trimester of pregnancy. Examination of the newborn shows watery discharge in both eyes and mild eyelid swelling. Which of the following is the most likely cause of this patient's presentation?

Answer: Chlamydia trachomatis

Choices:
A. Silver nitrate exposure
B. Staphylococcus aureus
C. Chlamydia trachomatis
D. Neisseria gonorrhoeae
E. Herpes simplex virus 2


Question: An investigator is studying central nervous system neurotransmitters in mice. He injects the spinal cord with a protease that cleaves SNARE proteins, thereby blocking the release of neurotransmitters from the Renshaw cells in the spinal cord. Which of the following consequences would be expected?

Answer: Spastic paralysis

Choices:
A. Disinhibited behavior
B. Hydrophobia
C. Positive Kernig sign
D. Spastic paralysis
E. Ascending flaccid paralysis


Question: A 32-year-old G2P2 at 33 weeks and 4 days of gestation presents to the emergency room with low-grade fever, mild low back pain, and dysuria for 1 day. She has a history of urinary tract infections, including one during this current pregnancy that was treated successfully with cephalexin. On examination, she is nontoxic but mildly uncomfortable; she has CVA tenderness on her right side. Her urinalysis is positive for leukocyte esterase and nitrites, and she is admitted to the hospital for IV antibiotics with ceftriaxone. Her present condition places her at increased risk for which of the following:

Answer: Preterm labor

Choices:
A. Low birth weight
B. Pre-eclampsia
C. Postpartum hemorrhage
D. Preterm labor
E. Post-term labor


Question: A 16-year-old African-American boy is brought to the physician because of a 2-month history of progressive right shoulder pain. He has had many episodes of joint and bone pain in the past, and as a child, had recurrent painful swelling of his hands and feet. His brother had a stroke at 6 years of age and now has an intellectual disability. The patient is at the 60th percentile for height and 55th percentile for weight. His vital signs are within normal limits. Physical examination shows tenderness of the right anterior humerus without noticeable swelling or skin changes. Active and passive range of motion of the right shoulder is decreased and there is pain with movement. The leukocyte count is 4600/mm3. An x-ray of the right shoulder shows subchondral lucency of the humeral head with sclerosis and joint space narrowing. Which of the following is the most likely explanation for this patient's symptoms?

Answer: Infarction of the bone trabeculae

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


Question: A 50-year-old woman comes to the emergency department after waking up with facial swelling and with difficulties swallowing. She was recently diagnosed with hypertension and started on an antihypertensive drug. She follows a strict vegetarian diet. Her pulse is 110/min and blood pressure is 135/85 mm Hg. Physical examination shows marked edematous swelling of the face, lips, and tongue. There is no rash. Serum C4 levels are within the reference range. Which of the following is the most likely cause of this patient's symptoms?

Answer: Impaired breakdown of kinins

Choices:
A. Deficiency of C1 esterase inhibitor
B. Scombroid poisoning
C. Antibody-mediated cytotoxic reaction
D. Nonimmunologic release of histamine
E. Impaired breakdown of kinins


Question:
An 82-year-old man presents to the primary care physician with complaints of urinary leakage over the last 2 months. The leakage occurred without any additional symptoms. He has a history of prostatic hyperplasia. The vital signs include: blood pressure 140/90 mm Hg, heart rate 84/min, respiratory rate 18/min, and temperature 36.6°C (98.0°F). Physical examination reveals a palpable and distended bladder. Urinalysis reveals:
Color Yellow
Clarity/turbidity Clear
pH 5.5
Specific gravity 1.015
Nitrites Negative
Leukocyte esterase Negative
Which of the following is the best initial management for this patient?

Answer: Bladder catheterization

Choices:
A. Anticholinergics
B. Surgery
C. Bladder catheterization
D. Tamsulosin
E. Pelvic floor muscle training


Question: A 25-year-old female presents to her geneticist due to the fear that she may have inherited her father's disease. He was diagnosed at the age of 41 when his symptoms of chorea, coordination problems, and cognitive decline begin to occur. He was diagnosed with a disease resulting from the expansion of CAG repeats on chromosome 4 and later developed severe dementia and died at the age of 56. The daughter was found to have double the amount of CAG repeats and was told by the geneticist that she may have an earlier onset with increased severity of disease. What phenomenon describes this?

