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

Context: A 42-year-old woman comes to the emergency department because of hematuria and pain in both flanks.

Context: She also complains of swelling of both feet and facial puffiness.

Context: Her mother also has a history of urinary stone and underwent a kidney transplant.

Context: Her temperature is 38.0°C (100.4°F), pulse is 110/min, and blood pressure is 150/98 mm Hg.

Choices:
A. Osteolytic bone lesions
B. Multiple hepatic cysts
C. Mitral valve stenosis
D. Popliteal aneurysm

Answer: Multiple hepatic cysts

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

2. She has hematuria and pain in both flanks.

3. She has a history of recurrent urinary tract infections.

4. She complains of swelling of both feet and facial puffiness.

5. She has passed urinary stones twice before.

6. Her mother has a history of urinary stone and underwent a kidney transplant.

10. Abdominal examination shows palpable, bilateral flank masses.

11. Results of a complete blood count are within the reference range.

12. Her serum creatinine concentration is 2.7 mg/dL.

1. She has a history of recurrent urinary tract infections.

2. She complains of swelling of both feet and facial puffiness.

3. She has passed urinary stones twice before.

4. Her mother has a history of urinary stone and underwent a kidney transplant.

8. Abdominal examination shows palpable, bilateral flank masses.

9. Results of a complete blood count are within the reference range.

10. Her serum creatinine concentration is 2.7 mg/dL.


Question: Given the following options, what is the next best step in patient management?

Context: A 51-year-old man with a past medical history of peptic ulcer disease currently treated via outpatient triple therapy presents to the urgent care center complaining of acute abdominal pain which began suddenly less than 2 hours ago.

Context: The physical examination shows his abdomen to be mildly distended, diffusely tender to palpation, and positive for rebound tenderness.

Context: Physical exam is unremarkable.

Context: The vital signs include: temperature 36.7°C (98.0°F), blood pressure 96/54 mm Hg, heart rate 112/min, and respiratory rate 19/min.

Choices:
A. Abdominal radiographs
B. CT abdomen and pelvis
C. H. pylori testing
D. Serum gastrin level

Answer: CT abdomen and pelvis

1. A 51-year-old man has a past medical history of peptic ulcer disease.

2. He is currently treated via outpatient triple therapy.

3. He presents to the urgent care center complaining of acute abdominal pain.

4. The pain began suddenly less than 2 hours ago.

5. The physical examination shows his abdomen to be mildly distended.

6. His abdomen is diffusely tender to palpation.

7. His abdomen is positive for rebound tenderness.

8. His physical exam is otherwise unremarkable.

1. The physical examination shows his abdomen to be mildly distended.

2. The physical examination shows his abdomen to be diffusely tender to palpation.

3. The physical examination shows his abdomen to be positive for rebound tenderness.

5. Vital signs include: temperature 36.7°C (98.0°F).

6. Vital signs include: blood pressure 96/54 mm Hg.

7. Vital signs include: heart rate 112/min.

8. Vital signs include: respiratory rate 19/min.


Question: Which of the following is mostly responsible for this patient's late onset of symptoms?

Context: A 10-month-old boy is brought to the physician because of fever and a cough for 3 days.

Context: He was also treated for pneumococcal pneumonia and H.

Context: influenzae meningitis this past month.

Context: He was delivered at term.

Context: He is at the 20th percentile for height and the 10th percentile for weight.

Context: His temperature is 39°C (102.2°F), pulse is 122/min, and respirations are 44/min.

Context: Palatine tonsils are absent.

Choices:
A. Reduced T-cell receptor excision circles by 6 months
B. Involution of the thymus begins at 6 months
C. Splenic dysfunction occurs by 6 months
D. Maternal IgG decreases by 6 months

Answer: Maternal IgG decreases by 6 months

1. A 10-month-old boy is brought to the physician.

2. He has had a fever and a cough for 3 days.

3. He was treated for otitis media 3 and 4 months ago.

4. He was treated for pneumococcal pneumonia and H. influenzae meningitis this past month.

6. Pregnancy and neonatal period were uncomplicated.

7. He was breast-fed until 6 months of age.

8. He has a maternal uncle who died of recurrent respiratory tract infections at 28 years of age.

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

10. He is at the 10th percentile for weight.

14. Examination shows crackles at the left lung base.

16. An x-ray shows an infiltrate in the left lower lung lobe.

17. Flow cytometry shows absence of B-cells.

1. Treated for otitis media 3 and 4 months ago

2. Treated for pneumococcal pneumonia and H. influenzae meningitis this past month

4. Pregnancy and neonatal period were uncomplicated

6. Maternal uncle died of recurrent respiratory tract infections at 28 years of age

7. At the 20th percentile for height and the 10th percentile for weight

8. Temperature is 39°C (102.2°F), pulse is 122/min, and respirations are 44/min

9. Examination shows crackles at the left lung base

11. An x-ray shows an infiltrate in the left lower lung lobe

12. Flow cytometry shows absence of B-cells


Question: Which of the following is the most inclusive list of spinal roots that contribute to the affected nerve in this patient?

Context: A 55-year-old right-handed woman is being evaluated for a long history of numbness and tingling in both of her hands, particularly in the third digits, that is worse at night.

Context: Physical examination showed thenar eminence atrophy, decreased sensation in the 3 first digits of both hands that extends proximally, and weakness on thumb abduction and thumb opposition; deep tendon reflexes are normal.

Context: Phalen and Tinel tests are positive.

Choices:
A. C4, C5
B. C6, C7, C8
C. C3, C4, C5
D. C5, C6, C7, C8, T1

Answer: C5, C6, C7, C8, T1

1. Patient is a 55-year-old right-handed woman.

2. Patient has a long history of numbness and tingling in both hands, particularly in the third digits, that is worse at night.

3. Patient works as a medical office assistant in a local travel medicine clinic.

4. Patient has a past medical history of hypothyroidism, managed medically with thyroxine.

5. Physical examination showed thenar eminence atrophy.

6. Physical examination showed decreased sensation in the 3 first digits of both hands that extends proximally.

7. Physical examination showed weakness on thumb abduction and thumb opposition.

8. Physical examination showed normal deep tendon reflexes.

1. She works as a medical office assistant in a local travel medicine clinic.

2. Her past medical history is significant for hypothyroidism, managed medically with thyroxine.

3. Physical examination showed thenar eminence atrophy.

4. Physical examination showed decreased sensation in the 3 first digits of both hands that extends proximally.

5. Physical examination showed weakness on thumb abduction and thumb opposition.

6. Physical examination showed normal deep tendon reflexes.


Question: Surgical correction of this patient's condition will most likely prevent which of the following from developing later in life?

Context: A 7-year-old girl is referred to a pediatric cardiologist after a heart murmur was auscultated during a routine school health examination.

Context: She is healthy, does not have any significant medical history, and had an uneventful birth without any complications.

Context: Her vital signs are as follows: T 37.2 C, HR 92, BP 104/62, RR 24, SpO2 99%.

Context: Physical examination is significant for a midsystolic ejection murmur heard best at the 2nd intercostal space near the left sternal border, a loud S1 heart sound, a widely fixed split S2 heart sound, and no evidence of cyanosis or clubbing.

Context: An echocardiogram is conducted and reveals a left-to-right shunt across the interatrial septum.

Choices:
A. Arteriovenous fistula
B. Pulmonary stenosis
C. Pulmonary hypertension
D. Aortic root dilation

Answer: Pulmonary hypertension

1. A 7-year-old girl is referred to a pediatric cardiologist.

2. The referral is due to a heart murmur auscultated during a routine school health examination.

3. The patient has not experienced any symptoms of shortness of breath, fatigue, chest pain, or palpitations.

4. The patient is healthy and does not have any significant medical history.

5. The patient had an uneventful birth without any complications.

8. The patient's blood pressure is 104/62.

9. The patient's respiratory rate is 24.

11. Physical examination is significant for a midsystolic ejection murmur heard best at the 2nd intercostal space near the left sternal border.

12. Physical examination is also significant for a loud S1 heart sound.

13. Physical examination is also significant for a widely fixed split S2 heart sound.

14. Physical examination is also significant for no evidence of cyanosis or clubbing.

16. The echocardiogram reveals a left-to-right shunt across the interatrial septum.

1. The patient has not experienced symptoms of shortness of breath, fatigue, chest pain, or palpitations.

2. The patient is healthy and does not have any significant medical history.

3. The patient had an uneventful birth without any complications.

5. Physical examination reveals a midsystolic ejection murmur heard best at the 2nd intercostal space near the left sternal border.

6. Physical examination reveals a loud S1 heart sound.

7. Physical examination reveals a widely fixed split S2 heart sound.

8. Physical examination reveals no evidence of cyanosis or clubbing.

9. An echocardiogram reveals a left-to-right shunt across the interatrial septum.


Question: Which of the following is the most likely explanation of the patient's laboratory findings?"

Context: A 21-year-old man is brought to the emergency department by the police because of altered mental status.

Context: Laboratory studies show: | Serum | Na+ 140 mEq/L | Cl- 102 mEq/L | Arterial blood gas analysis on room air: | On admission Three hours later | pH 7.47 7.39 | PaCO2 24 mm Hg 31 mm Hg | PO2 84 mm Hg 82 mm Hg | HCO3- 20 mEq/L 18 mEq/L | .

Choices:
A. Salicylate toxicity
B. Diabetic ketoacidosis
C. Recurrent vomiting
D. Adrenal insufficiency

Answer: Salicylate toxicity

1. A 21-year-old man is brought to the emergency department by the police.

2. The police found him covering his ears and shouting near a highway rest area.

3. Upon questioning, he was unable to look directly at the police and answer coherently.

4. On the way to the hospital, he reported feeling nauseous and vomited twice.

9. He is admitted to the hospital for evaluation.

10. Three hours after admission, he has a tonic-clonic seizure.

13. Arterial blood gas analysis on room air pH on admission is 7.47.

14. Arterial blood gas analysis on room air PaCO2 on admission is 24 mm Hg.

15. Arterial blood gas analysis on room air PO2 on admission is 84 mm Hg.

16. Arterial blood gas analysis on room air HCO3- on admission is 20 mEq/L.

17. Arterial blood gas analysis on room air pH three hours later is 7.39.

18. Arterial blood gas analysis on room air PaCO2 three hours later is 31 mm Hg.

19. Arterial blood gas analysis on room air PO2 three hours later is 82 mm Hg.

20. Arterial blood gas analysis on room air HCO3- three hours later is 18 mEq/L.

1. The police found him covering his ears and shouting near a highway rest area.

2. Upon questioning, he was unable to look directly at the police and answer coherently.

3. On the way to the hospital, he reported feeling nauseous and vomited twice.

4. His temperature is 38.2°C (100.8°F), pulse is 100/min, respirations are 28/min, and blood pressure is 110/77 mm Hg.

5. He is admitted to the hospital for evaluation.

6. Three hours after admission, he has a tonic-clonic seizure.

7. Laboratory studies show: Serum Na+ 140 mEq/L, Cl- 102 mEq/L, Arterial blood gas analysis on room air: On admission - pH 7.47, PaCO2 24 mm Hg, PO2 84 mm Hg, HCO3- 20 mEq/L. Three hours later - pH 7.39, PaCO2 31 mm Hg, PO2 82 mm Hg, HCO3- 18 mEq/L.


