Question: Which of the following features are not associated of Waardenburg’s syndrome?

Context: She informs you that she is pregnant, and that the father of her child has Waardenburg’s syndrome.

Context: She asks you about common findings in Waardenburg’s syndrome.

Choices:
A. Heterochromia
B. Conductive hearing loss
C. Lateral displacement of inner canthi
D. Broad nasal root

Answer: Conductive hearing loss

General Pediatrics
Clinical Genetics and Genomics

1. A 35-year-old female presents to your office for a routine physical.

2. She informs you that she is pregnant.

3. The father of her child has Waardenburg's syndrome.

4. She asks you about common findings in Waardenburg's syndrome.

2. The father of her child has Waardenburg’s syndrome.

3. She is asking about common findings in Waardenburg’s syndrome.


Question: Which of the following is the most likely underlying mechanism of this patient's fall?

Context: Examination shows a mildly swollen right ankle with no tenderness over the medial or lateral malleolus; range of motion is full with mild pain.

Choices:
A. Loss of the ATM protein
B. Absence of dystrophin protein
C. Arylsulfatase A deficiency
D. SMN1 gene defect

Answer: Absence of dystrophin protein

General Pediatrics
Pediatric Emergency Medicine

1. A 4-year-old boy is brought to the emergency department for evaluation after falling.

2. He has fallen multiple times in the last year.

3. His parents report that he did not walk until he was 18 months old.

4. Examination shows a mildly swollen right ankle with no tenderness over the medial or lateral malleolus.

5. Range of motion is full with mild pain.

6. He has marked enlargement of both calves.

7. When standing up, the patient uses his hands against his knees and thighs to slowly push himself up into a standing position.

1. He has fallen multiple times in the last year.

2. His parents report that he did not walk until he was 18 months old.

3. Examination shows a mildly swollen right ankle with no tenderness over the medial or lateral malleolus.

4. Range of motion is full with mild pain in the right ankle.

5. He has marked enlargement of both calves.

6. When standing up, the patient uses his hands against his knees and thighs to slowly push himself up into a standing position.


Question: Administering succinylcholine during this procedure would most likely result in which of the following complications?

Context: A 25-year-old man is brought to the emergency department with second- and third-degree burns covering 30% of the surface area of his body.

Context: He is alert and active.

Context: His temperature is 36.5°C (97.7°F), pulse is 62/min, respirations are 18/min, and blood pressure is 105/70 mm Hg.

Context: Respirations are 30/min.

Context: There is an inspiratory stridor.

Choices:
A. Prolonged muscle weakness
B. Malignant hyperthermia
C. Cardiac arrhythmia
D. Respiratory depression

Answer: Cardiac arrhythmia

1. A 25-year-old man is brought to the emergency department.

2. He has second- and third-degree burns covering 30% of the surface area of his body.

4. He has no personal or family history of serious illness.

9. Pulse oximetry on 2 liters by nasal cannula shows an oxygen saturation of 98%.

10. Intravenous fluids, intravenous and topical antibiotics, and intravenous pain medications are administered in the intensive care unit.

11. Twenty-four hours later, the patient develops respiratory distress.

14. The patient requires rapid sequence intubation.

2. The patient has no personal or family history of serious illness.

3. The patient's temperature is 36.5°C (97.7°F).

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

6. The patient's blood pressure is 105/70 mm Hg.

7. Pulse oximetry on 2 liters by nasal cannula shows an oxygen saturation of 98%.

8. Intravenous fluids, intravenous and topical antibiotics, and intravenous pain medications are administered in the intensive care unit.

9. Twenty-four hours later, the patient develops respiratory distress.

10. The patient's respirations are 30/min.

11. The patient has an inspiratory stridor.

12. The patient requires rapid sequence intubation.


Question: What ausculatory finding would explain the mechanism by which her more recent complaint occurred?

Context: A 32-year-old woman presents to the emergency department with 2 hours of left-sided weakness.

Context: Her husband reports that she had been complaining of pain and swelling in her right calf for several weeks prior to this event.

Choices:
A. Holosystolic murmur radiating to the axilla
B. Wide, fixed splitting of S2
C. Crescendo-decrescendo murmur heard loudest at the right second intercostal space
D. An S2 that splits during expiration

Answer: Wide, fixed splitting of S2

1. A 32-year-old woman presents to the emergency department.

2. She has had left-sided weakness for 2 hours.

3. Her husband reports she had been complaining of pain and swelling in her right calf for several weeks prior to this event.

4. The couple had recently returned from a vacation in Europe.

1. The patient's husband reported her complaints of pain and swelling in her right calf.

2. The pain and swelling had been ongoing for several weeks before the event.

3. The couple had recently returned from a vacation in Europe.


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

Context: A 41-year-old woman presents with pain in her abdomen for the last couple of hours.

Context: She says pain is intermittent and localized to the right hypochondriac region.

Context: She admits to eating fatty foods this morning before the pain started.

Context: She also complains of nausea but has not vomited yet.

Context: She describes episodes with similar symptoms in the past after a fatty meal but were less severe.

Context: Past medical history is irrelevant.

Context: The vital signs include: heart rate 85/min, respiratory rate 16/min, temperature 37.6°C (99.6°F), and blood pressure 120/80 mm Hg.

Context: Physical examination is within normal limits.

Context: An abdominal ultrasound is pending.

Choices:
A. Somatostatin
B. Cholecystokinin
C. Gastrin
D. Secretin

Answer: Cholecystokinin

2. Patient has been experiencing pain in her abdomen for the last couple of hours.

3. Pain is intermittent and localized to the right hypochondriac region.

4. Patient admits to eating fatty foods this morning before the pain started.

5. Patient also complains of nausea but has not vomited yet.

6. Patient has had episodes with similar symptoms in the past after a fatty meal but were less severe.

7. Patient's past medical history is irrelevant.

9. Patient's respiratory rate is 16/min.

10. Patient's temperature is 37.6°C (99.6°F).

11. Patient's blood pressure is 120/80 mm Hg.

12. Patient's physical examination is within normal limits.

2. Pain is localized to the right hypochondriac region

3. Ate fatty foods this morning before the pain started

6. Episodes with similar symptoms in the past after a fatty meal were less severe

10. Vital signs: temperature 37.6°C (99.6°F)

11. Vital signs: blood pressure 120/80 mm Hg

12. Physical examination is within normal limits


Question: Which of the following is the most likely causal pathogen?

Context: A 53-year-old man comes to the physician because of a 1-day history of fever and chills, severe malaise, and cough with yellow-green sputum.

Context: His temperature is 38.5°C (101.3°F), pulse is 96/min, respirations are 26/min, and blood pressure is 98/62 mm Hg.

Choices:
A. Pseudomonas aeruginosa
B. Streptococcus pyogenes
C. Haemophilus influenzae
D. Streptococcus pneumoniae

Answer: Streptococcus pneumoniae

1. A 53-year-old man comes to the physician.

2. He has a 1-day history of fever and chills, severe malaise, and cough with yellow-green sputum.

3. He works as a commercial fisherman on Lake Superior.

4. His current medications include metoprolol and warfarin.

9. Examination shows increased fremitus and bronchial breath sounds over the right middle lung field.

10. An x-ray of the chest shows consolidation of the right upper lobe.

1. He works as a commercial fisherman on Lake Superior.

2. Current medications include metoprolol and warfarin.

7. Examination shows increased fremitus and bronchial breath sounds over the right middle lung field.

8. An x-ray of the chest shows consolidation of the right upper lobe.


Question: Which of the following is the most appropriate antibiotic to pair with the tamsulosin?

Context: A 46-year-old man presents to his physician because of persistent pelvic and scrotal pain for the past month.

Context: He also has had occasional fevers, chills, dysuria, and increased urinary frequency over the last few months.

Context: He was prescribed trimethoprim and sulfamethoxazole for the urinary symptoms, but he is still having symptoms currently.

Context: He is sexually active with multiple male and female partners and uses condoms inconsistently.

Context: The patient has hypertension and takes lisinopril.

Context: He also takes PrEP (Truvada, which contains tenofovir and emtricitabine).

Context: On physical exam, his temperature is 36.7℃ (98.1℉), the blood pressure is 115/70 mm Hg, the pulse is 74/min, and the respirations are 14/min.

Context: The patient is prescribed tamsulosin.

Choices:
A. Cefepime
B. Gentamicin
C. Levofloxacin
D. Trimethoprim and sulfamethoxazole

Answer: Levofloxacin

2. Patient has persistent pelvic and scrotal pain for the past month.

3. Patient has occasional fevers, chills, dysuria, and increased urinary frequency over the last few months.

4. Patient was prescribed trimethoprim and sulfamethoxazole for the urinary symptoms, but still having symptoms.

5. Patient is sexually active with multiple male and female partners and uses condoms inconsistently.

6. Patient has hypertension and takes lisinopril.

7. Patient takes PrEP (Truvada, which contains tenofovir and emtricitabine).

8. Patient's temperature is 36.7℃ (98.1℉).

9. Patient's blood pressure is 115/70 mm Hg.

12. Digital rectal exam reveals a mildly tender and mildly enlarged prostate.

13. Urine specimens sent for culture and sensitivity testing.

14. Urine sample taken after prostate massage shows a 10-fold increase in bacteria counts.

15. Test results for antimicrobial sensitivity include ampicillin, cefepime, gentamicin, levofloxacin, and meropenem.

1. The patient has had occasional fevers, chills, dysuria, and increased urinary frequency over the last few months.

2. The patient was prescribed trimethoprim and sulfamethoxazole for the urinary symptoms.

3. The patient is still having symptoms currently.

4. The patient is sexually active with multiple male and female partners.

5. The patient uses condoms inconsistently.

8. The patient takes PrEP (Truvada, which contains tenofovir and emtricitabine).

9. On physical exam, the patient's temperature is 36.7℃ (98.1℉).

10. On physical exam, the patient's blood pressure is 115/70 mm Hg.

11. On physical exam, the patient's pulse is 74/min.

12. On physical exam, the patient's respirations are 14/min.

13. A digital rectal exam reveals a mildly tender and mildly enlarged prostate.

14. Urine specimens are sent for culture and sensitivity testing.

15. A urine sample taken after prostate massage shows a 10-fold increase in bacteria counts.

16. The test results for antimicrobial sensitivity include ampicillin, cefepime, gentamicin, levofloxacin, and meropenem.

17. The patient is prescribed tamsulosin.


Question: This drug is most likely to result in which of the following laboratory changes?

Context: A 29-year-old woman comes to the emergency department because of progressive numbness and weakness in her right arm and right leg for 1 day.

Context: She does not smoke or drink alcohol.

Context: Her temperature is 37°C (98.6°F), pulse is 78/min, respirations are 14/min, and blood pressure is 115/71 mm Hg.

Context: Muscle strength is 3/5 in the right arm and leg and 5/5 on the left side.

