Question: A 9-year-old girl has recently begun having daily staring-spells in which she becomes unresponsive for several seconds. Following these episodes, she rapidly returns to normal with no recollection of the event. Her performance in school has begun to deteriorate. The child's pediatrician refers her to a pediatric neurologist, and, after an appropriate neurological work-up, the child is diagnosed with absence seizures. Her neurologist recommends initiating an anti-seizure medication, but the patient adamantly refuses due to fear of side effects and her belief that the condition is not affecting her quality of life. Which of the following is the most appropriate next step?

Answer: Obtain consent from one parent before initiating therapy

Choices:
A. Do not initiate therapy at this time
B. Prescribe a long acting depot medication
C. Discuss the patient's school performance with her teachers
D. Obtain consent from one parent before initiating therapy
E. Obtain consent from both parents before initiating therapy


Question: A 44-year-old woman comes to the physician because of pain and swelling below her left eye for 3 days. She has also had excessive watering from her eyes during this period. She has no history of serious illness and takes no medications. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 110/70 mm Hg. Examination shows erythema, tenderness, warmth, and swelling below the medial canthus of the left eye. There is purulent discharge from the lower lacrimal punctum on palpation of the swelling. The remainder of the examination shows no abnormalities. The discharge is sent for cultures. Which of the following is the most appropriate next step in management?

Answer: Oral amoxicillin-clavulanate therapy

Choices:
A. Topical ciprofloxacin
B. Intravenous ceftriaxone
C. Irrigation of lacrimal cannaliculi
D. Oral amoxicillin-clavulanate therapy
E.
CT scan of the orbit
"


Question:
A 40-year-old man comes to the physician because of decreased sexual arousal and erectile dysfunction that has put strain on his marriage for the last year. He has also had fatigue and generalized weakness for the past 9 months. He has noticed his bowel movements have not been as frequent as usual. He has occasional dry coughing and back pain. He has not had fever, headache, or changes in vision. One year ago, he traveled to South Africa with his wife. He looks fatigued. He is 168 cm (5 ft 6 in) tall and weighs 89 kg (196 lb); BMI is 31.6 kg/m2. His temperature is 36.5°C (97.7°F), pulse is 50/min, and blood pressure is 125/90 mm Hg. Physical examination shows dry skin and a distended abdomen. Neurological examination reveals delayed deep tendon reflexes. Laboratory studies show:
Hemoglobin 11.0 g/dL
Platelet count 380,000/mm3
Serum
Na+ 130 mEq/L
Cl- 97 mEq/L
K+ 4.5 mEq/L
HCO3- 25 mEq/L
Glucose 95 mg/dL
TSH 0.2 μU/mL
Which of the following is the most likely cause of these findings?"

Answer: Pituitary adenoma

Choices:
A. Hemochromatosis
B. Tuberculosis
C. Pituitary adenoma
D. Graves disease
E. Hashimoto thyroiditis


Question:
A 52-year-old man with limited, unresectable small cell lung cancer comes to the emergency department because of fever for the past 2 days. He has been on numerous chemotherapy regimens. His last round of treatment was with cisplatin and etoposide and ended 10 days ago. He feels fatigued but has not had nausea or vomiting. His temperature is 38.5°C (101.3°F), blood pressure is 100/60 mm Hg, and pulse is 115/min. The lungs are clear to auscultation. Examination shows a soft, nontender abdomen. Laboratory studies show:
Hemoglobin 10.2 g/dL
Leukocyte count 4,000/mm3
Total neutrophils 8%
Eosinophils 2%
Lymphocytes 80%
Monocytes 10%
Urinalysis shows no abnormalities. Blood culture samples are obtained. Which of the following is the most appropriate next step in management?"

Answer: Cefepime

Choices:
A. Cefepime
B. Piperacillin
C. Clindamycin
D. Bronchoscopy with bronchoalveolar lavage
E. High-resolution chest CT


Question: A 28-year-old woman presents in respiratory distress. Auscultation of the lungs reveals bilateral crepitations and a friction rub. Lab findings show pancytopenia, proteinuria, and a false-positive test for syphilis. A chest X-ray shows bilateral pleural effusions. Which of the following findings are most likely?

Answer: Photosensitivity

Choices:
A. Photosensitivity
B. Urethritis
C. Xerostomia
D. Esophageal dysmotility
E. Aortitis


Question:
A 2-month-old infant is brought in by his mother for runny nose and cough. She reports he had an ear infection 2 weeks ago, and since then he has had a productive cough and nasal congestion. His medical history is significant for multiple ear infections and eczematous dermatitis. He has also been hospitalized for 2 episodes of severe viral bronchiolitis. The mother reports that the infant has a good appetite but has had intermittent, non-bloody diarrhea. The patient is at the 20th percentile for weight. On physical examination, the patient has widespread, dry, erythematous patches, mucopurulent nasal drip, and crusting of the nares. His tongue is coated by a thick white film which is easily scraped off. Crackles are heard at the left lung base. Labs are drawn, as shown below:

Hemoglobin: 12.8 g/dL
Platelets: 280,000/mm^3
Leukocytes: 7,500/mm^3
Neutrophils: 5,500/mm^3
Lymphocytes: 2,000/mm^3

Serum:
Na+: 138 mEq/L
Cl-: 96 mEq/L
K+: 4.3 mEq/L
HCO3-: 23 mEq/L
Urea nitrogen: 18 mg/dL
Glucose: 90 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: : 9.2 mg/dL

Which of the following is the most likely cause of this patient’s presentation?

Answer: Adenosine deaminase deficiency

Choices:
A. 22q11.2 deletion
B. Adenosine deaminase deficiency
C. Defective leukocyte adhesion
D. Defective tyrosine kinase
E. WAS gene mutation


Question: A 51-year-old inmate was released from prison 1 month ago and visits his general practitioner for evaluation of a positive HIV diagnosis he received from a local free clinic a week ago. The patient states that he had spent the last 2 years in prison and that, during that time, he had engaged in multiple unprotected sexual acts with fellow male inmates. When he was released from prison recently, he decided to get tested for HIV and was diagnosed positive. He is currently married with 2 children and has been paroled back to the home he shares with them. He has not told either his wife or his children of his diagnosis. He adamantly states that he is not homosexual, but that his wife would assume that he is if she found out he had contracted HIV while in prison. He states that he is terrified his wife will leave him or possibly keep his children from seeing him if she finds out about his HIV status.  He wants to be treated without the threat of his wife finding out. He insists that he will use the proper precautions to ensure his wife and children don’t contract HIV from him and reiterates the importance of keeping his diagnosis a secret. He continues and states that “they are all I have. If they leave me, I have no one.” Which of the following is the most appropriate response in this patient’s case?

Answer: Advise the patient the positive diagnosis will be reported to the public health office, but you would also encourage him to have a discussion with his family.

Choices:
A. Honor the patient’s wishes and treat him without telling his wife or reporting him to the Department of Health
B. Tell the patient you will honor his wishes, but report him to the Department of Health so they can tell his wife
C. Obtain a court order to notify the patient’s wife
D. Consult an ethics committee to determine whether or not to report him to the Department of Health
E. Advise the patient the positive diagnosis will be reported to the public health office, but you would also encourage him to have a discussion with his family.


Question: A 62-year-old man with end-stage renal disease is brought to the emergency department because of fever, severe abdominal pain, and shaking chills for 4 hours. His last hemodialysis was 2 days ago. On arrival, he appears ill and is poorly responsive. Blood cultures grow gram-positive, catalase-positive cocci that express mecA. Intravenous antibiotic therapy is begun with an agent that disrupts cell membranes by creating transmembrane channels. Which of the following adverse events is associated with the use of this agent?

Answer: Rhabdomyolysis

Choices:
A. Photosensitivity
B. Mucocutaneous necrosis
C. Rhabdomyolysis
D. Ototoxicity
E. QT prolongation


Question: A 25-year-old woman comes to the physician because of pain and weakness in her left leg that started 2 days ago while running a marathon. Physical examination shows impaired flexion of the left knee joint and impaired extension of the left hip joint. An MRI of the left lower extremity shows injury to the long head of the biceps femoris muscle and the semitendinosus muscle. Which of the following is the most likely origin of the injured muscles?

Answer: Ischial tuberosity

Choices:
A. Superior pubic ramus
B. Ischial tuberosity
C. Anterior superior iliac spine
D. Greater trochanter
E. Linea aspera


Question: A 32-year-old man and his 29-year-old wife come to the physician because they have been unable to conceive despite regular unprotected sexual intercourse for 13 months. The woman reports regular menstrual cycles since the age of 13. Menses occur at regular 28-day intervals and last 5–7 days. Ovulation predictor kits consistently turn positive around day 14. The man has a negative history of mumps. They each smoked one pack of cigarettes per day until one year ago. The man works in construction and his wife is a secretary for a law firm. Examination of the scrotum in a standing position shows soft bands palpated in the upper pole of the left scrotum with an intact left testicle. Following Valsalva maneuver, the patient reports a dull, aching pain in his left hemiscrotum. A light held behind the scrotum does not shine through. The right scrotum appears normal. Semen studies show normal sperm count with moderately decreased motility and abnormal morphology. Which of the following is most likely to improve the patient's ability to conceive?

Answer: Ligation of dilated pampiniform venous plexus

Choices:
A. Ligation of dilated pampiniform venous plexus
B. Orchidopexy
C. Conservative management with scrotal support
D. Surgical excision of the hydrocele sac
E. Administration of ceftriaxone and doxycycline


Question: A 29-year-old man comes into his primary care physician's office with a chief complaint of a cough. The patient states that the cough started yesterday and he is asking if he needs antibiotics. While conversing with the patient, you note that he seems cold, mistrustful, and does not display much emotion. The patient worked for a software company but recently took a different position that allows him to work from home. The patient states that he switched positions because while at the office he made a mistake during a presentation. He felt that afterwards, his fellow workers thought less of him and he was embarrassed to show his face around the office. The patient wishes he could have related better to his coworkers. He currently lives in a barn on the outskirts of town with his many cats. On physical exam you note a healthy young man, adorned in overalls and denim shoes. His physical exam is notable for erythema of the posterior pharynx. The patient is informed that he has a viral upper respiratory infection and is sent home with instructions to rest and hydrate himself. Which of the following personality disorders best characterizes this patient?

Answer: Avoidant

Choices:
A. Avoidant
B. Schizoid
C. Schizotypal
D. Paranoid
E. Dependent


Question: A 49-year-old man is undergoing an elective hernia repair. No significant past medical history or current medications. The patient has been working as a cardiovascular surgeon in the same hospital for the past 15 years. In obtaining informed consent, the patient’s doctor has described all the available options for the procedure with their pros and cons, has offered different materials for the hernioplasty, and described the exact procedure. He has not focused too much on the possible complications and the risks and benefits of not performing the operation, because the patient insists he already knows everything that can happen since he is a surgeon himself. The patient has given his consent, but on the day of the operation, he changes his mind regarding the material of the synthetic mesh to be used for the hernioplasty. Which of the following is true about informed consent in this case?

