Question: In addition to placing the patient in the right lateral decubitus position, which of the following is the most appropriate next step in management?

Context: A 58-year-old man comes to the emergency department because of multiple episodes of coughing up blood over the past 2 hours.

Context: He says that he has coughed up approximately half a cup of bright-red blood each time.

Context: He has a history of hypertension and chronic obstructive pulmonary disease.

Context: He drinks 2 to 3 beers every evening.

Context: He appears anxious and cachectic.

Choices:
A. Radionuclide scan
B. Upper endoscopy
C. Arteriography
D. Bronchoscopy

Answer: Bronchoscopy

General Pulmonary Disease
Pulmonary Disease

2. Patient has had multiple episodes of coughing up blood over the past 2 hours.

3. Patient has coughed up approximately half a cup of bright-red blood each time.

4. Patient has had progressively worsening shortness of breath on exertion and a productive cough with occasionally blood-tinged sputum for the past 6 months.

5. Patient has a history of hypertension and chronic obstructive pulmonary disease.

6. Patient has worked in a car manufacturing company for over 20 years.

7. Patient drinks 2 to 3 beers every evening.

8. Patient has smoked 1 pack of cigarettes daily for the past 30 years.

9. Patient's medications include amlodipine, tiotropium, and an albuterol inhaler as needed.

10. Patient's temperature is 37.2 °C (99.0 °F).

11. Patient's blood pressure is 102/68 mm Hg.

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

15. Patient appears anxious and cachectic.

16. Examination of the lung shows decreased breath sounds bilaterally.

17. There is no cervical or axillary lymphadenopathy.

19. Patient's leukocyte count is 8,800/mm3.

20. Patient's platelet count is 160,000/mm3.

21. Patient's coagulation parameters are within normal limits.

22. Serum studies and urine analysis show no abnormalities.

23. Patient is intubated and mechanically ventilated.

25. X-ray of the chest shows hyperinflation of the lung fields.

26. X-ray of the chest shows a 2-cm nodule in the right lower lobe.

1. The patient has coughed up approximately half a cup of bright-red blood each time.

2. He has had progressively worsening shortness of breath on exertion and a productive cough with occasionally blood-tinged sputum for the past 6 months.

3. The patient has a history of hypertension and chronic obstructive pulmonary disease.

4. He has worked in a car manufacturing company for over 20 years.

5. The patient drinks 2 to 3 beers every evening.

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

7. His medications include amlodipine, tiotropium, and an albuterol inhaler as needed.

8. His temperature is 37.2 °C (99.0 °F), blood pressure is 102/68 mm Hg, pulse is 108/min, and respirations are 22/min.

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

10. The patient appears anxious and cachectic.

11. Examination of the lung shows decreased breath sounds bilaterally.

12. There is no cervical or axillary lymphadenopathy.

13. His hemoglobin is 11.5 g/dL, leukocyte count is 8,800/mm3, and a platelet count is 160,000/mm3.

14. His coagulation parameters are within normal limits.

15. Serum studies and urine analysis show no abnormalities.

16. He is intubated and mechanically ventilated, and infusion of 0.9% saline is begun.

17. An x-ray of the chest shows hyperinflation of the lung fields and a 2-cm nodule in the right lower lobe.


Question: Which of the following is the most appropriate next step for the physician?

Context: A previously healthy 3-year-old girl is brought to the physician because she refuses to use her left arm after “tripping over a stone” that morning on the way to the supermarket while holding her mother's hand.

Context: She did not hit the ground.

Context: She appears anxious.

Choices:
A. Administer ibuprofen and ice packs
B. Forced hyperpronation of the arm
C. Notify child protective services
D.
Perform nerve conduction studies and electromyography
"

Answer: Forced hyperpronation of the arm

1. A 3-year-old girl was brought to the physician.

3. She tripped over a stone that morning while holding her mother's hand.

5. Development has been normal for her age.

7. Her vital signs are within normal limits.

8. The left forearm is held close to her body in partial extension and pronation.

9. There is no swelling or bruising of the elbow or the forearm.

10. Palpation of the proximal radius produces pain.

11. The child cries on attempting to passively supinate the forearm.

2. Development has been normal for her age.

4. Her vital signs are within normal limits.

5. The left forearm is held close to her body in partial extension and pronation.

6. There is no swelling or bruising of the elbow or the forearm.

7. Palpation of the proximal radius produces pain.

8. The child cries on attempting to passively supinate the forearm.


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

Context: A previously healthy 29-year-old woman comes to the physician because of a 3-day history of low-grade fever, muscle aches, and a rash.

Context: She has had 4 male sexual partners over the past year and uses condoms inconsistently.

Context: Examination shows a diffuse maculopapular rash that includes the palms and soles.

Choices:
A. Assess for double-stranded DNA antibodies
B. Administer penicillin G
C. Analyze rash with darkfield microscopy
D. Test for fluorescent treponemal antibody absorption

Answer: Test for fluorescent treponemal antibody absorption

1. A 29-year-old woman came to the physician.

2. She had a 3-day history of low-grade fever, muscle aches, and a rash.

3. She had 4 male sexual partners over the past year.

5. Examination showed a diffuse maculopapular rash that included the palms and soles.

6. Testing for nonspecific anticardiolipin antibodies was positive.

1. She has had 4 male sexual partners over the past year.

3. Examination shows a diffuse maculopapular rash.

4. The rash includes the palms and soles.

5. Testing for nonspecific anticardiolipin antibodies is positive.


Question: Of the following, which is true regarding aldosterone antagonists in patients with heart failure?

Context: A 59-year-old man with New York Heart Association Class II heart failure presents to your outpatient clinic for routine follow-up.

Context: His blood pressure is 134/89 mm Hg and heart rate is 75/min.

Context: You would like to add on spironolactone.

Choices:
A. Aldosterone antagonists do not require renal dosing
B. Aldosterone antagonists are indicated for patients in all stages of heart failure
C. Aldosterone antagonists decrease morbidity and mortality in heart failure patients
D. Aldosterone antagonists can cause visual disturbances

Answer: Aldosterone antagonists decrease morbidity and mortality in heart failure patients

1. A 59-year-old man presents to an outpatient clinic for routine follow-up.

2. The man has New York Heart Association Class II heart failure.

5. Physical examination reveals clear lung sounds bilaterally with normal S1 and S2 heart sounds.

6. He currently takes captopril, bisoprolol, and furosemide.

7. The doctor would like to add on spironolactone.

3. Physical examination reveals clear lung sounds bilaterally.

4. Physical examination reveals normal S1 and S2 heart sounds.

5. Current medications include captopril, bisoprolol, and furosemide.

6. Considering adding on spironolactone.


Question: The cells most likely affected in this patient’s current condition are analogous to which of the following cell types?

Context: A 32-year-old man comes to the physician because of a 1-week history of fever, nausea, headache, and confusion.

Context: He is sexually active with a new partner that he met 2 months ago and they use condoms inconsistently.

Context: He appears ill.

Choices:
A. Osteoblasts
B. Mast cells
C. Schwann cells
D. Langerhans cells

Answer: Langerhans cells

1. A 32-year-old man comes to the physician.

2. He has a 1-week history of fever, nausea, headache, and confusion.

3. Three weeks ago, he had an episode of a sore throat, diarrhea, and generalized lymphadenopathy.

4. He is sexually active with a new partner he met 2 months ago.

7. Physical examination shows nuchal rigidity.

8. Further evaluation shows infection with a single-stranded, positive-sense RNA virus.

1. Three weeks ago, he had an episode of a sore throat, diarrhea, and generalized lymphadenopathy.

2. He is sexually active with a new partner that he met 2 months ago.

5. Physical examination shows nuchal rigidity.

6. Further evaluation shows infection with a single-stranded, positive-sense RNA virus.


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

Context: He states that he has felt abnormally weak during this time and has had trouble focusing in the setting of losing 5 pounds.

Context: The patient states he has a decreased appetite and also has not had a bowel movement in the past 5 days and feels uncomfortable.

Context: His temperature is 97.5°F (36.4°C), blood pressure is 132/83 mmHg, pulse is 115/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Context: His cranial nerve exam is unremarkable and his gait is stable.

Choices:
A. Calcium level
B. Lead level
C. Potassium level
D. TSH level

Answer: Calcium level

Geriatric Medicine
General Internal Medicine

1. A 64-year-old man presents for a routine physical.

2. He states that he has felt abnormally weak during this time.

3. He has had trouble focusing in the setting of losing 5 pounds.

4. The patient states he has a decreased appetite.

5. He has not had a bowel movement in the past 5 days and feels uncomfortable.

6. On review of system, he endorses abdominal pain.

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

12. Physical exam is notable only for the patient being able to recall 1 of 3 objects.

13. His cranial nerve exam is unremarkable.

15. Urinalysis is initially notable for a clear and voluminous sample with a low specific gravity.

1. The patient has felt abnormally weak.

2. The patient has had trouble focusing.

4. The patient has a decreased appetite.

5. The patient has not had a bowel movement in the past 5 days.

8. The patient's temperature is 97.5°F (36.4°C).

9. The patient's blood pressure is 132/83 mmHg.

11. The patient's respirations are 15/min.

12. The patient's oxygen saturation is 98% on room air.

13. The patient is able to recall 1 of 3 objects.

14. The patient's cranial nerve exam is unremarkable.

16. The urinalysis is initially notable for a clear and voluminous sample.

17. The urinalysis has a low specific gravity.


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

Context: Ten days after a motor vehicle collision, a 28-year-old man develops jaundiced skin.

Context: Upon initial presentation for his injuries, the patient was taken for an emergency laparotomy, which revealed significant internal hemorrhage from blunt abdominal trauma to the spleen.

Context: He required rapid transfusion with a total of 7 units of packed red blood cells.

Context: He has recovered well from the procedure until this morning, when he began to develop jaundiced skin and sclerae.

Context: He does not have pruritus.

Context: He has had no prior surgeries and takes no other medications.

Context: He is sexually active with one female partner.

Context: Prior to the accident, he drank 4 beers per day.

Context: His vital signs are within normal limits.

Context: There are no palpable abdominal masses.

Context: There is a midline surgical scar with no erythema, purulence, or drainage.

Context: He has healing abrasions on the upper left side of his face and bruises over the anterior abdomen.

Context: Laboratory studies show: | Hemoglobin 9.7 g/dL | Hematocrit 30% | Leukocyte count 7,000/mm3 | Platelet count 135,000/mm3 | Serum | Total bilirubin 3.9 mg/dL | Indirect bilirubin 3.7 mg/dL | Direct bilirubin 0.2 mg/dL | Aspartate aminotransferase (AST) 60 U/L | Alanine aminotransferase (ALT) 92 U/L | .

Choices:
A. Biliary obstruction
B. Hepatocellular injury
C. Increased formation of bilirubin
D.
Decreased hepatic uptake of unconjugated bilirubin
"

Answer: Increased formation of bilirubin

2. Patient presented 10 days after motor vehicle collision.

3. Patient underwent emergency laparotomy due to blunt abdominal trauma to the spleen.

4. Patient required rapid transfusion with a total of 7 units of packed red blood cells.

5. Patient had no prior surgeries and takes no other medications.

6. Patient is sexually active with one female partner.

7. Prior to the accident, patient drank 4 beers per day.

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

9. Abdominal examination is limited due to pain.

11. Midline surgical scar with no erythema, purulence, or drainage.

12. Patient has healing abrasions on the upper left side of his face and bruises over the anterior abdomen.

13. CT scans show a resolving hematoma in the peritoneal cavity.

14. Patient has jaundiced skin and sclerae.

16. Laboratory studies show: Hemoglobin 9.7 g/dL, Hematocrit 30%, Leukocyte count 7,000/mm3, Platelet count 135,000/mm3, Total bilirubin 3.9 mg/dL, Indirect bilirubin 3.7 mg/dL, Direct bilirubin 0.2 mg/dL, Aspartate aminotransferase (AST) 60 U/L, Alanine aminotransferase (ALT) 92 U/L.