Choices:
A. Monocytosis
B. Lymphocytosis
C. Eosinopenia
D. Granulocytopenia

Answer: Eosinopenia

Neurology with Special Qualification in Child Neurology

1. A 29-year-old woman comes to the emergency department.

2. She has progressive numbness and weakness in her right arm and right leg for 1 day.

3. Two months ago, she had blurry vision and headache for a week, which resolved without treatment.

9. Muscle strength is 3/5 in the right arm and leg.

10. Muscle strength is 5/5 on the left side.

11. MRI of the brain shows gadolinium-enhancing lesions in the left central sulcus, cervical spinal cord, and optic nerve.

12. Intravenous methylprednisolone therapy is started.

1. Two months ago, she had blurry vision and headache for a week

2. The blurry vision and headache resolved without treatment

8. Muscle strength is 3/5 in the right arm and leg and 5/5 on the left side

9. MRI of the brain shows gadolinium-enhancing lesions in the left central sulcus, cervical spinal cord, and optic nerve

10. Intravenous methylprednisolone therapy is started


Question: Which of the following disorders does this patient potentially suffer from?

Context: A 30-year-old male biology graduate student was dismissed from his PhD program after 8 years because he was not able to produce a thesis, claiming that his data was never exactly how he wanted it.

Context: He has had similar problems in his undergraduate courses, often failing to complete his assignments on time because he had to revise them until they were perfect.

Choices:
A. Schizoid personality disorder
B. Narcissistic personality disorder
C. Obsessive compulsive personality disorder
D. Paranoid personality disorder

Answer: Obsessive compulsive personality disorder

Obsessive compulsive personality disorder

1. A 30-year-old male biology graduate student was dismissed from his PhD program after 8 years.

2. He was not able to produce a thesis, claiming that his data was never exactly how he wanted it.

3. He would spend weeks planning out a simple experiment, since everything had to be just right.

4. For many experiments, he would start over because he felt he went out of order in adding the reagents to his media for his cells.

5. He has had similar problems in his undergraduate courses.

6. He often failed to complete his assignments on time because he had to revise them until they were perfect.

1. He spends weeks planning out a simple experiment.

2. Everything has to be just right for his experiments.

3. He starts over for many experiments because he feels he went out of order in adding reagents to his media for his cells.

4. He has had similar problems in his undergraduate courses.

5. He often fails to complete his assignments on time.

6. He revises his assignments until they are perfect.


Question: Which of the following serum markers is most strongly associated with this patient’s condition?

Context: A 62-year-old male presents to his primary care physician complaining of an unintended 10-pound weight loss over the last 4 months.

Context: He also reports vague abdominal discomfort, weakness, and occasional yellowing of his skin and eyes.

Context: Physical exam demonstrates hepatomegaly and abdominal distention.

Choices:
A. Carcinoembryonic antigen (CEA)
B. Cancer antigen 19-9 (CA 19-9)
C. Alpha-fetoprotein (AFP)
D. Beta-human chorionic gonadotropin (ß-HCG)

Answer: Alpha-fetoprotein (AFP)

1. A 62-year-old male presents to his primary care physician.

2. He has experienced an unintended 10-pound weight loss over the last 4 months.

3. He reports vague abdominal discomfort, weakness, and occasional yellowing of his skin and eyes.

4. He has a history of cirrhosis secondary to alcohol abuse and hepatitis C infection.

5. Physical exam demonstrates hepatomegaly.

6. Physical exam demonstrates abdominal distention.

1. The patient reports vague abdominal discomfort.

3. The patient reports occasional yellowing of his skin and eyes.

4. The patient has a history of cirrhosis secondary to alcohol abuse.

5. The patient has a history of hepatitis C infection.

6. Physical exam demonstrates hepatomegaly.

7. Physical exam demonstrates abdominal distention.


Question: This study is best described as which of the following?

Context: The investigators examined the total number of cases of syphilis and genitourinary chlamydia in the United States using a national health survey of a nationally representative sample of US citizens conducted in 2012.

Choices:
A. Single-blind clinical trial
B. Double-blind clinical trial
C. Cross-sectional study
D. Case-control study

Answer: Cross-sectional study

Infectious Disease
Medical Microbiology Pathology

1. A research group designed a study to investigate the epidemiology of syphilis in the United States.

2. The investigators examined the total number of cases of syphilis and genitourinary chlamydia in the United States.

3. The investigators used a national health survey of a nationally representative sample of US citizens conducted in 2012.

4. The investigators ultimately found that a history of genitourinary chlamydia infection is associated with syphilis.

1. The investigators examined the total number of cases of syphilis in the United States.

2. The investigators examined the total number of cases of genitourinary chlamydia in the United States.

3. The examination was based on a national health survey.

5. The survey used a nationally representative sample of US citizens.

6. A history of genitourinary chlamydia infection is associated with syphilis.


Question: Which of the following is the best treatment for this patient’s condition while waiting for the ascitic fluid culture results?

Context: A 56-year-old African American male presents with altered mental status, abdominal pain, and a fever of 100.4F.

Context: His past medical history is significant for alcohol use and cirrhosis of the liver.

Context: Paracentesis demonstrates serum ascites albumen gradient of 1.3 g/dL, and the ascitic fluid polymorphonuclear cell count is 280 cells/mm^3.

Choices:
A. Nadolol
B. Cefotaxime
C. Penicillin
D. Gentamicin

Answer: Cefotaxime

1. Patient is 56-year-old African American male.

2. Patient presents with altered mental status, abdominal pain, and fever of 100.4F.

3. Patient has past medical history of alcohol use and cirrhosis of the liver.

4. Physical exam reveals shifting dullness.

5. Paracentesis demonstrates serum ascites albumen gradient of 1.3 g/dL.

6. Ascitic fluid polymorphonuclear cell count is 280 cells/mm^3.

1. His past medical history includes alcohol use.

2. His past medical history includes cirrhosis of the liver.

3. Shifting dullness is noted on physical exam.

4. Paracentesis demonstrates a serum ascites albumin gradient of 1.3 g/dL.

5. The ascitic fluid polymorphonuclear cell count is 280 cells/mm^3.


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

Context: A 4-year-old boy who recently emigrated from Ghana is brought to the physician because of a 5-day history of pain and swelling in his hands.

Context: The patient appears distressed.

Context: His temperature is 38.1°C (100.5°F).

Context: Physical examination shows pallor.

Choices:
A. Coronary artery aneurysm
B. Hyperuricemia
C. Thickened heart valves
D. Microhematuria

Answer: Microhematuria

1. A 4-year-old boy recently emigrated from Ghana.

2. He has a 5-day history of pain and swelling in his hands.

3. He has had similar episodes in the past.

7. The dorsum of his hands and fingers are swollen.

8. The dorsum of his hands and fingers are warm.

9. The dorsum of his hands and fingers are tender to palpation.

1. He has had similar episodes in the past.

5. The dorsum of his hands and fingers are swollen, warm, and tender to palpation.


Question: Which of the following is the most likely explanation for the laboratory findings in this patient?

Context: A 47-year-old woman is admitted to the hospital because of a 2-week history of low-grade fever, fatigue, and a 3-kg (6.6-lb) weight loss.

Context: Her temperature is 38°C (100.4°F).

Context: Her serum creatinine is 1.8 mg/dL.

Choices:
A. Occlusion of renal arteries by cholesterol crystals
B. Deposition of antigen-antibody complexes
C. Intravascular fragmentation of red blood cells
D. Hypersensitivity to penicillin haptens

Answer: Deposition of antigen-antibody complexes

Infectious Disease
General Internal Medicine
Rheumatology

1. A 47-year-old woman is admitted to the hospital.

2. She has a 2-week history of low-grade fever, fatigue, and a 3-kg (6.6-lb) weight loss.

4. Physical examination shows pallor and a cardiac murmur.

6. Urinalysis shows red cell casts and 2+ protein.

7. A CT scan of the abdomen with contrast shows no abnormalities.

8. Despite appropriate medical therapy, the patient dies.

9. A photograph of the heart taken during autopsy is shown.

2. Physical examination shows pallor and a cardiac murmur.

4. Urinalysis shows red cell casts and 2+ protein.

5. A CT scan of the abdomen with contrast shows no abnormalities.

6. Despite appropriate medical therapy, the patient dies.

7. A photograph of the heart taken during autopsy is shown.


Question: Which of the following nerve roots is most likely to be affected in this patient?

Context: A 36-year-old woman comes to the physician because of a 2-month history of progressively worsening lower back pain and weakness in the lower extremities.

Context: She was diagnosed with pulmonary tuberculosis 6 months ago and is currently taking isoniazid and rifampin.

Context: Strength is 2/5 with right-sided dorsiflexion and the patellar reflex is absent.

Choices:
A. S2
B. S1
C. L3
D. L4

Answer: L4

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

2. She has a 2-month history of progressively worsening lower back pain and weakness in the lower extremities.

3. The pain is worse with movement and improves with lying down on a flat surface.

4. She was diagnosed with pulmonary tuberculosis 6 months ago.

5. She is currently taking isoniazid and rifampin.

6. Physical examination shows sensory loss over the lateral aspect of the mid-thigh, patella, and medial aspect of the right lower leg.

7. Strength is 2/5 with right-sided dorsiflexion.

9. An x-ray of the spine shows a paravertebral opacity with anterior wedging of the vertebral body.

2. The pain improves with lying down on a flat surface.

3. She was diagnosed with pulmonary tuberculosis 6 months ago.

4. She is currently taking isoniazid and rifampin.

5. Physical examination shows sensory loss over the lateral aspect of the mid-thigh, patella, and medial aspect of the right lower leg.

6. Strength is 2/5 with right-sided dorsiflexion.

8. An x-ray of the spine shows a paravertebral opacity.

9. The x-ray shows anterior wedging of the vertebral body.


Question: Arterial blood gas analysis on room air shows: | pH 7.56 | PCO2 40 mm Hg | PO2 94 mm Hg | HCO3- 30 mEq/L | Measurement of which of the following is the most appropriate next step in diagnosis?"

Context: A 24-year-old primigravid woman at 8 weeks' gestation is brought to the emergency department because of a 5-day history of nausea and vomiting.

Context: Her symptoms are worse in the morning.

Context: She appears tired.

Context: Her temperature is 37°C (98.6°F), pulse is 105/min, and blood pressure is 108/60 mm Hg.

Context: Examination shows dry mucous membranes and cool extremities, with delayed capillary refill time.

Choices:
A. Serum osmolal gap
B. Serum anion gap
C. Urine albumin to urine creatinine ratio
D. Urine chloride concentration

Answer: Urine chloride concentration

1. Patient is a 24-year-old primigravid woman.

3. Patient has a 5-day history of nausea and vomiting.

4. Patient has not been able to tolerate much food or drink.

6. Patient has tried multiple oral antiemetics with limited relief.

7. Patient has not had fevers, chills, abdominal pain, urinary symptoms, or diarrhea.

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

11. Patient's blood pressure is 108/60 mm Hg.

12. Examination shows dry mucous membranes.

14. Examination shows delayed capillary refill time.

1. She has not been able to tolerate much food or drink.

2. Her symptoms are worse in the morning.

3. She has tried multiple oral antiemetics with limited relief.

4. She has not had fevers, chills, abdominal pain, urinary symptoms, or diarrhea.

9. Examination shows dry mucous membranes and cool extremities.

10. Examination shows delayed capillary refill time.


Question: Which of the following is the most appropriate recommendation at this time?

