Question: A 26-year-old man presents with a 6-month history of headaches. Over the past 6 months, he has developed headaches that are 4/10 in intensity and occur every other day for 1–2 hours. The headaches are bilateral and feel like a ‘band is squeezing his head’. He denies photophobia, phonophobia, nausea, and vomiting. He has had no visual loss or photopsia. No significant past medical history. He is an avid weightlifter and works at a moving company, where he is constantly lifting heavy items. Additionally, he recently got his 21-year-old girlfriend and his other 23-year-old girlfriend pregnant, which he says is causing a lot of stress. Physical examination is unremarkable. Which of the following is the next best step in the management of this patient?

Answer: Ibuprofen

Choices:
A. Amitriptyline
B. Magnetic resonance image (MRI) of the head
C. Ophthalmologic evaluation
D. Ibuprofen
E. Sumatriptan


Question: A histologic section is obtained from the central canal of the spinal cord. A special stain is used to identify a specific glial cell that makes up the lining of the central canal and ventricles in the central nervous system. Which of the following best describes the primary function that the cells highlighted in blue serve?

Answer: Production and circulation of CSF

Choices:
A. Maintenance of the blood brain barrier
B. Production and circulation of CSF
C. Protective membrane surrounding spinal cord
D. Conduct voluntary muscle action potentials
E. Increasing action potential conduction velocity


Question: A 58-year-old man presents to the emergency department with a 4-hour history of severe abdominal pain. He has noted brief episodes of postprandial abdominal pain for the last 2 months, but this pain is much more severe and diffuse. He also reports nausea and has had several episodes of non-bloody, non-bilious emesis since the pain started. Past medical history is notable for hyperlipidemia diagnosed 10 years ago and managed with lifestyle modifications; he has never been hospitalized. Vital signs are unremarkable. Physical examination shows dry mucous membranes and a soft, non-distended abdomen that is diffusely tender. Laboratory tests are notable for a lipase level of 3,125 U/L. CT of the abdomen shows an enlarged gallbladder and peripancreatic fluid with dilation of the pancreatic and common bile ducts. Which of the following is the best next step in the management of this patient?

Answer: Endoscopic retrograde cholangiopancreatography (ERCP)

Choices:
A. Cholecystectomy
B. Colonoscopy
C. Endoscopic retrograde cholangiopancreatography (ERCP)
D. Esophagogastroduodenoscopy (EGD)
E. Nasogastric tube placement


Question: A 55-year-old man presents to his primary care physician for his annual check-up. He says that he has generally been feeling well; however, he has noticed that he has had some intermittent very low grade fevers of unknown etiology. His past medical history is significant for well-controlled hypertension and diabetes. On physical exam he is found to have painless enlargement of a number of cervical and axillary lymph nodes. A biopsy of the enlarged nodes is obtained and genetic testing shows that part of chromosomes 14 and 18 are joined together. Which of the following would most likely be observed in cells with this genetic change?

Answer: Decreased release of cytochrome c

Choices:
A. Decreased activation of CD95
B. Decreased activity of p53
C. Decreased release of cytochrome c
D. Increased activation of Apaf-1
E. Increased activation of FADD


Question: A 75-year-old man is brought to the emergency room because of dizziness and palpitations for the past hour. His pulse is 185/min and blood pressure is 100/52 mm Hg. An ECG shows a narrow-complex, regular tachycardia without P waves. A drug is administered that activates cardiac potassium channels and causes transient atrioventricular block. Which of the following adverse effects is most likely to occur?

Answer: Chest pain

Choices:
A. Sedation
B. Chest pain
C. Dry cough
D. Perioral paresthesia
E. Yellow vision


Question: A 70-year-old man is brought to the emergency department with painful discharge from his right ear with difficulty hearing for 3 days. His temperature is 39.5°C (103.1°F) and pulse is 120/minute. Physical examination shows mild facial asymmetry with the right corner of his mouth lagging behind the left when the patient smiles. There is severe ear pain when the right auricle is pulled superiorly. Otoscopic examination shows granulation tissue at the transition between the cartilaginous and the osseous part of the ear canal. Which of the following is most likely associated with this patient's condition?

Answer: Glucose intolerance

Choices:
A. Invasive tumor of external auditory canal
B. Decreased intracranial perfusion
C. Glucose intolerance
D. Pus-filled mastoid air cells
E. Positive streptococcal culture


Question: A 24-year-old female with a history of recurrent infections, bipolar disorder, and no prenatal care gives birth to a male infant. On physical exam in the delivery room, you observe a tuft of hair over the infant's lumbosacral region. Which of the following drugs was this mother most likely taking during pregnancy?

Answer: Valproate

Choices:
A. Chloramphenicol
B. Gentamicin
C. Lithium
D. Valproate
E. Folic acid


Question: A 25-year-old woman presents to the physician with the complaint of several episodes of headache in the past 4 weeks that are affecting her school performance. The episodes are getting progressively worse, and over-the-counter headache and migraine medication do not seem to help. She also mentions having to raise her head each time to look at the board when taking notes; she cannot simply glance up with just her eyes while facing her notes. She has no significant past medical or family history and was otherwise well prior to this visit. Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema. What structure is most likely to be affected by this patient's condition?

Answer: Aqueduct of Sylvius

Choices:
A. Third ventricle
B. Aqueduct of Sylvius
C. Tegmentum
D. Corpora quadrigemina
E. Inferior colliculi


Question: A 75-year-old woman is brought to the emergency department because of a 6-hour history of severe headache, nausea, and 1 episode of vomiting. On arrival, she is lethargic and oriented only to self. Her pulse is 50/min, respirations are 8/min and shallow, and blood pressure is 150/96 mm Hg. Examination shows medial deviation of the left globe and ecchymoses of the upper eyelids. Appropriate pharmacotherapy with an intravenous drug is initiated, and the patient's urine output subsequently increases. The patient is at greatest risk of which of the following adverse effects?

Answer: Pulmonary edema

Choices:
A. Drug-induced hypersensitivity syndrome
B. Hyperuricemia
C. Tinnitus
D. Increased intraocular pressure
E. Pulmonary edema


Question: A 31-year-old gravida 2 para 2 woman presents to her primary care physician for follow up. Two weeks ago, she gave birth via vaginal delivery to a 9.5 lb (4.3 kg) male infant. The delivery was complicated by a vaginal laceration that required extensive suturing once the infant was delivered. Immediately after delivery of the placenta she experienced intense shaking and chills that resolved within 1 hour. She has felt well since the delivery but admits to 6 days of malodorous smelling vaginal discharge that is tan in color. She has a history of vaginal candidiasis and is worried that it may be recurring. Her temperature is 98.8°F (37.1°C), blood pressure is 122/73 mmHg, pulse is 88/min, respirations are 16/min, and BMI is 33 kg/m^2. Speculum exam reveals a 1.5 cm dark red, velvety lesion on the posterior vaginal wall with a tan discharge. The pH of the discharge is 6.4. Which of the following is the most likely diagnosis?

Answer: Rectovaginal fistula

Choices:
A. Bacterial vaginosis
B. Endometritis
C. Rectovaginal fistula
D. Vaginal melanoma
E. Vesicovaginal fistula


Question: A 50-year-old male presents to the emergency room after getting hit by a car while biking. He complains of severe pain in both thighs. His thighs appear swollen, bruised, and angulated. Radiographic imaging demonstrates bilateral femoral shaft fractures. He subsequently undergoes surgical fixation of his fractures. Initially he has an uneventful post-operative course; however, on post-op day 4 he becomes confused and develops chest pain, tachypnea, and dyspnea. A new petechial rash is seen over his chest and neck. Electrocardiogram reveals normal sinus rhythm. Which of the following is the most likely cause of this patient’s respiratory symptoms?

Answer: Occlusion of the pulmonary vessels by fat globules

Choices:
A. Lobar lung consolidation
B. Aspiration of stomach contents
C. Occlusion of the left anterior descending artery
D. Occlusion of the pulmonary vessels by fat globules
E. Spontaneous pneumothorax


Question: A group of researchers is conducting a study to assess the validity and reliability of patient history in determining the amount and duration of drug abuse. In this study, 60 subjects with hepatitis were asked details of their history of drug abuse, such as the duration of drug abstinence, the amount and duration of drug abuse, and the treatment history. Additionally, a source close to or related to each of the study subjects (most often a spouse) was asked similar questions about the subject by a second researcher who was blinded to the subject’s drug abuse history. Results revealed that the duration of drug abstinence correlated highly between subjects and the source (Spearman’s r = 0.94, p-value < 0.001), as did the individual's score on the stimulant relapse risk scale (SRRS, Spearman’s r = 0.74, p-value < 0.001), a ranked metric of relapse risk. Which of the following statements regarding this results of this study is true?

Answer: Spearman’s correlation coefficient reveals a strong association between the SRRS scores, as assessed by the study subject and their related source.

Choices:
A. Spearman’s rank correlation coefficient was used for these data because both of the variables were normally distributed.
B. If the authors had conducted a study on larger sample size, Pearson’s correlation coefficient for these data would have been calculated.
C. There is a linear relationship between the duration of drug abstinence as assessed by the subject and their close/related source.
D. Spearman’s correlation coefficient reveals a strong association between the SRRS scores, as assessed by the study subject and their related source.
E. We can conclude that 88.4% (= 0.94 x 0.94) of the variability in the duration of drug abstinence (as assessed by the study subjects) can be 'explained' by the variability in the duration of drug abstinence as assessed by their sources.


Question: A 27-year-old man comes to the emergency department for progressive weakness and numbness in his legs for 5 days. Symptoms originally started with tingling in both feet and have progressed to involve the knees and hips; he is currently unable to walk without assistance. Two weeks ago, the patient had diarrhea that subsided without antibiotics. Neurologic examination shows weakness, decreased sensation, and absent patellar reflexes in both lower extremities. Lumbar puncture shows elevated CSF protein and no white blood cells. Which of the following structures is most likely affected in this patient?

Answer: Schwann cells

Choices:
A. Postsynaptic acetylcholine receptors
B. Muscle endomysium
C. Schwann cells
D. Presynaptic terminals of cholinergic neurons
E. Cerebral white matter


Question: A 23-year-old man presents to the emergency department presenting with sudden-onset dyspnea and left-sided chest pain over the last hour. This event started when he was in class sitting for an exam. He reports that the pain is worse with inspiration and does not radiate. He says he has anxiety and takes alprazolam as needed. He smokes half a pack of cigarettes a day and drinks alcohol socially. The temperature is 36.7°C (98.0°F), the blood pressure is 130/80 mm Hg, the pulse is 82/min, and the respiratory rate is 14/min. Pulse oximetry shows 97% on room air. The patient’s weight is 63.5 kg (140 lb), height is 185 cm (6 ft 1 in), and he has a BMI of 18.5 kg/m2. A chest X-ray is taken (see exhibit). After an hour of supplemental oxygen, rest, and careful monitoring his dyspnea improves and chest pain resolves without medication. Which of the following is the most appropriate further management of this patient?