Answer: Anticipation

Choices:
A. Variable expression
B. Incomplete penetrance
C. Pleiotropy
D. Anticipation
E. Heteroplasmy


Question: A 25-year-old man presents to the emergency department after being rescued from a house fire 30 minutes ago. He is conscious and in distress. On examination, he is noted to have 1st-degree burns involving 54% of his total body surface area. He has type 1 diabetes and takes insulin every day. He is admitted to the burn unit and treated appropriately. Ten days after admission, the physician notices blue-green pus oozing from the burn wounds. He is afebrile with a pulse of 90/min and a blood pressure of 130/80 mm Hg. A sample exudate is collected with a sterile swab and sent to the laboratory for culture, which yields the growth of aerobic gram-negative rods. Which of the following antibiotics will be most effective in treating this patient’s condition?

Answer: Piperacillin with gentamicin

Choices:
A. Azithromycin with rifampin
B. Piperacillin with gentamicin
C. Piperacillin
D. Ticarcillin
E. Azithromycin


Question: A 67-year-old man with a past medical history of obesity and diabetes presents to the emergency department with fatigue. The patient has become more confused over the past several days and has been urinating profusely. His temperature is 99.0°F (37.2°C), blood pressure is 120/68 mmHg, pulse is 160/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam is notable for a confused man with dry mucous membranes. He is unable to answer simple questions and is moving all extremities spontaneously. Which of the following is also likely to be found in this patient?

Answer: Blurred vision

Choices:
A. Blurred vision
B. Meningeal symptoms
C. Seizures
D. Tremulousness
E. Unilateral weakness


Question: A 42-year-old man presents with acute onset jaundice. Past medical history is significant for COPD diagnosed 4 years ago, managed medically, and admission for acute pancreatitis 6 months ago. The patient denies any history of smoking, alcohol use or recreational drugs. Which of the following is the most likely etiology of liver damage in this patient?

Answer: α1-antitrypsin (AAT) deficiency

Choices:
A. α1-antitrypsin (AAT) deficiency
B. Gilbert syndrome
C. Glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency)
D. Dubin–Johnson syndrome
E. Hepatitis C


Question: An 8-year-old girl presents to the emergency department with respiratory distress, facial edema, and a skin rash after eating a buffet dinner with her family. Her parents say they were eating at a seafood buffet when, all of a sudden, the patient began to cough and feel short of breath. They say nothing like this has ever happened before. The patient has a history of seasonal allergies for which she occasionally takes cetirizine. Her blood pressure is 80/52 mm Hg; heart rate, 122/min; and respiratory rate, 22/min. On physical examination, the patient has severe edema over her face and audible stridor. Of the following options, which is the most appropriate next step in the management of this patient?

Answer: Intramuscular epinephrine

Choices:
A. Intramuscular epinephrine
B. Oral diphenhydramine
C. Intravenous epinephrine
D. Extra-strength topical diphenhydramine
E. Inhaled sodium cromolyn


Question: A 33-year-old man presents to his physician complaining of a small mass he noticed in his scrotum about 1 month ago. The mass feels loosely attached to the right testicle and is firm, and not painful. He has no history of a serious illness and takes no medications. He is married with 2 children. His vital signs are within normal limits. Examination shows a 1-cm spherical mass in the superior part of the right testis that has a smooth border. It transilluminates with a flashlight. The mass does not enlarge when the patient coughs or bears down. Scrotal ultrasonography shows an extratesticular hypoechoic mass near the epididymal head of the right testicle with posterior acoustic enhancement and without internal shadows. Which of the following is the most appropriate next step in management?

Answer: No therapy at this time

Choices:
A. Ceftriaxone + doxycycline
B. Ligation of processus vaginalis
C. Microsurgical varicocelectomy
D. Orchiectomy
E. No therapy at this time


Question: A 51-year-old asymptomatic woman undergoes colposcopy due to a high-grade intraepithelial lesion based on a Pap smear. Colposcopy shows a visible lesion 2 cm in diameter located on the posterior cervical lip and confined to the cervix with sharp borders, a coarse mosaic pattern after application of acetic acid, and contact bleeding. The histologic evaluation of the biopsy shows glandular epithelial cells with nuclear hyperchromasia and enlargement, increased mitoses, a fusion of glands, and stromal infiltration to 8 mm. The chest X-ray and abdominal ultrasound are negative for any additional findings. Which of the following interventions is a proper management strategy for the presented patient?

