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

Context: A 40-year-old man comes to the physician because of a 5-kg (11-lb) weight loss over the past month and easy bruising.

Context: He appears pale.

Context: His pulse is 70/min, his blood pressure is 125/75 mm Hg, and his temperature is 38°C (100.4°F).

Context: His liver is enlarged.

Context: Laboratory results show: | Leukocytes 10,500/mm3 | Hemoglobin 10.2 g/dL | Platelets 52,000/mm3 | Fibrinogen 110 mg/dL (Reference: 150-400 mg/dL) | Cytogenetic analysis shows leukocytes with a reciprocal translocation of chromosomes 15 and 17.

Choices:
A. Cyclophosphamide
B. All-trans retinoic acid
C. Cryoprecipitate transfusion
D. Imatinib

Answer: All-trans retinoic acid

1. A 40-year-old man comes to the physician.

2. He has experienced a 5-kg (11-lb) weight loss over the past month.

4. He has not changed his diet significantly.

5. He has noticed that his arms now bruise more easily.

10. Examination shows a palm-sized hematoma on his right arm.

11. His spleen is palpable 5 cm below the costal margin.

13. Laboratory results show leukocytes 10,500/mm3.

14. Laboratory results show hemoglobin 10.2 g/dL.

15. Laboratory results show platelets 52,000/mm3.

16. Laboratory results show fibrinogen 110 mg/dL (Reference: 150-400 mg/dL).

17. Laboratory results show cytogenetic analysis with leukocytes with a reciprocal translocation of chromosomes 15 and 17.

1. He has not changed his diet significantly.

2. He also noticed that his arms now bruise more easily.

7. Examination shows a palm-sized hematoma on his right arm.

8. His spleen is palpable 5 cm below the costal margin.

10. Laboratory results show: Leukocytes 10,500/mm3.

13. Fibrinogen 110 mg/dL (Reference: 150-400 mg/dL).

14. Cytogenetic analysis shows leukocytes with a reciprocal translocation of chromosomes 15 and 17.


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

Context: At a routine exam, a 68-year-old female patient is discovered to have a serum calcium level of 11.5 mg/dL.

Context: Follow-up laboratory tests show a high parathyroid hormone with low phosphorus and mildly elevated alkaline phosphatase.

Context: Review of symptoms includes complaints of fatigue, constipation, and diffuse bone pain for which she takes vitamin D.

Context: Past medical history is significant for type 2 diabetes mellitus for 25 years and essential hypertension for 15 years.

Context: Family history is irrelevant.

Choices:
A. Vitamin D intoxication
B. Familial hypocalciuric hypercalcaemia
C. Solitary parathyroid adenoma
D. Thyrotoxicosis

Answer: Solitary parathyroid adenoma

Endocrinology, Diabetes, and Metabolism
Internal Medicine

General Endocrinology
Endocrinology, Diabetes, and Metabolism

3. Follow-up laboratory tests show high parathyroid hormone with low phosphorus and mildly elevated alkaline phosphatase.

4. 24-hour urine calcium level is elevated.

5. Patient has complaints of fatigue, constipation, and diffuse bone pain.

7. Patient has past medical history of type 2 diabetes mellitus for 25 years and essential hypertension for 15 years.

8. Patient has history of kidney stones.

1. Follow-up laboratory tests show high parathyroid hormone.

2. Follow-up laboratory tests show low phosphorus.

3. Follow-up laboratory tests show mildly elevated alkaline phosphatase.

5. Review of symptoms includes complaints of fatigue.

6. Review of symptoms includes complaints of constipation.

7. Review of symptoms includes complaints of diffuse bone pain.

8. The patient takes vitamin D for diffuse bone pain.

9. Past medical history is significant for type 2 diabetes mellitus for 25 years.

10. Past medical history is significant for essential hypertension for 15 years.

11. The patient has a history of kidney stones.


Question: Which of the following is associated with the pathophysiology underlying this patient's disorder?

Context: A 27-year-old man and his wife present to an infertility clinic for evaluation after they tried unsuccessfully to conceive for 2 years.