Question: Which of the following is the most likely mechanism of action for this treatment?

Context: A 58-year-old man makes an appointment with his nephrologist because he has been feeling weak and increasingly fatigued over the last month.

Context: Specifically, he has not been able to do activities of daily living independently because he feels short of breath after several minutes of activity.

Context: Laboratory tests are obtained and results are shown below: |  | Hemoglobin: 8.9 g/dL (normal: 13.5-17.5 g/dL) | Platelet count: 198,000/mm^3 (normal: 150,000-400,000/mm^3) | Mean corpuscular volume: 87 µm^3 (normal: 80-100 µm^3) | Reticulocyte count: 0.1% (normal: 0.5-1.5%) |  | Based on these findings, the patient is given appropriate treatment to address his symptoms.

Choices:
A. Activation of receptors on erythroid progenitor cells
B. Chelation of heavy metals
C. Provision of finished blood products
D. Removal of red blood cell clearing organ

Answer: Activation of receptors on erythroid progenitor cells

1. A 58-year-old man makes an appointment with his nephrologist.

2. He has been feeling weak and increasingly fatigued over the last month.

3. He has not been able to do activities of daily living independently because he feels short of breath after several minutes of activity.

4. His past medical history is significant for rapidly progressive glomerulonephritis that led to kidney failure.

5. He has been on hemodialysis for the last 6 months and has been compliant with attending every dialysis session.

6. Physical exam reveals conjunctival pallor.

7. Laboratory tests are obtained and results are shown below:

8. Hemoglobin: 8.9 g/dL (normal: 13.5-17.5 g/dL)

10. Mean corpuscular volume: 87 µm^3 (normal: 80-100 µm^3)

11. Reticulocyte count: 0.1% (normal: 0.5-1.5%)

12. Based on these findings, the patient is given appropriate treatment to address his symptoms.

1. The patient is unable to perform activities of daily living independently due to shortness of breath after several minutes of activity.

2. The patient has a history of rapidly progressive glomerulonephritis leading to kidney failure.

3. The patient has been undergoing hemodialysis for the past 6 months and has been compliant with attending every dialysis session.

4. Physical exam reveals conjunctival pallor.

5. Laboratory tests show: Hemoglobin: 8.9 g/dL (normal: 13.5-17.5 g/dL), Platelet count: 198,000/mm^3 (normal: 150,000-400,000/mm^3), Mean corpuscular volume: 87 µm^3 (normal: 80-100 µm^3), Reticulocyte count: 0.1% (normal: 0.5-1.5%).

6. Based on these findings, the patient is given appropriate treatment to address his symptoms.


Question: Which of the following best describes the pathogenesis of this patient's histopathological findings?

Context: A 33-year-old African American woman comes to the physician because of a 4-month history of progressive fatigue, shortness of breath, constipation, and a nonproductive cough.

Context: Physical examination is unremarkable.

Choices:
A. MHC I binding to CD8+ T cells
B. Antigen binding to IgM
C. TNF-α secretion by CD4+ T cells
D. IL-5 secretion by Th2 cells

Answer: TNF-α secretion by CD4+ T cells

1. A 33-year-old African American woman comes to the physician.

2. She has a 4-month history of progressive fatigue, shortness of breath, constipation, and a nonproductive cough.

3. She returned from a trip to Nigeria 6 months ago.

4. Physical examination is unremarkable.

5. Serum calcium concentration is 11.7 mg/dL.

6. An x-ray of the chest shows bilateral hilar lymphadenopathy with coarse, nodular opacities in both lower lobes.

7. A photomicrograph of a biopsy specimen of the affected area of the lungs is shown.

1. She returned from a trip to Nigeria 6 months ago.

2. Physical examination is unremarkable.

3. Serum calcium concentration is 11.7 mg/dL.

4. An x-ray of the chest shows bilateral hilar lymphadenopathy with coarse, nodular opacities in both lower lobes.

5. A photomicrograph of a biopsy specimen of the affected area of the lungs is shown.


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

Context: A 15-day-old female newborn is brought to the physician for evaluation of red eyes with discharge for 3 days.

Context: She was born at 37 weeks' gestation to a 26-year-old woman.

Context: Examination of the newborn shows watery discharge in both eyes and mild eyelid swelling.

Choices:
A. Staphylococcus aureus
B. Chlamydia trachomatis
C. Neisseria gonorrhoeae
D. Herpes simplex virus 2

Answer: Chlamydia trachomatis

1. A 15-day-old female newborn was brought to the physician for evaluation of red eyes with discharge for 3 days.

2. The newborn was born at 37 weeks' gestation.

4. Pregnancy and delivery were uncomplicated.

5. The mother received irregular prenatal care during the 3rd trimester of pregnancy.

6. Examination of the newborn showed watery discharge in both eyes.

7. Examination of the newborn showed mild eyelid swelling.

1. The baby was born at 37 weeks' gestation.

3. The pregnancy and delivery were uncomplicated.

4. The mother received irregular prenatal care during the 3rd trimester of pregnancy.

5. Examination of the newborn shows watery discharge in both eyes.

6. Examination of the newborn shows mild eyelid swelling.


Question: Which of the following consequences would be expected?

Context: He injects the spinal cord with a protease that cleaves SNARE proteins, thereby blocking the release of neurotransmitters from the Renshaw cells in the spinal cord.

Choices:
A. Disinhibited behavior
B. Hydrophobia
C. Positive Kernig sign
D. Spastic paralysis

Answer: Spastic paralysis

1. An investigator is studying central nervous system neurotransmitters in mice.

2. He injects the spinal cord with a protease.

4. The cleaving of SNARE proteins blocks the release of neurotransmitters from the Renshaw cells in the spinal cord.

4. Cleaving SNARE proteins blocks the release of neurotransmitters.

5. The release of neurotransmitters is blocked from the Renshaw cells in the spinal cord.


Question: Her present condition places her at increased risk for which of the following:

Context: A 32-year-old G2P2 at 33 weeks and 4 days of gestation presents to the emergency room with low-grade fever, mild low back pain, and dysuria for 1 day.

Context: She has a history of urinary tract infections, including one during this current pregnancy that was treated successfully with cephalexin.

Context: On examination, she is nontoxic but mildly uncomfortable; she has CVA tenderness on her right side.

Context: Her urinalysis is positive for leukocyte esterase and nitrites, and she is admitted to the hospital for IV antibiotics with ceftriaxone.

Choices:
A. Low birth weight
B. Pre-eclampsia
C. Postpartum hemorrhage
D. Preterm labor

Answer: Preterm labor

General Obstetrics and Gynecology
General Obstetrics and Gynecology.

1. A 32-year-old G2P2 is presenting to the emergency room.

2. She is 33 weeks and 4 days of gestation.

3. She has low-grade fever, mild low back pain, and dysuria for 1 day.

4. She has a history of urinary tract infections.

5. She had a UTI during this current pregnancy.

6. The UTI was treated successfully with cephalexin.

7. On examination, she is nontoxic but mildly uncomfortable.

8. She has CVA tenderness on her right side.

9. Her urinalysis is positive for leukocyte esterase and nitrites.

10. She is admitted to the hospital for IV antibiotics with ceftriaxone.

1. She has a history of urinary tract infections.

2. She had a urinary tract infection during her current pregnancy.

3. The infection was successfully treated with cephalexin.

6. She has CVA tenderness on her right side.

7. Her urinalysis is positive for leukocyte esterase.

8. Her urinalysis is positive for nitrites.

11. The IV antibiotics are with ceftriaxone.


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

Context: A 16-year-old African-American boy is brought to the physician because of a 2-month history of progressive right shoulder pain.

Context: He has had many episodes of joint and bone pain in the past, and as a child, had recurrent painful swelling of his hands and feet.

Context: The patient is at the 60th percentile for height and 55th percentile for weight.

Context: Active and passive range of motion of the right shoulder is decreased and there is pain with movement.

Context: The leukocyte count is 4600/mm3.

Choices:
A. Infection of the dermis and subcutaneous tissue
B. Infection of the bone
C. Infarction of the bone trabeculae
D. Loss of bone mineral density

Answer: Infarction of the bone trabeculae

3. Patient has had 2 months of progressive right shoulder pain.

4. Patient has had many episodes of joint and bone pain in the past.

5. Patient had recurrent painful swelling of hands and feet as a child.

6. Patient's brother had a stroke at 6 years of age.

7. Patient's brother has an intellectual disability.

8. Patient is at 60th percentile for height.

9. Patient is at 55th percentile for weight.

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

11. Physical examination shows tenderness of right anterior humerus without noticeable swelling or skin changes.

12. Active and passive range of motion of right shoulder is decreased.

13. Patient has pain with movement of right shoulder.

15. X-ray of right shoulder shows subchondral lucency of humeral head with sclerosis and joint space narrowing.

1. He has had many episodes of joint and bone pain in the past.

2. As a child, he had recurrent painful swelling of his hands and feet.

3. His brother had a stroke at 6 years of age and now has an intellectual disability.

4. The patient is at the 60th percentile for height.

5. The patient is at the 55th percentile for weight.

6. His vital signs are within normal limits.

7. Physical examination shows tenderness of the right anterior humerus without noticeable swelling or skin changes.

8. Active and passive range of motion of the right shoulder is decreased.

9. There is pain with movement in the right shoulder.

11. An x-ray of the right shoulder shows subchondral lucency of the humeral head with sclerosis and joint space narrowing.


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

Context: A 50-year-old woman comes to the emergency department after waking up with facial swelling and with difficulties swallowing.

Context: She was recently diagnosed with hypertension and started on an antihypertensive drug.

Context: She follows a strict vegetarian diet.

Context: Her pulse is 110/min and blood pressure is 135/85 mm Hg.

Context: There is no rash.

Choices:
A. Deficiency of C1 esterase inhibitor
B. Scombroid poisoning
C. Nonimmunologic release of histamine
D. Impaired breakdown of kinins

Answer: Impaired breakdown of kinins

1. A 50-year-old woman comes to the emergency department.

2. She woke up with facial swelling and difficulties swallowing.

3. She was recently diagnosed with hypertension.

4. She started on an antihypertensive drug.

5. She follows a strict vegetarian diet.

8. Physical examination shows marked edematous swelling of the face, lips, and tongue.

10. Serum C4 levels are within the reference range.

1. She was recently diagnosed with hypertension.

2. She started on an antihypertensive drug.

3. She follows a strict vegetarian diet.

6. Physical examination shows marked edematous swelling of the face, lips, and tongue.

8. Serum C4 levels are within the reference range.


Question: Which of the following is the best initial management for this patient?