Answer: Supplemental oxygen

Choices:
A. Needle thoracostomy
B. IV antibiotics
C. Supplemental oxygen
D. CT angiogram of chest
E. Lorazepam and follow-up with psychiatry


Question:
A 36-year-old male is brought to the emergency department by fire and rescue after being found down in his apartment by his wife. His wife reports that the patient had been complaining of chest pain for the last few hours but refused to go to the hospital. She went to the grocery store for about half an hour and found her husband unresponsive on the ground when she returned home. The patient’s wife reports that his past medical history is significant for a “heart murmur” and that the patient’s father died at age 32 for unknown reasons. In the trauma bay, the patient’s temperature is 98.8°F (37.1°C), blood pressure is 88/41 mmHg, pulse is 116/min, and respirations are 12/min. On physical exam, the patient has a Glascow Coma Score (GCS) of 7. He has a tall stature with long limbs and long, slender fingers. He is also noted to have a pectus deformity. On cardiac exam, the patient has a diastolic decrescendo murmur at the left third intercostal space. He has weak brachial and femoral pulses.

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

Answer: Spontaneous separation in the arterial wall

Choices:
A. Coronary atherosclerosis
B. Hypertrophic cardiomyopathy
C. Spontaneous rupture of the aorta
D. Spontaneous rupture of the mitral chordae tendinae
E. Spontaneous separation in the arterial wall


Question: A 44-year-old man comes to the physician because of severe lower back pain for 1 week. He has also had fatigue, weight gain, and episodic headaches during the past 3 months. He has no history of serious illness and takes no medications. His pulse is 88/min and blood pressure is 155/102 mm Hg. Physical examination shows facial plethora and truncal obesity. The skin appears stretched, with multiple ecchymotic patches over the upper and lower extremities bilaterally. Cardiopulmonary examination shows no abnormalities. There are bilateral paravertebral muscle spasms and severe tenderness over the second lumbar vertebra. An x-ray of the lumbar spine shows decreased bone density and a compression fracture of the L2 vertebra. Further evaluation of this patient is most likely to show which of the following findings?

Answer: T-wave flattening on ECG

Choices:
A. Nuchal muscle hypertrophy
B. Low serum glucose levels
C. Suprasellar mass on cranial MRI
D. T-wave flattening on ECG
E. Positive Chvostek sign


Question: Two weeks after undergoing coronary artery bypass surgery for acute myocardial infarction, a 62-year-old man comes to the physician because of a 4-day history of fever, stabbing chest pain, and fatigue. Initially the pain was only present when he was lying supine, but now it is present all the time and only subsides when he is leaning forward. He has hypertension and mild mitral regurgitation. He has smoked one pack of cigarettes daily for 44 years but quit prior to surgery. Current medications include aspirin, clopidogrel, metoprolol, captopril, and atorvastatin. His temperature is 38.3°C (102°F), pulse is 84/min and regular, respirations are 16/min, and blood pressure is 132/86 mm Hg. During inspiration the blood pressure drops to 117/80 mm Hg. On physical examination there are jugular venous pulsations 4 cm above the sternal angle. Heart sounds are faint. There is 2+ edema in the lower extremities. Which of the following is the most likely cause of this patient's symptoms?

Answer: Decreased left ventricular diastolic filling

Choices:
A. Increase in mean aortic pressure
B. Left ventricular volume overload
C. Decreased left ventricular diastolic filling
D. Supraventricular arrhythmia
E.
Decreased right ventricular contractility
"


Question: A 28-year-old woman comes to the physician with her mother because of a 1-week history of feeling unusually energetic. The mother describes her state as “hyper” and reports that she often paces around her room. During this period, the patient has not slept. She had similar episodes 2 months and 5 months ago. The mother also states that, for the past 8 months, the patient has believed she is a famous singer and is going on a world tour next year. The patient does not have a partner and has only a few friends. She was working as a dental technician until 6 months ago, when she started to hear voices telling her to quit. She has not held a job since then. She does not use illicit drugs. Vital signs are within normal limits. Physical and neurological examinations show no abnormalities. On mental status examination, her speech is pressured, but she suddenly stops talking in the middle of sentences and does not finish them. She occasionally directs her attention to empty corners in the room, as if she were listening to someone. Which of the following is the most likely diagnosis?

Answer: Schizoaffective disorder

Choices:
A. Schizoaffective disorder
B. Schizotypal personality disorder
C. Schizophrenia
D. Delusional disorder
E. Mood disorder with psychotic features


Question: A 4-year-old boy presents the pediatrician with his parents for a consultation after his school teacher complained about his abnormal behavior and his inability to make friends in school. They mention that the boy does not interact well with others at home, school, or daycare. On physical examination, his vital signs are stable with normal weight, height, and head circumference for his age and sex. His general examination and systemic examination, including neurologic examination, are completely normal. His recent audiologic evaluation shows normal hearing, and intellectual disability has been ruled out by a clinical psychologist. Which of the following investigations is indicated as part of his diagnostic evaluation at present?

Answer: No further testing is needed

Choices:
A. Magnetic Resonance Imaging (MRI) of brain
B. Positron Emission Tomography (SPECT) Scanning of head
C. Electroencephalography
D. Genetic testing for in MECP2 gene mutations
E. No further testing is needed


Question: A 57-year-old man comes to the physician because of a 5-day history of fever, joint pain, malaise, and a diffuse rash. Two months ago, he was diagnosed with latent tuberculosis and the appropriate treatment was administered. Examination shows a scaly, maculopapular rash over the chest, arms, and back. Which of the following is the most likely explanation for this patient's current condition?

Answer: Decreased acetyltransferase activity

Choices:
A. Decreased pyridoxal kinase activity
B. Decreased acetaldehyde dehydrogenase activity
C. Decreased acetyltransferase activity
D. Decreased cytochrome p450 activity
E. Decreased glucose-6-phosphate dehydrogenase activity


Question: A 40-hour-old baby girl is being evaluated for failure to pass meconium. She is the product of a full-term vaginal delivery to a G2P2 36-year-old mother. The pregnancy was uncomplicated, and the only medication that the mother took was a prenatal vitamin. The baby has been exclusively breastfed, and she has an adequate latch. On physical examination, the newborn’s abdomen is distended and on digital rectal examination, reveals that the rectum is empty. What is the most likely additional finding?

Answer: Absence of ganglion cells in the submucosal plexus on suction biopsy of the rectum

Choices:
A. Absence of ganglion cells in the submucosal plexus on suction biopsy of the rectum
B. Acid-producing mucosa visualized in a technetium scan
C. Presence of IgA anti-endomysial antibody
D. Abdominal ultrasound showing bowel-within-bowel
E. Inability to pass a 10-French catheter from the mouth into the stomach


Question: A 65-year-old man presents to the physician with a low-grade fever, fatigue, and anorexia for the past 10 days. The patient denies any chest pain, cough, or shortness of breath. He has been a smoker for the last 10 years and consumes alcohol occasionally. His past medical history is significant for colorectal carcinoma. His temperature is 38.3°C (101.0°F), the blood pressure is 130/90 mm Hg, and the pulse is 100/min. Physical examination shows reddish-brown spots under his nail bed (as shown in the exhibit) and tender erythematous fingers tips. Cardiac auscultation reveals a new holosystolic murmur best heard at the apex with no radiation. Chest X-ray, electrocardiogram, and urinalysis are normal. Which of the following is the best next step in diagnosing this patient’s condition?

Answer: Obtain blood samples for blood culture

Choices:
A. Obtain anti-CCP antibody titers
B. Echocardiography
C. Obtain blood samples for blood culture
D. Initiate empiric antibiotics
E. Reassurance and symptomatic management


Question: A 27-year-old man presents for followup 3 months after starting an antiretroviral regimen consisting of efavirenz, tenofovir, and emtricitabine. Labs drawn just prior to presentation reveal an undetectable viral load and a T-lymphocyte count of 317/mm^3. By comparison, his viral load was 6100/mL and his T-lymphocyte count was 146/mm^3 at the time of treatment initiation. He reports that he is tolerating the medications well and is not experiencing any major side effects. Which of the following treatment regimens should be recommended for this patient given the fully suppressed viral load?

Answer: Continue current regimen of efavirenz, tenofovir, and emtricitabine

Choices:
A. Continue current regimen of efavirenz, tenofovir, and emtricitabine
B. Continue efavirenz and emtricitabine but discontinue tenofovir
C. Continue efavirenz and tenofovir but discontinue emtricitabine
D. Continue tenofovir and emtricitabine but discontinue efavirenz
E. Discontinue efavirenz, tenofovir, and emtricitabine


Question: A 60-year-old male painter with severe chest pain is found to have atherosclerosis of his coronary arteries. What type of cells were most likely injured in the initial stage of his disease?

Answer: Endothelial cells

Choices:
A. Myocytes
B. Fibroblasts
C. Neutrophils
D. Endothelial cells
E. Smooth muscle cells


Question: A 27-year-old woman, gravida 1, at 26 weeks gestation presents to the physician during a prenatal visit. She feels well. Her pregnancy has been uncomplicated. Her initial laboratory tests at 8 weeks confirmed her blood type as B-. Her partner is blood type A+. At the clinic, her temperature is 37.2°C (99.0°F), and blood pressure is 108/60 mm Hg. Pelvic examination shows a uterus consistent in size with a 24-week gestation. Fetal heartbeats are normal. A sample of blood is collected for blood type screening and verification. Regarding Rh D immunoglobulin (RhoGam) administration, the most appropriate next step is which of the following?

Answer: At 28 weeks gestation if anti-D screen is negative

Choices:
A. At 28 weeks gestation if anti-D screen is negative
B. At 28 weeks gestation if anti-D screen is positive
C. Within 72 hours after birth if anti-D screen is negative
D. Within 72 hours after birth if anti-D screen is positive
E. Rh D immunoglobulin (RhoGam) is not required in this patient regardless of test results


Question: A 32-year-old obese man visits your dermatology clinic after his barber saw a darkened area on the back of his neck. He has not seen his primary care physician in many years and does not know if he has diabetes. A rapid blood glucose test showed a normal glucose level. Otherwise, he reports recent loss of appetite with slight weight loss. What could be causing this patient’s newly-discovered dermatologic change?

Answer: Gastric adenocarcinoma

Choices:
A. Hypothyroidism
B. Gastric adenocarcinoma
C. Diabetes insipidus
D. Diabetes mellitus
E. Barrett’s esophagus


Question: A 59-year-old man comes to the physician because of a 6-month history of progressive blurry vision in both eyes. His vision has not improved with the use of reading glasses. His blood pressure is 155/98 mm Hg. Physical examination shows his visual acuity to be 20/80 in the right eye and 20/60 in the left eye. A photograph of the fundoscopic examination of the right eye is shown. Which of the following is the most likely cause of this patient's symptoms?

Answer:
Diabetic retinopathy
"

Choices:
A. Retinal detachment
B. Idiopathic intracranial hypertension
C. Open-angle glaucoma
D. Central retinal artery occlusion
E.
Diabetic retinopathy
"


Question: A 16-year-old high school cheerleader is brought by her mother to the emergency department after falling on her back during a stunt. She strongly believes that the accident happened because the team couldn’t catch her ‘enormous and bloated’ body. Lately, she has been in a lot of stress as dance regionals are coming up soon and she wants to lose 6.8 kg (15 lb). She is also experiencing intermittent palpitations and dizziness, even during rest. The physical examination reveals a slender girl with bilateral swelling on her cheeks and abrasions on the dorsum of her right hand. When her mother left the room, she admitted to taking furosemide that she found in the medicine cabinet. The vital signs include: temperature 36.2°C (97.2°F), blood pressure 90/60 mm Hg, pulse rate 50/min, respiratory rate 12/min, height 162 cm (5 ft 4 in), and weight 40.9 kg (90 lb). A magnetic resonance image (MRI) of the thoracic spine shows a vertebral compression fracture. She is refusing to eat anything but ice. What is the most appropriate next step in the management of this patient’s symptoms?