1. The patient had emergency laparotomy for significant internal hemorrhage from blunt abdominal trauma to the spleen.

2. The patient received a total of 7 units of packed red blood cells.

3. The patient developed jaundiced skin and sclerae.

5. The patient had no prior surgeries and takes no other medications.

6. The patient is sexually active with one female partner.

7. Prior to the accident, the patient drank 4 beers per day.

8. The patient's vital signs are within normal limits.

10. There are no palpable abdominal masses.

11. The patient has a midline surgical scar with no erythema, purulence, or drainage.

12. The patient has healing abrasions on the upper left side of his face and bruises over the anterior abdomen.

14. Laboratory studies show: Hemoglobin 9.7 g/dL, Hematocrit 30%, Leukocyte count 7,000/mm3, Platelet count 135,000/mm3, Total bilirubin 3.9 mg/dL, Indirect bilirubin 3.7 mg/dL, Direct bilirubin 0.2 mg/dL, Aspartate aminotransferase (AST) 60 U/L, Alanine aminotransferase (ALT) 92 U/L.


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

Context: A 69-year-old man comes to the physician because of a cough for the past 3 months.

Context: The cough is mostly dry, but the patient recalls a recent episode in which he coughed up mucus with dark red streaks.

Context: Over the past month, he has had poor appetite and a 5-kg (11-lb) weight loss.

Context: He also has occasional back pain, which has worsened in recent weeks.

Context: He has no recent travel history.

Context: He does not drink alcohol.

Context: His vitals are within normal limits.

Context: There is no peripheral lymphadenopathy.

Context: Laboratory studies show a hemoglobin concentration of 13.5 g/dL, serum calcium concentration of 12.3 mg/dL, and a total serum protein of 7.0 g/dL.

Context: X-rays of the chest are shown.

Choices:
A. Tuberculosis
B. Lobar pneumonia
C. Small cell lung carcinoma
D.
Squamous cell lung carcinoma
"

Answer:
Squamous cell lung carcinoma
"

2. Patient has had a cough for 3 months.

4. Patient recently coughed up mucus with dark red streaks.

5. Patient has felt tired for the past few months.

6. Patient has had poor appetite and a 5-kg (11-lb) weight loss over the past month.

7. Patient has occasional back pain, which has worsened in recent weeks.

8. Patient has no recent travel history.

9. Patient has smoked a pack of cigarettes daily for 30 years.

11. Patient's vitals are within normal limits.

12. Auscultation of the lungs reveals wheezing in the lower right lung field.

16. Laboratory studies show a hemoglobin concentration of 13.5 g/dL.

17. Laboratory studies show a serum calcium concentration of 12.3 mg/dL.

18. Laboratory studies show a total serum protein of 7.0 g/dL.

2. The patient recalls a recent episode in which he coughed up mucus with dark red streaks.

3. He has felt tired for the past few months.

4. Over the past month, he has had poor appetite.

5. He has experienced a 5-kg (11-lb) weight loss.

6. He has occasional back pain, which has worsened in recent weeks.

8. He has smoked a pack of cigarettes daily for 30 years.

10. His vitals are within normal limits.

11. Auscultation of the lungs reveals wheezing in the lower right lung field.

12. There is no peripheral lymphadenopathy.

13. The liver is of normal size, and the spleen is not palpable.

14. Laboratory studies show a hemoglobin concentration of 13.5 g/dL.

15. Laboratory studies show a serum calcium concentration of 12.3 mg/dL.

16. Laboratory studies show a total serum protein of 7.0 g/dL.


Question: This neoplasm most likely derived from which of the following types of epithelial tissue?

Context: A 37-year-old man comes to the physician because of a 3-month history of worsening painful swallowing, hoarseness, and bilateral otalgia.

Context: He does not smoke or drink alcohol.

Choices:
A. Stratified squamous epithelium with submucosal glands
B. Simple columnar epithelium with cilia
C. Pseudostratified columnar epithelium with cilia
D. Pseudostratified columnar epithelium with cartilage

Answer: Stratified squamous epithelium with submucosal glands

1. A 37-year-old man comes to the physician.

2. He has a 3-month history of worsening painful swallowing, hoarseness, and bilateral otalgia.

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

5. Laryngoscopic examination shows an abnormal mass located on the right true vocal cord.

6. Immunohistochemistry of the mass shows expression of HPV-16 DNA.

1. He has had a 10-kg (22-lb) weight loss during this period.

3. Laryngoscopic examination shows an abnormal mass located on the right true vocal cord.

4. Immunohistochemistry of the mass shows expression of HPV-16 DNA.


Question: These patients are at greatest risk for which of the following complications?

Context: An investigator is studying patients with an autosomal dominant mutation in the long arm of chromosome 10.

Context: This mutation alters the structure of CD95 receptors and impairs the binding of a ligand to this receptor.

Choices:
A. Partial albinism
B. Autoimmune cytopenia
C. Acute myeloid leukemia
D. Diabetes mellitus

Answer: Autoimmune cytopenia

1. An investigator is studying patients.

2. The patients have an autosomal dominant mutation.

3. The mutation is in the long arm of chromosome 10.

4. The mutation alters the structure of CD95 receptors.

5. The mutation impairs the binding of a ligand to this receptor.

1. Mutation alters the structure of CD95 receptors.

2. Mutation impairs the binding of a ligand to the CD95 receptor.


Question: Which of the following is most likely a direct effect of these metabolites?

Context: He is following a 25-year-old female volunteer who is training for a marathon.

Context: During her training sessions, laboratory studies show increased concentrations of adenosine and lactate in the active muscles.

Choices:
A. Decreased capillary pressure
B. Decreased systemic vascular resistance
C. Increased venous return
D. Increased mixed venous oxygen saturation

Answer: Decreased systemic vascular resistance

1. An investigator is studying cardiovascular changes during exercise.

2. The investigator is following a 25-year-old female volunteer.

3. The volunteer is training for a marathon.

4. The training consists of running on a treadmill for increasing amounts of time.

5. During her training sessions, laboratory studies show increased concentrations of adenosine in the active muscles.

6. During her training sessions, laboratory studies show increased concentrations of lactate in the active muscles.

1. He is following a 25-year-old female volunteer.

2. The female volunteer is training for a marathon.

3. Her training consists of running on a treadmill for increasing amounts of time.

4. Laboratory studies show increased concentrations of adenosine in the active muscles during her training sessions.

5. Laboratory studies show increased concentrations of lactate in the active muscles during her training sessions.


Question: The patient's symptoms are most likely caused by antibodies against which of the following?

Context: A previously healthy 16-year-old girl is brought to the physician by her parents because of behavior changes and involuntary limb movements over the past 2 days.

Context: She also has a 2-week history of fever, headache, and fatigue.

Context: Her temperature is 38°C (100.4°F), pulse is 110/min, respirations are 20/min, and blood pressure is 102/72 mm Hg.

Context: Urine toxicology screening is negative.

Context: Cerebrospinal fluid analysis shows a leukocyte count of 70 cells/mm3 (90% lymphocytes) and a protein concentration of 51 mg/dL.

Choices:
A. Purkinje cell Yo antigens
B. GM1 ganglioside
C. Neuronal Hu antigens
D. Glutamate receptors

Answer: Glutamate receptors

Neurology with Special Qualification in Child Neurology

2. Parents brought her to the physician due to behavior changes and involuntary limb movements over the past 2 days.

3. Patient has a 2-week history of fever, headache, and fatigue.

8. Mental status examination shows impaired speech and a disorganized thought process.

9. Muscle strength is 5/5 in all extremities.

10. Urine toxicology screening is negative.

11. Cerebrospinal fluid analysis shows a leukocyte count of 70 cells/mm3 (90% lymphocytes).

12. Cerebrospinal fluid analysis shows a protein concentration of 51 mg/dL.

13. Abdominal ultrasound shows a large right adnexal mass.

1. 2-week history of fever, headache, and fatigue

6. Impaired speech and a disorganized thought process

7. Muscle strength is 5/5 in all extremities

8. Urine toxicology screening is negative

9. Cerebrospinal fluid analysis shows a leukocyte count of 70 cells/mm3 (90% lymphocytes) and a protein concentration of 51 mg/dL

10. Abdominal ultrasound shows a large right adnexal mass


Question: The pathogen most likely responsible for this patient's presentation contains a toxin that acts by which of the following mechanisms?

Context: A 7-year-old boy is brought to the physician by his mother because of low-grade fevers and a cough lasting for 2 weeks.

Context: He has no history of serious illness and has not received any routine childhood vaccinations.

Context: His temperature is 38.3°C (101°F).

Choices:
A. Increases intracellular cAMP
B. Increases intracellular cGMP
C. Inactivates host elongation factor
D. Inactivates host 60S ribosome

Answer: Increases intracellular cAMP

2. Patient's mother brought him to the physician.

3. Patient has low-grade fevers and a cough lasting for 2 weeks.

4. Patient has vomited several times after fits of coughing.

5. Patient has no history of serious illness.

6. Patient has not received any routine childhood vaccinations.

7. Patient's temperature is 38.3°C (101°F).

8. Physical examination shows erythema of the nasal and oral mucosa.

9. Patient has a long series of consecutive coughs, during which he appears diaphoretic.

10. Coughing is followed by a loud inspiratory gasp.

11. Laboratory studies show a leukocyte count of 16,300/mm3 (67% lymphocytes).

1. He has vomited several times after fits of coughing.

2. He has no history of serious illness.

3. He has not received any routine childhood vaccinations.

5. Physical examination shows erythema of the nasal and oral mucosa.

6. While in the exam room, he has a long series of consecutive coughs, during which he appears diaphoretic.

7. The coughing is followed by a loud inspiratory gasp.

8. Laboratory studies show a leukocyte count of 16,300/mm3 (67% lymphocytes).


Question: The CSF analysis will most likely reveal which of the following?

Context: A 21-year-old college student is rushed to the ER because of a high-grade fever that started this morning.

Context: She vomited several times last night.

Context: Her temperature is 38.9°C (102.0°F), respiratory rate is 20/min, pulse is 112/min, and blood pressure is 105/78 mm Hg.

Context: She is highly sensitive to light.

Context: Her neck feels stiff on passive flexion, with positive Kernig’s and Brudzinski’s signs.

Context: Cerebrospinal fluid (CSF) samples are sent to the lab for analysis and she is started on intravenous fluids and antibiotics.

