Question: Which of the following tests is the best next step in evaluating this patient?

Context: A 29-year-old woman presents to the physician’s office complaining of swollen hands for the past 3 weeks.

Context: The patient’s medical history is significant for hypothyroidism that is managed with levothyroxine.

Context: She has no recent travel history.

Context: Vital signs are normal.

Context: On examination, the patient has a butterfly-shaped, non-blanching rash on her face with mild cervical lymphadenopathy.

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

Answer: Antinuclear antibody

1. A 29-year-old woman presents to the physician's office.

2. She is complaining of swollen hands for the past 3 weeks.

3. It is associated with stiffness in the morning, which lasts about 10 minutes.

4. The patient's medical history is significant for hypothyroidism.

8. On examination, the patient has a butterfly-shaped, non-blanching rash on her face.

9. She has mild cervical lymphadenopathy.

10. The metacarpophalangeal and proximal interphalangeal joints are tender and appear swollen.

11. Cardiopulmonary examination reveals a grade 2/6 holosystolic murmur heard best at the apex.

1. Associated with stiffness in the morning

3. Patient's medical history includes hypothyroidism

4. Hypothyroidism is managed with levothyroxine

7. Patient has a butterfly-shaped, non-blanching rash on her face

8. Patient has mild cervical lymphadenopathy

9. Metacarpophalangeal joints are tender

10. Proximal interphalangeal joints appear swollen


Question: The structural changes in this patient's heart are most likely associated with which of the following?

Context: A 61-year-old male dies in a motor vehicle accident.

Context: Autopsy of the heart reveals dilatation of the left atrium and expansion of the left ventricular cavity with associated eccentric hypertrophy.

Choices:
A. Pulmonic stenosis
B. Mitral insufficiency
C. Chronic hypertension
D. Congenital atrial septal defect

Answer: Mitral insufficiency

Adult Congenital Heart Disease
Congenital Cardiac Surgery
General Internal Medicine
General Cardiology

2. The cause of death was a motor vehicle accident.

3. An autopsy of the heart was performed.

5. The left ventricular cavity was expanded.

6. Eccentric hypertrophy was associated with the expansion.

2. Dilatation of the left atrium was observed.

3. Expansion of the left ventricular cavity was observed.

4. Eccentric hypertrophy was associated with the left ventricular cavity expansion.


Question: Which of the following changes best describes the direct effect of the prescribed medication on his cardiovascular physiology in the cardiac output/venous return versus right atrial pressure graph?

Context: A 52-year-old business executive presents to his physician with complaints of intermittent chest pain which started 2 months ago.

Context: The pain radiates to his left arm and jaw, occurs only when he climbs the stairs or runs on a treadmill, and is relieved by rest.

Context: He has been hypertensive and diabetic for the last 10 years and has been compliant with his medications.

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

Answer: iv

General Cardiology
Cardiovascular Disease

1. A 52-year-old business executive presents to his physician.

2. He has intermittent chest pain which started 2 months ago.

3. He describes his pain as crushing, centrally located, and typically lasting about 5 minutes but never more than 10 minutes.

4. The pain radiates to his left arm and jaw.

5. The pain occurs only when he climbs the stairs or runs on a treadmill.

7. He has been hypertensive and diabetic for the last 10 years.

8. He has been compliant with his medications.

9. His physical exam findings are within normal limits.

10. Lab tests are normal except for a significantly elevated LDL-cholesterol level.

11. A stress ECG shows ST-segment depression in the anterior chest leads when his heart rate and blood pressure increase to over 40% from their baseline values.

12. The physician decides to initiate a medication to relieve his symptoms.

1. Patient describes pain as crushing, centrally located, and lasting about 5 minutes but never more than 10 minutes.

2. Pain radiates to left arm and jaw, occurs only when climbing stairs or running on a treadmill, and is relieved by rest.

3. Patient has been hypertensive and diabetic for the last 10 years and has been compliant with medications.

4. Physical exam findings are within normal limits.

5. Lab tests are normal except for significantly elevated LDL-cholesterol level.

6. Stress ECG shows ST-segment depression in the anterior chest leads when heart rate and blood pressure increase to over 40% from baseline values.

7. Physician decides to initiate a medication to relieve symptoms.


Question: Mutations in which of the following genes are most likely responsible for these findings?

Context: He was diagnosed with HIV 6 years ago and has been on highly active antiretroviral therapy with emtricitabine, tenofovir, and darunavir.

Context: His last CD4+ T-lymphocyte count was 520/mm3 (N > 500) and HIV viral load was undetectable.

Context: Today, his CD4+ T-lymphocyte count is 410/mm3 and his HIV viral load is 240 copies/mL.

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

Answer: pol

1. A 34-year-old man comes to the physician for a follow-up appointment.

2. He was diagnosed with HIV 6 years ago.

3. He has been on highly active antiretroviral therapy with emtricitabine, tenofovir, and darunavir.

4. He reports that he has been compliant with his medication regimen.

5. His last CD4+ T-lymphocyte count was 520/mm3 (N > 500).

6. His last HIV viral load was undetectable.

7. Today, his CD4+ T-lymphocyte count is 410/mm3.

8. Today, his HIV viral load is 240 copies/mL.

9. Further evaluation shows resistance to emtricitabine and tenofovir.

2. On highly active antiretroviral therapy

3. Medication regimen includes emtricitabine, tenofovir, and darunavir

4. Reports compliance with medication regimen

5. Last CD4+ T-lymphocyte count was 520/mm3 (N > 500)

7. Today's CD4+ T-lymphocyte count is 410/mm3

8. Today's HIV viral load is 240 copies/mL

9. Shows resistance to emtricitabine and tenofovir


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

Context: A 61-year-old woman with a history of stage IV pancreatic cancer comes to the emergency department with insomnia due to intractable midepigastric pain.

Context: The pain had been constant for months but has worsened over the past few weeks despite the fact that she is already taking hydrocodone 10 mg and ibuprofen 400 mg.

Context: She has a past medical history of chronic pain and major depressive disorder.

Context: In the past month, she has been taking her pain medications with increasing frequency, going from twice a day to four times a day.

Context: Her other medications include venlafaxine and eszopiclone.

Context: She describes her mood as low, but states she does not have any suicidal thoughts.

Context: She appears fatigued and slightly cachectic.

Context: Her temperature is 36°C (96.8°F), pulse is 100/min, and blood pressure is 128/65 mm Hg.

Choices:
A. Discontinue hydrocodone and ibuprofen, and start IV ketorolac
B. Switch from hydrocodone to hydromorphone
C. Switch from eszopiclone to zolpidem
D.
Allow the patient to take hydrocodone and ibuprofen up to every four hours
"

Answer: Switch from hydrocodone to hydromorphone

2. Patient has a history of stage IV pancreatic cancer.

3. Patient presents to the emergency department with insomnia due to intractable midepigastric pain.

4. Pain has been constant for months but has worsened over the past few weeks.

5. Patient is already taking hydrocodone 10 mg and ibuprofen 400 mg.

6. Patient has a past medical history of chronic pain and major depressive disorder.

7. Patient has been taking her pain medications with increasing frequency, going from twice a day to four times a day.

8. Patient's other medications include venlafaxine and eszopiclone.

9. Patient describes her mood as low, but states she does not have any suicidal thoughts.

10. Patient appears fatigued and slightly cachectic.

11. Patient's temperature is 36°C (96.8°F).

13. Patient's blood pressure is 128/65 mm Hg.

14. Physical examination shows a mass in the midepigastric region.

1. The pain had been constant for months

2. The pain has worsened over the past few weeks

3. She is already taking hydrocodone 10 mg

4. She is already taking ibuprofen 400 mg

5. She has a past medical history of chronic pain

6. She has a past medical history of major depressive disorder

7. In the past month, she has been taking her pain medications with increasing frequency

8. She has increased her pain medication frequency from twice a day to four times a day

9. Her other medications include venlafaxine

10. Her other medications include eszopiclone

12. She states she does not have any suicidal thoughts

18. Physical examination shows a mass in the midepigastric region


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

Context: Two days into hospitalization for pyelonephritis and sepsis, a 48-year-old woman develops severe sudden-onset dyspnea.

Context: She is fatigued and pale.

Context: Her blood pressure is 115/65 mm Hg, the pulse is 120/min, the respiratory rate is 36/min, and the temperature is 39.7°C (103.5°F).

Context: Cardiac examination shows no murmurs.

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

Answer: Low tidal volume ventilation

Pulmonary Disease
General Pulmonary Disease

1. A 48-year-old woman is hospitalized for pyelonephritis and sepsis.

2. Two days into hospitalization, she develops severe sudden-onset dyspnea.

3. She has no history of serious cardiopulmonary disease.

9. Her oxygen saturation is 80% on 60% FiO2.

10. She has severe nasal flaring, supraclavicular and intercostal respiratory retractions, and paradoxical abdominal movements.

11. Inspiratory crackles are heard over both lung fields.

12. Cardiac examination shows no murmurs.

13. A chest X-ray is taken before orotracheal intubation.

1. She has no history of serious cardiopulmonary disease.

7. Her oxygen saturation is 80% on 60% FiO2.

9. She has supraclavicular and intercostal respiratory retractions.

10. She has paradoxical abdominal movements.

13. A chest X-ray, taken before orotracheal intubation, is shown.


Question: In such a situation, which of the following vaccines should definitely be recommended to this patient?

Context: The FEV1/FVC ratio is 0.66.

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

Answer: Influenza vaccine

General Pulmonary Disease
Pulmonary Disease

1. A 48-year-old man presents to the physician with a cough with expectoration and breathlessness on exertion for the last 4 years.

2. There is no history of any other medical conditions.

3. He has been a smoker for the last 10 years.

4. He recently immigrated from a developing country and his immunization status is unknown.

5. After a complete physical examination of the patient, the physician orders a chest radiogram which shows increased bronchovascular markings and flattening of the diaphragm.

6. His spirometry findings include an FEV1 of 82% of predicted, which increases to 88% of predicted at 15 minutes after the administration of inhaled albuterol.

8. The physician explains the diagnosis to the patient and emphasizes the importance of smoking cessation.

9. He also offers him specific vaccinations.

10. However, the patient mentions that he does not have medical insurance and due to his poor financial situation, he can afford only 1 of the suggested vaccines.

