Question: Which of the following is the most likely mechanism of the patient illness?

Context: A 41-year-old man presents with progressive fatigue, pain in the front of the chest, and difficulty breathing with minimal exertion while trying to sleep.

Context: He reports having a flu-like illness consisting of fatigue, muscle pain, and cough 10 days ago that resolved spontaneously without seeking a medical help.

Context: He has no past medical history.

Context: His vital signs include a blood pressure of 100/70 mm Hg, a temperature of 37.5°C (99.5°F), and a regular radial pulse of 105/min.

Context: On physical examination, the patient looks tired, the jugular venous pressure is elevated, pulmonary rales are present on both sides, and an S3 gallop is audible.

Choices:
A. Rupture of an atherosclerotic plaque in the coronary artery
B. Viral-mediated inflammation with local and systemic immunological activation
C. Infection of the endocardial surface of the heart with microembolization and immune complex deposition
D. Immune-mediated inflammation of the heart triggered by a preceding streptococcal infection

Answer: Viral-mediated inflammation with local and systemic immunological activation

2. Patient has progressive fatigue, pain in the front of the chest, and difficulty breathing with minimal exertion while trying to sleep.

3. Patient had a flu-like illness consisting of fatigue, muscle pain, and cough 10 days ago that resolved spontaneously without seeking a medical help.

5. Patient does not smoke cigarettes or drink alcohol.

6. Patient's blood pressure is 100/70 mm Hg.

7. Patient's temperature is 37.5°C (99.5°F).

9. Patient looks tired on physical examination.

10. Patient's jugular venous pressure is elevated.

11. Pulmonary rales are present on both sides.

13. Patient's ECG shows nonspecific ST-segment and T-wave abnormalities.

14. 2-dimensional echocardiogram shows global left ventricular motion abnormalities and dilatation of the left ventricle.

1. He had a flu-like illness 10 days ago with fatigue, muscle pain, and cough.

2. The flu-like illness resolved spontaneously without seeking medical help.

4. He does not smoke cigarettes or drink alcohol.

7. His radial pulse is regular and 105/min.

8. On physical examination, the patient looks tired.

9. The jugular venous pressure is elevated.

10. Pulmonary rales are present on both sides.

12. His ECG shows nonspecific ST-segment and T-wave abnormalities.

13. A 2-dimensional echocardiogram shows global left ventricular motion abnormalities and dilatation of the left ventricle.

14. Troponin I and Creatine Kinase-MB are elevated.


Question: Which of the following public health interventions is most likely to decrease this number?

Context: Results show a significant increase in the number of mitral valve replacements performed in Vietnam in adults aged 30–50 years compared to the same age group in the United States.

Choices:
A. Prompt antibiotic treatment for bacterial pharyngitis
B. Improved access to drug rehabilitation centers
C. Genetic screening program for FBN1 gene mutation
D. Screening echocardiography for prolapsed anterior mitral valve leaflets

Answer: Prompt antibiotic treatment for bacterial pharyngitis

Public Health and General Preventive Medicine

1. A group of epidemiologists is studying the rates of cardiac surgeries performed in several Southeast Asian countries compared to the United States.

2. Results show a significant increase in the number of mitral valve replacements performed in Vietnam.

3. The increase is in adults aged 30–50 years.

4. The same age group in the United States is being compared.

1. Results show a significant increase in the number of mitral valve replacements performed in Vietnam.

2. The increase is in adults aged 30–50 years.

3. The increase is compared to the same age group in the United States.


Question: Which of the following treatment regimens is most appropriate in this patient?

Context: A 31-year-old male presents to his primary care physician complaining of low back pain and fevers.

Context: He denies trauma or recent illness.

Context: A urinalysis demonstrates leukocytes.

Choices:
A. Ampicillin and gentamicin
B. Ciprofloxacin and trimethroprim-sulfamethoxazole
C. Terazosin
D. Ceftriaxone and doxycycline

Answer: Ceftriaxone and doxycycline

2. Patient is complaining of low back pain and fevers.

3. Patient has a four-day history of intermittent fevers, chills, and low back pain.

4. Patient denies trauma or recent illness.

5. Patient's past medical history is notable for recurrent renal stones, diabetes mellitus, and alcohol abuse.

6. Patient takes metformin but admits to missing several doses.

7. Patient has had multiple sexual partners and uses condoms intermittently.

8. Patient's temperature is 100.6°F (38.1°C).

9. Patient's blood pressure is 110/70 mmHg.

12. On examination, patient demonstrates mild tenderness to palpation along his lower back.

13. Sensation to touch is intact in the bilateral lower extremities.

14. Strength in leg and hip flexion and extension is 5/5 bilaterally.

15. Physician is unable to perform a digital rectal examination due to pain.

1. He reports a four-day history of intermittent fevers, chills, and low back pain.

3. His past medical history is notable for recurrent renal stones, diabetes mellitus, and alcohol abuse.

4. He takes metformin but admits to missing several doses.

5. He has had multiple sexual partners and uses condoms intermittently.

6. His temperature is 100.6°F (38.1°C), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 21/min.

7. On examination, he demonstrates mild tenderness to palpation along his lower back.

8. Sensation to touch is intact in the bilateral lower extremities.

9. Strength in leg and hip flexion and extension is 5/5 bilaterally.

10. The physician is unable to perform a digital rectal examination due to pain.

11. A urinalysis demonstrates leukocytes.


Question: Which of the following treatments would be effective for this patient’s most likely condition?

Context: On presentation, the boy’s only complaint is that he has never been able to completely keep up with his classmates during gym or on the playground because he feels fatigued and short of breath.

Context: A panel of hematologic tests are obtained with the following results: |  | Hemoglobin: 11 g/dL | Leukocyte count: 4,250/mm^3 | Platelet count: 185,000/mm^3 | Mean corpuscular volume: 116 µm^3 | Blood smear: neutrophils with extra lobes |  | Crystals are also found within this patient's urine.

Choices:
A. Administration of uridine
B. Administration of purine
C. Cobalamin supplementation
D. Folate supplementation

Answer: Administration of uridine

1. A 12-year-old boy is brought to his pediatrician in order to be medically cleared for playing baseball.

2. The boy's only complaint is that he has never been able to completely keep up with his classmates during gym or on the playground because he feels fatigued and short of breath.

3. A review of his prior medical history reveals that he hit all his developmental milestones as expected and has otherwise been healthy.

4. He lives with his parents and eats a diet consisting of mostly fast food and soda.

5. Physical exam reveals a thin, pale boy with decreased color under his eyelids.

6. A panel of hematologic tests are obtained with the following results: Hemoglobin: 11 g/dL, Leukocyte count: 4,250/mm^3, Platelet count: 185,000/mm^3, Mean corpuscular volume: 116 µm^3, Blood smear: neutrophils with extra lobes.

7. Crystals are also found within this patient's urine.

1. The boy complains of feeling fatigued and short of breath during physical activities.

2. The boy has hit all his developmental milestones as expected.

3. The boy lives with his parents and consumes a diet consisting mostly of fast food and soda.

4. Physical exam reveals a thin, pale boy with decreased color under his eyelids.

9. Blood smear shows neutrophils with extra lobes.

10. Crystals are found in the patient's urine.


Question: Which of the following is the most likely cause of this patient's presentation?

Context: The results of the patient's lab work are below: |  | Serum: | Na+: 145 mEq/L | K+: 2.9 mEq/L | Cl-: 100 mEq/L | HCO3-: 30 mEq/L | BUN: 18 mg/dL | Ca2+: 10.9 mg/dL | Mg2+: 2.0 mEq/L | Creatinine: 1.2 mg/dL | Glucose: 110 mg/dL |  | The patient's blood pressure at this visit is 145/100 mmHg and she has still not experienced her menses.

Choices:
A. Increased mineralocorticoid production
B. Vomiting
C. Increased reabsorption at the collecting duct
D. Decreased renal artery blood flow

Answer: Increased mineralocorticoid production

1. A 27-year-old woman presents to her primary care physician for a follow-up appointment.

2. At her previous visit she had missed her previous two menses and also had a blood pressure of 147/100 mmHg.

3. The patient has a past medical history of anxiety, depression, bulimia nervosa and irritable bowel syndrome.

4. Her physician prescribed her an exercise program as well as started her on hydrochlorothiazide and ordered lab work.

5. The results of the patient's lab work are: Na+: 145 mEq/L, K+: 2.9 mEq/L, Cl-: 100 mEq/L, HCO3-: 30 mEq/L, BUN: 18 mg/dL, Ca2+: 10.9 mg/dL, Mg2+: 2.0 mEq/L, Creatinine: 1.2 mg/dL, Glucose: 110 mg/dL.

6. The patient's blood pressure at this visit is 145/100 mmHg and she has still not experienced her menses.

7. Her cardiac, abdominal, and pulmonary exams are within normal limits.

8. Inspection of the patient's oropharynx is unremarkable as is inspection of her extremities.

9. The patient is started on furosemide and sent home.

1. The patient missed her previous two menses.

2. The patient had a blood pressure of 147/100 mmHg.

3. The patient has a past medical history of anxiety, depression, bulimia nervosa, and irritable bowel syndrome.

4. The physician prescribed an exercise program for the patient.

5. The physician started the patient on hydrochlorothiazide.

6. The physician ordered lab work for the patient.

7. The results of the patient's lab work are as follows:

8. Serum: Na+: 145 mEq/L, K+: 2.9 mEq/L, Cl-: 100 mEq/L, HCO3-: 30 mEq/L, BUN: 18 mg/dL, Ca2+: 10.9 mg/dL, Mg2+: 2.0 mEq/L, Creatinine: 1.2 mg/dL, Glucose: 110 mg/dL.

9. The patient's blood pressure at this visit is 145/100 mmHg.

10. The patient has still not experienced her menses.

11. The patient's cardiac, abdominal, and pulmonary exams are within normal limits.

12. Inspection of the patient's oropharynx is unremarkable.

13. Inspection of the patient's extremities is unremarkable.

14. The patient is started on furosemide and sent home.


Question: Which of the following is most likely to confirm the diagnosis?

Context: Thirty minutes ago, he was carrying heavy moving boxes from his house to a truck when he felt short of breath and suddenly lost consciousness.

Context: He was not confused after this episode.

Context: He does not have chest pain.

Context: These symptoms resolved with rest.

Context: Vital signs are within normal limits.

Context: His temperature is 36.7°C (98°F), heart rate is 95/min and pulse is delayed but regular, respirations are 20/min, and blood pressure is 104/80 mm Hg.

Choices:
A. CT angiography
B. Echocardiogram
C. Cardiac enzymes
D.
Electroencephalogram
"

Answer: Echocardiogram

1. A 59-year-old man is brought to the emergency room by his wife.

2. Thirty minutes ago, he was carrying heavy moving boxes from his house to a truck.

3. He felt short of breath and suddenly lost consciousness.

4. His wife states that he fell to the ground and was unresponsive for 15 seconds before he regained consciousness.

5. He was not confused after this episode.

7. On questioning, he recalls experiencing episodic shortness of breath and chest tightness while playing tennis over the past year.