Answer: The patient’s doctor should have included possible complications of the given operation and risks and benefits of not performing it, regardless of the patient’s education or prior experience.

Choices:
A. The informed consent could be shortened to just the description of the available options for synthetic mesh because the patient is a medical specialist.
B. The informed consent obtained from this patient in this hospital is invalid because he works in the hospital.
C. There is no need to receive an informed consent from a patient who is a doctor himself.
D. The patient’s doctor should have included possible complications of the given operation and risks and benefits of not performing it, regardless of the patient’s education or prior experience.
E. Even though the patient has changed his mind about the type of mesh material, since the basic procedure is still the same, informed consent does not need to be obtained from the patient again.


Question: A 55-year-old man presents to his primary care provider complaining of blood clots in his urine. On further questioning, he also reports suprapubic discomfort and a feeling of bladder fullness with difficulty voiding. The patient reports recently starting treatment for a newly diagnosed non-Hodgkin lymphoma. Vital signs are within normal limits. Physical exam reveals pain on palpation of the suprapubic region. What is the mechanism of action of the drug most likely responsible for the patient’s complaints?

Answer: Alkylating agent

Choices:
A. Alkylating agent
B. Intercalating agent
C. Reverse transcriptase inhibitor
D. Microtubule inhibitor
E. Folic acid analogue


Question: A 25-year-old man presents to his primary care physician with lower back pain. He states that he has had the pain for the past two years. The patient works as a butcher, and recently was moving heavy meat carcasses. The patient states that his pain is worse in the morning and that nothing improves it aside from swimming. The patient has a past medical history of anabolic steroid abuse, acne, hypertension and obesity. His current medications are hydrochlorothiazide, ibuprofen, topical benzoyl peroxide, and acetaminophen. On physical exam there is no tenderness upon palpation of the spine. There is limited range of motion of the spine in all 4 directions. Which of the following is most likely to confirm the most likely diagnosis in this patient?

Answer: MRI of the sacroiliac joint

Choices:
A. Radiograph of the spine
B. MRI of the spine
C. The straight leg test and the clinical presentation
D. MRI of the sacroiliac joint
E. HLA typing


Question:
A 42-year-old African American female presents to your clinic complaining of excessive thirst and urination. She reports that these symptoms began one week ago, and they have been affecting her ability to work as a schoolteacher. Labs are drawn and are listed below.

Serum:
Na+: 145 mEq/L
Cl-: 101 mEq/L
K+: 4.4 mEq/L
HCO3-: 25 mEq/L
Urea nitrogen: 24 mg/dL
Glucose: 115 mg/dL
Creatinine: 0.7 mg/dL
Hemoglobin: 10.5 g/dL
Hematocrit: 25%
Leukocyte count: 11,000/mm^3
Platelets: 200,000/mm^3

Urine:
Specific gravity: 1.006
Epithelial cells: 5/hpf
Glucose: negative
Protein: 20 mg/dL
RBC: 6/hpf
WBC: 1/hpf
Leukocyte esterase: negative
Nitrites: negative
Bacterial: none

A water deprivation test is performed with the following results:

Serum osmolality: 305 mOsm/kg
Urine osmolality: 400 mOsm/kg
Urine specific gravity: 1.007

Desmopressin is administered, and the patient's urine osmolality increases to 490 mOsm/kg. The patient's antidiuretic hormone is measured and is within normal limits. Which of the following may be associated with this patient’s condition?

Answer: Dactylitis

Choices:
A. Coarse tremor
B. Auditory hallucinations
C. Amenorrhea
D. Peripheral neuropathy
E. Dactylitis


Question: A 42-year-old male with a history of schizophrenia presents to his psychiatrist for a normal follow-up visit. He is accompanied by his case manager. The patient was diagnosed with schizophrenia at the age of 27. After being trialed on two different medications, he was deemed to be stable on a third medication which he has been taking for the past 10 years. He reports that he occasionally hears voices. He lives in supportive housing, and his caretakers report that he prefers to be alone but is not disruptive. His temperature is 99°F (37.2°C), blood pressure is 130/90 mmHg, pulse is 105/min, and respirations are 18/min. On exam, he demonstrates a flattened affect and disorganized speech. A funduscopic examination reveals pigmented plaques at the retinal periphery. No deposits are seen in the cornea or anterior lens. This patient has most likely been treated with which of the following medications?

Answer: Thioridazine

Choices:
A. Clozapine
B. Fluphenazine
C. Olanzapine
D. Chlorpromazine
E. Thioridazine


Question: A 6-month-old girl is brought to the emergency department because her lips turned blue for several minutes earlier during feeding. Her father reports that the patient had similar episodes while playing that resolved quickly. During the examination, she sits calmly in her father's lap. When her ears are examined, the patient begins to cry and her lips and fingers begin to turn blue. Further evaluation of this patient is most likely to show which of the following?

Answer: Right axis deviation on ECG

Choices:
A. Machine-like hum on auscultation
B. Diminutive left ventricle on echocardiogram
C. Decreased blood pressure in both lower extremities
D. Pulmonary vascular congestion on chest x-ray
E. Right axis deviation on ECG


Question: A 52-year-old female presents to clinic complaining of sudden onset of flank tenderness that was fluctuating and radiating into her groin. Laboratory analysis reveals a serum calcium of 12.4 (normal 8.4-10.2) and a serum phosphorous of 2.5 (normal 2.7-4.5) and a chloride:phosphorous ratio >33. You suspect primary hyperparathyroidism. Which of the following mechanisms is responsible for the patient’s current condition?

Answer: Increased RANK-L production

Choices:
A. PTH binding to receptors on osteoclasts
B. Parafollicular, or C-cell, synthesis of calcitonin
C. Increased RANK-L production
D. Decreased M-CSF production
E. Increased synthesis of osteoid by osteoblasts


Question: A 53-year-old man comes to the physician because of a 2-week history of fatigue, generalized itching, and yellowing of the eyes and skin. He underwent a liver transplantation because of acute liver failure following α-amanitin poisoning 1 year ago. Physical examination shows scleral icterus and abdominal distention with shifting dullness. A liver biopsy specimen shows decreased hepatic duct density. Further histological examination of the liver biopsy specimen is most likely to show which of the following findings?

Answer: Interstitial fibrosis

Choices:
A. Graft vessel vasculitis
B. Neoplastic cells containing bile
C. Fibrinoid necrosis
D. Interstitial fibrosis
E.
Viral inclusions
"


Question:
A 23-year-old man comes to the emergency department because of a 5-day history of progressively worsening dyspnea. He has had intermittent episodes of chest pain, which was 4/10 in intensity and increased on inspiration. He does triathlons and has not been able to train because of the discomfort. He has had no fever or syncopal episodes. He had an upper respiratory tract infection 3 weeks ago. His father died of heart disease at the age of 55 years. His temperature is 36.8°C (98.2°F), pulse is 113/min, and blood pressure is 100/70 mm Hg. Examination shows jugular venous distention. Inspiratory crackles are heard throughout the thorax. Cardiac examination shows an S3 gallop. Laboratory studies show:
Hemoglobin 14.8 g/dL
Leukocyte count 9200/mm3
Platelet count 230,000/mm3
ESR 41 mm/hr
Serum
Creatinine 1.1 mg/dL
Glucose 92 mg/dL
LDH 120 U/L
Troponin I 0.204 ng/mL (N< 0.1 ng/mL)
An x-ray of the chest shows an enlarged cardiac silhouette and prominent vascular markings in both lung fields. An ECG shows diffuse T-wave inversions. Which of the following echocardiographic findings is most likely in this patient?"

Answer: Left ventricular dilation and global hypokinesis

Choices:
A. Swinging heart with compression of the left heart chambers
B. Increased left ventricular wall thickness
C. Mitral valve stenosis with left atrial enlargement
D. Left ventricular dilation and global hypokinesis
E. Vegetations on the mitral valve


Question: Two days after undergoing abdominal surgery for lysis of adhesions, a 52-year-old man has nausea and one episode of bilious vomiting. The patient's nausea is somewhat alleviated in the prone position. The patient has had a 70-kg (154-lb) weight loss since undergoing bariatric surgery 1 year ago. Physical examination shows abdominal distention. Sudden movement of the patient elicits a sloshing sound on auscultation of the abdomen. An upper gastrointestinal series of the abdomen with oral contrast shows no passage of contrast past the third segment of the duodenum. The obstruction in this patient is most likely caused by which of the following structures?

Answer: Superior mesenteric artery

Choices:
A. Superior mesenteric artery
B. Gallbladder
C. Common bile duct
D. Portal vein
E. Inferior vena cava


Question: A 16-year-old girl is brought to the physician because her mother is concerned about her lack of appetite and poor weight gain. She has had a 7-kg (15-lb) weight loss over the past 3 months. The patient states that she should try to lose more weight because she does not want to be overweight anymore. She maintains a diary of her daily calorie intake. Menarche was at the age of 13 years, and her last menstrual period was 3 months ago. She is on the high school track team. She is sexually active with 2 male partners and uses condoms inconsistently. She is at 50th percentile for height and below the 5th percentile for weight and BMI. Her temperature is 37°C (98.6°F), pulse is 58/min and blood pressure is 96/60 mm Hg. Examination shows fine hair over the trunk and extremities. Which of the following is the most likely diagnosis?

Answer: Anorexia nervosa

Choices:
A. HIV infection
B. Type 1 diabetes mellitus
C. Hyperthyroidism
D. Obsessive compulsive disorder
E. Anorexia nervosa


Question: A 25-year-old male presents with progressively worsening headaches over the past two months. He also feels that he has been losing his balance more often over the past week, but he denies any motor weakness or sensory impairment. His neurological exam reveals impaired upward gaze, pupils that constrict poorly to light but react to accommodation, and bilateral upper eyelid retraction. On tandem walking, he tends to fall on both sides. The remainder of the physical examination is unremarkable. What is the most likely diagnosis in this patient?

Answer: Pineal tumor

Choices:
A. Frontal lobe tumor
B. Multiple sclerosis
C. Pituitary mass
D. Pineal tumor
E. Craniopharyngioma


Question: A 32-year-old woman presents to an urgent care facility after having sustained a deep cut 8 hours ago while hiking in the Appalachian mountains. Immediately after she sustained the injury she rinsed out the dirt with a bottle of saline from her first aid kit. She immigrated to the United States at age 20 and was unvaccinated upon arrival. Her medical records indicate that she has since received one dose of Tdap and one Td booster 3 years ago. She is afebrile, well appearing, and her wound appears clean without signs of infection at this time. What is the next best step in management?