Context: A 34-year-old pregnant woman, gravida 2, para 0, at 28 weeks of gestation presents to the physician for a prenatal visit.

Context: She has not had regular prenatal care.

Context: She appears well.

Choices:
A. Hepatitis A vaccination
B. Plan to formula feed the newborn
C. Start combination therapy with interferon α and ribavirin
D. Undergo liver biopsy

Answer: Hepatitis A vaccination

1. A 34-year-old pregnant woman presents to the physician for a prenatal visit.

2. She is gravida 2, para 0, and 28 weeks of gestation.

3. She has not had regular prenatal care.

4. Her most recent abdominal ultrasound was at 20 weeks of gestation.

5. The ultrasound confirmed accurate fetal dates and appropriate fetal development.

6. She takes levothyroxine for hypothyroidism.

7. She used to work as a nurse before she emigrated from Brazil 13 years ago.

8. She lost her immunization records during the move and cannot recall all of her vaccinations.

10. Her vital signs are within normal limits.

11. The physical examination reveals a fundal height of 26 cm.

12. No abnormalities are found during the physical exam.

13. An ELISA test conducted for HIV is negative.

14. Serology test results for hepatitis B surface antibody and hepatitis C antibody are positive for both.

15. The laboratory test results for hepatitis B core antibody, hepatitis B surface antigen, and hepatitis A antibody are negative.

16. The polymerase chain reaction analysis of hepatitis C RNA is positive for genotype 1.

1. She has not had regular prenatal care.

2. Her most recent abdominal ultrasound was at 20 weeks of gestation, and it confirmed accurate fetal dates and appropriate fetal development.

3. She takes levothyroxine for hypothyroidism.

4. She used to work as a nurse before she emigrated from Brazil 13 years ago.

5. She lost her immunization records during the move and cannot recall all of her vaccinations.

7. Her vital signs are within normal limits.

8. The physical examination reveals a fundal height of 26 cm.

9. No abnormalities are found during the physical exam.

10. An ELISA test conducted for HIV is negative.

11. Serology test results for hepatitis B surface antibody and hepatitis C antibody are positive for both.

12. The laboratory test results for hepatitis B core antibody, hepatitis B surface antigen, and hepatitis A antibody are negative.

13. The polymerase chain reaction analysis of hepatitis C RNA is positive for genotype 1.


Question: Which of the following does this screening test detect?

Context: A 36-year-old man presents with a 3-week history of fever, enlarged lymph nodes, fatigue, and a dry cough.

Context: The patient’s wife says she has noticed that he lost a lot of weight over the last 6 months and seems very pale.

Context: Over the last week, he has noticed a worsening non-productive cough and night sweats.

Context: His blood count shows anemia and low lymphocyte count.

Context: He tells the physician that he had multiple unprotected sexual relationships with women other than his wife about 6 years ago and is fearful this may be related to his current health concerns.

Context: A test is performed which screens for the cause of this patient's immunodeficiency.

Choices:
A. Anti-HCV antigen
B. Lactic dehydrogenase
C. p24 antigen
D. CCR5 mutation

Answer: p24 antigen

2. Patient has a 3-week history of fever, enlarged lymph nodes, fatigue, and a dry cough.

3. Patient's wife has noticed weight loss and paleness over the last 6 months.

4. Patient has a worsening non-productive cough and night sweats over the last week.

5. Patient's blood count shows anemia and low lymphocyte count.

6. Patient had multiple unprotected sexual relationships with women other than his wife about 6 years ago.

7. Patient is fearful this may be related to his current health concerns.

8. Test is performed to screen for cause of patient's immunodeficiency.

1. The patient has lost a lot of weight over the last 6 months.

3. Over the last week, the patient has noticed a worsening non-productive cough and night sweats.

4. The patient's blood count shows anemia.

5. The patient's blood count shows low lymphocyte count.

6. The patient had multiple unprotected sexual relationships with women other than his wife about 6 years ago.

7. The patient is fearful this may be related to his current health concerns.

8. A test is performed which screens for the cause of the patient's immunodeficiency.


Question: Laboratory studies show: | Hemoglobin 9 g/dL | Leukocyte count 1,500/mm3 | Percent segmented neutrophils 50% | Platelet count 85,000/mm3 | To reduce the likelihood of complications, it is most appropriate to administer which of the following?

Context: Seven days after initiation of induction chemotherapy for acute myeloid leukemia, a 56-year-old man develops leukopenia.

Context: He feels well.

Context: His temperature is 36.7°C (98.1°F), blood pressure is 110/65 mm Hg, pulse is 72/min, and respiratory rate is 14/min.

Choices:
A. Ciprofloxacin
B. Granulocyte colony-stimulating factor
C. Vancomycin
D. No pharmaco-prophylaxis at this time

Answer: Ciprofloxacin

1. A 56-year-old man developed leukopenia seven days after initiation of induction chemotherapy for acute myeloid leukemia.

3. He has no history of serious cardiopulmonary disease.

8. Examination of the skin, head and neck, heart, lungs, abdomen, and perirectal area reveals no abnormalities.

2. He has no history of serious cardiopulmonary disease.

7. Examination of the skin reveals no abnormalities.

8. Examination of the head and neck reveals no abnormalities.

9. Examination of the heart reveals no abnormalities.

10. Examination of the lungs reveals no abnormalities.

11. Examination of the abdomen reveals no abnormalities.

12. Examination of the perirectal area reveals no abnormalities.


Question: Which of the following drugs most likely caused prolonged muscle paralysis in this patient?

Context: A 40-year-old man undergoes an elective cholecystectomy for repeated attacks of cholelithiasis over the last 5 years.

Context: In the operating room, rapid sequence intubation is performed using a certain muscle relaxant to prevent aspiration of gastric contents.

Context: During the procedure, atracurium is administered to maintain muscle relaxation and, 1.5 hours after the operation, the anesthesiologist administers neostigmine to reverse the paralysis.

Context: The patient, however, continues to remain paralyzed and cannot be extubated.

Choices:
A. Midazolam
B. Pancuronium
C. Succinylcholine
D. Tubocurarine

Answer: Succinylcholine

1. A 40-year-old man underwent an elective cholecystectomy.

2. The man had repeated attacks of cholelithiasis over the last 5 years.

3. Rapid sequence intubation was performed using a certain muscle relaxant to prevent aspiration of gastric contents.

4. Atracurium was administered to maintain muscle relaxation.

5. 1.5 hours after the operation, the anesthesiologist administered neostigmine to reverse the paralysis.

6. The patient continued to remain paralyzed and could not be extubated.

1. Rapid sequence intubation is performed in the operating room.

2. A muscle relaxant is used to prevent aspiration of gastric contents during rapid sequence intubation.

3. Atracurium is administered during the procedure to maintain muscle relaxation.

4. 1.5 hours after the operation, neostigmine is administered by the anesthesiologist.

5. Neostigmine is administered to reverse the paralysis.

6. The patient remains paralyzed and cannot be extubated.


Question: The most likely pathology underlying this patient's symptoms is derived from which of the following embryonic layers?

Context: A 12-year-old boy is brought to the emergency department by ambulance after he was struck by a car while crossing the road.

Context: He is found to have a femur fracture and multiple bruises on presentation, but he is alert and hemodynamically stable.

Context: He says that the car "came out of nowhere" and that he has had multiple similar near misses in recent months.

Context: He has no past medical history but says that he has been having headaches that he describes as dull and continuous.

Context: He has also noticed that he has been waking up at night several times to go to the restroom.

Context: Otherwise, he has been healthy with no major concerns.

Choices:
A. Mesoderm
B. Neural crest
C. Neuroectoderm
D. Surface ectoderm

Answer: Surface ectoderm

Neurodevelopmental Disabilities
Pediatric Emergency Medicine

1. A 12-year-old boy was brought to the emergency department by ambulance.

2. He was struck by a car while crossing the road.

3. He has a femur fracture and multiple bruises on presentation.

4. He is alert and hemodynamically stable.

5. He says the car "came out of nowhere" and he has had multiple similar near misses in recent months.

7. He has been having headaches that he describes as dull and continuous.

8. He has been waking up at night several times to go to the restroom.

9. He has been healthy with no major concerns.

10. A basic metabolic panel shows mild hypernatremia.

1. He is found to have a femur fracture on presentation.

2. He is found to have multiple bruises on presentation.

4. He is hemodynamically stable on presentation.

5. He says that the car "came out of nowhere".

6. He has had multiple similar near misses in recent months.

9. He describes the headaches as dull and continuous.

10. He has been waking up at night several times to go to the restroom.

11. He has been healthy with no major concerns.

12. A basic metabolic panel shows mild hypernatremia.


Question: Which of the following is most likely to be the underlying cause for the fracture in this patient?

Context: A 40-year-old man presents with left hip pain.

Context: He says that symptoms started a month ago and have progressively worsened.

Context: He says the pain has rendered him unable to report to work for the last 2 weeks.

Context: The pain was initially 4/10 in intensity, dull with no radiation and was aggravated to 5/10 in intensity upon weight-bearing.

Context: Initially, it improved with rest and Tylenol.

Context: He initially attributed it to heavy work and took a few days off work, but he did not seek medical attention.

Context: However, it worsened over time to its present 8/10 intensity and does not respond to Tylenol anymore.

Context: The patient denies any history of injury, weight loss, change in appetite, or recent travel.

Context: His past medical history is significant for Crohn's disease, managed with a combination of prednisone and mesalamine and presently in remission.

Context: The rest of the examination, including a complete neurological examination, is unremarkable.

Context: On abdominal imaging of the left hip joint, a transcervical fracture is noted in the left hip with surrounding bony sclerosis.

Context: A DEXA scan shows a T-score of  -2.5 at the hips and -1.5 at the lumbar spine (normal T-score ≥ -1.0).

Choices:
A. Trauma
B. Chronic steroid use
C. Metastatic lesion
D. Sciatica

Answer: Chronic steroid use

3. Symptoms started a month ago and have progressively worsened.

4. Pain has rendered him unable to report to work for the last 2 weeks.

5. Pain initially 4/10 in intensity, dull with no radiation.

6. Pain aggravated to 5/10 in intensity upon weight-bearing.

7. Initially improved with rest and Tylenol.

8. Patient attributed it to heavy work and took a few days off work, but did not seek medical attention.

9. Pain worsened over time to 8/10 intensity and does not respond to Tylenol anymore.

10. Patient denies any history of injury, weight loss, change in appetite, or recent travel.

11. Patient's past medical history is significant for Crohn's disease, managed with a combination of prednisone and mesalamine and presently in remission.