9. He has no personal history of serious illness and takes no medication.

10. Vital signs are within normal limits.

1. Thirty minutes ago, he was carrying heavy moving boxes from his house to a truck.

2. He felt short of breath and suddenly lost consciousness.

3. His wife states that he fell to the ground and was unresponsive for 15 seconds before he regained consciousness.

4. He was not confused after this episode.

6. On questioning, he recalls experiencing episodic shortness of breath and chest tightness while playing tennis over the past year.

8. He has no personal history of serious illness and takes no medication.

9. Vital signs are within normal limits.

11. Heart rate is 95/min and pulse is delayed but regular.


Question: Which of the following is the most appropriate initial step in treatment?

Context: A previously healthy 2-year-old girl is brought to the physician by her mother because of a dry, harsh cough for 2 days that worsens at night.

Context: She has also had mild rhinorrhea and fever.

Context: Her older brother has asthma and had a cold last week.

Context: Immunizations are up-to-date.

Context: She appears to be in mild distress.

Context: Her temperature is 38.1°C (100.5°F), pulse is 140/min, respirations are 35/min, and blood pressure is 99/56 mm Hg.

Context: There is mild inspiratory stridor upon agitation that resolves with rest.

Choices:
A. Ceftriaxone
B. Bronchoscopy
C. Chest x-ray
D. Cool mist and dexamethasone

Answer: Cool mist and dexamethasone

General Pediatrics
Pediatric Pulmonology

2. Patient is brought to the physician by her mother.

3. Patient has a dry, harsh cough for 2 days that worsens at night.

4. Patient has mild rhinorrhea and fever.

5. Patient's older brother has asthma and had a cold last week.

6. Patient's immunizations are up-to-date.

7. Patient appears to be in mild distress.

8. Patient's temperature is 38.1°C (100.5°F).

11. Patient's blood pressure is 99/56 mm Hg.

12. Pulse oximetry on room air shows an oxygen saturation of 96%.

13. Examination shows clear rhinorrhea and a dry, hoarse cough.

14. Examination shows mild inspiratory stridor upon agitation that resolves with rest.

15. Examination shows no other abnormalities.

4. Her older brother had a cold last week.

11. Pulse oximetry on room air shows an oxygen saturation of 96%.

13. Examination shows a dry, hoarse cough.

14. There is mild inspiratory stridor upon agitation.

15. The inspiratory stridor resolves with rest.

16. The remainder of the examination shows no abnormalities.


Question: Which of the following is the most likely diagnosis?

Context: A 78-year-old man comes to the physician for evaluation of progressive hearing loss in both ears over the past year.

Context: Vital signs are within normal limits.

Choices:
A. Cerumen impaction
B. Ototoxicity
C. Vestibulocochlear nerve damage
D. Presbycusis

Answer: Presbycusis

2. Patient has progressive hearing loss in both ears over the past year.

3. Patient has difficulties understanding conversations in crowded places and when more than one person talks at the same time.

4. Patient has no dizziness, ear discharge, ringing noise, or ear pain.

5. Patient has a history of hypertension, hypercholesterolemia, and type 2 diabetes mellitus.

6. Patient is taking enalapril, metformin, and atorvastatin.

7. Vital signs are within normal limits.

8. Otoscopic examination shows pearly gray, translucent tympanic membranes with a normal light reflex.

9. A vibrating 512 Hz tuning fork is placed on the left mastoid process.

10. Patient no longer hears a tone when the fork is placed on the left mastoid process.

11. Patient reports to hear the tone again when the fork is held over the ipsilateral ear.

12. Similar results when the same test is repeated on the right side.

13. No lateralization when a vibrating 512 Hz tuning fork is placed in the middle of the forehead.

1. He has difficulties understanding conversations in crowded places and when more than one person talks at the same time.

2. He has no dizziness, ear discharge, ringing noise, or ear pain.

3. He has a history of hypertension, hypercholesterolemia, and type 2 diabetes mellitus.

4. Medications include enalapril, metformin, and atorvastatin.

5. Vital signs are within normal limits.

6. Otoscopic examination shows pearly gray, translucent tympanic membranes with a normal light reflex.

7. A vibrating 512 Hz tuning fork is placed on the left mastoid process.

8. Once the patient no longer hears a tone, the fork is held over the ipsilateral ear and the patient reports to hear the tone again.

9. The same test is repeated on the right side with similar results.

10. There is no lateralization when a vibrating 512 Hz tuning fork is placed in the middle of the forehead.


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

Context: A 35-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit.

Context: She feels well.

Context: She states that she did not follow up with her gynecologist on a regular basis due to a busy work schedule.

Context: Urinalysis shows: | Blood negative | Protein 3+ | RBC 1–2/hpf | RBC casts negative | After four hours of observation, her vital signs are unchanged.

Choices:
A. Induce labor
B. Administration of methyldopa
C. Reassurance
D. Fetal monitoring with continuous cardiotocography

Answer: Induce labor

1. A 35-year-old woman is gravida 3, para 2, at 37 weeks' gestation.

3. She did not follow up with her gynecologist on a regular basis due to a busy work schedule.

4. Pregnancy and delivery of her first two children were uncomplicated.

5. Her blood pressure was 127/75 mm Hg at her initial obstetrics appointment.

9. Pelvic examination shows a uterus consistent in size with a 37-week gestation.

10. Physical examination shows 2+ edema in the lower extremities.

11. Urinalysis shows: Blood negative, Protein 3+, RBC 1–2/hpf, RBC casts negative.

12. After four hours of observation, her vital signs are unchanged.

2. She did not follow up with her gynecologist on a regular basis due to a busy work schedule.

3. Pregnancy and delivery of her first two children were uncomplicated.

4. Her blood pressure was 127/75 mm Hg at her initial obstetrics appointment.

5. Her temperature is 37.2°C (99°F), pulse is 90/min, and blood pressure is 145/95 mm Hg.

6. Pelvic examination shows a uterus consistent in size with a 37-week gestation.

7. Physical examination shows 2+ edema in the lower extremities.

8. Urinalysis shows: | Blood negative | Protein 3+ | RBC 1–2/hpf | RBC casts negative.

9. After four hours of observation, her vital signs are unchanged.


Question: Which of the following trinucleotide repeats is found in this disease?

Context: A 31-year-old presents with self-described complaints of being "fidgety and irritable" that is unlike his "calm personality a few years ago".

Context: What is concerning to him is that his father was diagnosed with a similar condition at the age of 38.

Context: His father began a progressive decline - losing interest in his life and family, becoming messy, experiencing involuntary movements, and worsening dementia as he grew older.

Context: Genetic tests were performed on the patient which confirmed that he has a larger number of repeats than his father.

Choices:
A. CAG
B. CTG
C. GAA
D. UGA

Answer: CAG

1. A 31-year-old presents with self-described complaints of being "fidgety and irritable".

2. This is unlike his "calm personality a few years ago".

3. His father was diagnosed with a similar condition at the age of 38.

4. His father began a progressive decline.

5. His father's decline included losing interest in his life and family, becoming messy, experiencing involuntary movements, and worsening dementia as he grew older.

6. Genetic tests were performed on the patient.

7. The genetic tests confirmed that he has a larger number of repeats than his father.

8. He is concerned that the disease may begin earlier for him or may have already started.

1. His father was diagnosed with a similar condition at the age of 38.

2. His father began a progressive decline.

3. His father lost interest in his life and family.

5. His father experienced involuntary movements.

6. His father's dementia worsened as he grew older.

7. Genetic tests were performed on the patient.

8. The genetic tests confirmed that he has a larger number of repeats than his father.

9. He is concerned that the disease may begin earlier for him or may have already started.


Question: This patient's condition is most likely caused by mutation of an oncogene that encodes for a protein involved in which of the following cellular processes?

Context: A 48-year-old woman comes to the physician because of a 3-month history of low-grade fever, unintentional weight loss, night sweats, and a right-sided neck mass.

Context: Examination shows pallor.

Context: There is a non-tender and immobile right-sided cervical mass and enlarged axillary and inguinal lymph nodes.

Context: The liver is palpated 4 cm below the right costal margin, and the spleen is palpated 3 cm below the left costal margin.

Context: Histopathologic examination of a cervical lymph node biopsy specimen shows a nodular proliferation of centrocytes and centroblasts that stain positive for CD20.

Choices:
A. Hydrolysis of guanosine triphosphate
B. Upregulation of cytokine receptor binding
C. Transfer of phosphate from ATP to cellular protein
D. Inhibition of programmed cell death

Answer: Inhibition of programmed cell death

1. A 48-year-old woman comes to the physician.

2. She has a 3-month history of low-grade fever.

3. She has a 3-month history of unintentional weight loss.

4. She has a 3-month history of night sweats.

7. There is a non-tender and immobile right-sided cervical mass.

8. There are enlarged axillary and inguinal lymph nodes.

9. The liver is palpated 4 cm below the right costal margin.

10. The spleen is palpated 3 cm below the left costal margin.

11. Histopathologic examination of a cervical lymph node biopsy specimen shows a nodular proliferation of centrocytes and centroblasts.

12. The nodular proliferation stains positive for CD20.

13. Genetic analysis shows a reciprocal translocation of chromosomes 14 and 18.

2. There is a non-tender and immobile right-sided cervical mass.

3. Enlarged axillary and inguinal lymph nodes are present.

4. The liver is palpated 4 cm below the right costal margin.

5. The spleen is palpated 3 cm below the left costal margin.

6. Histopathologic examination of a cervical lymph node biopsy specimen shows a nodular proliferation of centrocytes and centroblasts.

7. The centrocytes and centroblasts stain positive for CD20.

8. Genetic analysis shows a reciprocal translocation of chromosomes 14 and 18.


Question: What is the mechanism of action of the medication that can treat this patient’s condition?

Context: The patient denies fevers, weight loss, chills, chest pain, or shortness of breath, but reports mild abdominal discomfort and some dark stools that he attributes to iron supplements.

Context: A physical examination demonstrates a moderate fluid wave of the abdomen and shaking of the hands while the wrists are extended.

Choices:
A. Antagonist against 5-HT3
B. Long-acting somatostatin analog
C. Mu-opioid receptor agonist
D. Trapping of ammonia in the colon

Answer: Trapping of ammonia in the colon

Neurology
Emergency Medicine
Internal Medicine

Neurology with Special Qualification in Child Neurology

1. A 59-year-old man is brought to the emergency department for changes in mental status.

2. His wife noticed that since lunch time today, he has been “zoning out” and forgetting simple things such as where the bathroom is.

3. She decided to call the ambulance as he got uncharacteristically violent during dinner when he threw his plate to the floor.

4. The patient denies fevers, weight loss, chills, chest pain, or shortness of breath.

5. The patient reports mild abdominal discomfort and some dark stools that he attributes to iron supplements.

6. A physical examination demonstrates a moderate fluid wave of the abdomen.

7. A physical examination demonstrates shaking of the hands while the wrists are extended.

1. His wife noticed that since lunch time today, he has been “zoning out” and forgetting simple things such as where the bathroom is.

2. She decided to call the ambulance as he got uncharacteristically violent during dinner when he threw his plate to the floor.

3. The patient denies fevers, weight loss, chills, chest pain, or shortness of breath.

4. The patient reports mild abdominal discomfort and some dark stools that he attributes to iron supplements.

5. A physical examination demonstrates a moderate fluid wave of the abdomen.

6. A physical examination demonstrates shaking of the hands while the wrists are extended.


Question: Which of the following manifestations is more specific for this patient’s condition?