Answer: Admit and start parenteral nutrition

Choices:
A. Admit and start parenteral nutrition
B. Stabilize the fracture with a brace and discharge patient
C. Switch furosemide to hydrochlorothiazide
D. Start bisphosphonates
E. Refer to psychiatrist for outpatient cognitive behavioral therapy


Question: A 44-year-old man presents to an oncologist after being diagnosed with small cell lung carcinoma confirmed with a biopsy last week. He worked as a plant technician in the metal processing unit at a factory for the last 14 years. Family history is unremarkable. It is concluded that this cancer is most likely mediated by mutations triggered by chronic chemical exposure at his work. Which of the following enzymes is primarily inhibited at the biochemical level by the chemical agent responsible for this patient’s condition?

Answer: Pyruvate dehydrogenase

Choices:
A. Pyruvate dehydrogenase
B. Phosphofructokinase
C. Dihydrofolate reductase
D. Glucose-6-phosphate dehydrogenase
E. Aconitase


Question: A 41-year-old woman presents to the emergency room with a 2-day history of flank pain, nausea, and vomiting. She denies any urinary frequency or urgency and denies any recent changes in her diet. Her temperature is 100.4°F (38°C), blood pressure is 152/96 mmHg, and pulse is 104/min. On physical exam, there is bilateral flank tenderness to palpation. In addition, neurologic testing reveals decreased strength in her left upper extremity and an inability to sustain lateral gaze with her right eye. An electrocardiogram reveals an irregularly irregular heart rhythm. Which of the following is associated with the most likely cause of this patient's symptoms?

Answer: Hereditary thrombophilia

Choices:
A. Drug allergy
B. Hereditary thrombophilia
C. Hypertension
D. Placental abruption
E. Streptococcus infection


Question: A 20-year-old African American woman comes to the clinic after missing her last two periods. Her cycles are usually regular, occurring at 28-32 day intervals with moderate bleeding and some abdominal discomfort. She also complains of occasional diffuse and generalized headaches. She is a college student and works part-time as a bartender. Past medical history is insignificant. Blood pressure is 110/70 mm Hg, pulse rate is 80 /min, respiratory rate is 14 /min, and temperature is 36.5°C (97.7°F). Physical examination is significant for mild breast tenderness and some secretions from the nipple area. Urine pregnancy test is negative. Which of the following is the best initial step in her management?

Answer: Serum prolactin levels

Choices:
A. MRI brain
B. Serum prolactin levels
C. LH/FSH ratio
D. Ultrasound of abdomen and pelvis
E. Dopamine agonists


Question: A 25-year-old man comes to the physician because he and his wife have been unable to conceive a child despite having regular unprotected sexual intercourse. He is 187 cm (6 ft 1 in) tall and weighs 79 kg (174 lb). Examination shows long extremities, bilateral gynecomastia, and small, firm testes. A peripheral blood smear shows a dense, dark-staining spot at the periphery of the nucleus of a cell. Which of the following is the most likely explanation for the finding on this patient's peripheral blood smear?

Answer: Methylation of cytosine nucleotides

Choices:
A. Acetylation of histone lysine residues
B. Impaired removal of RBC nuclei remnants
C. Methylation of cytosine nucleotides
D. Aggregation of ribosomes
E. Precipitation of oxidized hemoglobin


Question: A 22-year-old woman college student presents with diarrhea and crampy abdominal pain that is relieved by defecation. She states that she has had a lot of ‘stomach issues’ in the past, especially during exam weeks. The past medical history is significant for major depressive disorder diagnosed 2 years ago that has been managed with Prozac. She does not have a family history of irritable bowel disease, autoimmune disease, or cancer. The symptoms do not seem to be worse with any particular food, though she admits to eating a lot of pizza and deli sandwiches with minimal fruits and vegetables. She denies recent travel and has not experienced fever, weight loss, nausea, or vomiting. She has not noticed blood in her stool. The physical exam and laboratory findings are unremarkable. Which of the following is a diagnostic criteria for the disorder that is most likely responsible for the patient’s presentation?

Answer: Symptoms present at least 1 day per week for 3 consecutive months with symptom onset at least 6 months before diagnosis

Choices:
A. Symptoms present at least 6 months
B. Symptoms not relieved with defecation
C. No change in stool frequency
D. Symptoms present at least 1 day per week for 3 consecutive months with symptom onset at least 6 months before diagnosis
E. No change in stool consistency


Question: A 69-year-old female presents to the emergency department with crampy abdominal pain. She has a past medical history of hypertension, dyslipidemia, and cholelithiasis status post cholecystectomy. The patient states she has not passed stool or gas for 48 hrs. On physical exam vitals are T 98.4 F HR 105 bpm BP 155/101 mmHg RR 16 SpO2 96%, abdominal exam is notable for distension, tympany to percussion, and tenderness to palpation without rebound or guarding. Which of the following findings are most likely on radiograph?

Answer: Ladder-like series of distended bowel loops with air-fluid levels on abdominal radiograph

Choices:
A. Free air under the diaphragm on upright abdominal radiograph
B. Apple core defect after lower GI series
C. Multiple punctate mucosal outpouchings through the serosa on lower GI series
D. Ladder-like series of distended bowel loops with air-fluid levels on abdominal radiograph
E. Loss of haustral markings and "lead pipe" appearance to the descending colon on lower GI series


Question: A 56-year-old man comes to the physician because of a 2-month history of worsening pain in his left buttock. The pain is described as a deep, dull ache that is worse at night. He does not report any recent trauma. He has hyperlipidemia. He has smoked one pack of cigarettes daily for the past 30 years and drinks one beer every night. He does not use illicit drugs. His only medication is simvastatin. Physical examination shows tenderness over the left gluteal region. Neurologic examination shows no focal findings. An x-ray of the pelvis shows a 4-cm, poorly defined, osteolytic lesion in the left ilium with a moth-eaten pattern of bone destruction, multiple well-defined sclerotic lesions, and an aggressive periosteal reaction. The remainder of the physical examination, including rectal examination, shows no abnormalities. Chest x-ray and abdominal ultrasonography show no abnormalities. Which of the following is the most likely diagnosis?

Answer: Chondrosarcoma

Choices:
A. Giant cell tumor
B. Fibrosarcoma
C. Plasmacytoma
D. Osteochondroma
E. Chondrosarcoma


Question: An otherwise healthy 49-year-old man comes to the physician because of a 1-month history of worsening headaches and increasing irritability. Examination shows bilateral papilledema. An MRI of the brain shows a mass in the right temporal lobe with heterogeneous peripheral rim enhancement that crosses the midline. He undergoes surgical resection of the mass. Gross examination shows a poorly-demarcated mass with areas of hemorrhage and necrosis. Microscopic examination of the mass will most likely show which of the following?

Answer: Pleomorphic cells forming pseudopalisades

Choices:
A. Closely-packed capillaries and foamy stromal cells
B. Pleomorphic cells forming pseudopalisades
C. Cells with clear cytoplasm and central round nuclei
D. Small blue cells arranged in rosettes
E. Areas of lamellated calcification


Question: A male newborn develops hyperammonemia, encephalopathy, and respiratory alkalosis 3 days after a normal delivery. He enters into a coma the next day and dies a week later. Family history is positive for parental consanguinity. Histopathologic examination of the liver shows diffuse microvesicular steatosis, distinct focal hepatocellular fibrosis, and Kupffer cell glycogenosis. Citrulline levels are low. What enzyme is most likely deficient in this patient’s case?

Answer: Carbamoyl phosphate synthetase I

Choices:
A. Carbamoyl phosphate synthetase I
B. Cystathionine synthase deficiency
C. Homogentisic acid dioxygenase
D. Ornithine transcarbamylase
E. Propionyl-CoA carboxylase


Question: A 48-year-old woman is brought to the emergency department immediately following a motor vehicle accident in an unconscious state. She is managed as per emergency treatment protocols with the airway, breathing, and circulation being appropriately managed by mechanical ventilation, intravenous fluids, and other supportive drugs. A complete diagnostic evaluation suggests a diagnosis of traumatic brain injury and rules out the presence of fractures and other visceral injuries. About 36 hours after the accident, pulse oximetry shows deteriorating oxygen saturation. Chest auscultation reveals widespread rales over bilateral lung fields. Her arterial blood gas analysis shows a PaO2 of 100 mm Hg at FiO2 of 60%. Her bedside echocardiogram is normal and suggests a pulmonary capillary wedge pressure of 11 mm Hg. Which of the following signs is most likely to be present in her chest radiogram?

Answer: Bilateral asymmetric pulmonary infiltrates with peripheral distribution

Choices:
A. Deep sulcus sign with radiolucency along the costophrenic sulcus
B. Lung collapse at the hilum on one side and shift of the mediastinum to the opposite side
C. Bilateral asymmetric pulmonary infiltrates with peripheral distribution
D. Increased size of cardiac silhouette and cephalization of pulmonary vessels
E. Abrupt tapering of a pulmonary artery


Question: A 58-year-old man with a history of heart failure is admitted to the hospital for a cardiac transplantation. Five years ago, the patient had a mitral valve replacement with a porcine valve, but since then his heart failure symptoms have not improved. He developed persistent New York Heart Association class IV symptoms and was placed on the transplant waiting list. The heart to be transplanted originated from a deceased donor and the family has given consent for the transplantation. The patient is subsequently started on cyclosporine, and the postoperative period is unremarkable. He is readmitted to the emergency department 10 months later due to chest pain and severe shortness of breath. What is true about the medication prescribed to this patient?

Answer: Inhibits calcineurin

Choices:
A. Inhibits IMP dehydrogenase
B. Binds FK506 binding protein
C. Blocks IL-2R
D. Inhibits calcineurin
E. Is a precursor of 6-mercaptopurine


Question: An investigator studying renal physiology uses para-aminohippuric acid (PAH) to estimate the renal plasma flow in a human volunteer. An intravenous infusion of 400 mg of PAH solution is administered to the subject; effective renal plasma flow is calculated to be 600 ml/min. Next, an intravenous infusion of 1000 mg of PAH solution is administered to the subject; effective renal plasma flow is calculated to be 400 mL/min. Which of the following explains the measured decline in the calculated effective renal plasma flow?

Answer: Decreased PAH clearance

Choices:
A. Decreased serum protein binding
B. Increased plasma oncotic pressure
C. Efferent arteriole dilation
D. Afferent arteriole dilation
E. Decreased PAH clearance


Question:
A 55-year-old man presents to his primary care physician with a 2-month history of fatigue. He says that he has been feeling tired, even after mild exertion, and decided to be evaluated because it has begun interfering with his job as a construction worker. He reports that he has been feeling numbness and tingling in his feet and has been tripping more frequently. His past medical history is significant for hypertension and type 2 diabetes well-controlled on metformin. His surgical history is significant for weight-loss surgery 2 years ago. Physical exam reveals bilateral vibration sensory deficits as well as conjunctival pallor. Selected lab results are presented as follows:

Hemoglobin: 9.1 g/dL
Hematocrit: 27%
Platelet count: 265,000/mm^3
Mean corpuscular volume: 112 µm^3
Reticulocyte count: 0.19%

Which of the following findings would most likely also be seen in this patient?