Choices:
A. Eosinophils
B. Decreased protein concentration
C. Lymphocytosis
D. Polymorphonuclear leukocytosis

Answer: Polymorphonuclear leukocytosis

1. A 21-year-old college student is rushed to the ER.

2. The student has a high-grade fever that started this morning.

3. The student vomited several times last night.

4. The student is complaining of a severe, unremitting headache.

5. The student's temperature is 38.9°C (102.0°F).

6. The student's respiratory rate is 20/min.

8. The student's blood pressure is 105/78 mm Hg.

9. The student is highly sensitive to light.

10. The student's neck feels stiff on passive flexion.

11. The student has positive Kernig’s and Brudzinski’s signs.

12. The student has a non-blanching maculopapular rash all over the body.

13. Cerebrospinal fluid (CSF) samples are sent to the lab for analysis.

14. The student is started on intravenous fluids and antibiotics.

1. She vomited several times last night.

2. She is complaining of a severe, unremitting headache.

8. Her neck feels stiff on passive flexion.

9. She has positive Kernig’s and Brudzinski’s signs.

10. There is a non-blanching maculopapular rash all over the body.

11. Cerebrospinal fluid (CSF) samples are sent to the lab for analysis.

12. She is started on intravenous fluids and antibiotics.


Question: In addition to discontinuing the propranolol, which of the following drugs should be administered?

Context: A 58-year-old man with chronic obstructive pulmonary disease and hypertension comes to the physician because of shortness of breath 3 days after starting propranolol.

Context: His temperature is 36.7°C (98.1°F), pulse is 64/min, respirations are 20/min, and blood pressure is 138/88 mm Hg.

Choices:
A. Albuterol
B. Prednisone
C. Tiotropium bromide
D. Theophylline

Answer: Albuterol

1. A 58-year-old man has chronic obstructive pulmonary disease and hypertension.

2. He came to the physician because of shortness of breath 3 days after starting propranolol.

7. Auscultation of the lungs shows diffuse expiratory wheezes.

5. Auscultation of the lungs shows diffuse expiratory wheezes


Question: Which of the following would be expected on a peripheral blood smear?

Context: A 6-year-old boy is admitted with a one-week history of diarrhea, which was sometimes bloody and originally began after a birthday party.

Context: He has become lethargic and has not been eating or drinking.

Context: His vital signs are as follows: T 38.5 C, HR 135, BP 82/54.

Context: Physical examination is significant for petechiae on his legs and diffuse abdominal tenderness to palpation.

Context: Lab-work shows BUN 72 mg/dL, creatinine 8.1 mg/dL, and platelet count < 10,000.

Context: PT and PTT are within normal limits.

Choices:
A. Rouleaux formation
B. Fragmented red blood cells
C. Spur cells
D. Giant platelets

Answer: Fragmented red blood cells

2. He has a one-week history of diarrhea.

4. The diarrhea originally began after a birthday party.

10. Physical examination is significant for petechiae on his legs.

11. Physical examination is significant for diffuse abdominal tenderness to palpation.

13. Lab-work shows creatinine 8.1 mg/dL.

14. Lab-work shows platelet count < 10,000.

15. PT and PTT are within normal limits.

4. His vital signs are: T 38.5 C, HR 135, BP 82/54.

5. Physical examination shows petechiae on his legs.

6. Physical examination shows diffuse abdominal tenderness to palpation.

9. Lab-work shows platelet count < 10,000.

10. PT and PTT are within normal limits.


Question: Which of the following cells express molecules encoded by these genes?

Context: While studying, he learns that both class I and class II MHC molecules are expressed on specific types of cells.

Context: Currently, he is studying the HLA-DP, HLA-DQ, HLA-DRα, and HLA-DRβ genes.

Choices:
A. Eosinophils
B. Mesenchymal cells
C. Platelets
D. Thymic epithelial cells

Answer: Thymic epithelial cells

1. A microbiology student is studying the different types of cell surface markers on immune cells.

2. He is interested in the human major histocompatibility complex (MHC).

3. He is interested in human leukocyte antigens (HLAs).

4. Both class I and class II MHC molecules are expressed on specific types of cells.

5. He is currently studying the HLA-DP gene.

6. He is currently studying the HLA-DQ gene.

7. He is currently studying the HLA-DRα gene.

8. He is currently studying the HLA-DRβ gene.

1. He is interested in the human major histocompatibility complex (MHC) and human leukocyte antigens (HLAs).

2. Both class I and class II MHC molecules are expressed on specific types of cells.

3. He is studying the HLA-DP, HLA-DQ, HLA-DRα, and HLA-DRβ genes.


Question: Which of the following is the incidence of lung cancer per 1,000 people per year?

Context: The data gathered from the study are given in the table below: | Time point Total cases of lung cancer | t = 0 years 100 | t = 5 years 500 | t = 10 years 600 | .

Choices:
A. 104
B. 0.6
C. 87
D. 125

Answer: 87

1. A 10-year study of 1,000 residents in a small US town is conducted to determine the risk of developing lung cancer.

2. The study assesses each subject with a comprehensive physical exam and chest X-ray at 3-time points: at baseline, at the 5-year point, and at the conclusion of the study.

3. At each time point, the total number of cases of lung cancer in the population is recorded.

4. The data gathered from the study is given in the table below.

5. At time point t = 0 years, there are 100 total cases of lung cancer.

6. At time point t = 5 years, there are 500 total cases of lung cancer.

7. At time point t = 10 years, there are 600 total cases of lung cancer.

1. The study assesses each subject with a comprehensive physical exam and chest X-ray at 3-time points: at baseline, at the 5-year point, and at the conclusion of the study.

2. At each time point, the total number of cases of lung cancer in the population is recorded.

3. The data gathered from the study are given in the table below:

4. Time point t = 0 years, Total cases of lung cancer: 100

5. Time point t = 5 years, Total cases of lung cancer: 500

6. Time point t = 10 years, Total cases of lung cancer: 600


Question: If a kidney biopsy had been performed while the patient’s condition was pathologic, which of the following would you expect to find upon glomerular electron microscopy?

Context: Urine protein excretion is 5.2 g over 24 hours, and serum analysis reveals hyperlipidemia.

Context: The patient responds to treatment with prednisone, and, 8 weeks later, his urine does not contain measurable protein.

Choices:
A. Effacement of podocyte foot processes
B. Subepithelial ‘spike and dome’ deposits
C. Subepithelial humps
D. Subendothelial thickening

Answer: Effacement of podocyte foot processes

1. A 7-year-old boy suffers from generalized edema.

2. Urine protein excretion is 5.2 g over 24 hours.

3. Serum analysis reveals hyperlipidemia.

4. The patient responds to treatment with prednisone.

5. 8 weeks later, his urine does not contain measurable protein.

1. Urine protein excretion is 5.2 g over 24 hours.

2. Serum analysis reveals hyperlipidemia.

3. The patient responds to treatment with prednisone.

4. Eight weeks later, his urine does not contain measurable protein.


Question: Which of the following would most likely improve this patient's symptoms?

Context: A previously healthy 3-month-old girl is brought to the emergency department because her lips turned blue while passing stools 20 minutes ago.

Context: She has not stopped crying since then.

Context: She was born at 38 weeks' gestation.

Context: She is alert and agitated.

Choices:
A. Knee-chest positioning
B. Supine positioning
C. Lower limb elevation
D. Prone positioning

Answer: Knee-chest positioning

Pediatric Cardiology
General Pediatrics
Pediatric Emergency Medicine

1. A 3-month-old girl was brought to the emergency department.

3. She has not stopped crying since then.

5. She is at the 50th percentile for length.

6. She is below the 30th percentile for weight.

12. Pulse oximetry on room air shows an oxygen saturation of 70%.

13. Oxygen saturation increases to 81% on administration of 100% oxygen.

14. Physical examination shows perioral cyanosis and retractions of the lower ribs with respiration.

15. Cardiac examination shows a harsh grade 2/6 systolic crescendo-decrescendo murmur at the left upper sternal border.

1. She has not stopped crying since then.

3. She is at the 50th percentile for length and below the 30th percentile for weight.

5. Her temperature is 36.6°C (98°F), pulse is 180/min, respirations are 50/min, and blood pressure is 70/50 mm Hg.

6. Pulse oximetry on room air shows an oxygen saturation of 70%, which increases to 81% on administration of 100% oxygen.

7. Physical examination shows perioral cyanosis and retractions of the lower ribs with respiration.

8. Cardiac examination shows a harsh grade 2/6 systolic crescendo-decrescendo murmur at the left upper sternal border.


Question: Which of the following best describes the pathogenesis of the disease process in this patient?"

Context: Laboratory studies show: | Hemoglobin 11.0 g/dL | Mean corpuscular volume 74 μm3 | Red cell distribution width 14 (N=13-15) | Serum ferritin 77 ng/mL | Peripheral blood smear shows small, pale red blood cells.

Context: Hemoglobin electrophoresis is normal.

Choices:
A. Decreased production of β-globin proteins
B. Amino acid substitution in the β-globin protein
C. Cis deletion of α-globin genes
D. Acquired inhibition of heme synthesis

Answer: Cis deletion of α-globin genes

1. An 8-year-old girl of Asian descent is brought to the physician because of fatigue.

2. She is not able to keep up with the rest of her classmates in gym class because she tires easily.

3. Physical examination shows pale conjunctivae.

4. Laboratory studies show Hemoglobin 11.0 g/dL.

5. Laboratory studies show Mean corpuscular volume 74 μm3.

6. Laboratory studies show Red cell distribution width 14 (N=13-15).

7. Laboratory studies show Serum ferritin 77 ng/mL.

8. Peripheral blood smear shows small, pale red blood cells.

9. Hemoglobin electrophoresis is normal.

1. She is not able to keep up with the rest of her classmates in gym class because she tires easily.

2. Physical examination shows pale conjunctivae.

3. Laboratory studies show: Hemoglobin 11.0 g/dL.

4. Laboratory studies show: Mean corpuscular volume 74 μm3.

5. Laboratory studies show: Red cell distribution width 14 (N=13-15).

6. Laboratory studies show: Serum ferritin 77 ng/mL.

7. Peripheral blood smear shows small, pale red blood cells.

8. Hemoglobin electrophoresis is normal.


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

Context: A 52-year-old postmenopausal woman comes to the physician with a 6-month history of difficulty biting down and chewing that is becoming progressively worse.

Context: Vital signs are within normal limits.

Context: Laboratory studies show: | Hemoglobin 14.6 g/dL | Leukocyte count 9,000/mm3 | Platelet count 256,000/mm3 | Serum | Alkaline phosphatase 1100 U/L | Vitamin D 40 ng/ml (N = 20–100 ng/mL) | Calcium 9.5 mg/dL | Parathyroid hormone 300 pg/mL | A plain x-ray of the skull is shown.

Choices:
A. Hematopoietic cell transplantation
B. Transsphenoidal hypophysectomy
C. Intravenous zoledronate
D. Estrogen replacement therapy

Answer: Intravenous zoledronate

Neurology
Dermatology
Orthopaedic Surgery
Otolaryngology

Neuromuscular Medicine
General Otolaryngology
General Orthopaedic Surgery
General Dermatology

1. Patient is a 52-year-old postmenopausal woman.

2. Patient has a 6-month history of difficulty biting down and chewing that is becoming progressively worse.

3. Patient has been taking acetaminophen for headaches and nonspecific pain in her hips and back.

4. Patient complains that her hearing has been deteriorating as she gets older.

5. Vital signs are within normal limits.

6. Examination shows a mildly tender, 1-cm, bony, immobile swelling in the left side of her forehead.

7. Intraoral examination shows bilateral expansion of the maxillary alveolus and malocclusion.

8. Audiometry shows bilateral mixed conductive and sensorineural hearing loss.

9. Laboratory studies show: Hemoglobin 14.6 g/dL, Leukocyte count 9,000/mm3, Platelet count 256,000/mm3, Serum Alkaline phosphatase 1100 U/L, Vitamin D 40 ng/ml (N = 20–100 ng/mL), Calcium 9.5 mg/dL, Parathyroid hormone 300 pg/mL.

