Question: What is her CHADS2 score?

Context: A 73-year-old woman with atrial fibrillation presents to your clinic to discuss the need for anticoagulation.

Context: Her PMH is significant for high blood pressure, diabetes mellitus type II, osteoporosis, and depression.

Context: She has never had a stroke or TIA.

Context: Her physical examination is remarkable for an irregular heart rate.

Context: She has a blood pressure of 136/94 mm Hg and a heart rate of 74/min.

Choices:
A. 1
B. 2
C. 4
D. Too little information to tell

1. A 73-year-old woman presents to clinic to discuss need for anticoagulation.

2. Patient's past medical history (PMH) is significant for high blood pressure, diabetes mellitus type II, osteoporosis, and depression.

3. Patient previously smoked but quit about 16 years ago.

4. Patient has never had a stroke or TIA.

5. Patient's physical examination is remarkable for an irregular heart rate.

6. Patient's blood pressure is 136/94 mm Hg.

1. PMH includes high blood pressure, diabetes mellitus type II, osteoporosis, and depression.

2. She previously smoked but quit about 16 years ago.

4. Physical examination is remarkable for an irregular heart rate.


Question: Which of the following is most likely responsible for the improvement in this patient's neurological status?

Context: A 26-year-old woman is admitted to the hospital because of a 3-day history of tingling and weakness in the lower extremities.

Choices:
A. Synthesis of monoamine neurotransmitters
B. Remyelination of peripheral nerves
C. Replication of oligodendrocyte precursor cells
D.
Lymphocytic infiltration in the endoneurium
"

Answer: Remyelination of peripheral nerves

1. A 26-year-old woman is admitted to the hospital.

2. She has a 3-day history of tingling and weakness in the lower extremities.

3. Neurologic examination shows areflexia of the ankle and knee joints bilaterally.

4. Motor strength is 1/5 in both lower legs.

5. Over the next 3 weeks, her condition progresses to involve both upper extremities.

7. Six weeks after admission, deep tendon reflexes are 1+ in the ankles.

1. Neurologic examination shows areflexia of the ankle and knee joints bilaterally.

2. Motor strength is 1/5 in both lower legs.

3. Over the next 3 weeks, the patient's condition progresses to involve both upper extremities, and she requires ventilatory support.

4. Six weeks after admission, deep tendon reflexes are 1+ in the ankles, and she is able to wiggle her toes.


Question: This patient is most likely deficient in a vitamin that has which of the following functions?

Context: A 42-year-old woman presents to her primary care physician for fatigue and blurry vision.

Context: She is a refugee from Syria who arrived in the United States 1 week ago.

Context: She has one son who is 9 years old and was seen by a pediatrician the day prior.

Context: She reports that while she was in the refugee camp, she ate very little and gave most of her food to her son to ensure that he stayed healthy.

Context: She denies any past medical history and takes no medications.

Context: She does not smoke or drink alcohol.

Context: Her temperature is 97.8°F (36.6°C), blood pressure is 108/68 mmHg, pulse is 102/min, and respirations are 18/min.

Context: On exam, she appears fatigued but is fully cooperative with the examination.

Context: Her tongue is darkly erythematous.

Choices:
A. Cofactor for homocysteine methyltransferase
B. Cofactor for pyruvate dehydrogenase enzyme
C. Precursor to FAD and FMN
D. Constituent of NAD+ and NADP+

Answer: Precursor to FAD and FMN

2. Patient presents with fatigue and blurry vision.

4. Patient arrived in the United States 1 week ago.

5. Patient lived in a refugee camp for 8 months.

6. Patient worked at a grocery store in Syria before being displaced from her home.

7. Patient has one son who is 9 years old.

8. Patient's son was seen by a pediatrician the day prior.

9. Patient ate very little and gave most of her food to her son while in the refugee camp.

10. Patient denies any past medical history and takes no medications.

11. Patient does not smoke or drink alcohol.

12. Patient's temperature is 97.8°F (36.6°C).

13. Patient's blood pressure is 108/68 mmHg.

16. Patient appears fatigued but is fully cooperative with the examination.

17. Patient has fissures at the corners of her mouth.

18. Funduscopic examination reveals corneal vascularization in both eyes.

19. Patient's tongue is darkly erythematous.

2. She arrived in the United States 1 week ago.

3. She has lived for the last 8 months in a refugee camp.

4. She worked at a grocery store in Syria before being displaced from her home.

6. Her son was seen by a pediatrician the day prior.

7. She reports that while she was in the refugee camp, she ate very little and gave most of her food to her son.

10. She does not smoke or drink alcohol.

16. She is fully cooperative with the examination.

17. There are fissures at the corners of her mouth.

18. A funduscopic examination reveals corneal vascularization in both eyes.


Question: Which of the following statements describing the patient’s current state is most accurate?

Context: A 70-year-old man was first evaluated for an enlarging neck mass with complaints of night sweats, fever, and weight loss.

Context: The physician notes a marked improvement, but is concerned about a common complication of chemotherapy.

Choices:
A. Rasburicase is a xanthine oxidase inhibitor
B. This complication only occurs in response to radiation
C. Rasburicase converts uric acid to allantoin, increasing its secretion
D. Hypophosphatemia is expected to develop in this patient

Answer: Rasburicase converts uric acid to allantoin, increasing its secretion

1. A 70-year-old man was first evaluated for an enlarging neck mass.

2. The man had complaints of night sweats, fever, and weight loss.

3. Excisional biopsy confirmed the diagnosis of Burkitt lymphoma.

4. The patient was started on a CODOX-M/IVAC chemotherapy regime.

5. The physician noted a marked improvement.

6. The physician was concerned about a common complication of chemotherapy.

7. The patient was prescribed rasburicase in response to this complication.

1. Excisional biopsy confirms the diagnosis of Burkitt lymphoma.

2. The patient is started on a CODOX-M/IVAC chemotherapy regime.

3. The physician notes a marked improvement.

4. The physician is concerned about a common complication of chemotherapy.

5. The patient is prescribed rasburicase in response to this complication.


Question: The patient's condition is most likely associated with which of the following pathophysiologic changes?

Context: A previously healthy 41-year-old man is brought to the emergency department 30 minutes after collapsing at home.

Context: Cardiopulmonary resuscitation is attempted for 10 minutes without success.

Context: A photograph of sections of the heart obtained at autopsy is shown.

Choices:
A. Retrograde blood flow from the aorta into the left ventricle
B. Fixed obstruction of the left ventricular outflow tract
C. Marked noncompliance of the left ventricular wall
D. Severe narrowing of the left anterior descending artery

Answer: Marked noncompliance of the left ventricular wall

1. A 41-year-old man was brought to the emergency department.

3. He collapsed at home 30 minutes prior.

4. Cardiopulmonary resuscitation was attempted for 10 minutes.

6. A photograph of sections of the heart was obtained at autopsy.

1. Cardiopulmonary resuscitation was attempted for 10 minutes.

2. The resuscitation attempt was not successful.

3. A photograph of sections of the heart was obtained at autopsy.


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

Context: Laboratory studies show: | Hemoglobin 9.8 mg/dL | Serum | Urea nitrogen 50 mg/dL | Creatinine 2.8 mg/dL | Calcium 12.9 mg/dL | Urine | Protein negative | Blood negative | .

Choices:
A. Renal deposition of AL amyloid
B. Immunoglobulin light chains
C. Decreased cardiac ejection fraction
D. Anti-streptococcal antibodies

Answer: Immunoglobulin light chains

1. A 68-year-old woman comes to the physician with increasing fatigue and shortness of breath for 2 weeks.

2. She has only passed very small amounts of urine over the past few days.

3. During this time, she has also noticed that her feet appear unusually puffy for a few hours every morning.

4. Three weeks ago, she had a sore throat that resolved spontaneously after several days without antibiotic therapy.

5. She has a 6-month history of lower back and thoracic pain, for which she takes ibuprofen daily.

6. Her only other medication is a laxative for constipation, which she first experienced 8 months ago.

7. Her sister has systemic lupus erythematosus.

8. Her temperature is 37.9°C (98.9°F), pulse is 110/min, respirations are 22/min, and blood pressure is 150/100 mm Hg.

9. Examination shows pedal edema and conjunctival pallor.

10. There is tenderness to palpation over the lumbar spine and the 8th rib on the right.

11. Cardiac examination shows no abnormalities.

12. Laboratory studies show: Hemoglobin 9.8 mg/dL.

1. She has only passed very small amounts of urine over the past few days.

2. She has also noticed that her feet appear unusually puffy for a few hours every morning.

3. Three weeks ago, she had a sore throat that resolved spontaneously after several days without antibiotic therapy.

4. She has a 6-month history of lower back and thoracic pain, for which she takes ibuprofen daily.

5. Her only other medication is a laxative for constipation, which she first experienced 8 months ago.

6. Her sister has systemic lupus erythematosus.

7. Her temperature is 37.9°C (98.9°F), pulse is 110/min, respirations are 22/min, and blood pressure is 150/100 mm Hg.

8. Examination shows pedal edema and conjunctival pallor.

9. There is tenderness to palpation over the lumbar spine and the 8th rib on the right.

10. Cardiac examination shows no abnormalities.

11. Laboratory studies show: Hemoglobin 9.8 mg/dL, Serum Urea nitrogen 50 mg/dL, Creatinine 2.8 mg/dL, Calcium 12.9 mg/dL, Urine Protein negative, Blood negative.


Question: From whom should the surgeon get consent for the procedure?

Context: A 13-month-old male needs to have surgery for an undescended testicle.

Context: His 19-year-old father is not involved.

Choices:
A. The mother
B. The father
C. A grandparent
D. The hospital's medical ethics committee

Answer: The mother

1. A 13-month-old male needs to have surgery.

2. The surgery is for an undescended testicle.

3. The child lives with his 16-year-old mother only.

4. His 19-year-old father is not involved.

1. The child lives with his 16-year-old mother.

2. The mother is the only caregiver for the child.

3. The father of the child is 19 years old.

4. The father is not involved in the child's life.


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

Context: A 7-year-old boy is brought to the emergency department after he was bitten by a dog.

Context: The patient was at a friend's house, and he was bitten when he pulled the dog's tail while it was eating.

Context: The patient is currently doing well and has a dog bite on his right distal forearm.

Context: His temperature is 98.2°F (36.8°C), blood pressure is 100/60 mmHg, pulse is 123/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Choices:
A. Closure of the wound via sutures
B. Euthanasia of the animal
C. Quarantine and observe the animal
D. Rabies vaccine and rabies immunoglobulin

Answer: Quarantine and observe the animal

1. A 7-year-old boy was brought to the emergency department.

3. He was at a friend's house when he was bitten.

4. He pulled the dog's tail while it was eating.

6. He has a dog bite on his right distal forearm.

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

12. The wound was thoroughly irrigated in the emergency department.

2. The patient was bitten when he pulled the dog's tail while it was eating.

3. The patient has a dog bite on his right distal forearm.

5. The patient's temperature is 98.2°F (36.8°C).

6. The patient's blood pressure is 100/60 mmHg.

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

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

10. The wound is thoroughly irrigated in the emergency department.


Question: Which of the following set of laboratory results and peripheral blood smear findings would most likely be seen in this patient?