Context: His father died of diabetes complications and his mother has been recently diagnosed with proliferative diabetic retinopathy.

Context: His blood pressure is 160/95 mm Hg, temperature is 36.9°C (98.4°F), pulse is 90/min, body mass index is 36 kg/m², fasting blood sugar 170 mg/dL, and A1c is 9%.

Choices:
A. Kussmaul respiration
B. Unintentional weight loss
C. Acanthosis nigricans
D. Polyurea

Answer: Acanthosis nigricans

General Internal Medicine
Endocrinology, Diabetes, and Metabolism

1. An otherwise healthy 49-year-old man presents to his primary care doctor for routine screening.

2. He does not have any symptoms and take no medications.

3. He has smoked 15–20 cigarettes daily for the past 9 years.

4. His father died of diabetes complications.

5. His mother has been recently diagnosed with proliferative diabetic retinopathy.

10. His fasting blood sugar is 170 mg/dL.

1. The patient does not have any symptoms.

3. The patient has smoked 15–20 cigarettes daily for the past 9 years.

4. The patient's father died of diabetes complications.

5. The patient's mother has been recently diagnosed with proliferative diabetic retinopathy.

6. The patient's blood pressure is 160/95 mm Hg.

7. The patient's temperature is 36.9°C (98.4°F).

9. The patient's body mass index is 36 kg/m².

10. The patient's fasting blood sugar is 170 mg/dL.


Question: Which of the following is the most likely site of action of this drug in the kidney?

Context: A 30-year-old woman is brought to the emergency department because of severe headache and vomiting that started after she was hiking in the mountains at high altitude.

Choices:
A. Proximal convoluted tubule
B. Ascending loop of Henle
C. Glomerulus
D. Early distal convoluted tubule

Answer: Proximal convoluted tubule

Emergency Medicine
Family Medicine
Internal Medicine

Neurocritical Care
Pulmonary Disease
Sports Medicine

1. A 30-year-old woman is brought to the emergency department.

2. She has severe headache and vomiting.

3. Her symptoms started after she was hiking in the mountains at high altitude.

4. She normally lives in a city that is close to sea level.

5. Therapy is initiated with a drug that alkalinizes the urine.

1. She normally lives in a city.
2. The city is close to sea level.
3. Therapy is initiated.
4. The therapy involves a drug.
5. The drug alkalinizes the urine.


Question: In addition to drawing her blood for viral serologies, which of the following is the most appropriate next step?

Context: A 35-year-old woman comes to employee health services 30 minutes after a work-related incident.

Context: She works as a phlebotomist and reports that blood splashed into her right eye when she was drawing blood from a 30-year-old male patient.

Context: He is an intravenous drug user and is sexually active with several male and female partners.

Context: The phlebotomist has no history of serious illness and takes no medications.

Context: Her immunizations are up-to-date.

Choices:
A. Start raltegravir, tenofovir, and emtricitabine
B. Start zidovudine
C. Start tenofovir and emtricitabine
D. Administer hepatitis B immune globulin and vaccine

Answer: Start raltegravir, tenofovir, and emtricitabine

1. A 35-year-old woman came to employee health services 30 minutes after a work-related incident.

3. Blood splashed into her right eye when she was drawing blood from a 30-year-old male patient.

4. Immediately following the incident, she flushed her eye with water for several minutes.

5. The patient from whom she drew blood was admitted for hemoptysis, weight loss, and night sweats.

7. He is sexually active with several male and female partners.

8. The phlebotomist has no history of serious illness.

11. Physical examination shows no abnormalities.

2. Blood splashed into her right eye when she was drawing blood from a 30-year-old male patient.

3. She flushed her eye with water for several minutes immediately following the incident.

4. The patient from whom she drew blood was admitted for hemoptysis, weight loss, and night sweats.

5. The patient is an intravenous drug user and is sexually active with several male and female partners.

6. The phlebotomist has no history of serious illness.

7. The phlebotomist takes no medications.

9. Physical examination shows no abnormalities.


Question: Which of the following is the most likely diagnosis?

Context: A 65-year-old Asian woman comes to the physician for a routine health maintenance examination.

Context: On questioning, she has had occasional night sweats during the past 2 months.

Context: She has not had fevers or weight loss.

Context: The lungs are clear to auscultation.

Context: Cardiac examination shows an S4.

Context: A photograph of the lesion is shown.

Choices:
A. Traumatic subungual hemorrhage
B. Malignant melanoma
C. Onychomycosis
D. Squamous cell carcinoma

Answer: Malignant melanoma

1. Patient is a 65-year-old Asian woman.

2. Patient has had occasional night sweats during the past 2 months.

3. Patient has not had fevers or weight loss.

4. Patient had an acute myocardial infarction 7 months ago and was treated with percutaneous coronary intervention.

5. Patient has hypertension, hyperlipidemia, and gastroesophageal reflux disease.

6. Patient has smoked one pack of cigarettes daily for 37 years.

7. Patient's current medications include aspirin, atorvastatin, ramipril, metoprolol, and esomeprazole.

8. Patient is 178 cm (5 ft 10 in) tall and weighs 89 kg (207 lbs); BMI is 29.7 kg/m2.

9. Patient's temperature is 37.4°C (99.3°F), pulse is 84/min, respirations are 18/min, and blood pressure is 145/80 mm Hg.

12. Patient has a nontender skin lesion near the right large toenail.

14. No other abnormalities found on examination.

1. She has had occasional night sweats during the past 2 months.

2. She has not had fevers or weight loss.

3. Seven months ago, she had an acute myocardial infarction and was treated with percutaneous coronary intervention.

4. She has hypertension, hyperlipidemia, and gastroesophageal reflux disease.

5. She has smoked one pack of cigarettes daily for 37 years.

6. Current medications include aspirin, atorvastatin, ramipril, metoprolol, and esomeprazole.

7. She is 178 cm (5 ft 10 in) tall and weighs 89 kg (207 lbs); BMI is 29.7 kg/m2.

8. Her temperature is 37.4°C (99.3°F), pulse is 84/min, respirations are 18/min, and blood pressure is 145/80 mm Hg.

11. There is a nontender skin lesion near the right large toenail.

12. A photograph of the lesion is shown.

13. The remainder of the examination shows no abnormalities.


Question: Which of the following microorganisms is the most likely cause of this patient’s symptoms?

Context: A 12-year-old girl brought to the clinic by her mother has a 3-day history of fever and sore throat and hematuria since this morning.

Context: The patient’s mother says she had a fever up to 39.5℃ (103.1℉) for the last 3 days and a severe sore throat, which has improved slightly.

Context: The mother states that she noticed her daughter had red urine today.

Context: The patient’s temperature is 39.3℃ (102.8℉), pulse is 89/min, respiratory rate is 25/min, and blood pressure is 109/69 mm Hg.

Context: On physical examination, her pharynx is erythematous.

Context: A urine dipstick is performed and shows the following results: | Urine Dipstick | Specific Gravity 1.019 | Glucose None | Ketones None | Nitrites Negative | Leukocyte Esterase Negative | Protein None | Blood 3+ |  .

Choices:
A. Streptococcus pyogenes
B. Adenovirus
C. Escherichia coli O157:H7
D. Proteus mirabilis

Answer: Adenovirus

Pediatric Nephrology
Pediatric Infectious Diseases

1. A 12-year-old girl was brought to the clinic by her mother.

2. The patient has a 3-day history of fever and sore throat.

3. The patient has had hematuria since this morning.

4. The patient's mother says the fever has been up to 39.5℃ (103.1℉) for the last 3 days.

5. The patient's mother says the sore throat has improved slightly.

6. The patient's mother noticed her daughter had red urine today.

7. The patient's temperature is 39.3℃ (102.8℉).

9. The patient's respiratory rate is 25/min.

10. The patient's blood pressure is 109/69 mm Hg.

11. On physical examination, the patient's pharynx is erythematous.

12. There is significant swelling of the tonsils bilaterally.

13. There is a white exudate covering the tonsils bilaterally.

14. Ophthalmologic examination reveals evidence of conjunctivitis bilaterally.

15. Otoscopic examination is significant for gray-white tympanic membranes bilaterally.

16. The remainder of the exam is unremarkable.

18. The urine dipstick showed a specific gravity of 1.019.

19. The urine dipstick showed no glucose.

20. The urine dipstick showed no ketones.

21. The urine dipstick showed negative nitrites.

22. The urine dipstick showed negative leukocyte esterase.

23. The urine dipstick showed no protein.

1. The patient's mother reports a fever up to 39.5℃ (103.1℉) for the last 3 days and a severe sore throat.

2. The patient's mother noticed her daughter had red urine today.

3. The patient's temperature is 39.3℃ (102.8℉), pulse is 89/min, respiratory rate is 25/min, and blood pressure is 109/69 mm Hg.

4. On physical examination, the patient's pharynx is erythematous.

5. There is significant swelling of the tonsils bilaterally, and there is a white exudate covering them.

6. Ophthalmologic examination reveals evidence of conjunctivitis bilaterally.

7. Otoscopic examination is significant for gray-white tympanic membranes bilaterally.

8. The remainder of the exam is unremarkable.

9. A urine dipstick test shows the following results: Specific Gravity 1.019, Glucose None, Ketones None, Nitrites Negative, Leukocyte Esterase Negative, Protein None, Blood 3+.


Question: What physical finding would suggest involvement of the nerve in its course through the parotid gland?

Context: A 73-year-old woman with a past medical history of diabetes, hypertension, and hyperlipidemia presents to the emergency department with swelling in her left neck.

Context: The onset was a few months ago.

Context: She denies any fever, night sweats or itching.

Context: Surgery is planned and the tumor is removed while trying to preserve a nerve that could be involved.

Choices:
A. Loss of taste on the left anterior 2/3 of the tongue
B. Hypersensitivity to sound in the left ear
C. Inability to smile on the left side
D. Numbness of the left cheek

Answer: Inability to smile on the left side

1. A 73-year-old woman presents to the emergency department with swelling in her left neck.

2. The onset of the swelling was a few months ago.

3. The woman has lost 6.8 kg (15.0 lb) over the same duration.

4. The woman denies any fever, night sweats or itching.

5. Physical examination reveals a painless swelling in front of her left ear.

6. There is painless lymphadenopathy below the ear.

7. Biopsy of the lymph nodes reveals mucoepidermoid carcinoma of the parotid gland.

8. Surgery is planned to remove the tumor while trying to preserve a nerve that could be involved.

9. The woman has a past medical history of diabetes, hypertension, and hyperlipidemia.

1. The onset of symptoms was a few months ago.

2. She has lost 6.8 kg (15.0 lb) over the same duration.

3. She denies any fever, night sweats, or itching.

4. Physical examination reveals a painless swelling in front of her left ear.

5. There is painless lymphadenopathy below the ear.

6. Biopsy of the lymph nodes reveals mucoepidermoid carcinoma of the parotid gland.

8. The tumor is removed while trying to preserve a nerve that could be involved.


Question: Concurrent treatment with which of the following agents most likely predisposed the patient to this episode?

Context: A 43-year-old man is brought to the emergency department by his wife after a near-syncopal episode.

Context: On arrival, he is fully oriented.