Context: In addition, he has testicular atrophy and very little body hair, which is distributed primarily in the pubic region.

Context: Further analysis reveals azoospermia, and appropriate tests confirming the diagnosis are performed.

Context: The couple is told about the cause of their inability to conceive and given further options to pursue.

Choices:
A. Abnormal signaling through androgen receptors
B. Abnormal conversion of testosterone
C. Increased aromatase activity
D. Increased production of prolactin

Answer: Increased aromatase activity

Reproductive Endocrinology and Infertility

1. A 27-year-old man and his wife present to an infertility clinic for evaluation.

2. They have been trying unsuccessfully to conceive for 2 years.

3. He has no prior medical history and does not currently take any medications.

4. On evaluation, he is found to have long extremities and gynecomastia.

5. He also has testicular atrophy and very little body hair, which is distributed primarily in the pubic region.

6. Further analysis reveals azoospermia.

7. Appropriate tests confirming the diagnosis are performed.

8. The couple is told about the cause of their inability to conceive.

9. The couple is given further options to pursue.

2. He does not currently take any medications.

3. On evaluation, he is found to have long extremities.

4. On evaluation, he is found to have gynecomastia.

7. The body hair is distributed primarily in the pubic region.

8. Further analysis reveals azoospermia.

9. Appropriate tests confirming the diagnosis are performed.

10. The couple is told about the cause of their inability to conceive.

11. The couple is given further options to pursue.


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

Context: A 32-year-old GP2 presents to an outpatient clinic for a routine gynecologic examination.

Context: The patient appears well, although she mentions that during the past 6 months she has noticed small amounts of vaginal bleeding in the middle of her menstrual cycles.

Context: Her last pregnancy was 3 years ago.

Context: She mentions that she is up to date with her Pap smear; all of her Pap smears have been normal.

Context: The physical examination is essentially normal.

Choices:
A. No further intervention with follow-up in 6 months
B. Electrocautery and cryofreezing
C. Cervical brush biopsy
D. Removal of the lesion with a ring forceps

Answer: Removal of the lesion with a ring forceps

3. Patient is presenting to an outpatient clinic for a routine gynecologic examination.

4. Patient has noticed small amounts of vaginal bleeding in the middle of her menstrual cycles for the past 6 months.

5. Patient's last pregnancy was 3 years ago.

6. Patient's menstrual cycles have been regular, lasting about 2–3 days.

7. Patient is up to date with her Pap smear.

8. All of patient's Pap smears have been normal.

9. Patient denies any recent travel or history of trauma.

10. Patient is sexually active with her husband and they use condoms consistently.

12. Patient drinks alcohol occasionally.

13. Patient has never used illicit drugs.

14. Physical examination is essentially normal.

15. Ultrasound reveals a fleshy mass with a pedunculated stalk deep in the cervical canal.

16. Uterine lining measures 5 mm in thickness and is homogeneous.

17. Multiple small leiomyomas are also observed.

18. Patient is otherwise asymptomatic and has no other complaints.

19. Rest of the physical examination is unremarkable.

1. The patient has noticed small amounts of vaginal bleeding in the middle of her menstrual cycles over the past 6 months.

3. Her subsequent menstrual cycles have been regular, lasting about 2–3 days.

4. She is up to date with her Pap smear and all of her Pap smears have been normal.

5. She denies any recent travel or history of trauma.

6. The patient is sexually active with her husband and they use condoms consistently.

7. She does not smoke, drinks alcohol occasionally, and has never used illicit drugs.

8. An ultrasound reveals a fleshy mass with a pedunculated stalk deep in the cervical canal.

9. The uterine lining measures 5 mm in thickness and is homogeneous.

10. Multiple small leiomyomas are also observed.

11. The patient is otherwise asymptomatic and has no other complaints.

12. The rest of the physical examination is unremarkable.


Question: Which of the following is the most likely underlying pathology?

Context: An 11-year-old girl presents to her pediatrician with complaints of headache and rapid leg fatigue with exercise.

