Question: A 45-year-old man with a history of hypertension, IV drug use, and type 1 diabetes is brought to the emergency room due to nausea, vomiting, and altered consciousness. He was brought in by his sister who found him asleep on her couch. He is difficult to arouse and does not respond to questions. His sister does not know his medications; however, he has a known history of medication noncompliance. On physical exam his temperature is 99°F (37.2°C), blood pressure is 100/70 mmHg, pulse is 112/min, respirations are 26/min, and pulse oximetry is 99% on room air. He is arousable but is not cooperative with the exam. His breaths are deep and you notice a fruity-smell coming from his mouth. Exam is otherwise unremarkable. Which of the following findings would you also expect to see in this patient?

Answer: Decreased total body potassium

Choices:
A. Decreased total body potassium
B. Decreased lactate concentration
C. Increased bicarbonate concentration
D. Decreased hydrogen ion concentration
E. Decreased free fatty acid concentration


Question: A 31-year-old woman and her 32-year-old husband come to the physician because they have not been able to conceive since they married 1.5 years ago. They are sexually active and have not used any form of contraception during this period. She was diagnosed with cervicitis due to Chlamydia trachomatis infection 4 years ago, which was treated with oral azithromycin. The wife reports that she has regular menses and is otherwise healthy. Her last menstrual bleeding was 2 weeks ago. Neither partner shows abnormalities on physical examination. Which of the following is the most appropriate next step in management?

Answer: Semen analysis

Choices:
A. Clomiphene citrate challenge test
B. Chromosomal karyotyping
C. Postcoital testing
D. Post-ejaculatory urinalysis
E. Semen analysis


Question: A 66-year-old man comes to the physician with a 4-month history of recurrent crusty lesions on the dorsal surface of his hands. When he scrapes off the crusts, they reappear after a few days. The lesions are mildly pruritic and occasionally burn. He works as a landscaper. A photograph of his right hand is shown. Which of the following is the most likely diagnosis?

Answer: Actinic keratosis

Choices:
A. Sporotrichosis
B. Basal cell carcinoma
C. Actinic keratosis
D. Lichen planus
E.
Seborrheic keratosis
"


Question: A 50-year-old woman presents to the emergency department with severe abdominal pain and discomfort for several hours. She says that the pain started suddenly and rates it as an 8/10 pain. There are no exacerbating factors but the pain gets relieved by leaning forward. She also complains of nausea and vomiting. She has vomited 4 times in the last 2 hours. Her past medical history is significant for HIV, diabetes, asthma, depression, and acute angle glaucoma. She states that she is very diligent with her medications and has never missed a pill. She says that she does not smoke or drink alcohol. Her temperature is 37°C (98.6°F), respirations are 15/min, pulse is 97/min, and blood pressure is 102/98 mm Hg. On examination, she is pale, diaphoretic, and in extreme discomfort. She does not allow an abdominal exam. Laboratory results show a serum amylase of 456 U/L and a serum lipase of 562 U/L. Treatment of which of the following conditions most likely led to this patient's current condition?

Answer: Acquired immunodeficiency syndrome

Choices:
A. Asthma
B. Acute angle glaucoma
C. Acquired immunodeficiency syndrome
D. Depression
E. Diabetes


Question:
A 66-year-old man is brought to the emergency department after 3 consecutive days of nausea and multiple episodes of vomiting every day. He has been receiving cisplatin as part of treatment for small cell lung carcinoma diagnosed about a year ago. Upon admission, he is found to be drowsy with muscle weakness. The patient’s vital signs are as follows: blood pressure is 98/60 mm Hg, heart rate is 120/min, respiratory rate is 14/min, and body temperature is 36.5°C (97.7°F). Physical examination reveals a mildly cachectic male with mild abdominal tenderness to palpation. The following tests are performed:
Laboratory test
Serum Na+ 136 mEq/L
Serum Cl- 78 mEq/L
Serum K+ 3.0 mEq/L
Serum creatinine (SCr)  1.0 mg/dL
    Arterial blood gas
pH 7.58
PO2 95 mm Hg
PCO2 49 mm Hg
SO2% 98%
HCO3- 44.4 mEq/L
Which of the following is the most likely cause of this patient’s acid-base abnormality?

Answer: Excessive hydrogen ion loss

Choices:
A. Increased potassium secretion
B. Excessive hydrogen ion loss
C. Carbon dioxide retention
D. Increased bicarbonate absorption
E. Decreased bicarbonate excretion


Question: A 30-year-old woman presents with a white patch on her tongue that she noticed a few weeks ago. She denies any changes in taste sensation or pain, weight loss, or night sweats. Past medical history is significant for a 10-year history of type 1 diabetes mellitus, managed currently on insulin therapy. Her last HbA1c a month ago was 9%. On physical examination, there are white patches present over the dorsum of her tongue (as seen in the image) that can easily be scraped off. Microscopic examination of KOH treated scrapings shows pseudohyphae. The patient is advised to have better blood glucose control and is prescribed a drug for these oral patches, which she is instructed to swish in her mouth for several minutes and then swallow. Which of the following best describes the mechanism of action of this drug?

Answer: Disruption of cell membrane integrity

Choices:
A. Inhibition of synthesis of lanosterol
B. Inhibit of synthesis of ergosterol
C. Inhibit of cell wall synthesis
D. Disruption of cell membrane integrity
E. Inhibition of nucleic acid synthesis


Question: A 34-year-old African-American woman comes to the physician because of a 6-month history of fatigue, increasing shortness of breath on exertion, and a dry cough. She also has chronic constipation with bowel movements once every two to three days. She has not had fevers, night sweats, or weight loss. She has a history of hypertension and arthritis of both ankle joints. Current medications include hydrochlorothiazide and daily multivitamins. Her vital signs are within normal limits. Her serum sodium is 138 mEq/L, potassium is 3.9 mEq/L, and calcium is 11.5 mg/dL. An x-ray of the chest shows bilateral hilar lymphadenopathy and normal lung parenchyma. Which of the following is the most likely cause of this patient's hypercalcemia?

Answer: Elevated 1,25-dihydroxyvitamin D3 levels

Choices:
A. Elevated 1,25-dihydroxyvitamin D3 levels
B. PTH-related protein production
C. Thiazide-induced renal calcium reabsorption
D. Chronic kidney disease
E.
Vitamin A toxicity
"


Question: A 78-year-old man comes to the physician because of difficulty swallowing and regurgitation of undigested food for the past several months. The patient reports that his symptoms have gotten progressively worse. Physical examination shows severe halitosis and a gurgling sound after he swallows a small amount of water. Results of fluoroscopic barium esophagography are shown. The nerve responsible for motor innervation of the affected muscle is also responsible for which of the following functions?

Answer: Parasympathetic innervation of the AV node

Choices:
A. Parasympathetic innervation of the AV node
B. Sensory innervation of the posterior tongue
C. Visceral sensory innervation of the carotid sinus
D. Motor innervation of the ventral tongue
E. Somatosensory innervation of the semi-circular canals


Question: A 1-day-old boy is brought to the emergency department by ambulance after his parents found him to be increasingly lethargic. He was born at home with inconsistent prenatal care. Since then, his parents report that his head appears to be getting bigger over the past few hours. He also feeds poorly and has had a few episodes of vomiting. On presentation, he is found to have limb spasticity with adducted thumbs. His head circumference is bigger than expected and he appears to be unable to look up when following objects. Which of the following findings would most likely also be seen in this patient?

Answer: Obstruction of the cerebral aqueduct

Choices:
A. Abnormally large posterior fossa
B. Downwardly displaced cerebellum
C. Elongated facial structure
D. Obstruction of the cerebral aqueduct
E. Tuft of hair on the spine


Question: A 48-year-old woman presents to the emergency department with a 2-day history of chest pain. The patient’s symptoms started gradually after moving heavy objects during packing. The pain is constant and nagging but intensifies with lateral movement. The patient has no history of serious illness and takes no medications, currently. She does not smoke. Her vitals are as follows: blood pressure 125/75 mm Hg; pulse 75/min; respiratory rate 14/min; and temperature 36.9℃ (98.4℉). Examination of the anterior chest wall shows the absence of swelling, erythema, or warmth. The 3rd and 4th left rib bones are tender anteriorly near the sternum. An electrocardiogram is shown. The test for cardiac troponin I is negative. Which of the following is the most appropriate initial step in the management of this patient?

Answer: Ibuprofen

Choices:
A. Ibuprofen
B. Intercostal nerve block
C. Local injection of lidocaine (for Tietze syndrome, which is unresponsive to NSAIDs)
D. Serial ECG for 12 hours
E. Sublingual nitroglycerin


Question: A 28-year-old woman who recently immigrated from Kenya presents with fatigue, shortness of breath, and palpitations for a few weeks. Review of systems is significant for a painful swollen knee. The patient is afebrile, and her vital signs are within normal limits. On physical examination, her voice seems hoarse, although her pharynx does not show signs of an inflammatory process. Cardiopulmonary auscultation is significant for a loud first heart sound with a split second heart sound and a mid-diastolic rumbling murmur with an opening snap best heard over the cardiac apex. Transthoracic echocardiography shows a calcified mitral valve with an opening area of 1.5 cm2 (normal: 3.0–3.5 cm2). The patient is recommended to have her mitral valve replaced because of the risk for complications such as atrial fibrillation which may lead to the formation of a life-threatening blood clot that can travel to other parts of the body. Which of the following organs is most likely to be spared in this patient?

Answer: Lungs

Choices:
A. Lungs
B. Kidneys
C. Spleen
D. Brain
E. Small bowel


Question: A 14-year-old girl with a BMI of 17 complains of frequent urination, excessive thirst, and abdominal pain. Her parents have noticed that she appears to have lost some weight. Her past medical history is significant for celiac disease. A random plasma blood glucose is 267 mg/dL. Which of the following is a property of the hormone that is deficient in this patient?

Answer: Enhances potassium uptake

Choices:
A. Down-regulates glycogen synthase activity
B. Up-regulates glycogen phosphorylase activity
C. Enhances potassium uptake
D. Downregulates HMG-CoA reductase
E. Crosses the placenta to affect the fetus


Question:
A 37-year-old woman presents to her primary care physician with a 6-month history of fatigue. She denies any recent history of fevers, chills or headaches. She does not smoke or drink alcohol. A CBC demonstrates a microcytic anemia. Iron studies are ordered and demonstrate the following:
Serum iron: 40 µg/dL (normal 50–170 µg/dL);
TIBC: 230 µg/dL (normal 250–370 µg/dL);
Transferrin saturation: 10% (normal 15–50%);
Serum ferritin: 180 µg/L (normal 15-150 µg/L);
Which of the following is a likely cause of this patient's iron studies findings?