Context: His pulse is 100/min and blood pressure is 92/60 mm Hg.

Context: An ECG shows no evidence of ischemia.

Choices:
A. Ibuprofen
B. Hydrochlorothiazide
C. Lithium
D. Trimethoprim/sulfamethoxazole

Answer: Hydrochlorothiazide

1. A 43-year-old man is brought to the emergency department by his wife.

3. He was doing yard work when he began feeling dizzy and had to lie down.

4. He was started on lisinopril earlier in the day.

8. His serum electrolytes are within normal limits.

9. An ECG shows no evidence of ischemia.

4. Earlier in the day, he was started on lisinopril.

8. Serum electrolytes are within normal limits.


Question: What additional diagnostic test would be helpful in establishing a diagnosis?

Context: A 4-year-old Caucasian girl previously diagnosed with asthma presents with recurrent sinusitis, otitis media, and clubbing of the nail bed.

Context: A "sweat test" is performed and comes back normal.

Choices:
A. Nasal transepithelial potential difference
B. Skeletal survey
C. Complete blood cell count
D. Urinalysis

Answer: Nasal transepithelial potential difference

1. Patient is a 4-year-old Caucasian girl.

2. Patient has a previous diagnosis of asthma.

3. Patient presents with recurrent sinusitis.

5. Patient has clubbing of the nail bed.

6. Patient has a family history of a distant cousin with cystic fibrosis.

1. Family history is significant for a distant cousin with cystic fibrosis.


Question: Which of the following would most likely be positive in this patient?

Context: She is sexually active and complains of dyspareunia.

Choices:
A. Anti-double stranded (Ds) DNA
B. HLA-B51
C. ANCA
D. HLA-B27

Answer: HLA-B51

1. A 35-year-old woman presents with a complaint of oral ulcers.

2. It is the third recurrence of ulcers in the last 8 months.

5. Examination shows the presence of a uveitis.

2. The ulcers have recurred in the last 8 months


Question: What is the most likely cause of this patient’s symptoms?

Context: A 22-year-old female software analyst presents to a medical clinic for evaluation of tingling and numbness in both hands for the past 2 months.

Context: Her symptoms are usually aggravated by the end of the work day and absent on most off days.

Context: She has been a type I diabetic for 2 years and is currently on insulin.

Context: She admits to being sexually active but has had irregular periods for the past 3 months.

Context: A urine pregnancy test is negative.

Choices:
A. Hypothyroidism
B. Acute intermittent porphyria
C. Amyotrophic lateral sclerosis
D. Multiple sclerosis

Answer: Hypothyroidism

1. A 22-year-old female software analyst presents to a medical clinic.

2. She has tingling and numbness in both hands for the past 2 months.

3. Her symptoms are usually aggravated by the end of the work day.

4. Her symptoms are absent on most off days.

5. She has been a type I diabetic for 2 years.

8. She has had irregular periods for the past 3 months.

1. Her symptoms are usually aggravated by the end of the work day.

2. Her symptoms are absent on most off days.

3. She has been a type I diabetic for 2 years.

6. She has had irregular periods for the past 3 months.


Question: What is the normal function of the protein that is overexpressed due to the translocation seen in this patient?

Context: A 60-year-old male presents to his primary care physician complaining of fatigue.

Context: He reports a six-month history of gradually worsening tiredness.

Context: More recently, he has experienced intermittent fevers and night sweats.

Context: His temperature is 99.5°F (37.5°C), blood pressure is 115/80 mmHg, pulse is 80/min, and respirations are 18/min.

Context: A lymph node biopsy is performed and karyotypic analysis of the biopsy reveals an 11;14 translocation.

Choices:
A. Promote cell growth
B. Mediate cell cycle transition to mitosis
C. Mediate cell cycle transition to G2 phase
D. Mediate cell cycle transition to S phase

Answer: Mediate cell cycle transition to S phase

Medical Genetics and Genomics
Internal Medicine

Molecular Genetic Pathology
Clinical Genetics and Genomics
Hematology

1. A 60-year-old male presents to his primary care physician.

3. He has a six-month history of gradually worsening tiredness.

4. He has experienced intermittent fevers and night sweats.

9. On examination, painless cervical lymphadenopathy is noted.

11. Karyotypic analysis of the biopsy reveals an 11;14 translocation.

1. The patient reports a six-month history of gradually worsening tiredness.

2. The patient has experienced intermittent fevers and night sweats.

3. The patient's temperature is 99.5°F (37.5°C).

4. The patient's blood pressure is 115/80 mmHg.

6. The patient's respirations are 18/min.

7. On examination, painless cervical lymphadenopathy is noted.

9. Karyotypic analysis of the biopsy reveals an 11;14 translocation.


Question: Which of the following is the most appropriate next step in the management of this patient?

Context: An 8-year-old boy presents with abdominal pain and constipation.

Context: The patient’s mother says that the symptoms gradually onset 2 months ago.

Context: The patient describes the pain as moderate to severe, gnawing and diffusely localized.

Context: His mother mentioned that he is a good student but has been irritable lately, and his homework has been full of careless mistakes.

Context: The vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/65 mm Hg, pulse 82/min, respiratory rate 19/min, and oxygen saturation 99% on room air.

Context: The abdomen is diffusely tender to palpation with no rebound or guarding.

Context: There is a left wrist drop.

Context: Laboratory results are significant for the following: | Sodium 141 mEq/L | Potassium 4.1 mEq/L | Chloride 101 mEq/L | Bicarbonate 25 mEq/L | Blood urea nitrogen (BUN) 27 mg/dL | Creatinine 1.7 mg/dL | Glucose (fasting) 80 mg/dL | White blood cell (WBC) count 8,700/mm3 | Red blood cell (RBC) count 4.20 x 106/mm3 | Hematocrit 41.5% | Hemoglobin 10.3 g/dL | Platelet count 190,000/mm3 | Mean corpuscular volume (MCV) 65 mm3 | Lead 72 mcg/dL.

Choices:
A. Chelation therapy with dimercaptosuccinic acid (succimer)
B. Chelation therapy with dimercaprol
C. Chelation therapy with dimercaprol and calcium disodium edetate (EDTA)
D. Plain abdominal radiographs

Answer: Chelation therapy with dimercaprol and calcium disodium edetate (EDTA)

2. Patient presents with abdominal pain and constipation.

3. Symptoms gradually onset 2 months ago.

4. Patient describes pain as moderate to severe, gnawing and diffusely localized.

5. No significant past medical history and no current medications.

6. Patient lives in a house built in the 1990s with his parents and has a sister who goes to daycare.

7. Patient is a good student but has been irritable lately, and his homework has been full of careless mistakes.

8. Vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/65 mm Hg, pulse 82/min, respiratory rate 19/min, and oxygen saturation 99% on room air.

9. Patient is alert and cooperative on physical examination.

10. Abdomen is diffusely tender to palpation with no rebound or guarding.

12. Nontender, flat bluish line above the gums is noted.

13. Laboratory results are significant for sodium 141 mEq/L, potassium 4.1 mEq/L, chloride 101 mEq/L, bicarbonate 25 mEq/L, BUN 27 mg/dL, creatinine 1.7 mg/dL, and glucose (fasting) 80 mg/dL, White blood cell (WBC) count 8,700/mm3, Red blood cell (RBC) count 4.20 x 106/mm3, Hematocrit 41.5%, Hemoglobin 10.3 g/dL, Platelet count 190,000/mm3, Mean corpuscular volume (MCV) 65 mm3, Lead 72 mcg/dL.

1. The patient's symptoms gradually onset 2 months ago.

2. The patient describes the pain as moderate to severe, gnawing, and diffusely localized.

3. The patient has no significant past medical history and is not taking any current medications.

4. The patient lives in a house built in the 1990s with his parents and has a sister who goes to daycare.

5. The patient's mother mentioned that he is a good student but has been irritable lately, and his homework has been full of careless mistakes.

6. The patient's vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/65 mm Hg, pulse 82/min, respiratory rate 19/min, and oxygen saturation 99% on room air.

7. On physical examination, the patient is alert and cooperative.

8. The patient's abdomen is diffusely tender to palpation with no rebound or guarding.

10. A nontender, flat bluish line above the gums is noted.

11. Laboratory results show: Sodium 141 mEq/L, Potassium 4.1 mEq/L, Chloride 101 mEq/L, Bicarbonate 25 mEq/L, Blood urea nitrogen (BUN) 27 mg/dL, Creatinine 1.7 mg/dL, Glucose (fasting) 80 mg/dL, White blood cell (WBC) count 8,700/mm3, Red blood cell (RBC) count 4.20 x 106/mm3, Hematocrit 41.5%, Hemoglobin 10.3 g/dL, Platelet count 190,000/mm3, Mean corpuscular volume (MCV) 65 mm3, and Lead 72 mcg/dL.


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

Context: Two days after undergoing a left total hip replacement, a 68-year-old man has increasing shortness of breath and chest pain for 30 minutes.

Context: He has type 2 diabetes mellitus and bilateral osteoarthritis of the hips.

Context: His temperature is 37.8°C (100°F), pulse is 110/min, respirations are 30/min, and blood pressure is 106/70 mm Hg.

Context: The lungs are clear to auscultation.

Context: The right lower extremity is swollen.

Context: Pedal pulses are palpable.

Context: His hematocrit is 30%.

Context: Arterial blood gas analysis on room air shows: | pH 7.48 | pCO2 27 mm Hg | pO2 68 mm Hg | HCO3- 23 mEq/L | An electrocardiogram shows sinus tachycardia and right axis deviation.

Choices:
A. Administer alteplase
B. Obtain a spiral CT angiogram
C. Obtain an x-ray of the chest
D. Perfom an echocardiography

Answer: Obtain a spiral CT angiogram

2. Patient has type 2 diabetes mellitus and bilateral osteoarthritis of the hips.

3. Patient's medications prior to admission were metformin and naproxen.

4. Patient's temperature is 37.8°C (100°F).

7. Patient's blood pressure is 106/70 mm Hg.

8. Pulse oximetry on room air shows an oxygen saturation of 89%.

10. Cardiac examination shows no abnormalities.

12. Right foot flexion in an upward direction causes pain in the right calf.

14. Supplemental oxygen and intravenous fluid resuscitation are begun.

16. Arterial blood gas analysis on room air shows: pH 7.48, pCO2 27 mm Hg, pO2 68 mm Hg, HCO3- 23 mEq/L.

17. An electrocardiogram shows sinus tachycardia and right axis deviation.

18. Patient has increasing shortness of breath and chest pain for 30 minutes, two days after undergoing a left total hip replacement.

2. He has bilateral osteoarthritis of the hips.

3. Prior to admission to the hospital, his medications were metformin and naproxen.

11. The right lower extremity is swollen.


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

Context: An 11-month-old male presents to the emergency department with his father after “passing out” at home.

Context: The patient’s temperature is 98.5°F (36.9°C), blood pressure is 86/64 mmHg, pulse is 98/min, and respirations are 26/min.