Context: Urinalysis reveals: | Color Yellow | Clarity/turbidity Clear | pH 5.5 | Specific gravity 1.015 | Nitrites Negative | Leukocyte esterase Negative | .

Choices:
A. Anticholinergics
B. Surgery
C. Bladder catheterization
D. Pelvic floor muscle training

Answer: Bladder catheterization

Female Pelvic Medicine and Reconstructive Surgery

1. An 82-year-old man presents to the primary care physician with complaints of urinary leakage over the last 2 months.

2. The leakage occurred without any additional symptoms.

3. He has a history of prostatic hyperplasia.

8. Physical examination reveals a palpable and distended bladder.

10. Urinalysis clarity/turbidity is Clear.

12. Urinalysis specific gravity is 1.015.

14. Urinalysis leukocyte esterase is Negative.

1. The leakage occurred without any additional symptoms.

2. He has a history of prostatic hyperplasia.

3. The vital signs include: blood pressure 140/90 mm Hg, heart rate 84/min, respiratory rate 18/min, and temperature 36.6°C (98.0°F).

4. Physical examination reveals a palpable and distended bladder.

6. Urinalysis reveals: Clarity/turbidity Clear.

8. Urinalysis reveals: Specific gravity 1.015.

9. Urinalysis reveals: Nitrites Negative.

10. Urinalysis reveals: Leukocyte esterase Negative.


Question: What phenomenon describes this?

Context: A 25-year-old female presents to her geneticist due to the fear that she may have inherited her father's disease.

Context: He was diagnosed at the age of 41 when his symptoms of chorea, coordination problems, and cognitive decline begin to occur.

Context: He was diagnosed with a disease resulting from the expansion of CAG repeats on chromosome 4 and later developed severe dementia and died at the age of 56.

Context: The daughter was found to have double the amount of CAG repeats and was told by the geneticist that she may have an earlier onset with increased severity of disease.

Choices:
A. Variable expression
B. Incomplete penetrance
C. Anticipation
D. Heteroplasmy

Answer: Anticipation

1. A 25-year-old female presents to her geneticist.

2. Her father was diagnosed with a disease at the age of 41.

3. His symptoms were chorea, coordination problems, and cognitive decline.

4. The disease was caused by the expansion of CAG repeats on chromosome 4.

5. Her father developed severe dementia and died at the age of 56.

6. The daughter was found to have double the amount of CAG repeats.

7. The geneticist told her she may have an earlier onset with increased severity of disease.

1. The patient was diagnosed at the age of 41.

2. His symptoms included chorea, coordination problems, and cognitive decline.

3. The disease resulted from the expansion of CAG repeats on chromosome 4.

7. The geneticist told the daughter that she may have an earlier onset with increased severity of the disease.


Question: Which of the following antibiotics will be most effective in treating this patient’s condition?

Context: He is conscious and in distress.

Context: A sample exudate is collected with a sterile swab and sent to the laboratory for culture, which yields the growth of aerobic gram-negative rods.

Choices:
A. Azithromycin with rifampin
B. Piperacillin with gentamicin
C. Piperacillin
D. Ticarcillin

Answer: Piperacillin with gentamicin

1. A 25-year-old man presents to the emergency department after being rescued from a house fire 30 minutes ago.

3. On examination, he is noted to have 1st-degree burns involving 54% of his total body surface area.

4. He has type 1 diabetes and takes insulin every day.

5. He is admitted to the burn unit and treated appropriately.

6. Ten days after admission, the physician notices blue-green pus oozing from the burn wounds.

7. He is afebrile with a pulse of 90/min and a blood pressure of 130/80 mm Hg.

8. A sample exudate is collected with a sterile swab and sent to the laboratory for culture.

9. The laboratory culture yields the growth of aerobic gram-negative rods.

2. On examination, he is noted to have 1st-degree burns involving 54% of his total body surface area.

3. He has type 1 diabetes and takes insulin every day.

4. He is admitted to the burn unit and treated appropriately.

5. Ten days after admission, the physician notices blue-green pus oozing from the burn wounds.

6. He is afebrile with a pulse of 90/min and a blood pressure of 130/80 mm Hg.

7. A sample exudate is collected with a sterile swab and sent to the laboratory for culture.

8. The culture yields the growth of aerobic gram-negative rods.


Question: Which of the following is also likely to be found in this patient?

Context: A 67-year-old man with a past medical history of obesity and diabetes presents to the emergency department with fatigue.

Context: The patient has become more confused over the past several days and has been urinating profusely.

Context: His temperature is 99.0°F (37.2°C), blood pressure is 120/68 mmHg, pulse is 160/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Context: He is unable to answer simple questions and is moving all extremities spontaneously.

Choices:
A. Blurred vision
B. Meningeal symptoms
C. Seizures
D. Tremulousness

Answer: Blurred vision

1. A 67-year-old man presents to the emergency department.

2. The patient has a past medical history of obesity and diabetes.

3. The patient has become more confused over the past several days.

4. The patient has been urinating profusely.

5. The patient's temperature is 99.0°F (37.2°C).

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

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

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

10. The patient is confused and has dry mucous membranes.

11. The patient is unable to answer simple questions.

12. The patient is moving all extremities spontaneously.

1. The patient has become more confused over the past several days.

2. The patient has been urinating profusely.

3. The patient's temperature is 99.0°F (37.2°C).

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

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

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

8. Physical exam is notable for a confused man with dry mucous membranes.

9. The patient is unable to answer simple questions.

10. The patient is moving all extremities spontaneously.


Question: Which of the following is the most likely etiology of liver damage in this patient?

Context: Past medical history is significant for COPD diagnosed 4 years ago, managed medically, and admission for acute pancreatitis 6 months ago.

Context: The patient denies any history of smoking, alcohol use or recreational drugs.

Choices:
A. α1-antitrypsin (AAT) deficiency
B. Glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency)
C. Dubin–Johnson syndrome
D. Hepatitis C

Answer: α1-antitrypsin (AAT) deficiency

Gastroenterology
General Gastroenterology
Hepatology

1. A 42-year-old man presents with acute onset jaundice.

2. Past medical history is significant for COPD diagnosed 4 years ago.

4. Patient had an admission for acute pancreatitis 6 months ago.

5. Patient denies any history of smoking.

6. Patient denies any history of alcohol use.

7. Patient denies any history of recreational drugs.

1. Past medical history includes COPD diagnosed 4 years ago.

3. The patient had an admission for acute pancreatitis 6 months ago.

4. The patient denies any history of smoking.

5. The patient denies any history of alcohol use.

6. The patient denies any history of recreational drugs.


Question: Of the following options, which is the most appropriate next step in the management of this patient?

Context: An 8-year-old girl presents to the emergency department with respiratory distress, facial edema, and a skin rash after eating a buffet dinner with her family.

Context: Her parents say they were eating at a seafood buffet when, all of a sudden, the patient began to cough and feel short of breath.

Context: They say nothing like this has ever happened before.

Context: The patient has a history of seasonal allergies for which she occasionally takes cetirizine.

Context: Her blood pressure is 80/52 mm Hg; heart rate, 122/min; and respiratory rate, 22/min.

Context: On physical examination, the patient has severe edema over her face and audible stridor.

Choices:
A. Intramuscular epinephrine
B. Intravenous epinephrine
C. Extra-strength topical diphenhydramine
D. Inhaled sodium cromolyn

Answer: Intramuscular epinephrine

2. Patient presented to the emergency department with respiratory distress, facial edema, and a skin rash.

3. Patient was eating at a seafood buffet with her family when she began to cough and feel short of breath.

4. Patient's parents say nothing like this has ever happened before.

5. Patient has a history of seasonal allergies for which she occasionally takes cetirizine.

6. Patient's blood pressure is 80/52 mm Hg.

8. Patient's respiratory rate is 22/min.

9. Patient has severe edema over her face.

1. The patient's parents were eating at a seafood buffet.

2. The patient began to cough and feel short of breath suddenly.

3. The patient has no history of similar incidents.

4. The patient has a history of seasonal allergies.

5. The patient occasionally takes cetirizine for her allergies.

6. The patient's blood pressure is 80/52 mm Hg.

8. The patient's respiratory rate is 22/min.

9. The patient has severe edema over her face.

10. The patient has audible stridor on physical examination.


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

Context: A 33-year-old man presents to his physician complaining of a small mass he noticed in his scrotum about 1 month ago.

Context: He is married with 2 children.

Context: Examination shows a 1-cm spherical mass in the superior part of the right testis that has a smooth border.

Context: It transilluminates with a flashlight.

Context: Scrotal ultrasonography shows an extratesticular hypoechoic mass near the epididymal head of the right testicle with posterior acoustic enhancement and without internal shadows.

Choices:
A. Ligation of processus vaginalis
B. Microsurgical varicocelectomy
C. Orchiectomy
D. No therapy at this time

Answer: No therapy at this time

1. A 33-year-old man presents to his physician.

2. He noticed a small mass in his scrotum about 1 month ago.

3. The mass feels loosely attached to the right testicle and is firm, and not painful.

4. He has no history of a serious illness and takes no medications.

6. His vital signs are within normal limits.

7. Examination shows a 1-cm spherical mass in the superior part of the right testis.

9. It transilluminates with a flashlight.

10. The mass does not enlarge when the patient coughs or bears down.

11. Scrotal ultrasonography shows an extratesticular hypoechoic mass near the epididymal head of the right testicle.

12. The mass has posterior acoustic enhancement and without internal shadows.

1. The mass feels loosely attached to the right testicle

4. The patient has no history of a serious illness

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

9. Examination shows a 1-cm spherical mass in the superior part of the right testis

11. The mass transilluminates with a flashlight

12. The mass does not enlarge when the patient coughs or bears down

13. Scrotal ultrasonography shows an extratesticular hypoechoic mass near the epididymal head of the right testicle

14. The mass has posterior acoustic enhancement

15. The mass does not have internal shadows


Question: Which of the following interventions is a proper management strategy for the presented patient?

Context: A 51-year-old asymptomatic woman undergoes colposcopy due to a high-grade intraepithelial lesion based on a Pap smear.

Context: Colposcopy shows a visible lesion 2 cm in diameter located on the posterior cervical lip and confined to the cervix with sharp borders, a coarse mosaic pattern after application of acetic acid, and contact bleeding.

Context: The histologic evaluation of the biopsy shows glandular epithelial cells with nuclear hyperchromasia and enlargement, increased mitoses, a fusion of glands, and stromal infiltration to 8 mm.

Context: The chest X-ray and abdominal ultrasound are negative for any additional findings.