12. On physical examination, there is limited flexion and extension at the left hip.

13. Rest of the examination, including a complete neurological examination, is unremarkable.

14. Abdominal imaging of the left hip joint shows a transcervical fracture with surrounding bony sclerosis.

15. DEXA scan shows a T-score of -2.5 at the hips and -1.5 at the lumbar spine (normal T-score ≥ -1.0).

3. Pain has rendered him unable to report to work for the last 2 weeks

6. Pain was aggravated to 5/10 in intensity upon weight-bearing

7. Pain initially improved with rest and Tylenol

8. Patient attributed pain to heavy work and took a few days off work

9. Pain worsened over time to its present 8/10 intensity

10. Pain does not respond to Tylenol anymore

11. Patient denies history of injury, weight loss, change in appetite, or recent travel

12. Past medical history is significant for Crohn's disease

13. Crohn's disease is managed with a combination of prednisone and mesalamine

14. Crohn's disease is presently in remission

15. On physical examination, there is limited flexion and extension at the left hip

16. Rest of the examination, including a complete neurological examination, is unremarkable

17. Abdominal imaging of the left hip joint shows a transcervical fracture in the left hip with surrounding bony sclerosis

18. DEXA scan shows a T-score of -2.5 at the hips and -1.5 at the lumbar spine


Question: Where was the thoracentesis needle most likely placed?

Context: A 78-year-old woman with a history of breast cancer, status-post bilateral mastectomy, presents to the emergency department with progressive difficulty breathing, worsening fatigue, and 5 pounds of unintended weight loss over the past month.

Context: The ED resident performs thoracentesis with chest tube placement and admits her to the floor.

Context: Overnight, the patient requests multiple pain medications for right upper abdominal pain and is found to have increasingly sanguinous drainage.

Choices:
A. Lower border of the 10th rib at the right midaxillary line
B. Lower border of the 9th rib at the right midaxillary line
C. Upper border of the 7th rib at the right midclavicular line
D. Upper border of the 10th rib at the right midaxillary line

Answer: Lower border of the 10th rib at the right midaxillary line

1. A 78-year-old woman presents to the emergency department.

2. She has a history of breast cancer and a bilateral mastectomy.

3. She has progressive difficulty breathing and worsening fatigue.

4. She has lost 5 pounds in the past month.

5. A portable chest x-ray reveals a massive right pleural effusion.

6. The ED resident performs thoracentesis with chest tube placement.

7. The patient is admitted to the floor.

8. The patient requests multiple pain medications for right upper abdominal pain.

9. The patient has increasingly sanguinous drainage.

1. A portable chest x-ray reveals a massive right pleural effusion.

2. The ED resident performs thoracentesis with chest tube placement.

3. The patient is admitted to the floor.

4. Overnight, the patient requests multiple pain medications for right upper abdominal pain.

5. The patient is found to have increasingly sanguinous drainage.


Question: Which of the following statements best describes the effects of molecule A on Vmax and Km on the metabolic reactions of the novel drug?

Context: While studying the metabolism of a novel drug, the researcher identifies a molecule that inhibits its metabolism by binding with enzyme E.

Context: Molecule A inhibits the enzyme E by reversibly binding at the same active site on the enzyme where the drug binds.

Choices:
A. Value of Vmax is unchanged but value of Km is increased
B. Value of Vmax is decreased but value of Km is unchanged
C. Values of both Vmax and Km are unchanged
D. Value of Vmax is unchanged but value of Km is decreased

Answer: Value of Vmax is unchanged but value of Km is increased

Internal Medicine
Clinical Biochemical Genetics

Clinical Pharmacology
Clinical Pharmacology and Therapeutics
Clinical Pharmacology and Toxicology
General Medical Genetics and Genomics

1. The researcher is studying the metabolism of a novel drug.

2. The researcher identifies a molecule, A.

4. Molecule A binds reversibly at the same active site on the enzyme where the drug binds.

2. Inhibition is achieved by reversibly binding

3. Molecule A binds at the active site on enzyme E

4. The active site is the same site where the drug binds


Question: Inhibition of which of the following hormones would be most beneficial for this patient?

Context: A 70-year-old man presents to a physician’s office with shortness of breath for 1 month.

Context: He denies a cough and fever.

Choices:
A. Angiotensin II
B. Prostaglandin E1
C. Aldosterone
D. Epinephrine

Answer: Angiotensin II

2. Patient has shortness of breath for 1 month.

3. Patient is "easily winded" and cannot keep up with grandchildren when playing in the park.

4. Patient has had to increase number of pillows under head to sleep comfortably.

6. Patient has medical history of hypercholesterolemia and hypertension.

7. Patient is taking aspirin, carvedilol, and rosuvastatin.

11. Physical examination reveals distended jugular veins, bilateral pitting edema of lower limbs, and fine crackles at base of lungs.

12. Echocardiogram reveals ejection fraction of 40%.

1. He is “easily winded” and is unable to keep up with his grandchildren when playing in the park.

2. Over the last few weeks, he had to increase the number of pillows under his head to sleep comfortably.

4. The medical history includes hypercholesterolemia and hypertension.

5. His current medications are aspirin, carvedilol, and rosuvastatin.

6. The vital signs are as follows: blood pressure 150/90 mm Hg, pulse 90/min, and respiratory rate 14/min.

7. The physical examination reveals distended jugular veins, bilateral pitting edema of the lower limbs, and fine crackles at the base of the lungs.

8. An echocardiogram reveals an ejection fraction of 40%.


Question: WBC 20–25/hpf | Which of the following would have most likely prevented this complication?"

Context: He was discharged 6 days ago.

Context: He has a history of hypertension.

Context: He appears anxious.

Context: Urinalysis shows: | Blood 1+ | Protein 1+ | Nitrite positive | Leukocyte esterase positive | RBC 1–2/hpf | .

Choices:
A. Intermittent catheterization
B. Prophylactic oral ciprofloxacin
C. Topical mupirocin application
D. Screening for bacteriuria

Answer: Intermittent catheterization

1. A 51-year-old man comes to the physician because of severe pain while urinating for 4 days.

2. He has also had to urinate more often than usual.

3. Three weeks ago, he underwent surgery for an incarcerated hernia.

4. While recovering, he developed septic shock and was treated in the intensive care unit.

7. Current medications include amlodipine and oxycodone.

12. Examination shows tenderness to palpation in the suprapubic area; no guarding is present.

13. There is a well-healed surgical scar in the right inguinal region.

14. There is no costovertebral angle tenderness.

18. Urinalysis shows: Leukocyte esterase positive.

1. He has had to urinate more often than usual.

2. Three weeks ago, he underwent surgery for an incarcerated hernia.

3. While recovering, he developed septic shock and was treated in the intensive care unit.

6. Current medications include amlodipine and oxycodone.

8. His temperature is 37.8°C (100°F), pulse is 96/min, and blood pressure is 122/80 mm Hg.

9. Examination shows tenderness to palpation in the suprapubic area; no guarding is present.

10. There is a well-healed surgical scar in the right inguinal region.

11. There is no costovertebral angle tenderness.

12. Urinalysis shows: | Blood 1+ | Protein 1+ | Nitrite positive | Leukocyte esterase positive | RBC 1–2/hpf |


Question: Which of the following is the most appropriate pharmacotherapy for this patient's neurological symptoms?

Context: A 40-year-old woman with HIV infection comes to the emergency department because of a 4-week history of progressively worsening fatigue and headache.

Context: Analysis of this patient's cerebrospinal fluid (CSF) shows a leukocyte count of 30/mm3 (60% lymphocytes), a protein concentration of 52 mg/dL, and a glucose concentration of 37 mg/dL.

Context: An India ink stain of the CSF is shown.

Choices:
A. Pyrimethamine, sulfadiazine, and folinic acid
B. Isoniazid, rifampin, pyrazinamide, and ethambutol
C. Amphotericin B and flucytosine
D. Fluconazole

Answer: Amphotericin B and flucytosine

1. A 40-year-old woman with HIV infection comes to the emergency department.

2. She has a 4-week history of progressively worsening fatigue and headache.

3. On mental status examination, the patient is somnolent and oriented only to person.

4. Her CD4+ lymphocyte count is 80/mm3 (N ≥ 500).

5. Analysis of this patient's cerebrospinal fluid (CSF) shows a leukocyte count of 30/mm3 (60% lymphocytes).

6. Analysis of this patient's cerebrospinal fluid (CSF) shows a protein concentration of 52 mg/dL.

7. Analysis of this patient's cerebrospinal fluid (CSF) shows a glucose concentration of 37 mg/dL.

8. An India ink stain of the CSF is shown.

1. On mental status examination, the patient is somnolent.

2. On mental status examination, the patient is oriented only to person.

3. Her CD4+ lymphocyte count is 80/mm3 (N ≥ 500).

4. Analysis of this patient's cerebrospinal fluid (CSF) shows a leukocyte count of 30/mm3.

5. Analysis of this patient's cerebrospinal fluid (CSF) shows 60% lymphocytes.


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

Context: He drinks a few shots of vodka daily.

Context: He has no history of severe illness.

Context: Vital signs are within normal limits.

Context: Laboratory studies show: | Hemoglobin 11.6 g/dL | Leukocyte count 8,700/mm3 | Platelet count 172,000/mm3 | Serum | Urea nitrogen 17 mg/dL | Creatinine 1.1 mg/dL | Bilirubin | Total 6 mg/dL | Direct 5.2 mg/dL | Alkaline phosphatase 220 IU/L | Ultrasonography shows dilated extrahepatic and pancreatic ducts and a distended gall bladder.

Choices:
A. Malignant biliary tract obstruction
B. Acetaminophen-induced liver injury
C. Hemolysis
D. Chronic pancreatitis

Answer: Malignant biliary tract obstruction

1. A 64-year-old man comes to the physician because of a 2-week history of intermittent epigastric discomfort.

2. He reports that his urine has been very dark, and his stools have been pale for the past week.

3. His appetite has decreased, and he has had a 4.5-kg (10-lb) weight loss during this period.

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

5. He drinks a few shots of vodka daily.

7. He has chronic left knee pain, for which he takes acetaminophen.

8. Vital signs are within normal limits.

9. Examination shows jaundice of the skin and scleral icterus.

10. There are scratch marks on the extremities.

11. Abdominal examination shows a nontender, palpable mass in the right upper quadrant.

12. The remainder of the examination is normal.

13. Laboratory studies show: Hemoglobin 11.6 g/dL

14. Laboratory studies show: Leukocyte count 8,700/mm3

15. Laboratory studies show: Platelet count 172,000/mm3

16. Laboratory studies show: Serum Urea nitrogen 17 mg/dL

17. Laboratory studies show: Creatinine 1.1 mg/dL

18. Laboratory studies show: Bilirubin Total 6 mg/dL

19. Laboratory studies show: Direct 5.2 mg/dL

20. Laboratory studies show: Alkaline phosphatase 220 IU/L

21. Ultrasonography shows dilated extrahepatic and pancreatic ducts and a distended gall bladder.

1. Patient reports dark urine and pale stools for the past week.

2. Patient has experienced decreased appetite and 4.5-kg weight loss in the same period.

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

4. Patient drinks a few shots of vodka daily.

5. Patient has no history of severe illness.

6. Patient has chronic left knee pain and takes acetaminophen for it.

7. Vital signs are within normal limits.

8. Examination shows jaundice of the skin and scleral icterus.

9. Scratch marks are present on the extremities.

10. Abdominal examination shows a nontender, palpable mass in the right upper quadrant.

11. The remainder of the examination is normal.

12. Laboratory studies show: Hemoglobin 11.6 g/dL, Leukocyte count 8,700/mm3, Platelet count 172,000/mm3, Serum Urea nitrogen 17 mg/dL, Creatinine 1.1 mg/dL, Bilirubin Total 6 mg/dL, Direct 5.2 mg/dL, Alkaline phosphatase 220 IU/L.