Answer: Tetanus toxoid and tetanus immunoglobulin

Choices:
A. Tetanus immunoglobulin only
B. Tetanus titers and if negative, tetanus toxoid and immunoglobulin within 48 hours
C. Tetanus toxoid only
D. Tetanus toxoid and tetanus immunoglobulin
E. Tetanus toxoid and tetanus immunoglobulin today; tetanus toxoid again on days 3, 7, and 14 after exposure


Question: A 39-year-old woman presents to the emergency department with a chief concern of abdominal pain. She states that her symptoms occurred shortly after she began eating dinner that evening. She states that the pain is in the right side of her abdomen and travels to her right shoulder. She has a past medical history of polycystic ovarian syndrome, obesity, type II diabetes mellitus, and hypertension. Her current medications include metformin, insulin, atorvastatin, aspirin, and lisinopril. Her temperature is 99.5°F (37.5°C), blood pressure is 110/75 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 99% on room air. On abdominal exam, the patient demonstrates tenderness in the right upper quadrant. The patient is started on IV fluids and morphine. Four hours later, she states that the pain has abated. Which of the following is associated with this patient's most likely diagnosis?

Answer: Cholecystokinin

Choices:
A. Acetylcholine
B. Cholecystokinin
C. Gastrin
D. Histamine
E. Secretin


Question: A 12-year-old girl is brought to the primary physician because of severe ear pain and yellow discharge from her left ear for the past 2 days. It is also mildly pruritic. The pain started during her last day of summer camp, where she spent a lot of time outdoors hiking, horseback riding, and swimming. Her temperature is 37°C (98.6°F), pulse is 76/min, and blood pressure is 110/75 mm Hg. Examination shows tragal tenderness and a red and edematous external auditory canal. A diagnostic tuning fork is placed in the middle of the patient's forehead. The patient reports hearing the sound more loudly in the left ear. To complete the workup, the tuning fork is placed on the mastoid process of the left ear. Once she can no longer hear the sound, the tuning fork is placed in front of the auricle, and she reports no longer hearing the sound. On the right side, once the sound from the mastoid process subsides and the tuning fork is placed in front of the right ear, she reports hearing the sound again. Which of the following is the most likely cause of the patient's symptoms?

Answer: Infection with Pseudomonas aeruginosa

Choices:
A. Infection with Aspergillus species
B. Infection with varicella-zoster virus
C. Abnormal squamous epithelial growth
D. Infection with Pseudomonas aeruginosa
E.
Pleomorphic replacement of normal bone
"


Question:
A 50-year-old man comes to the emergency department because of severe lower chest pain for the past hour. The pain radiates to the back and is associated with nausea. He has had two episodes of non-bloody vomiting since the pain started. He has a history of hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 30 years. He drinks five to six beers per day. His medications include enalapril and metformin. His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. The lungs are clear to auscultation. Examination shows a distended abdomen with epigastric tenderness and guarding but no rebound; bowel sounds are decreased. Laboratory studies show:
Hemoglobin 14.5 g/dL
Leukocyte count 5,100/mm3
Platelet count 280,000/mm3
Serum
Na+ 133 mEq/L
K+ 3.5 mEq/L
Cl- 98 mEq/L
Total bilirubin 1.0 mg/dL
Amylase 160 U/L
Lipase 880 U/L (N = 14–280)
An ECG shows sinus tachycardia. Which of the following is the most likely diagnosis?"

Answer: Acute pancreatitis

Choices:
A. Acute mesenteric ischemia
B. Aortic dissection
C. Peptic ulcer disease
D. Myocardial infarction
E. Acute pancreatitis


Question: A 29-year-old woman presents to the physician’s office complaining of swollen hands for the past 3 weeks. It is associated with stiffness in the morning, which lasts about 10 minutes. The patient’s medical history is significant for hypothyroidism that is managed with levothyroxine. She has no recent travel history. Vital signs are normal. On examination, the patient has a butterfly-shaped, non-blanching rash on her face with mild cervical lymphadenopathy. The metacarpophalangeal and proximal interphalangeal joints are tender and appear swollen. Cardiopulmonary examination reveals a grade 2/6 holosystolic murmur heard best at the apex. Which of the following tests is the best next step in evaluating this patient?

Answer: Antinuclear antibody

Choices:
A. Anti-double-stranded-DNA antibody
B. Anti-U1 ribonucleoprotein antibody
C. Lupus anticoagulant
D. Antinuclear antibody
E. Anti-histone antibody


Question: A 61-year-old male dies in a motor vehicle accident. Autopsy of the heart reveals dilatation of the left atrium and expansion of the left ventricular cavity with associated eccentric hypertrophy. The structural changes in this patient's heart are most likely associated with which of the following?

Answer: Mitral insufficiency

Choices:
A. Pulmonic stenosis
B. Mitral insufficiency
C. Chronic hypertension
D. Wolff-Parkinson-White syndrome
E. Congenital atrial septal defect


Question: A 52-year-old business executive presents to his physician with complaints of intermittent chest pain which started 2 months ago. He describes his pain as crushing, centrally located, and typically lasting about 5 minutes but never more than 10 minutes. The pain radiates to his left arm and jaw, occurs only when he climbs the stairs or runs on a treadmill, and is relieved by rest. He has been hypertensive and diabetic for the last 10 years and has been compliant with his medications. His physical exam findings are within normal limits. Lab tests are normal except for a significantly elevated LDL-cholesterol level. A stress ECG shows ST-segment depression in the anterior chest leads when his heart rate and blood pressure increase to over 40% from their baseline values. The physician decides to initiate a medication to relieve his symptoms. Which of the following changes best describes the direct effect of the prescribed medication on his cardiovascular physiology in the cardiac output/venous return versus right atrial pressure graph?

Answer: iv

Choices:
A. i
B. ii
C. iii
D. iv
E. vi


Question: A 34-year-old man comes to the physician for a follow-up appointment. He was diagnosed with HIV 6 years ago and has been on highly active antiretroviral therapy with emtricitabine, tenofovir, and darunavir. He reports that he has been compliant with his medication regimen. His last CD4+ T-lymphocyte count was 520/mm3 (N > 500) and HIV viral load was undetectable. Today, his CD4+ T-lymphocyte count is 410/mm3 and his HIV viral load is 240 copies/mL. Further evaluation shows resistance to emtricitabine and tenofovir. Mutations in which of the following genes are most likely responsible for these findings?

Answer: pol

Choices:
A. tat
B. pol
C. rev
D. gag
E. env


Question: A 61-year-old woman with a history of stage IV pancreatic cancer comes to the emergency department with insomnia due to intractable midepigastric pain. The pain had been constant for months but has worsened over the past few weeks despite the fact that she is already taking hydrocodone 10 mg and ibuprofen 400 mg. She has a past medical history of chronic pain and major depressive disorder. In the past month, she has been taking her pain medications with increasing frequency, going from twice a day to four times a day. Her other medications include venlafaxine and eszopiclone. She describes her mood as low, but states she does not have any suicidal thoughts. She appears fatigued and slightly cachectic. Her temperature is 36°C (96.8°F), pulse is 100/min, and blood pressure is 128/65 mm Hg. Physical examination shows a mass in the midepigastric region. Which of the following is the most appropriate next step in management?

Answer: Switch from hydrocodone to hydromorphone

Choices:
A. Discontinue hydrocodone and ibuprofen, and start IV ketorolac
B. Switch from hydrocodone to hydromorphone
C. Administer regional block of the celiac plexus using lidocaine
D. Switch from eszopiclone to zolpidem
E.
Allow the patient to take hydrocodone and ibuprofen up to every four hours
"


Question: Two days into hospitalization for pyelonephritis and sepsis, a 48-year-old woman develops severe sudden-onset dyspnea. She has no history of serious cardiopulmonary disease. She is fatigued and pale. Her blood pressure is 115/65 mm Hg, the pulse is 120/min, the respiratory rate is 36/min, and the temperature is 39.7°C (103.5°F). Her oxygen saturation is 80% on 60% FiO2. She has severe nasal flaring, supraclavicular and intercostal respiratory retractions, and paradoxical abdominal movements. Inspiratory crackles are heard over both lung fields. Cardiac examination shows no murmurs. A chest X-ray, taken before orotracheal intubation, is shown. Which of the following is the most appropriate next step in management?

Answer: Low tidal volume ventilation

Choices:
A. Broad-spectrum antibiotics
B. High-dose glucocorticoids
C. High positive end-expiratory pressure
D. Intravenous fluids
E. Low tidal volume ventilation


Question: A 48-year-old man presents to the physician with a cough with expectoration and breathlessness on exertion for the last 4 years. There is no history of any other medical conditions. He has been a smoker for the last 10 years. He recently immigrated from a developing country and his immunization status is unknown. After a complete physical examination of the patient, the physician orders a chest radiogram which shows increased bronchovascular markings and flattening of the diaphragm. His spirometry findings include an FEV1 of 82% of predicted, which increases to 88% of predicted at 15 minutes after the administration of inhaled albuterol. The FEV1/FVC ratio is 0.66. The physician explains the diagnosis to the patient and emphasizes the importance of smoking cessation. He also offers him specific vaccinations. However, the patient mentions that he does not have medical insurance and due to his poor financial situation, he can afford only 1 of the suggested vaccines. In such a situation, which of the following vaccines should definitely be recommended to this patient?

Answer: Influenza vaccine

Choices:
A. 13-valent pneumococcal conjugate vaccine
B. 23-valent pneumococcal polysaccharide vaccine
C. Haemophilus influenzae type b vaccine
D. Influenza vaccine
E. Pertussis vaccine


Question:
A five-year-old female presents to the pediatrician for a well visit. The patient’s parents report that she recently entered kindergarten and her teacher expressed concern that the patient is not meeting developmental milestones. She struggles to name colors and has not expressed any interest in learning to read. The patient’s parents have also noticed that the patient is not completing tasks that her older siblings were doing by this age, including dressing herself independently and going to the bathroom by herself. The patient rolled over at 9 months, sat without support at 12 months, and walked at 20 months. Her parents also report that the patient is very social, and that adults frequently comment on her friendly personality. The patient is in the 15th percentile for weight and 5th percentile for height. On physical exam, the patient has a broad forehead, flat nasal bridge, long philtrum, and a wide mouth. She has a strabismus on neurological exam, and her cardiac exam is significant for a heart murmur. Laboratory testing is below:

Serum:
Na+: 145 mEq/L
K+: 3.9 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/
Urea nitrogen: 11 mg/dL
Glucose: 76 mg/dL
Creatinine: 0.9 mg/dL
Ca2+: 11.9 mg/dL

Which of the following cardiac abnormalities is associated with this condition?

Answer: Supravalvular aortic stenosis

Choices:
A. Bicuspid aortic valve
B. Coarctation of the aorta
C. Complete atrioventricular septal defect
D. Supravalvular aortic stenosis
E. Tetralogy of Fallot


Question: A 20-year-old male comes to the physician because of a 1-week-history of a painless ulceration on his penis. The patient is sexually active with multiple partners and does not use barrier protection. Physical examination shows a shallow, firm ulcer with a smooth base along the shaft of the penis and nontender bilateral inguinal adenopathy. Which of the following is most likely to confirm the diagnosis in this patient?

Answer: Dark field microscopy

Choices:
A. Tzanck preparation
B. Culture swab
C. Urine polymerase chain reaction
D. Dark field microscopy
E. Serologic detection of antibodies


Question: A 31-year-old man presents to the clinic as a follow-up visit after recently being diagnosed with medullary thyroid cancer. Last year, he was diagnosed with a pheochromocytoma that was successfully resected. His family history is positive for medullary thyroid cancer in his father and paternal grandmother with a mucosal neuroma in his brother. What additional finding is most likely to be present in this patient on physical examination?