Answer: High methylmalonic acid and high homocysteine levels

Choices:
A. Elevated bilirubin levels
B. High methylmalonic acid and high homocysteine levels
C. High transferrin levels
D. Low haptoglobin levels
E. Normal methylmalonic acid and high homocysteine levels


Question: A 27-year-old woman is brought to the emergency department by her coworker after having a generalized seizure at work. Her coworker reports that she is at 30 weeks' gestation and has mentioned headache and right upper quadrant pain earlier that day. Her temperature is 37°C (98.6°F), pulse is 91/min, and blood pressure is 170/102 mm Hg. Pulmonary examination shows bilateral rales. There is diffuse edema in the lower extremities. Deep tendon reflexes are increased bilaterally. She is not oriented to person, place, and time. Which of the following is the most appropriate initial pharmacotherapy?

Answer: Magnesium sulfate

Choices:
A. Calcium gluconate
B. Aspirin
C. Phenytoin
D. Lorazepam
E. Magnesium sulfate


Question: A 23-year-old woman presents to the emergency department because of nausea. She has been experiencing severe intermittent nausea and diarrhea for the last year and refuses to leave the emergency department until she is told what is causing her symptoms. She hates hospitals but has reluctantly undergone numerous workups and imaging studies in order to discern what is wrong. All of the studies have been normal. She says that these symptoms have been causing her severe distress and is impairing her ability to perform her job. She says that she feels as if the nausea is worse when she is trying to work but says that she will continue to work as an insurance agent despite the physical discomfort. She has started restricting her diet to only graham crackers because she thinks that helps her symptoms. She has also started avoiding eating lunch because of the nausea. Which of the following disorders is most consistent with this patient's presentation?

Answer: Somatic symptom disorder

Choices:
A. Conversion disorder
B. Factitious disorder
C. Illness anxiety disorder
D. Malingering
E. Somatic symptom disorder


Question:
A 37-year-old homeless man is brought in by ambulance to the emergency department after being found unresponsive. He was found in an area of IV drug use with drug paraphernalia including glassine envelopes with a white powder residue. There is no past medical history available. He is treated with intranasal naloxone and stabilized in the field. Upon arrival to the hospital, his blood pressure is 100/70 mm Hg, pulse rate is 90/min, respiratory rate is 18/min, and temperature is 38.9°C (102.0°F). On physical examination, the patient is jaundiced with white scrapable exudates on the oral mucosa. His arms are covered with stigmata of IV drug use. Heart auscultation reveals a holosystolic murmur that is loudest at the left sternal border. The lungs are clear to auscultation bilaterally. Laboratory work is performed which shows:
Hemoglobin 10.9 g/dL
Hematocrit 37.7%
Leukocyte count 1,500/mm3
Neutrophils 65%
Lymphocytes 30%
Monocytes 5%
Mean corpuscular volume 82.2 μm3
Platelet count 190,000/mm3
Erythrocyte sedimentation rate 35 mm/h
Aspartate aminotransferase 2,400 U/L
Alanine aminotransferase 3,200 U/L
CD4 count 27 cells/mm3
HIV-1 antibody positive
Hepatitis C virus antibody positive
Quantiferon-gold test negative
Which of the laboratory findings will be found in this patient?

Answer: Positive blood culture

Choices:
A. Atypical lymphocytes on blood smear
B. Positive blood culture
C. Elevated antistreptolysin O (ASO) titer
D. Elevated levels of cardiac troponin I and T
E. Positive sputum culture


Question: A 35-year-old woman, gravida 6, para 5, at 35 weeks' gestation comes to the emergency department because of vaginal bleeding for 2 hours. This is her second episode in the past 2 days. She has had no prenatal care. Her children were delivered vaginally. Her pulse is 122/min, respirations are 20/min, and blood pressure is 88/59 mm Hg. The abdomen is nontender, and no contractions are felt. There is active bright red vaginal bleeding. The fetal heart rate is 110/min. Two large-bore peripheral intravenous cannulas are inserted and intravenous fluids are administered. Three units of blood are typed and cross-matched. Which of the following is the most appropriate step in management?

Answer: Perform cesarean delivery

Choices:
A. Perform cesarean delivery
B. Hospitalization and observation
C. Administer magnesium sulfate
D. Induce labor
E. Perform cervical cerclage


Question: A 2710-g (6-lb) male newborn is delivered at 38 weeks of gestation to a 26-year-old woman, gravida 2, para 2. The pregnancy, labor, and delivery were uncomplicated. Breastfeeding is initiated. Which of the following supplements is most important to prevent a potentially life-threatening condition in this newborn?

Answer: Vitamin K

Choices:
A. Vitamin B1
B. Vitamin K
C. Folic acid
D. Iron
E. Vitamin D


Question: A 4-month-old adopted infant is brought to the pediatrician because of feeding problems and recurrent fungal and bacterial infections. Her family has almost no background information about the infant. They report that she is a little fragile and looks different compared to other infants her age. Physical evaluation reveals a cleft lip with intact hard and soft palate and mild jaw malformation. An echocardiogram reveals an interrupted aortic arch. Further investigation reveals leukopenia and mild hypocalcemia. These findings support a diagnosis of which of the following?

Answer: DiGeorge syndrome

Choices:
A. Chediak-Higashi syndrome
B. DiGeorge syndrome
C. Severe combined immunodeficiency (SCID)
D. Adenosine deaminase (ADA) deficiency
E. Wiskott-Aidrich syndrome


Question: A 48-year-old homeless man presents to clinic complaining of fatigue and fevers that "began recently." Cardiac exam reveals a holosystolic murmur, heard best over the left lower sternal border. The murmur increases on inspiration. He also has track marks on his arms bilaterally. This presentation is consistent with which defect?

Answer: Tricuspid regurgitation

Choices:
A. Ventricular septal defect
B. Tricuspid regurgitation
C. Mitral regurgitation
D. Aortic stenosis
E. Pulmonary stenosis


Question:
A 65-year-old diabetic man presents to the emergency department with severe retrosternal chest pain, vomiting, and diaphoresis for the last half hour. He has a history of diabetic chronic kidney disease. He is on insulin therapy. Oral medications include aspirin, losartan, and metformin. The vital signs include: temperature 36.8°C (98.2°F), pulse 88/min, respiration rate 14/min, and blood pressure 120/65 mm Hg. The weight is 78 kg (172.0 lb). The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The electrocardiogram (ECG) shows ST-segment elevation in the precordial leads V-1–V-4. Left ventricular ejection fraction is estimated at 55%. The laboratory test results are as follows:
Laboratory test
Hemoglobin 15 g/dL
Leukocyte count 9,500/mm3
Serum
Glucose 215 mg/dL
Na+ 140 mEq/L
Cl− 102 mEq/L
K+ 4.1 mEq/L
Urea nitrogen 22 mg/dL
Creatinine 1.4 mg/dL
Cardiac troponin I 0.8 ng/mL
The patient is being considered for primary percutaneous coronary intervention. Which of the following management steps is most likely to decrease the risk for development of acute renal failure in this patient?

Answer: Intravenous normal saline

Choices:
A. Intravenous furosemide
B. Intravenous normal saline
C. Reduced intravenous contrast dose
D. Preemptive hemodialysis
E. Withholding losartan


Question: A 7-year-old boy is brought in to your clinic by his mother, who is complaining of her son’s “dry scalp and hair loss.” She reports a scaling spot on his scalp developed around 2 months ago, soon after moving to a new school, which then became a larger bald spot. She denies that anyone in the household is exhibiting similar symptoms, but does recall a note that came home from school warning of a lice outbreak. Thus far, she has only tried daily baths with little improvement. The patient denies pain or itchiness, but the mother reports she does notice him scratching his scalp. The mother also reports that since her son has started at the new school, she has noticed an increase in his tics including excessive blinking and clearing of his throat. The patient's medical history is significant for asthma, allergic rhinitis, and attention deficient hyperactivity disorder. His current medications include fluticasone, salmeterol, loratadine, and methylphenidate. Family history includes obsessive compulsive disorder in his older sister. The mother also reports her father had a debilitating skin and joint disorder. On examination, you note swollen lymph glands at the back of the patient's ears and neck, and there are residual black dots within a patch of alopecia. Which of the following is the most likely diagnosis?

Answer: Tinea capitis

Choices:
A. Nummular dermatitis
B. Psoriasis
C. Tinea capitis
D. Pediculosis capitis
E. Trichotillomania


Question: A 68-year-old man is brought to the emergency department because of a 1-day history of fever and cloudy urine. He lives in a group home and has a chronic indwelling urinary catheter for benign prostatic hyperplasia. He has depression, for which he takes vilazodone. His temperature is 38.3°C (100.9°F), pulse is 89/min, and blood pressure is 110/74 mm Hg. Urine cultures grow Enterococcus faecium resistant to vancomycin, and therapy with intravenous linezolid is initiated. Eight hours later, he becomes agitated and starts to sweat profusely. His temperature is 39.6°C (103.3°F), pulse is 120/min, and blood pressure is 184/105 mm Hg. Neurologic examination shows increased deep tendon reflexes and clonus of the arms and legs. In addition to discontinuation of his current medication, administration of which of the following drugs is most appropriate in this patient?

Answer: Cyproheptadine

Choices:
A. Flumazenil
B. Dantrolene
C. Octreotide
D. Cyproheptadine
E.
Benztropine
"


Question: A 54-year-old man is newly diagnosed with diabetes. As part of his clinical care, he undergoes testing to determine his kidney function. His glomerular filtration rate is found to be 80 mL/min. He is curious about how glomerular filtration occurs and which molecules are filtered the fastest and slowest. He is told that albumin is filtered less readily than sodium. Aside from size of the 2 molecules, which of the following features of the glomerular basement membrane accounts for this additional finding?

Answer: Negative charge

Choices:
A. Thickness
B. Positive charge
C. Negative charge
D. Fenestrations
E. Presence of podocytes


Question: A 2-year-old boy with recurrent ear infections is brought to the pediatrician for a follow-up examination. He can walk with support and his vocabulary consists of approximately 50 words. His maternal uncle died in childhood from an unknown disease. Physical examination shows coarse facial features with an enlarged tongue. The abdomen is distended and both the liver and spleen tip are palpable. Laboratory studies show elevated total urinary glycosaminoglycan levels and an absence of plasma iduronate-2-sulfatase. Which of the following additional findings is most likely in this patient?

Answer: Aggressive behavior

Choices:
A. Optic atrophy
B. Leukopenia and thrombocytopenia
C. Cherry-red macula
D. Corneal clouding
E. Aggressive behavior


Question: A 29-year-old woman presents to a physician at 16 weeks gestation with fevers and a cough for 2 days. The cough is productive and occurs more often in the morning. Her medical history is not significant. Physical and laboratory evaluations suggest a diagnosis of community-acquired pneumonia. The physician explains to her that she needs to be treated with antibiotic therapy. She asks the physician if she can take levofloxacin because she tolerates levofloxacin. The physician explains that levofloxacin should be avoided during pregnancy because fetal exposure may increase the risk of a specific medical condition. Which of the following medical conditions is the physician referring to?