13. Ultrasonography shows dilated extrahepatic and pancreatic ducts and a distended gall bladder.


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

Context: A 27-year-old woman is brought to the physician after passing out at home.

Context: She has no history of serious illness.

Context: Vital signs are within normal limits.

Choices:
A. Septal myectomy
B. Amlodipine
C. Cardiac pacemaker
D. Metoprolol

Answer: Metoprolol

1. A 27-year-old woman is brought to the physician.

2. Her husband reports that she suddenly lost consciousness for approximately 30 seconds while shoveling snow in the driveway.

3. Immediately before the episode, she felt light-headed and short of breath.

4. Two months ago, she experienced a similar episode while running in her yard with her children.

5. She has no history of serious illness.

6. Her father died of sudden cardiac death at the age of 44 years.

7. Vital signs are within normal limits.

8. Cardiac examination shows a systolic ejection murmur best heard along the left sternal border that decreases with hand grip.

9. The remainder of the examination shows no abnormalities.

1. Her husband reports that she suddenly lost consciousness for approximately 30 seconds while shoveling snow in the driveway.

2. Immediately before the episode, she felt light-headed and short of breath.

3. Two months ago, she experienced a similar episode while running in her yard with her children.

4. She has no history of serious illness.

5. Her father died of sudden cardiac death at the age of 44 years.

6. Vital signs are within normal limits.

7. Cardiac examination shows a systolic ejection murmur best heard along the left sternal border that decreases with hand grip.

8. The remainder of the examination shows no abnormalities.


Question: The patient most likely has a deficiency of which of the following enzymes?

Context: A 7-month-old male infant is brought to the physician because of a 2-month history of fatigue and weakness.

Context: He is at the 20th percentile for height and 3rd percentile for weight.

Context: Crackles are heard at both lung bases.

Context: Serum glucose is 105 mg/dL.

Choices:
A. Acid maltase
B. Iduronate sulfatase
C. Glucose-6-phosphatase
D. Alpha-galactosidase

Answer: Acid maltase

Pediatrics
Medical Genetics and Genomics

General Pediatrics
Clinical Biochemical Genetics

1. A 7-month-old male infant is brought to the physician.

2. The infant has a 2-month history of fatigue and weakness.

3. His mother reports that he has difficulty feeding.

4. He is at the 20th percentile for height.

5. He is at the 3rd percentile for weight.

6. Physical examination shows an enlarged tongue.

7. Crackles are heard at both lung bases.

8. The liver is palpated 1 cm below the right costal margin.

9. Neurologic examination shows decreased muscle tone in the extremities.

11. An x-ray of the chest shows cardiomegaly.

1. His mother reports that he has difficulty feeding.

2. He is at the 20th percentile for height.

3. He is at the 3rd percentile for weight.

4. Physical examination shows an enlarged tongue.

5. Crackles are heard at both lung bases.

6. The liver is palpated 1 cm below the right costal margin.

7. Neurologic examination shows decreased muscle tone in the extremities.

9. An x-ray of the chest shows cardiomegaly.


Question: What is the standard deviation for the systolic blood pressure readings?

Context: The systolic blood pressure readings over the last 5 days are as follows: | Day 1: 130 mm Hg | Day 2: 132 mm Hg | Day 3: 128 mm Hg | Day 4: 132 mm Hg | Day 5: 128 mm Hg | .

Choices:
A. 1 mm Hg
B. 1.5 mm Hg
C. 2 mm Hg
D. 2.5 mm Hg

Answer: 2 mm Hg

General Internal Medicine
General Family Medicine

1. A 43-year-old man presents to a medical office for follow-up of hypertension.

2. He was recently diagnosed and has been managing his condition with diet modification and moderate-intensity exercise.

3. Today, he brings a list of his recent at-home morning blood pressure readings.

4. The systolic blood pressure reading on Day 1 was 130 mm Hg.

5. The systolic blood pressure reading on Day 2 was 132 mm Hg.

6. The systolic blood pressure reading on Day 3 was 128 mm Hg.

7. The systolic blood pressure reading on Day 4 was 132 mm Hg.

8. The systolic blood pressure reading on Day 5 was 128 mm Hg.

1. The patient was recently diagnosed with a medical condition.

2. The patient has been managing his condition with diet modification.

3. The patient has been managing his condition with moderate-intensity exercise.

4. The patient brings a list of his recent at-home morning blood pressure readings.

5. The systolic blood pressure reading on Day 1 was 130 mm Hg.

6. The systolic blood pressure reading on Day 2 was 132 mm Hg.

7. The systolic blood pressure reading on Day 3 was 128 mm Hg.

8. The systolic blood pressure reading on Day 4 was 132 mm Hg.

9. The systolic blood pressure reading on Day 5 was 128 mm Hg.


Question: Based on this electrophoresis, which of the following types of hemoglobin are dominant in this patient's blood?

Context: An 11-year-old boy is brought to the physician by his mother because of worsening fatigue.

Choices:
A. HbA and HbC
B. HbS only
C. HbA only
D. HbS and HbC

Answer: HbS and HbC

1. An 11-year-old boy is brought to the physician by his mother.

2. The mother reports that the boy has worsening fatigue.

3. The boy has trouble keeping up with his older brothers when playing outside.

4. Physical examination shows conjunctival pallor.

5. A hemoglobin electrophoresis is performed.

6. The patient's results are compared to those of a patient with known sickle cell anemia.

7. The patient's results are compared to those of a child with normal hemoglobin.

1. His mother reports that he seems to have trouble keeping up with his older brothers when playing outside.

2. Physical examination shows conjunctival pallor.

3. A hemoglobin electrophoresis is performed.

4. This patient's results are shown in comparison to those of a patient with known sickle cell anemia and a child with normal hemoglobin.


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

Context: His symptoms started 1 day before.

Context: Family history is unremarkable.

Context: His blood pressure is 230/130 mm Hg in both arms, the temperature is 36.9°C (98.4°F), and the pulse is 90/min.

Choices:
A. Hypertensive urgency
B. Hypertensive emergency
C. Aortic aneurysm
D. Malignant hypertension

Answer: Hypertensive emergency

Cardiovascular Disease
General Emergency Medicine

1. A 55-year-old African American man presents to the emergency department with central chest pressure.

3. The pain was initially intermittent in nature but has become constant and radiates to his jaw and left shoulder.

4. He also complains of some difficulty breathing.

5. The patient was diagnosed with essential hypertension 1 year ago, but he is not taking any medications for it.

6. The patient denies smoking, alcohol, or drug use.

8. His blood pressure is 230/130 mm Hg in both arms.

11. ECG shows diffuse T wave inversion and ST depression in lateral leads.

12. Laboratory testing is significant for elevated troponin.

2. Pain was initially intermittent, now constant and radiates to jaw and left shoulder

4. Diagnosed with essential hypertension 1 year ago

5. Not taking any medications for hypertension

8. Blood pressure is 230/130 mm Hg in both arms

12. Laboratory testing significant for elevated troponin


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

Context: Vital signs are within normal limits.

Context: She is alert and fully oriented.

Choices:
A. Positive GM1 ganglioside autoantibodies
B. Positive Lyme ELISA test
C. Low vitamin B12 level
D. Elevated TSH and decreased FT4 levels

Answer: Positive GM1 ganglioside autoantibodies

1. A 38-year-old woman comes to the physician for the evaluation of progressive weakness and numbness for 3 months.

2. The symptoms started in her lower legs and gradually moved to her upper legs and arms.

3. During the last 5 days, she has also had bilateral facial weakness with headaches.

4. She has hepatitis B and Graves' disease.

5. She is sexually active with one male partner and they use condoms inconsistently.

6. Her current medications include methimazole and a multivitamin.

7. Vital signs are within normal limits.

9. She has bilateral upper and lower facial paralysis.

10. There is generalized weakness of the muscles.

11. Sensation to light touch is decreased throughout and is absent in her fingertips and toes.

12. Deep tendon reflexes are 1+ bilaterally.

1. The symptoms started in her lower legs and gradually moved to her upper legs and arms.

2. During the last 5 days, she has also had bilateral facial weakness with headaches.

3. She has hepatitis B and Graves' disease.

4. She is sexually active with one male partner and they use condoms inconsistently.

5. Her current medications include methimazole and a multivitamin.

6. Vital signs are within normal limits.

8. She has bilateral upper and lower facial paralysis.

9. There is generalized weakness of the muscles.

10. Sensation to light touch is decreased throughout and is absent in her fingertips and toes.

11. Deep tendon reflexes are 1+ bilaterally.


Question: Infection with which of the following organisms would portend the worst prognosis with the highest mortality rate for this patient?

Context: A 32-year-old G2P1 at 32 weeks gestation presents to the emergency department with complaints of severe abdominal pain, fatigue, and nausea.

Context: Physical examination is significant for profound jaundice and tenderness to palpation of the right upper quadrant of the abdomen.

Context: The patient returned 2 weeks ago from a 1 month-long trip to India.

Context: She received sporadic pre-natal care while traveling and reports no known complications in her current pregnancy to date.

Context: She denies any past medical problems and states that her prior pregnancy proceeded as a normal vaginal birth without any complications.

Choices:
A. Hepatitis A
B. Hepatitis B
C. Hepatitis D
D. Hepatitis E

Answer: Hepatitis E

Internal Medicine
Obstetrics and Gynecology

Infectious Disease
Gastroenterology
Maternal

4. Patient presents to emergency department with severe abdominal pain, fatigue, and nausea.

5. Physical examination is significant for profound jaundice.

6. Physical examination is significant for tenderness to palpation of right upper quadrant of abdomen.

7. Patient returned 2 weeks ago from 1 month-long trip to India.

8. Patient received sporadic pre-natal care while traveling.

9. Patient reports no known complications in current pregnancy to date.

10. Patient denies any past medical problems.

11. Patient states prior pregnancy proceeded as normal vaginal birth without any complications.

1. Physical examination shows profound jaundice.

2. Physical examination shows tenderness to palpation of the right upper quadrant of the abdomen.

3. The patient returned from a 1 month-long trip to India 2 weeks ago.

4. The patient received sporadic pre-natal care while traveling.

5. The patient reports no known complications in her current pregnancy.

6. The patient denies any past medical problems.

7. The patient's prior pregnancy proceeded as a normal vaginal birth without complications.


Question: Pathologic examination of the biopsy specimen is most likely to show which of the following?

Context: A 42-year-old woman comes to the physician because of an episode of coughing with bloody sputum.

Context: Over the past 5 months, she has had a persistent nonproductive cough, excessive fatigue, and a 5.6-kg (12.3-lb) weight loss.

Context: She does not smoke.