Context: Her vital signs are: HR 77, BP in left arm 155/100, RR 14, SpO2 100%, T 37.0 C.

Choices:
A. Peripheral arterial disease
B. Vasospasm
C. Coarctation of the aorta
D. Tetralogy of Fallot

Answer: Coarctation of the aorta

1. An 11-year-old girl presents to her pediatrician.

2. She has complaints of headache and rapid leg fatigue with exercise.

8. On palpation, her left dorsalis pedis pulse is delayed as compared to her left radial pulse.

9. Her lower extremities feel slightly cool.

10. Blood pressure obtained on the left lower extremity is 120/80.

2. Her vital signs: BP in left arm 155/100

6. On palpation, her left dorsalis pedis pulse is delayed as compared to her left radial pulse

7. Her lower extremities feel slightly cool

8. Blood pressure obtained on the left lower extremity is 120/80


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

Context: A 34-year-old woman comes to the gynecologist complaining of vaginal swelling and discomfort.

Context: She states that over the past 2 weeks she has noticed swelling of her right labia.

Context: The swelling continued to grow in size and now causes her discomfort when walking.

Context: She denies any history of known trauma.

Context: On physical exam, there is a fluctuant, swelling of the right labia, most prominently at the posterior vestibule.

Choices:
A. Bartholin gland cyst
B. Folliculitis
C. Granuloma inguinale
D. Vulvar cancer

Answer: Bartholin gland cyst

1. A 34-year-old woman comes to the gynecologist.

2. She is complaining of vaginal swelling and discomfort.

3. She has noticed swelling of her right labia over the past 2 weeks.

4. The swelling has continued to grow in size.

5. The swelling causes her discomfort when walking.

6. She denies abnormal discharge or bleeding from the swelling or from the vulva.

7. She normally shaves the area, but with the recent pain, she has been unable to.

8. She denies any history of known trauma.

9. The patient is relatively healthy and takes only a multivitamin.

10. She never received the vaccine for human papillomavirus (HPV).

11. On physical exam, there is a fluctuant, swelling of the right labia.

12. The swelling is most prominently at the posterior vestibule.

1. The patient has noticed swelling of her right labia over the past 2 weeks.

2. The swelling causes discomfort when walking.

3. There is no abnormal discharge or bleeding from the swelling or from the vulva.

4. The patient normally shaves the area but has been unable to due to recent pain.

6. The patient is relatively healthy and takes only a multivitamin.

7. The patient has not received the vaccine for human papillomavirus (HPV).

8. On physical exam, there is a fluctuant swelling of the right labia, most prominently at the posterior vestibule.


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

Context: A 4-month-old boy is brought to the physician because of noisy breathing for 2 months that has progressively become louder.

Context: The noisy breathing improves when he is in the prone position.

Context: It is worse when he is agitated, feeding, or lying on his back.

Context: His temperature is 37.1°C (98.8°F), pulse is 120/min, and respirations are 50/min.

Context: Examination shows inspiratory stridor.

Choices:
A. Observation
B. Surgical division
C. Ceftriaxone therapy
D. Supraglottoplasty

Answer: Observation

1. A 4-month-old boy is brought to the physician.

2. Noisy breathing has been present for 2 months and has progressively become louder.

3. Noisy breathing improves when he is in the prone position.

4. Noisy breathing is worse when he is agitated, feeding, or lying on his back.

5. He was born at term and has been healthy since.

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

10. Examination shows inspiratory stridor.

1. The noisy breathing improves in the prone position.

2. Noisy breathing is worse when he is agitated, feeding, or lying on his back.

3. He was born at term and has been healthy since.

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

8. Examination shows inspiratory stridor.


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

Context: A 16-year-old girl comes to the physician with a 4-day history of painful vulvar lesions, generalized fatigue, and malaise.

Context: During this period, she has also had dysuria.

Context: She is sexually active with 2 male partners and uses condoms inconsistently.

Context: Her immunizations are up-to-date; she completed the vaccination course for human papilloma virus 2 months ago.