Answer: Marfanoid habitus

Choices:
A. Ash leaf spot
B. Hyperparathyroidism
C. Pituitary adenoma
D. Neurofibromas
E. Marfanoid habitus


Question: Digestion begins in the mouth by breaking food up into smaller particles through mastication and mixing it with saliva containing amylase. Food then enters the stomach, where gastric acid and pepsin initiate protein digestion. The resulting chyme is then expelled into the duodenum where pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids. These digested lipids are then ready for absorption across the gastrointestinal mucosa. Resection of which of the following segments of the gastrointestinal tract would prevent the absorption of these digested lipids?

Answer: Jejunum

Choices:
A. Jejunum
B. Ileum
C. Ascending colon
D. Descending colon
E. Rectum


Question: A group of investigators is studying hemodynamic regulatory mechanisms in a human volunteer subject. The volunteer is administered a stimulant drug, and a sudden increase in blood pressure is observed. It is hypothesized that the increase in blood pressure causes stretching of the atria. Increased atrial stretch would most likely lead to which of the following changes?

Answer: Decreased reabsorption of sodium

Choices:
A. Increased excretion of potassium and hydrogen ions
B. Vasodilation and decreased platelet aggregation
C. Decreased reabsorption of sodium
D. Increased reabsorption of solute-free water
E. Vasoconstriction and stimulation of thirst


Question: A 26-month-old boy is presented to the outpatient clinic by his parents complaining of a productive cough for the last 5 days. His mother reports a history of recurrent chest infections during the past year. He also has a history of chronic bloody diarrhea and pronounced bleeding after his circumcision. The vital signs are as follows: blood pressure 100/60 mm Hg, pulse 100/min, temperature 38.0°C (100.4°F), and respiratory rate 27/min. On examination, there are purpuric eruptions over the extremities as well as eczematous patches on the flexural surfaces of his elbows and knees. Chest auscultation reveals crepitus over the base of the right lung. Chest radiography is suggestive of consolidation in the right lower lobe. Blood test results show anemia, thrombocytopenia with small platelets, and leukopenia. With a suspicion of a congenital immunodeficiency, flow cytometry is ordered which reveals a Wiskott-Aldrich syndrome protein (WASP) mutation. Which of the following would be the definitive treatment of this patient’s condition?

Answer: Early hematopoietic stem cell transplantation (HSCT)

Choices:
A. Early hematopoietic stem cell transplantation (HSCT)
B. Intravenous immunoglobulin (IVIG)
C. Rituximab
D. Chemotherapy
E. Corticosteroids


Question: Four hours after undergoing an open emergency surgery under general anesthesia for a bleeding abdominal aortic aneurysm, a 55-year-old man is unable to move both his legs. During the surgery, he had prolonged hypotension, which was corrected with IV fluids and vasopressors. He has a history of hypertension and hyperlipidemia. He has smoked one pack of cigarettes daily for 35 years. Prior to admission, his medications were hydrochlorothiazide and atorvastatin. The patient is conscious and oriented to place and person. His temperature is 37.7°C (99°F), pulse is 74/min, and blood pressure is 100/70 mm Hg. Examination shows muscle strength of 1/5 in the lower extremities. Further evaluation of this patient is most likely to show which of the following?

Answer:
Normal proprioception in the extremities
"

Choices:
A. Normal temperature sensation in the extremities
B. Babinski's sign present bilaterally
C. Normal bulbocavernosus reflex
D. Bilaterally increased knee and ankle jerk
E.
Normal proprioception in the extremities
"


Question: A 30-year-old woman seeks evaluation at a local walk-in clinic with a week-long history of lightheadedness and palpitations. She also complains of fatigability and shortness of breath of the same duration. The past medical history is significant for menarche at 9 years of age, heavy menstrual bleeding for the past several years and abdominal pain that worsens during menses. She stopped trying to conceive a child after 2 spontaneous abortions in the past 4 years and has been on iron oral supplementation for the last 2 years. She adds that she feels a dull pressure-like discomfort in her pelvis and constipation. The physical examination is significant for pale mucous membranes and a grade 2/6 ejection systolic murmur in the area of the pulmonic valve. Pelvic examination reveals an enlarged, mobile uterus with an irregular contour. The hemoglobin level is 10 g/dL and the hematocrit is 27%. Based on these findings, which of the following is the most likely diagnosis?

Answer: Uterine leiomyoma

Choices:
A. Uterine adenomyosis
B. Uterine leiomyoma
C. Endometrial hyperplasia
D. Endometrial carcinoma
E. Endometrial polyp


Question: A study is conducted in a town with a population of 225,000, where the people are followed-up for the development of emphysema. A total of 1,000 smokers are selected and followed-up, out of which 200 actually develop the disease. A control group of 1,000 non-smokers is formed, out of which 20 develop emphysema. The prevalence of smoking in the general population is 40%. The researcher calculates all possible risk estimates, including the odds ratio. What percentage of the risk of developing emphysema can be attributed to smoking?

Answer: 18%

Choices:
A. 40%
B. 20%
C. 10%
D. 2%
E. 18%


Question: A medical student is performing clinical research by analyzing the aggregated data of all patients from a national database. In performing the study, she uses all the data collected from patients who had an appendectomy and analyzes the risk factors that are associated with readmission after discharge. She first excludes some of the data based on previously determined exclusion criteria and then performs analysis on the rest. She performs a multiple regression on all variables and finds that one of the risk factors demonstrates a < 5% probability of being the same between groups. She takes this result and presents it to faculty; however, they respond that the finding is meaningless. Which of the following faults to this study most likely explains why the result was considered meaningless?

Answer: Failure to consider clinical significance versus statistical significance

Choices:
A. Data should not be excluded from the analysis
B. Data should not have been aggregated
C. Failure to consider clinical significance versus statistical significance
D. Single rather than multiple regression should have been performed
E. Usage of the wrong threshold for significance


Question: A 60-year-old man presents to the emergency department with ‘discomfort’ in his chest and a ‘squeezing’ sensation in his neck. The symptoms started 45 minutes ago while he was washing the dishes. He also complains of nausea. He has been a regular smoker for 45 years, averaging a pack of cigarettes each day. He also drinks heavily on weekends. His medical history is significant for a stroke 3 months ago, but the patient admits he has not been taking his medications. Vital signs show: pulse 62/min, respiratory rate 20/min, blood pressure 176/94 mm Hg, and temperature 36.9°C (98.4°F). Physical examination reveals a visibly distressed man who is sweating profusely. The chest is clear to auscultation and a 4th heart sound can be heard. Aspirin was administered upon arrival. His ECG is shown in the picture. Which of the following features is a contraindication for thrombolytic therapy in this patient?

Answer: Stroke 3 months ago

Choices:
A. Patient's age
B. Aspirin administration
C. Elevated blood pressure
D. History of smoking
E. Stroke 3 months ago


Question:
A 3-year-old girl is brought by her parents to the office for bloody diarrhea and a seizure. The parents say she started having fever, abdominal pain, and diarrhea about 3 days ago, but the bloody diarrhea started 12 hours ago. The seizure was the last symptom to appear 3 hours ago, and it consisted of repetitive movement of arms and legs with loss of consciousness. Her 4-year-old brother had a similar case with bloody diarrhea 2 weeks ago. Her vital signs include: blood pressure is 130/85 mm Hg, her respiratory rate is 25/min, her heart rate is 120/min, and her temperature is 39.2°C (102.6°F). On physical examination, she looks pale and sleepy, the cardiopulmonary auscultation is normal, the abdomen is painful on palpation, and the skin assessment reveals the presence of disseminated pinpoint petechiae. The urinalysis show hematuria. The Coombs test is negative. The complete blood count results are as follows:
Hemoglobin 7 g/dL
Hematocrit 25 %
Leukocyte count 17,000/mm3
Neutrophils 70%
Bands 2%
Eosinophils 1%
Basophils 0%
Lymphocytes 22%
Monocytes 5%
Platelet count 7,000/mm3
Her coagulation tests are as follows:
Partial thromboplastin time (activated) 30 seconds
Prothrombin time 12 seconds
Reticulocyte count 1 %
Thrombin time < 2 seconds deviation from control
What is the most likely diagnosis?

Answer: Hemolytic-uremic syndrome

Choices:
A. Disseminated intravascular coagulation
B. Henoch-Schonlein purpura
C. Salmonella infection
D. Systemic vasculitis
E. Hemolytic-uremic syndrome


Question: A 68-year-old woman presents to the emergency room with productive cough and fever. She has a chronic cough that has been getting progressively worse over the last 2 weeks. Last night she developed a fever and vomited. She smoked one pack of cigarettes per day for 40 years and recently quit. Her past medical history includes COPD and her medications include ipratropium and fluticasone. On physical exam her temperature is 102.2°F (39°C), blood pressure is 131/78 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 95% on room air. She has decreased breath sounds bilaterally with diffuse crackles. You obtain a sputum sample and identify an organism that grows selectively on medium containing factors V and X. Which of the following organisms is the most likely cause of this patient's symptoms?

Answer: Haemophilus influenzae

Choices:
A. Haemophilus influenzae
B. Streptococcus pneumoniae
C. Bacteroides species
D. Mycoplasma pneumoniae
E. Fusobacterium species


Question: A 36-year-old man comes to the physician because of progressive fatigue and night sweats for 2 months. During this time, he has also had a 10-kg (22-lb) weight loss. Physical examination shows painless swelling of the cervical, axillary, and inguinal lymph nodes. Examination of the abdomen shows hepatosplenomegaly. Histologic examination of a lymph node biopsy specimen shows Reed-Sternberg cells. A diagnosis of Hodgkin lymphoma is made. The patient is started on a chemotherapeutic regimen that includes bleomycin. The mechanism of action of this drug is most similar to that of which of the following?

Answer: Metronidazole

Choices:
A. Trimethoprim
B. Sulfamethoxazole
C. Rifampin
D. Metronidazole
E. Chloramphenicol


Question: An 7-year-old girl is brought to the pediatrician by her concerned mother, because she is "more physically matured" than the rest of the girls in her class. On physical exam, she is noted to have breast development and pubic hair. On gonadotropin reseasing hormone (GnRH) stimulation, she has an increase in leutienizing hormone (LH) levels. Thyroid function tests and an MRI of the head are both within normal limits. Which of the following is the most appropriate treatment for this condition?