Choices:
A. Small cell lung carcinoma
B. Large cell lung carcinoma
C. Bronchial carcinoid tumor
D. Adenocarcinoma

Answer: Adenocarcinoma

Pulmonary Pathology
Hematopathology
General Pulmonary Disease

1. A 42-year-old woman comes to the physician.

2. She has had a persistent nonproductive cough for the past 5 months.

3. She has had excessive fatigue for the past 5 months.

4. She has had a 5.6-kg (12.3-lb) weight loss for the past 5 months.

6. Physical examination shows no abnormalities.

7. An x-ray of the chest shows a 2.0-cm nodule with irregular borders at the upper lobe of the left lung.

8. She had an episode of coughing with bloody sputum.

9. A CT-guided biopsy of the lung nodule is performed.

1. Over the past 5 months, she has had a persistent nonproductive cough.

2. Over the past 5 months, she has had excessive fatigue.

3. Over the past 5 months, she has had a 5.6-kg (12.3-lb) weight loss.

5. Physical examination shows no abnormalities.

6. An x-ray of the chest shows a 2.0-cm nodule with irregular borders at the upper lobe of the left lung.

7. A CT-guided biopsy of the lung nodule is performed.


Question: Which of the following statements is correct regarding this study result?

Context: A group of researchers is conducting a prospective study to examine if dietary fiber intake is protective against coronary heart disease.

Context: Specifically, they are looking at the frequency of coronary heart incidents in a group of middle-aged men taking various daily amounts of water-insoluble fiber.

Context: The Pearson correlation coefficient that was obtained regarding the relationship between the amount of daily water-insoluble fiber intake and the frequency of coronary heart incidents in their study was 0.11 with a p-value of 0.006.

Choices:
A. There is a significant correlation between the daily fiber intake and the frequency of coronary heart incidents because the correlation coefficient is significant.
B. There is a significant correlation between fiber intake and the frequency of coronary heart incidents because the correlation coefficient is not significant.
C. There is a significant correlation between fiber intake and the frequency of coronary heart incidents because the value of the correlation coefficient shows a very good and robust correlation.
D. There is no correlation between fiber intake and the frequency of coronary heart incidents because the correlation coefficient is significant.

Answer: There is no correlation between fiber intake and the frequency of coronary heart incidents because the correlation coefficient is significant.

1. A group of researchers is conducting a prospective study.

2. The study is examining if dietary fiber intake is protective against coronary heart disease.

3. The study is looking at the frequency of coronary heart incidents in a group of middle-aged men.

4. The men are taking various daily amounts of water-insoluble fiber.

5. The Pearson correlation coefficient obtained regarding the relationship between the amount of daily water-insoluble fiber intake and the frequency of coronary heart incidents was 0.11.

6. The p-value of the Pearson correlation coefficient was 0.006.

1. Researchers are studying the frequency of coronary heart incidents in middle-aged men.

2. The study involves middle-aged men taking various daily amounts of water-insoluble fiber.

3. The Pearson correlation coefficient obtained for the relationship between daily water-insoluble fiber intake and coronary heart incidents was 0.11.

4. The p-value for the correlation coefficient was 0.006.


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

Context: A 24-year-old man comes to the physician because of a painful swelling above his buttocks for 1 week.

Context: He has obstructive sleep apnea and type 2 diabetes mellitus.

Context: His only medication is metformin.

Context: He appears anxious.

Context: He is 175 cm (5 ft 9 in) tall and weighs 114 kg (251 lb); BMI is 37 kg/m2.

Context: His temperature is 38.1°C (100.6°F), pulse is 96/min and blood pressure is 124/86 mm Hg.

Context: Examination shows facial acne.

Context: A cyst is seen above the natal cleft.

Choices:
A. Coccygectomy
B. Incision and drainage
C. Retinoid therapy
D. Surgical resection and primary wound closure

Answer: Incision and drainage

2. Patient has a painful swelling above his buttocks for 1 week.

3. Patient is unable to sit for extended periods because of the pain.

4. Patient has obstructive sleep apnea and type 2 diabetes mellitus.

5. Patient's only medication is metformin.

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

12. Patient's blood pressure is 124/86 mm Hg.

14. Patient has a cyst above the natal cleft.

15. Patient has tenderness to palpation at the cyst and surrounding tissue.

16. Skin around the cyst is warm and erythematous.

1. He is unable to sit for extended periods because of the pain.

13. A cyst is seen above the natal cleft.

14. There is tenderness to palpation at the cyst and surrounding tissue.

15. The skin around the cyst is warm and erythematous.


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

Context: A 17-year-old girl comes to the physician because of a 3-year history of acne on her face and chest.

Context: She has no itching or scaling.

Context: She has no history of serious illness.

Context: She takes no medications.

Choices:
A. Oral antibiotics
B. Topical benzoyl peroxide
C. Topical antibiotic
D. Oral isotretinoin

Answer: Topical benzoyl peroxide

1. A 17-year-old girl comes to the physician.

2. She has a 3-year history of acne on her face and chest.

4. She is concerned about the possibility of facial scarring.

6. She has no history of serious illness.

11. Her vital signs are within normal limits.

12. Examination shows several open comedones on the face and chest.

2. She is concerned about the possibility of facial scarring and has never sought treatment.

3. She has no history of serious illness.

5. She is 160 cm (5 ft 3 in) tall and weighs 58 kg (130 lb); BMI is 23 kg/m2.

6. Her vital signs are within normal limits.

7. Examination shows several open comedones on the face and chest.


Question: Which of the following drugs most likely has a similar mechanism of action as the drug prescribed to this patient?

Context: A 12-year-old boy is brought to the emergency department by his mother because he has been having difficulty breathing.

Context: He started having symptoms about 3 days ago when he started experiencing persistent coughing, runny nose, and a low grade fever.

Context: Since then he has been experiencing dyspnea that grew worse until he felt that he could no longer breathe.

Context: His mom says that this has happened many times before.

Context: During stabilization, he is prescribed a drug for treatment of his condition.

Context: The patient's mother recognizes the drug since her father, a 40-pack-year smoker, also takes the medication and she is told that the drug is able to beneficially inhibit a receptor on smooth muscle in both cases.

Choices:
A. Cortisol
B. Glycopyrrolate
C. Theophylline
D. Zileuton

Answer: Glycopyrrolate

2. Patient was brought to the emergency department by his mother.

3. Patient has been having difficulty breathing.

4. Patient started having symptoms 3 days ago.

5. Symptoms included persistent coughing, runny nose, and a low grade fever.

6. Patient has been experiencing dyspnea that grew worse until he felt he could no longer breathe.

7. Patient's mother says this has happened many times before.

8. On presentation, physical exam reveals an anxious, thin boy who is using his accessory muscles to breathe.

9. Prolonged expiratory wheezes are heard on auscultation of his lungs bilaterally.

10. During stabilization, patient is prescribed a drug for treatment of his condition.

11. Patient's mother recognizes the drug since her father, a 40-pack-year smoker, also takes the medication.

12. Drug is able to beneficially inhibit a receptor on smooth muscle in both cases.

1. He started having symptoms about 3 days ago

2. Symptoms include persistent coughing, runny nose, and a low grade fever

3. He has been experiencing dyspnea that grew worse

4. His mom says this has happened many times before

5. On presentation, physical exam reveals an anxious, thin boy

6. He is using his accessory muscles to breathe

7. Prolonged expiratory wheezes are heard on auscultation of his lungs bilaterally

8. He is prescribed a drug for treatment of his condition

9. The patient's mother recognizes the drug

10. The drug is able to beneficially inhibit a receptor on smooth muscle


Question: Which of the following medications would you prescribe for this patient?

Context: A 35-year-old taxi driver presents to his physician with complaints of itchy, watery eyes and excessive sneezing that have become more severe with the change of the seasons.

Context: He has previously taken an over-the-counter medication in the past with moderate relief of his symptoms, but it made him very drowsy.

Context: He asks to switch to a medication that will not cause drowsiness that may impair his driving.

Choices:
A. Cetirizine
B. Chlorpheniramine
C. Diphenhydramine
D. Hydroxyzine

Answer: Cetirizine

1. A 35-year-old taxi driver presents to his physician.

2. He has itchy, watery eyes and excessive sneezing.

3. His symptoms become more severe with the change of the seasons.

4. He has previously taken an over-the-counter medication with moderate relief of his symptoms.

5. The over-the-counter medication made him very drowsy.

6. He asks to switch to a medication that will not cause drowsiness.

7. The medication should not impair his driving.

1. He has previously taken an over-the-counter medication.

2. The over-the-counter medication provided moderate relief of his symptoms.

3. The over-the-counter medication made him very drowsy.

4. He asks to switch to a medication that will not cause drowsiness.


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

Context: A 19-year-old female college student comes to the physician for a sudden loss of visual acuity of her right eye.

Choices:
A. Joint hypermobility syndrome
B. Sturge-Weber syndrome
C. Ehlers-Danlos syndrome
D. Marfan syndrome

Answer: Marfan syndrome

1. Patient is a 19-year-old female college student.

2. Patient has sudden loss of visual acuity of her right eye.

3. Patient was unable to read the time on the alarm clock when she woke up in the morning.

4. When she closes her right eye, she is able to see sharply.

5. When she closes her left eye, she has blurry double vision.

6. Patient does not recall trauma to her eye.

7. Patient has been working long nights on her honors thesis.

8. Patient has a history of occasional shoulder luxation.

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

13. On physical examination, slender and long fingers are noted.

14. Patient has several flat, demarcated brownish nevi on her left cheek.

15. Ocular examination shows upward temporal subluxation of her right lens.

1. She noticed that she was unable to read the time on the alarm clock when she woke up in the morning.

2. When she closes her right eye, she is able to see sharply.

3. When she closes her left eye, she has blurry double vision.

4. She does not recall trauma to her eye but has been working long nights on her honors thesis.

5. She has a history of occasional shoulder luxation.

6. She is 180 cm (5 ft 11 in) tall, and weighs 62 kg (136 lbs); her BMI is 19.1 kg/m2.

7. Her vital signs are within normal limits.

8. On physical examination, slender and long fingers are noted.

9. She has several flat, demarcated brownish nevi on her left cheek.

10. Ocular examination shows upward temporal subluxation of her right lens.


Question: Which of the following serum markers is most likely elevated in this patient?

Context: He reports a 6-month history of gradually progressive epigastric pain and 10 pounds of unexpected weight loss.

Context: He has also noticed that his skin feels itchier than usual.

Context: He has a 10-pack-year smoking history and a distant history of cocaine abuse.

Context: His temperature is 100.1°F (37.8°C), blood pressure is 135/85 mmHg, pulse is 100/min, and respirations are 20/min.

Context: On exam, he has notable hepatomegaly and a palpable gallbladder.