Answer: Rheumatoid arthritis

Choices:
A. Lead poisoning
B. Dysfunctional uterine bleeding
C. Splenic sequestration of RBCs
D. Rheumatoid arthritis
E. RBC enzyme deficiency


Question: A 32-year-old man presents with epigastric gnawing pain occurring after meals. Occasionally, dull pain awakens him at night. He also complains of bloating and occasional constipation. He has been having these symptoms for almost 2 years and uses antacids and castor oil for relief. Recently, he began to note that these remedies provide less relief than in the past. He reports no significant weight loss, night sweats, or a change in stool color. He has no family history of peptic ulcer disease or gastrointestinal malignancies. The patient does not smoke cigarettes but drinks alcohol occasionally. He rarely uses NSAIDs for symptomatic treatment. His blood pressure is 120/80 mm Hg, heart rate is 85/min, respiratory rate is 14/min, and temperature is 36.6°C (97.9°F). A physical examination revealed epigastric tenderness on palpation and the abdomen was distended. A urea breath test was performed, which was positive. Which of the following statements regarding the test results in this patient is true?

Answer: The causative agent possesses urease; thus, it is possible to detect urease by giving the patient urea with labeled C-14 orally and then measuring the carbon dioxide content in the exhaled breath.

Choices:
A. The test detected increased ammonia content in the patient’s exhaled breath with qualitative tests for ammonia detection.
B. The test detected products of increased cellular breakdown by the causative agent induced by urea ingestion.
C. The causative agent possesses urease; thus, it is possible to detect urease by giving the patient urease with labeled N-14 orally and then measuring the ammonia content in the exhaled breath.
D. The causative agent possesses urease; thus, it is possible to detect urease by giving the patient urea with labeled C-14 orally and then measuring the carbon dioxide content in the exhaled breath.
E. The causative agent possesses urease; thus, it is possible to detect urease by giving the patient urease and then measuring the pH of the exhaled breath to determine whether or not there was an increased breakdown of ammonia.


Question: A 45-year-old man is brought into the emergency department after he was found collapsed in a housing development stairwell. He was found in a pool of vomit, barely breathing. Used syringes and a tourniquet were found near the patient. His blood pressure is 100/70 mm Hg, pulse is 65/min, and respiratory rate is 6/min. Physical examination reveals a thin and disheveled man with track marks on both arms. The appropriate reversal agent is administered. Which of the following findings would be most likely seen in this patient as a result of administering  this reversal agent?

Answer: Yawning

Choices:
A. Yawning
B. Miosis
C. Smooth skin
D. Pupil constriction
E. Tremulousness


Question: A 33-year-old woman comes to the physician because of a 1-year history of irregular menses and infertility. She has a history of an eating disorder and has received dietary and behavioral therapy over the past 6 months with minimal improvement in her symptoms. She is 170 cm (5 ft 7 in) tall and weighs 49 kg (104 lb); her BMI is 17 kg/m2. Physical examination is significant for pallor and thin, soft, depigmented hair on the arms and back. After an extensive workup, the physician recommends pulsatile GnRH therapy. One week after initiating therapy, a pelvic ultrasound shows a 24-mm hypoechogenic cavity in the right ovary. The patient subsequently receives a drug that results in the resumption of meiosis and the loss of gap junctions between the cumulus granulosa cells and the oocyte. This patient most likely received which of the following drugs?

Answer: Human chorionic gonadotropin

Choices:
A. Follicle-stimulating hormone
B. Mifepristone
C. Human chorionic gonadotropin
D. Medroxyprogesterone
E. Cyproterone citrate


Question: A 52-year-old woman visits her primary care practitioner, who has been following her closely after she was diagnosed with peptic ulcer disease. She tested positive for H. pylori in a urea breath test, which was later confirmed by an endoscopic biopsy. Her family history is significant for colorectal carcinoma, as well as ovarian cancer. Her past medical history is relevant for cigarette smoking and peptic ulcer disease, which has been under treatment twice, initially with a clarithromycin-containing regime. This was followed by a bismuth-containing regime after a fecal antigen test was positive 4 weeks later. A recent endoscopy and fecal antigen test detected H. pylori in her stomach mucosa. In addition to a protein pump inhibitor (PPI), which of the following should be added to the treatment regime of this patient?

Answer: Levofloxacin, amoxicillin

Choices:
A. Bismuth subsalicylate, metronidazole, tetracycline
B. Levofloxacin, amoxicillin
C. Levofloxacin, nitazoxanide, and doxycycline
D. Clarithromycin, amoxicillin
E. Rifabutin, amoxicillin


Question: An 8-year-old boy is brought to the pediatrician’s office with his mother for a routine check-up. Although her son is doing well, the mother has some concerns with regards to his overall health. He was born at 39 weeks gestation via spontaneous vaginal birth. He is up to date on all vaccines and has met most of developmental milestones. She reports that he is shorter than his classmates and seems less developed physically than his older brother and sister when they were his age. Additionally, the boy’s teacher has some concerns regarding his learning capability not being at the level of his peers. His height and weight are at the 10th and 15th percentile respectively. He has a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F). At physical exam the child appears cheerful, well developed, and well nourished. He is small for his age. with upslanting palpebral fissures, flat occiput, low set ears, and a flat nose. Which of the following techniques would most likely identify the cause of this patient’s presentation?

Answer: Karyotype

Choices:
A. Punnett square
B. LOD score
C. Karyotype
D. Polymerase chain reaction
E. Gene mapping


Question: A 55-year-old woman visits her primary care provider for concerns of frequent headaches. She complains of recurrent headaches and involuntary weight loss, which she attributes to a constant pain along the right side of her jaw that occasionally radiates to her right eye. Her past medical history includes diabetes mellitus type 2 and chronic glomerulonephritis resulting in stage II chronic kidney disease. Her mother passed away in her 70s and had been diagnosed with multiple sclerosis at the age of 50. Today, her blood pressure is 135/90 mm Hg, heart rate is 88/min, respiratory rate is 15/min, and temperature is 36.6°C (97.9°F). The right side of her face is painful to palpation from her jaw to the right side of her scalp. Which of the symptoms below is most commonly associated with the patient’s condition?

Answer: Neck stiffness

Choices:
A. Limb muscle weakness
B. Neck stiffness
C. Diplopia
D. Heliotrope rash
E. Shock-like pain in face


Question: A 66-year-old man presents to his primary care provider for a routine checkup. He says that he feels well overall but has experienced some intermittent back pain and vague epigastric pain over the past 6 months. He also has experienced cramping in both legs that is worse whenever he walks for long periods of time. He has a history of poorly controlled hypertension, diabetes mellitus, recurrent renal stones, and major depressive disorder. He takes lisinopril, nifedipine, metformin, glyburide, and fluoxetine. He has a 55-pack-year smoking history and drinks alcohol socially. His temperature is 98.4°F (36.9°C), blood pressure is 155/85 mmHg, pulse is 92/min, and respirations are 16/min. On exam, he is well-appearing and in no acute distress. A normal S1 and S2 are heard on auscultation. He has no abdominal tenderness to palpation. A light pulsatile mass is felt in the mid-epigastrium. Achilles and patellar reflexes are 2+ bilaterally. His gait is normal. Which of the following additional findings is most strongly associated with this patient’s condition?

Answer: Abdominal bruit

Choices:
A. Abdominal bruit
B. Asymmetric upper extremity pulses
C. Continuous machine-like murmur
D. Costovertebral tenderness
E. Diastolic decrescendo murmur


Question: A 17-year-old male collapses 25 minutes into a soccer game. He is unresponsive and pulseless. Despite adequate resuscitation by a bystander, the patient is pronounced dead when the ambulance arrives. The patient had no past medical history other than a heart murmur as a child and he took no medications. His family history is notable for an uncle who died suddenly of unknown causes at the age of 25. A mutation in which of the following proteins most likely contributed to this patient’s condition?

Answer: Myosin heavy chain

Choices:
A. Myosin heavy chain
B. Dystrophin
C. Tropomyosin
D. Fibrilin
E. Elastin


Question: A 36-year-old woman, gravida 3, para 2, at 31 weeks' gestation comes to the emergency department because of painless, bright red vaginal bleeding for one day. She has not felt any contractions. Her other children were delivered by Cesarean section because of breech position. Fetal heart rate is reactive with no decelerations. Which of the following findings is most likely on ultrasound?

Answer: Placenta over the cervical os

Choices:
A. Retroplacental hematoma
B. Adnexal bleeding
C. Placenta over the cervical os
D. Gestational sac in a dilated cervix
E. Membranous umbilical vessels


Question: A 24-year-old man is brought to the emergency department for bowling at a local bowling alley while inappropriately dressed. The patient refused to speak with police and was seen conversing with inanimate objects in the back of the police car. The patient states that his clothes were contaminated by assassins who have been tracking him for years. The patient refuses to answer any further questions, and continues to whisper toward someone else. The patient has a past medical history of homelessness, alcohol abuse, marijuana use, and cocaine abuse. Physical exam is notable for a healthy young man who seems mistrustful of all hospital personnel. The patient is started on a medication and is transferred to the psychiatric inpatient unit. The patient’s condition improves, but he still often speaks of a contamination that is on his clothes and skin that is coming from external parties. The patient is started on a new medication. He is then sent to group therapy, followed by physical activity in the yard. The physician is called over when the patient is found down in the recreation yard while he was exercising. The patient is not responsive, and his limbs seem to resist passive force. His temperature is 104°F (40°C), pulse is 112/min, blood pressure is 140/90 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air. Which of the following best describes the most likely diagnosis?

Answer: Dopamine blockade

Choices:
A. Defective ryanodine receptor
B. Dehydration
C. Dopamine blockade
D. Inadequate evaporative cooling
E. Infection


Question:
A 23-year-old male presents to the emergency department after he was found naked wandering his neighborhood. The patient is disheveled and has not bathed in months. The patient has a past medical history of alcohol abuse and schizophrenia that is well controlled with haloperidol. The patient is started on haloperidol and most of his symptoms improve dramatically; however, he continues to refuse to eat food from the hospital as he believes it to be contaminated. The patient stays on the inpatient psychiatric unit and lab values are drawn and return as follows:

Serum:
Na+: 135 mEq/L
K+: 3.0 mEq/L
Cl-: 92 mEq/L
HCO3-: 22 mEq/L
BUN: 7 mg/dL
Ca2+: 8.4 mg/dL
Creatinine: 0.6 mg/dL
Glucose: 70 mg/dL

That patient is started on an intravenous solution containing potassium chloride and is closely monitored. His oral intake also seems to be improving. Lab values are ordered again the following day and return as follows:

Serum:
Na+: 137 mEq/L
K+: 2.9 mEq/L
Cl-: 95 mEq/L
HCO3-: 22 mEq/L
BUN: 8 mg/dL
Ca2+: 9.0 mg/dL
Creatinine: 1.0 mg/dL
Glucose: 77 mg/dL

The patient is continued on IV fluids and his clinical symptoms seem to further improve. Repeat labs the following three days remains largely unchanged. The patient's symptoms improve and he is determined to be at his baseline in terms of functioning. Which of the following is the best next step in management?