Answer: Leuprolide

Choices:
A. Ketoconazole
B. Leuprolide
C. Finasteride
D. Octreotide
E. Anastrozole


Question:
A 45-year-old woman presents to the emergency department with hematemesis. Her son said that the patient had complained of gnawing abdominal pain that worsened before and improved after meals for the past 3 weeks. She frequently travels for work and is often stressed. She drinks alcohol socially and does not smoke tobacco or marijuana. She has not had anything to eat or drink for the past 24 hours due to the pain, but coughed up "several cup of" frank red blood before arrival. Her temperature is 98°F (37°C), blood pressure is 80/50 mmHg, pulse is 140/min, respirations are 23/min, and oxygen saturation is 96% on room air. Gastric ultrasound reveals high gastric residual volume. The patient is empirically started on 3 units of uncrossmatched O-negative blood transfusion and pantoprazole. The patient's initial laboratory data return in the meantime:

Hemoglobin: 5 g/dL
Hematocrit: 18 %
Leukocyte count: 8,000/mm^3 with normal differential
Platelet count: 400,000/mm^3

Serum:
Na+: 140 mEq/L
Cl-: 115 mEq/L
K+: 3.2 mEq/L
HCO3-: 26 mEq/L
BUN: 60 mg/dL
Glucose: 104 mg/dL
Creatinine: 1.1 mg/dL

Blood type: AB
Rhesus status: negative

After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours. The patient now complains of feeling hot with intermittent shivering. She denies any other symptoms. Her temperature is 101°F (38.3°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air. Her lungs are clear to auscultation bilaterally, and no accessory respiratory muscle use is observed. No rash is seen. What is the most likely diagnosis?

Answer: Febrile nonhemolytic reaction

Choices:
A. Citrate toxicity
B. Febrile hemolytic reaction
C. Febrile nonhemolytic reaction
D. Transfusion related bacterial contamination
E. Transfusion related acute lung injury


Question: A 66-year-old man comes to the physician because of a 3-week history of shortness of breath with exertion. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications include aspirin, losartan, simvastatin, and insulin. His temperature is 37.1°C (98.8°F), pulse is 74/min, and blood pressure is 150/84 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Cardiac examination is shown. Further evaluation of this patient is most likely to show which of the following?

Answer: Elevated serum brain natriuretic peptide levels

Choices:
A. Earlier onset of abnormal cardiac sound with standing
B. Elevated serum brain natriuretic peptide levels
C. Digital clubbing
D. Left-to-right shunt through the atrial septum
E. Bounding pulses of peripheral arteries


Question: A 27-year-old gravida 2, para 2 woman presents to her OB/GYN’s office concerned that she may be pregnant. She and her husband use condoms for contraception. The night before, the condom broke during intercourse. She has 2 children under the age of 3 and does not want another child at this time. She says she cannot take “the pill” because she had a blood clot in her leg after her last cesarean section successfully treated with 6 months of anticoagulation. She smokes cigarettes and drinks alcohol regularly. Which of the following would be the most appropriate recommendation for this patient?

Answer: Recommend copper IUD

Choices:
A. Reassure her that she is likely not pregnant
B. Refer her to an abortion clinic
C. Recommend etonogestrel implant
D. Recommend copper IUD
E. Recommend levonorgestrel IUD


Question:
A 25-year-old Ashkenazi Jewish man presents to his primary care physician for a follow-up visit. One week ago, he presented with a chief complaint of priapism while engaging in intercourse with two of his partners. During that visit, it was determined that his blood pressure was 175/100 mmHg. He returns this week to have his vitals rechecked. His temperature is 99.5°F (37.5°C), pulse is 80/min, blood pressure is 182/100 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air. Bloodwork is drawn and is shown below.

Serum:
Na+: 139 mEq/L
K+: 3.7 mEq/L
Cl-: 100 mEq/L
HCO3-: 28 mEq/L
Urea nitrogen: 9 mg/dL
Glucose: 122 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: 9.8 mg/dL
Mg2+: 1.7 mg/dL

After a physical exam is performed, which of the following is the best initial step in management for this patient's underlying condition?

Answer: Duplex ultrasound

Choices:
A. Begin lifestyle modification and weight loss program
B. Begin lifestyle modification, weight loss program, and hydrochlorothiazide
C. 24-hour urinary cortisol
D. Duplex ultrasound
E. Serum aldosterone level


Question:
A 63-year-old man is brought to the emergency department after having 8–9 episodes of red watery stool. He has no abdominal pain or fever. He underwent an angioplasty 4 years ago and received 2 stents in his left main coronary artery. He has hypertension, hypercholesterolemia, coronary artery disease, and chronic constipation. Current medications include aspirin, metoprolol, and simvastatin. He drinks one beer daily. He is in distress. His temperature is 37.3°C (99.1°F), pulse is 110/min, respirations are 14/min, and blood pressure is 86/58 mm Hg. Examination shows pale conjunctivae. The abdomen is soft and nontender. Bowel sounds are increased. The lungs are clear to auscultation. Cardiac examination shows an S4 gallop. Rectal examination shows frank blood. Laboratory studies show:
Hemoglobin 9.8 g/dL
Leukocyte count 7,800/mm3
Platelet count 280,000/mm3
Prothrombin time 14 seconds (INR=0.9)
Serum
Na+ 135 mEq/L
K+ 4.1 mEq/L
Cl- 101 mEq/L
Urea nitrogen 16 mg/dL
Glucose 96 mg/dL
Creatinine 0.7 mg/dL
Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered. A nasogastric tube is inserted. Aspiration shows clear gastric content containing bile. Directly afterwards, his pulse is 133/min and blood pressure is 80/54 mm Hg. Which of the following is the most appropriate next step in management?"

Answer: Angiography

Choices:
A. Angiography
B. Laparotomy
C. Colonoscopy
D. Esophagogastroduodenoscopy
E. Enteroscopy


Question: A 15-month-old boy with Down syndrome is brought to the physician for a well-child examination. The mother is concerned about giving the child any more vaccinations, as she reports he had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12-months of age. He has had a runny nose for 2 days. He has a seizure disorder with a seizure lasting 1–2 minutes a few times a week that has not been controlled by medications. He was treated for intussusception at 6 months of age. His father was diagnosed with HIV 2 years ago. His medications include phenytoin, levetiracetam, and vitamin supplements. He is allergic to amoxicillin and has previously developed localized urticaria after consumption of eggs. His immunizations are up-to-date. Vital signs are within normal limits. Examination shows low-set ears, hypertelorism, and a flat head. The remainder of the examination shows no abnormalities. Which of the following is a relative contraindication for administering one or more routine vaccinations in this patient at this time?

Answer:
Uncontrolled seizure disorder
"

Choices:
A. Egg protein allergy
B. Fever of 38.7°C (101.7°F) after previous vaccination
C. Current upper respiratory tract infection
D. History of intussusception
E.
Uncontrolled seizure disorder
"


Question: A 1-year-old boy is brought to his pediatrician’s office due to regression of development. She has observed that he is not progressing as he did during the 1st year of his life. There seems to be a regression in some behavioral and other milestones. She is also concerned about his facial development. On examination, the vital signs are normal. He has coarse facial features with a bulging frontal bone. Additionally, his lips are enlarged and corneal clouding is observed. Urine studies show an increase in dermatan sulfate. Which of the following genetic conditions is most likely related to these clinical features?

Answer: Hurler syndrome

Choices:
A. Hunter syndrome
B. Morquio syndrome
C. Tay-Sachs disease
D. Hurler syndrome
E. Fabry disease


Question: A 6-year-old African American girl is brought to the physician by her mother because she has recently developed axillary and pubic hair. She also has multiple pustules on her forehead and has had oily skin for 3 months. Her mother reports that she recently bought some deodorant for the girl because of her body odor. Her mother has hypothyroidism. She is at the 95th percentile for height and the 99th percentile for weight and BMI. Her vital signs are within normal limits. She has no palpable glandular breast tissue. There is coarse hair under both axilla and sparse dark hair on the mons pubis and along the labia majora. Which of the following is the most likely explanation for this patient's examination findings?

Answer: High levels of insulin

Choices:
A. High levels of insulin
B. Adrenal enzyme deficiency
C. Overproduction of leptin
D. Pituitary tumor
E. Ovarian cyst


Question: A 45-year-old woman comes to the physician for a health maintenance examination. Her father has a history of type 2 diabetes mellitus. She has gained 18-kg (40-lb) since the birth of her son 6 years ago. Her BMI is 31 kg/m2. Physical examination shows hyperpigmented plaques in the axillae and posterior neck. Laboratory studies show a hemoglobin A1c of 6.4% and an elevated serum insulin level. Which of the following factors is most likely involved in the pathogenesis of this patient's condition?

Answer: Increased levels of serum fatty acids

Choices:
A. Increased serum levels of glucagon-like peptide-1
B. Positive MHC class I serotype
C. Increased levels of serum fatty acids
D. Decreased levels of serum cortisol
E. Positive HLA-DR4 serotype


Question: An 89-year-old woman presents with worsening dyspnea on exertion and generalized fatigue. She has fainted once. Exam reveals a crescendo-decrescendo systolic ejection murmur that radiates to the carotids. What pathological step preceded calcification in her condition?

Answer: Cellular injury and necrosis

Choices:
A. Commissural fibrosis
B. Congenital bicuspid valve
C. Fibrillin-1 deficiency
D. Cellular injury and necrosis
E. Cellular hypertrophy


Question: A 22-year-old man presents to the emergency department for chest pain. He says that the chest pain began a few hours prior to presentation and is associated with nausea, abdominal discomfort, and sweating. He has experienced similar symptoms multiple times in the past, which brings him great concern because he believes he may be having a heart attack. This concern has persisted for 2 months. This has caused him to avoid taking long train rides or driving on divided highways. Approximately 7 months ago his parents divorced. Medical history is significant for obesity. He denies any medications or illicit drug use. Physical examination is unremarkable. An electrocardiogram demonstrates sinus tachycardia with a pulse of 110/min. Which of the following is most likely the diagnosis?

Answer: Panic disorder

Choices:
A. Adjustment disorder
B. Illness anxiety disorder
C. Panic disorder
D. Somatic symptom disorder
E. Specific phobia


Question: An investigator is developing a new vaccine. Eukaryote ribosomes are utilized to create a novel protein. After the aminoacyl-tRNA binds to the A site, which of the following is the next step in protein formation?

Answer: Catalysis of peptide bond

Choices:
A. Catalysis of peptide bond
B. Recognition of UAG codon by release factor
C. Assembly of 40s subunit with tRNA
D. Advancement of ribosome in 3' direction
E. Assembly of 60S subunit with mRNA


Question: A 70-year-old Caucasian woman presents with a 2-week history of blood-tinged sputum. Her past medical history is significant for peptic ulcer disease for which she underwent triple-drug therapy. She is a lifetime non-smoker and worked as a teacher before retiring at the age of 60 years. A review of systems is significant for a weight loss of 6.8 kg (15 lb) over the last 5 months. Her vitals include: blood pressure 135/85 mm Hg, temperature 37.7°C (99.9°F), pulse 95/min, and respiratory rate 18/min. Physical examination is unremarkable. A contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung. A CT-guided biopsy is performed and reveals malignant tissue architecture and gland formation with a significant amount of mucus. Which of the following is the most significant risk factor for this patient’s most likely diagnosis?