Choices:
A. Loop electrosurgical excision procedure (LEEP)
B. Modified radical (Wertheim) hysterectomy
C. Platinum-based chemotherapy
D. Simple hysterectomy with bilateral salpingo-oophorectomy

Answer: Modified radical (Wertheim) hysterectomy

1. A 51-year-old asymptomatic woman underwent colposcopy.

2. The colposcopy was due to a high-grade intraepithelial lesion based on a Pap smear.

3. Colposcopy showed a visible lesion 2 cm in diameter located on the posterior cervical lip and confined to the cervix with sharp borders.

4. Colposcopy showed a coarse mosaic pattern after application of acetic acid.

6. The histologic evaluation of the biopsy showed glandular epithelial cells with nuclear hyperchromasia and enlargement.

7. The histologic evaluation of the biopsy showed increased mitoses.

8. The histologic evaluation of the biopsy showed a fusion of glands.

9. The histologic evaluation of the biopsy showed stromal infiltration to 8 mm.

10. The chest X-ray was negative for any additional findings.

11. The abdominal ultrasound was negative for any additional findings.

1. Colposcopy shows a visible lesion 2 cm in diameter located on the posterior cervical lip and confined to the cervix with sharp borders.

2. The lesion has a coarse mosaic pattern after application of acetic acid.

4. The histologic evaluation of the biopsy shows glandular epithelial cells with nuclear hyperchromasia and enlargement.

7. The biopsy shows stromal infiltration to 8 mm.

8. The chest X-ray is negative for any additional findings.

9. The abdominal ultrasound is negative for any additional findings.


Question: In the formation of an atherosclerotic plaque, which of the following pairings is correct?

Context: A 65-year-old man presents to the Emergency Department complaining of substernal chest pain.

Context: An acute coronary event is suspected and a coronary catheterization procedure reveals an atherosclerotic plaque in the patient's left anterior descending artery.

Choices:
A. Fibroblasts -- foam cells
B. Smooth muscle cells (SMC) -- extracellular matrix (ECM) deposition
C. Endothelial cells -- downregulation of VCAM-1
D. LDL chemical reduction -- endothelial dysfunction

Answer: Smooth muscle cells (SMC) -- extracellular matrix (ECM) deposition

General Cardiology
Interventional Cardiology

1. A 65-year-old man presents to the Emergency Department.

2. He is complaining of substernal chest pain.

3. An acute coronary event is suspected.

4. A coronary catheterization procedure is performed.

5. An atherosclerotic plaque is found in the patient's left anterior descending artery.

1. An acute coronary event is suspected.

2. A coronary catheterization procedure is performed.

3. The procedure reveals an atherosclerotic plaque.

4. The plaque is located in the patient's left anterior descending artery.


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

Context: A 15-year-old boy is brought to the physician by his mother because of a 2-month history of pain in his left hip.

Context: The pain started suddenly and has worsened over the past 2 weeks.

Context: The pain radiates down the thigh and is aggravated by movement.

Context: He had a fall while cycling around a month ago.

Context: He had a urinary tract infection 3 months ago that resolved with trimethoprim/sulfamethoxazole.

Context: There is no family history of serious illness.

Context: His immunizations are up-to-date.

Context: He is 165 cm (5 ft 5 in) tall and weighs 85 kg (187 lb); BMI is 31.2 kg/m2.

Context: His temperature is 37.5°C (99.5°F), pulse is 65/min, and blood pressure is 104/70 mm Hg.

Context: Examination shows an antalgic gait.

Context: The left groin is tender to palpation and internal rotation is limited due to pain.

Context: His leukocyte count is 9,800/mm3 and erythrocyte sedimentation rate is 12 mm/h.

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

Choices:
A. Long leg cast
B. Surgical pinning of femoral head
C. Intra-articular lidocaine
D. Proximal femoral osteotomy

Answer: Surgical pinning of femoral head

2. Patient has had pain in his left hip for 2 months.

3. Pain started suddenly and has worsened over the past 2 weeks.

4. Pain radiates down the thigh and is aggravated by movement.

5. Patient had a fall while cycling around a month ago.

6. Patient had a urinary tract infection 3 months ago that resolved with trimethoprim/sulfamethoxazole.

7. No family history of serious illness.

9. Patient is 165 cm (5 ft 5 in) tall and weighs 85 kg (187 lb); BMI is 31.2 kg/m2.

10. Temperature is 37.5°C (99.5°F), pulse is 65/min, and blood pressure is 104/70 mm Hg.

12. Left groin is tender to palpation and internal rotation is limited due to pain.

13. Flexing the hip causes external rotation and abduction.

14. Leukocyte count is 9,800/mm3 and erythrocyte sedimentation rate is 12 mm/h.

2. The pain has worsened over the past 2 weeks

5. He had a fall while cycling around a month ago

6. He had a urinary tract infection 3 months ago

7. The urinary tract infection resolved with trimethoprim/sulfamethoxazole

8. There is no family history of serious illness

17. The left groin is tender to palpation

18. Internal rotation is limited due to pain

19. Flexing the hip causes external rotation and abduction

21. His erythrocyte sedimentation rate is 12 mm/h


Question: What is the preferred treatment for this condition?

Context: A 58-year-old man is hospitalized and treated with clindamycin for a pulmonary abscess.

Context: During his hospital stay he develops abdominal pain and bloody diarrhea, and has a WBC of 14,000; serum creatinine is 0.9 mg/dL.

Context: On teaching rounds, you learn that the responsible pathogen produces a multi-unit toxin that binds to the colonic mucosa, causing actin depolymerization that results in cell death and mucosal necrosis.

Choices:
A. Metronidazole
B. Penicillin G
C. Tetracycline
D. Erythromycin

Answer: Metronidazole

General Infectious Disease
Infectious Disease

2. He is treated with clindamycin for a pulmonary abscess.

3. During his hospital stay he develops abdominal pain and bloody diarrhea.

6. The responsible pathogen produces a multi-unit toxin.

7. The toxin binds to the colonic mucosa.

9. Actin depolymerization results in cell death and mucosal necrosis.

1. Patient develops abdominal pain during hospital stay.

2. Patient develops bloody diarrhea during hospital stay.

4. Patient's serum creatinine level is 0.9 mg/dL.

5. Responsible pathogen produces a multi-unit toxin.

8. Actin depolymerization results in cell death.


Question: Which result would you expect to find on her screening tests?

Context: A 61-year-old Caucasian woman presents to her physician for a routine checkup.

Context: She consumes alcohol occasionally.

Choices:
A. A score of 17 on PHQ-9 test
B. T score –2.01 on DEXA scan
C. Dilation of the abdominal aorta on ultrasound examination
D. Presence of focal hyperintensities on mammography

Answer: T score –2.01 on DEXA scan

1. Patient is a 61-year-old Caucasian woman.

2. Patient has primary hypertension and rheumatoid arthritis.

3. Patient does not report any relevant symptoms.

4. Patient's medications include valsartan 160 mg, hydrochlorothiazide 25 mg daily, and methylprednisolone 28 mg every other day.

5. Patient's blood pressure varies from 130/80 to 120/60 mm Hg.

6. Patient had humeral and tibial fractures from a self-height fall and stepping over a fence, respectively, that occurred 6 months apart.

7. Patient is in menopause and is not on hormone replacement therapy.

8. Patient currently does not smoke but has a 10-pack-year history of smoking.

9. Patient consumes alcohol occasionally.

10. Patient weighs 56 kg (123.5 lb) and her height is 169 cm (5 ft 7 in).

11. Patient does not report a family history of any cancer.

12. Patient's father died after a myocardial infarction at the age of 63.

13. Patient performs daily household activities but is not engaged in either aerobic or strength training.

14. Patient mainly consumes vegetables, cereals, and dairy products.

15. Patient's blood pressure is 125/80 mm Hg, heart rate is 67/min, respiratory rate is 14/min, and temperature is 36.5°C (97.7°F).

16. Patient's physical examination is unremarkable.

1. She has primary hypertension and rheumatoid arthritis.

2. She currently does not report any relevant symptoms, such as weight change, increased or decreased appetite, sleep or mood problems, gastrointestinal symptoms, fever, or night sweats.

3. Her medications include valsartan 160 mg, hydrochlorothiazide 25 mg daily, and methylprednisolone 28 mg every other day.

4. According to her diary, her blood pressure varies from 130/80 to 120/60 mm Hg.

5. In the past year, she had humeral and tibial fractures from a self-height fall and stepping over a fence, respectively, that occurred 6 months apart.

6. She is in menopause and is not on hormone replacement therapy.

7. Currently, she does not smoke but has a 10-pack-year history of smoking.

9. She weighs 56 kg (123.5 lb), and her height is 169 cm (5 ft 7 in).

10. She does not report a family history of any cancer.

11. Her father died after a myocardial infarction at the age of 63.

12. She performs daily household activities but is not engaged in either aerobic or strength training.

13. She mainly consumes vegetables, cereals, and dairy products.

14. Her blood pressure is 125/80 mm Hg, heart rate is 67/min, respiratory rate is 14/min, and temperature is 36.5°C (97.7°F).

15. Her physical examination is unremarkable.


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

Context: A 24-year-old man is brought to the emergency department by his sister because she has noticed that he has been behaving differently over the past 4 weeks.

Context: Today, the patient attempted to set their house on fire while yelling that he was trying to “save us all.” The patient has a history of psychotic symptoms treated with aripiprazole.

Context: His sister states that he stopped taking his medications about 3 weeks ago.

Context: He works as a dishwasher but has not been to work for several days.

Context: His vital signs are within normal limits.

Context: Throughout the interview, the patient continuously stares at the ceiling and makes little eye contact with the physician.

Context: When asked about the incident today, he states that he has been hearing the voice of “the great one” who has informed him that aliens are in his neighborhood in the form of rats and cockroaches that need to be “torched to prevent the alien invasion.” He is refusing treatment and insists on going home.

Choices:
A. Administer aripiprazole and follow-up after 24 hours
B. Refer the patient to a psychologist for cognitive behavioral therapy
C. Involuntarily hospitalize the patient
D. Ask the patient's sister to convince him to stay overnight

Answer: Involuntarily hospitalize the patient

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

3. Sister noticed patient behaving differently over the past 4 weeks.

4. Patient attempted to set their house on fire while yelling.

5. Patient has a history of psychotic symptoms treated with aripiprazole.

6. Sister states patient stopped taking medications 3 weeks ago.

8. Patient has not been to work for several days.

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

10. Mental status examination shows blunted affect.

11. Patient continuously stares at the ceiling and makes little eye contact with the physician.

12. Patient has been hearing the voice of “the great one”.

13. Voice has informed patient that aliens are in his neighborhood in the form of rats and cockroaches.

14. Patient believes aliens need to be “torched to prevent the alien invasion.”

15. Patient is refusing treatment and insists on going home.

1. The patient attempted to set their house on fire.

2. The patient was yelling that he was trying to "save us all."

3. The patient has a history of psychotic symptoms.

4. The psychotic symptoms were treated with aripiprazole.

5. The patient's sister states that he stopped taking his medications about 3 weeks ago.

7. The patient has not been to work for several days.

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

9. Mental status examination shows a blunted affect.

10. Throughout the interview, the patient continuously stares at the ceiling.

11. The patient makes little eye contact with the physician.

12. The patient states that he has been hearing the voice of "the great one."

13. The voice has informed him that aliens are in his neighborhood.

14. The aliens are in the form of rats and cockroaches.

15. The patient believes they need to be "torched to prevent the alien invasion."


Question: Which of the following is the most appropriate pharmacotherapy?"