Answer: IV fluids containing magnesium

Choices:
A. Discharge the patient on IM haloperidol
B. Discharge the patient on oral haloperidol
C. IV fluids containing potassium
D. IV fluids containing magnesium
E. Increase oral intake


Question: A 2-year-old girl is brought to the physician because of high-grade fever and crying while passing urine. Four months ago, she was treated for a febrile urinary tract infection with cefixime. There is no family history of serious illness. Her temperature is 39.2°C (102.6°F) and pulse is 123/min. Physical examination shows no abnormalities. Urine dipstick shows leukocyte esterase; urinalysis shows WBCs. Urine culture shows Escherichia coli sensitive to cefixime. A voiding cystourethrogram is shown. Without treatment, which of the following is this patient most likely to develop?

Answer: Renal scarring

Choices:
A. Renal cell carcinoma
B. Hypotension
C. Renal scarring
D. Ureter stenosis
E. Nephrotic syndrome


Question: A 37-year-old man presents to his primary care physician with a chief complaint of diarrhea. The patient states that his symptoms have worsened recently. He works as a farmer and is dressed in tattered and old denim. He lives alone, and this is the first time he has come to town in years. The patient’s diet is mostly dairy products and some meat products. He denies any systemic symptoms and states that diarrhea tends to occur right after a meal. He also claims that at times he struggles to fall asleep, and sometimes he feels he lacks energy. The patient is instructed to avoid consuming dairy products for a week and to return with a report of his symptoms. As you set up the return appointment with this patient you notice that he is rather emotionless. He also states that he lacks anybody that he can list as an emergency contact so he leaves that section of his medical forms blank. What is the most likely diagnosis?

Answer: Schizoid personality disorder

Choices:
A. Antisocial personality disorder
B. Avoidant personality disorder
C. Major depressive disorder
D. Schizoid personality disorder
E. Schizotypal personality disorder


Question: A 77-year-old man presents to the emergency department with a change in his mental status. The patient’s daughter states that he can cook and clean up after himself and only needs help paying bills. Yesterday the patient seemed fine; however, this morning she noticed that he struggled to perform simple tasks and was forgetful while cooking, leaving the stove on. They recently returned from a trip to Mexico and admit to drinking unfiltered water and eating local cuisines while abroad. The patient has a past medical history of hypertension and diabetes. His temperature is 97.5°F (36.4°C), blood pressure is 187/118 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 100% on room air. Which of the following is the most likely diagnosis?

Answer: Vascular dementia

Choices:
A. Alzheimer dementia
B. Frontotemporal dementia
C. Lewy body dementia
D. Normal pressure hydrocephalus
E. Vascular dementia


Question:
A 65-year-old male with a past medical history of left ventricular hypertrophy presents to the emergency room because of a history of progressive shortness of breath and a cough productive of frothy pink sputum. Physical examination reveals crackles at the lung bases bilaterally. The patient denies fever, chills, or any recent infection. A radiograph of the chest shows septal lines and areas of opacification in both lung fields (see image).
Which of the following most likely accounts for this patient’s dyspnea?

Answer: Alveolar and interstitial fluid accumulation

Choices:
A. Obstruction of blood flow through pulmonary arteries
B. Destruction of interalveolar septa
C. Excess mucous production in bronchiolar epithelium
D. A collection of air in the pleural space
E. Alveolar and interstitial fluid accumulation


Question: A 42-year-old man is brought to the emergency department because of several episodes of black, tarlike stool and lightheadedness over the past couple of days. He underwent an appendectomy at the age of 16. He has hypertension and tension headaches. He drinks 4 beers daily. Current medications include amlodipine and naproxen. His temperature is 36.7°C (98°F), pulse is 100/min, and his blood pressure is 100/70 mm Hg. The lungs are clear to auscultation bilaterally. The abdomen is soft, nondistended, and nontender. The liver is palpated 3 cm below the right costal margin. His hemoglobin concentration is 10 g/dL. Intravenous fluid resuscitation is begun. An esophagogastroduodenoscopy is performed, which does not show bleeding. Which of the following is the most appropriate next step in management?

Answer: Colonoscopy

Choices:
A. Double-balloon enteroscopy
B. Capsule endoscopy
C. Colonoscopy
D. Laparotomy
E.
Angiography
"


Question:
A 68-year-old man comes to the physician because of constipation and decreased appetite during the past several months. In the past 2 weeks, he has also noticed an increasing frequency of urination. He has not had any dysuria or flank pain. He has a history of hypertension, calcium pyrophosphate crystal arthritis, and alcoholic cirrhosis. Current medications include hydrochlorothiazide, rifaximin, lactulose, and naproxen as needed for the joint pain. He quit drinking 5 years ago. He does not smoke cigarettes. His vital signs are within normal limits. Physical examination shows decreased bowel sounds but is otherwise unremarkable. Serum studies show:
Creatinine 1.1 mg/dL
Calcium 11.8 mg/dL
Phosphorus 2.1 mg/dL
Magnesium 1.6 mg/dL
Total protein 6 g/dL
Albumin 3.1 g/dL
AST 53 U/L
ALT 43 U/L
Which of the following is the most appropriate next step in diagnosis?"

Answer: Serum parathyroid hormone level

Choices:
A. Serum parathyroid-related protein level
B. Urine and serum protein electrophoresis
C. Serum parathyroid hormone level
D. 24-hour urine calcium level
E. X-ray of the chest


Question: A 68-year-old African American male presents to his primary care provider complaining of progressively worsening back pain. The pain is localized to the lower back and sometimes wakes him up from sleep. He has a history of hypertension and admits to a 50 pack-year smoking history. Further questioning reveals that he has also experienced fatigue and an unintentional weight loss of 18 pounds over the past year. Laboratory analysis is notable for an elevated alkaline phosphatase. A radiograph of the patient’s spine demonstrates multiple sclerotic lesions in the lumbar vertebral bodies. Which of the following tests would most likely confirm the diagnosis in this patient?

Answer: Transrectal ultrasound-guided prostate biopsy

Choices:
A. Renal biopsy
B. Serum protein electrophoresis
C. Fine needle aspiration of the thyroid
D. Transrectal ultrasound-guided prostate biopsy
E. Chest radiograph


Question: A 75-year-old man presents to his primary care physician because he has been experiencing increasing muscle and joint pain over the last 3 months. He says that he also feels increasingly fatigued and weak despite no change to his daily routine. His past medical history is significant for an infection when he was 12 years of age that led to 2 months of paralysis and mechanical ventilation through a tracheostomy tube. At the time, he developed the paralysis after 3 days of fever and sore throat. He recalls that he was still able to feel everything and was embarrassed that his daily activities had to be performed for him by caregivers. The most likely cause of this patient's symptoms is associated with which of the following structures?

Answer: Naked (+) stranded RNA virus

Choices:
A. DNA virus
B. Enveloped (+) stranded RNA virus
C. Enveloped (-) stranded RNA virus
D. Naked (+) stranded RNA virus
E. Naked (-) stranded RNA virus


Question: A 2-year-old boy was rushed to the emergency department in the early morning by his mother because he was unresponsive to deep pain stimuli. The patient’s mother said that he has been suffering from a fever, cough and runny nose for the last 10 days. 2 days ago, they visited a free clinic and received medication. When she gave him the medication yesterday, the patient had 3 episodes of vomiting and his condition rapidly worsened. This morning, the patient did not wake up, even after multiple attempts. On physical examination, the patient is febrile, hypotensive, and tachycardic. Peripheral pulses are 1+, and his extremities are pale and cool to touch. Pupils are equal and slowly reactive to light. Significant hepatomegaly is noted. Which of the following is the most likely etiology of this patient’s symptoms?

Answer: Decrease in beta-oxidation

Choices:
A. Decrease in electron transport chain
B. Decrease in beta-oxidation
C. Increase in gluconeogenesis
D. Increase in beta-oxidation
E. Increase in glycolysis


Question: A 24-year-old patient presents to your gastroenterology practice on a referral from her primary care provider. The patient has been experiencing postprandial bloating and abdominal pain for one year. Symptoms occur following the ingestion of milk products. Which of the following drugs has a mechanism of action that is similar to the pathophysiology of this patient's disease?

Answer: Magnesium hydroxide

Choices:
A. Omeprazole
B. Bismuth
C. Ranitidine
D. Octreotide
E. Magnesium hydroxide


Question: In which location is dimeric IgA most likely to be found in highest concentrations?

Answer: Colostrum

Choices:
A. Colostrum
B. Blood from the fetus
C. Blood from the mother
D. Fetal bone marrow
E. Fetal thymus


Question: A 25-year-old man presents to the ER after a street fight. His girlfriend reports that he was struck with a bat in the head. After the initial hit, she reported that he briefly lost consciousness but then was normal for several hours. Since then, he has been rapidly decompensating. He is grabbing his head in pain and his mental status is altered. Vital signs are stable. Neurological exam reveals that his right pupil is dilated and his right lid is drooping. If this patient's symptoms are allowed to progress without intervention, which of the following would be expected to occur?

Answer: Right sided hemiparesis

Choices:
A. Right sided hemiparesis
B. Left sided hemiparesis
C. Down and in gaze of the right pupil
D. Right sided homonymous hemianopsia.
E. Right eye with an inability to abduct


Question: A 7-year-old girl is brought to the emergency department because of diffuse abdominal pain and multiple episodes of vomiting for 2 hours. She started developing fever, headache, and neck pain 3 days ago. On arrival, she is unresponsive. Her temperature is 40.3°C (104.5°F) and palpable blood pressure is 45 mm Hg. Physical examination shows diffuse purpuric skin lesions. In spite of all appropriate therapy, she dies shortly thereafter. Autopsy shows massive parenchymal hemorrhage of the adrenal glands. Which of the following was the portal of entry for the most likely causal organism?

Answer: Nasopharynx

Choices:
A. Nasopharynx
B. Genital mucosa
C. Choroid plexus
D. Gastrointestinal tract
E. Skin


Question: A 50-year-old female comes to the emergency department with sudden onset left-sided calf pain starting 20 minutes ago. Her past medical history is notable for diabetes, hypertension, and chronic atrial fibrillation controlled on an anti-arrhythmic. Upon arrival to the emergency department, her blood pressure is 150/91 mmHg, pulse is 100/min, and respirations of 22/min. Examination of the leg reveals a pale left calf with diminished dorsalis pedis and posterior tibial pulses. Prompt intervention relieves the patient’s symptoms. Which of the following, if seen microscopically, would indicate that her calf myocytes are more likely to recover without permanent damage?

Answer: Cellular swelling

Choices:
A. Cellular swelling
B. Mitochondrial vacuolization
C. Nuclear pyknosis
D. Plasma membrane damage
E. Fragmented cells and debris


Question: A 56-year-old man comes to the physician because of progressive worsening of vision in both his eyes over the past 6 months. He reports that he first noticed some blurring of his vision and glare in the evenings, which have both gotten worse in this period. He works as a tower crane operator and spends most of his day outdoors. Ophthalmologic examination shows visual acuity of 20/100 in both eyes. A photograph of the eye is shown. Damage to which of the following structures is most likely responsible for this patient's current symptoms?