Answer: Sex

Choices:
A. Medications
B. Occupational history
C. Past medical history
D. Race
E. Sex


Question: Four days after admission to the hospital for community-acquired pneumonia, a 68-year-old woman has abdominal pain and multiple episodes of loose stools. They are watery, foul-smelling, and occasionally streaked with blood. She has approximately 6 episodes daily. She feels tired. She is currently being treated with intravenous ceftriaxone and oral azithromycin. She underwent a laparoscopic cholecystectomy 5 years ago. She returned from a trip to Bolivia 4 weeks ago. Her temperature is 37.5°C (99.5°F), pulse is 98/min, and blood pressure is 138/80 mm Hg. Bronchial breath sounds are heard over her right lung. Abdominal examination shows mild diffuse tenderness throughout the lower quadrants. The abdomen is not distended. The remainder of her examination shows no abnormalities. Her hemoglobin concentration is 12 g/dL, leukocyte count is 14,100/mm3, and erythrocyte sedimentation rate is 37 mm/h. Which of the following is the most appropriate next step in management?

Answer: Enzyme immunoassay for glutamate dehydrogenase antigen

Choices:
A. Stool for ova and parasites
B. Fecal lactoferrin
C. Enzyme immunoassay for glutamate dehydrogenase antigen
D. Stool acidity test
E. Sigmoidoscopy


Question: An otherwise healthy 52-year-old man comes to the physician because of a 2-month history of palpitations. He says that he can feel his heart beat in his chest all the time. For the past 3 weeks, he has shortness of breath on exertion. He has not had chest pain, orthopnea, or nocturnal dyspnea. He emigrated from Nepal at the age of 25 years. He does not take any medications. His temperature is 36.5°C (97.7°F), pulse is 103/min, and blood pressure is 138/56 mm Hg. The lungs are clear to auscultation. Cardiac examination is shown. Which of the following is the most likely diagnosis?

Answer: Aortic valve regurgitation

Choices:
A. Pulmonary valve stenosis
B. Aortic valve regurgitation
C. Tricuspid valve regurgitation
D. Pulmonary valve regurgitation
E. Mitral valve prolapse


Question: A 55-year-old male presents to the emergency department after he was seen having a seizure. On presentation he is comatose and very jaundiced despite having no previous medical history and dies shortly thereafter. Over the next several hours 5 more patients present to the ER with severe diarrhea, abdominal pain, and bleeding abnormalities. They all recently returned from a several day camping trip where they slept in the woods and cooked with ingredients they were able to find in the wild. The original patient was also part of this camping trip. Postmortem analysis reveals massive hepatic necrosis. Which of the following activities was most likely inhibited by the cause of this patient's presentation?

Answer: Transcription of mRNA

Choices:
A. Splicing of mRNA
B. Transcription of mRNA
C. Transcription of rRNA
D. Transcription of tRNA
E. Translation of mRNA


Question: A 46-year-old woman is brought to the emergency department for respiratory depression. Routine urine toxicology screening is positive for alcohol, fentanyl, and benzodiazepines. Blood glucose is 80 mg/dL. Naloxone, flumazenil, and lactated Ringer's solution are administered intravenously. Two hours later, the woman has a tonic-clonic seizure lasting for one minute. Her pulse is 100/min, blood pressure is 145/90 mm Hg, and respiratory rate is 24/min. Pulse oximetry on room air shows an oxygen saturation of 98%. The patient appears drowsy and diaphoretic. She is not oriented to place or time but responds to her name. Examination shows a hematoma on her left temple. Neurological examination shows stiff extremities and a tremor in both hands. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of this patient's seizure?

Answer: Benzodiazepine withdrawal

Choices:
A. Hypoglycemia
B. Benzodiazepine withdrawal
C. Alcohol withdrawal
D. Fentanyl overdose
E. Subdural hemorrhage


Question: A 22-year-old man comes to the emergency department because of sudden onset of facial swelling, abdominal pain, and nausea 1 hour after eating some trail mix. He does not have shortness of breath or hoarseness. He has never had a similar episode before. He has asthma treated with an albuterol inhaler, which he uses less than once a month. His pulse is 90/min, respirations are 25/min, and blood pressure is 125/80 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows perioral swelling and scattered urticaria over the face and the fingers of his right hand. There is no swelling of the oropharynx and no audible stridor. The lungs are clear to auscultation bilaterally. Treatment with intravenous diphenhydramine is begun. Shortly after, the abdominal pain and nausea have resolved, the swelling has improved, and the rash has started to fade. Which of the following is the most appropriate next step in management?

Answer: Prescribe epinephrine autoinjector

Choices:
A. Recommend avoidance of peanuts
B. Perform patch test
C. Prescribe epinephrine autoinjector
D. Advise to carry oral cetirizine at all times
E. Administer oral prednisone


Question: A 2-year-old boy is referred by his primary care physician to a geneticist because of prolonged and recurrent infections. Specifically, he has had an abnormally large number of upper respiratory and gastrointestinal infections over the last year. He was born with a defect in the cardiac septum that was repaired right after birth and has remained asymptomatic since then. On evaluation, the patient appears to have hyperactive reflexes and his arm twitches upon blood pressure measurement. The regions of this patient's lymph nodes that is likely abnormal also contains which of the following?

Answer: High endothelial venules

Choices:
A. Efferent sinuses
B. High endothelial venules
C. Plasma cell cords
D. Primary follicles
E. Subcapsular macrophages


Question:
A 45-year-old woman presents with a 2-year history of fatigue, paresthesia, diarrhea, and abdominal pain. She says she experiences 2–3 episodes of non-bloody diarrhea per month associated with crampy abdominal pain. She also has the bilateral tingling sensation of her upper and lower limbs in a glove and stocking pattern which is sometimes associated with the burning sensation of her hands and legs. Past medical history is unremarkable. The patient denies smoking, alcohol consumption, illicit drug use. Her vital signs include: blood pressure 100/60 mm Hg without postural changes, heart rate 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉). Laboratory findings are significant for the following:
Hgb 7.2 gm/dL
MCV 110 fL
RBC 3.6 X109/L
Platelets 10,000/mm3
Total count  4,200/mm3
Reticulocyte 0.8%
A peripheral blood smear demonstrates hypersegmented neutrophils. Anti-intrinsic factor and anti-tissue transglutaminase antibodies were negative. An upper GI series with small bowel follow-through is performed which shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string. Which of the following is the most likely diagnosis in this patient?

Answer: Crohn's disease

Choices:
A. Pernicious anemia
B. Celiac disease
C. Crohn's disease
D. Bacterial overgrowth
E. Hypothyroidism


Question: A 15-month-old boy is brought to his pediatrician by his mother with a swollen and painful right elbow. She reports that he stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground. The mother reports that he did not appear to be in a great deal of pain after the fall, and that she noted the swelling of the joint a few hours after the fall. He recently started walking approximately 2 weeks ago. He does not have any known medical issues, and he is not currently on medication. The mother's pregnancy was without complications and the boy was delivered vaginally without complications at 40 weeks. Aspiration of the right elbow joint reveals frank blood. Which of the following should be included in the work-up of this patient?

Answer: Prothrombin time/partial thromboplastin time

Choices:
A. Peripheral blood smear
B. Creatinine level and percutaneous kidney biopsy
C. Prothrombin time/partial thromboplastin time
D. 24 hour urine collection for porphyrin levels
E. Rheumatoid factor


Question: A 45-year-old male comes into your office one week after he was tackled playing football with his friends. The patient states that the medial aspect of his knee collided with another player's knee. Since then, he has been taking ibuprofen for knee pain. On exam, the patient's right knee appears larger than his left knee with a small effusion. The patient has intact sensation and strength in both lower extremities. The patient's right knee has no laxity on valgus stress test, but is very lax on varus stress test. Lachman's test and posterior drawer test both have firm endpoints without laxity. McMurray's test is positive and the patient states he feels catching and locking during the test. Which of the following structures has this patient injured in addition to the meniscus?

Answer: Lateral collateral ligament

Choices:
A. Anterior cruciate ligament
B. Posterior cruciate ligament
C. Medial collateral ligament
D. Lateral collateral ligament
E. Medial patellofemoral ligament


Question: A 19-month-old girl is brought for a well-child examination. She was born at term and has been healthy. On physical examination, the child is alert and active. Her temperature is 37.3 °C (99.1 °F), pulse is 102/min, respirations are 24/min, and blood pressure is 102/54 mm Hg. She is at the 75th percentile for height and 80th percentile for weight. Cardiac examination shows a normal S1 and a split S2 during inspiration. A grade 2/6 soft mid-systolic murmur is heard maximally at the lower left sternal border. A contrast echocardiogram is performed and reveals a mild transient right-to-left interatrial shunt that becomes apparent when the child coughs. Which of the following is the most appropriate next step in management?

Answer: No intervention

Choices:
A. No intervention
B. Warfarin therapy
C. Aspirin therapy
D. Surgical closure
E. Regular echocardiographies


Question: A 6-year-old girl is brought to the emergency department because of right knee pain for the past 3 days. During this period, the girl has refused to walk. Her mother reports that her symptoms began after she fell down while playing. Three weeks ago, the patient had a sore throat and was treated with penicillin V. Her father has hemophilia A and has had repeated episodes of joint pain and swelling following minor injury. The patient's immunizations are up-to-date. Her temperature is 38.1°C (100.6°F), pulse is 120/min, and respirations are 21/min. The right knee joint is warm and erythematous. The girl starts to cry as soon as the physician tries to flex the knee joint. Further evaluation of this patient is likely to show which of the following findings?

Answer: Gram-positive cocci in synovial fluid

Choices:
A. Positive antinuclear antibody test
B. Gram-positive cocci in synovial fluid
C. Prolonged prothrombin time
D. Increased antistreptolysin O titers
E. Rhomboid crystals in synovial fluid


Question: A 35-year-old man attempted to climb Mount Everest. At an altitude of 7,000 meters, he became short of breath and developed a dusky blue tinge around his face and lips. A physician in the climbing party performs a rudimentary physical exam which reveals a respiratory rate of 30/min, blood pressure of 130/90 mm Hg, heart rate of 108/min, and temperature of 36.4°C (97.5°F), with few basal crackles on the right side of chest. No jugular venous distension or dependent edema is noted. With this information, the mountain climber is sent down the mountain for further evaluation. Investigation reveals a normal chest X-ray with a normal heart size. What is the most likely cause of this patient’s condition?

Answer: Hypoxemic hypoxia

Choices:
A. Diffusion defect
B. Anemic hypoxia
C. Ischemic hypoxia
D. Hypoxemic hypoxia
E. Methemoglobinemia


Question: A 28-year-old man who was involved in a motorcycle accident presents to the nearest trauma center to get his wounds treated. After the initial evaluation and resuscitation by the emergency trauma team, a CT scan shows a skull base fracture. Which of the following clinical features can be seen as a long-term complication of posterior pituitary dysfunction?

Answer: Polydipsia

Choices:
A. Erectile dysfunction
B. Decreased lean body mass
C. Hyponatremia
D. Polydipsia
E. Cold intolerance


Question: A 19-year-old woman comes to the physician for a follow-up examination. She has a history of type 1 diabetes mellitus and is compliant with her medications. After reviewing the patient's recent blood sugar levels, the physician changes the patient's antidiabetic regimen by changing the dosage of an insulin that does not produce an observable peak in serum insulin concentration. The dosage of which of the following types of insulin was most likely changed in this patient's medication regimen?