Context: Her temperature is 38.1°C (100.6°F), pulse is 100/min, respirations are 12/min, and blood pressure is 110/70 mm Hg.

Choices:
A. Acyclovir therapy
B. Azithromycin therapy
C. Doxycycline therapy
D. Penicillin therapy

Answer: Acyclovir therapy

Pediatrics
Obstetrics and Gynecology
Dermatology

Pediatric Infectious Diseases
General Obstetrics and Gynecology
General Dermatology

2. Patient has a 4-day history of painful vulvar lesions, generalized fatigue, and malaise.

3. Patient has had dysuria during this period.

4. Patient is sexually active with 2 male partners.

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

7. Patient completed the vaccination course for human papilloma virus 2 months ago.

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

11. Patient's blood pressure is 110/70 mm Hg.

12. Pelvic examination shows several shallow ulcers on an erythematous base over the labia majora and minora.

13. Patient has bilateral, tender inguinal lymphadenopathy.

2. She is sexually active with 2 male partners.

5. She completed the vaccination course for human papilloma virus 2 months ago.

10. Pelvic examination shows several shallow ulcers on an erythematous base over the labia majora and minora.

11. There is bilateral, tender inguinal lymphadenopathy.


Question: These cells most likely originated from which of the following structures?

Context: A 57-year-old man comes to the physician because of progressively worsening epigastric pain and 6.8-kg (15-lb) weight loss for the past 2 months.

Context: He appears thin.

Choices:
A. Lymphoid tissue in the terminal ileum
B. Mature hepatocytes in the liver
C. Exocrine ducts in the body of the pancreas
D. Squamous epithelium in the proximal esophagus

Answer: Exocrine ducts in the body of the pancreas

1. A 57-year-old man comes to the physician.

2. He has experienced progressively worsening epigastric pain for the past 2 months.

3. He has lost 6.8 kg (15 lb) in the past 2 months.

4. Two weeks ago, he noticed painful, red blotches on the medial aspect of his right calf.

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

7. Physical examination shows tender erythematous nodules on the right ankle and left antecubital fossa.

8. Endoscopy shows a large mass in the antrum of the stomach.

9. A biopsy specimen of the gastric mass shows disorganized mucin-secreting cells with surrounding fibrosis.

1. Two weeks ago, he noticed painful, red blotches on the medial aspect of his right calf.

2. He has smoked one pack of cigarettes daily for the last 35 years.

4. Physical examination shows tender erythematous nodules on the right ankle and left antecubital fossa.

5. Endoscopy shows a large mass in the antrum of the stomach.

6. A biopsy specimen of the gastric mass shows disorganized mucin-secreting cells with surrounding fibrosis.


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

Context: A 62-year-old woman comes to the emergency department because of painful and difficult swallowing.

Context: Her voice has also become muffled.

Context: She has been well until last night and reports having intermittent fevers at home.

Context: The patient has smoked a pack of cigarettes a day since age 19 but is otherwise healthy.

Context: Her temperature is 39°C (102.2°F), blood pressure is 142/93 Hg/mm, heart rate is 109/min, and respiratory rate is 18/min.

Context: Her voice is muffled and there is inspiratory stridor.

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

Choices:
A. Pseudomonas aeruginosa
B. Corynebacterium diphtheriae
C. Parainfluenza virus
D. Haemophilus influenzae type b

Answer: Haemophilus influenzae type b

1. A 62-year-old woman comes to the emergency department.

2. She has painful and difficult swallowing.

5. She reports having intermittent fevers at home.

6. She has smoked a pack of cigarettes a day since age 19.

12. On examination, her head is extended.

16. There is tender bilateral cervical lymphadenopathy.

17. There is pain upon palpation of the hyoid.

18. The remainder of the examination shows no abnormalities.

19. Laboratory studies show a leukocyte count of 18,000/mm3.

20. 83% of the leukocytes are neutrophils.