Context: A 35-year-old woman, otherwise healthy, presents with frequent nosebleeds and bruising on her legs.

Context: She says that her symptoms started about 6 months ago and have not improved.

Context: She remembers that her 8-year-old son had similar symptoms about a month ago following a viral respiratory infection, but his symptoms quickly resolved without treatment.

Context: Review of systems is significant for her last period 2 weeks ago being a bit heavier than usual.

Context: Her vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/75 mm Hg, pulse 98/min, respirations 15/min, and oxygen saturation 99% on room air.

Context: On physical examination, the patient is alert and cooperative.

Context: Cardiac exam is normal.

Context: Lungs are clear to auscultation.

Context: There is non-palpable purpura present on the lower extremities bilaterally.

Choices:
A. Platelets: Decreased | Bleeding time: Increased | PT: Normal | PTT: Normal | Blood smear: Schistocytes present
B. Platelets: Decreased | Bleeding time: Increased | PT: Increased| PTT: Increased | Blood smear: Schistocytes present
C. Platelets: Increased | Bleeding time: Decreased| PT: Normal| PTT: Normal | Blood smear: Schistocytes absent
D. Platelets: Decreased | Bleeding time: Increased | PT: Normal| PTT: Normal| Blood smear: Schistocytes absent

Answer: Platelets: Decreased | Bleeding time: Increased | PT: Normal| PTT: Normal| Blood smear: Schistocytes absent

3. Patient presents with frequent nosebleeds and bruising on her legs.

4. Symptoms started about 6 months ago and have not improved.

5. Patient's 8-year-old son had similar symptoms about a month ago following a viral respiratory infection, but his symptoms quickly resolved without treatment.

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

7. Family history is significant for her father dying at age 65 of myocardial infarction.

8. Patient's last period 2 weeks ago was a bit heavier than usual.

9. Vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/75 mm Hg, pulse 98/min, respirations 15/min, and oxygen saturation 99% on room air.

10. Patient is alert and cooperative on physical examination.

13. Non-palpable purpura present on the lower extremities bilaterally.

1. Symptoms started about 6 months ago and have not improved

2. 8-year-old son had similar symptoms about a month ago following a viral respiratory infection

3. Son's symptoms quickly resolved without treatment

6. Family history significant for father dying at age 65 of myocardial infarction

7. Last period 2 weeks ago was a bit heavier than usual

8. Vital signs: temperature 37.0°C (98.6°F), blood pressure 100/75 mm Hg, pulse 98/min, respirations 15/min, oxygen saturation 99% on room air

12. Non-palpable purpura present on the lower extremities bilaterally


Question: Which of the following is the most appropriate modification in this patient’s drug therapy?

Context: Her medications include inhaled salmeterol and fluticasone propionate and oral amitriptyline, the dose of which was increased recently due to uncontrolled depressive symptoms.

Choices:
A. Adding ipratropium bromide inhaler
B. Reducing the dose of albuterol
C. Switching amitriptyline to fluoxetine
D. No change is required at this time

Answer: Switching amitriptyline to fluoxetine

1. A 65-year-old woman comes to the physician because of urinary straining and delayed flow of urine for 1 month.

2. She has a medical history significant for long-standing asthma.

3. Recently, she has been taking albuterol more frequently on an as-needed basis.

4. She was diagnosed with major depression last year.

5. Currently, her symptoms of depression are under control.

6. Her medications include inhaled salmeterol and fluticasone propionate and oral amitriptyline.

7. The dose of amitriptyline was increased recently due to uncontrolled depressive symptoms.

8. The vital signs include: temperature 37.1°C (99.8°F), pulse rate 80/min, respiratory rate 14/min, and blood pressure 110/70 mm Hg.

9. On examination, she has dry oral mucous membranes.

10. The remainder of the examination shows no abnormalities.

1. She has a medical history significant for long-standing asthma.

2. She has been taking albuterol more frequently on an as-needed basis.

3. She was diagnosed with major depression last year.

4. Currently, her symptoms of depression are under control.

5. Her medications include inhaled salmeterol and fluticasone propionate and oral amitriptyline.

6. The dose of amitriptyline was increased recently due to uncontrolled depressive symptoms.

7. Vital signs: temperature 37.1°C (99.8°F), pulse rate 80/min, respiratory rate 14/min, and blood pressure 110/70 mm Hg.

8. On examination, she has dry oral mucous membranes.

9. The remainder of the examination shows no abnormalities.


Question: Based on the description of these patients symptoms and current treatment regime, which of the following categories describes the severity of this child’s symptoms?

Context: On physical examination, she doesn’t seem to be in distress, and currently, the lungs are clear on auscultation.

Choices:
A. Mild intermittent
B. Mild persistent
C. Moderate persistent
D. Severe persistent

Answer: Moderate persistent

1. An 8-year-old girl is brought by her mother to her pediatrician’s office for a follow-up visit.

2. She was diagnosed with asthma about 4 years ago and has been on medications ever since.

3. She came into the doctor’s office about a month ago with an escalation of her symptoms.

4. She told her doctor that she has been struggling to breathe almost every single day.

5. This difficulty increased when she played outdoors with her friends.

6. She said that she used to wake up at least 3 times a week from sleep to use her inhaler.

7. She uses a short-acting β-agonist inhaler to control her symptoms.

8. At the previous visit, her doctor had started her on a small dose of fluticasone (inhaled) as well as a long-acting β-agonist inhaler.

9. She has some improvement in her symptoms.

10. On physical examination, she doesn’t seem to be in distress.

11. Currently, the lungs are clear on auscultation.

12. Her forced expiratory volume in one second is about 70% of the predicted value.

1. She was diagnosed with asthma about 4 years ago.

2. She has been on medications ever since.

4. She has been struggling to breathe almost every single day.

5. Her difficulty increased when she played outdoors with her friends.

6. She used to wake up at least 3 times a week from sleep to use her inhaler.


Question: Which drug is suitable in her case for the prevention of headaches?

Context: The pain is usually unilateral, pulsatile in character, exacerbated by light and noise, and usually lasts for a few hours to a full day.

Context: She also has essential tremors.

Choices:
A. Ergotamine
B. Verapamil
C. Valproic
D. Propranolol

Answer: Propranolol

1. An 18-year-old woman presents with recurrent headaches.

4. The pain is exacerbated by light and noise.

5. The pain usually lasts for a few hours to a full day.

6. The pain is sometimes triggered by eating chocolates.

7. These headaches disturb her daily routine activities.

8. The physical examination was within normal limits.

3. The pain is exacerbated by light and noise.

4. The pain usually lasts for a few hours to a full day.

5. The pain is sometimes triggered by eating chocolates.

6. These headaches disturb her daily routine activities.

7. The physical examination was within normal limits.


Question: An MRI scan of the head is most likely to show which of the following?

Context: A 26-year-old man is brought to the emergency department by the police after threatening to harm his roommate earlier today.

Context: He states that he has spent the majority of the last year alone in his room “working on a project at home to save the earth from an evil alien power.” There is no family history of serious illness.

Context: Vital signs are within normal limits.

Choices:
A. Periventricular plaques and white matter lesions
B. Ring-enhancing lesion
C. Hyperintense temporal lobe lesion
D. Enlarged cerebral ventricles

Answer: Enlarged cerebral ventricles

Neurology with Special Qualification in Child Neurology

1. A 26-year-old man is brought to the emergency department by the police.

2. He threatened to harm his roommate earlier today.

3. He reports that someone on the radio told him to do so.

4. His family reports that he has become increasingly more withdrawn from family and friends during the past two years.

5. He states that he has spent the majority of the last year alone in his room “working on a project at home to save the earth from an evil alien power.”

6. There is no family history of serious illness.

7. He has smoked marijuana on a daily basis since he was thirteen.

8. Vital signs are within normal limits.

9. On mental status examination, he has a flat affect.

10. On mental status examination, his speech is disorganized.

1. He reports that someone on the radio told him to do so.

2. His family reports that, during the past two years, the patient has become increasingly more withdrawn from family and friends.

3. He states that he has spent the majority of the last year alone in his room “working on a project at home to save the earth from an evil alien power.”

4. There is no family history of serious illness.

5. He has smoked marijuana on a daily basis since he was thirteen.

6. Vital signs are within normal limits.

7. On mental status examination, he has a flat affect and his speech is disorganized.


Question: Which of the following is the most life-threatening complication of amobarbital withdrawal?

Context: A 46-year-old anesthesiologist is found placing several syringes of amobarbital in his backpack prior to leaving the hospital.

Context: When confronted, the anesthesiologist admits that he began abusing the medication the previous year, after his divorce was finalized.

Context: He has been using it on a daily basis since then, and his most recent usage was 8 hours ago.

Choices:
A. Internal bleeding
B. Respiratory depression
C. Cardiovascular collapse
D. Self-inflicted violence

Answer: Cardiovascular collapse

1. A 46-year-old anesthesiologist was found placing several syringes of amobarbital in his backpack.

3. He admitted to abusing the medication since the previous year.

4. His divorce was finalized the previous year.

5. He has been using the medication on a daily basis since then.

6. His most recent usage was 8 hours ago.

1. The anesthesiologist admits to abusing medication.

3. The abuse started after his divorce was finalized.

4. He has been using the medication daily since then.

5. His most recent usage was 8 hours ago.


Question: What is the mechanism of action of the medication that can be used in the management of this patient’s condition?

Context: A 55-year-old man is brought to the emergency department for 1 episode of bloody emesis.

Context: He reports feeling lightheaded this morning and shortly after breakfast, he felt nauseous and had an episode of bloody emesis.

Context: A physical examination demonstrates mild jaundice and ascites.

Choices:
A. Antagonists of ß1 and ß2 adrenergic receptors
B. Reversible block of histamine H2 receptors
C. Somatostatin analog leading to constriction of the splanchnic vessels
D. Stimulation of cGMP production leading to vascular smooth muscle relaxation

Answer: Somatostatin analog leading to constriction of the splanchnic vessels

1. A 55-year-old man is brought to the emergency department.

2. He reports feeling lightheaded this morning.

3. He felt nauseous shortly after breakfast.

5. He denies any trauma, fever, abnormal ingestions, or recent infections.

6. He endorses black stools over the past few days.

7. His past medical history is significant for alcohol abuse and cirrhosis.

8. A physical examination demonstrates mild jaundice.

9. A physical examination demonstrates ascites.

1. He reports feeling lightheaded this morning.

2. Shortly after breakfast, he felt nauseous.

8. He endorses black stools over the past few days.

9. His past medical history is significant for alcohol abuse.

10. His past medical history is significant for cirrhosis.

11. A physical examination demonstrates mild jaundice.

12. A physical examination demonstrates ascites.


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

Context: Shortly after undergoing a bipolar prosthesis for a displaced femoral neck fracture of the left hip acquired after a fall the day before, an 80-year-old woman suddenly develops dyspnea.

Context: The surgery under general anesthesia with sevoflurane was uneventful, lasting 98 minutes, during which the patient maintained oxygen saturation readings of 96–100% on 8 L of oxygen.