Answer: Insulin glargine

Choices:
A. Insulin glargine
B. Insulin glulisine
C. Regular insulin
D. Insulin lispro
E. NPH insulin


Question: A 31-year-old woman visits her local walk-in clinic for 2 days of dysuria, increased voiding frequency, urgency, and intense suprapubic pain. She just came back a day ago from a short honeymoon trip to Prague. On physical examination, the patient is found with exquisite suprapubic pain. Costovertebral tenderness is absent and pelvic examination is normal. Her vital signs are: temperature 36.5°C (97.7°F), heart rate 78/min, respiratory rate 15/min. Which of the following organisms would be most likely isolated in this patient?

Answer: Staphylococcus saprophyticus

Choices:
A. Streptococcus agalactiae
B. Enterococcus faecalis
C. Proteus mirabilis
D. Klebsiella pneumoniae
E. Staphylococcus saprophyticus


Question: A 14-year-old boy is brought to the physician by his mother because of a 1-week history of fever, fatigue, and throat pain. He appears lethargic. His temperature is 38.5°C (101.3°F). Physical examination shows bilateral cervical lymphadenopathy. Oral examination shows the findings in the photograph. A peripheral blood smear shows lymphocytosis with atypical lymphocytes. A heterophile antibody test is positive. Which of the following is the most appropriate recommendation by the physician?

Answer: Avoid contact sports

Choices:
A. Start oral amoxicillin therapy
B. Start antiretroviral therapy
C. Schedule bone marrow biopsy
D. Avoid contact sports
E. Avoid crowded places


Question: A 62-year-old carpenter presents to your clinic complaining of worsening joint pain in her hands. She states that the pain is present in all of her fingers, but is worse in the right hand and that it gets better when she has a few days off from work. She notes no paresthesias, fever, or fatigue. On examination, the patient is afebrile and all vital signs are stable. She has hard, non-tender lesions overlying the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand and all 5 digits on this hand have a decreased range of motion. An X-ray of her hands is shown. What is the most likely pathogenesis leading to the X-ray findings?

Answer: Repetitive movement injury

Choices:
A. Repetitive movement injury
B. Overgrowth of a gram-positive bacteria
C. Deposition of monosodium urate crystals
D. Genetic predisposition associated with the HLA-B27 gene
E. Production of rheumatoid factor and other autoantibodies


Question: A 7-year-old girl presents to the emergency department with a bloody nose that spontaneously started bleeding 20 minutes ago. On physical examination, she appears well and has no lymphadenopathy. Her heart has a regular rate and rhythm, her lungs are clear to auscultation bilaterally, and her abdomen is soft without hepatosplenomegaly, but she does have petechiae over her lower extremities. A complete blood count is obtained and reveals a leukocyte count of 11,300 cells/mcL, hemoglobin 12.1 g/dL, hematocrit 36%, and platelets 15,000/mcL. A peripheral smear shows a few morphologically normal platelets. Her mother reports that she had a viral infection 2 weeks ago but has been otherwise healthy. Which of the following is the next best step?

Answer: Start intravenous immunoglobulin

Choices:
A. Start intravenous immunoglobulin
B. Give 1 unit of packed erythrocytes
C. Perform a splenectomy
D. Perform a bone marrow aspiration
E. Observation


Question: A 2-year-old boy is brought to the physician by his parents because their son frequently avoids eye contact and has no friends in daycare. He was born at term and has been healthy except for an episode of otitis media 6 months ago. His immunizations are up-to-date. He is at the 95th percentile for height, 20th percentile for weight, and 95th percentile for head circumference. Vital signs are within normal limits. Examination shows elongated facial features and large ears. The patient is shy and does not speak or follow instructions. He continually opens and closes his mother's purse and does not maintain eye contact. Which of the following is the most likely cause of this patient's presentation?

Answer: CGG trinucleotide repeat expansion on X-chromosome

Choices:
A. CGG trinucleotide repeat expansion on X-chromosome
B. Deletion of the long arm on chromosome 7
C. Genomic imprinting on chromosome 15
D. Trisomy
E. An additional X chromosome


Question:
A 78-year-old man is admitted to hospital for treatment of a severe attack of pneumonia he has been experiencing for the past three days. A week earlier, he had been feeling well until he developed what he describes as a mild cold. Over the next few days, he began to have difficulty breathing and developed a productive cough and fever. As his condition worsened despite antibiotic therapy at home, he was admitted for intravenous antibiotics and observation. He has a 50-pack-year history of smoking and has been diagnosed with chronic obstructive pulmonary disease (COPD). Prior to admission, the man was taking inhaled formoterol, budesonide, and oxygen at home. He has been drinking 3 alcoholic drinks daily for the last 60 years and smoked marijuana during his 20s. His lab results from 1 week ago and from his day of admission to hospital are as follows:
7 days ago
On admission to hospital
Serum glucose (random)  130 mg/dL
Serum electrolytes
Sodium 142 mEq/L
Potassium 3.9 mEq/L
Chloride 101 mEq/L
Serum creatinine 0.8 mg/dL
Blood urea nitrogen 9 mg/dL
Cholesterol, total 170 mg/dL
HDL-cholesterol 42 mg/dL
LDL-cholesterol 110 mg/dL
Triglycerides 130 mg/dL
Serum glucose (random)  100 mg/dL
Serum electrolytes
Sodium 140 mEq/L
Potassium 4.0 mEq/L
Chloride 100 mEq/L
Serum creatinine 0.9 mg/dL
Blood urea nitrogen 11 mg/dL
Cholesterol, total 130 mg/dL
HDL-cholesterol 30 mg/dL
LDL-cholesterol 80 mg/dL
Triglycerides 180 mg/dL
What best explains the change in this patient’s lipid profile over this time period?

Answer: Physiological response

Choices:
A. COPD exacerbation
B. Drug side effect
C. Physiological response
D. Pneumonia complication
E. Undiagnosed dyslipidemia


Question: A 42-year-old woman comes to the physician because of a 4-week history of progressive difficulty swallowing solid foods. The patient reports feeling like food gets stuck in her throat, and that she has to drink a lot of water to swallow her meals. Over the past 3 months, she has had progressive fatigue and occasional dyspnea while performing her daily activities. Her pulse is 104/min, respirations are 19/min, and blood pressure is 110/70 mm Hg. Physical examination shows conjunctival pallor, erythema around the corners of the mouth, and dry, scaly lips. Her fingernails appear spoon-shaped and brittle. Auscultation of the heart shows a grade 1/6 systolic murmur best heard at the second left intercostal space. Esophagogastroduodenoscopy shows thin membranes that are protruding into the upper third of the esophagus. Further evaluation of the patient is most likely to show which of the following?

Answer: Craving for non-nutritive substances

Choices:
A. Altered sense of smell
B. Intolerance to cold temperatures
C. Thickening of the skin
D. Eosinophilic infiltration of the esophagus
E. Craving for non-nutritive substances


Question: A 27-year-old nullipara makes an appointment with her gynecologist to discuss the results of her cervical cancer screening. She is not vaccinated against HPV and has a single sexual partner. She and her partner are planning pregnancy, so she recently discontinued oral contraception and began to take folate and iron supplements. She has no history of gynecologic diseases. Her first Pap smear showed atypical squamous cells of undetermined significance, but 2 subsequent Pap smears had normal results. The most recent Pap smear was reported as a high-grade squamous intraepithelial lesion. Colposcopy was performed at the next visit and a biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone. The pathologic assessment shows CIN 3. Which of the following statements regarding the management of this patient is correct?

Answer: Close follow-up with cytology and colposcopy may be considered in this patient.

Choices:
A. Observation of young patients with CIN 3 is preferred because of a high chance of regression.
B. The annual rate of progression of CIN 3 to cancer is > 10%, so the patient should be treated as soon as possible.
C. Close follow-up with cytology and colposcopy may be considered in this patient.
D. Additional HPV testing would be useful to guide the therapy.
E. Pregnancy is not recommended in women with high-grade cervical lesions, so treatment is reasonable.


Question: A 47-year-old woman comes to the physician because of a 3-month history of recurrent episodes of nausea and feeling like the room is spinning. Each episode lasts less than a minute and usually occurs when she gets out of bed in the morning or suddenly turns her head. She has not vomited and does not have headaches. She is asymptomatic between episodes. Which of the following findings most closely correlates with this patient's symptoms?

Answer: Nystagmus

Choices:
A. Intention tremor
B. Nystagmus
C. Binocular diplopia
D. Abnormal Rinne test
E. Orthostatic hypotension


Question: A 56-year-old man is brought to the emergency department by his wife because of increasing confusion and lethargy for the past 12 hours. He is oriented only to person. His temperature is 37.3°C (99.1°F), pulse is 109/min, respirations are 18/min, and blood pressure is 108/67 mm Hg. Examination shows abdominal distention and several erythematous, lacy lesions on the chest that blanch with pressure. His hands make a flapping motion when they are dorsiflexed. Which of the following is the most likely precipitating factor for this patient's symptoms?

Answer: Presence of hemoglobin in the intestine

Choices:
A. Elevated systemic vascular resistance
B. Destruction of gut anaerobes
C. Thiamine pyrophosphate deficiency
D. Presence of hemoglobin in the intestine
E. Low protein consumption


Question: A 63-year-old man comes to the physician because of a 4-hour history of severe pain in the right knee. His temperature is 38.0°C (100.1°F). Examination shows erythema, edema, and warmth of the right knee; range of motion is limited by pain. Arthrocentesis of the knee joint yields cloudy fluid with a leukocyte count of 24,000/mm3 (74% segmented neutrophils). Polarized light microscopy shows needle-shaped, negatively birefringent crystals. Five hours after treatment with a drug is begun, he develops abdominal cramp, diarrhea, and vomiting. The patient was most likely treated with a drug that predominantly acts on which of the following parts of the cell?

Answer: Cytoskeleton

Choices:
A. Cell wall
B. Cytosolic enzyme
C. Nucleus
D. Cytoskeleton
E. Membrane transporter


Question: A 1-year-old boy presents to the emergency department for several days of irritability and poor feeding. His parents are very concerned that he has been acting differently. The patient has an unremarkable past medical history and has been followed by a pediatrician. His temperature is 102°F (38.9°C), blood pressure is 57/38 mmHg, pulse is 170/min, respirations are 35/min, and oxygen saturation is 99% on room air. During the exam the infant is irritable and is crying. Musculoskeletal exam reveals that the patient's knee can not be extended while the patient's hip is in a flexed position without significant patient irritation. Fundoscopy is within normal limits. Abdominal, cardiac, and pulmonary exam are within normal limits. Which of the following is the next best step in management?