10. A plain x-ray of the skull is shown.

1. She has been taking acetaminophen for headaches and nonspecific pain in her hips and back.

2. She also complains that her hearing has been deteriorating as she gets older.

3. Vital signs are within normal limits.

4. Examination shows a mildly tender, 1-cm, bony, immobile swelling in the left side of her forehead.

5. Intraoral examination shows bilateral expansion of the maxillary alveolus and malocclusion.

6. Audiometry shows bilateral mixed conductive and sensorineural hearing loss.

7. Laboratory studies show: Hemoglobin 14.6 g/dL, Leukocyte count 9,000/mm3, Platelet count 256,000/mm3, Serum Alkaline phosphatase 1100 U/L, Vitamin D 40 ng/ml (N = 20–100 ng/mL), Calcium 9.5 mg/dL, Parathyroid hormone 300 pg/mL.


Question: Serum studies obtained 5 days after admission show: | Na+ 138 mEq/L | Cl− 101 mEq/L | Mg2+ 1.3 mEq/L | Urea nitrogen 42 mg/dL | Creatinine 1.8 mg/dL | Arterial blood gas analysis on room air: | pH 7.51 | PCO2 52 mm Hg | PO2 60 mm Hg | HCO3- 33 mmol/L | Further evaluation of this patient is most likely to show which of the following findings?"

Context: A 66-year-old man is brought to the emergency department because of worsening shortness of breath and progressive swelling of his legs for 1 week.

Context: He has hypertension and hyperlipidemia.

Context: His temperature is 37.5°C (99°F), pulse is 95/min, respirations are 12/min, and blood pressure is 113/70 mm Hg.

Context: An S3 gallop is heard on auscultation.

Context: There is jugular venous distension and pitting edema of both ankles.

Context: He is admitted to the hospital and treatment with intravenous bumetanide is initiated.

Choices:
A. Elevated serum aldosterone
B. Decreased urine chloride
C. Decreased serum renin
D. Elevated serum potassium

Answer: Elevated serum aldosterone

1. A 66-year-old man is brought to the emergency department.

2. He has worsening shortness of breath and progressive swelling of his legs for 1 week.

3. He has hypertension and hyperlipidemia.

4. His current medications include amlodipine and pravastatin.

9. Pulmonary examination shows bilateral coarse crackles.

10. An S3 gallop is heard on auscultation.

12. There is pitting edema of both ankles.

14. Treatment with intravenous bumetanide is initiated.

1. He has hypertension and hyperlipidemia.

2. Current medications include amlodipine and pravastatin.

7. Pulmonary examination shows bilateral coarse crackles.

8. An S3 gallop is heard on auscultation.

10. There is pitting edema of both ankles.

12. Treatment with intravenous bumetanide is initiated.


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

Context: A 16-year-old boy is brought to the emergency department by his parents after collapsing at home.

Context: He was resting at home after an uneventful dental procedure that involved the extraction of several teeth.

Context: At the hospital, his temperature is 37.0° C (98.6° F), respiratory rate is 15/min, pulse rate is 67/min, and blood pressure is 122/98 mm Hg.

Context: Oxygen saturation is 85% on room air.

Choices:
A. Cyanide poisoning
B. Methemoglobinemia
C. Sulfhemoglobinemia
D. Carbon monoxide poisoning

Answer: Methemoglobinemia

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

4. Patient had an uneventful dental procedure involving the extraction of several teeth.

5. Patient became drowsy and then unconscious and was unrousable.

6. Patient's temperature is 37.0° C (98.6° F).

7. Patient's respiratory rate is 15/min.

9. Patient's blood pressure is 122/98 mm Hg.

10. Patient's oxygen saturation is 85% on room air.

11. Patient is deeply cyanosed despite a good respiratory effort and a clear airway.

12. Patient's lungs are clear to auscultation, bilaterally.

13. An endotracheal tube was introduced and assisted ventilation was induced, but patient's condition did not improve.

14. Dental records reveal the details of the procedure where the local anesthetic pilocarpine was administered.

1. The patient was resting at home after a dental procedure involving the extraction of several teeth.

2. He became drowsy and then unconscious and was unrousable.

3. At the hospital, his temperature is 37.0° C (98.6° F).

7. Oxygen saturation is 85% on room air.

8. The patient is deeply cyanosed despite a good respiratory effort and a clear airway.

9. His lungs are clear to auscultation, bilaterally.

10. Even though an endotracheal tube is introduced and assisted ventilation is induced, his condition does not improve.

11. A review of dental records reveals the details of the procedure where the local anesthetic pilocarpine was administered.


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

Context: Patient Information.

Context: Age: 1 day.

Context: Sex: F.

Context: Ethnicity: Hispanic.

Context: Site of Care: office.

Context: History.

Context: Reason for Visit/Chief Concern: brought in by her parents because “her arm looks funny”.

Context: History of Present Illness: mother had no prenatal care.

Context: labor was spontaneous with rupture of membranes yielding fluid with dark green streaks.

Context: the infant was delivered vaginally 1 day ago at home at approximately 39 weeks' gestation.

Context: the delivery was complicated by shoulder dystocia, which was managed with suprapubic pressure and the McRoberts maneuver.

Context: father reports that the infant's right arm “just hangs by the side” and that she never bends her right elbow.

Context: the infant is breastfeeding, stooling, and voiding without complication.

Context: Past Medical History: none.

Context: Family History: mother has type 2 diabetes mellitus.

Context: Medications: none.

Context: Immunizations: has not received any routine vaccinations.

Context: Allergies: no known drug allergies.

Context: Social History: the infant lives with her mother, father, and paternal grandmother.

Context: no one in the residence smokes.

Context: Physical Examination.

Context: Temp Pulse Resp BP O2 Sat Ht Wt Head circumference.

Context: 154/min 45/min 87/49 mm Hg.

Context: 50 cm.

Context: (20 in; 69th percentile).

Context: 4,400 g.

Context: (9 lb 11 oz; 99th percentile).

Context: 35 cm.

Context: (13.8 in; 82nd percentile).

Context: Appearance: well-appearing; crying during the examination.

Context: HEENT: red reflex is seen bilaterally; there is a fluctuant area over the left parietal bone that crosses suture lines.

Context: Pulmonary: clear to auscultation.

Context: Cardiac: regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops.

Context: Abdominal: no tenderness, masses, or hepatosplenomegaly; bowel sounds normal; umbilical stump is intact and clamped.

Context: Extremities: hips are stable bilaterally.

Context: Musculoskeletal: clavicles are intact bilaterally; the right upper extremity hangs limply from the shoulder in full extension, adduction, and fixed internal rotation; the hand is pronated, and the wrist and fingers are flexed.

Context: Skin: dry, warm; no jaundice.

Context: Neurologic: normal suck and grasp reflexes; the Moro reflex is normal in the left upper extremity and absent in the right upper extremity; deep tendon reflexes are 2+ bilaterally. Please refer to the summary above to answer this question.

Choices:
A. Injury to the median nerve
B. Damage to the upper trunk of the brachial plexus
C. Damage to the lower trunk of the brachial plexus
D. Aspiration of meconium

Answer: Damage to the upper trunk of the brachial plexus

General Orthopaedic Surgery
Surgery of the Hand

- Reason for Visit/Chief Concern: brought in by her parents because “her arm looks funny”

- History of Present Illness: mother had no prenatal care

- Labor was spontaneous with rupture of membranes yielding fluid with dark green streaks

- The infant was delivered vaginally 1 day ago at home at approximately 39 weeks' gestation

- The delivery was complicated by shoulder dystocia, which was managed with suprapubic pressure and the McRoberts maneuver

- Father reports that the infant's right arm “just hangs by the side” and that she never bends her right elbow

- The infant is breastfeeding, stooling, and voiding without complication

- Family History: mother has type 2 diabetes mellitus

- Immunizations: has not received any routine vaccinations

- Social History: the infant lives with her mother, father, and paternal grandmother; no one in the residence smokes

- Wt: 4,400 g (9 lb 11 oz; 99th percentile)

- Head circumference: 35 cm (13.8 in; 82nd percentile)

- Appearance: well-appearing; crying during the examination

- HEENT: red reflex is seen bilaterally; there is a fluctuant area over the left parietal bone that crosses suture lines

- Cardiac: regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops

- Abdominal: no tenderness, masses, or hepatosplenomegaly; bowel sounds normal; umbilical stump is intact and clamped

- Extremities: hips are stable bilaterally

- Musculoskeletal: clavicles are intact bilaterally; the right upper extremity hangs limply from the shoulder in full extension, adduction, and fixed internal rotation; the hand is pronated, and the wrist and fingers are flexed

- Neurologic: normal suck and grasp reflexes; the Moro reflex is normal in the left upper extremity and absent in the right upper extremity; deep tendon reflexes are 2+ bilaterally.

5. Reason for Visit/Chief Concern: brought in by her parents because “her arm looks funny”

6. History of Present Illness: mother had no prenatal care

7. Labor was spontaneous with rupture of membranes yielding fluid with dark green streaks

8. The infant was delivered vaginally 1 day ago at home at approximately 39 weeks' gestation

9. The delivery was complicated by shoulder dystocia, which was managed with suprapubic pressure and the McRoberts maneuver

10. Father reports that the infant's right arm “just hangs by the side” and that she never bends her right elbow

11. The infant is breastfeeding, stooling, and voiding without complication

13. Family History: mother has type 2 diabetes mellitus

15. Immunizations: has not received any routine vaccinations

17. Social History: the infant lives with her mother, father, and paternal grandmother

25. Wt: 4,400 g (9 lb 11 oz; 99th percentile)

26. Head circumference: 35 cm (13.8 in; 82nd percentile)

27. Appearance: well-appearing; crying during the examination

28. HEENT: red reflex is seen bilaterally; there is a fluctuant area over the left parietal bone that crosses suture lines

30. Cardiac: regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops

31. Abdominal: no tenderness, masses, or hepatosplenomegaly; bowel sounds normal; umbilical stump is intact and clamped

32. Extremities: hips are stable bilaterally

33. Musculoskeletal: clavicles are intact bilaterally; the right upper extremity hangs limply from the shoulder in full extension, adduction, and fixed internal rotation; the hand is pronated, and the wrist and fingers are flexed

35. Neurologic: normal suck and grasp reflexes; the Moro reflex is normal in the left upper extremity and absent in the right upper extremity; deep tendon reflexes are 2+ bilaterally


Question: Which of the following pathogens is the most likely cause of this patient’s condition?

Context: A 34-year-old man presents with severe left inguinal pain and swelling since last night.

Context: He has just returned from a summer trip to the southwestern United States where he spent most of his time working with homeless and unemployed people in an area that straddles New Mexico and Utah.

Context: Upon further inquiry, he denies any contact with wild or domestic animals including pets, but he does remember occasionally seeing mice in his motel room and found their droppings on the floor.

Context: On physical exam his temperature is 38.5°C (101.3°F), pulse is 95/min, respiration rate is 18/min, and blood pressure is 130/85 mm Hg.