Answer: Arthropathy

Choices:
A. Arthropathy
B. Congenital heart defect
C. Deafness
D. Neural tube defect
E. Ocular anomalies


Question:
A large, multicenter study is conducted to assess the prevalence and mortality rate of pneumonia requiring hospitalization caused by various pathogens in 3 states over the past year. The study encompassed 250,000 adults between 45–79 years of age. The results for five different pathogens are shown:
All cases Fatal cases
Pathogen Number Percentage Number Percentage
S. aureus 460 34.8 69 50.3
Influenza virus 288 21.8 12 8.8
P. aeruginosa 136 10.3 17 12.4
S. pneumoniae 338 25.5 27 19.7
Klebsiella spp. 101 7.6 12 8.8
Total 1323 100 137 100
A journalist would like to report the yearly case fatality rate of the pneumonia pathogen responsible for most hospitalizations in these states. Based on the study results, which of the following responses by the investigator is most accurate?"

Answer: 15.0%

Choices:
A. 10.4%
B. 50.3%
C. 34.8%
D. 15.0%
E. 12.5%


Question:
A 52-year-old woman is admitted to the surgical unit after a laparoscopic hysterectomy for uterine leiomyomas performed 2 days ago. The surgery was performed under general anesthesia, blood loss was minimal, and there were no intraoperative complications. The patient reports lower abdominal pain and discomfort. Medical history is significant for multiple sclerosis that is well-controlled with ocrelizumab. Her last multiple sclerosis flare was approximately 7 years ago and presented with paresthesias and weakness of the upper extremities. Her temperature is 99°F (37.2 °C), blood pressure is 125/85 mmHg, pulse is 99/min, and respirations are 19/min. On physical exam, the patient appears restless and uncomfortable. The surgical incision sites are mildly erythematous and without discharge. There is tenderness with deep suprapubic palpation. Neurologic exam is unremarkable. Laboratory studies show:

Serum:
Na+: 144 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 26 mEq/L
Glucose: 105 mg/dL
Creatinine: 3.1 mg/dL

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

Answer: Bladder scan

Choices:
A. Bethanechol administration
B. Bladder scan
C. Intravenous fluids
D. Urine studies
E. Urodynamic studies


Question: A 38-year-old female visits your office complaining of several years of joint swelling and stiffness that is worse in the morning and improves throughout the day. Physical examination reveals bilateral deformities at her proximal interphalangeal and metacarpophalangeal joints. The presence of which of the following in this patient’s serum would most help 'rule in' a diagnosis of rheumatoid arthritis:

Answer: Anti-citrullinated protein antibody

Choices:
A. Rheumatoid factor
B. Anti-nuclear antibody
C. Anti-citrullinated protein antibody
D. Anti-centromere antibody
E. Anti-smooth muscle antibody


Question: A 3-week-old infant presents to the emergency department with thick white discharge from his eyes that has persisted for the past 24 hours. The patient's birth was not complicated, and he was born at home vaginally with a mid-wife supervising the birth. The patient has a documented allergy to penicillin which caused anaphylaxis after it was given secondary to a maternal syphilis infection. His temperature is 97.6°F (36.4°C), blood pressure is 75/40 mm Hg, pulse is 130/min, respiratory rate is 24/min, and oxygen saturation is 98% on room air. The patient is currently sleeping. Physical exam is notable for bilateral purulent drainage from the eyes. Which of the following is a complication associated with the best treatment for this patient?

Answer: Non-bilious projectile vomiting

Choices:
A. Damage to the lacrimal ducts
B. Non-bilious projectile vomiting
C. Optimal therapy has no known side-effects
D. Possible anaphylaxis and urticaria
E. Sedation and increased sleepiness


Question: A 10-year-old boy initially presented with a runny nose, fever, and watery eyes. His parents gave him aspirin. Over the next few days, the boy developed jaundice, became irritable, lethargic, and had seizures. The hepatic transaminases were significantly raised. The blood ammonia levels were also increased. A liver biopsy is performed. Which of the following histopathological findings will most likely be seen on the liver biopsy in this patient?

Answer: Cytoplasmic fatty vacuolization in hepatocytes and swollen mitochondria

Choices:
A. Hepatic granulomas
B. Iron accumulation and proliferation of smooth endoplasmic reticulum
C. Hepatocytes proliferation
D. Cytoplasmic fatty vacuolization in hepatocytes and swollen mitochondria
E. Bridging hepatic necrosis and fibrosis


Question: An 18-year-old woman presents with a dry cough for the past 2 weeks. She also says that she is tired all the time and feels feverish and chilly at times. She is a college student and lives in a dormitory and says that her roommate has a similar cough. Past medical history is unremarkable. The patient denies any smoking history, alcohol or recreational drug use. Her vitals signs include: temperature 36.8°C (98.2°F), pulse 72/min, blood pressure 118/63 mm Hg, and respiratory rate 15/min. Physical examination is unremarkable. A chest radiograph reveals interstitial infiltrates that look worse than her symptoms. A nasopharyngeal swab is sent to the lab for a bacterial culture which shows colonies having fried-egg appearance on Eaton’s agar. Cold agglutinins are positive. Which of the following antibiotics would be best to administer to this patient?

Answer: Erythromycin

Choices:
A. Vancomycin
B. Penicillin
C. Ceftriaxone
D. Erythromycin
E. Aztreonam


Question: A 9-year-old boy comes to the physician because of pain with swallowing and a burning sensation in his mouth for the past 10 days. Over the past 3 weeks, he has had increasing fatigue and runs out of breath easily. His father had gallstones, for which he underwent a cholecystectomy at the age of 30 years. The boy appears weak and lethargic. His temperature is 37.7°C (99.8°F), blood pressure is 110/68 mm Hg, pulse is 105/min, and respirations are 28/min. Examination shows pallor of the mucosal membranes, mild scleral icterus, and a swollen, red tongue. His spleen is enlarged and palpable 2–3 cm below the left costal margin. A complete blood cell count shows a hemoglobin concentration of 9.8 g/dL, mean corpuscular volume of 102 μm3, and a reticulocyte count of 0.4%. His peripheral blood smear shows erythrocytes without central pallor. Which of the following could have prevented this patient's chief complaints?

Answer: Folic acid supplementation

Choices:
A. Folic acid supplementation
B. Cholecystectomy
C. Gluten-free diet
D. Vaccination against pneumococci
E. Vitamin B12 injections


Question:
A 62-year-old man is brought to the hospital because of a 6-hour history of worsening upper abdominal pain, nausea, and vomiting. He is diagnosed with acute calculous cholecystitis and scheduled for cholecystectomy the next day. He has congestive heart failure, hyperlipidemia, and hypertension. Physical examination shows no abnormalities. Current medications include metoprolol and simvastatin. One month ago, spironolactone was added to his medication regimen. Preoperative serum studies show:
Na+ 138 mEq/L
K+ 6.1 mEq/L
Cl- 100 mEq/L
HCO3- 22 mEq/L
Urea nitrogen 13 mg/dL
Creatinine 1.0 mg/dL
An ECG shows normal sinus rhythm. In addition to discontinuation of spironolactone, which of the following is the most appropriate next step in management of this patient's hyperkalemia?"

Answer: Administer intravenous saline with furosemide

Choices:
A. Administer intravenous saline with furosemide
B. Administer intravenous sodium bicarbonate
C. Order dietary modification
D. Administer intravenous calcium gluconate
E. Initiate hemodialysis


Question: A 48-year-old woman comes to the physician for a follow-up examination. She has a history of type 2 diabetes mellitus and coronary artery disease. Current medications include metformin, aspirin, pravastatin, and losartan. Her body mass index is 30 kg/m2. Physical examination shows no abnormalities. Her hemoglobin A1c concentration is 8%. She does not want to start insulin injection therapy and is afraid that a new medication is going to cause weight gain. Empagliflozin is added to her diabetes regimen. This patient is at greatest risk for which of the following adverse effects of this new drug?

Answer: Vaginal candidiasis

Choices:
A. Localized lipodystrophy
B. Vaginal candidiasis
C. Hypoglycemia
D. Agranulocytosis
E. Lactic acidosis


Question: A 62-year-old man with coronary artery disease and type 2 diabetes mellitus comes to the emergency department because of frequent episodes of palpitations for 4 days. His pulse is 165/min and blood pressure is 98/70 mm Hg. An ECG shows monomorphic ventricular tachycardia. Intravenous pharmacotherapy is begun with a highly lipophilic drug that prolongs the duration of the myocardial action potential and refractory period and inhibits adrenergic stimulation of the myocardium. The patient's ventricular tachycardia converts to normal sinus rhythm. He is discharged home with an oral formulation of the same drug. Which of the following adverse effects is most commonly associated with long-term use of this medication?

Answer: Hyperthyroidism

Choices:
A. Priapism
B. Acne vulgaris
C. Angle-closure glaucoma
D. Hyperthyroidism
E. Hepatic adenoma


Question:
A 45-year-old woman presents to her primary care physician complaining of weight gain. She states that for the past few months she has gained 10 pounds, especially around her abdomen. She says that this is despite going to kickboxing classes 5 days a week. She reports mild fatigue and muscle soreness, which she attributes to her exercise classes. She also complains of dry skin and hair, but feels that this might be due to showering twice a day. Her medical history is significant for major depressive disorder. She takes citalopram and a multivitamin. She smokes a half pack of cigarettes a day. She drinks 1 glass of red wine every night after dinner, and 3-4 drinks mixed with hard liquor on the weekend with friends. Her temperature is 98°F (36.7°C), blood pressure is 122/75, and pulse is 65/min. Her physical examination is unremarkable, except for xerosis. Labs are obtained, as shown below:

Serum:
Na+: 130 mEq/L
K+: 4.1 mEq/L
Cl-: 101 mEq/L
BUN: 16 mg/dL
Glucose: 125 mg/dL
Creatinine: 0.9 mg/dL
Aspartate aminotransferase (AST): 56 U/L
Alanine aminotransferase (ALT): 70 U/L
Creatine kinase (CK): 223 U/L (normal 22 to 198 U/L)

Hemoglobin A1c: 5.3
Total cholesterol: 264 mg/dL (normal < 200 mg/dL)
Low-density lipoprotein (LDL) cholesterol: 117 mg/dL (normal < 100 mg/dL)
High-density lipoprotein (HDL) cholesterol: 48 (normal > 50 mg/dL)
Triglycerides: 163 mg/dL (normal < 150 mg/dL)

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

Answer: Thyroxine

Choices:
A. Fludrocortisone
B. Liver biopsy
C. Muscle biopsy
D. Simvastatin
E. Thyroxine


Question: A 31-year-old woman comes to the physician because of white lesions in her mouth that she first noticed 5 days ago. The lesions are not painful or itchy. She has asthma treated with theophylline, inhaled β-adrenergic agonists, and corticosteroids. She smokes half a pack of cigarettes daily. She appears healthy. Vital signs are within normal limits. Oral examination shows white plaques on the buccal mucosa and hard palate that are firmly adherent and cannot be scraped off. She has no cervical or axillary lymphadenopathy. Which of the following is the most appropriate next step in the management of this patient?