Answer: Lumbar puncture

Choices:
A. Blood and urine cultures
B. Head CT
C. Lumbar puncture
D. Vancomycin and ceftriaxone
E. Vancomycin, ceftriaxone, and prednisone


Question: A 74-year-old man comes to the physician because of a 2-month history of shortness of breath and leg swelling. He has trouble climbing one flight of stairs due to dyspnea. He has hypertension and was diagnosed with multiple myeloma 6 months ago. Current medications include hydrochlorothiazide. Cardiopulmonary examination shows jugular venous distention, bibasilar crackles, and pitting edema in the lower extremities. Transthoracic echocardiography shows a thickened myocardium with elevated diastolic filling pressures. Which of the following is the most likely underlying mechanism of this patient's cardiomyopathy?

Answer: Amyloid deposition

Choices:
A. Chronic vasoconstriction
B. Myosin gene mutation
C. Amyloid deposition
D. Chronic hypercalcemia
E. Iron deposition


Question: A 47-year-old man is brought to the emergency department 30 minutes after he was involved in a motor vehicle collision. On arrival, he is unconscious and unresponsive to painful stimuli. His pulse is 120/min, respirations are 10/min, and his blood pressure is 88/60 mm Hg. Infusion of 0.9% saline is begun, and intubation is attempted without success. Pulse oximetry on 20 L/min of oxygen via bag mask shows an oxygen saturation of 78%. The next appropriate step in the management of this patient involves passing a tube through an incision through which of the following structures?

Answer: Investing layer of deep cervical fascia

Choices:
A. Investing layer of deep cervical fascia
B. Annular ligament
C. Cricotracheal ligament
D. Prevertebral layer of deep cervical fascia
E. Thyrohyoid ligament


Question: Parents bring an 11-month-old baby to the clinic because the baby has a fever of 39.0°C (102.2°F). The baby is irritated and crying constantly. She is up to date on immunizations. A complete physical examination reveals no significant findings, and all laboratory tests are negative. Five days after resolution of her fever, she develops a transient maculopapular rash. What is the most likely diagnosis?

Answer: Roseola

Choices:
A. Roseola
B. Erythema infectiosum
C. Rubella
D. Measles
E. Kawasaki disease


Question: A 67-year-old man is brought to his primary care practitioner by his daughter who has noticed a ‘pill-rolling’ tremor in his right hand, along with a progressively slow, shuffling gait. The patient’s daughter says that these symptoms gradually started 2 weeks ago and have progressively worsened. His past medical history is significant for hypertension, which is well-controlled with losartan. He does not take any other medications. Physical examination reveals a slow shuffling gait, difficulty initiating movements, a resting tremor in his right hand that decreases in intensity with voluntary movement, and cogwheel-like rigidity in the right arm. The primary care practitioner decides to prescribe levodopa and carbidopa. Which of the following statements would best explain the mechanism of action of these drugs?

Answer: Increased dopamine synthesis

Choices:
A. Inhibition of the enzyme monoamine oxidase (MAO) B
B. Stimulation of dopamine receptors
C. Blockade of muscarinic receptors
D. Inhibition of dopamine reuptake
E. Increased dopamine synthesis


Question: A 79-year-old man with a long-standing history of hypertension and diabetes presents to the emergency department with sudden-onset of loss of motor function on the left side of his body. Neurologic exam shows normal sensation throughout the body. MRI of the brain is obtained and shows a small sub-cortical infarct involving a perforating vessel. Which of the following is the most likely underlying pathogenesis?

Answer: Lipohyalinosis of small vessels

Choices:
A. Embolism originating from the left atrium
B. Berry aneurysm
C. Lipohyalinosis of small vessels
D. Large vessel thrombosis
E. Fibromuscular dysplasia


Question: A cardiology specialist working in the university hospital center noticed that a large number of his patients who had myocardial infarctions also had some sort of malignancy in their medical history. In order to determine whether a relationship existed between myocardial infarction and malignant processes, he decided to pursue a case-control study. His selected cases consisted of a sample of patients hospitalized in an internal ward with a history of a myocardial infarction, while control cases were patients on the same ward without a history of a myocardial infarction. Their charts and medical documentation were then reviewed for a history of any type of malignancy. The results of the study led the cardiologist to conclude that, for patients with malignancy, the odds of having a myocardial infarction were 3.2 times higher when compared to patients without malignancy. If the cardiologist was aware of Berkson’s bias (also known as the admission rate bias), he could minimize it by which of the following?

Answer: Recruiting the controls from different wards to increase disease variability

Choices:
A. Including the diagnoses negatively related to the risk factor being studied
B. Increasing the number of cases and controls included in the study
C. Excluding controls that present a probability of hospital admission similar to cases
D. Recruiting the controls from different wards to increase disease variability
E. Excluding those patients with preferential recollection of exposures


Question: A 27-year-old woman presents to her primary care physician’s office with fatigue, headaches, and concentration difficulties. Her symptoms began approximately 7 months prior to presentation. Throughout this time, she reports problems with initiating and remaining asleep, has noticed periods of muscle soreness, and has feelings of restlessness. She states that she is very concerned about whether she will be able to pay her monthly expenses and if her parents are satisfied with her career choices. She is also worried about how her colleagues and supervisor think of her performance at work. She denies any significant past medical history besides occasional palpitations. She takes a daily multivitamin. Family history is significant for panic disorder in her mother. She currently lives alone and at times socializes with friends. She occasionally drinks alcohol during social gatherings, does not smoke, and denies any illicit drug use. Her temperature is 99°F (37.2 °C), blood pressure is 110/75, pulse is 101/min, and respirations are 18/min. Physical examination is unremarkable. Which of the following is the most appropriate pharmacologic treatment for this patient?

Answer: Buspirone

Choices:
A. Buspirone
B. Imipramine
C. Mirtazapine
D. Olanzapine
E. Trazodone


Question:
A 73-year-old man comes in to the emergency department because of nausea and severe pain in his upper abdomen and right shoulder blade for the past day. He was able to eat a little for breakfast but vomited up the meal a couple of hours later. He has type 2 diabetes mellitus treated with metformin. He has smoked half a pack of cigarettes daily for 40 years and drinks 4 beers every week. He appears acutely distressed. His temperature is 38.8°C (102°F), pulse is 124/min, and blood pressure is 92/68 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. The abdomen is soft and there is tenderness to palpation of the right upper quadrant with soft crepitus. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 14.3 g/dL
Leukocyte count 18,100/mm3
Platelet count 216,000/mm3
Serum
Aspartate aminotransferase (AST, SGOT) 41 U/L
Alanine aminotransferase (ALT, SGPT) 19 U/L
Alkaline phosphatase 110 U/L
Total bilirubin 0.9 mg/dL
Direct bilirubin 0.2 mg/dL
Albumin 4.1 g/dL
Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen. Which of the following is the most likely diagnosis?"

Answer: Emphysematous cholecystitis

Choices:
A. Chronic pancreatitis with pseudocyst rupture
B. Emphysematous cholecystitis
C. Gallstone ileus
D. Perforated duodenal ulcer
E. Primary sclerosing cholangitis


Question: A 26-year-old man presented with a headache and fatigue for the past few months. On presentation to the clinic, the blood pressure is 190/110 mm Hg; the femoral pulse is reduced compared to the radial pulse, and an ejection click is heard. There was no murmur. Which of the following is associated with his condition?

Answer: Coarctation of the aorta

Choices:
A. Mitral valve regurgitation
B. Ventricular septal defect (VSD)
C. Wolff-Parkinson-White syndrome
D. Coarctation of the aorta
E. Atrial septal defect (ASD)


Question: A 57-year-old man with a history of diabetes and stage 3 chronic kidney disease is admitted to the hospital for elective coronary angiography. The senior resident admitting the patient to the ward is concerned about his chronic renal impairment and the scheduled angiography, which will require the use of intravenous contrast. Which of the following strategies is most likely to decrease the likelihood that the procedure will exacerbate the patient’s renal failure?

Answer: Use non-iodinated contrast medium

Choices:
A. Intravenous mannitol before and during the procedure
B. Intravenous N-acetyl cysteine before and during the procedure
C. Hemodialysis immediately after the procedure
D. Use non-iodinated contrast medium
E. Forced diuresis with furosemide


Question: A 17-year-old girl is brought in a wheelchair because of gradually progressive difficulty in walking, incoordination, and frequent falls. Her symptoms started at 9 years old with clumsiness while walking. She later experienced difficulties with coordination, which later involved her arms and trunk. She was born at term with normal developmental milestones. The physical examination reveals severely ataxic gait, nystagmus, absent deep tendon reflexes, and loss of vibration and proprioception. Presuming it is an inherited condition, what is the most likely genetic pathophysiology of this disorder?

Answer: GAA trinucleotide repeats

Choices:
A. Dystrophin gene mutation
B. GAA trinucleotide repeats
C. Mitochondrial DNA mutation
D. NOTCH3 mutation
E. PMP22 gene duplication


Question: A previously healthy 51-year-old man is brought to the emergency department because of confusion for 2 hours. His wife reports that he fell and hit his head while changing a ceiling light the previous evening. On arrival, he is unconscious. His temperature is 37.1°C (98.8°F), pulse is 54/min, respirations are 8/min and irregular, and blood pressure is 198/106 mm Hg. The right pupil is dilated and fixed; the left pupil is round and reactive to light. There is extension of the extremities to painful stimuli. He is intubated and mechanically ventilated. A mannitol infusion is begun. A noncontrast CT scan of the brain shows herniation of the right medial temporal lobe. Which of the following is the most likely additional finding in this patient?

Answer: Right-sided hemiplegia

Choices:
A. Right-sided hemiplegia
B. Left-side facial nerve palsy
C. Bilateral spasticity
D. Multifocal myoclonus
E. Right eye esotropia and elevation


Question: A 1-year-old female presents to the emergency department with 2 days of fever up to 103ºF. During the course of her work-up, a urine culture reveals gram negative rods and a urinary tract infection (UTI) is diagnosed. She is placed on ceftriaxone and quickly defervesces. Follow-up of the urine culture reveals the causal bacteria was E. coli, without any concerning resistance patterns and was susceptible to ceftriaxone. This is her first UTI and there is no family history of renal abnormalities or vesicourethral reflux. In addition to her current therapy, what additional steps should be taken during the management of this child's UTI?

Answer: Renal bladder ultrasound

Choices:
A. Prophylactic antibiotic therapy to prevent future UTIs
B. Voiding cystourethrogram
C. Renal bladder ultrasound
D. Repeat urine culture
E. Renal scintigraphy


Question: A 22-year-old woman presents to her primary care physician because she has been having severe pruritus on her left leg. She says the symptoms started 1 week ago after she went on a hiking trip with her friends. She wore shorts during the hike and felt as if something brushed her skin on the front of her leg just below the knee. She has no past medical history and no family history of autoimmune diseases. On physical exam, she has red pruritic papules and vesicles on her left leg. Which of the following mechanisms was most likely involved in the development of this patient's symptoms?

Answer: Cytotoxicity due to T-cells

Choices:
A. Activation of cell surface receptors by antibodies
B. Cross-linking of IgE antibodies
C. Cytotoxicity due to antibodies
D. Cytotoxicity due to T-cells
E. Immune complex deposition