Context: A 13-year-old girl is brought to the emergency department by her father because of a severe nosebleed.

Context: She takes no medications and has no history of serious medical illness but has had frequent nosebleeds in the past.

Context: Laboratory studies show: | Hemoglobin 8 g/dL | Platelet count 195,000/mm3 | Prothrombin time 12 sec | Partial thromboplastin time 49 sec | Fibrin split products negative | The bleeding time is 11 minutes.

Choices:
A. Prothrombin complex concentrate
B. Rituximab
C. Desmopressin
D. Intravenous immunoglobulin

Answer: Desmopressin

1. A 13-year-old girl is brought to the emergency department by her father.

3. She has no history of serious medical illness.

4. She has had frequent nosebleeds in the past.

5. Physical examination shows brisk bleeding from the right nare and pooled blood in the posterior pharynx.

6. Laboratory studies show Hemoglobin 8 g/dL.

7. Laboratory studies show Platelet count 195,000/mm3.

8. Laboratory studies show Prothrombin time 12 sec.

9. Laboratory studies show Partial thromboplastin time 49 sec.

10. Laboratory studies show Fibrin split products negative.

2. Patient has no history of serious medical illness.

3. Patient has had frequent nosebleeds in the past.

4. Physical examination shows brisk bleeding from the right nare.

5. Physical examination shows pooled blood in the posterior pharynx.

9. Partial thromboplastin time is 49 sec.


Question: Which of the following is the most appropriate treatment for the most likely diagnosis?

Context: He states that since yesterday he has had joint pain, and today he noticed a rash.

Context: The patient smokes cigars, drinks 1 to 4 drinks per day, is sexually active, and uses cocaine occasionally.

Context: His temperature is 101°F (38.3°C), blood pressure is 125/65 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 98% on room air.

Context: Physical exam reveals pustular skin lesions and an inflamed and painful right knee that is warm to the touch.

Choices:
A. Cefixime and azithromycin
B. Ceftriaxone
C. Ceftriaxone and vancomycin
D. Piperacillin and tazobactam

Answer: Cefixime and azithromycin

1. A 33-year-old man presents to the emergency department with joint pain.

2. He states that since yesterday he has had joint pain.

4. The patient does not have a significant past medical history.

6. The patient drinks 1 to 4 drinks per day.

8. The patient uses cocaine occasionally.

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

14. Physical exam reveals pustular skin lesions.

15. Physical exam reveals an inflamed and painful right knee that is warm to the touch.

1. The patient has had joint pain since yesterday.

3. The patient does not have a significant past medical history.

5. The patient drinks 1 to 4 drinks per day.

7. The patient uses cocaine occasionally.

8. The patient's temperature is 101°F (38.3°C).

9. The patient's blood pressure is 125/65 mmHg.

11. The patient's respirations are 14/min.

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

13. Physical exam reveals pustular skin lesions.

14. Physical exam reveals an inflamed and painful right knee that is warm to the touch.


Question: Which of the following is the primary mechanism of action of levonorgestrel?

Context: A 20-year-old woman presents to a physician following unprotected coitus with her boyfriend about 10 hours ago.

Context: She tells the physician that although they usually use a barrier method of contraception, but this time they did not.

Context: She does not want to become pregnant.

Context: She also mentions that she has been diagnosed with major depression and does not want to take an estrogen-containing oral contraceptive pill.

Context: After counseling, the physician prescribes an enteric-coated pill containing 1.5 mg of levonorgestrel.

Choices:
A. Delayed ovulation through inhibition of follicular development
B. Thickening of cervical mucus
C. Atrophy of endometrium
D. Reduction in motility of cilia in fallopian tubes

Answer: Delayed ovulation through inhibition of follicular development

1. A 20-year-old woman presented to a physician.

2. The woman had unprotected coitus with her boyfriend about 10 hours ago.

3. The woman and her boyfriend usually use a barrier method of contraception.

4. This time they did not use a barrier method of contraception.

5. The woman does not want to become pregnant.

6. The woman has been diagnosed with major depression.

7. The woman does not want to take an estrogen-containing oral contraceptive pill.

8. The physician prescribed an enteric-coated pill containing 1.5 mg of levonorgestrel.

1. The patient usually uses a barrier method of contraception.

2. This time, the patient did not use a barrier method of contraception.

3. The patient does not want to become pregnant.

4. The patient has been diagnosed with major depression.

5. The patient does not want to take an estrogen-containing oral contraceptive pill.

6. The physician prescribes an enteric-coated pill containing 1.5 mg of levonorgestrel after counseling.


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

Context: A 4-year-old girl is brought to the emergency department because of colicky abdominal pain for 1 day.

Context: Urinalysis shows red blood cells and hexagonal-shaped crystals.

Choices:
A. Increased stool fat content
B. Inability of intercalated cells to secrete H+
C. Impaired intestinal ornithine reabsorption
D. Urease-positive bacteria in the renal pelvis

Answer: Impaired intestinal ornithine reabsorption

1. A 4-year-old girl is brought to the emergency department.

2. She has colicky abdominal pain for 1 day.

3. She has had two similar episodes in the past.

5. Urinalysis shows hexagonal-shaped crystals.

6. Urine sodium cyanide nitroprusside test is positive.

1. She has had two similar episodes in the past.

3. Urinalysis shows hexagonal-shaped crystals.

4. Urine sodium cyanide nitroprusside test is positive.


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

Context: A 49-year-old woman, gravida 1, para 1, comes to the physician because of shorter and less frequent menstrual periods over the past year.

Context: During this time, she has also had frequent mood swings and a 2.5-kg (5-lb) weight loss.

Context: She occasionally wakes up at night because she is too warm and sweating profusely.

Context: These episodes are followed by chills and anxiety that subside within minutes.

Context: She has no history of abnormal Pap smears.

Context: She is sexually active with her husband, who had a vasectomy 10 years prior.

Context: She is 163 cm (5 ft 3 in) tall and weighs 70 kg (154 lb); BMI is 26 kg/m2.

Context: Her temperature is 37°C (98.6°F), pulse is 103/min, respirations are 16/min, and blood pressure is 129/84 mm Hg.

Choices:
A. Perform transvaginal ultrasound
B. Measure serum β-hCG concentration
C. Obtain endometrial biopsy
D. Measure serum TSH concentration

Answer: Measure serum TSH concentration

3. Patient has had shorter and less frequent menstrual periods over the past year.

4. Patient has had frequent mood swings over the past year.

5. Patient has had a 2.5-kg (5-lb) weight loss over the past year.

6. Patient occasionally wakes up at night because she is too warm and sweating profusely.

7. Patient experiences chills and anxiety after waking up at night, which subside within minutes.

8. Patient has no history of abnormal Pap smears.

9. Patient is sexually active with her husband, who had a vasectomy 10 years prior.

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

16. Patient's blood pressure is 129/84 mm Hg.

17. Abdominal and genitourinary examination shows no abnormalities.

6. Sexually active with husband who had a vasectomy 10 years prior

14. Abdominal and genitourinary examination shows no abnormalities


Question: Which of the following findings is most likely to be detected in a skeletal survey?

Context: An 8-year-old boy is brought by his parents to the emergency department with a tender and swollen right leg.

Context: The boy said that he was playing soccer when he accidentally kicked a metal goal post.

Context: A review of his medical history reveals that he had a fracture of the left tibia at 4-years-old and a fracture of the right radius 6 months ago.

Context: Neither of the two was associated with major trauma and both healed well.

Context: There is no muscular hypotonia.

Context: His height and weight are normal for his age and sex and the skin is normal.

Choices:
A. A healed right scapular fracture
B. Ground-glass appearance of the cortices of the long bones
C. Widening and cupping of the metaphyses of the long bones
D. Wormian bones in the skull

Answer: Wormian bones in the skull

1. An 8-year-old boy is brought by his parents to the emergency department.

2. The boy said he was playing soccer when he accidentally kicked a metal goal post.

3. The boy 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 review of his medical history reveals a fracture of the left tibia at 4-years-old.

6. A review of his medical history reveals a fracture of the right radius 6 months ago.

7. Neither of the two fractures was associated with major trauma and both healed well.

8. At the hospital, his vital signs are stable and his sclerae are white-blue.

10. His height and weight are normal for his age and sex.

12. A tender swelling is present over his right leg and he can not put weight on that leg.

13. The radiograph of his right leg confirms a fracture of the shaft of the tibia at the junction of its upper one-third and lower two-thirds.

14. The clinician suspects physical abuse and orders a skeletal survey.

1. The boy said he was playing soccer when he accidentally kicked a metal goal post.

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

4. He is meeting all developmental milestones.

5. A review of his medical history reveals a left tibia fracture at 4-years-old.

6. A review of his medical history reveals a right radius fracture 6 months ago.

7. Neither fracture was associated with major trauma.

9. At the hospital, his vital signs are stable.

12. His height and weight are normal for his age and sex.

14. A tender swelling is present over his right leg.

16. The radiograph of his right leg confirms a fracture of the shaft of the tibia at the junction of its upper one-third and lower two-thirds.

17. The clinician suspects physical abuse.

18. The clinician orders a skeletal survey.


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

Context: A previously healthy 34-year-old man comes to the physician because of loose stools for the past 4 months.

Context: On average, he has 1 episode of loose non-bloody bowel movement with abdominal cramps each day around noon.

Context: He also complains of excess flatus but no bowel incontinence or urgency.

Context: He has had no fever or weight loss.

Context: He takes no medications.

Choices:
A. Cholestyramine
B. Elimination of all dairy products
C. Empirical therapy with metronidazole
D. Loperamide

Answer: Elimination of all dairy products

2. Patient has had loose stools for 4 months.

3. Patient has 1 episode of loose non-bloody bowel movement with abdominal cramps each day around noon.

4. Patient has no diarrhea when he does not have breakfast in the morning.

5. Patient complains of excess flatus but no bowel incontinence or urgency.

6. Patient has had no fever or weight loss.

7. Patient's symptoms are not associated with stress.

8. Patient has had no overseas or mountainous trips over the past year.

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

11. Physical examination shows no abnormalities.

1. He has 1 episode of loose non-bloody bowel movement with abdominal cramps each day around noon.

2. He has no diarrhea when he does not have breakfast in the morning.

3. He complains of excess flatus but no bowel incontinence or urgency.

5. His symptoms are not associated with stress.

6. He has had no overseas or mountainous trips over the past year.

8. His vital signs are within normal limits.

9. Physical examination shows no abnormalities.


Question: Which of the following physiologic changes is most likely expected after being prescribed that medication?