Answer: Biopsy of the lesions

Choices:
A. Topical nystatin
B. Biopsy of the lesions
C. Smoking cessation
D. Culture of the lesions
E. Monospot test


Question: An 11-year-old male is brought to his pediatrician for continuing management of a chronic lung infection. He has had many lung infections throughout childhood, and current sputum samples show oxidase positive, non-lactose fermenting gram-negative rods that produce a blue-green pigment. Physical exam shows nasal polyps and nail clubbing. He has also recently been experiencing floating foul smelling diarrhea, so he is prescribed enzymes and vitamin supplementation tablets. Which of the following chromosomes most likely contains the gene mutation responsible for this patient's symptoms?

Answer: 7

Choices:
A. 7
B. 11
C. 17
D. 22
E. X


Question: A 16-year-old girl is brought to the physician for a routine health maintenance examination. Her last visit was over a year ago. Menarche was at the age of 12 years; her last menstrual period was 4 months ago. She is on the school's gymnastics team and is currently preparing for an important competition. She is 165 cm (5 ft 5 in) tall and weighs 45 kg (99 lbs); BMI is 16.5 kg/m2. Her temperature is 36.8°C (98.2°F), pulse is 53/min, and blood pressure is 98/64 mm Hg. Examination shows yellowish discoloration of the skin. There are bilateral soft symmetric masses below her mandible. The skin over the dorsal side of her right hand is thickened. The patient is most likely to develop which of the following complications?

Answer: Fractures

Choices:
A. Recurrent infections
B. Ovarian cancer
C. Hyperkalemia
D. Fractures
E. Hyperthyroidism


Question: A 32-year-old female is seeing an endocrinologist for the first time after a recently-diagnosed illness by her primary care physician. Her temperature is 99.7 °F (37.6 °C), blood pressure is 110/65 mmHg, pulse is 89/min, and respirations are 11/min. Prior to starting medical management, the patient is cautioned to alert her providers if she becomes pregnant, as this medication crosses the placenta and is known to cause aplasia cutis. Which of the following activities is inhibited by this medication?

Answer: Coupling of iodine with tyrosine residues

Choices:
A. Conversion of T4 to T3
B. Coupling of iodine with tyrosine residues
C. Production of TRH
D. Response of peripheral tissues to thyroid hormone
E. Sensitivity of anterior pituitary to TRH


Question: A 62 year old woman presents to her doctor complaining of painful tingling and burning in her feet for the past year. Careful physical exam demonstrates that she has poor position sense in her bilateral lower extremities. Lab results reveal elevated urine and plasma methylmalonic acid concentrations. What vitamin deficiency is this woman most likely suffering from?

Answer: Vitamin B12

Choices:
A. Vitamin C
B. Vitamin B1
C. Vitamin B12
D. Biotin
E. Folic acid


Question: A 52-year-old man visits his psychiatrist saying he feels sad most of the time. 5 months ago, he lost his daughter in a motor vehicle accident and since then has been unable to cope with this loss. He spends most of his day thinking about her and this often distracts him from his daily activities. He also admits to hearing his daughter’s voice in his sleep and sometimes has dreams about her. During the day, he sometimes gets brief glimpses of her. He believes this is because he was not able to do anything to help her during the last moments of her life. Other than this, he is able to get along his daily life and has never contemplated suicide. But he often wishes he could be close to his daughter again. Which of the following best describes the symptoms this patient is expressing?

Answer: Normal grief reaction

Choices:
A. Brief psychotic disorder
B. Major depressive disorder
C. Normal grief reaction
D. Post-traumatic stress disorder
E. Morbid grief reaction


Question: A 68-year-old woman with hypertension and congestive heart failure is brought to the emergency department because of a 2-day history of shortness of breath and confusion. Her pulse is 112/min, respirations are 22/min, and blood pressure is 73/45 mm Hg. Examination shows cool extremities, jugular venous distention, and diffuse crackles in the lungs. Treatment with intravenous dobutamine is begun. Which of the following is the primary mechanism of action of this drug?

Answer: β1-adrenergic agonism

Choices:
A. α2-adrenergic agonism
B. β2-adrenergic antagonism
C. β1-adrenergic agonism
D. α1-adrenergic antagonism
E. D1 agonism


Question: A 58-year-old man comes to the physician for a follow-up examination dressed in a vampire costume. He is on his way to a Halloween party at an assisted-living facility, where he works as a patient care attendant. He feels well. He has a history of hypertension that is well controlled. He was also diagnosed with type 2 diabetes two months ago during a routine check up. His current medications include lisinopril and metformin. His father died of colon cancer at 52 years of age. His screening colonoscopy at age 55 was normal. He used to smoke half a pack of cigarettes daily for 10 years but quit 15 years ago. His temperature is 37°C (98.6°F), pulse is 90/min, respirations are 14/min, and blood pressure is 138/90 mm Hg. Physical examination shows no abnormalities. His hemoglobin A1c two months ago was 7.6%. Which of the following health maintenance recommendations is most appropriate at this time?

Answer: Influenza vaccine

Choices:
A. Hemoglobin A1c measurement
B. Influenza vaccine
C. Prostate-specific antigen measurement
D. Colonoscopy
E. Low-dose CT scan


Question:
A 33-year-old homeless man presents to the emergency department with an altered mental status. The patient was found minimally responsive at a local mall and was brought in by police. The patient has a past medical history of polysubstance abuse, anxiety, depression, and panic disorder. His current medications include sertraline, clonazepam, and amitriptyline. His temperature is 98.7°F (37.1°C), blood pressure is 117/68 mmHg, pulse is 80/min, respirations are 10/min, and oxygen saturation is 98% on room air. Physical exam is notable for a somnolent man. Neurological exam reveals 4 mm pupils, which are equal and reactive to light, and a patient who responds incoherently to questions when stimulated. The patient has normoactive bowel sounds and is non-tender in all 4 quadrants. Laboratory values are ordered as seen below.

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
Ethanol: negative

An initial ECG is unremarkable. Which of the following is the best treatment for this patient?

Answer: Observation

Choices:
A. Flumazenil
B. Fomepizole
C. Naloxone
D. Observation
E. Sodium bicarbonate


Question: A 6-month-old boy is brought to her pediatrician for a checkup and vaccines. He was born at 39 weeks gestation via spontaneous vaginal delivery. He is meeting all the developmental milestones. His prenatal history was complicated with maternal diabetes. He is being breastfed exclusively and has 3–4 wet diapers a day. On physical exam, the vital signs include: temperature 37.0°C (98.6°F), blood pressure 85/45 mm Hg, pulse 140/min, and respiratory rate is 31/min. On physical examination, the patient is alert and responsive. Height, weight, and head circumference are above the 90th percentile. Which of the following vaccines should be administered for this patient at this visit?

Answer: RV, DTaP, PCV, Hib, IPV

Choices:
A. RV, DTaP, PCV
B. RV, Tdap, PCV, Hib
C. RV, DTaP, PCV, Hib, IPV
D. Hep B, DTaP, Influenza
E. RV, Hep B, Hep A


Question: A 23-year-old woman is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision where she was the unrestrained driver. She was found thrown across the dashboard of the car. On arrival, she appears lethargic. She is unable to provide a history. Her pulse is 133/min, respirations are 23/min, and blood pressure is 90/60 mm Hg. Examination shows a 2-cm laceration over the right upper extremity. The pupils are equal and reactive to light. There are multiple bruises over the chest and abdomen. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and not distended. Neurologic examination shows no focal findings. 0.9% saline infusion is begun. Which of the following is the most appropriate next step in management?

Answer: Ultrasonography

Choices:
A. Observation
B. Exploratory laparotomy
C. CT scan of the abdomen
D. Ultrasonography
E. Diagnostic peritoneal lavage


Question: Three days after starting a new medication, a 66-year-old woman with resistant hypertension and hyperlipidemia comes to the doctor because of decreased urination. She denies dysuria, fevers, or chills. Blood pressure is 133/67 mm Hg. Physical examination shows no abnormalities. Compared to measurements from one week ago, the glomerular filtration rate is markedly decreased and plasma renin activity is elevated. A duplex ultrasound of the kidneys shows increased systolic flow velocity in both renal arteries when compared to the aorta. Which of the following drugs is the most likely cause of this patient's worsening renal function?

Answer: Enalapril

Choices:
A. Furosemide
B. Spironolactone
C. Hydrochlorothiazide
D. Enalapril
E. Atenolol


Question: An investigator is conducting an experiment to develop a new drug against HIV infection. HIV-infected and uninfected CD4 T-cell lines are mixed in-vitro with a chemically modified synthetic peptide triazole complex. The complex is found to have a high binding affinity to the gp120 protein, irreversibly inhibiting its function and reducing CD4 T cell infection. Inhibition of which of the following steps of HIV infection is the most likely therapeutic effect of this experimental drug?

Answer: Attachment to host CD4 T-cells

Choices:
A. Incorporation of viral genome into host cell DNA
B. Transcription of the viral genome
C. Fusion and entry into CD4 T-cells
D. Assembly of viral particles
E. Attachment to host CD4 T-cells


Question: A 35-year-old man presents to the physician for a medical evaluation necessary before joining the armed force services. He is a healthy man with no history of smoking or substance abuse. His past medical history is not significant. His vital signs are stable and his systemic examination is within normal limits. Examination of his respiratory system, including auscultation of his chest, does not reveal any abnormality. His laboratory investigations are within normal limits but his chest radiogram shows a solitary pulmonary nodule (SPN), size 9 mm (0.35 in) in diameter, in the middle zone of his right lung. The physician compares the radiogram with a radiogram obtained 3 years back for pre-employment medical evaluation. The physician notes that a similar SPN with the same size was present in the previous radiogram at the same location. Which of the following is the next best step in his evaluation?

Answer: No further workup

Choices:
A. No further workup
B. Thin-section computed tomography (CT) scan
C. Positron emission tomography (PET) scan
D. Follow-up after 12 months; if unchanged, no further follow-up
E. Follow-up every 6 months; CT scan when there are changes in the nodule


Question:
A 32-year-old man presents to his primary care physician because he has been experiencing fatigue and back pain over the last 2 days. He suffered from malaria after going on vacation 5 years ago and recently started taking a medication to deal with a latent form of this infection. He started developing these symptoms 36 hours after taking the first dose and noticed his urine became progressively darker during that time. On physical exam he is found to have scleral icterus and skin jaundice. Labs are obtained with the following results:

Hematocrit: 32% (Normal: 41%-53%)
Hemoglobin: 10.6 g/dL (Normal: 13.5-17.5 g/dL)
Leukocyte count: 8500/mm3 (Normal: 4500-11,000/mm3)
Platelet count: 273,000/mm3 (Normal: 150,000-400,000/mm3)

Which of the following would most likely be seen on a peripheral blood smear in this patient?