Context: She has a history of hypertension, osteoporosis, and osteoarthritis of her right knee.

Context: An ECG shows sinus tachycardia.

Choices:
A. Fat embolism
B. Thyrotoxic crisis
C. Malignant hyperthermia
D.
Meningitis
"

Answer: Fat embolism

1. An 80-year-old woman underwent a bipolar prosthesis for a displaced femoral neck fracture of the left hip acquired after a fall the day before.

2. The surgery was uneventful, lasting 98 minutes, during which the patient maintained oxygen saturation readings of 96–100% on 8 L of oxygen.

3. The patient has a history of hypertension, osteoporosis, and osteoarthritis of her right knee.

4. Her medications include ramipril, naproxen, ranitidine, and a multivitamin.

5. Shortly after the surgery, the patient suddenly develops dyspnea.

6. She appears cyanotic, drowsy, and is oriented only to person.

7. Her temperature is 38.6°C (101.5°F), pulse is 135/minute, respirations are 36/min, and blood pressure is 155/95 mm Hg.

8. Pulse oximetry on room air shows an oxygen saturation of 81%.

9. There are several scattered petechiae on the anterior chest wall.

10. Laboratory studies show a hemoglobin concentration of 10.5 g/dL, a leukocyte count of 9,000/mm3, a platelet count of 145,000/mm3, and a creatine kinase of 190 U/L.

1. The surgery was under general anesthesia with sevoflurane.

3. The patient maintained oxygen saturation readings of 96–100% on 8 L of oxygen during the surgery.

4. The patient has a history of hypertension, osteoporosis, and osteoarthritis of her right knee.

5. The patient's medications include ramipril, naproxen, ranitidine, and a multivitamin.

6. The patient appears cyanotic, drowsy, and is oriented only to person.

7. The patient's temperature is 38.6°C (101.5°F).

9. The patient's respirations are 36/min.

10. The patient's blood pressure is 155/95 mm Hg.

11. Pulse oximetry on room air shows an oxygen saturation of 81%.

12. There are several scattered petechiae on the anterior chest wall.

13. Laboratory studies show a hemoglobin concentration of 10.5 g/dL.

14. Laboratory studies show a leukocyte count of 9,000/mm3.

15. Laboratory studies show a platelet count of 145,000/mm3.

16. Laboratory studies show a creatine kinase of 190 U/L.


Question: Laboratory studies will most likely demonstrate the following in this patient?

Context: A 34-year-old woman presents to her primary care physician complaining of weakness and rash for the past 2 months.

Context: She says her symptoms had a gradual onset at first, but over the past 2 weeks she has grown more concerned as she now has difficulty going up and down the stairs in her apartment.

Context: Her rash is nonpruritic and confined to her knuckles.

Context: She denies fever, chills, and changes in bowel habits, cough, or shortness of breath.

Context: Up until the onset of her symptoms she had been an avid hiker in upstate New York.

Context: Temperature is 98.0°F (36.7°C) blood pressure is 110/72 mmHg, pulse is 88/min, and respirations are 20/min.

Choices:
A. Anti-histidyl tRNA synthetase antibodies
B. Anti-histone antibodies
C. Anti-HMG CoA reductase antibodies
D. Anti-mitochondrial antibodies

Answer: Anti-histidyl tRNA synthetase antibodies

2. Patient has been experiencing weakness and rash for the past 2 months.

3. Symptoms had a gradual onset at first.

4. Over the past 2 weeks patient has difficulty going up and down stairs.

5. Rash is nonpruritic and confined to knuckles.

6. Patient denies fever, chills, changes in bowel habits, cough, or shortness of breath.

7. Patient was an avid hiker in upstate New York prior to onset of symptoms.

12. Physical examination demonstrates 4-/5 strength in proximal lower extremities.

13. Cutaneous findings are demonstrated in figure A.

1. The patient's symptoms had a gradual onset at first.

2. Over the past 2 weeks, the patient has had difficulty going up and down the stairs in her apartment.

4. The rash is confined to the patient's knuckles.

5. The patient denies fever, chills, and changes in bowel habits, cough, or shortness of breath.

6. Up until the onset of her symptoms, the patient had been an avid hiker in upstate New York.

7. The patient's temperature is 98.0°F (36.7°C).

8. The patient's blood pressure is 110/72 mmHg.

10. The patient's respirations are 20/min.

11. Physical examination demonstrates 4-/5 strength in the proximal lower extremities.

12. The patient's cutaneous findings are demonstrated in figure A.


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

Context: A 4-day-old, full-term infant born by uncomplicated vaginal delivery is brought to a pediatrician by his mother, who notes that her son's skin appears yellow.

Context: She reports that the child cries several times per day, but sleeps 7-8 hours at night, uninterrupted.

Context: She has been breastfeeding exclusively and feels that he has been feeding well.

Context: He has been having a bowel movement on average once every 3 days.

Choices:
A. Breastfeeding jaundice
B. Breast milk jaundice
C. Glucose-6-phosphate dehydrogenase deficiency
D. Hepatitis A

Answer: Breastfeeding jaundice

1. A 4-day-old, full-term infant was born by uncomplicated vaginal delivery.

2. The infant was brought to a pediatrician by his mother.

3. The mother noted that her son's skin appears yellow.

4. The child cries several times per day.

5. The child sleeps 7-8 hours at night, uninterrupted.

6. The mother has been breastfeeding exclusively.

7. The mother feels that the infant has been feeding well.

8. The infant has been having a bowel movement on average once every 3 days.

1. The child cries several times per day.

2. The child sleeps 7-8 hours at night, uninterrupted.

3. The mother has been breastfeeding exclusively.

4. The mother feels that the child has been feeding well.

5. The child has been having a bowel movement on average once every 3 days.


Question: Which of the following is the strongest predisposing factor for this patient's condition?

Context: A 23-year-old female comes to the office because of a 3-week history of vaginal discharge and itching despite cleaning her genitals with a vaginal douche.

Context: Vaginal pH is 4.3 and a KOH test shows multiple pseudohyphae on microscopy.

Choices:
A. Suppression of vaginal bacterial flora
B. Increased vaginal pH
C. Intrauterine device
D. Unprotected sexual intercourse

Answer: Suppression of vaginal bacterial flora

1. A 23-year-old female comes to the office.

2. She has a 3-week history of vaginal discharge and itching.

3. She has been cleaning her genitals with a vaginal douche.

4. Her last menstrual period was one week ago.

5. She is sexually active with her new boyfriend.

8. She was treated for a sore throat infection one month ago.

9. Speculum examination shows erythema around the vaginal introitus and copious white discharge.

11. A KOH test shows multiple pseudohyphae on microscopy.

1. Her last menstrual period was one week ago.

2. She is sexually active with her new boyfriend.

3. She has an intrauterine device and does not use barrier protection.

4. She was treated for a sore throat infection one month ago.

5. Speculum examination shows erythema around the vaginal introitus and copious white discharge.

7. KOH test shows multiple pseudohyphae on microscopy.


Question: Which of the following interventions would have been most effective to prevent this condition?

Context: A 3-year-old boy who has no known past medical or family history is brought by his parents to his pediatrician for new symptoms.

Context: Specifically, his parents state that he has suffered from a fever associated with diarrhea and conjunctivitis over the past week or so.

Context: His parents note that he has never had an episode of diarrhea like this previously, but that several other children at his daycare had been ill recently.

Context: The blood pressure is 112/70 mm Hg, heart rate is 94/min, respiratory rate is 14/min, and temperature is 37.0°C (98.6°F).

Choices:
A. Appropriate immunization
B. Better hand-washing practices
C. Keeping all food stored in the refrigerator
D. Avoiding undercooked seafood

Answer: Better hand-washing practices

2. Patient has no known past medical or family history.

3. Patient has been suffering from a fever associated with diarrhea and conjunctivitis over the past week or so.

4. Patient has never had an episode of diarrhea like this previously.

5. Several other children at patient's daycare had been ill recently.

6. Patient's blood pressure is 112/70 mm Hg.

8. Patient's respiratory rate is 14/min.

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

10. Physical exam is significant for preauricular adenopathy.

1. The patient has suffered from a fever associated with diarrhea and conjunctivitis over the past week.

2. The patient has never had an episode of diarrhea like this previously.

3. Several other children at his daycare had been ill recently.

4. The patient's blood pressure is 112/70 mm Hg.

6. The patient's respiratory rate is 14/min.

7. The patient's temperature is 37.0°C (98.6°F).

8. The physical exam is significant for preauricular adenopathy.


Question: What would be the most likely finding on wet mount?

Context: A 24-year-old woman with no past medical history presents to her PCP for a routine checkup.

Context: She feels generally healthy but has noticed a new vaginal discharge that has a strange odor.

Context: The patient has been in a long-term relationship and denies any new sexual partners.

Context: Vital signs are within normal limits.

Context: The physical exam reveals thin, greyish-white vaginal discharge but is otherwise unremarkable.

Choices:
A. Motile, flagellated protozoans
B. Long, branching filamentous structures
C. Epithelial cells with stippling
D. Large mucoid capsules

Answer: Epithelial cells with stippling

Internal Medicine
Obstetrics and Gynecology
Pathology

Infectious Disease
General Obstetrics and Gynecology
Medical Microbiology Pathology

1. A 24-year-old woman presents to her PCP for a routine checkup.

3. She has noticed a new vaginal discharge with a strange odor.

4. She has been in a long-term relationship.

6. She denies vaginal itching, abnormal menstruation, or dyspareunia.

7. Vital signs are within normal limits.

8. The physical exam reveals thin, greyish-white vaginal discharge.

9. The physical exam is otherwise unremarkable.

10. A sample of this discharge is collected.

2. The patient has noticed a new vaginal discharge with a strange odor.

3. The patient has been in a long-term relationship.

4. The patient denies any new sexual partners.

6. The patient denies abnormal menstruation.

8. Vital signs are within normal limits.

9. The physical exam reveals thin, greyish-white vaginal discharge.

10. The physical exam is otherwise unremarkable.

11. A sample of the discharge is collected.


Question: Laboratory studies show: | Hemoglobin 13.5 g/dL | Leukocyte count 9,520/mm3 | Platelet count 853,000/mm3 | Serum | Na+ 136 mEq/L | K+ 3.7 mEq/L | Cl- 96 mEq/L | Ca2+ 11.0 mg/dL | HCO3- 25 mEq/L | Glucose 102 mg/dL | Creatinine 1.0 mg/dL | Uric acid 10.5 mg/dL | Further evaluation of this patient is most likely to show which of the following?

Context: A 50-year-old African-American woman comes to the physician because of right elbow pain for the past 12 hours.

Context: She also reports general malaise.

Context: She runs 5 km (3.1 miles) per week.

Context: She works as an accountant.