Answer: Lens

Choices:
A. Aqueous humor
B. Cornea
C. Vitreous body
D. Lens
E. Retina


Question:
A 25-year-old man presents to the clinic with the complaint of yellow discoloration of his skin. He reports that the discoloration appeared gradually over the past 5 days. He does not have any other complaints. He never had similar symptoms before. Past medical history is only significant for a recent flu infection that was so bad that he missed work for a week. Physical exam is significant for yellow sclera and slight yellowish discoloration of the skin over the face and neck. Liver function tests reveal:
Total bilirubin level 5 mg/dL
Direct bilirubin level 0.4 mg/dL
Aspartate aminotransferase (AST) 25 U/L
Alanine aminotransferase (ALT) 15 U/L
What is the most likely pathology giving rise to this patient’s condition?

Answer: Decreased conjugation of bilirubin by uridine-diphosphate glucuronyltransferase

Choices:
A. Decreased hepatic uptake of unconjugated bilirubin
B. Decreased conjugation of bilirubin by uridine-diphosphate glucuronyltransferase
C. Bile duct obstruction
D. Hemolysis
E. Decreased transport of bile into the bile canaliculi


Question: A 17-year-old girl is brought to the physician by her father because of concerns about her behavior. She worries excessively about her weight and body image, and has frequent diarrhea. She is 170 cm (5 ft 7 in) tall and weighs 63.5 kg (140 lb); BMI is 22 kg/m2. She appears anxious but well. Vital signs are within normal limits. Physical examination shows calluses on the knuckles of her right hand. Further evaluation of this patient is most likely to show which of the following findings?

Answer: Parotid gland swelling

Choices:
A. Lanugo body hair
B. Parotid gland swelling
C. Elevated blood pressure
D. Right upper quadrant tenderness
E. Jugular venous distention


Question: A 36-year-old woman comes to the emergency department because of left wrist pain and swelling that started immediately after a fall. She was walking her dog when the dog abruptly pulled away, causing her to fall forward onto both hands. Physical examination shows left wrist pain with pinching and grasping, moderate swelling, and mild tenderness. Her left thumb is placed in a thumb immobilization splint. An x-ray of the wrist 2 days later is shown. The most likely cause of these findings is a fracture of which of the following bones?

Answer: Scaphoid

Choices:
A. Scaphoid
B. Ulna
C. Radius
D. Lunate
E. Hamate


Question: A 2200-g (4-lb 14-oz) newborn is delivered at term to a 37-year-old primigravid woman. Apgar scores are 6 and 8 at 1 and 5 minutes, respectively. Examination in the delivery room shows that he is at the 2nd percentile for head circumference and at the 10th percentile for length. He has a small jaw, small eyes, and low-set ears. There is a keyhole-shaped defect in the iris of the left eye. He has seven fingers on each hand. There is an opening in the roof of the mouth extending into the soft and hard palate bilaterally. Cleft lip and cleft palate are present. A 3/6 holosystolic murmur is heard at the left lower sternal border. The heels are prominent, with convex-shaped deformity of the plantar surface of the feet. Which of the following is the most likely cause of these findings?

Answer: Trisomy 13

Choices:
A. Fragile X syndrome
B. Trisomy 21
C. Trisomy 18
D. Fetal alcohol syndrome
E. Trisomy 13


Question: A 55-year-old woman is rushed to the emergency department after being found lying unconscious in a burning house by a firefighter. No history can be obtained. Her vital signs include pulse 130/min and respirations 16/min. Physical examination reveals soot all over her face. Scattered wheezes can be heard on auscultation of the chest. A thorough survey of the body shows no evidence of any burn injuries. Which of the following changes in the oxygen-hemoglobin curve would most likely be expected in this patient?

Answer: The curve would be shifted left due to an increased oxygen binding affinity by hemoglobin.

Choices:
A. The curve would be shifted left due to an increased oxygen binding affinity by hemoglobin.
B. The curve would be shifted left due to metabolic acidosis in peripheral tissues.
C. The curve would be unchanged because all the hemoglobin molecules are bound to a gas molecule.
D. The curve would be unchanged because the partial pressure of oxygen is unchanged.
E. The curve would be shifted right due to decreased hemoglobin affinity for oxygen.


Question: A 73-year-old man with a past medical history significant for high blood pressure, hypothyroidism, and diabetes presents to the outpatient clinic. He complains of joint pain, muscle pain, and fatigue that has been present for the last several weeks. On examination, you notice a butterfly-shaped rash across the bridge of his nose and cheeks. He has a blood pressure of 124/72 mm Hg and heart rate of 64/min. Of the following, which medication is most likely responsible for his presentation?

Answer: Hydralazine

Choices:
A. Verapamil
B. Clonidine
C. Labetalol
D. Hydralazine
E. Terazosin


Question: A 65-year-old woman with a 6-month history of acute promyelocytic leukemia managed with all-trans-retinoic acid presents with severe abdominal pain, nausea, vomiting, and bloody urine. The patient states her symptoms onset acutely a few hours ago and has not improved. She describes the pain as severe, sharp and stabbing in character, and diffusely localized to the umbilical region, accompanied by nausea and vomiting. The patient also states that she noticed blood in her urine last time she urinated. No additional significant past medical history. Her vitals signs include: temperature 37.0°C (98.6°F), blood pressure 95/75 mm Hg, pulse 115/min, respiratory rate 23/min, and oxygen saturation 99% on room air. On physical examination, the patient is ill-appearing and in severe distress. The cardiac exam is normal. Lungs are clear to auscultation. The abdomen is severely tender and out of proportion with physical exam findings. There are diffuse petechiae present over the entire body. Laboratory results are pending. A peripheral blood smear is shown in the exhibit. A contrast CT of the abdomen shows findings consistent with acute mesenteric ischemia. Which of the following set of laboratory findings would most likely be seen in this patient?

Answer: PT: ↑ | PTT ↑ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓

Choices:
A. PT: ↑ | PTT ↑ | Bleeding time: ↓ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓
B. PT: ↑ | PTT ↑ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↑ | Platelet count: ↓
C. PT: ↓ | PTT ↓ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓
D. PT: ↑ | PTT ↑ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓
E. PT: ↓ | PTT ↓ | Bleeding time: ↓ | Fibrin split products: ↓ | D-dimer: ↓| Fibrinogen: ↓ | Platelet count: ↓


Question: A 32-year-old woman comes to the physician because of a throbbing left-sided headache that started 3 hours ago. Two hours ago, she took ibuprofen with no relief. She has been vomiting every 20 minutes since the start of the headache. She reports that she could not see very well for a few minutes this morning. A similar episode occurred last week. She is otherwise healthy and has recently started taking an oral contraceptive. Her vital signs are within normal limits. Physical examination shows no abnormalities except mild sensitivity to light. Visual acuity is 20/20. Which of the following is the most appropriate initial pharmacotherapy in this patient?

Answer: Intravenous prochlorperazine

Choices:
A. Intranasal dihydroergotamine and subcutaneous sumatriptan
B. Oral tramadol
C. Intravenous prochlorperazine
D. Oral propranolol
E.
Oral ketorolac and oral ergotamine
"


Question: A 66-year-old man presents with palpitation, syncope, and difficulty breathing. He has a past medical history of stroke and his current medications include warfarin. Physical examination is unremarkable. An ECG is performed and shows ventricular tachycardia. The patient is treated successfully with amiodarone. At the time of discharge, his medications include warfarin and amiodarone, and he is cautioned that his PT might be prolonged. Which of the following mechanisms best explains the effect of amiodarone on the coagulation profile of this patient?

Answer: Amiodarone inhibits CYP2C9 leading to an increased risk of bleeding

Choices:
A. Amiodarone induces CYP3A4 leading to a decreased effectiveness of warfarin
B. Amiodarone inhibits CYP2C9 leading to an increased risk of bleeding
C. Amiodarone causes hepatotoxicity which requires monitoring of the prothrombin time
D. Inorganic iodine from amiodarone decreases the effectiveness of warfarin
E. Amiodarone decreases the renal tubular secretion of warfarin leading to an increased risk of bleeding


Question: A 55-year-old woman presents to the emergency department with recent onset confusion and photophobia. Upon questioning her husband, you discover the patient has been sick over the past week with fevers and productive sputum. Her vital signs are Temperature 102.6 Pulse 80 Respirations 18 Blood Pressure 110/70. The physical exam is significant for lethargy and nuchal rigidity. A lumbar puncture is performed and demonstrates cloudy fluid with an opening pressure of 35 cm H20, cell count of 1500 cells/uL (neutrophil predominant), protein level of 50 mg/dL and glucose of 30 mg/dL. Computed tomography scan demonstrates no space-occupying lesions. What is the most appropriate initial treatment for this patient?

Answer: Vancomycin, ceftriaxone, ampicillin and dexamethasone

Choices:
A. Acyclovir
B. Supportive treatment, no antibiotics
C. Ceftriaxone and dexamethasone
D. Vancomycin, ceftriaxone, ampicillin and dexamethasone
E. Vancomycin, ceftriaxone and ampicillin


Question: A 58-year-old male presents to his primary care physician complaining of a painless bump on his penis. He first noticed the lesion 1 year ago but was too embarrassed to mention the issue at his last annual physical exam. The lesion has since grown in size and has recently become more erythematous. He has hypertension treated with lisinopril. At age 45, he was successfully treated for phimosis with a steroid cream. He first engaged in sexual intercourse at age 14 and has had “too many sexual partners to count” in his lifetime. He smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks one alcoholic beverage daily. Physical examination shows a nontender 5 mm x 5 mm ulcerated lesion with an erythematous base on the dorsum of the glans. There is no inguinal lymphadenopathy. Excisional biopsy of the lesion is performed. Which of the following pathological findings is most likely to be seen on the biopsy specimen?

Answer: Atypical squamous cells with varying degrees of mitotic activity

Choices:
A. Atypical squamous cells with varying degrees of mitotic activity
B. Spirochetes on dark-field microscopy
C. Nonspecific inflammatory features with C. trachomatis amplification on PCR
D. Multinucleated giant cells on Tzanck smear
E. Safety pin-shaped intracellular inclusions that appear purple on Giemsa stain


Question: A 54-year-old man comes to the physician for a follow-up appointment. Three weeks ago he underwent emergent cardiac catheterization because of a myocardial infarction and had to stay at the hospital longer than expected because of decreased kidney function. He says his symptoms have since improved greatly and he now produces even more urine than before the procedure. His serum creatinine concentration is 1.6 mg/dL and blood urea nitrogen concentration is 20 mg/dL.This patient is at increased risk for which of the following complications?