Answer: Modified radical (Wertheim) hysterectomy

Choices:
A. Loop electrosurgical excision procedure (LEEP)
B. Simple hysterectomy
C. Modified radical (Wertheim) hysterectomy
D. Platinum-based chemotherapy
E. Simple hysterectomy with bilateral salpingo-oophorectomy


Question: A 65-year-old man presents to the Emergency Department complaining of substernal chest pain. An acute coronary event is suspected and a coronary catheterization procedure reveals an atherosclerotic plaque in the patient's left anterior descending artery. In the formation of an atherosclerotic plaque, which of the following pairings is correct?

Answer: Smooth muscle cells (SMC) -- extracellular matrix (ECM) deposition

Choices:
A. Fibroblasts -- foam cells
B. Smooth muscle cells (SMC) -- extracellular matrix (ECM) deposition
C. Endothelial cells -- downregulation of VCAM-1
D. Smooth muscle cells -- migration from intima to media
E. LDL chemical reduction -- endothelial dysfunction


Question: A 15-year-old boy is brought to the physician by his mother because of a 2-month history of pain in his left hip. The pain started suddenly and has worsened over the past 2 weeks. The pain radiates down the thigh and is aggravated by movement. He had a fall while cycling around a month ago. He had a urinary tract infection 3 months ago that resolved with trimethoprim/sulfamethoxazole. There is no family history of serious illness. His immunizations are up-to-date. He is 165 cm (5 ft 5 in) tall and weighs 85 kg (187 lb); BMI is 31.2 kg/m2. His temperature is 37.5°C (99.5°F), pulse is 65/min, and blood pressure is 104/70 mm Hg. Examination shows an antalgic gait. The left groin is tender to palpation and internal rotation is limited due to pain. Flexing the hip causes external rotation and abduction. His leukocyte count is 9,800/mm3 and erythrocyte sedimentation rate is 12 mm/h. An x-ray of the pelvis is shown. Which of the following is the most appropriate next step in management?

Answer: Surgical pinning of femoral head

Choices:
A. Long leg cast
B. Intravenous antibiotic therapy
C. Surgical pinning of femoral head
D. Intra-articular lidocaine
E. Proximal femoral osteotomy


Question: A 58-year-old man is hospitalized and treated with clindamycin for a pulmonary abscess. During his hospital stay he develops abdominal pain and bloody diarrhea, and has a WBC of 14,000; serum creatinine is 0.9 mg/dL. On teaching rounds, you learn that the responsible pathogen produces a multi-unit toxin that binds to the colonic mucosa, causing actin depolymerization that results in cell death and mucosal necrosis. What is the preferred treatment for this condition?

Answer: Metronidazole

Choices:
A. Continue Clindamycin
B. Metronidazole
C. Penicillin G
D. Tetracycline
E. Erythromycin


Question: A 61-year-old Caucasian woman presents to her physician for a routine checkup. She has primary hypertension and rheumatoid arthritis. She currently does not report any relevant symptoms, such as weight change, increased or decreased appetite, sleep or mood problems, gastrointestinal symptoms, fever, or night sweats. Her medications include valsartan 160 mg, hydrochlorothiazide 25 mg daily, and methylprednisolone 28 mg every other day. According to her diary, her blood pressure varies from 130/80 to 120/60 mm Hg. In the past year, she had humeral and tibial fractures from a self-height fall and stepping over a fence, respectively, that occurred 6 months apart. She is in menopause and is not on hormone replacement therapy. Currently, she does not smoke but has a 10-pack-year history of smoking. She consumes alcohol occasionally. She weighs 56 kg (123.5 lb), and her height is 169 cm (5 ft 7 in). She does not report a family history of any cancer. Her father died after a myocardial infarction at the age of 63. She performs daily household activities but is not engaged in either aerobic or strength training. She mainly consumes vegetables, cereals, and dairy products. Her blood pressure is 125/80 mm Hg, heart rate is 67/min, respiratory rate is 14/min, and temperature is 36.5°C (97.7°F). Her physical examination is unremarkable. Which result would you expect to find on her screening tests?