1. The patient's voice has become muffled.

2. The patient has been well until last night.

3. The patient reports having intermittent fevers at home.

4. The patient has smoked a pack of cigarettes a day since age 19.

5. The patient's temperature is 39°C (102.2°F).

6. The patient's blood pressure is 142/93 Hg/mm.

8. The patient's respiratory rate is 18/min.

9. On examination, the patient's head is extended and she appears anxious.

11. The patient has inspiratory stridor.

12. The patient has tender bilateral cervical lymphadenopathy.

13. The patient has pain upon palpation of the hyoid.

14. The remainder of the examination shows no abnormalities.

15. Laboratory studies show a leukocyte count of 18,000/mm3 with 83% neutrophils.


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

Choices:
A. Oligodendroglioma
B. Glioblastoma
C. Schwannoma
D. Meningioma

Answer: Glioblastoma

1. A 56-year-old woman is brought to the emergency department by her husband 30 minutes after a generalized tonic-clonic seizure.

2. Over the past 3 months, she has had recurrent headaches and worsening early-morning vomiting.

3. She has no personal or family history of a seizure disorder.

4. An MRI of the brain shows a central mass.

6. One day before the surgery, the patient has another generalized seizure.

7. Despite resuscitative efforts, she dies.

8. Gross examination of the brain at autopsy is shown.

1. Over the past 3 months, she has had recurrent headaches and worsening early-morning vomiting.

2. She has no personal or family history of a seizure disorder.

3. An MRI of the brain shows a central mass; surgical resection is planned.

4. One day before the surgery, the patient has another generalized seizure and, despite resuscitative efforts, she dies.

5. Gross examination of the brain at autopsy is shown.


Question: Which of the following laboratory values should be assessed next in this patient?

Context: A 29-year-old woman (gravida 2, para 1) presents at 32 weeks gestation for routine follow-up care.

Context: Her previous pregnancy was complicated with preeclampsia, and she delivered at 35 weeks via cesarean delivery.

Context: Prior to pregnancy, she took amlodipine and hydrochlorothiazide; after she found out she was pregnant, she switched to methyldopa.

Context: According to her blood pressure diary, her systolic blood pressure varies between 120 and 130 mm Hg, and her diastolic blood pressure is usually normal.

Context: At presentation, the blood pressure is 140/80 mm Hg, heart rate is 76/min, respiratory rate is 15/min, and temperature is 36.9°C (98.4°F).

Context: The fetal heart rate is 143/min.

Context: Dipstick test shows 2+ protein.

Choices:
A. Coagulogram
B. Liver transaminases
C. Total bilirubin
D. Urinalysis

Answer: Liver transaminases

4. Patient's previous pregnancy was complicated with preeclampsia.

5. Patient delivered at 35 weeks via cesarean delivery.

6. Patient was diagnosed with arterial hypertension four years ago.

7. Patient took amlodipine and hydrochlorothiazide prior to pregnancy.

8. Patient switched to methyldopa after finding out she was pregnant.

9. Course of current pregnancy has been unremarkable.

10. Normal laboratory values at each checkup.

11. Systolic blood pressure varies between 120 and 130 mm Hg.

12. Diastolic blood pressure is usually normal.

13. Blood pressure at presentation is 140/80 mm Hg.

14. Heart rate at presentation is 76/min.

15. Respiratory rate at presentation is 15/min.

16. Temperature at presentation is 36.9°C (98.4°F).

18. Examination shows 1+ pitting lower leg edema.

20. 24-hour urine assessment demonstrates urinary protein excretion of 1 g/L.

1. Her previous pregnancy was complicated with preeclampsia.

2. She delivered at 35 weeks via cesarean delivery.

3. Four years ago, she was diagnosed with arterial hypertension.

4. Prior to pregnancy, she took amlodipine and hydrochlorothiazide.

5. After she found out she was pregnant, she switched to methyldopa.

6. The course of her current pregnancy has been unremarkable with normal laboratory values at each checkup.

7. According to her blood pressure diary, her systolic blood pressure varies between 120 and 130 mm Hg.

8. Her diastolic blood pressure is usually normal.

9. At presentation, the blood pressure is 140/80 mm Hg.

14. Examination shows a 1+ pitting lower leg edema.

16. 24-hour urine assessment demonstrates urinary protein excretion of 1 g/L.