1. No history of any other medical conditions.

2. He has been a smoker for the last 10 years.

3. Recently immigrated from a developing country.

5. Chest radiogram shows increased bronchovascular markings and flattening of the diaphragm.

6. Spirometry findings include an FEV1 of 82% of predicted.

7. FEV1 increases to 88% of predicted at 15 minutes after the administration of inhaled albuterol.

9. Physician emphasizes the importance of smoking cessation.

11. Patient does not have medical insurance.

12. Can afford only 1 of the suggested vaccines.


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

Context: A five-year-old female presents to the pediatrician for a well visit.

Context: The patient’s parents report that she recently entered kindergarten and her teacher expressed concern that the patient is not meeting developmental milestones.

Context: She struggles to name colors and has not expressed any interest in learning to read.

Context: The patient’s parents have also noticed that the patient is not completing tasks that her older siblings were doing by this age, including dressing herself independently and going to the bathroom by herself.

Context: The patient rolled over at 9 months, sat without support at 12 months, and walked at 20 months.

Context: Her parents also report that the patient is very social, and that adults frequently comment on her friendly personality.

Context: The patient is in the 15th percentile for weight and 5th percentile for height.

Context: On physical exam, the patient has a broad forehead, flat nasal bridge, long philtrum, and a wide mouth.

Context: She has a strabismus on neurological exam, and her cardiac exam is significant for a heart murmur.

Context: Laboratory testing is below: |  | Serum: | Na+: 145 mEq/L | K+: 3.9 mEq/L | Cl-: 100 mEq/L | HCO3-: 24 mEq/ | Urea nitrogen: 11 mg/dL | Glucose: 76 mg/dL | Creatinine: 0.9 mg/dL | Ca2+: 11.9 mg/dL |  | .

Choices:
A. Bicuspid aortic valve
B. Coarctation of the aorta
C. Supravalvular aortic stenosis
D. Tetralogy of Fallot

Answer: Supravalvular aortic stenosis

2. Patient recently entered kindergarten.

3. Teacher expressed concern that patient is not meeting developmental milestones.

5. Patient has not expressed any interest in learning to read.

6. Patient is not completing tasks that her older siblings were doing by this age.

8. Patient sat without support at 12 months.

11. Adults frequently comment on patient's friendly personality.

12. Patient is in the 15th percentile for weight.

13. Patient is in the 5th percentile for height.

18. Patient has a strabismus on neurological exam.

19. Patient has a heart murmur on cardiac exam.

1. The patient recently entered kindergarten.

2. The patient's teacher expressed concern about her not meeting developmental milestones.

3. The patient struggles to name colors.

4. The patient has not expressed any interest in learning to read.

5. The patient is not completing tasks her older siblings were doing at her age.

7. The patient sat without support at 12 months.

10. Adults frequently comment on the patient's friendly personality.

11. The patient is in the 15th percentile for weight.

12. The patient is in the 5th percentile for height.

13. On physical exam, the patient has a broad forehead.

14. On physical exam, the patient has a flat nasal bridge.

15. On physical exam, the patient has a long philtrum.

16. On physical exam, the patient has a wide mouth.

17. On neurological exam, the patient has a strabismus.

18. On cardiac exam, the patient has a heart murmur.


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

Context: A 20-year-old male comes to the physician because of a 1-week-history of a painless ulceration on his penis.

Context: The patient is sexually active with multiple partners and does not use barrier protection.

Context: Physical examination shows a shallow, firm ulcer with a smooth base along the shaft of the penis and nontender bilateral inguinal adenopathy.

Choices:
A. Tzanck preparation
B. Culture swab
C. Dark field microscopy
D. Serologic detection of antibodies

Answer: Dark field microscopy

1. A 20-year-old male comes to the physician.

2. The patient has a 1-week-history of a painless ulceration on his penis.

3. The patient is sexually active with multiple partners.

4. The patient does not use barrier protection.

5. Physical examination shows a shallow, firm ulcer with a smooth base along the shaft of the penis.

6. Physical examination shows nontender bilateral inguinal adenopathy.

3. The patient does not use barrier protection.

4. Physical examination shows a shallow, firm ulcer.

6. The ulcer is along the shaft of the penis.

8. The patient has bilateral inguinal adenopathy.


Question: What additional finding is most likely to be present in this patient on physical examination?

Context: A 31-year-old man presents to the clinic as a follow-up visit after recently being diagnosed with medullary thyroid cancer.

Context: Last year, he was diagnosed with a pheochromocytoma that was successfully resected.

Context: His family history is positive for medullary thyroid cancer in his father and paternal grandmother with a mucosal neuroma in his brother.

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

Answer: Marfanoid habitus

1. A 31-year-old man presents to the clinic as a follow-up visit.

2. He was recently diagnosed with medullary thyroid cancer.

3. Last year, he was diagnosed with a pheochromocytoma.

4. The pheochromocytoma was successfully resected.

5. His family history is positive for medullary thyroid cancer in his father.

6. His family history is positive for medullary thyroid cancer in his paternal grandmother.

1. Last year, he was diagnosed with a pheochromocytoma.

2. The pheochromocytoma was successfully resected.

3. His family history is positive for medullary thyroid cancer in his father.

4. His family history is positive for medullary thyroid cancer in his paternal grandmother.

5. His family history is positive for a mucosal neuroma in his brother.


Question: Resection of which of the following segments of the gastrointestinal tract would prevent the absorption of these digested lipids?

Context: Digestion begins in the mouth by breaking food up into smaller particles through mastication and mixing it with saliva containing amylase.

Context: Food then enters the stomach, where gastric acid and pepsin initiate protein digestion.

Context: The resulting chyme is then expelled into the duodenum where pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids.

Context: These digested lipids are then ready for absorption across the gastrointestinal mucosa.

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

Answer: Jejunum

2. Food is broken up into smaller particles through mastication.

3. Food is mixed with saliva containing amylase.

5. Gastric acid and pepsin initiate protein digestion in the stomach.

6. The resulting chyme is expelled into the duodenum.

7. Pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids in the duodenum.

8. Digested lipids are ready for absorption across the gastrointestinal mucosa.

2. Gastric acid and pepsin initiate protein digestion in the stomach.

3. The resulting chyme is expelled into the duodenum.

4. Pancreatic enzymes, such as lipase and phospholipase-A2, digest lipids in the duodenum.

5. Digested lipids are ready for absorption across the gastrointestinal mucosa.


Question: Increased atrial stretch would most likely lead to which of the following changes?

Context: A group of investigators is studying hemodynamic regulatory mechanisms in a human volunteer subject.

Context: The volunteer is administered a stimulant drug, and a sudden increase in blood pressure is observed.

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

Answer: Decreased reabsorption of sodium

1. A group of investigators is studying hemodynamic regulatory mechanisms.

2. The study involves a human volunteer subject.

3. The volunteer is administered a stimulant drug.

4. A sudden increase in blood pressure is observed.

5. It is hypothesized that the increase in blood pressure causes stretching of the atria.

1. The volunteer is administered a stimulant drug.

2. A sudden increase in blood pressure is observed.

3. It is hypothesized that the increase in blood pressure causes stretching of the atria.


Question: Which of the following would be the definitive treatment of this patient’s condition?

Context: A 26-month-old boy is presented to the outpatient clinic by his parents complaining of a productive cough for the last 5 days.

Context: On examination, there are purpuric eruptions over the extremities as well as eczematous patches on the flexural surfaces of his elbows and knees.

Context: With a suspicion of a congenital immunodeficiency, flow cytometry is ordered which reveals a Wiskott-Aldrich syndrome protein (WASP) mutation.

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

Answer: Early hematopoietic stem cell transplantation (HSCT)

1. A 26-month-old boy is presented to the outpatient clinic by his parents.

2. His parents are complaining of a productive cough for the last 5 days.

3. His mother reports a history of recurrent chest infections during the past year.

4. He also has a history of chronic bloody diarrhea and pronounced bleeding after his circumcision.

5. The vital signs are as follows: blood pressure 100/60 mm Hg, pulse 100/min, temperature 38.0°C (100.4°F), and respiratory rate 27/min.

6. On examination, there are purpuric eruptions over the extremities.

7. On examination, there are also eczematous patches on the flexural surfaces of his elbows and knees.

8. Chest auscultation reveals crepitus over the base of the right lung.

9. Chest radiography is suggestive of consolidation in the right lower lobe.

10. Blood test results show anemia, thrombocytopenia with small platelets, and leukopenia.

11. With a suspicion of a congenital immunodeficiency, flow cytometry is ordered.

12. Flow cytometry reveals a Wiskott-Aldrich syndrome protein (WASP) mutation.

1. His mother reports a history of recurrent chest infections during the past year.

2. He has a history of chronic bloody diarrhea.

3. He has a history of pronounced bleeding after his circumcision.

4. The vital signs are: blood pressure 100/60 mm Hg.

6. The vital signs are: temperature 38.0°C (100.4°F).

7. The vital signs are: respiratory rate 27/min.

8. On examination, there are purpuric eruptions over the extremities.

9. On examination, there are eczematous patches on the flexural surfaces of his elbows and knees.

10. Chest auscultation reveals crepitus over the base of the right lung.

11. Chest radiography is suggestive of consolidation in the right lower lobe.

13. Blood test results show thrombocytopenia with small platelets.

16. Flow cytometry reveals a Wiskott-Aldrich syndrome protein (WASP) mutation.


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

Context: Four hours after undergoing an open emergency surgery under general anesthesia for a bleeding abdominal aortic aneurysm, a 55-year-old man is unable to move both his legs.

Context: During the surgery, he had prolonged hypotension, which was corrected with IV fluids and vasopressors.

Context: He has a history of hypertension and hyperlipidemia.

Context: The patient is conscious and oriented to place and person.

Context: His temperature is 37.7°C (99°F), pulse is 74/min, and blood pressure is 100/70 mm Hg.

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

Answer:
Normal proprioception in the extremities
"

2. Patient underwent open emergency surgery under general anesthesia for a bleeding abdominal aortic aneurysm four hours ago.