Answer: T score –2.01 on DEXA scan

Choices:
A. A score of 17 on PHQ-9 test
B. T score –2.01 on DEXA scan
C. Dilation of the abdominal aorta on ultrasound examination
D. Presence of a tumor on colonoscopy
E. Presence of focal hyperintensities on mammography


Question: A 24-year-old man is brought to the emergency department by his sister because she has noticed that he has been behaving differently over the past 4 weeks. Today, the patient attempted to set their house on fire while yelling that he was trying to “save us all.” The patient has a history of psychotic symptoms treated with aripiprazole. His sister states that he stopped taking his medications about 3 weeks ago. He works as a dishwasher but has not been to work for several days. His vital signs are within normal limits. Mental status examination shows a blunted affect. Throughout the interview, the patient continuously stares at the ceiling and makes little eye contact with the physician. When asked about the incident today, he states that he has been hearing the voice of “the great one” who has informed him that aliens are in his neighborhood in the form of rats and cockroaches that need to be “torched to prevent the alien invasion.” He is refusing treatment and insists on going home. Which of the following is the most appropriate next step in management?

Answer: Involuntarily hospitalize the patient

Choices:
A. Administer aripiprazole and follow-up after 24 hours
B. Refer the patient to a psychologist for cognitive behavioral therapy
C. Involuntarily hospitalize the patient
D. Report the patient to the local police
E. Ask the patient's sister to convince him to stay overnight


Question:
A 13-year-old girl is brought to the emergency department by her father because of a severe nosebleed. She takes no medications and has no history of serious medical illness but has had frequent nosebleeds in the past. Physical examination shows brisk bleeding from the right nare and pooled blood in the posterior pharynx. Laboratory studies show:
Hemoglobin 8 g/dL
Platelet count 195,000/mm3
Prothrombin time 12 sec
Partial thromboplastin time 49 sec
Fibrin split products negative
The bleeding time is 11 minutes. Which of the following is the most appropriate pharmacotherapy?"

Answer: Desmopressin

Choices:
A. Prothrombin complex concentrate
B. Phytonadione
C. Rituximab
D. Desmopressin
E. Intravenous immunoglobulin


Question: A 33-year-old man presents to the emergency department with joint pain. He states that since yesterday he has had joint pain, and today he noticed a rash. The patient does not have a significant past medical history. The patient smokes cigars, drinks 1 to 4 drinks per day, is sexually active, and uses cocaine occasionally. His temperature is 101°F (38.3°C), blood pressure is 125/65 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam reveals pustular skin lesions and an inflamed and painful right knee that is warm to the touch. Which of the following is the most appropriate treatment for the most likely diagnosis?

Answer: Cefixime and azithromycin

Choices:
A. Azithromycin
B. Cefixime and azithromycin
C. Ceftriaxone
D. Ceftriaxone and vancomycin
E. Piperacillin and tazobactam


Question: A 20-year-old woman presents to a physician following unprotected coitus with her boyfriend about 10 hours ago. She tells the physician that although they usually use a barrier method of contraception, but this time they did not. She does not want to become pregnant. She also mentions that she has been diagnosed with major depression and does not want to take an estrogen-containing oral contraceptive pill. After counseling, the physician prescribes an enteric-coated pill containing 1.5 mg of levonorgestrel. Which of the following is the primary mechanism of action of levonorgestrel?

Answer: Delayed ovulation through inhibition of follicular development

Choices:
A. Delayed ovulation through inhibition of follicular development
B. Thickening of cervical mucus
C. Atrophy of endometrium
D. Mucosal hypertrophy and polyp formation in cervix
E. Reduction in motility of cilia in fallopian tubes


Question: A 4-year-old girl is brought to the emergency department because of colicky abdominal pain for 1 day. She has had two similar episodes in the past. Urinalysis shows red blood cells and hexagonal-shaped crystals. Urine sodium cyanide nitroprusside test is positive. Further evaluation of this patient is most likely to show which of the following findings?