Choices:
A. Arterial blood gas
B. Echocardiogram
C. Electrocardiogram (ECG)
D. Observation and reassurance

Answer: Observation and reassurance

1. An 11-month-old male presents to the emergency department with his father.

2. His father reports that the patient started crying after his older brother took a toy away from him.

3. The patient was difficult to soothe and then suddenly stopped breathing.

4. His father reports that his lips turned slightly blue, and the patient’s entire body became limp.

5. The episode lasted a few seconds, and the patient seemed to act normally afterwards.

6. The patient’s father notes that the patient’s older brother had similar episodes as a child.

7. He denies any family history of neurological disease.

8. The patient’s temperature is 98.5°F (36.9°C).

9. The patient's blood pressure is 86/64 mmHg.

11. The patient's respirations are 26/min.

12. On physical exam, the patient is in no acute distress playing on his father’s lap.

13. The patient's neurological exam is unremarkable.

1. The patient started crying after his older brother took a toy away from him.

3. The patient suddenly stopped breathing.

4. The patient's lips turned slightly blue.

5. The patient's entire body became limp.

7. The patient seemed to act normally afterwards.

8. The patient's older brother had similar episodes as a child.

9. There is no family history of neurological disease.

10. The patient's temperature is 98.5°F (36.9°C).

11. The patient's blood pressure is 86/64 mmHg.

13. The patient's respirations are 26/min.

14. On physical exam, the patient is in no acute distress playing on his father’s lap.

15. The patient's neurological exam is unremarkable.


Question: Which of the following is the most likely diagnosis?

Choices:
A. Gonococcal arthritis
B. Parvovirus B19
C. Rheumatoid arthritis
D. Transient synovitis

Answer: Parvovirus B19

1. A 27-year-old woman presents to the emergency department for pain in multiple joints.

2. She states that she has had symmetric joint pain that started yesterday and has been worsening.

3. It is affecting her wrists, elbows, and shoulders.

4. She also endorses a subjective fever and some fatigue but denies any other symptoms.

5. The patient works as a schoolteacher and is generally healthy.

6. She is currently sexually active with 2 male partners and uses condoms occasionally.

7. Her temperature is 100°F (37.8°C), blood pressure is 122/85 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air.

8. Her laboratory values are within normal limits.

9. Physical exam is notable for joint stiffness and pain in particular of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and the wrist.

10. The patient is discharged with ibuprofen.

11. Four weeks later, the patient follows up at her primary doctor and notes that her symptoms have improved and she is no longer taking any medications for symptom control.

1. The patient has symmetric joint pain affecting her wrists, elbows, and shoulders.

2. The joint pain started yesterday and has been worsening.

3. She endorses a subjective fever and some fatigue.

4. The patient denies any other symptoms.

5. She works as a schoolteacher and is generally healthy.

6. The patient is currently sexually active with 2 male partners and uses condoms occasionally.

11. Her oxygen saturation is 99% on room air.

12. Her laboratory values are within normal limits.

13. Physical exam is notable for joint stiffness and pain in particular of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and the wrist.

14. The patient is discharged with ibuprofen.

15. Four weeks later, the patient follows up at her primary doctor and notes that her symptoms have improved and she is no longer taking any medications for symptom control.


Question: Which of the following is the most likely cause of this patient's symptoms?

Context: A 57-year-old man with HIV and GERD comes to the emergency department because of productive cough with malodorous phlegm and night sweats for the past week.

Context: He has smoked 1 pack of cigarettes daily for 30 years and he drinks 8–10 beers daily.

Context: His temperature is 38.9°C (102.0°F).

Context: An x-ray of the chest is shown.

Choices:
A. Bronchiectasis
B. Adenocarcinoma in situ
C. Tuberculosis
D. Aspiration pneumonia

Answer: Aspiration pneumonia

1. A 57-year-old man with HIV and GERD comes to the emergency department.

2. He has had productive cough with malodorous phlegm and night sweats for the past week.

3. He has smoked 1 pack of cigarettes daily for 30 years.

6. Physical examination shows coarse crackles and dullness to percussion at the right lung base.

7. Scattered expiratory wheezing is heard throughout both lung fields.

8. The CD4+ T-lymphocyte count is 280/mm3 (N ≥ 500).

1. He has smoked 1 pack of cigarettes daily for 30 years.

4. Physical examination shows coarse crackles and dullness to percussion at the right lung base.

5. Scattered expiratory wheezing is heard throughout both lung fields.

6. The CD4+ T-lymphocyte count is 280/mm3 (N ≥ 500).


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

Context: A 20-year-old woman is brought to the emergency department by her boyfriend for right arm and leg weakness, numbness, and tingling that has been resolving gradually.

Context: The symptoms started 4 hours ago after she had an argument with her boyfriend during which she slapped and kicked him.

Context: She is alert and oriented.

Context: She has a negative Spurling test.

Choices:
A. Administer alteplase
B. Provide patient education
C. Prescribe aspirin
D.
Start biofeedback therapy
"

Answer: Provide patient education

2. Patient was brought to the emergency department by her boyfriend.

3. Patient has right arm and leg weakness, numbness, and tingling.

4. Symptoms have been resolving gradually.

5. Symptoms started 4 hours ago after an argument with her boyfriend during which she slapped and kicked him.

6. Patient has been limping and cannot use her right arm.

7. Patient has never had similar symptoms in the past.

8. Patient has a history of genital herpes and trichotillomania.

10. Physical examination shows upper and lower face symmetry and normal speech.

11. Patient has 5/5 strength in all extremities and 5/5 right ankle plantar flexion when lying down.

12. Patient has 4/5 strength in the right arm and leg when ambulating.

13. Patient cannot stand on her toes when asked.

14. Patient has 2+ deep tendon reflexes bilaterally.

15. Patient has normal proprioception, light touch sensation, and two-point discrimination in all extremities.

16. Patient has a negative Spurling test.

17. CT of the head without contrast shows no abnormalities.

1. The symptoms started 4 hours ago after an argument with her boyfriend.

2. During the argument, she slapped and kicked him.

3. She says she has been limping and cannot use her right arm anymore.

4. She has never had similar symptoms in the past.

5. She has a history of genital herpes and trichotillomania.

7. Physical examination shows upper and lower face symmetry and normal speech.

8. She has 5/5 strength in all extremities and 5/5 right ankle plantar flexion when lying down.

9. She has 4/5 strength in the right arm and leg when ambulating.

10. She cannot stand on her toes when asked.

11. Her deep tendon reflexes are 2+ bilaterally.

12. She has normal proprioception, light touch sensation, and two-point discrimination in all extremities.

14. CT of the head without contrast shows no abnormalities.


Question: Which of the following best describes the feelings that the psychiatrist has for the patient?

Context: A 14-year-old female presents to her psychiatrist in hopes that she can find help in dealing with the sexual abuse that occurred in her childhood.

Context: While retelling her story of the numerous encounters the patient had with her abuser, the psychiatrist begins to feel protective and parental towards the client, wishing that he could have somehow helped the young girl.

Choices:
A. Countertransference
B. Identification
C. Sublimation
D. Projection

Answer: Countertransference

1. A 14-year-old female presents to her psychiatrist.

2. The patient is seeking help in dealing with sexual abuse that occurred in her childhood.

3. The patient is retelling her story of numerous encounters with her abuser.

4. The psychiatrist begins to feel protective and parental towards the client.

5. The psychiatrist wishes he could have somehow helped the young girl.

1. The patient had numerous encounters with her abuser.

2. The psychiatrist feels protective and parental towards the client.

3. The psychiatrist wishes he could have somehow helped the young girl.


Question: Which of the following trinucleotide DNA sequences would initiate protein translation when converted to mRNA? | Note: sequences are written 3'-->5'

Choices:
A. TAC
B. ATC
C. ATT
D. AAA

Answer: TAC

General Medical Genetics and Genomics
Molecular Genetic Pathology


Question: Which side-effect is associated with the drug of choice for the treatment of this patient’s condition?

Context: A 47-year-old woman visits the emergency department due to painful, swollen fingers in both of her hands.

Context: On examination, nodules are seen over her Achilles tendon and both wrists are erythematous, swollen, and tender to touch.

Context: Laboratory tests are presented below: | Hemoglobin: 11.0 g/dL | Hematocrit: 40.5% | Leukocyte count: 7400/mm3 | Mean corpuscular volume: 80.1 μm3 | Platelet count: 210,000/mm3 | Erythrocyte sedimentation rate: 55 mm/h | Anti-cyclic citrullinated peptide antibody: 45 (Normal reference values: < 20) | .

Choices:
A. Retinopathy
B. Arterial hypertension
C. Pneumonitis
D. Reactivation of latent tuberculosis

Answer: Pneumonitis

1. A 47-year-old woman visits the emergency department.

2. She has painful, swollen fingers in both of her hands.

3. She has worked as a bus driver for the county school system for the last 20 years.

4. Her past medical history is significant for a transient ischemic attack 5 years ago.

5. She reports that she has lost weight in the last 2 months.

6. There have been no changes in her diet.

7. She generally feels fatigued all day.

8. On examination, nodules are seen over her Achilles tendon.

9. Both wrists are erythematous, swollen, and tender to touch.

15. Erythrocyte sedimentation rate: 55 mm/h

16. Anti-cyclic citrullinated peptide antibody: 45 (Normal reference values: < 20)

1. She has worked as a bus driver for the county school system for the last 20 years.

2. Her past medical history is significant for a transient ischemic attack 5 years ago.

3. She reports that she has lost weight in the last 2 months although there have been no changes in her diet.

4. She also says that she generally feels fatigued all day.

5. On examination, nodules are seen over her Achilles tendon.

6. Both wrists are erythematous, swollen, and tender to touch.

7. Laboratory tests: Hemoglobin: 11.0 g/dL.

12. Erythrocyte sedimentation rate: 55 mm/h.

13. Anti-cyclic citrullinated peptide antibody: 45 (Normal reference values: < 20).


Question: The patient was most likely treated with an antibiotic that binds to which of the following?

Context: Before the next dose with the same agent, the patient is given diphenhydramine and ranitidine and the antibiotic is subsequently given at a slower infusion rate without complications.

Choices:
A. Transpeptidase
B. Topoisomerase II
C. Dihydrofolate reductase
D. D-alanyl-D-alanine

Answer: D-alanyl-D-alanine

1. A 37-year-old man comes to the emergency room with fever, chills, and left lower leg pain for 2 days.

2. He was recently discharged from the hospital after arthroscopic knee surgery.

3. Physical examination shows an erythematous lesion with poorly defined margins over the left shin but no fluctuance.

4. Treatment with an intravenous antibiotic is begun.

5. Shortly after starting the infusion, the patient develops flushing, erythema, and pruritus of the upper body.

6. The symptoms resolve after discontinuation of the infusion.

7. Before the next dose with the same agent, the patient is given diphenhydramine and ranitidine.

8. The antibiotic is subsequently given at a slower infusion rate without complications.

1. The patient recently had arthroscopic knee surgery.

2. Physical examination shows an erythematous lesion with poorly defined margins over the left shin but no fluctuance.

3. Treatment with an intravenous antibiotic is begun.

4. Shortly after starting the infusion, the patient develops flushing, erythema, and pruritus of the upper body.

5. The symptoms resolve after discontinuation of the infusion.

6. Before the next dose with the same agent, the patient is given diphenhydramine and ranitidine.

7. The antibiotic is subsequently given at a slower infusion rate without complications.


Question: Which of the following pathologies most likely underlies this patient’s condition?