Context: A 37-year-old male with a history of diabetes is prescribed a drug that would decrease the risk of the patient developing glomerular renal capillary damage, nodular glomerular sclerosis, and eventual nephrotic syndrome.

Context: After some time being on this medication, the patient complains of a bad cough.

Choices:
A. Decreased aldosterone, decreased GFR, decreased renal plasma flow, increased bradykinin
B. Increased aldosterone, increased GFR, decreased renal plasma flow, increased bradykinin
C. Decreased aldosterone, decreased GFR, increased renal plasma flow, increased bradykinin
D. Increased aldosterone, increased GFR, increased renal plasma flow, increased bradykinin

Answer: Decreased aldosterone, decreased GFR, increased renal plasma flow, increased bradykinin

1. A 37-year-old male has a history of diabetes.

2. The patient was prescribed a drug to decrease the risk of developing glomerular renal capillary damage, nodular glomerular sclerosis, and eventual nephrotic syndrome.

3. After some time being on this medication, the patient complained of a bad cough.

2. The patient has been on the medication for some time.

3. The patient complains of a bad cough.


Question: Which of the following would be the best treatment for this patient’s change in mental status?

Context: A 69-year-old woman presents with insomnia and altered mental status.

Context: The patient is accompanied by her husband who says her symptoms began acutely 4 days ago with no obvious trigger and have not improved.

Context: Before this point, she had been living independently with no signs of cognitive impairment.

Context: The patient’s husband says that the patient is often non-compliant with medication and eats and drinks little unless prompted.

Context: Past medical history is significant for hypertension, diabetes mellitus type 2, chronic pyelonephritis, and depression.

Context: Oriented x 1.

Context: She believes it is 1967, and she is at the bookstore.

Context: She talks to non-existent people and uses words inappropriately.

Context: Lungs are clear to auscultation.

Context: Urinalysis is pending.

Choices:
A. Changing trazodone to amitriptyline
B. Antibiotic therapy
C. Discontinuation of metoprolol
D. Lifelong administration of memantine

Answer: Antibiotic therapy

2. Patient presents with insomnia and altered mental status.

3. Patient's husband says symptoms began acutely 4 days ago with no obvious trigger and have not improved.

4. Patient had been living independently with no signs of cognitive impairment.

5. Patient's husband says patient is often non-compliant with medication and eats and drinks little unless prompted.

6. Patient has past medical history of hypertension, diabetes mellitus type 2, chronic pyelonephritis, and depression.

7. Patient is currently taking aspirin, metoprolol, hydrochlorothiazide, losartan, metformin, and trazodone.

8. Patient's vitals include temperature 38.1℃ (100.6℉), blood pressure 130/70 mm Hg, pulse 91/min, respiratory rate 17/min, and oxygen saturation 99% on room air.

9. Patient is agitated and easily distracted on physical examination.

11. Patient believes it is 1967 and she is at the bookstore.

12. Patient talks to non-existent people and uses words inappropriately.

13. Cardiac sounds are muffled but otherwise normal.

15. On abdominal examination, the tip of the urinary bladder can be palpated.

16. Costovertebral angle tenderness is present bilaterally.

17. Catheterization of the bladder yields cloudy, foul-smelling urine.

1. The patient is accompanied by her husband.

2. The symptoms began acutely 4 days ago with no obvious trigger.

4. Before this point, the patient had been living independently with no signs of cognitive impairment.

5. The patient is often non-compliant with medication.

6. The patient eats and drinks little unless prompted.

7. Past medical history includes hypertension, diabetes mellitus type 2, chronic pyelonephritis, and depression.

8. Current medications are aspirin, metoprolol, hydrochlorothiazide, losartan, metformin, and trazodone.

9. Vitals include: temperature 38.1℃ (100.6℉), blood pressure 130/70 mm Hg, pulse 91/min, respiratory rate 17/min, and oxygen saturation 99% on room air.

10. On physical examination, the patient is agitated and easily distracted.

12. The patient believes it is 1967 and she is at the bookstore.

13. The patient talks to non-existent people and uses words inappropriately.

14. Cardiac sounds are muffled but otherwise normal.

16. On abdominal examination, the tip of the urinary bladder can be palpated.

17. Costovertebral angle tenderness is present bilaterally.

18. Catheterization of the bladder yields cloudy, foul-smelling urine.


Question: Which of the following medical treatments is indicated for this patient’s condition?

Context: A 65-year-old man presents to the physician with a concern for several lumps on his jaw.

Context: He has a history of dental caries and admits to maintaining poor oral hygiene.

Context: On physical examination, he has 3 nontender and indurated masses at the angle of his jaw that are draining thick yellow pus.

Choices:
A. Amoxicillin-clavulanate
B. Dapsone and rifampin
C. Penicillin
D. Trimethoprim-sulfamethoxazole

Answer: Penicillin

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

3. He admits to maintaining poor oral hygiene.

4. On physical examination, he has 3 nontender and indurated masses at the angle of his jaw.

5. The masses are draining thick yellow pus.

6. Microscopy of the drained pus reveals yellow granules filled with bacteria.

2. He admits to maintaining poor oral hygiene.

3. On physical examination, he has 3 nontender and indurated masses at the angle of his jaw.

4. The masses are draining thick yellow pus.

5. Microscopy of the drained pus reveals yellow granules.

6. The yellow granules are filled with bacteria.


Question: Which of the following was most likely the second compound administered to this patient?

Context: A 23-year-old man presents with severe right lower quadrant abdominal pain for the past 2 hours.

Context: He says the pain started in the periumbilical region and has now shifted to the lower right quadrant.

Context: He describes the pain as spasmodic.

Context: Past medical history is insignificant, and the patient denies any history of smoking, alcohol, or drug use.

Context: The patient’s vital signs show: pulse 88/min, respiratory rate 18/min, blood pressure 126/84 mm Hg, and temperature 38.4°C (101.0°F).

Context: On physical examination, there is severe tenderness to palpation in the right lower quadrant with rebound and guarding.

Context: The patient is rushed to the operating room for a laparoscopic appendectomy.

Context: The following preoperative laboratory tests are obtained: | Serum glucose (random) 123 mg/dL |   Serum electrolytes | Sodium 143 mEq/L | Potassium 4.7 mEq/L | Chloride 102 mEq/L |     Serum creatinine 1.7 mg/dL | Blood urea nitrogen 32 mg/dL |     Hemoglobin (Hb%) 12.5 g/dL | Mean corpuscular volume (MCV)  80 fl | Reticulocyte count 1% | Erythrocyte count 5.1 million/mm³ | Leukocyte count 14,000/mm³ | Neutrophils 80% | During the induction of anesthesia, isoflurane and a second compound are administered.

Context: The patient’s blood pressure is now 158/94 mm Hg.

Choices:
A. Atracurium
B. Nitrous oxide
C. Neostigmine
D. Succinylcholine

Answer: Succinylcholine

General Surgery
Emergency Medicine
Surgery

General Surgery
General Emergency Medicine

2. Patient has had severe right lower quadrant abdominal pain for the past 2 hours.

3. Pain started in the periumbilical region and has shifted to the lower right quadrant.

5. Patient denies any history of smoking, alcohol, or drug use.

6. Patient's vital signs: pulse 88/min, respiratory rate 18/min, blood pressure 126/84 mm Hg, temperature 38.4°C (101.0°F).

7. Physical examination reveals severe tenderness to palpation in the right lower quadrant with rebound and guarding.

8. Patient is rushed to the operating room for a laparoscopic appendectomy.

9. Preoperative laboratory tests: serum glucose (random) 123 mg/dL, serum electrolytes (sodium 143 mEq/L, potassium 4.7 mEq/L, chloride 102 mEq/L), serum creatinine 1.7 mg/dL, blood urea nitrogen 32 mg/dL, hemoglobin (Hb%) 12.5 g/dL, mean corpuscular volume (MCV) 80 fl, reticulocyte count 1%, erythrocyte count 5.1 million/mm³, leukocyte count 14,000/mm³, neutrophils 80%.

10. During induction of anesthesia, isoflurane and a second compound are administered.

11. 25 minutes after induction, patient develops significant muscle rigidity and temperature increases to 40.8°C (105.4°F).

12. Patient's blood pressure is now 158/94 mm Hg.

1. The patient reports pain starting in the periumbilical region and shifting to the lower right quadrant.

2. The patient describes the pain as spasmodic.

3. The patient has no significant past medical history and denies smoking, alcohol, or drug use.

4. Vital signs: pulse 88/min, respiratory rate 18/min, blood pressure 126/84 mm Hg, temperature 38.4°C (101.0°F).

5. Physical examination reveals severe tenderness to palpation in the right lower quadrant with rebound and guarding.

6. The patient undergoes a laparoscopic appendectomy.

7. Preoperative laboratory tests: Serum glucose (random) 123 mg/dL, Serum electrolytes - Sodium 143 mEq/L, Potassium 4.7 mEq/L, Chloride 102 mEq/L, Serum creatinine 1.7 mg/dL, Blood urea nitrogen 32 mg/dL, Hemoglobin (Hb%) 12.5 g/dL, Mean corpuscular volume (MCV) 80 fl, Reticulocyte count 1%, Erythrocyte count 5.1 million/mm³, Leukocyte count 14,000/mm³, Neutrophils 80%.

8. Isoflurane and a second compound are administered during the induction of anesthesia.

9. About 25 minutes after induction, the patient develops significant muscle rigidity and his temperature increases to 40.8°C (105.4°F).

10. The patient's blood pressure is now 158/94 mm Hg.


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

Context: A 16-year-old boy is brought to the physician because of a 3-week history of loose stools.

Context: A biopsy confirms the diagnosis.

Choices:
A. Gluten-free diet
B. Proctocolectomy
C. Mesalamine therapy
D.
Cyclosporine therapy
"

Answer: Mesalamine therapy

General Gastroenterology
Pediatric Gastroenterology

2. Patient has had loose stools for 3 weeks.

3. Patient has 2-3 episodes of loose stools per day.

4. Loose stools are occasionally bloody.

5. Patient has had crampy abdominal pain, generalized fatigue, and a 2-kg (5-lb) weight loss.

6. Patient's temperature is 37.1°C (98.8°F).

8. Patient's blood pressure is 106/68 mm Hg.

9. Examination shows mild lower abdominal tenderness to palpation.

10. Test of the stool for ova and parasites is negative.

11. Patient's hemoglobin concentration is 11.8 g/dL.

12. Patient's leukocyte count is 12,400/mm3.

13. Patient's erythrocyte sedimentation rate is 14 mm/h.

14. Colonoscopy shows inflamed, friable mucosa extending just beyond the rectum that bleeds on contact with the endoscope.