Answer: Hypokalemia

Choices:
A. Hypermagnesemia
B. Metabolic alkalosis
C. Hypernatremia
D. Hypokalemia
E. Hyporeninemia


Question:
A 35-year-old woman visits her primary care provider with complaints of easy fatigability, breathlessness on exertion, and altered sensations in her lower limbs. Past medical history is positive for hypertension. She takes hydrochlorothiazide and lisinopril, ethinyl estradiol-progestin, and a multivitamin every day. Family history is noncontributory. She drinks alcohol almost every day and smokes cigarettes when she drinks. Today her heart rate is 95/min, respiratory rate is 17/min, blood pressure is 130/92 mm Hg, and temperature of 37.0°C (98.6°F). Overall, she has marked pallor with slight bluing of her lips and distal fingertips. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Additionally, she has loss of touch, and vibration sense in both of her lower limbs. Her CBC is as follows:
Hemoglobin 8.0 g/dL
MCV 112 fL
WBC 2,500/mm3
Platelets 95,000/mm3
What is the most likely diagnosis?

Answer: Vitamin B12 deficiency

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


Question: A 40-year-old man is brought by his wife with nausea and vomiting. He had been working for four hours on repairing his car with the garage shutter closed and the car running but did not lose consciousness. The patient’s blood pressure is 120/70 mmHg, respirations are 28/min, pulse is 120/min, and SaO2 is 98% on room air. The patient has no medical history and is not taking any medications. The patient has 1 alcoholic drink/week and does not use any other illicit drugs. Ophthalmologic exam reveals bilateral retinal hemorrhages. The compound responsible for this patient’s clinical presentation has what mechanism of action?

Answer: Inhibits the electron transport chain

Choices:
A. Inhibits the electron transport chain
B. Interferes with membrane lipid peroxidation
C. Inhibits acetylcholine esterase
D. Prevents acetylcholine release
E. DNA alkylation


Question: A 54-year-old man is hospitalized after a left hemicolectomy for colon cancer. On postoperative day 1, his hemoglobin is noted on routine labs to have dropped overnight from 7.1 g/dL to 5.3 g/dL. The patient does not report feeling any differently. On exam, his temperature is 100.4°F (38.0°C), blood pressure is 102/80 mmHg, pulse is 95/min, and respirations are 14/min. The patient’s urine output in his Foley bag has been 1.0 cc/kg/hr for the last 8 hours. Prior to the operation, the patient had a temperature of 98.8°F (37.1°C), blood pressure of 122/70 mmHg, and a pulse of 65/min. Which of these findings is most concerning regarding the severity of his hypovolemia?

Answer: Decreased systolic blood pressure

Choices:
A. Decreased pulse pressure
B. Decreased systolic blood pressure
C. Increased heart rate
D. Increased temperature
E. Urine output


Question: An obese 45-year-old female presents to the emergency room complaining of abdominal pain. She reports a 4-hour history of severe right upper quadrant pain following a fatty meal. She has a history of multiple similar episodes over the past year. An ultrasound of the right upper quadrant reveals gallstones. Due to the recurrent nature of her disease, she undergoes an elective laparoscopic cholecystectomy. While in the operating room, the surgeons use the laparoscope to visualize a structure connecting the liver to the anterior wall of the abdominal wall. Which of the following embryologic structures eventually ends up within the visualized structure?

Answer: Umbilical vein

Choices:
A. Ductus venosus
B. Umbilical artery
C. Umbilical vein
D. Urachus
E. Vitelline duct


Question: A 28-year-old woman presents with a recent history of severe headaches. The patient states that the headaches came on gradually about 1 week ago and have steadily worsened. She describes the headaches as severe, diffuse, and frequently causing nausea and vomiting, especially in the mornings. Past medical history is significant for bacterial meningitis, approx. one month ago, that was successfully treated. Current medications are combined oral contraceptives and fluoxetine. A review of systems is significant for fatigue and daytime sleepiness. Family history is significant for her mother and aunt who suffer from migraines with aura. Her temperature is 37.0°C (98.6°F), the blood pressure is 110/70 mm Hg, the pulse is 70/min, the respiratory rate is 16/min, and the oxygen saturation is 99% on room air. The cardiac exam is normal. Lungs are clear to auscultation. The neurological exam is normal. The ophthalmic exam reveals the indistinct margins of the optic disc, bilaterally. Which of the following is the most likely cause of the headaches in this patient?

Answer: Hydrocephalus

Choices:
A. Genetics
B. Hydrocephalus
C. Intracranial mass
D. Trigeminal neuralgia
E. Infection


Question: A 72-year-old presents to the Emergency Room with hemoptysis. He has smoked 1 pack of cigarettes a day for the past 30 years. Physical examination of the face is shown in Image A and is accompanied by left upper extremity edema. Of the following, which is the most likely cause of the patient’s symptoms:

Answer: Superior sulcus tumor

Choices:
A. Pleural effusion
B. Superior sulcus tumor
C. Pulmonary embolus
D. Mass in the thoracic region of the spinal cord
E. Mass effect obstructing the superior vena cava


Question: A 59-year-old man who was recently diagnosed with renal cell carcinoma comes to the physician for a follow-up evaluation. The physician recommends starting treatment with a chemotherapeutic agent that is also used to treat neovascular age-related macular degeneration. A recent history of which of the following conditions would discourage the use of this drug?

Answer: Gastrointestinal bleeding

Choices:
A. Interstitial lung disease
B. Chronic kidney disease
C. Platinum allergy
D. Folate deficiency
E. Gastrointestinal bleeding


Question: A 36-year-old woman presents with a persistent cough productive of blood-streaked sputum, night sweats, and weight loss. No significant past medical history. She denies any history of smoking, alcohol consumption, or recreational drug use. She works as a nurse at a local hospital and lives in an apartment with her extended family. Her vital signs are a blood pressure of 100/80 mm Hg, heart rate of 94/min, respiratory rate of 17/min, and temperature of 35.9℃ (96.6℉). Physical examination reveals dullness to percussion and diminished breath sounds over the upper lobe of the left lung. During the discussion regarding the required workup, the patient tells the physician about recent contact with a patient with tuberculosis. She asks the physician not to report her case because she is concerned she will lose her job. Which of the following statements is correct?

Answer: If this patient is diagnosed with active pulmonary tuberculosis, it should be reported even without the patient’s consent, and the patient should receive isolation and treatment.

Choices:
A. If this patient is diagnosed with active pulmonary tuberculosis, it should be reported even without the patient’s consent, and the patient should receive isolation and treatment.
B. The patient has a right to privacy, so, without her consent, the physician can not report her case even if she is diagnosed with active pulmonary tuberculosis.
C. If this patient turns out to have active pulmonary tuberculosis, her case can stay unreported only if her apartment cohabitants do not include children or pregnant women.
D. If this patient turns out to have active pulmonary tuberculosis, her case can stay unreported only if she agrees to stay home from work and remain isolated at home for her entire treatment period.
E. Only active pulmonary tuberculosis is a reportable disease.


Question: A 33-year-old woman gravida 2, para 1, at 35 weeks gestation is admitted to the hospital with fever and active labor. She reports a 2-day history of fluid leakage from the vagina without pain or vaginal bleeding. Her pregnancy has otherwise been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. Her previous pregnancy was complicated by a preterm delivery at 34 weeks gestation. The patient reports a 10-pack-year history of smoking before pregnancy and smoked 4 cigarettes daily during pregnancy. At the hospital, her temperature is 39.6°C (103.3°F), blood pressure is 108/60 mm Hg, and pulse is 125/min. Her BMI is 18.2 kg/m2. Uterine palpation reveals tenderness. Cervical examination indicates 100% effacement and 10 cm dilation. Her lungs are clear to auscultation. The baseline fetal heart rate is 180/min. Which of the following is the most appropriate next step in management?

Answer: Ampicillin and gentamicin

Choices:
A. Amnioinfusion
B. Ampicillin and gentamicin
C. Cesarean delivery
D. Intravenous betamethasone
E. Ritodrine hydrochloride


Question: A 49-year-old man, with a history of alcohol abuse over the last 2 decades, presents with a complaint of epigastric pain for about a year. He previously had one episode of acute pancreatitis for which he was hospitalized. He continued to drink 4–5 beers/day after he was discharged. His appetite is good, but he has a history of weight loss. He also complains of oily and bulky stools. He takes aluminum hydroxide gel and ranitidine for partial pain relief. Vital signs are stable. Routine physical exam and blood work are normal except for mild hypocalcemia. Abdominal CT scan is shown below. Which of the following tests is comparatively less useful in assessing the function of the organ involved in this condition?

Answer: Serum amylase and lipase levels

Choices:
A. Secretin stimulation test
B. Serum amylase and lipase levels
C. Serum trypsin level
D. Fecal elastase level
E. Magnetic resonance cholangiopancreatography (MRCP)


Question:
A 34-year-old woman presents to the office due to a pulmonary embolism confirmed by computed tomography (CT) chest angiogram, which she was recently hospitalized for. She does not have any recent surgical trauma or travel history. She complains of having episodes where her fingers become white and then blue, and they are usually accompanied by pain in the same region. These episodes tend to happen more frequently during winter and have been ongoing for about 2 years now. She also had a spontaneous abortion at 12 weeks of gestation last year. She does not have a family history of venous thromboembolic disease. The vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg. Physical examination is non-contributory. The complete blood count (CBC) results are as follows:
Hemoglobin 14.2 g/dL
Hematocrit 39%
Leukocyte count 4,950/mm3
Neutrophils 59%
Bands 3%
Eosinophils 1%
Basophils 0%
Lymphocytes 31%
Monocytes 4%
Platelet count 120,000/mm3
The coagulation test results are as follows:
Partial thromboplastin time (activated) 56 seconds
Prothrombin time 15 seconds
Reticulocyte count 1.0%
Thrombin time < 2 seconds deviation from control
Which of the following diagnostic tests would be the most appropriate?

Answer: Lupus anticoagulant

Choices:
A. Antithrombin III
B. Protein C
C. Factor-V-Leiden
D. Lupus anticoagulant
E. Protein S


Question: A 36-year-old woman, gravida 3, para 2, at 34 weeks' gestation is brought to the emergency department for the evaluation of continuous, dark, vaginal bleeding that started one hour ago. She also reports severe lower abdominal pain. Her current pregnancy was complicated by preeclampsia. Her first two children were delivered vaginally. Current medications include methyldopa and a multivitamin. Her pulse is 100/min, respirations are 16/min, and blood pressure is 90/60 mm Hg. The abdomen is tender, and hypertonic contractions are felt. There is blood on the vulva and on the medial aspect of both thighs bilaterally. The fetus is in a cephalic presentation. The fetal heart rate is 170/min with several decelerations. Which of the following is the most appropriate next step in the management of this patient?

Answer: Emergency cesarean delivery

Choices:
A. Emergency cesarean delivery
B. Elective cesarean delivery
C. Administration of terbutaline
D. Ultrasound
E. Administration of oxytocin and normal vaginal birth


Question: A 16-year-old boy is brought to the emergency department because of severe left flank pain and nausea for 3 hours. The pain is colicky and radiates towards his groin. He drinks multiple glasses of iced tea every day. He has had similar episodes of abdominal pain in the past. His maternal uncle has a similar history of abdominal pain. His temperature is 37.1°C (98.8°F), pulse is 103/min, and blood pressure is 108/72 mm Hg. Examination shows a soft and nontender abdomen. Left costovertebral angle tenderness is present. An x-ray of the abdomen shows no abnormalities. A urinary cyanide nitroprusside test is positive. Further evaluation of this patient is most likely to show which of the following?