Question: Which of the following best describes this approach to the prevention of medical errors?

Context: Following a colonoscopy performed on a 63-year-old man, the gastroenterologist identifies a firm tumor approx.

Context: 80 cm (31.4 in) from the entry site.

Context: He also performs an endoscopic polypectomy and tattooing at 50 cm (19.6 in) from the entry site.

Context: One week later, the surgeon in the operating room is erroneously preparing to perform partial colectomy of the tattooed site.

Context: After confirming the patient’s name and before surgery, the surgical team reviews the patient’s history and medical documents orally based on institutional protocols.

Context: The surgery resident points out that the resected polyp is benign and the tumor lies 30 cm (11.8 in) distal to the tattooed area.

Choices:
A. Closed-loop communication
B. Preoperative time-out
C. Primordial prevention
D. Sentinel event

Answer: Preoperative time-out

Internal Medicine
Surgery
General Surgery

1. A colonoscopy was performed on a 63-year-old man.

2. An endoscopic polypectomy and tattooing was performed at 50 cm (19.6 in) from the entry site.

3. A pathologic report showed a benign polyp.

4. One week later, the surgeon was erroneously preparing to perform partial colectomy of the tattooed site.

5. The surgical team reviewed the patient’s history and medical documents orally based on institutional protocols.

6. The surgery resident pointed out that the resected polyp was benign and the tumor lies 30 cm (11.8 in) distal to the tattooed area.

7. The attending surgeon performed a partial colectomy on the correct site.

1. The distance from the entry site for endoscopic polypectomy and tattooing is 80 cm (31.4 in).

2. A pathologic report shows a benign polyp.

3. The surgeon erroneously prepares to perform partial colectomy of the tattooed site.

4. The surgical team reviews the patient’s history and medical documents orally before surgery.

6. The tumor lies 30 cm (11.8 in) distal to the tattooed area.

7. The attending surgeon performs a partial colectomy on the correct site.


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

Context: She has a history of type I diabetes controlled by insulin and delivered 1 child by normal spontaneous vaginal delivery 2 years ago.

Context: Urinalysis each time confirmed a urinary tract infection, and both urine cultures isolated organisms sensitive to nitrofurantoin.

Context: She has no complaints today.

Choices:
A. Admit to the hospital and treat with intravenous ceftriaxone
B. Treat with oral trimethroprim-sulfamethoxazole for 10 days then continue for prophylaxis until delivery
C. Treat with oral nitrofurantion for 10 days
D. Treat with oral nitrofurantion for 10 days then continue for prophylaxis until delivery

Answer: Treat with oral nitrofurantion for 10 days then continue for prophylaxis until delivery

1. A 28-year-old G2P1001 presents for a routine obstetric visit in her 36th week of pregnancy.

2. She has a history of type I diabetes controlled by insulin.

3. She delivered 1 child by normal spontaneous vaginal delivery 2 years ago.

4. Earlier in this pregnancy, she had 2 episodes of burning with urination and frequent urination.

5. Urinalysis each time confirmed a urinary tract infection.

6. Both urine cultures isolated organisms sensitive to nitrofurantoin.

7. Her symptoms resolved with 10-day courses of nitrofurantoin.

9. Urinalysis is positive for leukocyte esterase and nitrites.

1. She has a history of type I diabetes controlled by insulin.

2. She delivered 1 child by normal spontaneous vaginal delivery 2 years ago.

3. Earlier in this pregnancy, she had 2 episodes of burning with urination and frequent urination.

4. Urinalysis each time confirmed a urinary tract infection.

5. Both urine cultures isolated organisms sensitive to nitrofurantoin.

6. Her symptoms resolved with 10-day courses of nitrofurantoin.

8. Urinalysis is positive for leukocyte esterase and nitrites.


Question: Analysis of a left calf biopsy specimen from this patient is most likely to show which of the following?

Context: A 3-year-old boy is brought to the physician by his parents because of clumsiness and multiple falls over the past 4 months.