Context: The left inguinal area is swollen.

Context: A localized rash is found in the ipsilateral inner thigh above the knee (see image).

Choices:
A. Hantavirus
B. Rhabdovirus
C. Borrelia burgdorferi
D. Yersinia pestis

Answer: Yersinia pestis

2. Patient has severe left inguinal pain and swelling since last night.

3. Patient recently returned from a summer trip to the southwestern United States.

4. Patient spent most of his time working with homeless and unemployed people in an area that straddles New Mexico and Utah.

5. Patient denies any contact with wild or domestic animals including pets.

6. Patient remembers occasionally seeing mice in his motel room and found their droppings on the floor.

7. Patient's temperature is 38.5°C (101.3°F).

9. Patient's respiration rate is 18/min.

10. Patient's blood pressure is 130/85 mm Hg.

12. No skin erythema and not warm to palpation.

13. Several enlarged and soft lymph nodes with a hard underlying core.

14. Area is very tender and surrounded by edema.

15. Localized rash found in ipsilateral inner thigh above the knee.

16. Examination of heart, lungs, abdomen, and other limbs shows no abnormalities.

1. The patient has just returned from a summer trip to the southwestern United States.

2. He spent most of his time working with homeless and unemployed people in an area that straddles New Mexico and Utah.

3. He denies any contact with wild or domestic animals including pets.

4. He occasionally saw mice in his motel room and found their droppings on the floor.

5. On physical exam, his temperature is 38.5°C (101.3°F).

10. There is no skin erythema and it is not warm to palpation.

11. There are several enlarged and soft lymph nodes with a hard underlying core.

12. The area is very tender and surrounded by edema.

13. A localized rash is found in the ipsilateral inner thigh above the knee.

14. Examination of the heart, lungs, abdomen, and other limbs shows no abnormalities.


Question: Which of the following is the most appropriate advice for this patient’s mother?

Context: A 10-year-old unvaccinated girl presents to her pediatrician with a rash.

Context: Her mother reports that she has had a fever, “red eyes,” sore throat, and rash on her face for the last day.

Context: On physical examination, the girl appears sick but not toxic, and has nonpurulent conjunctivitis and an erythematous posterior pharynx without exudate or tonsillar hypertrophy.

Context: She has lymphadenopathy bilaterally.

Context: Her heart has a regular rate without murmurs, her lungs are clear to auscultation bilaterally, and her abdomen is soft without hepatosplenomegaly.

Context: She has red cheeks with circumoral pallor and no other skin findings.

Choices:
A. This infection could have been prevented with a vaccine.
B. Her symptoms were caused by human herpesvirus type 6 (HHV-6) or human herpesvirus type 7 (HHV-7).
C. She will likely develop a maculopapular truncal rash in a few days that will fade to become a lacy rash.
D. She should be started on oral valacyclovir.

Answer: She will likely develop a maculopapular truncal rash in a few days that will fade to become a lacy rash.

General Pediatrics
Pediatric Infectious Diseases

1. A 10-year-old unvaccinated girl presents to her pediatrician.

2. Her mother reports that she has had a fever.

3. Her mother reports that she has had "red eyes".

4. Her mother reports that she has had a sore throat.

5. Her mother reports that she has had a rash on her face for the last day.

6. On physical examination, the girl appears sick but not toxic.

7. On physical examination, the girl has nonpurulent conjunctivitis.

8. On physical examination, the girl has an erythematous posterior pharynx without exudate or tonsillar hypertrophy.

9. On physical examination, the girl has lymphadenopathy bilaterally.

10. On physical examination, the girl's heart has a regular rate without murmurs.

11. On physical examination, the girl's lungs are clear to auscultation bilaterally.

12. On physical examination, the girl's abdomen is soft without hepatosplenomegaly.

13. On physical examination, the girl has red cheeks with circumoral pallor.

14. On physical examination, the girl has no other skin findings.

1. Her mother reports that she has had a fever for the last day.

2. Her mother reports that she has had "red eyes" for the last day.

3. Her mother reports that she has had a sore throat for the last day.

4. Her mother reports that she has had a rash on her face for the last day.

5. On physical examination, the girl appears sick but not toxic.

6. On physical examination, the girl has nonpurulent conjunctivitis.

7. On physical examination, the girl has an erythematous posterior pharynx without exudate.

8. On physical examination, the girl has an erythematous posterior pharynx without tonsillar hypertrophy.

10. On physical examination, her heart has a regular rate without murmurs.

11. On physical examination, her lungs are clear to auscultation bilaterally.

12. On physical examination, her abdomen is soft without hepatosplenomegaly.

13. On physical examination, she has red cheeks with circumoral pallor.

14. On physical examination, she has no other skin findings.


Question: Which of the following changes in forced expiratory volume (FEV1) and forced vital capacity (FVC) are expected if she takes a pulmonary function test?

Context: A 42-year-old woman presents to the clinic for worsening fatigue and difficulty breathing for the last 6 months.

Context: Previously, she could routinely walk 3 miles after dinner, but now she can no longer walk more than 2 blocks without being short of breath.

Context: She also reports being tired soon after starting any type of physical activity.

Context: On further questioning, she recalls having on and off fevers, occasional night sweats, and losing 5 kg (11 lb) over the last 6 months.

Context: Her past medical history reveals 2 cesarean deliveries in her twenties and a hospitalization for acute appendicitis in her teens.

Context: She currently takes no medications and also denies smoking and recreational drug use.

Context: She drinks half a glass of wine with her evening meals.

Context: Her vitals include a respiratory rate of 14/min, a pulse rate of 87/min, a blood pressure of 110/89 mm Hg, and a temperature of 36.7°C (98.0°F).

Context: Physical examination is normal.

Context: A chest X-ray shows bilateral hilar lymphadenopathy.

Choices:
A. FEV1: decrease and FVC: decreased
B. FEV1: decreased and FVC: no change
C. FEV1: decreased and FVC: increased
D. FEV1: no change and FVC: no change

Answer: FEV1: decrease and FVC: decreased

General Pulmonary Disease
General Pulmonology

2. Patient has been experiencing worsening fatigue and difficulty breathing for the last 6 months.

3. Patient used to be able to walk 3 miles after dinner, but now can only walk 2 blocks without being short of breath.

4. Patient reports being tired soon after starting any type of physical activity.

5. Patient has had on and off fevers, occasional night sweats, and has lost 5 kg (11 lb) over the last 6 months.

6. Patient's past medical history includes 2 cesarean deliveries in her twenties and a hospitalization for acute appendicitis in her teens.

8. Patient denies smoking and recreational drug use.

9. Patient drinks half a glass of wine with her evening meals.

10. Patient's vitals include a respiratory rate of 14/min, a pulse rate of 87/min, a blood pressure of 110/89 mm Hg, and a temperature of 36.7°C (98.0°F).

12. Chest X-ray shows bilateral hilar lymphadenopathy.

1. Previously, she could routinely walk 3 miles after dinner

2. Now she can no longer walk more than 2 blocks without being short of breath

3. She reports being tired soon after starting any type of physical activity

4. On further questioning, she recalls having on and off fevers

5. She also recalls occasional night sweats

6. She has lost 5 kg (11 lb) over the last 6 months

7. Her past medical history reveals 2 cesarean deliveries in her twenties

8. Her past medical history reveals a hospitalization for acute appendicitis in her teens

10. She denies smoking and recreational drug use

11. She drinks half a glass of wine with her evening meals

12. Her vitals include a respiratory rate of 14/min

13. Her vitals include a pulse rate of 87/min

14. Her vitals include a blood pressure of 110/89 mm Hg

15. Her vitals include a temperature of 36.7°C (98.0°F)

17. A chest X-ray shows bilateral hilar lymphadenopathy


Question: This patient's symptoms are most likely caused by a side effect of which of the following medications?

Context: A 42-year-old woman is brought to the emergency department because of a severe, throbbing, occipital headache for 2 hours.

Context: The patient has recurrent migraine headaches and depression, for which she takes medication daily.

Context: Her temperature is 37.2°C (98.9 F), pulse is 88/min, respirations are 19/min, and blood pressure is 190/128 mmHg.

Choices:
A. Tranylcypromine
B. Almotriptan
C. Topiramate
D. Doxepin

Answer: Tranylcypromine

1. A 42-year-old woman is brought to the emergency department.

2. She has a severe, throbbing, occipital headache for 2 hours.

3. She also reports nausea, photophobia, and chest tightness.

4. The symptoms developed shortly after she had a snack consisting of salami and some dried fruits at a wine tasting event.

5. The patient has recurrent migraine headaches and depression.

6. She takes medication daily for her migraine headaches and depression.

7. She is mildly distressed, diaphoretic, and her face is flushed.

12. Deep-tendon reflexes are 2+ bilaterally.

4. The symptoms developed after having a snack of salami and dried fruits at a wine tasting event.

5. The patient has recurrent migraine headaches.

7. The patient takes medication daily for migraine headaches and depression.

11. The patient's temperature is 37.2°C (98.9 F).

13. The patient's respirations are 19/min.

14. The patient's blood pressure is 190/128 mmHg.

15. Deep-tendon reflexes are 2+ bilaterally.


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

Context: A 70-year-old man is brought to the emergency department because of severe back pain that began when he was lifting a box 1 hour ago.

Context: He also has a 2-year history of increasingly severe right hip pain.

Context: Physical examination shows tenderness to palpation of the lower spine as well as erythema of the skin over the right hip.

Context: Neurologic examination shows decreased hearing in the left ear; the Weber test localizes to the left side.

Context: Serum studies show an alkaline phosphatase concentration of 410 U/L, calcium concentration of 9.5 mg/dL, and parathyroid hormone level of 322 pg/mL.

Choices:
A. Osteoporosis
B. Osteomalacia
C. Osteitis deformans
D. Osteonecrosis

Answer: Osteitis deformans

Orthopaedic Sports Medicine
General Orthopaedic Surgery

1. A 70-year-old man is brought to the emergency department.

2. The man has severe back pain that began 1 hour ago.

3. The man has a 2-year history of increasingly severe right hip pain.

4. Physical examination shows tenderness to palpation of the lower spine.

5. Physical examination also shows erythema of the skin over the right hip.

6. Neurologic examination shows decreased hearing in the left ear.

7. The Weber test localizes to the left side.

8. Serum studies show an alkaline phosphatase concentration of 410 U/L.

9. Serum studies show a calcium concentration of 9.5 mg/dL.

10. Serum studies show a parathyroid hormone level of 322 pg/mL.

11. An x-ray of the spine shows a fracture of the L4 vertebra.

1. 2-year history of increasingly severe right hip pain

2. Physical examination shows tenderness to palpation of the lower spine

3. Physical examination shows erythema of the skin over the right hip

4. Neurologic examination shows decreased hearing in the left ear

5. Weber test localizes to the left side

6. Serum studies show alkaline phosphatase concentration of 410 U/L

7. Serum studies show calcium concentration of 9.5 mg/dL

8. Serum studies show parathyroid hormone level of 322 pg/mL

9. X-ray of the spine shows a fracture of the L4 vertebra


Question: Which of the following is true about cross-over study designs?

Context: A study investigating the use of adalimumab for the relief of peripheral arthropathy in patients with psoriatic arthritis was conducted.

Context: The study utilizes a crossover design in which half of the study participants are given adalimumab for a month while the other half takes placebo.