Answer: Hexagon-shaped crystals on urinalysis

Choices:
A. Rhomboid crystals on urinalysis
B. Urinary pH of 7.8
C. Serum anti-Saccharomyces cerevisiae antibodies
D. Proteus mirabilis on urine culture
E. Hexagon-shaped crystals on urinalysis


Question: A 57-year-old woman comes to the emergency department because of severe dyspnea, cough, and pleuritic chest pain for 20 minutes. Three weeks ago, she underwent surgery for a total right knee replacement. The patient appears distressed. Her pulse is 112/min, respirations are 24/min, and blood pressure is 88/55 mm Hg. Examination shows jugular venous distention. There is a mildly tender surgical scar on her right knee. A CT scan of the chest is shown. Which of the following is the most appropriate treatment for this patient's condition?

Answer: Alteplase

Choices:
A. Endovascular stent-grafting
B. Alteplase
C. Coronary angioplasty
D. Bumetanide
E. Pericardiocentesis


Question: A group of multidisciplinary researchers from a tertiary hospital decides to investigate whether there is an association between splenectomy and pulmonary tuberculosis. From the hospital database, they identify 19,000 patients over the age of 20 with newly diagnosed pulmonary tuberculosis, as well as 72,000 patients without pulmonary tuberculosis for comparison purposes. Both of these groups are matched for age, gender, and an index year when the condition was initially diagnosed. The odds of pulmonary tuberculosis development associated with splenectomy and other comorbidities is estimated. After controlling for all relevant confounders, the results show that splenectomy is associated with a two-fold higher incidence of pulmonary tuberculosis development. There is also a synergistic effect between splenectomy and other comorbid conditions in the development of pulmonary tuberculosis. What type of study has been used by the researchers in this example?

Answer: Case-control study

Choices:
A. Cohort study
B. Cross-sectional study
C. Case-control study
D. Ecological study
E. Intervention study


Question: A 53-year-old woman presents to the clinic with complaints of fatigue. She reports that over the past several months she has been lethargic and tired. She has gained 10 pounds over the past month but attributes it to her menopause. Her last menstrual period (LMP) was 1 year ago. Past medical history is significant for asthma and seasonal allergies, and medications include a rescue inhaler and cetirizine as need. Review of systems is negative except for cold intolerance and constipation. What is the best next step in evaluating this patient?

Answer: TSH levels

Choices:
A. Beta-hCG levels
B. FSH levels
C. Thyroid peroxidase antibody titer
D. TSH levels
E. Ultrasound of the neck


Question: A 33-year-old man presents to his primary care physician for fatigue, weight loss, and diffuse pruritus. The patient has a past medical history of multiple admissions for severe abdominal pain and bloody diarrhea as well as several episodes of ascending cholangitis which were successfully treated. He is currently a member of Alcoholics Anonymous. His temperature is 98.2°F (36.8°C), blood pressure is 124/75 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 99% on room air. Urinalysis is notable only for a dark urine sample with no red blood cells present. A rectal exam reveals pale stool and grossly visible blood. Physical exam is otherwise notable for pruritis, jaundice, and scleral icterus. Which of the following is the most likely underlying diagnosis?

Answer: Cholangiocarcinoma

Choices:
A. Acute cholecystitis
B. Ascending cholangitis
C. Cholangiocarcinoma
D. Cirrhosis
E. Colon cancer


Question:
A 43-year-old female presents with several years of pain and stiffness in her wrists and hands. Her symptoms have been getting progressively worse. She reports that her hands feel stiff for an hour or more after awaking in the morning. She undergoes subsequent testing, and is found to have anti-citrullinated protein antibodies. Her physician is concerned for rheumatoid arthritis, and discusses treatment with a biologic disease-modifying anti-rheumatic agent.

Which of the following must be done before beginning treatment with a TNF inhibitor?

Answer: Test for latent mycobacterial infection

Choices:
A. Confirm diagnosis with a test for rheumatoid factor
B. Confirm diagnosis with elevated ESR and CRP
C. Test for latent mycobacterial infection
D. Obtain a radiograph demonstrating osteophytes
E. Obtain an exercise stress test


Question: A 65-year-old man is brought to the emergency department with a complaint of right-sided numbness for 5 hours. The numbness started in the right-side of the face and has progressed to the same side arm and leg within 30 minutes. He denies limb weakness, walking difficulty, vision problem, or vertigo. He had similar symptoms 5 months ago that were resolved within 10 minutes. The past medical history includes type 2 diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia. The medication list includes allopurinol, amlodipine, aspirin, glimepiride, lisinopril, and rosuvastatin. The blood pressure is 165/102 mm Hg, and the rest of the vital signs are within normal limits. On examination, there are no facial droop and slurring of the speech noted. The muscle strength is normal in all 4 limbs with a normal tone and deep tendon reflexes. There is a decreased pinprick sensation and proprioception on the right arm and leg. The gait is normal. The blood sugar is 221 mg/dL. The CT scan of the head is normal. The MRI of the head with diffusion-weighted imaging reveals a 15 mm diffusion restriction in the left thalamus. Which of the following is the most crucial in the development of this patient’s condition?

Answer: Lipohyalinosis of small penetrating arteries due to chronic hypertension

Choices:
A. Emboli from deep leg veins with a patent foramen ovale
B. Emboli from the left ventricle of the heart
C. Leakage of blood from intracranial vessel due to uncontrolled hypertension
D. Lipohyalinosis of small penetrating arteries due to chronic hypertension
E. Significant stenosis of the left carotid artery


Question: A 23-year-old man presents to a psychiatrist for evaluation of situational anxiety. He reports that he recently started a new job that involves regular public speaking and is very stressed before every public speaking event. He describes developing a rapid heart rate and diaphoresis that interferes with his ability to speak well. He has no past medical history and takes no medications. He does not smoke or drink alcohol. His temperature is 98.6°F (37°C), blood pressure is 110/65 mmHg, pulse is 85/min, and respirations are 17/min. On exam, he is well-appearing and appropriately conversational. He is alert and fully oriented. The patient is prescribed propranolol to take before major public speaking events. Which of the following physiologic changes will occur when the patient takes this medication?

Answer: Decreased cardiac output and increased peripheral resistance

Choices:
A. Decreased cardiac output and decreased peripheral resistance
B. Decreased cardiac output and increased peripheral resistance
C. Increased cardiac output and decreased peripheral resistance
D. Increased cardiac output and increased peripheral resistance
E. Normal cardiac output and normal peripheral resistance


Question: A 69-year-old woman is brought into the emergency room by family members after they noted that she had become increasingly lethargic over the past 3 days. Her temperature is 39.5°C (103.1°F), the blood pressure is 75/40 mm Hg, the heart rate 130/min, the respiratory rate 24/min, and the oxygen saturation is 89% on room air. On examination, she is severely ill, drowsy, and unable to speak. Her skin is warm to the touch. White blood cell count is 15,000/mm3 and her urinalysis is positive for nitrites and leukocyte esterase. Which of the following is the best initial step in the management of this patient's condition?

Answer: Assessment of airway, breathing, and circulation

Choices:
A. Intramuscular adrenaline
B. Intravenous hydrocortisone
C. Infusion of hydroxyethyl starch (HES) solutions
D. Assessment of airway, breathing, and circulation
E. Intravenous noradrenaline


Question: A 28-year-old G2P1 woman at 29 weeks gestation presents to the obstetrician after noticing red spots on her undergarments over the past week. Her vaginal bleeding has not been painful; however, she is concerned that it has persisted. Her previous child was born by cesarean section and she is currently taking folate and a multivitamin. She endorses feeling fetal movements. Her temperature is 98.9°F (37.2°C), blood pressure is 120/84 mmHg, pulse is 88/min, respirations are 17/min, and oxygen saturation is 99% on room air. Physical exam is notable for a gravid uterus and non-tender abdomen. Speculum exam reveals a closed cervical os and a small amount of blood. Which of the following is the most likely diagnosis?

Answer: Placenta previa

Choices:
A. Placenta percreta
B. Placenta previa
C. Placental abruption
D. Uterine rupture
E. Vasa previa


Question: A 57-year-old woman comes to the emergency department 1 hour after experiencing a distressing 10-minute episode of stuttering during a business meeting. She has hypertension. She has smoked 2 packs of cigarettes daily for 30 years. Current medications include fosinopril and hydrochlorothiazide. Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 16/min, and blood pressure is 134/88 mm Hg. She is oriented to person, place, and time. Her speech is clear. When she is asked to hold both arms fully extended at shoulder level with palms upwards and eyes closed, her right palm turns inwards and downwards. Which of the following is the most likely cause of this patient's physical findings?

Answer: Upper motor neuron lesion

Choices:
A. Cerebellar lesion
B. Posterior column lesion
C. Inferior frontal gyrus lesion
D. Upper motor neuron lesion
E. Thalamus lesion


Question:
A 40-year-old man comes to the physician because of a 5-kg (11-lb) weight loss over the past month and easy bruising. He has not changed his diet significantly. He also noticed that his arms now bruise more easily. He appears pale. His pulse is 70/min, his blood pressure is 125/75 mm Hg, and his temperature is 38°C (100.4°F). Examination shows a palm-sized hematoma on his right arm. His spleen is palpable 5 cm below the costal margin. His liver is enlarged. Laboratory results show:
Leukocytes 10,500/mm3
Hemoglobin 10.2 g/dL
Platelets 52,000/mm3
Fibrinogen 110 mg/dL (Reference: 150-400 mg/dL)
Cytogenetic analysis shows leukocytes with a reciprocal translocation of chromosomes 15 and 17. Which of the following is the most appropriate treatment for this patient at this time?"

Answer: All-trans retinoic acid

Choices:
A. Rituximab
B. Cyclophosphamide
C. All-trans retinoic acid
D. Cryoprecipitate transfusion
E. Imatinib


Question: At a routine exam, a 68-year-old female patient is discovered to have a serum calcium level of 11.5 mg/dL. Follow-up laboratory tests show a high parathyroid hormone with low phosphorus and mildly elevated alkaline phosphatase. 24-hour urine calcium level is elevated. Review of symptoms includes complaints of fatigue, constipation, and diffuse bone pain for which she takes vitamin D. Past medical history is significant for type 2 diabetes mellitus for 25 years and essential hypertension for 15 years. The patient has a history of kidney stones. Family history is irrelevant. Which of the following is the most likely etiology of this patient's condition?

Answer: Solitary parathyroid adenoma

Choices:
A. Vitamin D intoxication
B. Familial hypocalciuric hypercalcaemia
C. Solitary parathyroid adenoma
D. Thyrotoxicosis
E. Humoral hypercalcemia of malignancy


Question: A 27-year-old man and his wife present to an infertility clinic for evaluation after they tried unsuccessfully to conceive for 2 years. He has no prior medical history and does not currently take any medications. On evaluation, he is found to have long extremities and gynecomastia. In addition, he has testicular atrophy and very little body hair, which is distributed primarily in the pubic region. Further analysis reveals azoospermia, and appropriate tests confirming the diagnosis are performed. The couple is told about the cause of their inability to conceive and given further options to pursue. Which of the following is associated with the pathophysiology underlying this patient's disorder?