Context: A 55-year-old man presents with worsening weakness of the left hand and progressive difficulty in walking for the last 2 months.

Context: He says he was previously healthy and active, hiking every weekend, but because of his increasing weakness and incoordination while walking, he stopped his weekly hiking excursion.

Context: His past medical history is unremarkable.

Context: Current medications are a daily multivitamin and occasional acetaminophen for headaches.

Context: He has no significant family history.

Context: His vitals include: pulse 70/min, respirations 14/min, temperature 37.0°C (98.6°F), and blood pressure 130/80 mm Hg.

Context: The left forearm shows significant atrophy, and mild lower limb muscle atrophy is also seen bilaterally.

Context: Hyporeflexia (1+) is present in the left arm, while hyperreflexia (3+) is seen in the legs bilaterally.

Context: The patient's speech is notably slow but no evidence of productive or expressive aphasia is present.

Context: The cranial nerves are intact.

Choices:
A. Demyelination of neurons in various parts of the brain
B. Degeneration of the dorsal columns of the spinal cord
C. Infarction of the posterior limb of the internal capsule
D. Loss of the pyramidal tract neurons and anterior horn cells of the spinal cord

Answer: Loss of the pyramidal tract neurons and anterior horn cells of the spinal cord

Degeneration of the dorsal columns of the spinal cord

2. Patient has been experiencing worsening weakness of the left hand and progressive difficulty in walking for the last 2 months.

3. Patient was previously healthy and active, hiking every weekend.

4. Patient stopped his weekly hiking excursion due to increasing weakness and incoordination while walking.

5. Patient's past medical history is unremarkable.

6. Patient's current medications are a daily multivitamin and occasional acetaminophen for headaches.

7. Patient has no significant family history.

8. Patient denies smoking, recreational drug use, or drinking.

9. Patient's vitals include: pulse 70/min, respirations 14/min, temperature 37.0°C (98.6°F), and blood pressure 130/80 mm Hg.

10. Physical examination reveals fasciculations in the tongue and distal extremities.

11. Left forearm shows significant atrophy.

12. Mild lower limb muscle atrophy is seen bilaterally.

13. Hyporeflexia (1+) is present in the left arm.

14. Hyperreflexia (3+) is seen in the legs bilaterally.

15. Babinski’s sign is positive bilaterally.

17. No evidence of productive or expressive aphasia is present.

1. The patient was previously healthy and active, hiking every weekend.

2. The patient stopped hiking due to increasing weakness and incoordination while walking.

3. The patient's past medical history is unremarkable.

4. The patient's current medications are a daily multivitamin and occasional acetaminophen for headaches.

5. The patient has no significant family history.

6. The patient denies smoking, recreational drug use, or drinking.

7. The patient's vitals include: pulse 70/min, respirations 14/min, temperature 37.0°C (98.6°F), and blood pressure 130/80 mm Hg.

8. Physical examination reveals fasciculations in the tongue and distal extremities.

9. The left forearm shows significant atrophy.

10. Mild lower limb muscle atrophy is seen bilaterally.

11. Hyporeflexia (1+) is present in the left arm.

12. Hyperreflexia (3+) is seen in the legs bilaterally.

13. Babinski’s sign is positive bilaterally.

14. The patient's speech is notably slow.

15. No evidence of productive or expressive aphasia is present.


Question: Which of the following best describes the likely causal virus of this patient’s symptoms?

Context: A 14-year-old male who is a recent immigrant from India visits your office complaining of difficulty walking.

Context: Physical examination reveals weakness upon right leg extension and absent right patellar tendon reflex.

Context: PCR of a stool sample and a swab of the pharynx both yield viral RNA.

Choices:
A. Non-enveloped, positive stranded, icosahedral virus
B. Enveloped, positive stranded, icosahedral virus
C. Enveloped, negative stranded, helical virus
D. Non-enveloped, negative stranded, helical virus

Answer: Non-enveloped, positive stranded, icosahedral virus

2. Patient is a recent immigrant from India.

3. Patient is visiting office complaining of difficulty walking.

4. Physical examination reveals weakness upon right leg extension.

5. Physical examination reveals absent right patellar tendon reflex.

6. PCR of a stool sample yields viral RNA.

7. PCR of a swab of the pharynx yields viral RNA.

1. Physical examination reveals weakness upon right leg extension.

2. Physical examination reveals absent right patellar tendon reflex.

3. PCR of a stool sample yields viral RNA.

4. PCR of a swab of the pharynx yields viral RNA.


Question: Further evaluation of this patient's urine is most likely to show which of the following?

Context: A 21-year-old woman is brought to the emergency department because of the sudden onset of left-sided back pain with radiation to the groin that began 2 hours ago.

Context: Her pulse is 103/min.

Context: Leukocyte count is 11,000/mm3.

Context: Urine dipstick is positive for blood and a urinary cyanide nitroprusside test is positive.

Choices:
A. pH of 7.8
B. Urease-producing bacteria
C. High uric acid concentration
D. Hexagon-shaped crystals

Answer: Hexagon-shaped crystals

1. A 21-year-old woman is brought to the emergency department.

2. She has sudden onset of left-sided back pain with radiation to the groin that began 2 hours ago.

3. She has had similar episodes in the past.

5. Examination shows a soft and non-tender abdomen.

6. Left costovertebral angle tenderness is present.

8. Urine dipstick is positive for blood.

9. Urinary cyanide nitroprusside test is positive.

10. An x-ray of the abdomen shows no abnormalities.

1. She has had similar episodes in the past.

3. Examination shows a soft and non-tender abdomen.

4. Left costovertebral angle tenderness is present.

6. Urine dipstick is positive for blood.

7. Urinary cyanide nitroprusside test is positive.

8. An x-ray of the abdomen shows no abnormalities.


Question: What will be most helpful in diagnosing sequelae resulting from the patient’s underlying condition?

Context: The pain is dull and constant.

Context: Over the past 2 weeks, he has also gained 3 kg (7 lb) and his shoes feel tight.

Choices:
A. CT angiogram with contrast
B. Non-contrast CT
C. Cystoscopy
D. Renal biopsy

Answer: CT angiogram with contrast

1. A 45-year-old man presents to the emergency department with sudden left lower back pain and bloody urine.

3. He can not localize exactly where it is.

4. Over the past 2 weeks, he has also gained 3 kg (7 lb).

6. He denies a history of any chronic medical conditions.

7. He denies a history of recent abdominal trauma or illness.

8. He has never noticed blood in his urine before.

9. In the hospital, his temperature is 36.8°C (98.2°F).

13. A review of medical records shows that his blood pressure was 115/75 mm Hg 6 months ago.

14. On physical exam, he appears distressed.

15. There are bruises on his left upper arm, chest, and right thigh.

16. The patient does not remember when he got them.

17. His heart has a regular rate and rhythm.

18. His lungs are clear to auscultation bilaterally.

19. He has 2+ pitting edema in both legs up to the knee.

21. A urine dipstick shows 3+ blood and 4+ protein.

22. Additional specimens are sent to chemistry for analysis.

2. He cannot localize exactly where it is.

3. Over the past 2 weeks, he has gained 3 kg (7 lb) and his shoes feel tight.

4. He denies a history of any chronic medical conditions, recent abdominal trauma or illness, and has never noticed blood in his urine before.

5. In the hospital, his temperature is 36.8°C (98.2°F), the heart rate is 98/min, the respiratory rate is 15/min, and the blood pressure is 135/85 mm Hg.

6. A review of medical records shows that his blood pressure was 115/75 mm Hg 6 months ago.

7. On physical exam, he appears distressed.

8. There are bruises on his left upper arm, chest, and right thigh.

9. The patient does not remember when he got them.

10. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally.

11. He has 2+ pitting edema in both legs up to the knee and his hands appear edematous.

12. A urine dipstick shows 3+ blood and 4+ protein.

13. Additional specimens are sent to chemistry for analysis.


Question: The difference in the level of severity of this disorder among family members in best explained by which of the following?

Context: A 21-year-old man visits his primary care provider complaining of visual disturbance in both eyes for a month and an episode of abnormal uncontrollable shaking that occurred twice last week.

Context: His mother has intermittent muscle weakness and his maternal uncle developed hemiplegia at the age of 35.

Context: Neuroimaging shows bilateral occipital lobe infarcts and a skeletal muscle biopsy reveals atypical muscle fibers that stain positive for subsarcomelar structures.

Choices:
A. Heteroplasmy
B. Mosaicism
C. Anticipation
D. Uniparental disomy

Answer: Heteroplasmy

1. A 21-year-old man visits his primary care provider.

2. He is complaining of visual disturbance in both eyes for a month.

3. He also had an episode of abnormal uncontrollable shaking that occurred twice last week.

4. He was previously healthy and did not take any medication.

5. His mother has intermittent muscle weakness.

6. His maternal uncle developed hemiplegia at the age of 35.

7. Neuroimaging shows bilateral occipital lobe infarcts.

8. A skeletal muscle biopsy reveals atypical muscle fibers that stain positive for subsarcomelar structures.

9. The physician suspects a maternally inherited genetic disorder.

3. His mother has intermittent muscle weakness.

4. His maternal uncle developed hemiplegia at the age of 35.

5. Neuroimaging shows bilateral occipital lobe infarcts.

6. A skeletal muscle biopsy reveals atypical muscle fibers.

7. The atypical muscle fibers stain positive for subsarcomelar structures.

8. The physician suspects a maternally inherited genetic disorder.


Question: How would you describe the data shown below?

Context: Your hospital administrators want to provide you with a tool to analyze the usage of emergency department visits by patients in your high-risk practice.

Context: The following graph is displayed on the dashboard of your electronic medical record to show you how often your patients utilize the ED so that you can provide higher quality and more cost-effective care.

Choices:
A. It is positively-skewed, with mean > median > mode.
B. It is positively-skewed, with mode > median > mean.
C. It is positively-skewed, with median > mode > mean.
D. It is negatively-skewed, with mode > median > mean.

Answer: It is positively-skewed, with mean > median > mode.

Health Care Administration, Leadership, and Management

1. Hospital administrators want to provide a tool to analyze emergency department visits by patients in a high-risk practice.

2. The dashboard of the electronic medical record displays a graph to show how often patients utilize the ED.

3. The X-axis of the graph indicates the number of times a patient has been to the ED in the last year.

4. The Y-axis of the graph indicates the number of patients who fit into that category.

1. The graph is displayed on the dashboard of the electronic medical record.

2. The graph shows how often patients utilize the ED.

3. The purpose is to provide higher quality and more cost-effective care.

4. The X-axis indicates the number of times a patient has been to the ED in the last year.

5. The Y-axis indicates the number of patients who fit into that category.


Question: Which of the following findings would most likely be abnormal during pregnancy?

Context: A 27-year-old G1P0000 at 17 weeks of gestation is interested in participating in a clinical trial for nausea management during pregnancy.

Context: Prior to enrolling in the trial, the investigators explain to the patient that they will be doing a full exam and some special testing to make sure she is experiencing a healthy pregnancy.