Choices:
A. Mutation in Janus kinase 2 gene
B. Howell-Jolly bodies
C. Antibodies against citrullinated peptides
D. Anti-phospholipid antibodies

Answer: Mutation in Janus kinase 2 gene

1. Patient is a 50-year-old African-American woman.

2. Patient has right elbow pain for the past 12 hours.

3. Pain is currently at 7 out of 10 in intensity.

4. Patient has not had any trauma to the right elbow.

5. Patient also reports general malaise.

6. Patient had a miscarriage at the age of 37 years.

7. Patient had carpal tunnel syndrome one year ago.

8. Patient was treated with a volar splint for carpal tunnel syndrome.

9. Patient was diagnosed with thrombophlebitis three months ago.

10. Patient was treated with ibuprofen and compression therapy for thrombophlebitis.

11. Patient runs 5 km (3.1 miles) per week.

13. Patient drinks 1–2 glasses of wine on weekends.

18. Patient's blood pressure is 130/80 mm Hg.

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

20. On physical examination, the skin above patient's right elbow is erythematous and severely tender to palpation.

1. The pain is currently at 7 out of 10 in intensity.

2. She has not had any trauma to the right elbow.

4. She had a miscarriage at the age of 37 years.

5. One year ago, she had carpal tunnel syndrome that was treated with a volar splint.

6. Three months ago, she was diagnosed with thrombophlebitis, which responded well to treatment with ibuprofen and compression therapy.

9. She drinks 1–2 glasses of wine on weekends.

10. She is 171 cm (5 ft 7 in) tall and weighs 70 kg (154 lbs); BMI is 23.9 kg/m2.

11. Her pulse is 110/min, blood pressure is 130/80 mm Hg, and temperature is 38.3°C (101°F).

12. On physical examination, the skin above her right elbow is erythematous and severely tender to palpation.


Question: Which of the following is a treatment option for the patient’s most likely diagnosis?

Context: A 64-year-old man is brought to his primary care physician by his daughter for forgetfulness.

Context: The patient’s daughter reports that over the past 2 weeks the patient has become more confused.

Context: He did not remember to pick up his car from the body shop last week, and yesterday, he did not show up to his grandson’s birthday party.

Context: When she went over to the patient’s house to check on him, she noticed the mailbox was stuffed with unopened letters.

Context: The patient says “I’m fine.

Context: I just have a headache.” The patient’s daughter adds, “I just hope you’re not drinking again dad.

Context: Your neighbor saw you fall outside the house a few weeks ago, and the other day you said you were nauseous and vomited.” The patient’s medical history is significant for a history of alcohol abuse, hypertension, hyperlipidemia, and atrial fibrillation.

Context: He takes aspirin, amlodipine, metoprolol, atorvastatin, and warfarin.

Context: He smokes cigars, but denies alcohol use since he started psychotherapy 7 months ago.

Context: The patient’s temperature is 97°F (36.1°C), blood pressure is 144/92 mmHg, and pulse is 82/min.

Context: Gait is normal.

Context: The patient’s INR is 2.5.

Context: Imaging is pending.

Choices:
A. Alteplase
B. Burr hole
C. Donepezil
D. Thiamine supplementation

Answer: Burr hole

1. A 64-year-old man is brought to his primary care physician by his daughter.

2. The daughter reports that the patient has become more confused over the past 2 weeks.

3. The patient did not remember to pick up his car from the body shop last week.

4. The patient did not show up to his grandson’s birthday party yesterday.

5. The daughter noticed the mailbox was stuffed with unopened letters when she went to check on the patient.

7. The daughter is concerned the patient is drinking again.

8. The patient's neighbor saw him fall outside the house a few weeks ago.

9. The patient said he was nauseous and vomited the other day.

10. The patient's medical history is significant for a history of alcohol abuse, hypertension, hyperlipidemia, and atrial fibrillation.

11. The patient takes aspirin, amlodipine, metoprolol, atorvastatin, and warfarin.

13. The patient denies alcohol use since he started psychotherapy 7 months ago.

14. The patient's temperature is 97°F (36.1°C).

15. The patient's blood pressure is 144/92 mmHg.

17. On physical examination, there is a 3 cm ecchymosis on the right scalp.

18. No focal neurological deficits are appreciated.

20. An initial complete blood count shows normocytic anemia.

1. The patient's daughter reports increased confusion over the past 2 weeks.

2. The patient forgot to pick up his car from the body shop last week.

3. The patient did not attend his grandson's birthday party.

4. The patient's mailbox was stuffed with unopened letters.

5. The patient claims to be fine but complains of a headache.

6. The patient's neighbor witnessed a fall outside the house a few weeks ago.

7. The patient experienced nausea and vomiting recently.

8. The patient has a history of alcohol abuse, hypertension, hyperlipidemia, and atrial fibrillation.

9. The patient takes aspirin, amlodipine, metoprolol, atorvastatin, and warfarin.

10. The patient smokes cigars but denies alcohol use since starting psychotherapy 7 months ago.

11. The patient's temperature is 97°F (36.1°C), blood pressure is 144/92 mmHg, and pulse is 82/min.

12. A 3 cm ecchymosis is present on the right scalp.

13. No focal neurological deficits are observed.

15. Initial complete blood count shows normocytic anemia.


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

Context: There is no history of serious illness.

Context: The temperature is 36.7℃ (98.1℉), pulse is 68, respirations are 12/min, and blood pressure is 125/70 mm Hg.

Context: The laboratory test results are as follows: | Hemoglobin 10 g/dL | Mean corpuscular volume 90 μm3 | Leukocyte count 80,000/mm3 | Platelet count 450,000/mm3 | The peripheral blood smear shows a predominance of neutrophils and the presence of band cells, myelocytes, promyelocytes, and blasts (< 5%).

Context: The cytogenetic study shows t(9;22).

Choices:
A. Acute lymphoid leukemia
B. Chronic myeloid leukemia
C. Hairy cell leukemia
D. Burkitt lymphoma

Answer: Chronic myeloid leukemia

1. A 60-year-old man presents to the physician for a follow-up examination.

2. During the previous visit, splenomegaly was detected on the abdominal exam, which has been confirmed by abdominal ultrasound.

3. He has no complaints other than fatigue for several months.

4. There is no history of serious illness.

5. His only medication is acetaminophen for knee pain.

10. On physical examination, the spleen size on percussion is 16 cm (6.2 in).

11. Otherwise, the physical examination shows no abnormalities.

12. The laboratory test results are as follows: Hemoglobin 10 g/dL.

16. The peripheral blood smear shows a predominance of neutrophils and the presence of band cells, myelocytes, promyelocytes, and blasts (< 5%).

17. The cytogenetic study shows t(9;22).

1. Splenomegaly was detected during the previous visit.

2. The splenomegaly was confirmed by abdominal ultrasound.

3. The patient has been experiencing fatigue for several months.

5. The patient's only medication is acetaminophen for knee pain.

10. The spleen size on percussion is 16 cm (6.2 in).

11. The physical examination shows no other abnormalities.

12. Laboratory test results: Hemoglobin 10 g/dL.

13. Laboratory test results: Mean corpuscular volume 90 μm3.

14. Laboratory test results: Leukocyte count 80,000/mm3.

15. Laboratory test results: Platelet count 450,000/mm3.

16. The peripheral blood smear shows a predominance of neutrophils.

17. The peripheral blood smear shows the presence of band cells, myelocytes, promyelocytes, and blasts (< 5%).

18. The cytogenetic study shows t(9;22).


Question: Which of the following enzymes is most likely impaired?

Context: Neurologic examination shows normal strength in all extremities and decreased sense to vibration in his lower extremities bilaterally.

Context: A peripheral blood smear is shown.

Choices:
A. Succinate dehydrogenase
B. Propionyl-CoA carboxylase
C. Pyruvate carboxylase
D. Methylmalonyl-CoA mutase

Answer: Methylmalonyl-CoA mutase

Balance problems could be related to a neurological issue. The subspecialty that would be most relevant for this patient is General Neurology.

1. A 55-year-old man comes to the physician because of balance problems.

2. He follows a vegan diet and does not eat meat, eggs, or dairy.

3. Physical examination shows pale oral mucosa and conjunctivae.

4. Neurologic examination shows normal strength in all extremities.

5. Neurologic examination shows decreased sense to vibration in his lower extremities bilaterally.

2. He does not eat meat, eggs, or dairy.

3. Physical examination shows pale oral mucosa.

4. Physical examination shows pale conjunctivae.

5. Neurologic examination shows normal strength in all extremities.

6. Neurologic examination shows decreased sense to vibration in his lower extremities bilaterally.


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

Context: Laboratory values are ordered as seen below. |  | Hemoglobin: 10 g/dL | Hematocrit: 32% | MCV: 78 µm^3 | Ferritin: 10 mg/mL | Total iron binding capacity: 620 mcg/dL | Leukocyte count: 6,500/mm^3 with normal differential | Platelet count: 190,000/mm^3 |  | Serum: | Na+: 141 mEq/L | Cl-: 102 mEq/L | K+: 4.1 mEq/L | HCO3-: 24 mEq/L | BUN: 20 mg/dL | Glucose: 99 mg/dL | Creatinine: 1.1 mg/dL | Ca2+: 10.2 mg/dL | TSH: 4.7 mIU/mL | AST: 12 U/L | ALT: 10 U/L |  | .

Choices:
A. Vitamin B9
B. Vitamin B12
C. Iron
D. Assess for depression

Answer: Iron

1. A 32-year-old woman presents to her primary care physician for generalized fatigue.

2. She states that she is doing well but that she always feels tired.

3. She started exercising to have more energy, finds that she tires easily, and has not felt motivated to return to the gym.

4. She is doing well and is excelling at her job.

5. She recently started a vegan diet in order to try and become healthy.

6. She is currently struggling with dating and is unable to find a compatible mate and feels hopeless about this.

7. The patient has a past medical history of uterine leiomyomas.

8. Her temperature is 99.5°F (37.5°C), blood pressure is 100/68 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 98% on room air.

9. Laboratory values are ordered as seen below.

14. Total iron binding capacity: 620 mcg/dL

15. Leukocyte count: 6,500/mm^3 with normal differential

1. The patient states that she is doing well but always feels tired.

2. She started exercising to have more energy, but finds that she tires easily and has not felt motivated to return to the gym.

4. She recently started a vegan diet to try and become healthy.

5. She is currently struggling with dating and is unable to find a compatible mate, feeling hopeless about this.

6. The patient has a past medical history of uterine leiomyomas.

7. Her temperature is 99.5°F (37.5°C), blood pressure is 100/68 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 98% on room air.

8. Laboratory values: Hemoglobin: 10 g/dL, Hematocrit: 32%, MCV: 78 µm^3, Ferritin: 10 mg/mL, Total iron binding capacity: 620 mcg/dL, Leukocyte count: 6,500/mm^3 with normal differential, Platelet count: 190,000/mm^3, Serum: Na+: 141 mEq/L, Cl-: 102 mEq/L, K+: 4.1 mEq/L, HCO3-: 24 mEq/L, BUN: 20 mg/dL, Glucose: 99 mg/dL, Creatinine: 1.1 mg/dL, Ca2+: 10.2 mg/dL, TSH: 4.7 mIU/mL, AST: 12 U/L, ALT: 10 U/L.


Question: The hormone responsible for the observed laboratory changes most likely increases glucose transport into which of the following types of cells?

Context: A 28-year-old woman, gravida 1, para 0, at 24 weeks' gestation comes to the physician for a prenatal visit.

Context: She feels well.