Answer: Increased aromatase activity

Choices:
A. Abnormal signaling through androgen receptors
B. Abnormal conversion of testosterone
C. Defective migration of hormone producing neurons
D. Increased aromatase activity
E. Increased production of prolactin


Question: A 32-year-old GP2 presents to an outpatient clinic for a routine gynecologic examination. The patient appears well, although she mentions that during the past 6 months she has noticed small amounts of vaginal bleeding in the middle of her menstrual cycles. Her last pregnancy was 3 years ago. Her subsequent menstrual cycles have been regular, lasting about 2–3 days. She mentions that she is up to date with her Pap smear; all of her Pap smears have been normal. She denies any recent travel or history of trauma. The patient is sexually active with her husband and they use condoms consistently. She does not smoke, drinks alcohol occasionally, and has never used illicit drugs. The physical examination is essentially normal. An ultrasound reveals a fleshy mass with a pedunculated stalk deep in the cervical canal. The uterine lining measures 5 mm in thickness and is homogeneous. Multiple small leiomyomas are also observed. The patient is otherwise asymptomatic and has no other complaints. The rest of the physical examination is unremarkable. Which of the following is the next best step in management?

Answer: Removal of the lesion with a ring forceps

Choices:
A. No further intervention with follow-up in 6 months
B. Electrocautery and cryofreezing
C. Cervical brush biopsy
D. Removal of the lesion with a ring forceps
E. Administration of antibiotics


Question: An 11-year-old girl presents to her pediatrician with complaints of headache and rapid leg fatigue with exercise. Her vital signs are: HR 77, BP in left arm 155/100, RR 14, SpO2 100%, T 37.0 C. On palpation, her left dorsalis pedis pulse is delayed as compared to her left radial pulse. Her lower extremities feel slightly cool. Blood pressure obtained on the left lower extremity is 120/80. Which of the following is the most likely underlying pathology?

Answer: Coarctation of the aorta

Choices:
A. Peripheral arterial disease
B. Vasospasm
C. Coarctation of the aorta
D. Tetralogy of Fallot
E. Aortic stenosis


Question: A 34-year-old woman comes to the gynecologist complaining of vaginal swelling and discomfort. She states that over the past 2 weeks she has noticed swelling of her right labia. The swelling continued to grow in size and now causes her discomfort when walking. She denies abnormal discharge or bleeding from the swelling or from the vulva. She normally shaves the area, but with the recent pain, she has been unable to. She denies any history of known trauma. The patient is relatively healthy and takes only a multivitamin. She never received the vaccine for human papillomavirus (HPV). On physical exam, there is a fluctuant, swelling of the right labia, most prominently at the posterior vestibule. Which of the following is the most likely diagnosis?

Answer: Bartholin gland cyst

Choices:
A. Bartholin gland cyst
B. Condyloma acuminata
C. Folliculitis
D. Granuloma inguinale
E. Vulvar cancer


Question: A 4-month-old boy is brought to the physician because of noisy breathing for 2 months that has progressively become louder. The noisy breathing improves when he is in the prone position. It is worse when he is agitated, feeding, or lying on his back. He was born at term and has been healthy since. His temperature is 37.1°C (98.8°F), pulse is 120/min, and respirations are 50/min. Pulse oximetry on room air shows an oxygen saturation of 98%. Examination shows inspiratory stridor. Which of the following is the most appropriate treatment?

Answer: Observation

Choices:
A. Dexamethasone therapy
B. Observation
C. Surgical division
D. Ceftriaxone therapy
E. Supraglottoplasty


Question: A 16-year-old girl comes to the physician with a 4-day history of painful vulvar lesions, generalized fatigue, and malaise. During this period, she has also had dysuria. She is sexually active with 2 male partners and uses condoms inconsistently. Her immunizations are up-to-date; she completed the vaccination course for human papilloma virus 2 months ago. Her temperature is 38.1°C (100.6°F), pulse is 100/min, respirations are 12/min, and blood pressure is 110/70 mm Hg. Pelvic examination shows several shallow ulcers on an erythematous base over the labia majora and minora. There is bilateral, tender inguinal lymphadenopathy. Which of the following is the most appropriate treatment for this patient's condition?

Answer: Acyclovir therapy

Choices:
A. Acyclovir therapy
B. Curettage
C. Azithromycin therapy
D. Doxycycline therapy
E. Penicillin therapy


Question: A 57-year-old man comes to the physician because of progressively worsening epigastric pain and 6.8-kg (15-lb) weight loss for the past 2 months. Two weeks ago, he noticed painful, red blotches on the medial aspect of his right calf. He has smoked one pack of cigarettes daily for the last 35 years. He appears thin. Physical examination shows tender erythematous nodules on the right ankle and left antecubital fossa. Endoscopy shows a large mass in the antrum of the stomach. A biopsy specimen of the gastric mass shows disorganized mucin-secreting cells with surrounding fibrosis. These cells most likely originated from which of the following structures?

Answer: Exocrine ducts in the body of the pancreas

Choices:
A. Lymphoid tissue in the terminal ileum
B. Mature hepatocytes in the liver
C. Exocrine ducts in the body of the pancreas
D. Squamous epithelium in the proximal esophagus
E. Glandular epithelium in the sigmoid colon


Question: A 62-year-old woman comes to the emergency department because of painful and difficult swallowing. Her voice has also become muffled. She has been well until last night and reports having intermittent fevers at home. The patient has smoked a pack of cigarettes a day since age 19 but is otherwise healthy. Her temperature is 39°C (102.2°F), blood pressure is 142/93 Hg/mm, heart rate is 109/min, and respiratory rate is 18/min. On examination, the patient's head is extended and she appears anxious. Her voice is muffled and there is inspiratory stridor. There is tender bilateral cervical lymphadenopathy and pain upon palpation of the hyoid. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 18,000/mm3 with 83% neutrophils. Which of the following is the most likely cause of this patient's presentation?

Answer: Haemophilus influenzae type b

Choices:
A. Adenovirus
B. Pseudomonas aeruginosa
C. Corynebacterium diphtheriae
D. Parainfluenza virus
E. Haemophilus influenzae type b


Question: A 56-year-old woman is brought to the emergency department by her husband 30 minutes after a generalized tonic-clonic seizure. Over the past 3 months, she has had recurrent headaches and worsening early-morning vomiting. She has no personal or family history of a seizure disorder. An MRI of the brain shows a central mass; surgical resection is planned. One day before the surgery, the patient has another generalized seizure and, despite resuscitative efforts, she dies. Gross examination of the brain at autopsy is shown. Which of the following was the most likely cause of this patient's symptoms?

Answer: Glioblastoma

Choices:
A. Oligodendroglioma
B. Glioblastoma
C. Schwannoma
D. Brain metastasis
E. Meningioma


Question: A 29-year-old woman (gravida 2, para 1) presents at 32 weeks gestation for routine follow-up care. Her previous pregnancy was complicated with preeclampsia, and she delivered at 35 weeks via cesarean delivery. Four years ago, she was diagnosed with arterial hypertension. Prior to pregnancy, she took amlodipine and hydrochlorothiazide; after she found out she was pregnant, she switched to methyldopa. The course of her current pregnancy has been unremarkable with normal laboratory values at each checkup. According to her blood pressure diary, her systolic blood pressure varies between 120 and 130 mm Hg, and her diastolic blood pressure is usually normal. At presentation, the blood pressure is 140/80 mm Hg, heart rate is 76/min, respiratory rate is 15/min, and temperature is 36.9°C (98.4°F). The fetal heart rate is 143/min. Examination shows a 1+ pitting lower leg edema. Dipstick test shows 2+ protein. 24-hour urine assessment demonstrates urinary protein excretion of 1 g/L. Which of the following laboratory values should be assessed next in this patient?

Answer: Liver transaminases

Choices:
A. Coagulogram
B. Liver transaminases
C. Total bilirubin
D. Lipidogram
E. Urinalysis


Question: Following a colonoscopy performed on a 63-year-old man, the gastroenterologist identifies a firm tumor approx. 80 cm (31.4 in) from the entry site. He also performs an endoscopic polypectomy and tattooing at 50 cm (19.6 in) from the entry site. A pathologic report shows a benign polyp. One week later, the surgeon in the operating room is erroneously preparing to perform partial colectomy of the tattooed site. After confirming the patient’s name and before surgery, the surgical team reviews the patient’s history and medical documents orally based on institutional protocols. The surgery resident points out that the resected polyp is benign and the tumor lies 30 cm (11.8 in) distal to the tattooed area. The attending surgeon performs a partial colectomy on the correct site. Which of the following best describes this approach to the prevention of medical errors?

Answer: Preoperative time-out

Choices:
A. Closed-loop communication
B. Preoperative time-out
C. Primordial prevention
D. Root cause analysis
E. Sentinel event


Question: A 28-year-old G2P1001 presents for a routine obstetric visit in her 36th week of pregnancy. She has a history of type I diabetes controlled by insulin and delivered 1 child by normal spontaneous vaginal delivery 2 years ago. Earlier in this pregnancy, she had 2 episodes of burning with urination and frequent urination. Urinalysis each time confirmed a urinary tract infection, and both urine cultures isolated organisms sensitive to nitrofurantoin. Her symptoms resolved with 10-day courses of nitrofurantoin. She has no complaints today. Urinalysis is positive for leukocyte esterase and nitrites. Which of the following is the best next step in management?

Answer: Treat with oral nitrofurantion for 10 days then continue for prophylaxis until delivery

Choices:
A. No treatment
B. Admit to the hospital and treat with intravenous ceftriaxone
C. Treat with oral trimethroprim-sulfamethoxazole for 10 days then continue for prophylaxis until delivery
D. Treat with oral nitrofurantion for 10 days
E. Treat with oral nitrofurantion for 10 days then continue for prophylaxis until delivery


Question: A 3-year-old boy is brought to the physician by his parents because of clumsiness and multiple falls over the past 4 months. He started walking at the age of 18 months and could walk up steps by the time he was 27 months old but now struggles to walk at all without assistance. When standing up from a lying position, he crawls onto his knees and slowly walks himself up with his hands. There is bilateral calf enlargement. Analysis of a left calf biopsy specimen from this patient is most likely to show which of the following?