Answer: Small round inclusions of denatured hemoglobin

Choices:
A. Helmet-shaped red blood cells
B. Small round inclusions of denatured hemoglobin
C. Small round inclusions of nuclear remnants
D. Target-shaped red blood cells
E. Teardrop-shaped red blood cells


Question:
A 30-year-old woman presents to the office for routine examination. She has no medical complaints except for mild burning sensation in her eyes and an occasional dry cough. She denies fever, headache, or any recent illnesses. Past medical history is unremarkable and she takes no medications. She does not smoke cigarettes or drinks alcohol. Her temperature is 37.0°C (98.6°F), the blood pressure is 110/70 mm Hg, the pulse is 78/min, and the respirations are 12/min. Physical examination is normal except for bilateral conjunctival injection. Laboratory results and chest X-ray is shown below:
Serum chemistry
  Sodium 145 mEq/L
  Potassium 4.1 mEq/L
  Chloride 98 mEq/L
  Calcium 13 mEq/L
  Bicarbonate 20 mEq/L
  Blood urea nitrogen 8 mEq/L
  Creatinine 0.7 mEq/L
  Glucose 96 mEq/L
Urine toxicology Negative
Which of the following abnormalities would most likely be seen in this patient?

Answer: Increased ACE levels

Choices:
A. Decreased alpha-1 antitrypsin levels
B. Increased ACE levels
C. Increased ADH levels
D. Presence of anti-dsDNA antibodies
E. Caseating granulomas in lung tissue biopsy


Question: A 60-year-old man presents to a physician with the complaint of a persistent cough for a year. He has visited multiple physicians to date, but there has been no conclusive diagnosis. He has been a smoker since the age of 30. There is no history of significant expectoration, blood in sputum, wheezing, or breathing difficulty, but he has lost approx. 6.35 kg (14 lb) of weight over the last 9 months. On physical examination, his vital signs are stable, and examination of the chest reveals decreased breath sounds over the left infrascapular region. His chest radiogram suggests atelectasis in the left lower lobe. A detailed evaluation confirms a diagnosis of non-small cell lung carcinoma involving the left main bronchus, which is 4 cm in size and is located 3.8 cm (1.5 in) from the carina. Ipsilateral hilar lymph nodes, ipsilateral subcarinal lymph nodes, and ipsilateral scalene lymph nodes are involved in metastasis with no distant metastasis. Investigations also suggest that the patient does not have any comorbidity that contraindicates any anti-cancer treatment modality and that his performance status is good. Which of the following is the initial treatment of choice for the patient?

Answer: Concurrent chemoradiotherapy

Choices:
A. Surgery followed by adjuvant chemotherapy
B. Chemotherapy only
C. Concurrent chemoradiotherapy
D. Sequential chemoradiotherapy
E. Radiation therapy only


Question: A previously healthy 25-year-old woman comes to the physician because of a 3-week history of fever, recurrent headaches, and anorexia. One month ago, she returned from a camping trip in Chile. Her temperature is 39.3°C (102.8°F). Examination shows a swelling in the left periorbital region and axillary, cervical, and inguinal lymphadenopathy. A blood sample is obtained. Processing of the sample with which of the following methods is most likely to confirm the diagnosis?

Answer: Staining with Giemsa dye

Choices:
A. Staining of mycolic acid
B. Staining with India ink
C. Staining with Giemsa dye
D. Staining of glycogen
E. Staining with silver


Question:
A 57-year-old man presents to the emergency department with chest and back pain. He states that his symptoms started suddenly 1 hour ago and have persisted. He has a past medical history of hypertension and diabetes. His temperature is 98.5°F (36.9°C), blood pressure is 168/111 mmHg, pulse is 95/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for an uncomfortable man but is otherwise within normal limits. An initial ECG is unremarkable. Laboratory values are ordered as seen below.

Hemoglobin: 15 g/dL
Hematocrit: 45%
Leukocyte count: 6,300/mm^3 with normal differential
Platelet count: 222,000/mm^3

Serum:
Na+: 141 mEq/L
Cl-: 103 mEq/L
K+: 4.5 mEq/L
HCO3-: 24 mEq/L
BUN: 42 mg/dL
Glucose: 129 mg/dL
Creatinine: 1.9 mg/dL
Ca2+: 10.2 mg/dL

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

Answer: Transesophageal echocardiography

Choices:
A. Aspirin
B. CT angiogram of the chest
C. D-dimer
D. Esmolol
E. Transesophageal echocardiography


Question: A 2-week-old infant is brought to the pediatrician for the first time by his parents. His mother received regular prenatal care and the child was born at home under the guidance of a midwife and a doula. The child appears well. The parents tell you they do not plan to have their child receive any vaccines. After a discussion regarding the risks and benefits of vaccines, the parents are still adamant in their wishes to forgo. Which of the following is the most appropriate course of action?

Answer: Document the visit, specifically the detailing of risks and benefits and the parents' refusal of treatment

Choices:
A. Call child protective services
B. Refuse to continue to care for the child
C. Seek a court order to deliver the vaccines against the wishes of the parents
D. Give any scheduled vaccines during that visit against the will of the parents
E. Document the visit, specifically the detailing of risks and benefits and the parents' refusal of treatment


Question: A 15-year-old boy is brought in to his pediatrician's office by his step-mother for uncontrollable behavior. She reports he has an extensive history of detention for outbursts in class. He recently got expelled from school for fist fighting. At home, he punches his younger brother when he’s angry. The family had to give their cat away to a neighbor because the patient tried to set it on fire. The patient’s medical history is significant for bed-wetting until he was 11. His father has adult attention deficit disorder. The patient states that he thinks school is a “joke.” He denies having close friends and says “the kids in my town are stupid anyway.” He calmly describes how he would like to burn down all their houses. He admits to trying alcohol and cocaine but denies any other illicit drugs. Which of the following is the patient’s most likely diagnosis?

Answer: Conduct disorder

Choices:
A. Antisocial personality disorder
B. Attention deficient hyperactivity disorder
C. Conduct disorder
D. Pyromania
E. Substance abuse


Question: A 30-year-old female complains of heat intolerance, excessive sweating, and recent unintentional weight loss. She denies alcohol, tobacco, and other drug use and does not take any medications. Laboratory analysis reveals elevated serum T4 and decreased serum TSH. You elect to manage the patient’s condition pharmacologically with methimazole. Methimazole interferes with the function of which of the following proteins?

Answer: Thyroid peroxidase

Choices:
A. Thyroxine-binding globulin
B. Sex-hormone binding globulin
C. Thyroid peroxidase
D. 5’-deiodinase
E. Sodium/iodide symporter


Question: A 40-year-old woman presents to her primary care physician with complaints of worsening muscle aches and diffuse weakness over the past several months. She states that she now has difficulty climbing stairs and extending her neck. Ultimately, she became more concerned when she began having trouble swallowing and experienced shortness of breath last night which has resolved. Her temperature is 98.5°F (36.9°C), blood pressure is 120/84 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for 2/5 strength of the proximal muscles of the upper and lower extremities. Dermatologic, cardiac, and pulmonary exam are unremarkable. The patient is tolerating oral secretions and has no difficulty swallowing or protecting her airway currently. Laboratory studies are notable for an elevated CRP and aldolase. Which of the following is the most appropriate treatment for this patient?

Answer: Prednisone

Choices:
A. Intravenous immunoglobulin
B. Methotrexate
C. Naproxen
D. Neostigmine
E. Prednisone


Question: A 50-year-old woman visits her primary care practitioner with the complaints of generalized weakness, lightheadedness, and fatigability for the past month. She also claims to have epigastric pain, heartburn, and a sensation of a lump in her throat. Her family history is irrelevant, but her medical history is significant for a Pap smear that reported atypical squamous cells of undetermined significance (ASCUS), which was followed up with a cervical biopsy negative for malignancy. She occasionally takes over-the-counter medicines to cope with the heartburn, and recently her hemoglobin was found to be 11 g/dL, for which she received iron and vitamin B12 supplementation. Physical examination is unremarkable, except for pale skin, and a pulse of 120/min. Which of the following is the next best step in the management of this patient?

Answer: Endoscopy

Choices:
A. Proton pump inhibitor
B. Anti-H2 agent
C. Endoscopy
D. Fecal occult blood test
E. Diet and lifestyle recommendations


Question: A 67-year-old man presents to a primary care clinic to establish care after moving from another state. According to his prior medical records, he last saw a physician 4 years ago and had no significant medical problems at that time. Records also show a normal EKG and normal colonoscopy results at that time. The patient reports feeling well overall, but review of systems is positive for 1 year of mild cough productive of clear sputum and 2 years of increased urinary frequency. He denies fever, chills, dyspnea, dysuria or hematuria. He denies illicit drug use but has been drinking approximately 1-2 beers per night and smoking 1 pack of cigarettes per day since age 20. Physical exam is unremarkable. Which of the following tests is indicated at this time?

Answer: Abdominal ultrasound

Choices:
A. Abdominal ultrasound
B. Bladder ultrasound
C. Colonoscopy
D. Serum prostate specific antigen (PSA) testing
E. Sputum culture


Question: An 8-year-old boy is brought to the physician for evaluation of an excessive bleeding after undergoing a dental procedure. Laboratory studies show a platelet count of 195,000/mm3, a partial thromboplastin time of 44 sec, and a prothrombin time of 12 sec. A one-stage clotting assay shows a decreased factor VIII. Therapy with a drug that acts on endothelial cells is initiated. This drug is most likely to result in which of the following?

Answer: Increased permeability to urea in the collecting duct

Choices:
A. Decreased cAMP in renal tubular cells
B. Increased tubular fluid osmolarity in the loop of Henle
C. Decreased binding of angiotensin II to AT1 receptor
D. Increased permeability to urea in the collecting duct
E. Increased bleeding time


Question: A young girl is brought to the physician by her mother for a well-child examination. She is at the 55th percentile for height and at the 40th percentile for weight. Vital signs are within normal limits. Physical examination shows no abnormalities. She is able to follow simple commands, such as “close your eyes, then stick out your tongue,” but she is unable to follow 3-step commands. She knows approximately 75 words, and half of her speech is understandable. She can say 2-word phrases, and she is able to name many parts of the body. Assuming normal development, which of the following milestones would be expected in a patient this age?

Answer: Kicks a ball

Choices:
A. Separates easily from parents
B. Kicks a ball
C. Pedals a tricycle
D. Hops on one foot
E. Draws a triangle


Question:
An investigator is studying the association between exclusive breastfeeding and body weight in infants. The body weights of 15 exclusively breastfed infants at the age of 6 months are measured. Results are shown:
Patient Body weight (kg)
1 7.0
2 6.0
3 6.1
4 6.8
5 7.2
6 6.4
7 6.2
8 6.8
9 6.5
10 7.3
11 6.3
12 8.5
13 6.9
14 6.6
15 5.2
One of the computed measures of central tendency is 6.8 kg. Which of the following characteristics is generally true about this measurement?"

Answer: It is resistant to outliers.

Choices:
A. It is the 50th percentile of a set of values.
B. It is not applicable for qualitative data analysis.
C. It is resistant to outliers.
D. Its value only occurs once in a data set.
E. It is useful to assess the extent of data variability.