3. Patient is unable to move both his legs.

4. Patient had prolonged hypotension during surgery, which was corrected with IV fluids and vasopressors.

5. Patient has a history of hypertension and hyperlipidemia.

6. Patient has smoked one pack of cigarettes daily for 35 years.

7. Patient's medications prior to admission were hydrochlorothiazide and atorvastatin.

8. Patient is conscious and oriented to place and person.

9. Patient's temperature is 37.7°C (99°F).

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

12. Patient's muscle strength in lower extremities is 1/5.

1. During the surgery, he had prolonged hypotension.

2. The prolonged hypotension was corrected with IV fluids and vasopressors.

5. He has smoked one pack of cigarettes daily for 35 years.

6. Prior to admission, his medications were hydrochlorothiazide and atorvastatin.

8. The patient is oriented to place and person.

12. Examination shows muscle strength of 1/5 in the lower extremities.


Question: Based on these findings, which of the following is the most likely diagnosis?

Context: A 30-year-old woman seeks evaluation at a local walk-in clinic with a week-long history of lightheadedness and palpitations.

Context: She also complains of fatigability and shortness of breath of the same duration.

Context: The past medical history is significant for menarche at 9 years of age, heavy menstrual bleeding for the past several years and abdominal pain that worsens during menses.

Context: She stopped trying to conceive a child after 2 spontaneous abortions in the past 4 years and has been on iron oral supplementation for the last 2 years.

Context: She adds that she feels a dull pressure-like discomfort in her pelvis and constipation.

Context: The physical examination is significant for pale mucous membranes and a grade 2/6 ejection systolic murmur in the area of the pulmonic valve.

Context: The hemoglobin level is 10 g/dL and the hematocrit is 27%.

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

Answer: Uterine leiomyoma

2. Patient has a week-long history of lightheadedness and palpitations.

3. Patient has a week-long history of fatigability and shortness of breath.

4. Patient had menarche at 9 years of age.

5. Patient has had heavy menstrual bleeding for several years.

6. Patient has abdominal pain that worsens during menses.

7. Patient has had 2 spontaneous abortions in the past 4 years.

8. Patient has been on iron oral supplementation for the last 2 years.

9. Patient feels a dull pressure-like discomfort in her pelvis.

11. Physical examination is significant for pale mucous membranes.

12. Physical examination is significant for a grade 2/6 ejection systolic murmur in the area of the pulmonic valve.

13. Pelvic examination reveals an enlarged, mobile uterus with an irregular contour.

1. She complains of fatigability and shortness of breath.

2. Her past medical history includes menarche at 9 years of age.

3. She has heavy menstrual bleeding for the past several years.

4. She experiences abdominal pain that worsens during menses.

5. She had 2 spontaneous abortions in the past 4 years.

6. She has been on iron oral supplementation for the last 2 years.

7. She feels a dull pressure-like discomfort in her pelvis.

9. Physical examination shows pale mucous membranes.

10. Physical examination reveals a grade 2/6 ejection systolic murmur in the area of the pulmonic valve.

11. Pelvic examination shows an enlarged, mobile uterus with an irregular contour.


Question: What percentage of the risk of developing emphysema can be attributed to smoking?

Context: A study is conducted in a town with a population of 225,000, where the people are followed-up for the development of emphysema.

Context: A total of 1,000 smokers are selected and followed-up, out of which 200 actually develop the disease.

Context: A control group of 1,000 non-smokers is formed, out of which 20 develop emphysema.

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

Answer: 18%

1. A study is conducted in a town with a population of 225,000.

2. The people are followed-up for the development of emphysema.

3. A total of 1,000 smokers are selected and followed-up.

4. Out of the 1,000 smokers, 200 actually develop the disease.

5. A control group of 1,000 non-smokers is formed.

6. Out of the 1,000 non-smokers, 20 develop emphysema.

7. The prevalence of smoking in the general population is 40%.

8. The researcher calculates all possible risk estimates, including the odds ratio.

1. A total of 1,000 smokers are selected and followed-up.

2. 200 of the selected smokers develop the disease.

3. A control group of 1,000 non-smokers is formed.

4. 20 of the non-smokers in the control group develop emphysema.

5. The prevalence of smoking in the general population is 40%.

6. The researcher calculates all possible risk estimates, including the odds ratio.


Question: Which of the following faults to this study most likely explains why the result was considered meaningless?

Context: A medical student is performing clinical research by analyzing the aggregated data of all patients from a national database.

Context: In performing the study, she uses all the data collected from patients who had an appendectomy and analyzes the risk factors that are associated with readmission after discharge.

Context: She first excludes some of the data based on previously determined exclusion criteria and then performs analysis on the rest.

Context: She performs a multiple regression on all variables and finds that one of the risk factors demonstrates a < 5% probability of being the same between groups.

Context: She takes this result and presents it to faculty; however, they respond that the finding is meaningless.

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

Answer: Failure to consider clinical significance versus statistical significance

1. A medical student is performing clinical research.

2. The research involves analyzing aggregated data from a national database.

3. The data is from patients who had an appendectomy.

4. The research is analyzing risk factors associated with readmission after discharge.

5. The medical student excludes some of the data based on previously determined exclusion criteria.

6. The medical student performs a multiple regression on all variables.

7. The multiple regression finds that one of the risk factors has a < 5% probability of being the same between groups.

8. The medical student presents the finding to faculty.

9. The faculty respond that the finding is meaningless.

1. She uses all the data collected from patients who had an appendectomy.

2. She analyzes the risk factors associated with readmission after discharge.

3. She excludes some of the data based on previously determined exclusion criteria.

4. She performs analysis on the rest of the data.

5. She performs a multiple regression on all variables.

6. She finds that one of the risk factors demonstrates a < 5% probability of being the same between groups.

8. The faculty responds that the finding is meaningless.


Question: Which of the following features is a contraindication for thrombolytic therapy in this patient?

Context: A 60-year-old man presents to the emergency department with ‘discomfort’ in his chest and a ‘squeezing’ sensation in his neck.

Context: He also complains of nausea.

Context: He also drinks heavily on weekends.

Context: Aspirin was administered upon arrival.

Context: His ECG is shown in the picture.

Choices:
A. Aspirin administration
B. Elevated blood pressure
C. History of smoking
D. Stroke 3 months ago

Answer: Stroke 3 months ago

General Cardiology
Interventional Cardiology
Cardiovascular Disease

2. Patient presents to the emergency department with ‘discomfort’ in his chest and a ‘squeezing’ sensation in his neck.

3. Symptoms started 45 minutes ago while he was washing the dishes.

5. Patient has been a regular smoker for 45 years, averaging a pack of cigarettes each day.

6. Patient also drinks heavily on weekends.

7. Patient's medical history is significant for a stroke 3 months ago.

8. Patient admits he has not been taking his medications.

9. Vital signs show: pulse 62/min, respiratory rate 20/min, blood pressure 176/94 mm Hg, and temperature 36.9°C (98.4°F).

10. Physical examination reveals a visibly distressed man who is sweating profusely.

11. Chest is clear to auscultation and a 4th heart sound can be heard.

12. Aspirin was administered upon arrival.

13. Patient's ECG is shown in the picture.

1. The symptoms started 45 minutes ago while he was washing the dishes.

3. He has been a regular smoker for 45 years, averaging a pack of cigarettes each day.

5. His medical history is significant for a stroke 3 months ago, but the patient admits he has not been taking his medications.

6. Vital signs show: pulse 62/min, respiratory rate 20/min, blood pressure 176/94 mm Hg, and temperature 36.9°C (98.4°F).

7. Physical examination reveals a visibly distressed man who is sweating profusely.

8. The chest is clear to auscultation and a 4th heart sound can be heard.

9. Aspirin was administered upon arrival.


Question: What is the most likely diagnosis?

Context: A 3-year-old girl is brought by her parents to the office for bloody diarrhea and a seizure.

Context: The parents say she started having fever, abdominal pain, and diarrhea about 3 days ago, but the bloody diarrhea started 12 hours ago.

Context: Her vital signs include: blood pressure is 130/85 mm Hg, her respiratory rate is 25/min, her heart rate is 120/min, and her temperature is 39.2°C (102.6°F).

Context: On physical examination, she looks pale and sleepy, the cardiopulmonary auscultation is normal, the abdomen is painful on palpation, and the skin assessment reveals the presence of disseminated pinpoint petechiae.

Context: The urinalysis show hematuria.

Context: The Coombs test is negative.

Context: The complete blood count results are as follows: | Hemoglobin 7 g/dL | Hematocrit 25 % | Leukocyte count 17,000/mm3 | Neutrophils 70% | Bands 2% | Eosinophils 1% | Basophils 0% | Lymphocytes 22% | Monocytes 5% | Platelet count 7,000/mm3 | Her coagulation tests are as follows: | Partial thromboplastin time (activated) 30 seconds | Prothrombin time 12 seconds | Reticulocyte count 1 % | Thrombin time < 2 seconds deviation from control | .

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

Answer: Hemolytic-uremic syndrome

Pediatric Nephrology
Pediatric Gastroenterology

1. A 3-year-old girl is brought by her parents to the office.

2. The parents say she started having fever, abdominal pain, and diarrhea about 3 days ago.

3. The bloody diarrhea started 12 hours ago.

4. The seizure was the last symptom to appear 3 hours ago.

5. The seizure consisted of repetitive movement of arms and legs with loss of consciousness.

6. Her 4-year-old brother had a similar case with bloody diarrhea 2 weeks ago.

10. Her temperature is 39.2°C (102.6°F).

11. On physical examination, she looks pale and sleepy.

12. The cardiopulmonary auscultation is normal.

13. The abdomen is painful on palpation.

14. The skin assessment reveals the presence of disseminated pinpoint petechiae.

27. The Partial thromboplastin time (activated) is 30 seconds.

30. The Thrombin time is < 2 seconds deviation from control.

1. The patient started having fever, abdominal pain, and diarrhea about 3 days ago.

2. The bloody diarrhea started 12 hours ago.

3. The seizure was the last symptom to appear 3 hours ago, and it consisted of repetitive movement of arms and legs with loss of consciousness.

4. The patient's 4-year-old brother had a similar case with bloody diarrhea 2 weeks ago.

5. The patient's blood pressure is 130/85 mm Hg.

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

8. The patient's temperature is 39.2°C (102.6°F).

9. On physical examination, the patient looks pale and sleepy.

10. The cardiopulmonary auscultation is normal.

11. The abdomen is painful on palpation.

12. The skin assessment reveals the presence of disseminated pinpoint petechiae.

15. The complete blood count results are as follows: Hemoglobin 7 g/dL, Hematocrit 25%, Leukocyte count 17,000/mm3, Neutrophils 70%, Bands 2%, Eosinophils 1%, Basophils 0%, Lymphocytes 22%, Monocytes 5%, Platelet count 7,000/mm3.