Context: She has no history of medical illness and takes no medications.

Context: Her fasting serum glucose is 91 mg/dL.

Choices:
A. Spermatocytes
B. Islet cells
C. Adipocytes
D. Placental cells

Answer: Adipocytes

1. A 28-year-old woman comes to the physician for a prenatal visit.

2. She is gravida 1, para 0, and at 24 weeks' gestation.

4. She has no history of medical illness.

6. Her fasting serum glucose is 91 mg/dL.

7. One hour after drinking a concentrated glucose solution, her serum glucose concentration is 94 mg/dL.

2. She has no history of medical illness.

4. Her fasting serum glucose is 91 mg/dL.

5. One hour after drinking a concentrated glucose solution, her serum glucose concentration is 94 mg/dL.


Question: Which of the following risk factors is associated with the most likely diagnosis?

Context: Laboratory studies are ordered as seen below. |  | Hemoglobin: 15 g/dL | Hematocrit: 43% | Leukocyte count: 6,500/mm^3 with normal differential | Platelet count: 194,000/mm^3 |  | Serum: | Na+: 138 mEq/L | Cl-: 102 mEq/L | K+: 4.4 mEq/L | HCO3-: 24 mEq/L | BUN: 20 mg/dL | Glucose: 120 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: 10.2 mg/dL | pH: 7.44 | PaCO2: 10 mmHg | PaO2: 90 mmHg | AST: 12 U/L | ALT: 10 U/L |  | The patient complains about difficulty breathing.

Context: Repeat laboratory values are notable for the findings below. |  | pH: 7.35 | PaCO2: 30 mmHg | PaO2: 80 mmHg |  | The patient is intubated and sent to the MICU.

Choices:
A. Female sex living in a Northern latitude
B. Hiking in tick-infested woods
C. Consuming meats cooked over a campfire
D. Central cervical spine trauma

Answer: Consuming meats cooked over a campfire

1. A 27-year-old woman presents to the emergency department with weakness of her legs which has progressed to an inability for her to stand.

2. The patient works as a school teacher in Alaska and regularly goes hiking and camping.

3. She recently returned from a camping trip where she hiked through tall brush and drank from mountain streams.

4. The patient was also involved in a motor vehicle accident 2 days ago but did not seek treatment.

5. The patient has a medical history that is unremarkable and is currently taking multivitamins and other than a recent bout of diarrhea is generally healthy.

6. Her temperature is 99.5°F (37.5°C), blood pressure is 120/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air.

7. Physical exam is notable for a very anxious woman with 1/5 strength of the patient’s lower extremities and 2/5 strength of her trunk muscles with diminished sensation.

8. Laboratory studies are ordered as seen below: Hemoglobin: 15 g/dL, Hematocrit: 43%, Leukocyte count: 6,500/mm^3 with normal differential, Platelet count: 194,000/mm^3, Serum: Na+: 138 mEq/L, Cl-: 102 mEq/L, K+: 4.4 mEq/L, HCO3-: 24 mEq/L, BUN: 20 mg/dL, Glucose: 120 mg/dL, Creatinine: 1.0 mg/dL, Ca2+: 10.2 mg/dL, pH: 7.44, PaCO2: 10 mmHg, PaO2: 90 mmHg, AST: 12 U/L, ALT: 10 U/L.

9. The patient complains about difficulty breathing.

10. Repeat laboratory values are notable for the findings below: pH: 7.35, PaCO2: 30 mmHg, PaO2: 80 mmHg.

11. The patient is intubated and sent to the MICU.

1. The patient works as a school teacher in Alaska.

2. The patient regularly goes hiking and camping.

3. The patient recently returned from a camping trip where she hiked through tall brush and drank from mountain streams.

4. The patient was involved in a motor vehicle accident 2 days ago but did not seek treatment.

5. The patient has a medical history that is unremarkable.

6. The patient is currently taking multivitamins.

7. The patient had a recent bout of diarrhea.

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

9. The patient's blood pressure is 120/68 mmHg.

11. The patient's respirations are 17/min.

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

13. Physical exam is notable for a very anxious woman.

14. The patient has 1/5 strength of the lower extremities and 2/5 strength of her trunk muscles with diminished sensation.

15. Laboratory studies show: Hemoglobin: 15 g/dL, Hematocrit: 43%, Leukocyte count: 6,500/mm^3 with normal differential, Platelet count: 194,000/mm^3, Serum: Na+: 138 mEq/L, Cl-: 102 mEq/L, K+: 4.4 mEq/L, HCO3-: 24 mEq/L, BUN: 20 mg/dL, Glucose: 120 mg/dL, Creatinine: 1.0 mg/dL, Ca2+: 10.2 mg/dL, pH: 7.44, PaCO2: 10 mmHg, PaO2: 90 mmHg, AST: 12 U/L, ALT: 10 U/L.

16. The patient complains about difficulty breathing.

17. Repeat laboratory values show: pH: 7.35, PaCO2: 30 mmHg, PaO2: 80 mmHg.

18. The patient is intubated and sent to the MICU.


Question: Which of the following reaction is favored under this condition?

Context: An 18-year-old male presents to the emergency room smelling quite heavily of alcohol and is unconscious.

Context: A previous medical history states that he does not have diabetes.

Context: The metabolism of ethanol in this patient's hepatocytes resulted in an increase of the [NADH]/[NAD+] ratio.

Choices:
A. Pyruvate to acetyl-CoA
B. Citrate to isocitrate
C. Oxaloacetate to malate
D. Oxaloacetate to phosphoenolpyruvate

Answer: Oxaloacetate to malate

1. An 18-year-old male presents to the emergency room.

2. The patient smells quite heavily of alcohol.

4. A blood test reveals severe hypoglycemic and ketoacidemia.

5. The patient does not have diabetes according to their medical history.

6. The metabolism of ethanol in the patient's hepatocytes increased the [NADH]/[NAD+] ratio.

1. A blood test reveals severe hypoglycemia.

3. The patient does not have diabetes according to previous medical history.

4. The metabolism of ethanol in the patient's hepatocytes resulted in an increase of the [NADH]/[NAD+] ratio.


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

Context: A previously healthy 7-year-old girl is brought to the physician for a well-child examination.

Context: She feels well.

Context: She emigrated from India 3 months ago.

Context: Her immunizations are up-to-date.

Context: Examination shows no abnormalities.

Context: Laboratory studies show: | Hemoglobin 13.2 g/dL | Leukocyte count 8900/mm3 | Platelet count 310,000/mm3 | Serum | Hepatitis B surface antigen negative | Hepatitis B antibody positive | Interferon-γ release assay positive | An x-ray of the chest shows no abnormalities.

Choices:
A. Perform acid-fast stain on induced sputum
B. Administer isoniazid
C. Perform tuberculin skin test
D. Administer isoniazid, rifampin, ethambutol and pyrazinamide

Answer: Administer isoniazid

3. Patient emigrated from India 3 months ago.

4. No family history of serious illness.

6. Patient is at 60th percentile for height and weight.

14. Serum Hepatitis B surface antigen is negative.

15. Serum Hepatitis B antibody is positive.

16. Interferon-γ release assay is positive.

17. X-ray of the chest shows no abnormalities.

2. She emigrated from India 3 months ago.

3. There is no family history of serious illness.

5. She is at 60th percentile for height and weight.

6. Her temperature is 37°C (98.6°F), pulse is 90/min, and respirations are 26/min.

8. Laboratory studies show: Hemoglobin 13.2 g/dL, Leukocyte count 8900/mm3, Platelet count 310,000/mm3, Serum Hepatitis B surface antigen negative, Hepatitis B antibody positive, Interferon-γ release assay positive.

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


Question: Based on the study results, which of the following statements best addresses the mother's question?"

Context: Please refer to the summary above to answer this question | An 8-year-old boy is brought to the physician by his mother for a well-child examination at a clinic for low-income residents.

Context: Although her son's elementary school offers free afterschool programming, her son has not been interested in attending.

Context: The mother is curious about the benefits of afterschool programming and asks for the physician's input.

Choices:
A. The patient's family history of psychiatric illness prevents any conclusions from being drawn from the study.
B. High-quality afterschool programming for low-income 8-year-olds may correlate with decreased bipolar disorder risk in adults.
C. High-quality afterschool programming should be free of charge for low-income children to improve adult mental health.
D.
High-quality afterschool programming for low-income 8-year-olds may correlate with decreased ADHD risk in adults.
"

Answer:
High-quality afterschool programming for low-income 8-year-olds may correlate with decreased ADHD risk in adults.
"

1. An 8-year-old boy is brought to the physician by his mother.

2. The examination is at a clinic for low-income residents.

3. The son's elementary school offers free afterschool programming.

4. The son has not been interested in attending the afterschool programming.

5. The son's maternal grandmother has major depressive disorder.

6. The son's paternal grandmother has major depressive disorder.

7. The mother is curious about the benefits of afterschool programming.

8. The mother asks for the physician's input.

1. The son's elementary school offers free afterschool programming.

2. The son has not been interested in attending the afterschool programming.

3. Both the son's maternal and paternal grandmothers have major depressive disorder.

4. The mother is curious about the benefits of afterschool programming.

5. The mother asks for the physician's input.


Question: Which of the following is the child most likely to develop?

Context: Two days after delivery, a 2450-g (5-lb 6-oz) male newborn has three episodes of green vomitus.

Context: He was born at 34 weeks' gestation.

Context: He appears irritable.

Context: His temperature is 37.3°C (99.1°F), pulse is 161/min, respirations are 56/min, and blood pressure is 62/44 mm Hg.

Context: Examination shows a distended abdomen; there is diffuse tenderness to palpation over the abdomen.

Context: Bowel sounds are decreased.

Choices:
A. Infertility
B. Alzheimer's disease
C. Asthma
D. Necrotizing enterocolitis

Answer: Infertility

1. Two days after delivery, a 2450-g (5-lb 6-oz) male newborn has had three episodes of green vomitus.

2. He has passed urine twice a day, but has not yet passed stool.

9. Examination shows a distended abdomen.

10. There is diffuse tenderness to palpation over the abdomen.

12. Digital rectal examination is unremarkable.

13. The remainder of the examination shows no abnormalities.

14. An x-ray of the abdomen shows dilated bowel loops.

15. Contrast enema demonstrates inspissated meconium plugs in the distal ileum and microcolon.


Question: Which of the following is most likely a cause of this baby’s symptoms?

Context: However, a week after delivery he developed a respiratory infection involving an aggressive cough followed by a high-pitched intake of breath.

Context: On examination, the infant’s vitals are normal but he appears lethargic and mildly dehydrated with depressed fontanelles and decreased skin turgor.

Choices:
A. Deficiency of nitric oxide synthase
B. Antibiotic use
C. Inadequate myenteric plexus innervation
D. Telescoping of the proximal bowel into a distal segment

Answer: Antibiotic use

Pediatric Surgery
Pediatric Gastroenterology

1. A 6-week-old boy is brought to see his pediatrician.

2. His mother says that he has not been feeding well and forcefully vomited after every feed over the past 4 days.

3. The infant was born at 39 weeks gestation via spontaneous vaginal delivery.

4. He is up to date on all vaccines and is meeting all developmental milestones.

5. A week after delivery he developed a respiratory infection involving an aggressive cough followed by a high-pitched intake of breath.