Context: After a 2 week washout period in which no one takes any adalimumab, the group that was originally on adalimumab is given placebo for a month while the group that was originally taking placebo is given adalimumab for a month.

Choices:
A. Crossover studies avoid the ethical issue of not giving all participants access to a novel therapeutic agent
B. Crossover studies minimize the effects of differences between participants
C. The purpose of the washout period is to increase the length of the study to gather more data
D. 1 and 2

Answer: 1 and 2

1. A study was conducted investigating the use of adalimumab for the relief of peripheral arthropathy in patients with psoriatic arthritis.

2. The study utilizes a crossover design.

3. Half of the study participants are given adalimumab for a month.

5. After a 2 week washout period, the group that was originally on adalimumab is given placebo for a month.

6. The group that was originally taking placebo is given adalimumab for a month.

7. Pain in all affected joints is assessed clinically by follow-up visits every two weeks for the duration of the study.

1. The study utilizes a crossover design.

2. Half of the study participants are given adalimumab for a month.

3. The other half takes placebo for a month.

4. After a 2 week washout period, no one takes any adalimumab.

5. The group originally on adalimumab is given placebo for a month.

6. The group originally taking placebo is given adalimumab for a month.

7. Pain in all affected joints is assessed clinically.

8. Follow-up visits occur every two weeks for the duration of the study.


Question: Which medication is likely responsible for these symptoms?

Context: A 64-year-old woman presented to the community health clinic complaining of nausea, bloating, pain in both knees, and a burning sensation in her feet.

Context: She has recently immigrated to the United States and was previously diagnosed with diabetes mellitus, hypertension, and osteoarthritis but no medical records are currently available.

Context: She has stopped taking her medication since immigrating; however, she does recall being on insulin but cannot recall the dosage or the specific type.

Context: She has a blood pressure of 172/120 mm Hg, heart rate of 95/min, respiratory rate of 15/min, and temperature of 37.0°C (98.6°F).

Context: Her random serum glucose is 364 mg/dL.

Choices:
A. Atorvastatin
B. Metoclopramide
C. Ramipril
D. Acetaminophen

Answer: Metoclopramide

1. A 64-year-old woman presented to the community health clinic.

2. She was complaining of nausea, bloating, pain in both knees, and a burning sensation in her feet.

3. She has recently immigrated to the United States.

4. She was previously diagnosed with diabetes mellitus, hypertension, and osteoarthritis.

5. No medical records are currently available.

6. She has stopped taking her medication since immigrating.

7. She recalls being on insulin but cannot recall the dosage or the specific type.

12. Her random serum glucose is 364 mg/dL.

13. She is started on atorvastatin, amlodipine, ramipril, aspirin, duloxetine, metoclopramide, acetaminophen, and insulin detemir.

14. Three weeks later, she presents with generalized weakness, walking difficulty, and hand tremors.

15. Physical examination reveals bilateral hand tremors, cogwheel rigidity, and bradykinesia.

16. She is walking with small narrow steps and reduced arm swing.

17. Today her random serum glucose is 150 mg/dL.

18. Her symptoms are presumed to be caused by a drug.

1. She has recently immigrated to the United States.

2. She was previously diagnosed with diabetes mellitus, hypertension, and osteoarthritis.

3. No medical records are currently available.

4. She has stopped taking her medication since immigrating.

5. She recalls being on insulin but cannot recall the dosage or the specific type.

6. She has a blood pressure of 172/120 mm Hg.

10. Her random serum glucose is 364 mg/dL.

11. She is started on atorvastatin, amlodipine, ramipril, aspirin, duloxetine, metoclopramide, acetaminophen, and insulin detemir.

12. Three weeks later, she presents with generalized weakness, walking difficulty, and hand tremors.

13. Physical examination reveals bilateral hand tremors, cogwheel rigidity, and bradykinesia.

14. She is walking with small narrow steps and reduced arm swing.

15. Today her random serum glucose is 150 mg/dL.

16. Her symptoms are presumed to be caused by a drug.


Question: This patient most likely has an injury to which of the following muscle tendons?

Context: A 51-year-old man presents to the emergency room after being the victim of a robbery and assault.

Context: Upon resisting, the stranger stabbed the patient’s right distal forearm before stealing his wallet and evading the scene.

Context: The patient was able to call an ambulance and has remained conscious despite mild bleeding from the injury site.

Context: He reports severe pain in his forearm and an inability to move his 2nd and 3rd fingers.

Context: He has no medical conditions and takes no medications.

Context: He is allergic to penicillin and ibuprofen.

Choices:
A. Flexor digitorum longus
B. Flexor digitorum profundus
C. Flexor digitorum superficialis
D. Flexor pollicis longus

Answer: Flexor digitorum profundus

1. A 51-year-old man presents to the emergency room.

2. He was the victim of a robbery and assault.

3. He was walking down an alley when he was approached by a stranger with a knife.

4. Upon resisting, the stranger stabbed the patient’s right distal forearm.

5. The stranger stole the patient's wallet and evaded the scene.

6. The patient was able to call an ambulance.

8. The patient has mild bleeding from the injury site.

9. The patient reports severe pain in his forearm.

10. The patient reports an inability to move his 2nd and 3rd fingers.

11. The patient has no medical conditions.

13. The patient is allergic to penicillin.

14. The patient is allergic to ibuprofen.

15. On exam, the patient is able to flex the proximal interphalangeal (PIP) joints of his 2nd through 5th fingers.

16. When the PIP joints of his 2nd through 5th fingers are restrained by the examiner, flexion is noted at the DIP joints of the 4th and 5th fingers but not the 2nd and 3rd digits.

17. Thumb flexion at the metacarpophalangeal (MCP) joint and interphalangeal (IP) joint is preserved.

18. Sensation is intact over the palmar and dorsal aspects of the radial and ulnar hand.

2. Patient was approached by a stranger with a knife.

3. Stranger stabbed the patient’s right distal forearm.

4. Stranger stole the patient's wallet and evaded the scene.

5. Patient was able to call an ambulance.

6. Patient has remained conscious despite mild bleeding from the injury site.

7. Patient reports severe pain in his forearm.

8. Patient reports an inability to move his 2nd and 3rd fingers.

11. Patient is allergic to penicillin and ibuprofen.

12. On exam, the patient is able to flex the PIP joints of his 2nd through 5th fingers.

13. When the PIP joints of his 2nd through 5th fingers are restrained by the examiner, flexion is noted at the DIP joints of the 4th and 5th fingers but not the 2nd and 3rd digits.

14. Thumb flexion at the MCP joint and IP joint is preserved.

15. Sensation is intact over the palmar and dorsal aspects of the radial and ulnar hand.


Question: Which of the following natural substances are most similar to the concentration profiles of drug X and drug Y in the proximal tubule?

Context: Researchers develop a drug X that acts on the loop of Henle but discover that it does not reach its intended site of action within the nephron.

Context: It is freely filtered but rapidly disappears from the proximal tubule.

Context: They modify several of the chemical properties of drug X to produce drug Y, which cannot be reabsorbed from the proximal tubule.

Choices:
A. Drug X: creatinine; Drug Y: glucose
B. Drug X: glucose; Drug Y: creatinine
C. Drug X: glucose; Drug Y: potassium
D. Drug X: potassium; Drug Y: creatinine

Answer: Drug X: glucose; Drug Y: creatinine

3. Drug X does not reach its intended site of action within the nephron.

5. Drug X rapidly disappears from the proximal tubule.

6. Researchers modify several of the chemical properties of drug X.

7. Drug X is modified to produce drug Y.

8. Drug Y cannot be reabsorbed from the proximal tubule.

1. Drug X is modified by a process to produce drug Y.

2. Drug Y cannot be reabsorbed from the proximal tubule.

4. Drug X rapidly disappears from the proximal tubule.


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

Context: A 66-year-old woman comes to the emergency department because of fever and difficulty swallowing for 5 hours.

Context: She appears anxious.

Context: Her temperature is 39.1°C (102.4°F).

Context: There is tender bilateral cervical lymphadenopathy and pain upon palpation of the hyoid.

Context: Laboratory studies show a leukocyte count of 18,800/mm3 with 85% neutrophils.

Choices:
A. Haemophilus influenzae type b
B. Streptococcus pyogenes
C. Corynebacterium diphtheriae
D.
Parainfluenza virus
"

Answer: Haemophilus influenzae type b

Otolaryngology
Internal Medicine
Pediatrics

General Otolaryngology
Pediatric Infectious Diseases
Infectious Disease

1. A 66-year-old woman comes to the emergency department.

2. She has had fever and difficulty swallowing for 5 hours.

5. Physical examination shows an extended neck and excessive drooling.

8. There is tender bilateral cervical lymphadenopathy.

9. There is pain upon palpation of the hyoid.

10. Laboratory studies show a leukocyte count of 18,800/mm3.

11. Laboratory studies show 85% neutrophils.

3. Physical examination shows an extended neck and excessive drooling.

4. Her voice is muffled and there is inspiratory stridor.

5. There is tender bilateral cervical lymphadenopathy.

6. There is pain upon palpation of the hyoid.

7. Laboratory studies show a leukocyte count of 18,800/mm3.

8. The leukocyte count shows 85% neutrophils.


Question: What is the cause of the persistent symptoms?

Context: A 65-year-old man with a history of coronary artery disease presents to your office complaining of ongoing chest pain with exertion.

Context: The patient has had a recent cardiac work-up that showed no areas of acute ischemia.

Context: At the last visit, the patient was prescribed sublingual nitroglycerin for symptom relief of stable angina.

Context: On further questioning, the patient states that he has been swallowing the tablet whole instead of allowing it to dissolve because he “does not like the taste”.

Choices:
A. Nitroglycerin tolerance
B. Unstable angina
C. First pass metabolism of nitroglycerin
D. Concomitant use of sildenafil

Answer: First pass metabolism of nitroglycerin

1. A 65-year-old man presents to the office.

2. The patient has a history of coronary artery disease.

3. The patient is complaining of chest pain with exertion.

4. The patient had a recent cardiac work-up that showed no areas of acute ischemia.

5. At the last visit, the patient was prescribed sublingual nitroglycerin.

6. The patient has been swallowing the tablet whole instead of allowing it to dissolve.

7. The patient does not like the taste of the nitroglycerin.

1. The patient had a recent cardiac work-up.

2. The cardiac work-up showed no areas of acute ischemia.

3. At the last visit, the patient was prescribed sublingual nitroglycerin.

4. The nitroglycerin was prescribed for symptom relief of stable angina.

5. The patient has been swallowing the nitroglycerin tablet whole.

6. The patient has not been allowing the tablet to dissolve.

7. The reason for not allowing the tablet to dissolve is that the patient does not like the taste.


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

Context: A 5-year-old boy is brought to the physician by his mother because of a 3-day history of low-grade fever and sore throat.

Context: This morning, she noticed a rash on his buttocks, hands, and feet.

Context: He does not have pruritus.

Context: His temperature is 38.3°C (100.9°F), pulse is 99/min, and blood pressure is 123/78 mm Hg.