Answer: Impaired intestinal ornithine reabsorption

Choices:
A. Increased stool fat content
B. Inability of intercalated cells to secrete H+
C. Increased urine homocysteine levels
D. Impaired intestinal ornithine reabsorption
E. Urease-positive bacteria in the renal pelvis


Question: A 49-year-old woman, gravida 1, para 1, comes to the physician because of shorter and less frequent menstrual periods over the past year. During this time, she has also had frequent mood swings and a 2.5-kg (5-lb) weight loss. She occasionally wakes up at night because she is too warm and sweating profusely. These episodes are followed by chills and anxiety that subside within minutes. She has no history of abnormal Pap smears. She is sexually active with her husband, who had a vasectomy 10 years prior. She is 163 cm (5 ft 3 in) tall and weighs 70 kg (154 lb); BMI is 26 kg/m2. Her temperature is 37°C (98.6°F), pulse is 103/min, respirations are 16/min, and blood pressure is 129/84 mm Hg. Abdominal and genitourinary examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Answer: Measure serum TSH concentration

Choices:
A. Offer hormone replacement therapy
B. Perform transvaginal ultrasound
C. Measure serum β-hCG concentration
D. Obtain endometrial biopsy
E. Measure serum TSH concentration


Question: An 8-year-old boy is brought by his parents to the emergency department with a tender and swollen right leg. The boy said that he was playing soccer when he accidentally kicked a metal goal post. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. A review of his medical history reveals that he had a fracture of the left tibia at 4-years-old and a fracture of the right radius 6 months ago. Neither of the two was associated with major trauma and both healed well. At the hospital, his vital signs are stable and his sclerae are white-blue. There is no muscular hypotonia. His height and weight are normal for his age and sex and the skin is normal. A tender swelling is present over his right leg and he can not put weight on that leg. The radiograph of his right leg confirms a fracture of the shaft of the tibia at the junction of its upper one-third and lower two-thirds. The clinician suspects physical abuse and orders a skeletal survey. Which of the following findings is most likely to be detected in a skeletal survey?

Answer: Wormian bones in the skull

Choices:
A. A healed right scapular fracture
B. Ground-glass appearance of the cortices of the long bones
C. Widening and cupping of the metaphyses of the long bones
D. Wormian bones in the skull
E. Mandibular asymmetry


Question: A previously healthy 34-year-old man comes to the physician because of loose stools for the past 4 months. On average, he has 1 episode of loose non-bloody bowel movement with abdominal cramps each day around noon. He has no diarrhea when he does not have breakfast in the morning. He also complains of excess flatus but no bowel incontinence or urgency. He has had no fever or weight loss. His symptoms are not associated with stress. He has had no overseas or mountainous trips over the past year. He takes no medications. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate initial recommendation?

Answer: Elimination of all dairy products

Choices:
A. Gluten-free diet
B. Cholestyramine
C. Elimination of all dairy products
D. Empirical therapy with metronidazole
E. Loperamide


Question: A 37-year-old male with a history of diabetes is prescribed a drug that would decrease the risk of the patient developing glomerular renal capillary damage, nodular glomerular sclerosis, and eventual nephrotic syndrome. After some time being on this medication, the patient complains of a bad cough. Which of the following physiologic changes is most likely expected after being prescribed that medication?

Answer: Decreased aldosterone, decreased GFR, increased renal plasma flow, increased bradykinin

Choices:
A. Decreased aldosterone, decreased GFR, decreased renal plasma flow, increased bradykinin
B. Increased aldosterone, increased GFR, decreased renal plasma flow, increased bradykinin
C. Decreased aldosterone, decreased GFR, decreased renal plasma flow, decreased bradykinin
D. Decreased aldosterone, decreased GFR, increased renal plasma flow, increased bradykinin
E. Increased aldosterone, increased GFR, increased renal plasma flow, increased bradykinin