Choices:
A. Hypertension
B. Increased cardiac output
C. Increase in factor VII
D. Respiratory alkalosis

Answer: Hypertension

1. A 27-year-old G1P0000 is interested in participating in a clinical trial.

2. The clinical trial is for nausea management during pregnancy.

3. The trial will be evaluating the effects of moderate ginger consumption on nausea symptoms.

4. The patient is 17 weeks of gestation.

5. Prior to enrolling in the trial, the investigators explain to the patient that they will be doing a full exam.

6. Prior to enrolling in the trial, the investigators explain to the patient that they will be doing some special testing.

7. The special testing is to make sure the patient is experiencing a healthy pregnancy.

1. The trial will be evaluating the effects of moderate ginger consumption.

2. The trial will be evaluating the effects on nausea symptoms.

3. The investigators will explain the trial to the patient.

4. The investigators will do a full exam on the patient.

5. The investigators will do some special testing on the patient.

6. The testing is to ensure the patient is experiencing a healthy pregnancy.


Question: Which of the following is most consistent with their son's symptoms?

Context: A 14-year-old Caucasian male of normal weight presents for a well-child checkup.

Context: During physical examination, his parents state that their son has been frequenting the bathroom more often than usual and his weight has decreased despite an increase in his caloric intake.

Choices:
A. Self-reactive T-cells
B. Amyloid deposits in pancreatic islet cells
C. Absence of leukocytic infiltrates in the pancreas
D. Hypoglycemia

Answer: Self-reactive T-cells

Pediatric Endocrinology
General Pediatrics

1. A 14-year-old Caucasian male is presenting for a well-child checkup.

3. His parents state he has been frequenting the bathroom more often than usual.

3. Their son has been frequenting the bathroom more often than usual


Question: Which of the following findings would you most likely expect to be reported in the ultrasound?

Context: A 56-year-old woman with a history of stage IIA cervical cancer presents to your office after her 5th episode of a complicated urinary tract infection.

Context: She complains of easy fatigability, weakness, and has noted that her shoes no longer fit.

Context: Given the patient’s medical history, the specialist makes a stage IIIB diagnosis; however, to confirm this, he orders abdominal and transvaginal ultrasounds and renal function tests.

Choices:
A. Bladder or rectum mucosa invasion
B. Distant metastasis
C. Parametrial invasion by cancer
D. Hydronephrosis

Answer: Hydronephrosis

1. A 56-year-old woman presents to the office.

2. She has a history of stage IIA cervical cancer.

3. She has had 5 episodes of a complicated urinary tract infection.

4. She complains of easy fatigability and weakness.

6. The physical examination is unremarkable, except for a blood pressure of 165/90 mm Hg and mild pitting lower extremity edema.

7. The rectovaginal exam revealed no masses.

8. The specialist makes a stage IIIB diagnosis.

9. To confirm this, he orders abdominal and transvaginal ultrasounds.

10. He also orders renal function tests.

1. The patient complains of easy fatigability.

3. The patient has noted that her shoes no longer fit.

4. The physical examination is unremarkable.

5. The patient has a blood pressure of 165/90 mm Hg.

6. The patient has mild pitting lower extremity edema.

8. The specialist makes a stage IIIB diagnosis based on the patient's medical history.

9. The specialist orders abdominal and transvaginal ultrasounds.

10. The specialist orders renal function tests.


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

Context: A 77-year-old man is brought to the physician because of a 2-day history of increasing shortness of breath and ankle swelling.

Context: He has type 2 diabetes mellitus, hypertension, coronary artery disease, and congestive heart failure.

Context: His temperature is 37.2°C (98.9°F), pulse is 100/min and regular, respirations are 20/min, and blood pressure is 100/65 mm Hg.

Context: Crackles are heard at both lung bases.

Context: Cardiac examination shows an S3 gallop.

Context: Laboratory studies show: | Hemoglobin 14.1 g/dL | Leukocyte count 7100/mm3 | Serum | Na+ 129 mEq/L | Cl- 99 mEq/L | K+ 4.8 mEq/L | Urea nitrogen 48 mg/dL | Glucose 196 mg/dL | Creatinine 2.1 mg/dL | .

Choices:
A. Discontinue metformin therapy
B. Begin vancomycin therapy
C. Begin nitroprusside therapy
D. Begin hydrochlorothiazide therapy

Answer: Discontinue metformin therapy

2. Patient has 2-day history of increasing shortness of breath and ankle swelling.

3. Patient has type 2 diabetes mellitus, hypertension, coronary artery disease, and congestive heart failure.

4. Patient is taking lisinopril, metformin, and aspirin.

5. Patient has smoked half a pack of cigarettes daily for 50 years.

6. Patient's temperature is 37.2°C (98.9°F).

7. Patient's pulse is 100/min and regular.

9. Patient's blood pressure is 100/65 mm Hg.

10. Pulse oximetry on room air shows an oxygen saturation of 91%.

11. Jugular venous pulsations 5 cm above the sternal angle.

12. Crackles are heard at both lung bases.

13. Cardiac examination shows an S3 gallop.

14. Patient has edema from the mid-tibia to the ankle bilaterally.

15. Laboratory studies show hemoglobin 14.1 g/dL.

16. Laboratory studies show leukocyte count 7100/mm3.

17. Laboratory studies show serum Na+ 129 mEq/L.

18. Laboratory studies show Cl- 99 mEq/L.

19. Laboratory studies show K+ 4.8 mEq/L.

20. Laboratory studies show urea nitrogen 48 mg/dL.

21. Laboratory studies show glucose 196 mg/dL.

22. Laboratory studies show creatinine 2.1 mg/dL.

5. Current medications include lisinopril, metformin, and aspirin.

6. He has smoked half a pack of cigarettes daily for 50 years.

11. Pulse oximetry on room air shows an oxygen saturation of 91%.

12. There are jugular venous pulsations 5 cm above the sternal angle.

13. Crackles are heard at both lung bases.

14. Cardiac examination shows an S3 gallop.

15. There is edema from the mid-tibia to the ankle bilaterally.

16. Laboratory studies show: Hemoglobin 14.1 g/dL.

17. Laboratory studies show: Leukocyte count 7100/mm3.

18. Laboratory studies show: Serum Na+ 129 mEq/L.

19. Laboratory studies show: Serum Cl- 99 mEq/L.

20. Laboratory studies show: Serum K+ 4.8 mEq/L.

21. Laboratory studies show: Urea nitrogen 48 mg/dL.

22. Laboratory studies show: Glucose 196 mg/dL.

23. Laboratory studies show: Creatinine 2.1 mg/dL.


Question: Which of the following is the most likely cause of the cardiotocography findings?

Context: A 32-year-old woman, gravida 2, para 1, at 40 weeks' gestation is admitted to the hospital 30 minutes after spontaneous rupture of membranes without labor pains.

Context: Her pulse is 90/min, respirations are 16/min, and blood pressure is 134/76 mm Hg.

Context: A cardiotocography reading is shown.

Choices:
A. Umbilical cord compression
B. Fetal head compression
C. Uteroplacental insufficiency
D. Fetal CNS depression

Answer: Umbilical cord compression

1. A 32-year-old woman is admitted to the hospital.

4. She experienced spontaneous rupture of membranes 30 minutes prior to admission.

6. She delivered her first child vaginally at 38 weeks' gestation.

7. Her pregnancy was complicated by hypothyroidism.

8. She has no other history of serious illness.

9. Her medications include levothyroxine and a multivitamin.

13. Pelvic examination shows a uterus consistent in size with a 40 week gestation.

14. A cardiotocography reading is shown.

1. She delivered her first child vaginally at 38 weeks' gestation.

2. Pregnancy was complicated by hypothyroidism.

3. She has no other history of serious illness.

4. Medications include levothyroxine and a multivitamin.

8. Pelvic examination shows a uterus consistent in size with a 40 week gestation.


Question: WBC 38,000/mm3 | RBC 4.20 x 106/mm3 | Hematocrit 27.3% | Hemoglobin 8.3 g/dL | Platelet count 355,000/mm3 | A peripheral blood smear and differential shows 92% small normocytic lymphocytes. | Which of the following is the most likely diagnosis in this patient?

Context: He currently has no complaints, and his last physical and laboratory studies were unremarkable.

Context: His past medical history is significant for hypercholesterolemia, well managed with rosuvastatin, and hypertension, well managed with hydrochlorothiazide.

Context: The patient is afebrile and his vital signs are within normal limits.

Context: Laboratory findings are significant for the following: | .

Choices:
A. Acute myelogenous leukemia
B. Chronic myelogenous leukemia
C. Chronic lymphocytic leukemia
D. Asymptomatic multiple myeloma

Answer: Chronic lymphocytic leukemia

1. A 55-year-old man presents for a routine check-up.

3. His last physical and laboratory studies were unremarkable.

4. His past medical history is significant for hypercholesterolemia.

5. Hypercholesterolemia is well managed with rosuvastatin.

6. His past medical history is also significant for hypertension.

7. Hypertension is well managed with hydrochlorothiazide.

8. His current medications also include aspirin.

10. His vital signs are within normal limits.

11. Physical examination reveals some generalized lymphadenopathy.

12. Laboratory findings are significant for the following.

1. The patient currently has no complaints.

2. His last physical and laboratory studies were unremarkable.

3. His past medical history includes hypercholesterolemia.

4. His hypercholesterolemia is well managed with rosuvastatin.

5. His past medical history also includes hypertension.

6. His hypertension is well managed with hydrochlorothiazide.

7. His current medications include aspirin.

9. His vital signs are within normal limits.

10. Physical examination reveals some generalized lymphadenopathy.

11. Laboratory findings are significant for certain results.


Question: What is the next step in management?

Context: A 72-year-old man with a history of diabetes, dyslipidemia, and hypertension presents to the emergency department with sudden-onset right-sided facial paresthesia, word-finding difficulty, and lightheadedness.

Context: He was at a restaurant, in general good health, enjoying a dinner with friends when the 1st symptoms started.

Context: He takes atorvastatin, lisinopril, hydrochlorothiazide, and a multivitamin every day.

Context: A review of symptoms was negative.

Context: His symptoms spontaneously resolved after 5 minutes.

Context: In the emergency department, the vital signs included: blood pressure of 132/80 mm Hg, heart rate of 86/min, respiratory rate of 20/min, and oxygen saturation of 99% on room air.

Context: The laboratory results included: | Hemoglobin 11.3 g/dL | Hematocrit 33% | WBC count 9,800/mm3 | Platelet count 247,000/mm3 | International normalized ratio (INR) 1.1 | Prothrombin time (PT) 11.5 seconds | Partial thromboplastin time (PTT) 32 seconds | His electrocardiogram (ECG) and his head computed tomography (CT) scan were normal.

Context: A duplex ultrasound scan shows 70–89% stenosis in the left carotid artery and 50% in the right.

Context: A brain magnetic resonance imaging (MRI) scan was negative for areas of ischemia or intracranial hemorrhage.

Context: His symptom recurrence prompted his hospital admission for inpatient care.

Choices:
A. Enoxaparin
B. Thrombolysis
C. Carotid endarterectomy
D. Carotid artery stenting

Answer: Carotid endarterectomy

2. Patient has a history of diabetes, dyslipidemia, and hypertension.

3. Patient presented to the emergency department with sudden-onset right-sided facial paresthesia, word-finding difficulty, and lightheadedness.