16. The patient's coagulation tests are as follows: Partial thromboplastin time (activated) 30 seconds, Prothrombin time 12 seconds, Reticulocyte count 1%, Thrombin time < 2 seconds deviation from control.


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

Context: A 68-year-old woman presents to the emergency room with productive cough and fever.

Context: Her past medical history includes COPD and her medications include ipratropium and fluticasone.

Context: On physical exam her temperature is 102.2°F (39°C), blood pressure is 131/78 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 95% on room air.

Context: You obtain a sputum sample and identify an organism that grows selectively on medium containing factors V and X.

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

Answer: Haemophilus influenzae

1. A 68-year-old woman presents to the emergency room.

2. She has a productive cough and fever.

3. She has a chronic cough that has been getting progressively worse over the last 2 weeks.

4. Last night she developed a fever and vomited.

5. She smoked one pack of cigarettes per day for 40 years and recently quit.

6. Her past medical history includes COPD.

7. Her medications include ipratropium and fluticasone.

8. On physical exam her temperature is 102.2°F (39°C).

12. Her oxygen saturation is 95% on room air.

13. She has decreased breath sounds bilaterally with diffuse crackles.

15. An organism is identified that grows selectively on medium containing factors V and X.

2. The chronic cough has been getting progressively worse over the last 2 weeks.

5. She smoked one pack of cigarettes per day for 40 years.

7. Her past medical history includes COPD.

8. Her medications include ipratropium and fluticasone.

9. On physical exam her temperature is 102.2°F (39°C).

13. Her oxygen saturation is 95% on room air.

14. She has decreased breath sounds bilaterally.

16. An organism was identified in a sputum sample.

17. The organism grows selectively on medium containing factors V and X.


Question: The mechanism of action of this drug is most similar to that of which of the following?

Context: A 36-year-old man comes to the physician because of progressive fatigue and night sweats for 2 months.

Context: During this time, he has also had a 10-kg (22-lb) weight loss.

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

Answer: Metronidazole

1. A 36-year-old man comes to the physician.

2. He has progressive fatigue and night sweats for 2 months.

3. He has had a 10-kg (22-lb) weight loss.

4. Physical examination shows painless swelling of the cervical, axillary, and inguinal lymph nodes.

5. Examination of the abdomen shows hepatosplenomegaly.

6. Histologic examination of a lymph node biopsy specimen shows Reed-Sternberg cells.

7. A diagnosis of Hodgkin lymphoma is made.

8. The patient is started on a chemotherapeutic regimen that includes bleomycin.

1. The patient has had a 10-kg (22-lb) weight loss.

2. Physical examination shows painless swelling of the cervical, axillary, and inguinal lymph nodes.

3. Examination of the abdomen shows hepatosplenomegaly.

4. Histologic examination of a lymph node biopsy specimen shows Reed-Sternberg cells.

5. A diagnosis of Hodgkin lymphoma is made.

6. The patient is started on a chemotherapeutic regimen that includes bleomycin.


Question: Which of the following is the most appropriate treatment for this condition?

Context: An 7-year-old girl is brought to the pediatrician by her concerned mother, because she is "more physically matured" than the rest of the girls in her class.

Context: Thyroid function tests and an MRI of the head are both within normal limits.

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

Answer: Leuprolide

1. An 7-year-old girl is brought to the pediatrician by her concerned mother.

2. The girl is "more physically matured" than the rest of the girls in her class.

3. On physical exam, she is noted to have breast development and pubic hair.

4. On gonadotropin reseasing hormone (GnRH) stimulation, she has an increase in leutienizing hormone (LH) levels.

5. Thyroid function tests are within normal limits.

6. An MRI of the head is within normal limits.

1. On physical exam, she is noted to have breast development.

2. On physical exam, she is noted to have pubic hair.

3. On gonadotropin releasing hormone (GnRH) stimulation, she has an increase in leutienizing hormone (LH) levels.

4. Thyroid function tests are within normal limits.

5. An MRI of the head is within normal limits.


Question: What is the most likely diagnosis?

Context: The patient's initial laboratory data return in the meantime: |  | Hemoglobin: 5 g/dL | Hematocrit: 18 % | Leukocyte count: 8,000/mm^3 with normal differential | Platelet count: 400,000/mm^3 |  | Serum: | Na+: 140 mEq/L | Cl-: 115 mEq/L | K+: 3.2 mEq/L | HCO3-: 26 mEq/L | BUN: 60 mg/dL | Glucose: 104 mg/dL | Creatinine: 1.1 mg/dL |  | Blood type: AB | Rhesus status: negative |  | After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours.

Context: She denies any other symptoms.

Context: No rash is seen.

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

Answer: Febrile nonhemolytic reaction

1. A 45-year-old woman presents to the emergency department with hematemesis.

2. Her son said that the patient had complained of gnawing abdominal pain that worsened before and improved after meals for the past 3 weeks.

3. She frequently travels for work and is often stressed.

4. She drinks alcohol socially and does not smoke tobacco or marijuana.

5. She has not had anything to eat or drink for the past 24 hours due to the pain, but coughed up "several cup of" frank red blood before arrival.

6. Her temperature is 98°F (37°C), blood pressure is 80/50 mmHg, pulse is 140/min, respirations are 23/min, and oxygen saturation is 96% on room air.

7. Gastric ultrasound reveals high gastric residual volume.

8. The patient is empirically started on 3 units of uncrossmatched O-negative blood transfusion and pantoprazole.

9. The patient's initial laboratory data return: Hemoglobin: 5 g/dL, Hematocrit: 18 %, Leukocyte count: 8,000/mm^3 with normal differential, Platelet count: 400,000/mm^3, Serum: Na+: 140 mEq/L, Cl-: 115 mEq/L, K+: 3.2 mEq/L, HCO3-: 26 mEq/L, BUN: 60 mg/dL, Glucose: 104 mg/dL, Creatinine: 1.1 mg/dL, Blood type: AB, Rhesus status: negative.

10. After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours.

11. The patient now complains of feeling hot with intermittent shivering.

13. Her temperature is 101°F (38.3°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air.

14. Her lungs are clear to auscultation bilaterally, and no accessory respiratory muscle use is observed.

1. The patient complained of gnawing abdominal pain that worsened before and improved after meals for the past 3 weeks.

2. The patient frequently travels for work and is often stressed.

3. The patient drinks alcohol socially and does not smoke tobacco or marijuana.

4. The patient has not had anything to eat or drink for the past 24 hours due to the pain, but coughed up "several cup of" frank red blood before arrival.

5. The patient's temperature is 98°F (37°C), blood pressure is 80/50 mmHg, pulse is 140/min, respirations are 23/min, and oxygen saturation is 96% on room air.

6. Gastric ultrasound reveals high gastric residual volume.

7. The patient is empirically started on 3 units of uncrossmatched O-negative blood transfusion and pantoprazole.

8. The patient's initial laboratory data return: Hemoglobin: 5 g/dL, Hematocrit: 18 %, Leukocyte count: 8,000/mm^3 with normal differential, Platelet count: 400,000/mm^3, Serum: Na+: 140 mEq/L, Cl-: 115 mEq/L, K+: 3.2 mEq/L, HCO3-: 26 mEq/L, BUN: 60 mg/dL, Glucose: 104 mg/dL, Creatinine: 1.1 mg/dL, Blood type: AB, Rhesus status: negative.

9. After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours.

10. The patient now complains of feeling hot with intermittent shivering.

11. The patient's temperature is 101°F (38.3°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air.

12. Her lungs are clear to auscultation bilaterally, and no accessory respiratory muscle use is observed. No rash is seen.


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

Context: A 66-year-old man comes to the physician because of a 3-week history of shortness of breath with exertion.

Context: Cardiac examination is shown.

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

Answer: Elevated serum brain natriuretic peptide levels

1. A 66-year-old man comes to the physician.

2. He has a 3-week history of shortness of breath with exertion.

3. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus.

4. His current medications include aspirin, losartan, simvastatin, and insulin.

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

1. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus.

2. Current medications include aspirin, losartan, simvastatin, and insulin.

3. His temperature is 37.1°C (98.8°F), pulse is 74/min, and blood pressure is 150/84 mm Hg.

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


Question: Which of the following would be the most appropriate recommendation for this patient?

Context: A 27-year-old gravida 2, para 2 woman presents to her OB/GYN’s office concerned that she may be pregnant.

Context: She has 2 children under the age of 3 and does not want another child at this time.

Context: She says she cannot take “the pill” because she had a blood clot in her leg after her last cesarean section successfully treated with 6 months of anticoagulation.

Context: She smokes cigarettes and drinks alcohol regularly.

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

Answer: Recommend copper IUD

1. A 27-year-old woman presents to her OB/GYN's office.

3. She and her husband use condoms for contraception.

4. The night before, the condom broke during intercourse.

5. She has 2 children under the age of 3.

6. She does not want another child at this time.

7. She cannot take "the pill" because she had a blood clot in her leg after her last cesarean section.

8. The blood clot was successfully treated with 6 months of anticoagulation.

1. She and her husband use condoms for contraception.

2. The condom broke during intercourse the night before.

3. She has 2 children under the age of 3.

4. She does not want another child at this time.

5. She cannot take "the pill" because she had a blood clot in her leg after her last cesarean section.

6. The blood clot was successfully treated with 6 months of anticoagulation.


Question: Bloodwork is drawn and is shown below. |  | Serum: | Na+: 139 mEq/L | K+: 3.7 mEq/L | Cl-: 100 mEq/L | HCO3-: 28 mEq/L | Urea nitrogen: 9 mg/dL | Glucose: 122 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: 9.8 mg/dL | Mg2+: 1.7 mg/dL |  | After a physical exam is performed, which of the following is the best initial step in management for this patient's underlying condition?

Context: A 25-year-old Ashkenazi Jewish man presents to his primary care physician for a follow-up visit.

Context: His temperature is 99.5°F (37.5°C), pulse is 80/min, blood pressure is 182/100 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air.