Choices:
A. Bombesin
B. CA-125
C. CA 19-9
D. S-100

Answer: CA 19-9

1. A 62-year-old man presents to his primary care provider complaining of abdominal pain.

2. He reports a 6-month history of gradually progressive epigastric pain.

3. He has also noticed 10 pounds of unexpected weight loss.

4. His past medical history is notable for gout, hypertension, and diabetes mellitus.

5. He takes allopurinol, enalapril, and glyburide.

6. He has a 10-pack-year smoking history.

7. He has a distant history of cocaine abuse.

12. On exam, he has notable hepatomegaly.

13. On exam, he has a palpable gallbladder.

14. A right upper quadrant ultrasound reveals an irregular extrahepatic mass originating from the gallbladder wall.

1. Patient reports a 6-month history of gradually progressive epigastric pain

2. Patient reports 10 pounds of unexpected weight loss

4. Patient's past medical history includes gout, hypertension, and diabetes mellitus

5. Patient takes allopurinol, enalapril, and glyburide

6. Patient has a 10-pack-year smoking history

7. Patient has a distant history of cocaine abuse

8. Patient's temperature is 100.1°F (37.8°C)

9. Patient's blood pressure is 135/85 mmHg

13. On exam, patient has a palpable gallbladder

14. Right upper quadrant ultrasound reveals an irregular extrahepatic mass originating from the gallbladder wall


Question: Which of the following could be used to culture the most likely cause of this disorder?

Context: A 4-year-old girl from a recently immigrated family presents to the emergency department with episodes of severe coughing lasting up to several minutes followed by vomiting.

Context: She had a low grade fever and runny nose over the last 2 weeks but these coughing episodes just began one day prior to presentation.

Context: A complete blood count shows a lymphocytic infiltrate and Gram stain reveals a gram-negative coccobacillus.

Choices:
A. Charcoal yeast with iron and cysteine
B. Eaton agar
C. Loffler medium
D. Regan-Lowe medium

Answer: Regan-Lowe medium

Pediatric Pulmonology
Pediatric Infectious Diseases

1. A 4-year-old girl from a recently immigrated family presents to the emergency department.

2. She has episodes of severe coughing lasting up to several minutes followed by vomiting.

3. She had a low grade fever and runny nose over the last 2 weeks.

4. The coughing episodes just began one day prior to presentation.

5. A complete blood count shows a lymphocytic infiltrate.

6. Gram stain reveals a gram-negative coccobacillus.

7. The emergency department physician explains that this organism causes disease by toxin-mediated inactivation of an inhibitory signaling molecule.

1. She had a low grade fever and runny nose over the last 2 weeks.

2. Coughing episodes began one day prior to presentation.

3. A complete blood count shows a lymphocytic infiltrate.

4. Gram stain reveals a gram-negative coccobacillus.

5. The emergency department physician explains that this organism causes disease by toxin-mediated inactivation of an inhibitory signaling molecule.


Question: Which of the following histopathologic findings characteristic of this patient’s most likely diagnosis is marked by the yellow circle?

Context: A colonoscopy is performed and shows continuous erythema, superficial ulcers, and pseudopolyps in the rectum and sigmoid colon.

Choices:
A. Goblet cell hyperplasia
B. Paneth cells metaplasia
C. Crypt abscess
D. Enterocyte dysplasia

Answer: Crypt abscess

1. A 28-year-old man presents with episodic abdominal pain and bloody diarrhea for the past week.

2. He says that the abdominal pain is diffusely localized to the periumbilical region and is dull and cramping in character.

3. He also reports episodes of painful, bloody diarrhea up to 7 times per day.

5. The colonoscopy shows continuous erythema, superficial ulcers, and pseudopolyps in the rectum and sigmoid colon.

6. A biopsy is taken and sent for histological evaluation.

7. One of the slides from the biopsy is shown in the image below.

1. The abdominal pain is diffusely localized to the periumbilical region.

2. The abdominal pain is dull and cramping in character.

3. The patient reports episodes of painful, bloody diarrhea up to 7 times per day.

4. A colonoscopy shows continuous erythema, superficial ulcers, and pseudopolyps in the rectum and sigmoid colon.

5. A biopsy is taken during the colonoscopy.

6. The biopsy is sent for histological evaluation.


Question: Which of the following is the most likely underlying cause of these findings?"

Context: A 14-year-old boy is brought to the emergency department because of a 2-day history of fatigue.

Context: He reports that during this time he has had occasional palpitations and shortness of breath.

Context: He has sickle cell disease.

Context: Current medications include hydroxyurea and folic acid.

Context: He appears fatigued.

Context: His temperature is 38.3°C (100.9°F), pulse is 120/min, respirations are 24/min, and blood pressure is 112/74 mm Hg.

Context: Examination shows pale conjunctivae.

Context: Laboratory studies show: | Hemoglobin 6.4 g/dl | Leukocyte count 6,000/mm3 | Platelet count 168,000/mm3 | Mean corpuscular volume 84 μm3 | Reticulocyte count 0.1% | .

Choices:
A. Parvovirus B19
B. Medication-induced hemolysis
C. Defect in erythrocyte membrane proteins
D. Hemolytic crisis

Answer: Parvovirus B19

Hematology
General Pediatrics
Pediatric Hematology

2. Patient has a 2-day history of fatigue.

3. Patient has occasional palpitations and shortness of breath.

5. Patient is currently taking hydroxyurea and folic acid.

7. Patient's temperature is 38.3°C (100.9°F).

10. Patient's blood pressure is 112/74 mm Hg.

12. Cardiac examination shows a midsystolic ejection murmur.

13. Laboratory studies show hemoglobin 6.4 g/dl.

14. Laboratory studies show leukocyte count 6,000/mm3.

15. Laboratory studies show platelet count 168,000/mm3.

16. Laboratory studies show mean corpuscular volume 84 μm3.

17. Laboratory studies show reticulocyte count 0.1%.

1. The patient reports occasional palpitations and shortness of breath.

3. The patient's current medications include hydroxyurea and folic acid.

5. The patient's temperature is 38.3°C (100.9°F).

7. The patient's respirations are 24/min.

8. The patient's blood pressure is 112/74 mm Hg.

10. Cardiac examination shows a midsystolic ejection murmur.

11. Laboratory studies show: Hemoglobin 6.4 g/dl.

12. Laboratory studies show: Leukocyte count 6,000/mm3.

13. Laboratory studies show: Platelet count 168,000/mm3.

14. Laboratory studies show: Mean corpuscular volume 84 μm3.

15. Laboratory studies show: Reticulocyte count 0.1%.


Question: Which of the following is the most likely underlying mechanism of these findings?

Context: A 44-year-old woman comes to the office because of 4 episodes of loss of consciousness over the past 2 weeks.

Context: Pulse is 115/min and irregular and blood pressure is 108/70 mm Hg.

Choices:
A. Increased pulmonary capillary wedge pressure
B. Increased central venous pressure
C. Increased oxygenated blood in the right ventricle
D. Increased mean arterial pressure

Answer: Increased pulmonary capillary wedge pressure

1. A 44-year-old woman comes to the office.

2. She has had 4 episodes of loss of consciousness over the past 2 weeks.

3. She recovered immediately and was not confused following the episodes.

4. She has also had increased shortness of breath, palpitations, and chest tightness for the past 6 months that resolves with rest.

5. She immigrated with her family from India 10 years ago.

8. Cardiac examination shows an accentuated and split S2.

9. There is an opening snap followed by a low-pitched diastolic murmur in the fifth left intercostal space at the midclavicular line.

10. An ECG shows atrial fibrillation and right axis deviation.

1. She recovered immediately and was not confused following the episodes.

2. For the past 6 months, she has also had increased shortness of breath, palpitations, and chest tightness that resolves with rest.

3. She immigrated with her family from India 10 years ago.

6. Cardiac examination shows an accentuated and split S2.

7. There is an opening snap followed by a low-pitched diastolic murmur in the fifth left intercostal space at the midclavicular line.

8. An ECG shows atrial fibrillation and right axis deviation.


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

Context: A 43-year-old woman is brought to the emergency department because of severe central chest pain, mild shortness of breath, and one episode of coughing up blood since waking up that morning.

Context: The pain worsens on inspiration, and she describes it as 8 out of 10 in intensity.

Context: Her temperature is 37.8°C (100°F), pulse is 103/min, respirations are 20/min, and blood pressure is 102/74 mm Hg.

Context: The lungs are clear to auscultation.

Context: Laboratory studies show a normal complete blood count, creatinine of 1.0 mg/dL, and a creatinine clearance of 81 mL/min (N = 75–115).

Context: Arterial blood gas analysis on room air shows: | pH 7.49 | PCO2 29 mm Hg | PO2 69 mm Hg | HCO3- 22 mEq/L | An x-ray of the chest shows no abnormalities.

Choices:
A. CT pulmonary angiography
B. D-dimer levels
C. Catheter embolectomy
D. Low molecular weight heparin therapy

Answer: Low molecular weight heparin therapy

1. A 43-year-old woman is brought to the emergency department.

2. She has severe central chest pain, mild shortness of breath, and one episode of coughing up blood since waking up that morning.

3. The pain worsens on inspiration and is 8 out of 10 in intensity.

4. Three months ago, she underwent a left modified radical mastectomy for invasive ductal carcinoma.

9. Pulse oximetry on room air shows an oxygen saturation of 93%.

10. The lungs are clear to auscultation.

11. Cardiac examination shows no abnormalities.

12. The left lower extremity is swollen and erythematous.

13. Laboratory studies show a normal complete blood count.

15. Creatinine clearance is 81 mL/min (N = 75–115).

16. Arterial blood gas analysis on room air shows: pH 7.49, PCO2 29 mm Hg, PO2 69 mm Hg, HCO3- 22 mEq/L.

17. An x-ray of the chest shows no abnormalities.

2. She describes the pain as 8 out of 10 in intensity

3. Three months ago, she underwent a left modified radical mastectomy for invasive ductal carcinoma

8. Pulse oximetry on room air shows an oxygen saturation of 93%

10. Cardiac examination shows no abnormalities

11. The left lower extremity is swollen and erythematous

12. Laboratory studies show a normal complete blood count

13. Laboratory studies show creatinine of 1.0 mg/dL

14. Laboratory studies show a creatinine clearance of 81 mL/min (N = 75–115)

15. Arterial blood gas analysis on room air shows: pH 7.49, PCO2 29 mm Hg, PO2 69 mm Hg, HCO3- 22 mEq/L

16. An x-ray of the chest shows no abnormalities


Question: Which of the following matches a drug with its correct characteristic?

Context: A 58-year-old Caucasian male with a history of peripheral vascular disease is admitted to the hospital with a painful, pulseless foot.

Context: He is prescribed antiplatelet and anticoagulant drugs.

Choices:
A. Warfarin: directly inhibits thrombin
B. Heparin: activates antithrombin 3
C. Aspirin: reversibly inhibits COX-1
D. Prasugrel: reduced risk of bleeding compared to other drugs in its class

Answer: Heparin: activates antithrombin 3

3. Patient has a history of peripheral vascular disease.

5. Patient has a painful, pulseless foot.

6. Patient is prescribed antiplatelet drugs.

7. Patient is prescribed anticoagulant drugs.

2. He is prescribed anticoagulant drugs.


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

Context: A 64-year-old woman comes to the physician because of several episodes of dizziness during the last month.

Context: The episodes last between 30–40 seconds and during the episodes she feels as though she is spinning.

Context: She has no nausea.