4. Patient was at a restaurant, in general good health, enjoying a dinner with friends when the 1st symptoms started.

5. Patient takes atorvastatin, lisinopril, hydrochlorothiazide, and a multivitamin every day.

7. Symptoms spontaneously resolved after 5 minutes.

8. Vital signs included: blood pressure of 132/80 mm Hg, heart rate of 86/min, respiratory rate of 20/min, and oxygen saturation of 99% on room air.

9. Laboratory results included: Hemoglobin 11.3 g/dL, Hematocrit 33%, WBC count 9,800/mm3, Platelet count 247,000/mm3, International normalized ratio (INR) 1.1, Prothrombin time (PT) 11.5 seconds, Partial thromboplastin time (PTT) 32 seconds.

10. Electrocardiogram (ECG) and head computed tomography (CT) scan were normal.

11. Duplex ultrasound scan shows 70–89% stenosis in the left carotid artery and 50% in the right.

12. In the course of evaluation, his aphasia recurred for 3 minutes.

13. Brain magnetic resonance imaging (MRI) scan was negative for areas of ischemia or intracranial hemorrhage.

14. Symptom recurrence prompted his hospital admission for inpatient care.

1. The patient was at a restaurant when the first symptoms started.

2. The patient takes atorvastatin, lisinopril, hydrochlorothiazide, and a multivitamin daily.

4. The symptoms spontaneously resolved after 5 minutes.

5. In the emergency department, the patient's vital signs were: blood pressure 132/80 mm Hg, heart rate 86/min, respiratory rate 20/min, and oxygen saturation 99% on room air.

6. Laboratory results showed: Hemoglobin 11.3 g/dL, Hematocrit 33%, WBC count 9,800/mm3, Platelet count 247,000/mm3, INR 1.1, PT 11.5 seconds, PTT 32 seconds.

7. The patient's ECG and head CT scan were normal.

8. A duplex ultrasound scan revealed 70–89% stenosis in the left carotid artery and 50% in the right.

9. During evaluation, the patient's aphasia recurred for 3 minutes.

10. A brain MRI scan showed no areas of ischemia or intracranial hemorrhage.

11. The symptom recurrence prompted the patient's hospital admission for inpatient care.


Question: Which of the following is the best 1st step in this patient’s management?

Context: A 70-year-old woman visits her physician complaining of dry mouth and dry eyes.

Context: She states that she has recently been having difficulty wearing her dentures on account of her dry mouth.

Context: She also says that her tongue sticks to the roof of her mouth, making it difficult to speak and swallow food.

Context: Her eyes have also been burning, and she has had to use over the counter eye drops much more often.

Context: On physical exam, mild bilateral enlargement of the parotid glands was noted, and an intraoral examination revealed a red, dry, and smooth mucosal surface on the dorsum of the tongue and buccal mucosa.

Context: The patient has a history of hypertension, for which she takes lisinopril.

Choices:
A. Administer prednisone
B. Obtain an electrocardiogram (ECG)
C. Perform a Schirmer test and obtain anti-Ro/anti-La titers
D. Perform a parotid gland biopsy

Answer: Perform a Schirmer test and obtain anti-Ro/anti-La titers

1. A 70-year-old woman visits her physician.

2. She is complaining of dry mouth and dry eyes.

3. She has difficulty wearing her dentures due to her dry mouth.

4. Her tongue sticks to the roof of her mouth, making it difficult to speak and swallow food.

5. Her eyes have been burning and she has been using over the counter eye drops more often.

6. These symptoms have persisted for several months.

7. On physical exam, mild bilateral enlargement of the parotid glands was noted.

8. An intraoral examination revealed a red, dry, and smooth mucosal surface on the dorsum of the tongue and buccal mucosa.

9. The patient has a history of hypertension.

10. She takes lisinopril for her hypertension.

1. The patient has been having difficulty wearing her dentures due to dry mouth.

2. Her tongue sticks to the roof of her mouth, making it difficult to speak and swallow food.

3. She has been experiencing burning eyes and has had to use over the counter eye drops more frequently.

4. These symptoms have been present for several months.

5. On physical exam, mild bilateral enlargement of the parotid glands was noted.

6. An intraoral examination revealed a red, dry, and smooth mucosal surface on the dorsum of the tongue and buccal mucosa.

7. The patient has a history of hypertension and takes lisinopril for it.


Question: This patient most likely has elevated levels of which of the following?

Context: A 61-year old obese nulliparous female presents to your office with right lower quadrant abdominal pain.

Context: Her medical history is significant for breast cancer and past use of postmenopausal estrogen replacement therapy.

Choices:
A. hCG
B. AFP
C. CA 19-9
D. CA 125

Answer: CA 125

General Obstetrics and Gynecology
General Surgery

1. A 61-year old female presents to your office.

4. The female has right lower quadrant abdominal pain.

5. The female has a medical history of breast cancer.

6. The female has a history of past use of postmenopausal estrogen replacement therapy.

1. Medical history includes breast cancer.

2. Past use of postmenopausal estrogen replacement therapy.


Question: Further evaluation of this patient is most likely to reveal which of the following?

Context: A 28-year-old man comes to the physician because of a swollen, tender left knee for the past 4 days.

Context: During this period, the patient has had pain with urination.

Context: Urinanalysis shows WBCs.

Choices:
A. HLA-B27 positive genotype
B. Hiking trip two months ago
C. Positive anti-dsDNA antibodies
D. Intravenous drug use

Answer: HLA-B27 positive genotype

2. Patient has had a swollen, tender left knee for the past 4 days.

3. Patient has had pain with urination during this period.

4. Patient has no history of serious illness and takes no medications.

5. Patient is sexually active with two male partners and they use condoms inconsistently.

6. Patient's older sister has systemic lupus erythematosus.

8. Patient weighs 98 kg (216 lb); BMI is 30.1 kg/m2.

9. Patient's temperature is 37°C (98.6°F).

11. Patient's blood pressure is 140/75 mm Hg.

12. Patient has conjunctivitis bilaterally.

13. Patient's left knee is warm, erythematous, and tender to touch.

14. Patient's range of motion is limited.

15. Laboratory studies show an erythrocyte sedimentation rate of 62 mm/h.

1. The patient has had pain with urination.

2. The patient has no history of serious illness and takes no medications.

3. He is sexually active with two male partners and they use condoms inconsistently.

4. His older sister has systemic lupus erythematosus.

5. He is 180 cm (5 ft 11 in) tall and weighs 98 kg (216 lb); BMI is 30.1 kg/m2.

6. His temperature is 37°C (98.6°F), pulse is 83/min, and blood pressure is 140/75 mm Hg.

7. Examination shows conjunctivitis bilaterally.

8. The left knee is warm, erythematous, and tender to touch; range of motion is limited.

9. Laboratory studies show an erythrocyte sedimentation rate of 62 mm/h.


Question: Which of the following is the most likely diagnosis?

Context: He says, “My teammates never understand how important it is to do things the right way.” Ever since high school, he has used the majority of his time to plan out assignments and does not have time to regularly participate in social activities.

Choices:
A. Obsessive-compulsive personality disorder
B. Obsessive-compulsive disorder
C. Schizoid personality disorder
D.
Adjustment disorder with mixed anxiety and depressed mood
"

Answer: Obsessive-compulsive personality disorder

1. A 21-year-old man comes to the physician because of nervousness and difficulty sleeping over the past 2 weeks.

2. Three months ago, he started a new team project at his job.

3. He says that he has trouble falling asleep at night because he thinks about the project.

4. He insists on checking the work of his teammates and spends several hours each week making elaborate lists and schedules.

5. He refuses to let others take on more tasks because he thinks that only he can complete them satisfactorily.

6. The project deadline has already been postponed once.

7. He says, “My teammates never understand how important it is to do things the right way.”

8. Ever since high school, he has used the majority of his time to plan out assignments.

9. He does not have time to regularly participate in social activities.

1. Three months ago, he started a new team project at his job.

2. He says that he has trouble falling asleep at night because he thinks about the project.

3. He insists on checking the work of his teammates and spends several hours each week making elaborate lists and schedules.

4. He refuses to let others take on more tasks because he thinks that only he can complete them satisfactorily.

5. The project deadline has already been postponed once.

6. He says, “My teammates never understand how important it is to do things the right way.”

7. Ever since high school, he has used the majority of his time to plan out assignments and does not have time to regularly participate in social activities.


Question: Which of the following drugs is most likely to be effective as a preventive therapy in this patient?

Context: He says the episodes are short-lived (usually lasting for a few seconds to 3-4 minutes), and he describes them as a severe throbbing orbital headache, accompanied by ipsilateral conjunctival injection and lacrimation.

Context: He says that often the episodes seem to be triggered by a cutaneous stimulus touching the face or while chewing food.

Context: Sometimes, he says he experiences countless attacks during a single day.

Context: The headaches do not respond to indomethacin and any other non-steroidal anti-inflammatory drug (NSAID).

Choices:
A. Ibuprofen
B. Acetaminophen
C. Lamotrigine
D. Amitriptyline

Answer: Lamotrigine

1. A 52-years-old man presents with a history of recurrent episodes of unilateral headaches.

2. The episodes are short-lived, usually lasting for a few seconds to 3-4 minutes.

3. He describes them as a severe throbbing orbital headache.

4. The headaches are accompanied by ipsilateral conjunctival injection and lacrimation.

5. The episodes seem to be triggered by a cutaneous stimulus touching the face or while chewing food.

6. Sometimes, he experiences countless attacks during a single day.

7. The headaches do not respond to indomethacin.

8. The headaches do not respond to any other non-steroidal anti-inflammatory drug (NSAID).

1. The episodes are short-lived, usually lasting for a few seconds to 3-4 minutes.

2. The episodes are described as a severe throbbing orbital headache.

3. The episodes are accompanied by ipsilateral conjunctival injection and lacrimation.

4. The episodes seem to be triggered by a cutaneous stimulus touching the face or while chewing food.

5. Sometimes, countless attacks are experienced during a single day.

6. The headaches do not respond to indomethacin.

7. The headaches do not respond to any other non-steroidal anti-inflammatory drug (NSAID).


Question: Which of the following is appropriate treatment of this patient?

Context: A 55-year-old obese man presents to the emergency department with abdominal pain.

Context: His temperature is 101.0°F (38.3°C), blood pressure is 157/98 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Context: Physical exam is notable for left lower quadrant abdominal tenderness and rectal exam is unremarkable.

Choices:
A. Ciprofloxacin and gentamicin
B. CT-guided percutaneous drainage
C. Laparoscopy and drainage
D. Piperacillin-tazobactam and vancomycin

Answer: CT-guided percutaneous drainage

1. A 55-year-old man presents to the emergency department with abdominal pain.

2. His pain started 2 days ago and has been worsening steadily.

3. His only current medication is allopurinol.

8. His oxygen saturation is 98% on room air.

9. Physical exam is notable for left lower quadrant abdominal tenderness.

12. CT scan demonstrates inflamed outpouchings of the colonic mucosa.

13. CT scan demonstrates a 4-cm abscess.

1. His pain started 2 days ago and has been worsening steadily.

2. His only current medication is allopurinol.

7. His oxygen saturation is 98% on room air.

8. Physical exam is notable for left lower quadrant abdominal tenderness.

10. A CT scan is performed demonstrating inflamed outpouchings of the colonic mucosa with a 4-cm abscess.