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

Answer: Duplex ultrasound

1. A 25-year-old Ashkenazi Jewish man presented to his primary care physician for a follow-up visit.

2. One week ago, he presented with a chief complaint of priapism while engaging in intercourse with two of his partners.

3. During that visit, it was determined that his blood pressure was 175/100 mmHg.

4. He returns this week to have his vitals rechecked.

9. His oxygen saturation is 98% on room air.

1. One week ago, he presented with a chief complaint of priapism while engaging in intercourse with two of his partners.

2. During that visit, it was determined that his blood pressure was 175/100 mmHg.

3. He returns this week to have his vitals rechecked.

8. His oxygen saturation is 98% on room air.


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

Context: A 63-year-old man is brought to the emergency department after having 8–9 episodes of red watery stool.

Context: He has no abdominal pain or fever.

Context: He drinks one beer daily.

Context: He is in distress.

Context: Examination shows pale conjunctivae.

Context: The abdomen is soft and nontender.

Context: Bowel sounds are increased.

Context: The lungs are clear to auscultation.

Context: Cardiac examination shows an S4 gallop.

Context: Rectal examination shows frank blood.

Context: Laboratory studies show: | Hemoglobin 9.8 g/dL | Leukocyte count 7,800/mm3 | Platelet count 280,000/mm3 | Prothrombin time 14 seconds (INR=0.9) | Serum | Na+ 135 mEq/L | K+ 4.1 mEq/L | Cl- 101 mEq/L | Urea nitrogen 16 mg/dL | Glucose 96 mg/dL | Creatinine 0.7 mg/dL | Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered.

Context: A nasogastric tube is inserted.

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

Answer: Angiography

2. Patient has had 8-9 episodes of red watery stool.

3. Patient has no abdominal pain or fever.

4. Patient underwent an angioplasty 4 years ago and received 2 stents in his left main coronary artery.

5. Patient has hypertension, hypercholesterolemia, coronary artery disease, and chronic constipation.

6. Patient's current medications include aspirin, metoprolol, and simvastatin.

9. Patient's temperature is 37.3°C (99.1°F).

12. Patient's blood pressure is 86/58 mm Hg.

14. Patient's abdomen is soft and nontender.

15. Patient's bowel sounds are increased.

16. Patient's lungs are clear to auscultation.

17. Patient's cardiac examination shows an S4 gallop.

18. Patient's rectal examination shows frank blood.

20. Patient's leukocyte count is 7,800/mm3.

21. Patient's platelet count is 280,000/mm3.

22. Patient's prothrombin time is 14 seconds (INR=0.9).

26. Patient's urea nitrogen is 16 mg/dL.

29. Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered.

31. Aspiration shows clear gastric content containing bile.

32. Patient's pulse is 133/min directly afterwards.

33. Patient's blood pressure is 80/54 mm Hg directly afterwards.

2. He underwent an angioplasty 4 years ago and received 2 stents in his left main coronary artery.

3. He has hypertension, hypercholesterolemia, coronary artery disease, and chronic constipation.

4. Current medications include aspirin, metoprolol, and simvastatin.

7. His temperature is 37.3°C (99.1°F), pulse is 110/min, respirations are 14/min, and blood pressure is 86/58 mm Hg.

11. The lungs are clear to auscultation.

12. Cardiac examination shows an S4 gallop.

13. Rectal examination shows frank blood.

14. Laboratory studies show: Hemoglobin 9.8 g/dL, Leukocyte count 7,800/mm3, Platelet count 280,000/mm3, Prothrombin time 14 seconds (INR=0.9), Serum Na+ 135 mEq/L, K+ 4.1 mEq/L, Cl- 101 mEq/L, Urea nitrogen 16 mg/dL, Glucose 96 mg/dL, Creatinine 0.7 mg/dL.

15. Two large bore intravenous catheters are inserted and 0.9% saline infusions are administered.

17. Aspiration shows clear gastric content containing bile.

18. Directly afterwards, his pulse is 133/min and blood pressure is 80/54 mm Hg.


Question: Which of the following is a relative contraindication for administering one or more routine vaccinations in this patient at this time?

Context: A 15-month-old boy with Down syndrome is brought to the physician for a well-child examination.

Context: The mother is concerned about giving the child any more vaccinations, as she reports he had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12-months of age.

Context: He has had a runny nose for 2 days.

Context: He has a seizure disorder with a seizure lasting 1–2 minutes a few times a week that has not been controlled by medications.

Context: He was treated for intussusception at 6 months of age.

Context: His father was diagnosed with HIV 2 years ago.

Context: His medications include phenytoin, levetiracetam, and vitamin supplements.

Context: He is allergic to amoxicillin and has previously developed localized urticaria after consumption of eggs.

Context: His immunizations are up-to-date.

Context: Vital signs are within normal limits.

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

Answer:
Uncontrolled seizure disorder
"

1. Patient is a 15-month-old boy with Down syndrome.

2. Mother is concerned about giving the child any more vaccinations.

3. Patient had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12-months of age.

4. Patient has had a runny nose for 2 days.

5. Patient has a seizure disorder with a seizure lasting 1–2 minutes a few times a week that has not been controlled by medications.

6. Patient was treated for intussusception at 6 months of age.

7. Patient's father was diagnosed with HIV 2 years ago.

8. Patient's medications include phenytoin, levetiracetam, and vitamin supplements.

10. Patient has previously developed localized urticaria after consumption of eggs.

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

12. Patient's vital signs are within normal limits.

13. Examination shows low-set ears, hypertelorism, and a flat head.

14. The remainder of the examination shows no abnormalities.

1. The child had a fever of 38.7°C (101.7°F) soon after his vaccinations at 12 months of age.

2. The child has had a runny nose for 2 days.

3. The child has a seizure disorder with seizures lasting 1–2 minutes a few times a week that has not been controlled by medications.

4. The child was treated for intussusception at 6 months of age.

5. The child's father was diagnosed with HIV 2 years ago.

6. The child's medications include phenytoin, levetiracetam, and vitamin supplements.

7. The child is allergic to amoxicillin and has previously developed localized urticaria after consumption of eggs.

8. The child's immunizations are up-to-date.

9. Examination shows low-set ears, hypertelorism, and a flat head.

10. The remainder of the examination shows no abnormalities.


Question: Which of the following genetic conditions is most likely related to these clinical features?

Context: A 1-year-old boy is brought to his pediatrician’s office due to regression of development.

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

Answer: Hurler syndrome

1. A 1-year-old boy is brought to his pediatrician's office.

2. The pediatrician has observed regression in some behavioral and other milestones.

3. The pediatrician is also concerned about his facial development.

4. On examination, the vital signs are normal.

5. He has coarse facial features with a bulging frontal bone.

8. Urine studies show an increase in dermatan sulfate.

1. She has observed that he is not progressing as he did during the 1st year of his life.

2. There seems to be a regression in some behavioral and other milestones.

3. She is also concerned about his facial development.

6. Additionally, his lips are enlarged and corneal clouding is observed.

7. Urine studies show an increase in dermatan sulfate.


Question: Which of the following is the most likely explanation for this patient's examination findings?

Context: A 6-year-old African American girl is brought to the physician by her mother because she has recently developed axillary and pubic hair.

Context: She also has multiple pustules on her forehead and has had oily skin for 3 months.

Context: Her mother reports that she recently bought some deodorant for the girl because of her body odor.

Context: Her mother has hypothyroidism.

Context: She is at the 95th percentile for height and the 99th percentile for weight and BMI.

Context: There is coarse hair under both axilla and sparse dark hair on the mons pubis and along the labia majora.

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

Answer: High levels of insulin

1. Patient is a 6-year-old African American girl.

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

3. Patient has recently developed axillary and pubic hair.

4. Patient has multiple pustules on her forehead.

5. Patient has had oily skin for 3 months.

6. Patient's mother recently bought deodorant for her due to body odor.

8. Patient is at the 95th percentile for height.

9. Patient is at the 99th percentile for weight and BMI.

10. Patient's vital signs are within normal limits.

11. Patient has no palpable glandular breast tissue.

12. Patient has coarse hair under both axilla.

13. Patient has sparse dark hair on the mons pubis and along the labia majora.

1. She has multiple pustules on her forehead.

3. Her mother recently bought deodorant for her because of her body odor.

5. She is at the 95th percentile for height.

6. She is at the 99th percentile for weight and BMI.

7. Her vital signs are within normal limits.

8. She has no palpable glandular breast tissue.

9. There is coarse hair under both axilla.

10. There is sparse dark hair on the mons pubis and along the labia majora.


Question: Which of the following factors is most likely involved in the pathogenesis of this patient's condition?

Context: Her BMI is 31 kg/m2.

Context: Laboratory studies show a hemoglobin A1c of 6.4% and an elevated serum insulin level.

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

Answer: Increased levels of serum fatty acids

1. A 45-year-old woman comes to the physician for a health maintenance examination.

2. Her father has a history of type 2 diabetes mellitus.

3. She has gained 18-kg (40-lb) since the birth of her son 6 years ago.

5. Physical examination shows hyperpigmented plaques in the axillae and posterior neck.

6. Laboratory studies show a hemoglobin A1c of 6.4%.

7. Laboratory studies show an elevated serum insulin level.

1. Her father has a history of type 2 diabetes mellitus.

2. She has gained 18-kg (40-lb) since the birth of her son 6 years ago.

4. Physical examination shows hyperpigmented plaques in the axillae and posterior neck.

5. Laboratory studies show a hemoglobin A1c of 6.4%.

6. Laboratory studies show an elevated serum insulin level.


Question: What pathological step preceded calcification in her condition?

Context: An 89-year-old woman presents with worsening dyspnea on exertion and generalized fatigue.

Context: She has fainted once.

Context: Exam reveals a crescendo-decrescendo systolic ejection murmur that radiates to the carotids.

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

Answer: Cellular injury and necrosis

General Cardiology
Cardiology
Pulmonary Disease

2. Patient presents with worsening dyspnea on exertion and generalized fatigue.

4. Exam reveals a crescendo-decrescendo systolic ejection murmur.

2. Exam reveals a crescendo-decrescendo systolic ejection murmur.


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

Context: He says that the chest pain began a few hours prior to presentation and is associated with nausea, abdominal discomfort, and sweating.

Context: He has experienced similar symptoms multiple times in the past, which brings him great concern because he believes he may be having a heart attack.

Context: This concern has persisted for 2 months.

Context: This has caused him to avoid taking long train rides or driving on divided highways.

Context: Physical examination is unremarkable.