Question: A 32-year-old man presents to his primary care provider with right leg weakness and numbness. He reports a 2-day history of “clumsiness” in his right lower extremity after playing in his company’s annual weekend-long charity baseball tournament. He says a similar episode happened 1 year ago during the same tournament. He has a history of major depressive disorder and right distal radius fracture status post-closed reduction and casting after falling 2 years ago. He takes fluoxetine. He also reports that he several years ago he had an isolated episode of decreased vision and inability to move his right eye that resolved on its own. He has a 15-pack-year smoking history and drinks 3-4 beers per week. His temperature is 98.4°F (36.9°C), blood pressure is 115/65 mmHg, pulse is 85/min, and respirations are 18/min. On exam, hip flexion, knee extension, and ankle dorsiflexion are all 3/5 on his right and 5/5 on his left. Right Achilles and patellar reflexes are 1+ on the right and 2+ on the left. He has decreased sensation to light touch throughout the right leg especially below the knee. Additional questioning would most likely reveal which of the following additional features about this patient’s current symptoms?

Answer: Symptom exacerbation in the heat

Choices:
A. Concomitant hyperreflexia
B. Symptom improvement in the heat
C. Symptom exacerbation in the heat
D. Symptom exacerbation with repetitive muscle contractions
E. Symptom improvement with repetitive muscle contractions


Question: A 56-year-old man comes to the physician because of throat pain and increasing difficulty swallowing food for the past 5 months. He has also had episodic left ear pain for the past 3 months. He has hypertension. His only medication is amlodipine. His father died of laryngeal cancer at the age of 55 years. He has smoked one pack of cigarettes daily for 36 years. He drinks 2–3 beers daily. Vital signs are within normal limits. Examination shows left cervical lymphadenopathy. Oropharyngeal examination shows a 3-cm ulcerating left tonsillar mass. Examination of both auditory canals is unremarkable. Which of the following is the most appropriate initial step in management?

Answer: Panendoscopy

Choices:
A. Esophagoscopy
B. Nasopharyngoscopy
C. Panendoscopy
D. Barium swallow
E.
Laryngoscopy
"


Question:
A 23-year-old woman presents to the emergency department with abdominal pain. The patient states that she has pain in her back that radiates to her abdomen. The pain started yesterday and is episodic. She describes the pain as a 10/10 when it occurs. The patient has a past medical history of asthma, anxiety, and chlamydia that was appropriately treated. Her current medications include fluoxetine. The patient's lab values are ordered as seen below.

Hemoglobin: 14 g/dL
Hematocrit: 40%
Leukocyte count: 8,500 cells/mm^3 with normal differential
Platelet count: 225,000/mm^3

Serum:
Na+: 140 mEq/L
Cl-: 100 mEq/L
K+: 4.9 mEq/L
HCO3-: 24 mEq/L
BUN: 22 mg/dL
Glucose: 89 mg/dL
Creatinine: 1.2 mg/dL
Ca2+: 10.0 mg/dL
AST: 11 U/L
ALT: 11 U/L

Urine:
Color: amber
Nitrites: negative
Na+: 12 mmol/24 hours
Beta-hCG: positive
Red blood cells: 11/hpf

Which of the following is the best test for this patient's most likely diagnosis?

Answer: Renal ultrasound

Choices:
A. Abdominal radiograph
B. Abdominal CT
C. Transvaginal ultrasound
D. Abdominal ultrasound
E. Renal ultrasound


Question: A baby is delivered via cesarean section on the 31st gestational week. The child has tachypnea, nasal flaring, and subcostal, and intercostal retraction. Nasogastric tube was positioned without problems. Chest radiography shows bilateral, diffuse, ground-glass appearance, air bronchograms, and poor lung expansion. What is the best treatment plan in the present case?

Answer: Surfactant administration and oxygen therapy

Choices:
A. Oxygen therapy
B. No therapy right away, only observation
C. Surfactant administration and oxygen therapy
D. Antibiotics
E. Emergency surgical repair of tracheoesophageal fistula


Question: A previously healthy 38-year-old man comes to the emergency department for evaluation of several hours of severe, right-sided, colicky flank pain that radiates to the groin. He drinks 2–3 energy drinks daily. An x-ray of the abdomen shows a 4-mm radiopaque mass in the right ureter. Microscopic examination of the urine shows biconcave, dumbbell-shaped crystals. Which of the following is most likely to prevent future episodes of flank pain?

Answer: Maintain adequate hydration

Choices:
A. Begin loop diuretic
B. Maintain acidic urine
C. Maintain adequate hydration
D. Start high-dose vitamin C
E. Restrict dietary calcium intake


Question: A 45-year-old woman presents for evaluation of mild painless postcoital bleeding for the past 6 months. Recently, she started to note irregular intermenstrual bleeding. She has a regular menstrual cycle that lasts 30 days. She has no history of genital infections or any other major gynecologic diseases. She has 1 sexual partner and uses barrier contraception for birth control. The pelvic examination shows an erosive necrotizing lesion (6 cm in diameter) that involves the posterior lip of the cervix and extends to the cervical canal and posterior vaginal apex. Cervical mobility is decreased. The uterus is not enlarged and the ovaries are non-palpable. A colposcopy is performed and a biopsy is obtained. The histologic evaluation shows irregularly-shaped nests of squamous epithelium cells with large pleomorphic nuclei, inconspicuous nucleoli, a clear cytoplasm, and increased mitoses that infiltrate the stroma for greater than 10 mm. Which of the following investigations is the main method for staging the patient’s condition?

Answer: Clinical examination

Choices:
A. Pelvic MRI
B. Surgical evaluation
C. Clinical examination
D. Pelvic CT
E. PET-CT


Question: A 69-year-old man presents for surgery due to chronic painful diverticula in the sigmoid colon. The patient is a Jehovah's witness and refuses a transfusion of blood products even in an emergency. Which artery should be briefly clamped to prevent bleeding during the partial sigmoidectomy?

Answer: Inferior mesenteric artery

Choices:
A. Superior mesenteric artery
B. Inferior mesenteric artery
C. Celiac trunk
D. Inferior rectal artery
E. Splenic artery


Question: A thymic sample from a fetus is examined. One cell type found was double-positive for the CD4 and CD8 receptors. What is the identity of these double-positive cells?

Answer: Immature T-cells of the thymic cortex

Choices:
A. T-cell progenitors cells in the bone marrow
B. B-cells
C. Immature T-cells of the thymic cortex
D. Immature T-cells of the thymic medulla
E. Macrophages


Question:
An investigator is studying the antimicrobial resistance profile of a bacterial pathogen using disk diffusion testing. The pathogen is isolated onto agar plates and antibiotic wafers are added to the plates. The inhibitory zone diameters are then recorded and used to define susceptibility thresholds. The results of the testing for the pathogen shown:
Drug Susceptibility
Penicillin G Resistant
Cefazolin Resistant
Doxycycline Susceptible
Imipenem Resistant
Azithromycin Susceptible
Vancomycin Resistant
Which of the following is most likely the organism being studied?"

Answer: Ureaplasma urealyticum

Choices:
A. Staphylococcus aureus
B. Clostridioides difficile
C. Pseudomonas aeruginosa
D. Borrelia burgdorferi
E. Ureaplasma urealyticum


Question: A 30-year-old man comes to the physician for evaluation of infertility. He does not smoke, drink, or take any medications. Physical examination shows no abnormalities. Serum analysis shows anti-sperm antibodies. What is the most likely cause of this patient's serum finding?

Answer: Defect in Sertoli cell function

Choices:
A. Increase in testicular temperature
B. Dysgenesis of seminiferous tubules
C. Dysgenesis of vas deferens
D. Defect in Sertoli cell function
E.
Defect in GnRH production
"


Question: A mother calls the psychiatrist, saying that she is concerned about her 18-year-old son who has become quite emaciated over the past several months. She has noticed that his pupils are enlarged, he has frequent nose bleeds, and he wears long sleeve shirts even in warm weather. His personality has changed quite dramatically as well, as he repeatedly steals from her and sells anything valuable in the house. He also has become overconfident, aggressive, and paranoid. Which of the following is a risk of the drug that the son is most likely using?

Answer: Sudden cardiac arrest

Choices:
A. Serotonin syndrome
B. Sudden cardiac arrest
C. CNS white matter lesions
D. Irreversible schizophrenia-like psychosis
E. Increased risk of schizophrenia in predisposed patients


Question: A 48-year-old man is brought to the physician by his wife because he has become increasingly restless and anxious. His wife says that he has seemed sad and irritable for the past 4 months. He lost his job as a store clerk because he often lied to avoid work, and spent most of his days on the phone placing bets on football games. He avoids all family-related events because he has borrowed money from most of his relatives. He is hopeful that his symptoms will improve once he is able to win some of his money back. He previously smoked 8–10 cigarettes daily but quit 1 month ago. He drinks beer on the weekends. On examination, he is uncooperative and dismissive. He is mildly tremulous. Neurologic examination is normal. He is oriented to person, place, and time. Which of the following is the most likely diagnosis?

Answer: Gambling disorder

Choices:
A. Gambling disorder
B. Opioid withdrawal
C. Alcohol withdrawal
D. Bipolar II disorder
E. Adjustment disorder


Question: A 28-year-old man comes to the emergency department because of an excruciating headache that started 30 minutes ago. The pain is located around the right eye and it awoke him from sleep. Over the past two weeks, he has had similar headaches around the same time of the day, and he reports pacing around restlessly during these episodes. Physical examination shows conjunctival injection and tearing of the right eye. In addition to supplemental oxygen therapy, administration of which of the following drugs is most likely to provide acute relief in this patient?

Answer: Sumatriptan

Choices:
A. Sumatriptan
B. Ibuprofen
C. Amitriptyline
D. Prednisone
E. Oxycodone


Question: A 27-year-old woman presents with loss of consciousness at work. The patient’s colleagues say that she had been complaining of a headache all day. Her past medical history is significant for diabetes mellitus type 1. Her blood pressure is 70/60 mm Hg, pulse is 105/min, temperature is 37.2°C (99.0°F), and her respiratory rate is 28/min and shallow. On physical examination, there is a black eschar formation on her nose and her breath has a fruity odor. Laboratory findings are significant for serum glucose of 750 mg/dL, potassium of 3.3 mmol/L, and blood pH of 7.1. Which of the following diabetic complications is most likely the cause of this patient’s presenting symptoms?

Answer: Diabetic ketoacidosis

Choices:
A. Diabetic ketoacidosis
B. Hyperosmolar coma
C. Lactic acidosis
D. Hypoglycemic coma
E. Hemorrhagic stroke


Question: A 61-year-old male presents to his primary care doctor with a six-month history of progressively worsening cough, shortness of breath, and 15-pound weight loss. Over the same time period, he has also started to notice occasional weakness in his legs that has made it difficult for him to stand up from his chair and climb stairs. The weakness appears to improve when he exercises at his local aerobics class. His past medical history is notable for hypertension and hyperlipidemia. He has smoked 2 packs of cigarettes per day for 35 years. Chest radiographs demonstrate a perihilar mass in his right lung. A biopsy of the lung lesion is shown. Which of the following is most likely true about this patient?

Answer: His weakness improves when calcium builds up in the presynaptic nerve terminal

Choices:
A. His weakness is due to a type III hypersensitivity reaction
B. He is at high risk of developing extraocular weakness
C. His weakness is due to antibodies directed against post-synaptic, voltage-gated ion channels
D. Administering a cholinesterase inhibitor will improve his symptoms
E. His weakness improves when calcium builds up in the presynaptic nerve terminal