Question: A 69-year-old woman presents with insomnia and altered mental status. The patient is accompanied by her husband who says her symptoms began acutely 4 days ago with no obvious trigger and have not improved. Before this point, she had been living independently with no signs of cognitive impairment. The patient’s husband says that the patient is often non-compliant with medication and eats and drinks little unless prompted. Past medical history is significant for hypertension, diabetes mellitus type 2, chronic pyelonephritis, and depression. Current medications are aspirin, metoprolol, hydrochlorothiazide, losartan, metformin, and trazodone. Vitals include: temperature 38.1℃ (100.6℉), blood pressure 130/70 mm Hg, pulse 91/min, respiratory rate 17/min, and oxygen saturation 99% on room air. On physical examination, the patient is agitated and easily distracted. Oriented x 1. She believes it is 1967, and she is at the bookstore. She talks to non-existent people and uses words inappropriately. Cardiac sounds are muffled but otherwise normal. Lungs are clear to auscultation. On abdominal examination, the tip of the urinary bladder can be palpated. Costovertebral angle tenderness is present bilaterally. Catheterization of the bladder yields cloudy, foul-smelling urine. Urinalysis is pending. Which of the following would be the best treatment for this patient’s change in mental status?

Answer: Antibiotic therapy

Choices:
A. Changing trazodone to amitriptyline
B. Lifelong administration of rivastigmine
C. Antibiotic therapy
D. Discontinuation of metoprolol
E. Lifelong administration of memantine


Question: A 65-year-old man presents to the physician with a concern for several lumps on his jaw. He has a history of dental caries and admits to maintaining poor oral hygiene. On physical examination, he has 3 nontender and indurated masses at the angle of his jaw that are draining thick yellow pus. Microscopy of the drained pus reveals yellow granules filled with bacteria. Which of the following medical treatments is indicated for this patient’s condition?

Answer: Penicillin

Choices:
A. Amoxicillin-clavulanate
B. Ciprofloxacin
C. Dapsone and rifampin
D. Penicillin
E. Trimethoprim-sulfamethoxazole


Question:
A 23-year-old man presents with severe right lower quadrant abdominal pain for the past 2 hours. He says the pain started in the periumbilical region and has now shifted to the lower right quadrant. He describes the pain as spasmodic. Past medical history is insignificant, and the patient denies any history of smoking, alcohol, or drug use. The patient’s vital signs show: pulse 88/min, respiratory rate 18/min, blood pressure 126/84 mm Hg, and temperature 38.4°C (101.0°F). On physical examination, there is severe tenderness to palpation in the right lower quadrant with rebound and guarding. The patient is rushed to the operating room for a laparoscopic appendectomy. The following preoperative laboratory tests are obtained:
Serum glucose (random) 123 mg/dL
  Serum electrolytes
Sodium 143 mEq/L
Potassium 4.7 mEq/L
Chloride 102 mEq/L
    Serum creatinine 1.7 mg/dL
Blood urea nitrogen 32 mg/dL
    Hemoglobin (Hb%) 12.5 g/dL
Mean corpuscular volume (MCV)  80 fl
Reticulocyte count 1%
Erythrocyte count 5.1 million/mm³
Leukocyte count 14,000/mm³
Neutrophils 80%
During the induction of anesthesia, isoflurane and a second compound are administered. About 25 minutes after induction, the patient develops significant muscle rigidity and his temperature increases to 40.8°C (105.4°F). The patient’s blood pressure is now 158/94 mm Hg. Which of the following was most likely the second compound administered to this patient?

Answer: Succinylcholine

Choices:
A. Atracurium
B. Bupivacaine
C. Nitrous oxide
D. Neostigmine
E. Succinylcholine


Question: A 16-year-old boy is brought to the physician because of a 3-week history of loose stools. He has 2–3 episodes of loose stools a day that are occasionally bloody. During this period, he has also had crampy abdominal pain, generalized fatigue, and a 2-kg (5-lb) weight loss. His temperature is 37.1°C (98.8°F), pulse is 82/min, and blood pressure is 106/68 mm Hg. Examination shows mild lower abdominal tenderness to palpation. Test of the stool for ova and parasites is negative. His hemoglobin concentration is 11.8 g/dL, leukocyte count is 12,400/mm3, and erythrocyte sedimentation rate is 14 mm/h. A colonoscopy shows inflamed, friable mucosa extending just beyond the rectum that bleeds on contact with the endoscope. A biopsy confirms the diagnosis. Which of the following is the most appropriate therapy for this patient?

Answer: Mesalamine therapy

Choices:
A. Gluten-free diet
B. Proctocolectomy
C. Mesalamine therapy
D. Infliximab therapy
E.
Cyclosporine therapy
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