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

Answer: Panic disorder

1. A 22-year-old man presents to the emergency department for chest pain.

2. The chest pain began a few hours prior to presentation.

3. The chest pain is associated with nausea, abdominal discomfort, and sweating.

4. He has experienced similar symptoms multiple times in the past.

5. He believes he may be having a heart attack.

6. His concern has persisted for 2 months.

7. He has avoided taking long train rides or driving on divided highways.

8. Approximately 7 months ago his parents divorced.

9. Medical history is significant for obesity.

10. He denies any medications or illicit drug use.

11. Physical examination is unremarkable.

12. An electrocardiogram demonstrates sinus tachycardia with a pulse of 110/min.

1. The patient reports that the chest pain started a few hours before seeking medical attention.

2. The chest pain is accompanied by nausea, abdominal discomfort, and sweating.

3. The patient has had similar symptoms on multiple occasions in the past.

4. The patient is concerned that he may be having a heart attack due to the recurring symptoms.

5. The patient has been worried about this for 2 months.

6. His concern has led him to avoid long train rides and driving on divided highways.

7. The patient's parents divorced approximately 7 months ago.

8. The patient has a significant medical history of obesity.

9. The patient denies using any medications or illicit drugs.

10. The physical examination did not reveal any remarkable findings.

11. An electrocardiogram shows sinus tachycardia with a pulse of 110/min.


Question: After the aminoacyl-tRNA binds to the A site, which of the following is the next step in protein formation?

Context: Eukaryote ribosomes are utilized to create a novel protein.

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

Answer: Catalysis of peptide bond

Molecular Genetic Pathology
Rheumatology

1. An investigator is developing a new vaccine.

1. Eukaryote ribosomes are present in eukaryotic cells.

2. Ribosomes are used to synthesize proteins.

3. The process of using ribosomes to create a new protein is called translation.


Question: Which of the following is the most significant risk factor for this patient’s most likely diagnosis?

Context: A 70-year-old Caucasian woman presents with a 2-week history of blood-tinged sputum.

Context: Her past medical history is significant for peptic ulcer disease for which she underwent triple-drug therapy.

Context: She is a lifetime non-smoker and worked as a teacher before retiring at the age of 60 years.

Context: A review of systems is significant for a weight loss of 6.8 kg (15 lb) over the last 5 months.

Context: Her vitals include: blood pressure 135/85 mm Hg, temperature 37.7°C (99.9°F), pulse 95/min, and respiratory rate 18/min.

Context: Physical examination is unremarkable.

Context: A contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung.

Context: A CT-guided biopsy is performed and reveals malignant tissue architecture and gland formation with a significant amount of mucus.

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

Answer: Sex

1. Patient is a 70-year-old Caucasian woman.

2. Patient has a 2-week history of blood-tinged sputum.

3. Patient has a past medical history of peptic ulcer disease.

4. Patient underwent triple-drug therapy for peptic ulcer disease.

6. Patient worked as a teacher before retiring at the age of 60 years.

7. Patient has had a weight loss of 6.8 kg (15 lb) over the last 5 months.

8. Patient's blood pressure is 135/85 mm Hg.

9. Patient's temperature is 37.7°C (99.9°F).

11. Patient's respiratory rate is 18/min.

12. Physical examination is unremarkable.

13. Contrast CT scan of the chest shows an irregular mass in the peripheral region of the inferior lobe of the right lung.

14. CT-guided biopsy reveals malignant tissue architecture and gland formation with a significant amount of mucus.

1. Past medical history includes peptic ulcer disease

2. Underwent triple-drug therapy for peptic ulcer disease

4. Worked as a teacher before retiring at age 60

5. Review of systems shows weight loss of 6.8 kg (15 lb) over last 5 months

10. Physical examination is unremarkable

11. Contrast CT scan of the chest shows irregular mass in peripheral region of inferior lobe of right lung

12. CT-guided biopsy reveals malignant tissue architecture and gland formation with significant amount of mucus


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

Context: Four days after admission to the hospital for community-acquired pneumonia, a 68-year-old woman has abdominal pain and multiple episodes of loose stools.

Context: They are watery, foul-smelling, and occasionally streaked with blood.

Context: She has approximately 6 episodes daily.

Context: She feels tired.

Context: She is currently being treated with intravenous ceftriaxone and oral azithromycin.

Context: She underwent a laparoscopic cholecystectomy 5 years ago.

Context: She returned from a trip to Bolivia 4 weeks ago.

Context: Her temperature is 37.5°C (99.5°F), pulse is 98/min, and blood pressure is 138/80 mm Hg.

Context: Bronchial breath sounds are heard over her right lung.

Context: The abdomen is not distended.

Context: The remainder of her examination shows no abnormalities.

Context: Her hemoglobin concentration is 12 g/dL, leukocyte count is 14,100/mm3, and erythrocyte sedimentation rate is 37 mm/h.

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

Answer: Enzyme immunoassay for glutamate dehydrogenase antigen

2. Patient was admitted to the hospital four days ago for community-acquired pneumonia.

3. Patient has abdominal pain and multiple episodes of loose stools.

4. Loose stools are watery, foul-smelling, and occasionally streaked with blood.

5. Patient has approximately 6 episodes of loose stools daily.

7. Patient is currently being treated with intravenous ceftriaxone and oral azithromycin.

8. Patient underwent a laparoscopic cholecystectomy 5 years ago.

9. Patient returned from a trip to Bolivia 4 weeks ago.

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

12. Patient's blood pressure is 138/80 mm Hg.

13. Bronchial breath sounds are heard over patient's right lung.

14. Abdominal examination shows mild diffuse tenderness throughout the lower quadrants.

16. Remainder of patient's examination shows no abnormalities.

17. Patient's hemoglobin concentration is 12 g/dL.

18. Patient's leukocyte count is 14,100/mm3.

19. Patient's erythrocyte sedimentation rate is 37 mm/h.

1. The patient's stool is watery, foul-smelling, and occasionally streaked with blood.

2. The patient has approximately 6 episodes of stool daily.

4. The patient is currently being treated with intravenous ceftriaxone and oral azithromycin.

5. The patient underwent a laparoscopic cholecystectomy 5 years ago.

6. The patient returned from a trip to Bolivia 4 weeks ago.

7. The patient's temperature is 37.5°C (99.5°F), pulse is 98/min, and blood pressure is 138/80 mm Hg.

8. Bronchial breath sounds are heard over the patient's right lung.

9. Abdominal examination shows mild diffuse tenderness throughout the lower quadrants.

10. The patient's abdomen is not distended.

11. The remainder of the patient's examination shows no abnormalities.

12. The patient's hemoglobin concentration is 12 g/dL, leukocyte count is 14,100/mm3, and erythrocyte sedimentation rate is 37 mm/h.


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

Context: An otherwise healthy 52-year-old man comes to the physician because of a 2-month history of palpitations.

Context: He says that he can feel his heart beat in his chest all the time.

Context: He does not take any medications.

Context: The lungs are clear to auscultation.

Context: Cardiac examination is shown.

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

Answer: Aortic valve regurgitation

Cardiovascular Disease
Cardiology
General Cardiology

2. Patient has a 2-month history of palpitations.

3. Patient feels his heart beat in his chest all the time.

4. Patient has shortness of breath on exertion for the past 3 weeks.

5. Patient has no chest pain, orthopnea, or nocturnal dyspnea.

6. Patient emigrated from Nepal at the age of 25 years.

7. Patient does not take any medications.

8. Patient's temperature is 36.5°C (97.7°F).

10. Patient's blood pressure is 138/56 mm Hg.

1. He can feel his heart beat in his chest all the time.

2. For the past 3 weeks, he has shortness of breath on exertion.

3. He has not had chest pain, orthopnea, or nocturnal dyspnea.

4. He emigrated from Nepal at the age of 25 years.

6. His temperature is 36.5°C (97.7°F), pulse is 103/min, and blood pressure is 138/56 mm Hg.


Question: Which of the following activities was most likely inhibited by the cause of this patient's presentation?

Context: On presentation he is comatose and very jaundiced despite having no previous medical history and dies shortly thereafter.

Context: They all recently returned from a several day camping trip where they slept in the woods and cooked with ingredients they were able to find in the wild.

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

Answer: Transcription of mRNA

Neurology with Special Qualification in Child Neurology

1. A 55-year-old male presents to the emergency department after he was seen having a seizure.

2. On presentation he is comatose and very jaundiced.

5. Over the next several hours 5 more patients present to the ER with severe diarrhea, abdominal pain, and bleeding abnormalities.

6. They all recently returned from a several day camping trip.

7. They slept in the woods and cooked with ingredients they were able to find in the wild.

8. The original patient was also part of this camping trip.

9. Postmortem analysis reveals massive hepatic necrosis.

1. A patient presented comatose and jaundiced.

2. The patient had no previous medical history.

3. The patient died shortly after presentation.

4. Five more patients presented to the ER with severe diarrhea, abdominal pain, and bleeding abnormalities.

5. The patients had recently returned from a camping trip.

6. During the camping trip, they slept in the woods and cooked with wild ingredients.

7. The original patient was part of the camping trip.

8. Postmortem analysis revealed massive hepatic necrosis.


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

Context: Blood glucose is 80 mg/dL.

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

Answer: Benzodiazepine withdrawal

General Emergency Medicine
Neurocritical Care
Medical Toxicology

1. A 46-year-old woman is brought to the emergency department for respiratory depression.

2. Routine urine toxicology screening is positive for alcohol, fentanyl, and benzodiazepines.

4. Naloxone, flumazenil, and lactated Ringer's solution are administered intravenously.

5. Two hours later, the woman has a tonic-clonic seizure lasting for one minute.

9. Pulse oximetry on room air shows an oxygen saturation of 98%.

10. The patient appears drowsy and diaphoretic.

11. She is not oriented to place or time but responds to her name.

12. Examination shows a hematoma on her left temple.

13. Neurological examination shows stiff extremities and a tremor in both hands.

14. The remainder of the examination shows no abnormalities.

1. Routine urine toxicology screening is positive for alcohol, fentanyl, and benzodiazepines.

3. Naloxone, flumazenil, and lactated Ringer's solution are administered intravenously.

4. Two hours later, the woman has a tonic-clonic seizure lasting for one minute.

5. Her pulse is 100/min, blood pressure is 145/90 mm Hg, and respiratory rate is 24/min.

6. Pulse oximetry on room air shows an oxygen saturation of 98%.

7. The patient appears drowsy and diaphoretic.

8. She is not oriented to place or time but responds to her name.

9. Examination shows a hematoma on her left temple.

10. Neurological examination shows stiff extremities and a tremor in both hands.

11. The remainder of the examination shows no abnormalities.


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

Context: A 22-year-old man comes to the emergency department because of sudden onset of facial swelling, abdominal pain, and nausea 1 hour after eating some trail mix.