Choices:
A. Benign paroxysmal positional vertigo
B. Persistent postural-perceptual dizziness
C. Meniere disease
D. Acoustic neuroma

Answer: Benign paroxysmal positional vertigo

1. A 64-year-old woman comes to the physician.

2. She has experienced several episodes of dizziness in the last month.

3. The episodes last between 30–40 seconds.

4. During the episodes she feels as though she is spinning.

5. Episodes usually occur immediately after lying down or suddenly sitting up from a reclined position.

6. Episodes also sometimes happen when she suddenly turns her head to look at something.

8. Last month, she had an upper respiratory tract infection that resolved spontaneously.

9. She has hypertension treated with hydrochlorothiazide.

10. Otoscopic examination shows no abnormalities.

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

1. The episodes last between 30–40 seconds.

2. During the episodes, she feels as though she is spinning.

3. Episodes usually occur immediately after lying down or suddenly sitting up from a reclined position.

4. They also sometimes happen when she suddenly turns her head to look at something.

6. Last month, she had an upper respiratory tract infection that resolved spontaneously.

7. She has hypertension treated with hydrochlorothiazide.

8. Otoscopic examination shows no abnormalities.

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


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

Context: A 31-year-old woman presents to her primary care physician because she has been experiencing diarrhea over the last several days.

Context: She returned from a cruise ship vacation 3 days ago and has recently been to many countries in Central and South America.

Context: Stool examination shows blood and neutrophils and imaging reveals abscesses in the liver.

Choices:
A. Acid fast cysts
B. Motile bacteria
C. Non-invasive trophozoites
D. Ulcers that are flask-shaped

Answer: Ulcers that are flask-shaped

In this case, the most relevant medical specialty would be Gastroenterology

In this case, the most relevant specialty would be Gastroenterology

General Gastroenterology.
General Gastroenterology
Gastroenterology

1. A 31-year-old woman presents to her primary care physician.

2. She has been experiencing diarrhea over the last several days.

3. She returned from a cruise ship vacation 3 days ago.

4. She has recently been to many countries in Central and South America.

5. After returning, she developed bloody diarrhea, nausea, and right-upper quadrant abdominal pain.

6. Stool examination shows blood and neutrophils.

7. Imaging reveals abscesses in the liver.

1. She returned from a cruise ship vacation 3 days ago.

2. She has recently been to many countries in Central and South America.

3. After returning, she developed bloody diarrhea, nausea, and right-upper quadrant abdominal pain.

4. Stool examination shows blood and neutrophils.

5. Imaging reveals abscesses in the liver.


Question: Which of the following mechanisms most likely contributes to the efficacy of this patient's pharmacotherapy?

Context: A 35-year-old woman that is currently being treated for chronic hepatitis C comes to the physician because of progressive fatigue for 10 days.

Context: Examination shows pale conjunctivae.

Context: Her hemoglobin concentration is 10.1 g/dL, serum total bilirubin concentration is 1.9 mg/dL, and LDH is 259 U/L (N = 45–90 U/L).

Choices:
A. Activation of leukocytes
B. Inhibition of reverse transcriptase
C. Inhibition of RNA polymerase
D. Decreased GMP synthesis

Answer: Decreased GMP synthesis

1. A 35-year-old woman is being treated for chronic hepatitis C.

2. She comes to the physician because of progressive fatigue for 10 days.

4. Her hemoglobin concentration is 10.1 g/dL.

5. Her serum total bilirubin concentration is 1.9 mg/dL.

7. The normal range for LDH is 45–90 U/L.

2. Hemoglobin concentration is 10.1 g/dL.

3. Serum total bilirubin concentration is 1.9 mg/dL.


Question: Which of the following effects are most likely to have occurred in this child’s eye from these eye drops?

Choices:
A. Contraction of the pupillary dilator muscle with no effect on the ciliary muscle
B. Relaxation of the pupillary dilator muscle with no effect on the ciliary muscle
C. Relaxation of the pupillary sphincter muscle with contraction of the ciliary muscle
D. Contraction of the pupillary dilator muscle with contraction of the ciliary muscle

Answer: Contraction of the pupillary dilator muscle with no effect on the ciliary muscle

1. A 7-year-old boy is brought to a pediatrician by his parents.

2. The parents say that the patient accidentally instilled a drop from a bottle of medicated eye drops into his right eye.

3. According to them, the patient’s grandfather uses the eye drops which were prescribed for him by an ophthalmologist.

4. The parents have brought the eye drops with them.

5. The pediatrician notes that the eye drops contain an α1 adrenergic agonist drug.

6. He examines the patient’s eye and finds that the eye drops have produced their expected effects.

7. He reassures the parents about the self-limited effect of the drug and the absence of any risk of long-term complications.

1. The patient accidentally instilled a drop from a bottle of medicated eye drops into his right eye.

2. The eye drops were prescribed for the patient's grandfather by an ophthalmologist.

3. The parents have brought the eye drops with them.

4. The eye drops contain an α1 adrenergic agonist drug.

5. The pediatrician notes that the eye drops have produced their expected effects.

6. The pediatrician reassures the parents about the self-limited effect of the drug and the absence of any risk of long-term complications.


Question: The most effective medication for her disorder has what mechanism of action?

Context: For the past 9 months, the patient has been having a hard time falling asleep because she “can’t turn her mind off.” She is a student in a nearby university and spends hours at the end of each day worrying about her classes as well as her upcoming tests.

Context: When she doesn’t have tests, she worries about her family and her boyfriend even though admits she has no specific concerns about them.

Context: This constant worrying has led to insomnia and an inability to focus in class.

Context: She has also been fatigued and hasn’t had the energy to go the gym as she usually does.

Choices:
A. Inhibit reuptake of serotonin
B. Inhibition of monoamine oxidase
C. Increase norepinephrine and dopamine
D. Block dopamine receptors

Answer: Inhibit reuptake of serotonin

1. A 21-year-old female comes to the physician’s office because of insomnia.

2. For the past 9 months, the patient has been having a hard time falling asleep because she “can’t turn her mind off.”

3. She is a student in a nearby university.

4. She spends hours at the end of each day worrying about her classes.

5. She spends hours at the end of each day worrying about her upcoming tests.

6. She worries about her family and her boyfriend even though admits she has no specific concerns about them.

7. This constant worrying has led to insomnia.

8. This constant worrying has led to an inability to focus in class.

10. She hasn't had the energy to go the gym as she usually does.

1. The patient has been having a hard time falling asleep for the past 9 months.

2. The patient's difficulty falling asleep is due to her inability to "turn her mind off."

3. The patient is a student at a nearby university.

4. The patient spends hours at the end of each day worrying about her classes and upcoming tests.

5. When she doesn't have tests, the patient worries about her family and her boyfriend.

6. The patient admits she has no specific concerns about her family and boyfriend.

7. The constant worrying has led to insomnia for the patient.

8. The patient has an inability to focus in class due to her constant worrying.

9. The patient has been experiencing fatigue.

10. The patient hasn't had the energy to go to the gym as she usually does.


Question: Which of the following is the most appropriate pharmacotherapy?

Context: A 7-year-old girl is brought to the physician because of a slightly itchy rash that first appeared 3 days ago.

Context: Her mother says she has also been complaining of headaches and achy muscles since yesterday evening.

Context: She has a history of atopic dermatitis.

Context: Her temperature is 39°C (102.2°F).

Context: A photograph of the rash is shown.

Choices:
A. Amoxicillin
B. Ceftriaxone
C. Penicillin G
D. Azithromycin

Answer: Amoxicillin

General Dermatology
Pediatric Dermatology

2. Patient has a slightly itchy rash that first appeared 3 days ago.

3. Patient has been complaining of headaches and achy muscles since yesterday evening.

4. Patient went on a camping trip for school 10 days ago.

5. Patient recalls being bitten several times by mosquitoes.

6. Patient has a history of atopic dermatitis.

7. Patient lives in Massachusetts with both parents and her 4-year-old sister.

8. Patient's temperature is 39°C (102.2°F).

9. Physical examination shows a 3-cm, nontender rash on her left upper torso.

10. There are also multiple 5 to 8-mm erythematous papules over the lower legs and forearms.

1. Her mother says she has been complaining of headaches and achy muscles since yesterday evening.

2. The girl went on a camping trip for school 10 days ago.

3. She recalls being bitten several times by mosquitoes.

4. She has a history of atopic dermatitis.

5. She lives in Massachusetts with both parents and her 4-year-old sister.

7. Physical examination shows a 3-cm, nontender rash on her left upper torso.

9. There are also multiple 5 to 8-mm erythematous papules over the lower legs and forearms.


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

Context: A 45-year-old man presents to the clinic for the third time in the past 3 weeks asking for an MRI of his lower back.

Context: The next day, he developed soreness in his lower back and spent the whole day online trying to figure out what was wrong with him.

Context: He has been to the emergency department a few times and subsequently has been redirected to the clinic where each time he was thoroughly examined and investigated for all the possible causes.

Context: The patient still exhibits worry and would like to get an MRI to make sure everything is ‘okay.’ .

Choices:
A. Illness anxiety disorder
B. Somatic symptom disorder
C. Factitious disorder
D. Munchausen syndrome

Answer: Illness anxiety disorder

1. A 45-year-old man presents to the clinic for the third time in the past 3 weeks.

2. He had initially gone to the gym as advised by his wife and had started doing some back exercises.

3. The next day, he developed soreness in his lower back.

4. He spent the whole day online trying to figure out what was wrong with him.

5. He has been to the emergency department a few times.

6. He has subsequently been redirected to the clinic.

7. Each time he was thoroughly examined and investigated for all the possible causes.

9. He would like to get an MRI to make sure everything is ‘okay.’

1. He initially went to the gym as advised by his wife.

2. He started doing some back exercises.

6. He has been redirected to the clinic each time.

7. Each time he was thoroughly examined and investigated for all possible causes.


Question: What is the best initial step in management?

Choices:
A. Oral loratadine
B. Intranasal corticosteroids
C. Sublingual oseltamivir
D. Oral montelukast

Answer: Intranasal corticosteroids

Pulmonary Disease
General Pediatrics
Infectious Disease
Pediatric Pulmonology

1. A 25-year-old woman presents to the urgent care clinic for cough for the past five days.

2. She recently moved to the area and has not yet established a primary care doctor.

3. She has noticed worsening runny nose with congestion, sneezing, and tearing over the past few days.

4. She initially thought that it was just due to dust from moving boxes into her new apartment.

5. Her symptoms did not improve after cleaning her belongings and vacuuming her floor.

6. She feels some relief after splashing her face with cold water.

7. Her symptoms recur within ten minutes.

10. Her physical exam reveals examples of findings shown in Figures A-C.

11. No rales or wheezes are appreciated on lung auscultation.

12. Bronchial breath sounds are heard at the bases.

13. The patient states that she will need to drive back home after this visit.

1. She recently moved to the area and has not yet established a primary care doctor.

2. She has noticed worsening runny nose with congestion, sneezing, and tearing over the past few days.

3. She initially thought that it was just due to dust from moving boxes into her new apartment, but her symptoms did not improve after cleaning her belongings and vacuuming her floor.

4. She feels some relief after splashing her face with cold water, but her symptoms recur within ten minutes.

5. She has no pets and does not take any medications.

6. Her physical exam reveals examples of findings shown in Figures A-C.

7. No rales or wheezes are appreciated on lung auscultation, but bronchial breath sounds are heard at the bases.

8. The patient states that she will need to drive back home after this visit.