6. Respiratory cultures were positive for a gram-negative coccobacilli for which he received erythromycin.

7. Since then he has remained healthy until now.

8. On examination, the infant’s vitals are normal.

9. He appears lethargic and mildly dehydrated with depressed fontanelles and decreased skin turgor.

10. A firm non-tender mass is palpated in the epigastric region.

1. His mother reports poor feeding and forceful vomiting after feeds for the past 4 days.

2. The infant was born at 39 weeks gestation via spontaneous vaginal delivery.

4. He is meeting all developmental milestones.

5. A week after delivery, he developed a respiratory infection with an aggressive cough and high-pitched intake of breath.

6. Respiratory cultures were positive for a gram-negative coccobacilli.

7. He received erythromycin for the infection.

8. On examination, the infant's vitals are normal.

9. He appears lethargic and mildly dehydrated.

10. He has depressed fontanelles and decreased skin turgor.

11. A firm non-tender mass is palpated in the epigastric region.


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

Context: A 67-year-old man presents to his primary care physician because he has been feeling increasingly short of breath.

Context: Specifically, after retirement he has been going on daily morning walks with his wife; however, over the last year he feels that his endurance has decreased.

Context: His medical history is significant for well-controlled hypertension but is otherwise unremarkable.

Context: When asked, he reveals that he worked in a variety of industries throughout his life.

Context: Testing demonstrates decreased forced vital capacity (FVC) and a normal forced expiratory volume (FEV) to FVC ratio.

Context: Pathology demonstrates changes primarily in the upper lobes where macrophages can be seen with dark round ingested particles.

Choices:
A. Increased risk of lung cancer
B. Increased risk of tuberculosis
C. Mesothelioma
D. Lung rheumatoid nodules

Answer: Lung rheumatoid nodules

1. A 67-year-old man presents to his primary care physician.

2. He has been feeling increasingly short of breath.

3. After retirement he has been going on daily morning walks with his wife.

4. Over the last year he feels that his endurance has decreased.

5. His medical history is significant for well-controlled hypertension.

6. His medical history is otherwise unremarkable.

7. He worked in a variety of industries throughout his life.

8. Testing demonstrates decreased forced vital capacity (FVC).

9. Testing demonstrates a normal forced expiratory volume (FEV) to FVC ratio.

10. Pathology demonstrates changes primarily in the upper lobes.

11. Pathology demonstrates macrophages can be seen with dark round ingested particles.

1. After retirement, he has been going on daily morning walks with his wife.

2. Over the last year, he feels that his endurance has decreased.

3. His medical history is significant for well-controlled hypertension.

4. His medical history is otherwise unremarkable.

5. He reveals that he worked in a variety of industries throughout his life.

6. Testing demonstrates decreased forced vital capacity (FVC).

7. Testing demonstrates a normal forced expiratory volume (FEV) to FVC ratio.

8. Pathology demonstrates changes primarily in the upper lobes.

9. Macrophages can be seen with dark round ingested particles in the upper lobes.


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

Context: A 75-year-old woman is brought to the emergency department because of vomiting, abdominal pain, and constipation for the past 2 days.

Context: She has urinated frequently over the past week and has become excessively thirsty during this time.

Context: She is a 30-pack-year smoker.

Context: She appears confused.

Context: Her blood pressure is 95/70 mm Hg, pulse is 110/min, respirations are 25/min, and temperature is 37.1°C (98.8°F).

Context: She has dry oral mucosa.

Context: A computed tomography scan is shown.

Choices:
A. Adenocarcinoma
B. Bronchoalveolar carcinoma
C. Large-cell carcinoma
D. Squamous cell carcinoma

Answer: Squamous cell carcinoma

1. A 75-year-old woman is brought to the emergency department.

2. She has been vomiting, having abdominal pain, and constipated for the past 2 days.

3. She has been urinating frequently over the past week and has become excessively thirsty during this time.

4. She has no significant past medical history.

12. Lung auscultation shows rhonchi and wheezing localized to the right middle lobe area.

13. An electrocardiogram (ECG) shows a shortened QT interval.

14. A computed tomography scan is shown.

1. She has urinated frequently over the past week.

2. She has become excessively thirsty during this time.

3. She has no significant past medical history.

11. Lung auscultation shows rhonchi and wheezing localized to the right middle lobe area.

12. An electrocardiogram (ECG) shows a shortened QT interval.

13. A computed tomography scan is shown.


Question: The virulence factor responsible for the edema seen in this patient has a mechanism of action similar to which of the following enzymes?

Context: A 23-year-old woman comes to the physician because of a painless lesion on the arm that first appeared 5 days after she visited a petting zoo.

Context: The lesion began as a small papule and then became a blister that has since ulcerated.

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

Context: There is axillary lymphadenopathy.

Choices:
A. Adenylate cyclase
B. Catalase
C. Guanylate cyclase
D. SNARE protein

Answer: Adenylate cyclase

1. A 23-year-old woman comes to the physician.

2. She has a painless lesion on her arm.

3. The lesion first appeared 5 days after she visited a petting zoo.

8. Examination shows a black eschar with edematous borders on the left upper arm.

5. Examination shows a black eschar on the left upper arm.


Question: A genetic defect, in which of the following proteins is most likely responsible for this patient’s condition?

Context: A 54-year-old man with a history of hypertension presents 6 days after being admitted for new-onset atrial fibrillation with the rapid ventricular rate with a painful lesion on his left leg.

Context: He says his heart rate has been well-controlled since starting metoprolol and warfarin in the hospital but says he has developed a painful lesion on his left leg.

Context: His blood pressure is 114/78 mm Hg, the heart rate is 84/min, and the respiratory rate is 15/min.

Context: On physical examination, there is a large, dark lesion on his left leg that feels cold (see image).

Choices:
A. Factor V
B. Factor XII
C. Protein C
D. Factor VIII

Answer: Protein C

1. A 54-year-old man has a history of hypertension.

2. He was admitted 6 days ago for new-onset atrial fibrillation with a rapid ventricular rate.

3. He has been taking metoprolol and warfarin since being admitted.

4. His heart rate has been well-controlled since starting the medications.

5. He has developed a painful lesion on his left leg.

9. On physical examination, there is a large, dark lesion on his left leg.

1. Patient reports well-controlled heart rate since starting metoprolol and warfarin.

2. Patient has developed a painful lesion on his left leg.

6. Physical examination reveals a large, dark lesion on the left leg.


Question: The patient’s condition is most likely caused by antibodies against which of the following compounds?

Context: A 35-year-old patient presents to the dermatologist with a new skin rash.

Context: They extend on both arms but are not in her mouth or torso.

Choices:
A. Desmoglein
B. Hemidesmosomes
C. Double-stranded DNA
D. U1 ribonucleotide polypeptide

Answer: Hemidesmosomes

2. Patient presents to dermatologist with new skin rash.

3. Patient has noticed new bumps on arm over past 1 month.

4. Bumps are 0.5 cm in diameter and filled with clear fluid.

5. Bumps extend on both arms but not in mouth or torso.

6. Lesions do not pop with pressure but remain tense.

7. Skin does not slough off with rubbing.

8. Patient denies any other symptoms including joint pain or fever.

9. Patient has no other medical history.

1. The patient has noticed new bumps on her arm over the past 1 month.

2. The bumps are about 0.5 cm in diameter and are filled with a clear fluid.

3. The bumps extend on both arms but are not in her mouth or torso.

4. The lesions do not pop with pressure but remain tense.

5. Her skin does not slough off with rubbing.

6. The patient denies any other symptoms including joint pain or fever.

7. The patient has no other medical history.


Question: Which of the following confirmatory tests is most appropriate?

Context: A 59-year-old woman presents to the emergency department because of shortness of breath.

Choices:
A. Pulmonary function test
B. Biopsy of cardiac tissue
C. Chest X-ray
D. No further testing required

Answer: Biopsy of cardiac tissue

2. Patient presents to the emergency department with shortness of breath.

3. Patient has increasing inability to breathe following strenuous activity, such as climbing stairs and walking a few blocks.

4. Patient's breathing becomes more pronounced when she takes a nap or lies down to sleep at night.

5. Patient has increased swelling in her legs.

6. Patient has a history of few episodes of syncope.

7. Patient's past medical history is otherwise unremarkable.

8. Patient's vital signs include: blood pressure 110/70 mm Hg, pulse 90/min, and respiratory rate 18/min.

9. An electrocardiogram (ECG) shows low voltage.

10. Echocardiography shows granular speckling with concentric thickening of the ventricular walls, more prominently of the right wall.

1. She has been experiencing an increasing inability to breathe following strenuous activity.

2. This includes climbing stairs and walking a few blocks down the street.

3. During the day, her breathing becomes more pronounced when she takes her a nap or lies down to sleep at night.

4. Another concerning symptom is the increased swelling in her legs.

5. She has a history of few episodes of syncope.

6. Her past medical history is otherwise unremarkable.

7. The vital signs include: blood pressure 110/70 mm Hg, pulse 90/min, and respiratory rate 18/min.

8. An electrocardiogram (ECG) shows low voltage.

9. Echocardiography shows granular speckling with concentric thickening of the ventricular walls, more prominently of the right wall.


Question: What is the most likely diagnosis?

Context: A 30-year-old previously healthy male presents to your office with complaints of facial pressure and rhinorrhea for the past 3 weeks.

Context: The patient reports that several weeks prior, he had a “common cold” which resolved.

Context: However, he has since developed worsening facial pressure, especially over his cheeks and forehead.

Context: He reports over 1 week of green tinged rhinorrhea.

Context: His temperature is 100.1 deg F (37.8 deg C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min.

Choices:
A. Acute viral rhinosinusitis
B. Acute bacterial rhinosinusitis
C. Allergic rhinitis
D. Chronic rhinosinusitis

Answer: Acute bacterial rhinosinusitis

3. Patient has had complaints of facial pressure and rhinorrhea for the past 3 weeks.

4. Patient had a "common cold" several weeks prior which resolved.

5. Patient has worsening facial pressure, especially over his cheeks and forehead.

6. Patient has had over 1 week of green tinged rhinorrhea.

7. Patient's temperature is 100.1 deg F (37.8 deg C).

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

11. Nasal exam reveals edematous turbinates and purulent discharge.

1. The patient had a "common cold" several weeks prior which resolved.

2. The patient has developed worsening facial pressure, especially over his cheeks and forehead.

3. The patient reports over 1 week of green tinged rhinorrhea.

4. The patient's temperature is 100.1 deg F (37.8 deg C).

5. The patient's blood pressure is 120/70 mmHg.

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

8. Nasal exam reveals edematous turbinates.

9. Nasal exam reveals purulent discharge.


Question: Based on these findings, which of the following nerves is most likely injured in this patient?

Context: A 25-year-old man is brought to the emergency department 30 minutes after he was involved in a motorcycle collision.