Choices:
A. Recommend avoidance of peanuts
B. Perform patch test
C. Prescribe epinephrine autoinjector
D. Administer oral prednisone

Answer: Prescribe epinephrine autoinjector

1. A 22-year-old man comes to the emergency department.

2. He has sudden onset of facial swelling, abdominal pain, and nausea 1 hour after eating some trail mix.

3. He does not have shortness of breath or hoarseness.

4. He has never had a similar episode before.

5. He has asthma treated with an albuterol inhaler, which he uses less than once a month.

9. Pulse oximetry on room air shows an oxygen saturation of 99%.

10. Physical examination shows perioral swelling and scattered urticaria over the face and the fingers of his right hand.

11. There is no swelling of the oropharynx and no audible stridor.

12. The lungs are clear to auscultation bilaterally.

13. Treatment with intravenous diphenhydramine is begun.

14. Shortly after, the abdominal pain and nausea have resolved.

1. He does not have shortness of breath or hoarseness.

2. He has never had a similar episode before.

3. He has asthma treated with an albuterol inhaler, which he uses less than once a month.

4. His pulse is 90/min, respirations are 25/min, and blood pressure is 125/80 mm Hg.

5. Pulse oximetry on room air shows an oxygen saturation of 99%.

6. Physical examination shows perioral swelling and scattered urticaria over the face and the fingers of his right hand.

7. There is no swelling of the oropharynx and no audible stridor.

8. The lungs are clear to auscultation bilaterally.

9. Treatment with intravenous diphenhydramine is begun.

10. Shortly after, the abdominal pain and nausea have resolved, the swelling has improved, and the rash has started to fade.


Question: The regions of this patient's lymph nodes that is likely abnormal also contains which of the following?

Context: A 2-year-old boy is referred by his primary care physician to a geneticist because of prolonged and recurrent infections.

Context: Specifically, he has had an abnormally large number of upper respiratory and gastrointestinal infections over the last year.

Context: He was born with a defect in the cardiac septum that was repaired right after birth and has remained asymptomatic since then.

Context: On evaluation, the patient appears to have hyperactive reflexes and his arm twitches upon blood pressure measurement.

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

Answer: High endothelial venules

Pediatric Immunology and Infectious Diseases

1. A 2-year-old boy is referred by his primary care physician to a geneticist.

2. The referral is due to prolonged and recurrent infections.

3. The patient has had an abnormally large number of upper respiratory and gastrointestinal infections over the last year.

4. The patient was born with a defect in the cardiac septum.

5. The defect was repaired right after birth.

6. The defect has remained asymptomatic since then.

7. On evaluation, the patient appears to have hyperactive reflexes.

8. The patient's arm twitches upon blood pressure measurement.

1. The patient has had an abnormally large number of upper respiratory infections over the last year.

2. The patient has had an abnormally large number of gastrointestinal infections over the last year.

3. The patient was born with a defect in the cardiac septum.

4. The defect in the cardiac septum was repaired right after birth.

5. The patient has remained asymptomatic since the repair of the cardiac septum.

6. On evaluation, the patient appears to have hyperactive reflexes.

7. The patient's arm twitches upon blood pressure measurement.


Question: Which of the following is the most likely diagnosis in this patient?

Context: A 45-year-old woman presents with a 2-year history of fatigue, paresthesia, diarrhea, and abdominal pain.

Context: She says she experiences 2–3 episodes of non-bloody diarrhea per month associated with crampy abdominal pain.

Context: She also has the bilateral tingling sensation of her upper and lower limbs in a glove and stocking pattern which is sometimes associated with the burning sensation of her hands and legs.

Context: Past medical history is unremarkable.

Context: The patient denies smoking, alcohol consumption, illicit drug use.

Context: Her vital signs include: blood pressure 100/60 mm Hg without postural changes, heart rate 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉).

Context: Laboratory findings are significant for the following: | Hgb 7.2 gm/dL | MCV 110 fL | RBC 3.6 X109/L | Platelets 10,000/mm3 | Total count  4,200/mm3 | Reticulocyte 0.8% | A peripheral blood smear demonstrates hypersegmented neutrophils.

Context: An upper GI series with small bowel follow-through is performed which shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string.

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

Answer: Crohn's disease

2. Patient has a 2-year history of fatigue, paresthesia, diarrhea, and abdominal pain.

3. Patient experiences 2–3 episodes of non-bloody diarrhea per month associated with crampy abdominal pain.

4. Patient has bilateral tingling sensation of her upper and lower limbs in a glove and stocking pattern which is sometimes associated with the burning sensation of her hands and legs.

5. Patient's past medical history is unremarkable.

6. Patient denies smoking, alcohol consumption, and illicit drug use.

7. Patient's vital signs include: blood pressure 100/60 mm Hg without postural changes, heart rate 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉).

8. Laboratory findings are significant for Hgb 7.2 gm/dL, MCV 110 fL, RBC 3.6 X109/L, Platelets 10,000/mm3, Total count 4,200/mm3, Reticulocyte 0.8%.

9. Peripheral blood smear demonstrates hypersegmented neutrophils.

10. Anti-intrinsic factor and anti-tissue transglutaminase antibodies were negative.

11. Upper GI series with small bowel follow-through shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string.

1. The patient experiences 2–3 episodes of non-bloody diarrhea per month.

2. The diarrhea is associated with crampy abdominal pain.

3. The patient has bilateral tingling sensation in a glove and stocking pattern in her upper and lower limbs.

4. The tingling sensation is sometimes associated with a burning sensation in her hands and legs.

5. The patient has an unremarkable past medical history.

6. The patient denies smoking, alcohol consumption, and illicit drug use.

7. The patient's blood pressure is 100/60 mm Hg without postural changes.

9. The patient's respiratory rate is 16/min.

10. The patient's temperature is 37.0℃ (98.6℉).

11. Laboratory findings show: Hgb 7.2 gm/dL, MCV 110 fL, RBC 3.6 X109/L, Platelets 10,000/mm3, Total count 4,200/mm3, Reticulocyte 0.8%.

12. A peripheral blood smear demonstrates hypersegmented neutrophils.

13. Anti-intrinsic factor and anti-tissue transglutaminase antibodies were negative.

14. An upper GI series with small bowel follow-through shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string.


Question: Which of the following should be included in the work-up of this patient?

Context: A 15-month-old boy is brought to his pediatrician by his mother with a swollen and painful right elbow.

Context: She reports that he stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground.

Context: The mother reports that he did not appear to be in a great deal of pain after the fall, and that she noted the swelling of the joint a few hours after the fall.

Context: He does not have any known medical issues, and he is not currently on medication.

Context: The mother's pregnancy was without complications and the boy was delivered vaginally without complications at 40 weeks.

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

Answer: Prothrombin time/partial thromboplastin time

Pediatric Rheumatology
General Orthopaedic Surgery

1. A 15-month-old boy is brought to his pediatrician by his mother.

2. The boy has a swollen and painful right elbow.

3. The mother reports that he stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground.

4. The mother reports that he did not appear to be in a great deal of pain after the fall.

5. The mother noted the swelling of the joint a few hours after the fall.

6. He recently started walking approximately 2 weeks ago.

7. He does not have any known medical issues.

9. The mother's pregnancy was without complications.

10. The boy was delivered vaginally without complications at 40 weeks.

11. Aspiration of the right elbow joint reveals frank blood.

1. The boy stumbled and fell on the carpeted floor of their living room, hitting his right elbow on the ground.

2. The mother reports that he did not appear to be in a great deal of pain after the fall.

3. The mother noted the swelling of the joint a few hours after the fall.

4. He recently started walking approximately 2 weeks ago.

5. He does not have any known medical issues.

7. The mother's pregnancy was without complications.

8. The boy was delivered vaginally without complications at 40 weeks.

9. Aspiration of the right elbow joint reveals frank blood.


Question: Which of the following structures has this patient injured in addition to the meniscus?

Context: A 45-year-old male comes into your office one week after he was tackled playing football with his friends.

Context: The patient states that the medial aspect of his knee collided with another player's knee.

Context: Since then, he has been taking ibuprofen for knee pain.

Context: McMurray's test is positive and the patient states he feels catching and locking during the test.

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

Answer: Lateral collateral ligament

2. Patient was tackled playing football one week prior.

3. Patient's medial knee collided with another player's knee.

4. Patient has been taking ibuprofen for knee pain.

5. Patient's right knee appears larger than left knee with a small effusion.

6. Patient has intact sensation and strength in both lower extremities.

7. Patient's right knee has no laxity on valgus stress test.

8. Patient's right knee is very lax on varus stress test.

9. Lachman's test and posterior drawer test have firm endpoints without laxity.

11. Patient states he feels catching and locking during McMurray's test.

1. The patient reports a collision between the medial aspect of his knee and another player's knee.

2. The patient has been taking ibuprofen for knee pain since the collision.

3. On exam, the patient's right knee appears larger than his left knee with a small effusion.

4. The patient has intact sensation and strength in both lower extremities.

5. The patient's right knee has no laxity on valgus stress test, but is very lax on varus stress test.

6. Lachman's test and posterior drawer test both have firm endpoints without laxity.

7. McMurray's test is positive and the patient experiences catching and locking during the test.


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

Context: She was born at term and has been healthy.

Context: Her temperature is 37.3 °C (99.1 °F), pulse is 102/min, respirations are 24/min, and blood pressure is 102/54 mm Hg.

Context: She is at the 75th percentile for height and 80th percentile for weight.

Context: Cardiac examination shows a normal S1 and a split S2 during inspiration.

Context: A contrast echocardiogram is performed and reveals a mild transient right-to-left interatrial shunt that becomes apparent when the child coughs.