1. He has 2–3 episodes of loose stools a day that are occasionally bloody.

2. During this period, he has also had crampy abdominal pain, generalized fatigue, and a 2-kg (5-lb) weight loss.

3. His temperature is 37.1°C (98.8°F), pulse is 82/min, and blood pressure is 106/68 mm Hg.

4. Examination shows mild lower abdominal tenderness to palpation.

5. Test of the stool for ova and parasites is negative.

6. His hemoglobin concentration is 11.8 g/dL, leukocyte count is 12,400/mm3, and erythrocyte sedimentation rate is 14 mm/h.

7. A colonoscopy shows inflamed, friable mucosa extending just beyond the rectum that bleeds on contact with the endoscope.


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

Context: A 26-year-old man presents with a 6-month history of headaches.

Context: He has had no visual loss or photopsia.

Context: No significant past medical history.

Context: Physical examination is unremarkable.

Choices:
A. Amitriptyline
B. Magnetic resonance image (MRI) of the head
C. Ophthalmologic evaluation
D. Ibuprofen

Answer: Ibuprofen

Neurology with Special Qualification in Child Neurology

2. Patient has had headaches for 6 months.

4. Headaches occur every other day for 1-2 hours.

5. Headaches are bilateral and feel like a ‘band is squeezing his head’.

6. Patient denies photophobia, phonophobia, nausea, and vomiting.

7. Patient has had no visual loss or photopsia.

8. Patient has no significant past medical history.

10. Patient works at a moving company, where he is constantly lifting heavy items.

11. Patient recently got his 21-year-old girlfriend and his other 23-year-old girlfriend pregnant.

12. Patient states this is causing a lot of stress.

13. Physical examination is unremarkable.

1. Over the past 6 months, he has developed headaches that are 4/10 in intensity and occur every other day for 1–2 hours.

2. The headaches are bilateral and feel like a ‘band is squeezing his head’.

3. He denies photophobia, phonophobia, nausea, and vomiting.

4. He has had no visual loss or photopsia.

6. He is an avid weightlifter and works at a moving company, where he is constantly lifting heavy items.

7. Additionally, he recently got his 21-year-old girlfriend and his other 23-year-old girlfriend pregnant, which he says is causing a lot of stress.

8. Physical examination is unremarkable.


Question: Which of the following best describes the primary function that the cells highlighted in blue serve?

Context: A special stain is used to identify a specific glial cell that makes up the lining of the central canal and ventricles in the central nervous system.

Choices:
A. Production and circulation of CSF
B. Protective membrane surrounding spinal cord
C. Conduct voluntary muscle action potentials
D. Increasing action potential conduction velocity

Answer: Production and circulation of CSF

1. A histologic section is obtained from the central canal of the spinal cord.

3. The special stain is used to identify a specific glial cell.

4. The glial cell makes up the lining of the central canal and ventricles in the central nervous system.

2. The stain is used to identify a specific glial cell.

3. The glial cell makes up the lining of the central canal.

4. The glial cell makes up the lining of the ventricles.

5. The central canal and ventricles are in the central nervous system.


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

Context: A 58-year-old man presents to the emergency department with a 4-hour history of severe abdominal pain.

Context: He has noted brief episodes of postprandial abdominal pain for the last 2 months, but this pain is much more severe and diffuse.

Context: He also reports nausea and has had several episodes of non-bloody, non-bilious emesis since the pain started.

Context: Past medical history is notable for hyperlipidemia diagnosed 10 years ago and managed with lifestyle modifications; he has never been hospitalized.

Context: Vital signs are unremarkable.

Choices:
A. Cholecystectomy
B. Colonoscopy
C. Endoscopic retrograde cholangiopancreatography (ERCP)
D. Esophagogastroduodenoscopy (EGD)

Answer: Endoscopic retrograde cholangiopancreatography (ERCP)

2. Patient has 4-hour history of severe abdominal pain.

3. Patient has had brief episodes of postprandial abdominal pain for the last 2 months.

4. Patient has nausea and several episodes of non-bloody, non-bilious emesis since the pain started.

5. Patient has past medical history of hyperlipidemia diagnosed 10 years ago and managed with lifestyle modifications.

8. Physical examination shows dry mucous membranes and a soft, non-distended abdomen that is diffusely tender.

9. Laboratory tests are notable for a lipase level of 3,125 U/L.

10. CT of the abdomen shows an enlarged gallbladder and peripancreatic fluid with dilation of the pancreatic and common bile ducts.

1. He has noted brief episodes of postprandial abdominal pain for the last 2 months.

2. The pain is much more severe and diffuse.

4. He has had several episodes of non-bloody, non-bilious emesis since the pain started.

5. Past medical history is notable for hyperlipidemia diagnosed 10 years ago.

6. Hyperlipidemia has been managed with lifestyle modifications.

9. Physical examination shows dry mucous membranes.

10. Physical examination shows a soft, non-distended abdomen that is diffusely tender.

11. Laboratory tests are notable for a lipase level of 3,125 U/L.

12. CT of the abdomen shows an enlarged gallbladder.

13. CT of the abdomen shows peripancreatic fluid.

14. CT of the abdomen shows dilation of the pancreatic and common bile ducts.


Question: Which of the following would most likely be observed in cells with this genetic change?

Context: He says that he has generally been feeling well; however, he has noticed that he has had some intermittent very low grade fevers of unknown etiology.

Context: A biopsy of the enlarged nodes is obtained and genetic testing shows that part of chromosomes 14 and 18 are joined together.

Choices:
A. Decreased activation of CD95
B. Decreased activity of p53
C. Decreased release of cytochrome c
D. Increased activation of Apaf-1

Answer: Decreased release of cytochrome c

Molecular Genetic Pathology
Clinical Genetics and Genomics

1. A 55-year-old man presents to his primary care physician for his annual check-up.

2. He says that he has generally been feeling well.

3. He has noticed that he has had some intermittent very low grade fevers of unknown etiology.

4. His past medical history is significant for well-controlled hypertension and diabetes.

5. On physical exam he is found to have painless enlargement of a number of cervical and axillary lymph nodes.

6. A biopsy of the enlarged nodes is obtained.

7. Genetic testing shows that part of chromosomes 14 and 18 are joined together.

2. He has noticed intermittent very low grade fevers of unknown etiology.

3. His past medical history includes well-controlled hypertension and diabetes.

4. On physical exam, he has painless enlargement of cervical and axillary lymph nodes.

5. A biopsy of the enlarged nodes is obtained.

6. Genetic testing shows part of chromosomes 14 and 18 are joined together.


Question: Which of the following adverse effects is most likely to occur?

Context: A 75-year-old man is brought to the emergency room because of dizziness and palpitations for the past hour.

Context: His pulse is 185/min and blood pressure is 100/52 mm Hg.

Context: A drug is administered that activates cardiac potassium channels and causes transient atrioventricular block.

Choices:
A. Chest pain
B. Dry cough
C. Perioral paresthesia
D. Yellow vision

Answer: Chest pain

1. A 75-year-old man is brought to the emergency room.

2. He has been experiencing dizziness and palpitations for the past hour.

5. An ECG shows a narrow-complex, regular tachycardia without P waves.

6. A drug is administered that activates cardiac potassium channels.

7. The drug causes transient atrioventricular block.

3. ECG shows narrow-complex, regular tachycardia without P waves.

5. The drug activates cardiac potassium channels.

6. The drug causes transient atrioventricular block.


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

Context: A 70-year-old man is brought to the emergency department with painful discharge from his right ear with difficulty hearing for 3 days.

Context: His temperature is 39.5°C (103.1°F) and pulse is 120/minute.

Choices:
A. Decreased intracranial perfusion
B. Glucose intolerance
C. Pus-filled mastoid air cells
D. Positive streptococcal culture

Answer: Glucose intolerance

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

2. He has painful discharge from his right ear.

3. He has difficulty hearing for 3 days.

6. Physical examination shows mild facial asymmetry.

7. The right corner of his mouth lags behind the left when the patient smiles.

8. There is severe ear pain when the right auricle is pulled superiorly.

9. Otoscopic examination shows granulation tissue at the transition between the cartilaginous and the osseous part of the ear canal.

3. Physical examination shows mild facial asymmetry with the right corner of his mouth lagging behind the left when the patient smiles.

4. There is severe ear pain when the right auricle is pulled superiorly.

5. Otoscopic examination shows granulation tissue at the transition between the cartilaginous and the osseous part of the ear canal.


Question: Which of the following drugs was this mother most likely taking during pregnancy?

Context: A 24-year-old female with a history of recurrent infections, bipolar disorder, and no prenatal care gives birth to a male infant.

Context: On physical exam in the delivery room, you observe a tuft of hair over the infant's lumbosacral region.

Choices:
A. Gentamicin
B. Lithium
C. Valproate
D. Folic acid

Answer: Valproate

1. A 24-year-old female gave birth to a male infant.

2. The female has a history of recurrent infections.

3. The female has a history of bipolar disorder.

5. On physical exam in the delivery room, a tuft of hair was observed over the infant's lumbosacral region.

4. Location: infant's lumbosacral region


Question: What structure is most likely to be affected by this patient's condition?

Context: A 25-year-old woman presents to the physician with the complaint of several episodes of headache in the past 4 weeks that are affecting her school performance.

Context: The episodes are getting progressively worse, and over-the-counter headache and migraine medication do not seem to help.

Context: She also mentions having to raise her head each time to look at the board when taking notes; she cannot simply glance up with just her eyes while facing her notes.

Context: She has no significant past medical or family history and was otherwise well prior to this visit.

Context: Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema.

Choices:
A. Third ventricle
B. Aqueduct of Sylvius
C. Tegmentum
D. Inferior colliculi

Answer: Aqueduct of Sylvius

1. A 25-year-old woman presents to the physician with the complaint of several episodes of headache in the past 4 weeks.

2. The episodes are affecting her school performance.

3. The episodes are getting progressively worse.

4. Over-the-counter headache and migraine medication do not seem to help.

5. She has to raise her head each time to look at the board when taking notes.

6. She cannot simply glance up with just her eyes while facing her notes.

7. She has no significant past medical or family history.

8. She was otherwise well prior to this visit.

9. Ophthalmic examination shows an upward gaze palsy.

10. Ophthalmic examination shows convergence-retraction nystagmus.

11. Ophthalmic examination shows papilledema.

1. The episodes are getting progressively worse.

2. Over-the-counter headache and migraine medication do not seem to help.

3. She mentions having to raise her head each time to look at the board when taking notes.

4. She cannot simply glance up with just her eyes while facing her notes.

5. She has no significant past medical or family history.

6. She was otherwise well prior to this visit.

7. Ophthalmic examination shows an upward gaze palsy.

8. Ophthalmic examination shows convergence-retraction nystagmus.

9. Ophthalmic examination shows papilledema.


Question: The patient is at greatest risk of which of the following adverse effects?