Choices:
A. Posterior interosseous nerve
B. Axillary nerve
C. Median nerve
D. Ulnar nerve

Answer: Median nerve

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

2. He was involved in a motorcycle collision 30 minutes prior.

3. Physical examination revealed a deep laceration on the volar surface of the distal left forearm.

4. Neurological examination showed loss of abduction and opposition of the left thumb.

5. The radial and ulnar pulses were palpable.

1. Physical examination shows a deep laceration on the volar surface of the distal left forearm.

2. Neurological examination shows loss of abduction and opposition of the left thumb.

3. The radial and ulnar pulses are palpable.


Question: Which of the following is the most likely location of his intestinal bleeding?

Context: A 70-year-old man presents to the emergency department after several episodes of bloody stools that started 6 hours ago.

Context: On examination, he is pale and cachectic.

Context: The patient’s abdomen is nontender to palpation on the exam.

Context: His heart rate is 120/min and blood pressure is 80/60 mm Hg.

Context: A stool sample from the patient shows stools with bright red blood, and a hemoccult test is positive.

Choices:
A. Ascending colon
B. Sigmoid colon
C. Stomach
D. Ileum

Answer: Sigmoid colon

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

2. The patient had several episodes of bloody stools that started 6 hours ago.

3. The patient denies nausea, vomiting, or diarrhea.

4. On examination, the patient is pale and cachectic.

5. The patient's abdomen is nontender to palpation on the exam.

7. The patient's blood pressure is 80/60 mm Hg.

8. A stool sample from the patient shows stools with bright red blood.

5. On examination, the patient is cachectic.

6. The patient’s abdomen is nontender to palpation.

8. The patient's blood pressure is 80/60 mm Hg.

9. A stool sample from the patient shows stools with bright red blood.


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

Context: A 48-year-old man comes to the physician because of a 4-month history of persistent cough productive of white phlegm.

Context: He coughs consistently throughout the day, and he has not noticed any particular triggers that make it worse.

Context: He has also recently experienced some shortness of breath with exertion.

Context: Vital signs are within normal limits.

Choices:
A. Asbestosis
B. Hypersensitivity pneumonitis
C. Asthma
D. Chronic bronchitis

Answer: Chronic bronchitis

General Pulmonary Disease
Pulmonary Disease

2. Patient has had a persistent cough for 4 months.

4. Cough is consistent throughout the day.

5. Patient has not noticed any particular triggers that make it worse.

6. Patient has recently experienced shortness of breath with exertion.

7. Patient has not had any weight loss, fever, or chills.

8. Patient had similar symptoms last year, which lasted about 6 months.

9. Patient has hypertension and takes amlodipine.

10. Patient has worked in construction for the past 10 years.

11. Patient has smoked a pack of cigarettes per day for 30 years.

12. Vital signs are within normal limits.

13. Examination shows an end-expiratory wheeze throughout all lung zones.

1. He coughs consistently throughout the day.

2. He has not noticed any particular triggers that make it worse.

3. He has recently experienced some shortness of breath with exertion.

4. He has not had any weight loss, fever, or chills.

5. He had similar symptoms last year, which lasted about 6 months.

6. He has hypertension, for which he takes amlodipine.

7. He has worked in construction for the past 10 years.

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

9. Vital signs are within normal limits.

10. Examination shows an end-expiratory wheeze throughout all lung zones.


Question: What is the best immediate treatment for this patient?

Context: A 26-year-old female with no significant past medical history presents to the emergency department complaining of chest pain.

Context: She states that she was visiting her boyfriend in the hospital and, approximately 10 minutes ago, she developed chest pain associated with sweating, palpitations, nausea, and chills.

Choices:
A. Morphine, oxygen, nitrogylcerin, aspirin, beta blockers, ACE inhibitor, and heparin
B. Alprazolam, reassurance, encouraging patient to slow breathing
C. Albuterol breathing treatment
D. Cognitive behavioral therapy

Answer: Alprazolam, reassurance, encouraging patient to slow breathing

General Emergency Medicine
Cardiovascular Disease

1. A 26-year-old female presents to the emergency department.

2. She has no significant past medical history.

3. She was visiting her boyfriend in the hospital.

4. Approximately 10 minutes ago, she developed chest pain.

5. The chest pain is associated with sweating, palpitations, nausea, and chills.

6. She appears very nervous and states that she is scared that she is dying.

7. Vital signs reveal tachycardia, hypertension, and tachypnea.

8. An EKG is obtained that is unremarkable besides tachycardia.

9. TSH and free T4 are within normal limits.

10. A urine drug screen is obtained and it is negative.

1. The patient was visiting her boyfriend in the hospital.

2. Approximately 10 minutes ago, she developed chest pain.

3. The chest pain was associated with sweating, palpitations, nausea, and chills.

5. She states that she is scared that she is dying.

6. Vital signs reveal tachycardia, hypertension, and tachypnea.

7. An EKG is obtained and shows tachycardia.

8. TSH and free T4 levels are within normal limits.

9. A urine drug screen is obtained and it is negative.


Question: Which of the following responses by the treating physician is the most appropriate?

Context: A 36-year-old woman is brought to the emergency department by her sister 1 hour after she was found unconscious at home.

Context: She appears lethargic.

Context: Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 5/min, and blood pressure is 120/70 mm Hg.

Context: The patient's condition improves with supportive treatment, and she is admitted for psychiatric evaluation.

Context: I'm her neighbor and childhood friend, and I'm worried about her.” .

Choices:
A. """Why don't you go ahead and ask her directly? She is currently in the psychiatric ward."""
B. """Her urine toxicology screening was positive for alcohol, benzodiazepines, and barbiturates."""
C. """I'm not the right person to ask. Please ask her primary care physician."""
D. """I understand your concern, but I am unable to provide information about this situation."""

Answer: """I understand your concern, but I am unable to provide information about this situation."""

General Emergency Medicine
Toxicology
Medical Toxicology

1. A 36-year-old woman was brought to the emergency department by her sister 1 hour after she was found unconscious at home.

7. Urine toxicology screening is positive for alcohol, benzodiazepines, and barbiturates.

8. The patient's condition improves with supportive treatment.

9. She is admitted for psychiatric evaluation.

10. Three days later, a physician colleague approaches the physician who treated the patient in the lobby of the hospital.

11. The physician colleague is the patient's neighbor and childhood friend.

12. The physician colleague is worried about the patient.

6. Urine toxicology screening is positive for alcohol, benzodiazepines, and barbiturates.

7. The patient's condition improves with supportive treatment.

8. She is admitted for psychiatric evaluation.

9. Three days later, a physician colleague approaches the physician who treated the patient in the lobby of the hospital and states, “I just want to know what happened. I'm her neighbor and childhood friend, and I'm worried about her.”


Question: Which of the following best describes the mechanism of rejection that happened in this patient?

Context: He was diagnosed with Wilson’s disease 20 years ago and underwent a human leukocyte antigen–matched liver transplant 15 years ago.

Context: Today he is feeling fine and has no complaints except for a new, mild jaundice that his wife noticed a few weeks ago.

Context: He denies any changes in stool or urine color and is not having any abdominal pain.

Context: On physical examination, his vital signs are within normal limits, and only mild scleral icterus is noticed.

Choices:
A. Donor allogeneic MHC molecules are taken up by recipient APCs and processed into peptides, and then the peptides are presented by recipient MHC molecules to donor T cells.
B. Donor allogeneic MHC molecules are taken up by donor APCs and processed into peptides, and then the peptides are presented by unprocessed donor allogeneic MHC molecules to recipient T cells.
C. Donor allogeneic MHC molecules are taken up by recipient APCs and processed into peptides, and then the peptides are presented by recipient MHC molecules to recipient T cells.
D. Recipient MHC molecules are taken up by donor APCs and processed into peptides, and then the peptides are presented by donor allogeneic MHC molecules to recipient T cells.

Answer: Donor allogeneic MHC molecules are taken up by recipient APCs and processed into peptides, and then the peptides are presented by recipient MHC molecules to recipient T cells.

General Allergy and Immunology
Nephrology

1. A 40-year-old man presents to a clinic for a regular follow-up.

2. He was diagnosed with Wilson’s disease 20 years ago.

3. He underwent a human leukocyte antigen–matched liver transplant 15 years ago.

4. He is feeling fine and has no complaints except for a new, mild jaundice.

5. His wife noticed the jaundice a few weeks ago.

6. He denies any changes in stool or urine color.

8. On physical examination, his vital signs are within normal limits.

9. Only mild scleral icterus is noticed.

1. Diagnosed with Wilson’s disease 20 years ago

2. Underwent a human leukocyte antigen–matched liver transplant 15 years ago

3. Feeling fine today with no complaints except for mild jaundice

4. Wife noticed the new jaundice a few weeks ago

5. Denies changes in stool or urine color

8. Mild scleral icterus is noticed on physical examination


Question: Which of the following was most likely prescribed during the previous visit?

Context: His mother is particularly disturbed because her son wakes up breathless one or 2 nights every week.

Context: Over the past few months, he has not been able to participate in any sport and is also using his inhaler more than 3 times a week.

Context: On examination, the patient appears to be in slight distress and seems pale and fatigued.

Context: A photograph of the lesion is shown.

Choices:
A. Inhaled beclomethasone
B. Inhaled ipratropium bromide
C. Nebulized theophylline
D. Inhaled salmeterol

Answer: Inhaled beclomethasone

1. A 6-year-old boy is brought to his pediatrician due to increased shortness of breath.

2. His mother reports that her son wakes up breathless one or 2 nights every week.

3. He was diagnosed with asthma 2 years ago.

4. Over the past few months, he has not been able to participate in any sport.

5. He is using his inhaler more than 3 times a week.

6. On examination, the patient appears to be in slight distress.

8. There are slight expiratory wheezes and crackles in both lungs.

9. The pediatrician starts him on a low dose of another inhaler which needs to be taken once daily.

10. She asks his mother to avoid any conditions that might aggravate her son’s symptoms and make it difficult for him to breathe.

11. Three months later, the mother is back with her son at the same pediatrician’s office.

12. She is concerned about a painless white plaque on his tongue.

13. When the physician scrapes the lesion it reveals a red base with minimal bleeding.

14. A photograph of the lesion is shown.

1. The patient wakes up breathless one or 2 nights every week.

2. He was diagnosed with asthma 2 years ago.

3. He has not been able to participate in any sport.

4. He is using his inhaler more than 3 times a week.

5. On examination, the patient appears to be in slight distress.

7. There are slight expiratory wheezes and crackles in both lungs.

8. The pediatrician starts him on a low dose of another inhaler which needs to be taken once daily.

9. The mother is asked to avoid any conditions that might aggravate her son’s symptoms.

10. Three months later, the mother is back with her son at the same pediatrician’s office.

11. She is concerned about a painless white plaque on his tongue.

12. When the physician scrapes the lesion it reveals a red base with minimal bleeding.

13. A photograph of the lesion is shown.


Question: How do you expect the venous pH, arterial pCO2, and venous pCO2 to respond?

Context: Spirometry testing, along with arterial and venous blood gases, are performed immediately before and after 15 minutes of exercising on a stationary bicycle.