Choices:
A. Herpes simplex virus 1
B. Coxsackie A virus
C. Parvovirus B19
D. Epstein-Barr virus

Answer: Coxsackie A virus

1. A 5-year-old boy is brought to the physician by his mother.

2. He has a 3-day history of low-grade fever and sore throat.

3. This morning, his mother noticed a rash on his buttocks, hands, and feet.

8. Physical examination shows oral vesicles.

9. A photograph of the rash on the feet is shown.

1. She noticed a rash on his buttocks, hands, and feet.

6. Physical examination shows oral vesicles.

7. A photograph of the rash on the feet is shown.


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

Context: An 8-year-old African-American male is found to have a holosystolic, harsh-sounding murmur upon physical examination.

Context: The murmur is best appreciated at the left sternal border, and is found to be louder when the patient squats.

Choices:
A. Ventricular septal defect
B. Patent ductus arteriosus
C. Atrial septal defect
D. Tricuspid atresia

Answer: Ventricular septal defect

1. An 8-year-old African-American male is found to have a holosystolic, harsh-sounding murmur.

2. The murmur is best appreciated at the left sternal border.

3. The murmur is louder when the patient squats.

1. The murmur is best appreciated at the left sternal border.

2. The murmur is found to be louder when the patient squats.


Question: What is the most likely explanation for this patient’s presentation?

Context: A 29-year-old G1P0 woman at 32 weeks of gestation comes to the emergency department complaining of vaginal bleeding for the past hour.

Context: She noticed some blood on the toilet paper when she went to the bathroom an hour ago, but now she is bleeding through her underwear.

Context: She denies any trauma, pain, abnormal discharge or odor, fever, or recent infections.

Context: The patient mentioned that that during her last ultrasound, the doctor told her that, “there’s an abnormality but not to worry,” but she can’t remember the name of the condition.

Context: Her temperature is 100.1°F (37.8°C), blood pressure is 120/70 mmHg, pulse is 86/min, and respirations are 15/min .

Context: A fetal heart tracing is obtained and shows a fetal heart rate of 130-140, long-term variability, and appropriate accelerations.

Choices:
A. Abnormal placental spiral artery development
B. Attachment of the placenta to the lower placental segment over the internal os
C. Cystic swelling of chorionic villi and trophoblast proliferation
D. Fetal vessels in close proximity to the cervical os

Answer: Attachment of the placenta to the lower placental segment over the internal os

Placenta Previa
General Obstetrics and Gynecology

3. Patient is complaining of vaginal bleeding for the past hour.

4. Patient noticed some blood on the toilet paper an hour ago.

5. Patient is now bleeding through her underwear.

6. Patient denies any trauma, pain, abnormal discharge or odor, fever, or recent infections.

7. Patient mentioned that during her last ultrasound, the doctor told her that “there’s an abnormality but not to worry,” but she can’t remember the name of the condition.

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

9. Patient's blood pressure is 120/70 mmHg.

12. Fetal heart tracing shows a fetal heart rate of 130-140.

13. Fetal heart tracing shows long-term variability.

14. Fetal heart tracing shows appropriate accelerations.

1. She noticed blood on the toilet paper an hour ago.

2. She is bleeding through her underwear.

3. She denies trauma, pain, abnormal discharge, odor, fever, or recent infections.

4. During her last ultrasound, the doctor mentioned an abnormality but told her not to worry.

5. She can't remember the name of the condition mentioned during the ultrasound.

10. A fetal heart tracing shows a fetal heart rate of 130-140, long-term variability, and appropriate accelerations.


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

Context: Her mother has rheumatoid arthritis for which she takes methotrexate, and her father died of prostatic carcinoma 7 years ago.

Context: No lymphadenopathy is noted.

Context: Laboratory results are shown below: | Complete blood count: | Hemoglobin 10 g/dL | Leukocytes   13,500/mm3 | Platelets 170,000/mm3 | ESR 65 mm/hr |    Antinuclear antibody Positive | Rheumatoid factor Positive | Anti dsDNA Negative | Anti Ro Positive | Anti-CCP Negative | Anti Jo 1   Negative | .

Choices:
A. Rheumatoid arthritis
B. Systemic lupus erythematosus
C. Primary Sjogren’s syndrome
D. Polymyositis

Answer: Primary Sjogren’s syndrome

1. A 55-year-old woman comes to the office complaining of a dry mouth for the past few months.

2. She has to drink water more frequently, as she finds it difficult to chew and swallow solid foods.

3. She has to wake up 3–5 times each night to drink due to intense thirst.

4. She also complains of a foreign body sensation in both the eyes for the past month.

5. She has had no joint pain, fever, weight loss, or urinary or bowel changes.

6. She does not smoke cigarettes but drinks alcohol socially.

7. Her mother has rheumatoid arthritis for which she takes methotrexate.

8. Her father died of prostatic carcinoma 7 years ago.

9. Her temperature is 36.7°C (98°F), blood pressure is 130/75 mm Hg, pulse is 80/min, respirations are 14/min, and BMI is 28 kg/m2.

10. On examination, the eyes and oral cavity appear dry, and dental caries are present.

12. Cardiopulmonary and abdominal examinations are negative.

13. Laboratory results show a hemoglobin of 10 g/dL, leukocytes of 13,500/mm3, platelets of 170,000/mm3, and ESR of 65 mm/hr.

1. She has to drink water more frequently due to difficulty chewing and swallowing solid foods.

2. She wakes up 3–5 times each night to drink due to intense thirst.

3. She complains of a foreign body sensation in both eyes for the past month.

4. She has had no joint pain, fever, weight loss, or urinary or bowel changes.

5. She does not smoke cigarettes but drinks alcohol socially.

6. Her mother has rheumatoid arthritis and takes methotrexate, and her father died of prostatic carcinoma 7 years ago.

7. Her temperature is 36.7°C (98°F), blood pressure is 130/75 mm Hg, pulse is 80/min, respirations are 14/min, and BMI is 28 kg/m2.

8. On examination, the eyes and oral cavity appear dry, and dental caries are present.

10. Cardiopulmonary and abdominal examinations are negative.

11. Laboratory results: Hemoglobin 10 g/dL, Leukocytes 13,500/mm3, Platelets 170,000/mm3, ESR 65 mm/hr, Antinuclear antibody Positive, Rheumatoid factor Positive, Anti dsDNA Negative, Anti Ro Positive, Anti-CCP Negative, Anti Jo 1 Negative.


Question: Which of the following is the most likely underlying cause of this patient’s condition?

Context: Despite confirmed H.

Context: The body mass index is 19 kg/m2.

Context: The laboratory studies show the following: | Laboratory test | Hemoglobin 10 g/dL | Mean corpuscular volume 75 μm3 | Leukocyte count 7500/mm3 with a normal differential | Serum   | Na+ 145 mEq/L | K+ 4.5 mEq/L | Ca+ 9.5 mg/dL | Phosphorus 4 mg/dL | Urea nitrogen 18 mg/dL | Creatinine 1.0 mg/dL | .

Choices:
A. Chronic alcohol consumption
B. Gastrin-secreting tumor
C. Primary hyperparathyroidism
D. Tobacco use

Answer: Gastrin-secreting tumor

1. A 42-year-old woman presents to the physician with chronic abdominal pain.

2. She was initially diagnosed with an ulcer in the 2nd part of the duodenum and severe esophagitis 6 years ago.

3. Despite confirmed H. pylori eradication and long-term therapy with pantoprazole, she has had frequent recurrences of duodenal and gastric ulcers.

4. The medical history is otherwise unremarkable.

5. She is a 10 pack-year smoker and consumes alcohol regularly.

6. Her father had severe gastric ulcer disease.

7. The vital signs are within normal limits.

9. Mild epigastric tenderness is noted on deep palpation of the epigastrium.

10. The laboratory studies show the following: Hemoglobin 10 g/dL.

11. The laboratory studies show the following: Mean corpuscular volume 75 μm3.

12. The laboratory studies show the following: Leukocyte count 7500/mm3 with a normal differential.

13. The laboratory studies show the following: Serum Na+ 145 mEq/L.

14. The laboratory studies show the following: Serum K+ 4.5 mEq/L.

15. The laboratory studies show the following: Serum Ca+ 9.5 mg/dL.

16. The laboratory studies show the following: Serum Phosphorus 4 mg/dL.

17. The laboratory studies show the following: Serum Urea nitrogen 18 mg/dL.

18. The laboratory studies show the following: Serum Creatinine 1.0 mg/dL.

1. The patient was initially diagnosed with an ulcer in the 2nd part of the duodenum and severe esophagitis 6 years ago.

2. Despite confirmed H. pylori eradication and long-term therapy with pantoprazole, she has had frequent recurrences of duodenal and gastric ulcers.

3. The medical history is otherwise unremarkable.

4. She is a 10 pack-year smoker and consumes alcohol regularly.

5. Her father had severe gastric ulcer disease.

6. The vital signs are within normal limits.

8. Mild epigastric tenderness is noted on deep palpation of the epigastrium.

9. Laboratory test results: Hemoglobin 10 g/dL, Mean corpuscular volume 75 μm3, Leukocyte count 7500/mm3 with a normal differential, Serum Na+ 145 mEq/L, K+ 4.5 mEq/L, Ca+ 9.5 mg/dL, Phosphorus 4 mg/dL, Urea nitrogen 18 mg/dL, Creatinine 1.0 mg/dL.


Question: What imaging finding would you expect in this patient?

Context: A 33-year-old woman comes to the emergency department for severe abdominal pain for the past hour.

Choices:
A. Gallbladder thickening and presence of cholelithiasis on ultrasound
B. Increase in appendicular diameter and fat stranding on computer tomography (CT)
C. Lack of an intrauterine pregnancy on ultrasound
D. Multiple pancreatic calcifications on CT

Answer: Multiple pancreatic calcifications on CT

1. A 33-year-old woman comes to the emergency department for severe abdominal pain.

2. The pain is 10/10, stabbing, and concentrated around the epigastric region with radiation to the back.

3. She had 2 episodes of emesis and complains of nausea.

4. She has had multiple similar episodes over the past 3 months which are not correlated with oral intake.

5. She denies fever, weight changes, headaches, palpitations, bowel changes, or chest pain.

6. She endorses nausea and stool that is hard to flush.

7. Her medical history is significant for diabetes that is controlled with metformin.

8. Her surgical history is significant for an elective cesarean section 5 years ago.

9. She is currently sexually active with contraceptive use.

1. The pain is 10/10, stabbing, and concentrated around the epigastric region with radiation to the back.

2. She had 2 episodes of emesis and complains of nausea.

3. She has had multiple similar episodes over the past 3 months which are not correlated with oral intake.

4. She denies fever, weight changes, headaches, palpitations, bowel changes, or chest pain, but endorses nausea and stool that is hard to flush.

5. Her medical history is significant for diabetes that is controlled with metformin.

6. Her surgical history is significant for an elective cesarean section 5 years ago.

7. She is currently sexually active with contraceptive use.


Question: This patient’s symptoms are most likely attributable to which of the following medications?

Context: A 37-year-old female presents to her primary care provider for a normal follow-up visit.

Context: Her past medical history is notable for poorly controlled type II diabetes mellitus despite good treatment adherence to oral medications.

Context: She has been trialed on metformin and glyburide but stopped them due to rapid weight gain, respectively.

Context: Her temperature is 99.2°F (37.3°C), blood pressure is 120/75 mmHg, pulse is 105/min, and respirations are 22/min.

Context: A hemoglobin A1c lab test is drawn.