Context: A 75-year-old woman is brought to the emergency department because of a 6-hour history of severe headache, nausea, and 1 episode of vomiting.

Context: Her pulse is 50/min, respirations are 8/min and shallow, and blood pressure is 150/96 mm Hg.

Context: Appropriate pharmacotherapy with an intravenous drug is initiated, and the patient's urine output subsequently increases.

Choices:
A. Drug-induced hypersensitivity syndrome
B. Hyperuricemia
C. Tinnitus
D. Pulmonary edema

Answer: Pulmonary edema

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

2. She has a 6-hour history of severe headache, nausea, and 1 episode of vomiting.

3. On arrival, she is lethargic and oriented only to self.

5. Her respirations are 8/min and shallow.

7. Examination shows medial deviation of the left globe and ecchymoses of the upper eyelids.

8. Appropriate pharmacotherapy with an intravenous drug is initiated.

9. The patient's urine output subsequently increases.

1. On arrival, she is lethargic and oriented only to self.

3. Her respirations are 8/min and shallow.

5. Examination shows medial deviation of the left globe.

6. Examination shows ecchymoses of the upper eyelids.

7. Appropriate pharmacotherapy with an intravenous drug is initiated.

8. The patient's urine output subsequently increases.


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

Context: A 31-year-old gravida 2 para 2 woman presents to her primary care physician for follow up.

Context: The pH of the discharge is 6.4.

Choices:
A. Bacterial vaginosis
B. Rectovaginal fistula
C. Vaginal melanoma
D. Vesicovaginal fistula

Answer: Rectovaginal fistula

1. Patient is a 31-year-old gravida 2 para 2 woman.

2. Two weeks ago, she gave birth via vaginal delivery to a 9.5 lb (4.3 kg) male infant.

3. Delivery was complicated by a vaginal laceration that required extensive suturing once the infant was delivered.

4. Immediately after delivery of the placenta she experienced intense shaking and chills that resolved within 1 hour.

5. She has felt well since the delivery but admits to 6 days of malodorous smelling vaginal discharge that is tan in color.

6. She has a history of vaginal candidiasis.

7. Temperature is 98.8°F (37.1°C), blood pressure is 122/73 mmHg, pulse is 88/min, respirations are 16/min, and BMI is 33 kg/m^2.

8. Speculum exam reveals a 1.5 cm dark red, velvety lesion on the posterior vaginal wall with a tan discharge.

1. Two weeks ago, she gave birth via vaginal delivery to a 9.5 lb (4.3 kg) male infant.

2. The delivery was complicated by a vaginal laceration that required extensive suturing once the infant was delivered.

3. Immediately after delivery of the placenta she experienced intense shaking and chills that resolved within 1 hour.

4. She has felt well since the delivery but admits to 6 days of malodorous smelling vaginal discharge that is tan in color.

5. She has a history of vaginal candidiasis and is worried that it may be recurring.

6. Her temperature is 98.8°F (37.1°C), blood pressure is 122/73 mmHg, pulse is 88/min, respirations are 16/min, and BMI is 33 kg/m^2.

7. Speculum exam reveals a 1.5 cm dark red, velvety lesion on the posterior vaginal wall with a tan discharge.


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

Context: A 50-year-old male presents to the emergency room after getting hit by a car while biking.

Context: Initially he has an uneventful post-operative course; however, on post-op day 4 he becomes confused and develops chest pain, tachypnea, and dyspnea.

Choices:
A. Lobar lung consolidation
B. Aspiration of stomach contents
C. Occlusion of the pulmonary vessels by fat globules
D. Spontaneous pneumothorax

Answer: Occlusion of the pulmonary vessels by fat globules

1. A 50-year-old male presents to the emergency room.

3. He complains of severe pain in both thighs.

4. His thighs appear swollen, bruised, and angulated.

5. Radiographic imaging demonstrates bilateral femoral shaft fractures.

6. He subsequently undergoes surgical fixation of his fractures.

7. Initially he has an uneventful post-operative course.

8. On post-op day 4 he becomes confused.

9. He develops chest pain, tachypnea, and dyspnea.

10. A new petechial rash is seen over his chest and neck.

11. Electrocardiogram reveals normal sinus rhythm.

1. Patient complains of severe pain in both thighs.

2. Thighs appear swollen, bruised, and angulated.

3. Radiographic imaging demonstrates bilateral femoral shaft fractures.

4. Patient undergoes surgical fixation of his fractures.

5. Patient has an uneventful post-operative course.

6. On post-op day 4, patient becomes confused and develops chest pain, tachypnea, and dyspnea.

7. A new petechial rash is seen over patient's chest and neck.

8. Electrocardiogram reveals normal sinus rhythm.


Question: Which of the following statements regarding this results of this study is true?

Context: In this study, 60 subjects with hepatitis were asked details of their history of drug abuse, such as the duration of drug abstinence, the amount and duration of drug abuse, and the treatment history.

Context: Additionally, a source close to or related to each of the study subjects (most often a spouse) was asked similar questions about the subject by a second researcher who was blinded to the subject’s drug abuse history.

Context: Results revealed that the duration of drug abstinence correlated highly between subjects and the source (Spearman’s r = 0.94, p-value < 0.001), as did the individual's score on the stimulant relapse risk scale (SRRS, Spearman’s r = 0.74, p-value < 0.001), a ranked metric of relapse risk.

Choices:
A. If the authors had conducted a study on larger sample size, Pearson’s correlation coefficient for these data would have been calculated.
B. There is a linear relationship between the duration of drug abstinence as assessed by the subject and their close/related source.
C. Spearman’s correlation coefficient reveals a strong association between the SRRS scores, as assessed by the study subject and their related source.
D. We can conclude that 88.4% (= 0.94 x 0.94) of the variability in the duration of drug abstinence (as assessed by the study subjects) can be 'explained' by the variability in the duration of drug abstinence as assessed by their sources.

Answer: Spearman’s correlation coefficient reveals a strong association between the SRRS scores, as assessed by the study subject and their related source.

1. A group of researchers is conducting a study to assess the validity and reliability of patient history in determining the amount and duration of drug abuse.

2. 60 subjects with hepatitis were asked details of their history of drug abuse, such as the duration of drug abstinence, the amount and duration of drug abuse, and the treatment history.

3. A source close to or related to each of the study subjects (most often a spouse) was asked similar questions about the subject by a second researcher who was blinded to the subject’s drug abuse history.

4. Results revealed that the duration of drug abstinence correlated highly between subjects and the source (Spearman’s r = 0.94, p-value < 0.001).

5. Results also revealed that the individual's score on the stimulant relapse risk scale (SRRS, Spearman’s r = 0.74, p-value < 0.001), a ranked metric of relapse risk correlated highly between subjects and the source.

1. 60 subjects with hepatitis were included in the study.

2. Subjects were asked about their history of drug abuse, including duration of drug abstinence, amount and duration of drug abuse, and treatment history.

3. A source close to each subject was asked similar questions about the subject's drug abuse history.

4. The second researcher who asked the questions was blinded to the subject's drug abuse history.

5. Results revealed a high correlation (Spearman’s r = 0.94, p-value < 0.001) between the duration of drug abstinence reported by subjects and their sources.

6. Results also showed a high correlation (Spearman’s r = 0.74, p-value < 0.001) between the individual's score on the stimulant relapse risk scale (SRRS) and the source's report.


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

Context: A 27-year-old man comes to the emergency department for progressive weakness and numbness in his legs for 5 days.

Context: Symptoms originally started with tingling in both feet and have progressed to involve the knees and hips; he is currently unable to walk without assistance.

Context: Lumbar puncture shows elevated CSF protein and no white blood cells.

Choices:
A. Postsynaptic acetylcholine receptors
B. Muscle endomysium
C. Schwann cells
D. Cerebral white matter

Answer: Schwann cells

1. A 27-year-old man comes to the emergency department.

2. He has progressive weakness and numbness in his legs for 5 days.

3. Symptoms originally started with tingling in both feet.

4. Symptoms have progressed to involve the knees and hips.

5. He is currently unable to walk without assistance.

6. Two weeks ago, the patient had diarrhea that subsided without antibiotics.

7. Neurologic examination shows weakness, decreased sensation, and absent patellar reflexes in both lower extremities.

8. Lumbar puncture shows elevated CSF protein.

9. Lumbar puncture shows no white blood cells.

1. Symptoms started with tingling in both feet

2. Symptoms progressed to involve the knees and hips

3. Patient is currently unable to walk without assistance

4. Two weeks ago, the patient had diarrhea

5. Diarrhea subsided without antibiotics

6. Neurologic examination shows weakness in both lower extremities

7. Neurologic examination shows decreased sensation in both lower extremities

8. Neurologic examination shows absent patellar reflexes in both lower extremities

9. Lumbar puncture shows elevated CSF protein

10. Lumbar puncture shows no white blood cells


Question: Which of the following is the most appropriate further management of this patient?

Context: A 23-year-old man presents to the emergency department presenting with sudden-onset dyspnea and left-sided chest pain over the last hour.

Context: This event started when he was in class sitting for an exam.

Context: Pulse oximetry shows 97% on room air.

Context: A chest X-ray is taken (see exhibit).

Choices:
A. Needle thoracostomy
B. IV antibiotics
C. Supplemental oxygen
D. CT angiogram of chest

Answer: Supplemental oxygen

2. Patient presents with sudden-onset dyspnea and left-sided chest pain over the last hour.

3. Event started when patient was in class sitting for an exam.

4. Pain is worse with inspiration and does not radiate.

5. Patient has anxiety and takes alprazolam as needed.

6. Patient smokes half a pack of cigarettes a day.

12. Pulse oximetry shows 97% on room air.

13. Patient's weight is 63.5 kg (140 lb).

14. Patient's height is 185 cm (6 ft 1 in).

17. After an hour of supplemental oxygen, rest, and careful monitoring, patient's dyspnea improves and chest pain resolves without medication.

1. The event started when he was in class sitting for an exam.

2. He reports that the pain is worse with inspiration and does not radiate.

3. He says he has anxiety and takes alprazolam as needed.

4. He smokes half a pack of cigarettes a day and drinks alcohol socially.

5. The temperature is 36.7°C (98.0°F), the blood pressure is 130/80 mm Hg, the pulse is 82/min, and the respiratory rate is 14/min.

6. Pulse oximetry shows 97% on room air.

7. The patient’s weight is 63.5 kg (140 lb), height is 185 cm (6 ft 1 in), and he has a BMI of 18.5 kg/m2.

8. A chest X-ray is taken (see exhibit).

9. After an hour of supplemental oxygen, rest, and careful monitoring his dyspnea improves and chest pain resolves without medication.