Choices:
A. Venous pH decreases, arterial pCO2 decreases, venous pCO2 decreases
B. Venous pH increases, arterial pCO2 decreases, venous pCO2 increases
C. Venous pH increases, arterial pCO2 increases, venous pCO2 increases
D. Venous pH decreases, arterial pCO2 stays the same, venous pCO2 increases

Answer: Venous pH decreases, arterial pCO2 stays the same, venous pCO2 increases

1. A 25-year-old medical student enrolls in an exercise research study.

2. Spirometry testing is performed immediately before and after 15 minutes of exercising on a stationary bicycle.

3. Arterial and venous blood gases are performed immediately before and after 15 minutes of exercising on a stationary bicycle.

4. The tests are performed immediately before exercising.

5. The tests are performed immediately after 15 minutes of exercising on a stationary bicycle.


Question: Which of the following enzymes contributes most to maintaining a normal serum glucose level in this patient?

Context: A 38-year-old imprisoned man is brought to the physician after going on a hunger strike for 36 hours.

Choices:
A. Phosphoenolpyruvate carboxykinase
B. Hydroxymethylglutaryl-CoA lyase
C. Glycogen phosphorylase
D. Phosphofructokinase-1

Answer: Phosphoenolpyruvate carboxykinase

2. He has gone on a hunger strike for 36 hours.

3. During this time, he has only had two cups of water.

5. Physical examination shows dry mucous membranes.

6. His serum glucose concentration is 70 mg/dL.

2. Physical examination shows dry mucous membranes.

3. His serum glucose concentration is 70 mg/dL.


Question: Which of the following best describes the most likely diagnosis?

Context: A 27-year-old man presents to the emergency department with a chief concern of abdominal pain and diarrhea.

Context: The patient states that for the past 4 days he has experienced abdominal pain, diarrhea, weakness and a subjective fever.

Context: He also endorses a weight loss of 11 pounds during this time.

Context: His current medications include fish oil, a multivitamin, sodium docusate, and fluoxetine.

Context: His temperature is 98.5°F (36.9°C), blood pressure is 110/75 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Context: Laboratory values are ordered as seen below: |  | Hemoglobin: 12 g/dL | Hematocrit: 36% | Leukocyte count: 8,000 cells/mm^3 with normal differential | Platelet count: 227,500/mm^3 |  | Serum: | Na+: 141 mEq/L | Cl-: 101 mEq/L | K+: 4.5 mEq/L | HCO3-: 24 mEq/L | BUN: 17 mg/dL | Glucose: 82 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: 10.1 mg/dL | AST: 12 U/L | ALT: 11 U/L |  | A stool guaiac test is performed which returns positive.

Choices:
A. ANCA positivity
B. ASCA positivity
C. Dilated vascular structure in the anal canal
D. Mucosal disruption

Answer: ASCA positivity

2. Patient presents to the emergency department with abdominal pain and diarrhea.

3. Patient has experienced abdominal pain, diarrhea, weakness and a subjective fever for the past 4 days.

4. Patient has lost 11 pounds during this time.

5. Patient has a past medical history of celiac disease, constipation, and depression.

6. Patient's current medications include fish oil, a multivitamin, sodium docusate, and fluoxetine.

7. Patient's temperature is 98.5°F (36.9°C).

8. Patient's blood pressure is 110/75 mmHg.

11. Patient's oxygen saturation is 98% on room air.

12. Physical exam is notable for a young man in mild distress.

13. Cardiac and pulmonary exams are within normal limits.

14. Abdominal exam is notable for generalized tenderness and increased bowel sounds.

15. Oral exam is notable for multiple shallow painful ulcers.

18. Leukocyte count is 8,000 cells/mm^3 with normal differential.

31. Patient is started on IV fluids and morphine.

1. The patient has experienced abdominal pain, diarrhea, weakness, and a subjective fever for the past 4 days.

2. The patient has experienced a weight loss of 11 pounds during the past 4 days.

3. The patient has a past medical history of celiac disease, constipation, and depression.

4. The patient's current medications include fish oil, a multivitamin, sodium docusate, and fluoxetine.

5. The patient's temperature is 98.5°F (36.9°C), blood pressure is 110/75 mmHg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air.

6. The patient's physical exam is notable for a young man in mild distress.

7. The patient's cardiac and pulmonary exams are within normal limits.

8. The patient's abdominal exam is notable for generalized tenderness and increased bowel sounds.

9. The patient's oral exam is notable for multiple shallow painful ulcers.

10. Laboratory values: Hemoglobin: 12 g/dL, Hematocrit: 36%, Leukocyte count: 8,000 cells/mm^3 with normal differential, Platelet count: 227,500/mm^3, Serum: Na+: 141 mEq/L, Cl-: 101 mEq/L, K+: 4.5 mEq/L, HCO3-: 24 mEq/L, BUN: 17 mg/dL, Glucose: 82 mg/dL, Creatinine: 1.0 mg/dL, Ca2+: 10.1 mg/dL, AST: 12 U/L, ALT: 11 U/L.

11. A stool guaiac test is performed which returns positive.

12. The patient is started on IV fluids and morphine.


Question: Which of the following is the mechanism of action of the medication?

Context: A previously healthy 31-year-old man is rushed to the emergency department after an all-night binge that included smoking, alcohol, and cocaine.

Context: At the hospital, the blood pressure is 110/70 mm Hg and the heart rate of 160/min and regular.

Context: The electrocardiogram (ECG) is shown.

Context: The patient is given the appropriate medication that improves his heart rate and returns his ECG to normal.

Choices:
A. Gamma-aminobutyric acid receptor agonist
B. Slowing of the atrioventricular (AV) node conduction time
C. Blocking of sodium/potassium adenosine triphosphatase pump
D. Prolongation of repolarization phase of cardiac action potential

Answer: Slowing of the atrioventricular (AV) node conduction time

1. A 31-year-old man is rushed to the emergency department.

2. He had an all-night binge that included smoking, alcohol, and cocaine.

3. He complains of chest fluttering, fatigue, and lightheadedness.

4. His past medical and family history are noncontributory.

5. Social history is positive for occasional smoking and social drinking.

6. At the hospital, the blood pressure is 110/70 mm Hg.

7. The heart rate is 160/min and regular.

8. The electrocardiogram (ECG) is shown.

9. A physical maneuver involving massage of the neck is attempted without improvement.

10. The patient is given the appropriate medication.

11. The medication improves his heart rate.

1. Patient complains of chest fluttering, fatigue, and lightheadedness.

2. Past medical and family history are noncontributory.

3. Social history is positive for occasional smoking and social drinking.

4. Blood pressure at the hospital is 110/70 mm Hg.

5. Heart rate at the hospital is 160/min and regular.

7. Physical maneuver involving massage of the neck is attempted without improvement.

8. Patient is given appropriate medication that improves heart rate and returns ECG to normal.


Question: Which of the following drugs would most likely achieve the desired effect?

Context: In particular, she is interested in how much a novel compound that binds to both alpha-1 and beta-1 adrenergic receptors will affect blood pressure.

Context: She studies this question in non-human primates, but finds that her results are confounded by the fact that the animals' heart rates start to decrease several minutes after administration of this novel compound.

Context: She therefore decides to pretreat these animals with a drug that is known to prevent this decrease in heart rate.

Choices:
A. Dobutamine
B. Hexamethonium
C. Metoprolol
D. Scopolamine

Answer: Hexamethonium

1. A scientist is studying how animals regulate their blood pressure in response to various stimuli.

2. She is interested in how much a novel compound that binds to both alpha-1 and beta-1 adrenergic receptors will affect blood pressure.

3. She studies this question in non-human primates.

4. Her results are confounded by the fact that the animals' heart rates start to decrease several minutes after administration of this novel compound.

5. She decides to pretreat these animals with a drug that is known to prevent this decrease in heart rate.

1. The researcher is interested in a novel compound that binds to alpha-1 and beta-1 adrenergic receptors.

2. The researcher studies the compound's effect on blood pressure in non-human primates.

3. The animals' heart rates start to decrease several minutes after administration of the novel compound.

4. The researcher decides to pretreat the animals with a drug known to prevent the decrease in heart rate.


Question: Based on the information provided in the drug advertisement, which of the following patients with HCC would be an appropriate treatment candidate and benefit the most from treatment with Noxbinle 100 mg in comparison to Metalimus 100 mg?

Context: A hepatologist has learned about the survival benefit of Noxbinle (tumorolimus) in hepatocellular carcinoma (HCC) patients from a fellow physician.

Context: She is looking at a list of HCC patients on her hospital's hepatology consult service and trying to identify candidates who might derive more survival benefits from Noxbinle as opposed to Metalimus.

Choices:
A. Non-cirrhotic patient with a history of hepatitis B and alcohol dependence
B. Alcoholic patient with severe cirrhosis on immunosuppressive therapy
C. Patient with severe cirrhosis, history of hepatitis C, and kidney stones
D. Patient with severe cirrhosis, history of hepatitis C, and asthma

Answer: Patient with severe cirrhosis, history of hepatitis C, and asthma

1. A hepatologist has learned about the survival benefit of Noxbinle (tumorolimus).

2. The survival benefit is for hepatocellular carcinoma (HCC) patients.

3. The hepatologist learned about the survival benefit from a fellow physician.

4. The hepatologist is looking at a list of HCC patients on her hospital's hepatology consult service.

5. The hepatologist is trying to identify candidates who might derive more survival benefits from Noxbinle as opposed to Metalimus.

1. She is looking at a list of HCC patients.

2. The list is for her hospital's hepatology consult service.

3. She is trying to identify candidates for Noxbinle.

4. She is trying to identify candidates for Metalimus.

5. She is trying to identify candidates who might derive more survival benefits from Noxbinle.

6. She is trying to identify candidates who might derive more survival benefits from Metalimus.


Question: In this fetus, what other renal structure would be expected to be absent?

Context: It is found that the fetus lacks proper ureters, major and minor calyces, and renal pelvises.

Choices:
A. Collecting ducts
B. Ductus deferens
C. Distal convoluted tubule
D. Bowman's capsule

Answer: Collecting ducts

1. An error occurs during the embryologic development of the kidney.

2. It is found that the fetus lacks proper ureters.

3. It is found that the fetus lacks major calyces.

4. It is found that the fetus lacks minor calyces.

5. It is found that the fetus lacks renal pelvises.

1. The fetus lacks proper ureters.
2. The fetus lacks major calyces.
3. The fetus lacks minor calyces.
4. The fetus lacks renal pelvises.


Question: Which of the following is most likely to achieve this desired effect?

Context: An investigator is studying the effects of tissue hypoxia on skeletal muscles.

Context: Skeletal muscle hypoxia is induced by decreasing oxygen delivery to peripheral tissues.

Choices:
A. Decrease the serum 2,3-bisphosphoglycerate concentration
B. Increase the serum hydrogen ion concentration
C. Increase the arterial partial pressure of carbon dioxide
D. Increase the serum temperature

Answer: Decrease the serum 2,3-bisphosphoglycerate concentration

1. An investigator is studying the effects of tissue hypoxia.

2. Tissue hypoxia affects skeletal muscles.

3. Skeletal muscle hypoxia is induced by decreasing oxygen delivery.

4. Oxygen delivery is decreased to peripheral tissues.

2. Induced by decreasing oxygen delivery