Choices:
A. Glipizide
B. Exenatide
C. Pioglitazone
D. Acarbose

Answer: Pioglitazone

Endocrinology, Diabetes, and Metabolism
General Internal Medicine

2. Patient is presenting for a normal follow-up visit.

3. Patient has a past medical history of poorly controlled type II diabetes mellitus.

4. Patient has been adherent to oral medications.

5. Patient was trialed on metformin and glyburide but stopped due to rapid weight gain.

6. Patient was started on a new oral diabetes medication three months ago.

7. Patient has noticed slowly progressive swelling in her lower extremities since starting the new medication.

8. Patient's temperature is 99.2°F (37.3°C).

9. Patient's blood pressure is 120/75 mmHg.

12. Patient has gained 10 pounds since her last visit.

13. Physical examination reveals 1+ pitting edema in the bilateral legs.

1. Her past medical history includes poorly controlled type II diabetes mellitus.

2. Despite good treatment adherence to oral medications, her diabetes is poorly controlled.

5. She stopped metformin due to rapid weight gain.

6. She stopped glyburide due to rapid weight gain.

7. She was started on a new oral diabetes medication three months ago.

8. Since starting the new medication, she has noticed slowly progressive swelling in her lower extremities.

13. She has gained 10 pounds since her last visit.

14. Physical examination reveals 1+ pitting edema in the bilateral legs.


Question: The nerve that was most likely injured in the surgery originates from which of the following spinal roots?

Context: She has recovered well from the surgery but noticed difficulties combing her hair with her right hand.

Choices:
A. C6-C8
B. C1-C3
C. T2-T5
D. C5–C7

Answer: C5–C7

General Neurological Surgery
General Neurology

1. A 21-year-old woman comes to the physician for a follow-up examination.

2. Four months ago, she underwent posterior arthrodesis for thoracolumbar scoliosis.

3. She has recovered well from the surgery.

4. She noticed difficulties combing her hair with her right hand.

5. A photograph of the patient's back is shown.

1. Four months ago, she underwent posterior arthrodesis.

2. The surgery was for thoracolumbar scoliosis.


Question: What must she have been exposed to at the party that led to such a dramatic side effect?

Context: A 45-year-old female is brought by ambulance to your emergency room after complaining of shortness of breath along with profuse sweating at a company social function.

Context: Her vitals were notable for elevated blood pressure with a normal exam and a stable electrocardiogram.

Context: She has been seeing a psychiatrist recently for her depression and was prescribed phenelzine after failing treatment with a first-line antidepressant therapy.

Choices:
A. Norepinephrine
B. Tyramine
C. Gluten
D. Dopamine

Answer: Tyramine

General Emergency Medicine
Internal Medicine

1. A 45-year-old female was brought to the emergency room by ambulance.

2. She was complaining of shortness of breath and profuse sweating at a company social function.

3. Her vitals showed elevated blood pressure.

6. She has been seeing a psychiatrist recently for depression.

7. She was prescribed phenelzine after failing treatment with a first-line antidepressant therapy.

1. Her vitals were notable for elevated blood pressure.

4. She has been seeing a psychiatrist recently for her depression.

6. She failed treatment with a first-line antidepressant therapy.


Question: Which of the following would most likely be expected for this patient's prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time?

Context: The patient’s mother says she has been noticing bruising on her child’s arms and some blood in her diapers.

Context: The infant was born at home after the mother received normal prenatal care.

Context: The patient has been exclusively breastfed since birth and is gaining weight appropriately.

Context: The patient is lethargic with a large, full anterior fontanelle.

Choices:
A. PT normal, aPTT normal, bleeding time normal
B. PT increased, aPTT normal, bleeding time normal
C. PT normal, aPTT normal, bleeding time increased
D. PT normal, aPTT increased, bleeding time normal

Answer: PT increased, aPTT normal, bleeding time normal

1. A 3-day-old female infant is brought by her mother to the pediatrician’s office.

2. The patient’s mother says she has been noticing bruising on her child’s arms.

3. The patient’s mother says she has been noticing some blood in her diapers.

5. The mother received normal prenatal care.

6. The patient has been exclusively breastfed since birth.

7. The patient is gaining weight appropriately.

8. On exam, multiple ecchymoses are noted throughout the patient’s torso and extremities.

10. The patient has a large, full anterior fontanelle.

11. On examination of the diaper, some dried blood mixed with a small amount of stool is noted.

1. The patient's mother has been noticing bruising on her child's arms.

2. The patient's mother has been noticing some blood in her child's diapers.

4. The mother received normal prenatal care.

5. The patient has been exclusively breastfed since birth.

6. The patient is gaining weight appropriately.

7. On exam, multiple ecchymoses are noted throughout the patient's torso and extremities.

9. The patient has a large, full anterior fontanelle.

10. On examination of the diaper, dried blood mixed with a small amount of stool is noted.


Question: The signal responsible for the elevated levels of these proteins was most likely secreted by which of the following cells?

Context: A 53-year-old woman comes to see her primary care physician because she has had fever and malaise for two days.

Context: She was in her usual state of health until three days ago when she began to feel tired in the evening and decided to go to bed early.

Context: She is otherwise healthy with no chronic conditions and lives by herself with two cats.

Context: She smokes one pack of cigarettes per day and drinks alcohol socially.

Context: On physical exam, she is found to have increased dullness to percussion at the lung bases and blood work is obtained showing elevated levels of C-reactive protein and hepcidin.

Choices:
A. Macrophages
B. Neutrophils
C. Regulatory T-cells
D. Type 2 helper T-cells

Answer: Macrophages

1. A 53-year-old woman comes to see her primary care physician.

2. She has had fever and malaise for two days.

3. She was in her usual state of health until three days ago.

4. She began to feel tired in the evening and decided to go to bed early.

5. The next day she developed a fever, productive cough, chills, and malaise.

6. She is otherwise healthy with no chronic conditions.

8. She smokes one pack of cigarettes per day.

10. On physical exam, she is found to have increased dullness to percussion at the lung bases.

11. Blood work is obtained showing elevated levels of C-reactive protein and hepcidin.

1. She was in her usual state of health until three days ago

2. Three days ago she began to feel tired in the evening

5. The next day she developed a productive cough

12. She smokes one pack of cigarettes per day

14. On physical exam, she is found to have increased dullness to percussion at the lung bases

15. Blood work is obtained showing elevated levels of C-reactive protein

16. Blood work is obtained showing elevated levels of hepcidin


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

Context: Three weeks after undergoing transurethral prostate resection for benign prostatic hyperplasia, a 70-year-old man has fever, malaise, and pain in his extremities.

Choices:
A. Enterococcus faecalis
B. Streptococcus gallolyticus
C. Cardiobacterium hominis
D. Staphylococcus epidermidis

Answer: Enterococcus faecalis

In this case, the most relevant specialty would be Infectious Disease

General Infectious Disease
Infectious Disease
General Infectious Disease.

1. A 70-year-old man underwent transurethral prostate resection for benign prostatic hyperplasia three weeks ago.

2. The man has fever, malaise, and pain in his extremities.

3. Physical examination shows subungal petechiae and tender red papules on his fingers and toes.

4. A new holosystolic murmur is heard on chest auscultation.

5. A photomicrograph of a Gram stain of an isolate from blood culture is shown.

6. The organism does not cause hemolysis on blood agar.

7. Addition of pyrrolidonyl-β-naphthylamide gives the bacterial colonies a cherry red color.

1. Physical examination shows subungal petechiae.

2. Physical examination shows tender red papules on fingers and toes.

3. A new holosystolic murmur is heard on chest auscultation.

4. A photomicrograph of a Gram stain of an isolate from blood culture is shown.

5. The organism does not cause hemolysis on blood agar.

6. Addition of pyrrolidonyl-β-naphthylamide gives the bacterial colonies a cherry red color.


Question: What is the mechanism of action of the medication received by the patient?

Context: An 85-year-old woman is brought to her primary care provider by her son for a checkup.

Context: Past medical history is significant for hypertension, hyperlipidemia, and a urinary tract infection that was successfully treated with an extended course of oral cephalexin 3 weeks ago.

Context: Family history is noncontributory.

Choices:
A. γ-carboxylation of pancreatic enzymes
B. Protein C deficiency
C. Activation of 7-dehydrocholesterol by UV light
D. γ-carboxylation of liver enzymes

Answer: γ-carboxylation of liver enzymes

1. An 85-year-old woman is brought to her primary care provider by her son.

2. She is feeling well with no major complaints.

3. Her son is concerned that she has been bruising much more easily over the last week or two.

4. Past medical history is significant for hypertension, hyperlipidemia, and a urinary tract infection.

5. The urinary tract infection was successfully treated with an extended course of oral cephalexin 3 weeks ago.

8. Today, her respiratory rate is 17/min.

9. Today, her blood pressure is 125/85 mm Hg.

10. Today, her temperature is 36.7°C (98.1°F).

11. On physical exam, her heart has a regular rate and rhythm.

12. On physical exam, her lungs are clear to auscultation bilaterally.

13. She has some poorly demarcated purple-yellow bruising and areas of dark purple bruising as well.

14. Further analysis reveals a prolonged PT that corrects with mixing.

15. Further analysis reveals normal liver function tests.

16. Further analysis reveals a stool test that is guaiac positive.

17. The physician administers an injection that should improve her condition.

18. The physician recommends further testing and a follow-up exam.

1. The patient is feeling well with no major complaints.

2. Her son is concerned that she has been bruising much more easily over the last week or two.

3. Past medical history includes hypertension, hyperlipidemia, and a urinary tract infection that was successfully treated with an extended course of oral cephalexin 3 weeks ago.

5. Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 125/85 mm Hg, and temperature is 36.7°C (98.1°F).

6. On physical exam, her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally.

7. She has some poorly demarcated purple-yellow bruising and areas of dark purple bruising as well.

8. Further analysis reveals a prolonged PT that corrects with mixing, normal liver function tests, and a stool test that is guaiac positive.

9. The physician administers an injection that should improve her condition and recommends further testing and a follow-up exam.


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

Context: A 35-year-old man presents with loose stools and left lower quadrant abdominal pain.

Context: He says he passes 8–10 loose stools per day.

Context: The patient reports a 20-pack-year smoking history.

Context: He also says he recently traveled abroad about 3 weeks ago to Egypt.

Context: The vital signs include: blood pressure 120/76 mm Hg, pulse 74/min, and temperature 36.5°C (97.8°F).

Choices:
A. Amebiasis
B. Crohn’s disease
C. Salmonellosis
D. Diverticulosis

Answer: Amebiasis

2. Patient has loose stools and left lower quadrant abdominal pain.

3. Patient passes 8-10 loose stools per day.

4. Volume of each bowel movement is small and appears mucoid with occasional blood.

5. Patient has a 20-pack-year smoking history.

6. Patient recently traveled abroad to Egypt about 3 weeks ago.

10. Physical examination shows mild to moderate tenderness to palpation in the left lower quadrant with no rebound or guarding.

11. Rectal examination shows presence of perianal skin ulcers.

1. The patient reports passing 8–10 loose stools per day.

2. The volume of each bowel movement is small and appears mucoid with occasional blood.

3. The patient has a 20-pack-year smoking history.

4. The patient recently traveled abroad about 3 weeks ago to Egypt.

5. Vital signs: blood pressure 120/76 mm Hg, pulse 74/min, and temperature 36.5°C (97.8°F).

6. On physical examination, mild to moderate tenderness to palpation in the left lower quadrant with no rebound or guarding is present.

7. Rectal examination shows the presence of perianal skin ulcers.