Answer: Degeneration of muscle fibers with fibrofatty replacement

Choices:
A. Perivascular inflammation with muscle fiber ischemia and atrophy
B. Proliferation of mitochondria within muscle fibers
C. Degeneration of muscle fibers with fibrofatty replacement
D. Atrophic muscle fibers interspersed among hypertrophic muscle fibers
E. Necrotic muscle fibers with lymphocytic infiltrate


Question: A 60-year-old man presented to the hospital with right upper quadrant abdominal pain. He has a history of hepatitis B. He underwent a CT of his abdomen which revealed a large mass (11.3 cm x 7.2 cm in diameter) with a metastatic retroperitoneal lymph node. He was diagnosed with hepatocellular carcinoma and initially received radiotherapy while on the transplant list to prevent local expansion of his malignancy. 3 months after radiotherapy, the patient experienced hematemesis and melena. He was admitted to the emergency department for evaluation. His vitals were: blood pressure 84/56 mmHg, heart rate 92/min, and respiratory rate 20/min. Laboratory evaluation revealed severe anemia with a hemoglobin level of 5.7 g/dL, INR 1.8 and platelets of 68,000 cells/mm3. He received a blood transfusion. An endoscopic examination demonstrated diffuse edematous hyperemic mucosa and multiple hemorrhagic patches with active oozing in the antrum. What is the most likely diagnosis for the lesions seen in endoscopy?

Answer: Intrinsic apoptotic pathway

Choices:
A. Intrinsic apoptotic pathway
B. Coagulative necrosis
C. Overexpression of BcL-2 gene
D. Cytotoxic CD8 T cells pathway
E. Extrinsic apoptotic pathway


Question: A 49-year-old Caucasian woman presents to your office for elevated blood pressure. She is a nurse and checks her blood pressure regularly while working in the wards. She presents with readings ranging between 163/101 and 156/94 mm Hg. After some research she conducted on her own, she has been exercising and following a low-fat, low-salt diet for the past 3 months. Her past medical history includes laparoscopic cholecystectomy for acute cholecystitis 2 years previously. Her mother and father have hypertension and her father had myocardial infarction at the age of 68 years. She takes no medications and denies smoking. She drinks 3 glasses of wine a week. Her blood pressure in the office after more than 10 minutes of rest was 153/89 mm Hg in her left arm and 145/90 mm Hg in her right arm. A review of her medical record reveals that her blood pressure was 142/92 mm Hg at her visit 1 year ago. Which of the following is the best next step in management?

Answer: Blood glucose

Choices:
A. Liver function tests
B. Urine microalbumin
C. Hemoglobin A1C
D. Blood glucose
E. Exercise stress test


Question: A 55-year-old man presents to his primary care physician for back pain. The patient states that his back pain is worse in the morning and improves with certain activities. He does not experience pain when cycling but notices the pain when standing or walking. 2 months prior to presentation he was lifting heavy boxes and furniture into his daughter's new home. He is requesting pain medication and a doctor's note to take off work for the week as his symptoms are disrupting his life. Which of the following is most likely to be seen in this patient?

Answer: Narrowing of the lumbar spinal canal on MRI

Choices:
A. Bamboo appearance of the spine on radiography
B. Herniated nucleus pulposus on MRI
C. Muscular tenderness with perispinal palpation
D. Multiple doctors visits for other unrelated problems
E. Narrowing of the lumbar spinal canal on MRI


Question:
A 75-year-old man presents to the emergency department from his doctor’s office with a 2-day history of urinary hesitancy, fever, and chills. He additionally notes that he has been getting up frequently during the night to urinate. For the last 2 years, it has taken him longer than usual to initiate urination and his stream has gotten weaker. He has a history of hypertension for which he takes losartan. His blood pressure is 128/84 mm Hg, heart rate is 84/min, respiratory rate is 14/min, and temperature is 38.2°C (100.8°F). No costovertebral angle tenderness is present on physical examination. The patient declines rectal examination. Significant laboratory results are as follows:
WBC 15.2 x  10°/L
Hemoglobin 13.4 g/dL
Platelets 185 x 109/L
Prostate-specific antigen (PSA) 10 ng/mL
What is the most likely cause of the patient’s symptoms?

Answer: Prostatitis

Choices:
A. Prostate cancer
B. Urinary tract infection
C. Pyelonephritis
D. Nephrolithiasis
E. Prostatitis


Question: A 6-year-old boy is brought to the physician for evaluation of bilateral erythematous skin lesions on the flexures of the elbows and knees. He has been scratching the areas frequently. He has had similar lesions intermittently for the last 2 years. A photograph of the lesions on the back of the knees is shown. This patient's skin lesions are most likely associated with which of the following?

Answer: Reversible decrease in FEV1/FVC ratio

Choices:
A. Reversible decrease in FEV1/FVC ratio
B. Glomerular subepithelial immune complex deposition
C. IgA anti-tissue transglutaminase antibodies
D. Hepatocyte infection with hepatitis C virus
E. Pencil-in-cup deformity of the fingers


Question: An important step in the formation of thyroid hormones is the formation of I2 via oxidation of I-. Which of the following molecules is responsible for this reaction?

Answer: Thyroid peroxidase

Choices:
A. Thyroid deiodinase
B. Thyroid peroxidase
C. 5'-deiodinase
D. Perchlorate
E. Propylthiouracil


Question: A 29-year-old woman presents to her primary care provider for a normal check-up at the prompting of her mother. When asked how she is doing, she replies that she feels depressed. Upon further questioning, she states that she feels “worthless” now that her ex-boyfriend left her 2 days ago. She has been sitting in his bed all day trying to call him but he is not answering her calls. She says that she will never find another man like him and feels like she should just “disappear” rather than continue living without him. She also reports that she can hear his voice when he’s not around, especially at night before she goes to bed. She denies having any other friends and has some social anxiety, particularly in large groups of people. A review of her medical record indicates that she has endured several episodes of verbal and physical abuse from her prior relationships which she suggested “were all her fault.” She has had 4 prior serious relationships and reports that she has not been single for more than a few days in the last 10 years. On exam, she is unkempt with poor self-care. This patient’s history is most consistent with which of the following conditions?

Answer: Dependent personality disorder

Choices:
A. Avoidant personality disorder
B. Borderline personality disorder
C. Dependent personality disorder
D. Histrionic personality disorder
E. Paranoid personality disorder


Question:
A 65-year-old man presents to the emergency department with confusion and chest pain. He states his symptoms started after he landed on a return flight from Brazil. Since then, the patient states that he feels anxious, short of breath, and has pleuritic chest pain. The patient has a past medical history of diabetes and chronic kidney disease. His medications include insulin, lisinopril, aspirin, and atorvastatin. His temperature is 101°F (38.3°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 96% on room air. Physical exam is notable for a confused man. The patient’s laboratory studies are ordered as seen below.

Serum:
Na+: 140 mEq/L
Cl-: 103 mEq/L
K+: 5.3 mEq/L
HCO3-: 25 mEq/L
BUN: 33 mg/dL
Glucose: 168 mg/dL
Creatinine: 1.8 mg/dL
Ca2+: 10.0 mg/dL
Troponin: < 0.05 mcg/L

A chest CT angiogram, an echocardiogram (ECG), and a second troponin are ordered and are all unremarkable. The patient’s chest pain resolves with diazepam. A lumbar puncture is performed and based on the results the patient is subsequently started on acyclovir. Which of the following is the best next step in management?

Answer: Bolus of IV fluids

Choices:
A. Bolus of IV fluids
B. Calcium gluconate
C. Cardiac catheterization
D. Hemodialysis
E. No further interventions needed


Question:
A 52-year-old homosexual man presents to the emergency department because of sudden right loin pain accompanied by nausea and vomiting. He has essential hypertension for 3 years for which he takes bisoprolol. He has a remote history of intravenous drug use. His temperature is 36.9°C (98.4°F), the blood pressure is 137/92 mm Hg, and the pulse is 95/min. Physical examination reveals right flank tenderness and 2+ edema of both legs up to the knees. Doppler ultrasonography shows an enlarged, echogenic right kidney with the absent venous signal. Laboratory results are shown:
Serum creatinine 2.2 mg/dL
Urine dipstick 4+ protein
Urine analysis 20–25 red cells/high power field
Which of the following is the most likely underlying etiology of this patient's condition?

Answer: Membranous nephropathy

Choices:
A. Acute pyelonephritis
B. Kidney stones
C. Hypertensive kidney disease
D. Membranous nephropathy
E. Penile cancer


Question: A 53-year-old woman is brought to the emergency department for a 2-hour history of balance problems. She was gardening when she suddenly felt very dizzy and she quickly called for her husband. When he arrived, she was sitting on the ground, swaying back and forth but overall leaning to the right. When she tried to stand up they found she was very unsteady and unbalanced, so her husband carried her to the car. In the emergency department, while lying in bed, she complains of a room-spinning sensation; when she sits up, she sways to the right. She is unable to walk more than 3 steps without falling. Finger-nose-finger and heel-knee-shin testing are abnormal. She has a past medical history of hypertension, polycystic ovarian syndrome, and type 2 diabetes mellitus. All of her vital signs are all within normal limits. Angiography would most likely show a dissection in which of the following vessels?

Answer: Vertebral artery

Choices:
A. Internal carotid artery
B. Anterior cerebral artery
C. Middle cerebral artery
D. Vertebral artery
E. Anterior spinal artery


Question: A 65-year-old man with squamous cell carcinoma of the lung presents with a sodium of 118 and an altered mental status. He is started on 3% normal saline over the next several hours. The patient’s mental status improves and and a repeat sodium six hours later is 129. Three days after treatment he demonstrates quadriparesis and dysarthria. Which of the following best describes this cause of the patients symptoms after treatment?

Answer: Osmotic demyelination syndrome

Choices:
A. Lateral medullary syndrome
B. Medial medullary syndrome
C. Osmotic demyelination syndrome
D. Hypercalcemia
E. Hypocalcemia


Question: A 27-year-old woman presents to the emergency department with severe wheezing, which started an hour ago. She informs the doctor that she has had mild persistent asthma for the last 2 years and is on inhaled corticosteroids, and uses them regularly. She has not experienced asthma symptoms for the last 2 months and there is no history of non-compliance. She mentions that her present symptoms came on about 20 minutes after her last meal. When the doctor makes specific inquiries, she recollects items in her lunch, which included canned milk product, commercially available roasted peanuts, homemade celery salad, and wine. She also mentions that she took a tablet of acetaminophen immediately after the meal because her legs were aching since morning, which she attributes to her morning walk at 6 am the same day. She has never developed respiratory symptoms in response to milk protein, peanuts, or acetaminophen until now. Skin prick testing for food allergens, performed a month back, was negative for all the common food allergens, including milk and peanuts. Which of the following is the most likely trigger for her current episode?

Answer: Food additive

Choices:
A. Ara-h-1 protein
B. β-lactoglobulin
C. Food additive
D. Acetaminophen
E. Exercise


Question: A 30-year old African-American woman comes into your office for pregnancy counseling with her husband. She states that both she and her husband have family histories of sickle cell disease. Based on previous genetic testing, they both also have a copy of the sickle cell gene from their parents, but neither of them has ever manifested symptoms associated with the disease. They want to conceive and are concerned about the chances that their child might have the disease. What is the chance the offspring will be a child WITHOUT sickle cell anemia?

Answer: 3/4

Choices:
A. 1/2
B. 3/4
C. 1/4
D. 2/3
E. 1/3