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

Answer: No intervention

1. A 19-month-old girl is brought for a well-child examination.

4. On physical examination, the child is alert and active.

5. Her temperature is 37.3 °C (99.1 °F).

9. She is at the 75th percentile for height.

10. She is at the 80th percentile for weight.

11. Cardiac examination shows a normal S1.

12. Cardiac examination shows a split S2 during inspiration.

13. A grade 2/6 soft mid-systolic murmur is heard maximally at the lower left sternal border.

14. A contrast echocardiogram is performed.

15. The contrast echocardiogram reveals a mild transient right-to-left interatrial shunt.

16. The shunt becomes apparent when the child coughs.

8. She is at the 75th percentile for height

9. She is at the 80th percentile for weight

10. Cardiac examination shows a normal S1

11. Cardiac examination shows a split S2 during inspiration

12. A grade 2/6 soft mid-systolic murmur is heard maximally at the lower left sternal border

13. A contrast echocardiogram is performed

14. The echocardiogram reveals a mild transient right-to-left interatrial shunt

15. The shunt becomes apparent when the child coughs


Question: Further evaluation of this patient is likely to show which of the following findings?

Context: A 6-year-old girl is brought to the emergency department because of right knee pain for the past 3 days.

Context: During this period, the girl has refused to walk.

Context: Her mother reports that her symptoms began after she fell down while playing.

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

Answer: Gram-positive cocci in synovial fluid

1. A 6-year-old girl is brought to the emergency department.

2. The girl has right knee pain for the past 3 days.

4. Her symptoms began after she fell down while playing.

5. Three weeks ago, the patient had a sore throat and was treated with penicillin V.

7. Her father has had repeated episodes of joint pain and swelling following minor injury.

8. The patient's immunizations are up-to-date.

12. The right knee joint is warm and erythematous.

13. The girl starts to cry as soon as the physician tries to flex the knee joint.

2. Her symptoms began after she fell down while playing.

3. Three weeks ago, the patient had a sore throat and was treated with penicillin V.

4. Her father has hemophilia A and has had repeated episodes of joint pain and swelling following minor injury.

5. The patient's immunizations are up-to-date.

6. Her temperature is 38.1°C (100.6°F), pulse is 120/min, and respirations are 21/min.

7. The right knee joint is warm and erythematous.

8. The girl starts to cry as soon as the physician tries to flex the knee joint.


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

Context: A physician in the climbing party performs a rudimentary physical exam which reveals a respiratory rate of 30/min, blood pressure of 130/90 mm Hg, heart rate of 108/min, and temperature of 36.4°C (97.5°F), with few basal crackles on the right side of chest.

Context: No jugular venous distension or dependent edema is noted.

Context: With this information, the mountain climber is sent down the mountain for further evaluation.

Context: Investigation reveals a normal chest X-ray with a normal heart size.

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

Answer: Hypoxemic hypoxia

1. A 35-year-old man attempted to climb Mount Everest.

2. At an altitude of 7,000 meters, he became short of breath and developed a dusky blue tinge around his face and lips.

3. A physician in the climbing party performed a rudimentary physical exam.

4. The physical exam revealed a respiratory rate of 30/min.

5. The physical exam revealed a blood pressure of 130/90 mm Hg.

6. The physical exam revealed a heart rate of 108/min.

7. The physical exam revealed a temperature of 36.4°C (97.5°F).

8. The physical exam revealed few basal crackles on the right side of chest.

9. The physical exam revealed no jugular venous distension.

10. The physical exam revealed no dependent edema.

11. The mountain climber was sent down the mountain for further evaluation.

12. Investigation revealed a normal chest X-ray.

13. Investigation revealed a normal heart size.

3. Dusky blue tinge around face and lips

8. Few basal crackles on the right side of chest

11. Mountain climber sent down the mountain for further evaluation


Question: Which of the following clinical features can be seen as a long-term complication of posterior pituitary dysfunction?

Context: A 28-year-old man who was involved in a motorcycle accident presents to the nearest trauma center to get his wounds treated.

Context: After the initial evaluation and resuscitation by the emergency trauma team, a CT scan shows a skull base fracture.

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

Answer: Polydipsia

1. A 28-year-old man was involved in a motorcycle accident.

2. He presents to the nearest trauma center to get his wounds treated.

3. The emergency trauma team performs an initial evaluation and resuscitation.

4. A CT scan shows a skull base fracture.

1. Initial evaluation and resuscitation performed by emergency trauma team


Question: The dosage of which of the following types of insulin was most likely changed in this patient's medication regimen?

Context: She has a history of type 1 diabetes mellitus and is compliant with her medications.

Context: After reviewing the patient's recent blood sugar levels, the physician changes the patient's antidiabetic regimen by changing the dosage of an insulin that does not produce an observable peak in serum insulin concentration.

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

Answer: Insulin glargine

Internal Medicine
Endocrinology, Diabetes, and Metabolism

Endocrinology, Diabetes, and Metabolism
General Endocrinology

1. A 19-year-old woman comes to the physician for a follow-up examination.

2. She has a history of type 1 diabetes mellitus.

3. She is compliant with her medications.

4. The physician reviews the patient's recent blood sugar levels.

5. The physician changes the patient's antidiabetic regimen.

7. The insulin does not produce an observable peak in serum insulin concentration.

1. The patient has a history of type 1 diabetes mellitus.

2. The patient is compliant with her medications.

3. The physician reviewed the patient's recent blood sugar levels.

4. The physician changed the patient's antidiabetic regimen.

5. The change involved adjusting the dosage of an insulin.

6. The insulin does not produce an observable peak in serum insulin concentration.


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

Context: A 31-year-old woman visits her local walk-in clinic for 2 days of dysuria, increased voiding frequency, urgency, and intense suprapubic pain.

Context: She just came back a day ago from a short honeymoon trip to Prague.

Context: On physical examination, the patient is found with exquisite suprapubic pain.

Context: Costovertebral tenderness is absent and pelvic examination is normal.

Context: Her vital signs are: temperature 36.5°C (97.7°F), heart rate 78/min, respiratory rate 15/min.

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

Answer: Staphylococcus saprophyticus

1. A 31-year-old woman visited her local walk-in clinic.

2. She had dysuria, increased voiding frequency, urgency, and intense suprapubic pain.

3. She had recently returned from a honeymoon trip to Prague.

4. On physical examination, the patient had exquisite suprapubic pain.

5. Costovertebral tenderness was absent.

1. The patient just came back from a short honeymoon trip to Prague a day ago.

2. On physical examination, the patient has exquisite suprapubic pain.

5. Vital signs: temperature 36.5°C (97.7°F), heart rate 78/min, respiratory rate 15/min.


Question: Which of the following is the most appropriate recommendation by the physician?

Context: A 14-year-old boy is brought to the physician by his mother because of a 1-week history of fever, fatigue, and throat pain.

Context: He appears lethargic.

Context: His temperature is 38.5°C (101.3°F).

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

Answer: Avoid contact sports

1. A 14-year-old boy is brought to the physician by his mother.

2. He has a 1-week history of fever, fatigue, and throat pain.

5. Physical examination shows bilateral cervical lymphadenopathy.

6. Oral examination shows the findings in the photograph.

7. A peripheral blood smear shows lymphocytosis with atypical lymphocytes.

8. A heterophile antibody test is positive.

3. Physical examination shows bilateral cervical lymphadenopathy.

4. Oral examination shows the findings in the photograph.

5. A peripheral blood smear shows lymphocytosis with atypical lymphocytes.

6. A heterophile antibody test is positive.


Question: What is the most likely pathogenesis leading to the X-ray findings?

Context: A 62-year-old carpenter presents to your clinic complaining of worsening joint pain in her hands.

Context: She states that the pain is present in all of her fingers, but is worse in the right hand and that it gets better when she has a few days off from work.

Context: On examination, the patient is afebrile and all vital signs are stable.

Context: She has hard, non-tender lesions overlying the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand and all 5 digits on this hand have a decreased range of motion.

Context: An X-ray of her hands is shown.

Choices:
A. Repetitive movement injury
B. Overgrowth of a gram-positive bacteria
C. Deposition of monosodium urate crystals
D. Production of rheumatoid factor and other autoantibodies

Answer: Repetitive movement injury

1. A 62-year-old carpenter presents to your clinic.

2. She is complaining of worsening joint pain in her hands.

3. The pain is present in all of her fingers.

5. The pain gets better when she has a few days off from work.

6. She notes no paresthesias, fever, or fatigue.

7. On examination, the patient is afebrile.

9. She has hard, non-tender lesions overlying the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand.

10. All 5 digits on the right hand have a decreased range of motion.

1. The patient reports pain in all fingers, worse in the right hand, and improved with time off work.

2. The patient denies experiencing paresthesias, fever, or fatigue.

3. On examination, the patient is afebrile and has stable vital signs.

4. The patient has hard, non-tender lesions over the proximal interphalangeal joints of the 2nd and 3rd fingers on the right hand.

5. All 5 digits on the right hand have a decreased range of motion.

6. An X-ray of the patient's hands is available.


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

Context: A 7-year-old girl presents to the emergency department with a bloody nose that spontaneously started bleeding 20 minutes ago.

Context: Her heart has a regular rate and rhythm, her lungs are clear to auscultation bilaterally, and her abdomen is soft without hepatosplenomegaly, but she does have petechiae over her lower extremities.

Context: A complete blood count is obtained and reveals a leukocyte count of 11,300 cells/mcL, hemoglobin 12.1 g/dL, hematocrit 36%, and platelets 15,000/mcL.

Context: Her mother reports that she had a viral infection 2 weeks ago but has been otherwise healthy.

Choices:
A. Start intravenous immunoglobulin
B. Perform a splenectomy
C. Perform a bone marrow aspiration
D. Observation

Answer: Start intravenous immunoglobulin

1. A 7-year-old girl presents to the emergency department with a bloody nose.

2. The nose spontaneously started bleeding 20 minutes ago.

3. On physical examination, she appears well and has no lymphadenopathy.

4. Her heart has a regular rate and rhythm.

5. Her lungs are clear to auscultation bilaterally.

6. Her abdomen is soft without hepatosplenomegaly.

7. She has petechiae over her lower extremities.

13. A peripheral smear shows a few morphologically normal platelets.

14. Her mother reports she had a viral infection 2 weeks ago.

1. On physical examination, she appears well

3. Her heart has a regular rate and rhythm

4. Her lungs are clear to auscultation bilaterally

5. Her abdomen is soft without hepatosplenomegaly

6. She has petechiae over her lower extremities

7. A complete blood count reveals a leukocyte count of 11,300 cells/mcL

11. A peripheral smear shows a few morphologically normal platelets

12. Her mother reports that she had a viral infection 2 weeks ago