Context: He started walking at the age of 18 months and could walk up steps by the time he was 27 months old but now struggles to walk at all without assistance.

Context: There is bilateral calf enlargement.

Choices:
A. Proliferation of mitochondria within muscle fibers
B. Degeneration of muscle fibers with fibrofatty replacement
C. Atrophic muscle fibers interspersed among hypertrophic muscle fibers
D. Necrotic muscle fibers with lymphocytic infiltrate

Answer: Degeneration of muscle fibers with fibrofatty replacement

1. A 3-year-old boy is brought to the physician by his parents.

2. The boy has experienced clumsiness and multiple falls over the past 4 months.

3. The boy started walking at the age of 18 months.

4. The boy could walk up steps by the time he was 27 months old.

5. The boy now struggles to walk at all without assistance.

6. When standing up from a lying position, he crawls onto his knees and slowly walks himself up with his hands.

1. He started walking at the age of 18 months.

2. He could walk up steps by the time he was 27 months old.

3. He now struggles to walk at all without assistance.

4. When standing up from a lying position, he crawls onto his knees.

5. He slowly walks himself up with his hands.


Question: What is the most likely diagnosis for the lesions seen in endoscopy?

Context: He has a history of hepatitis B.

Context: He was diagnosed with hepatocellular carcinoma and initially received radiotherapy while on the transplant list to prevent local expansion of his malignancy.

Context: He received a blood transfusion.

Choices:
A. Intrinsic apoptotic pathway
B. Coagulative necrosis
C. Overexpression of BcL-2 gene
D. Cytotoxic CD8 T cells pathway

Answer: Intrinsic apoptotic pathway

1. A 60-year-old man presented to the hospital with right upper quadrant abdominal pain.

3. He underwent a CT of his abdomen which revealed a large mass (11.3 cm x 7.2 cm in diameter) with a metastatic retroperitoneal lymph node.

4. He was diagnosed with hepatocellular carcinoma.

5. He initially received radiotherapy while on the transplant list to prevent local expansion of his malignancy.

6. 3 months after radiotherapy, the patient experienced hematemesis and melena.

7. He was admitted to the emergency department for evaluation.

8. His vitals were: blood pressure 84/56 mmHg, heart rate 92/min, and respiratory rate 20/min.

9. Laboratory evaluation revealed severe anemia with a hemoglobin level of 5.7 g/dL, INR 1.8 and platelets of 68,000 cells/mm3.

11. An endoscopic examination demonstrated diffuse edematous hyperemic mucosa and multiple hemorrhagic patches with active oozing in the antrum.

2. He underwent a CT of his abdomen which revealed a large mass (11.3 cm x 7.2 cm in diameter) with a metastatic retroperitoneal lymph node.

3. He was diagnosed with hepatocellular carcinoma.

4. He initially received radiotherapy while on the transplant list to prevent local expansion of his malignancy.

5. 3 months after radiotherapy, the patient experienced hematemesis and melena.

6. He was admitted to the emergency department for evaluation.

7. His vitals were: blood pressure 84/56 mmHg, heart rate 92/min, and respiratory rate 20/min.

8. Laboratory evaluation revealed severe anemia with a hemoglobin level of 5.7 g/dL, INR 1.8 and platelets of 68,000 cells/mm3.

10. An endoscopic examination demonstrated diffuse edematous hyperemic mucosa and multiple hemorrhagic patches with active oozing in the antrum.


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

Context: Her mother and father have hypertension and her father had myocardial infarction at the age of 68 years.

Context: She drinks 3 glasses of wine a week.

Choices:
A. Liver function tests
B. Urine microalbumin
C. Hemoglobin A1C
D. Blood glucose

Answer: Blood glucose

1. A 49-year-old Caucasian woman presents to your office for elevated blood pressure.

2. She is a nurse and checks her blood pressure regularly while working in the wards.

3. She presents with readings ranging between 163/101 and 156/94 mm Hg.

4. After some research she conducted on her own, she has been exercising and following a low-fat, low-salt diet for the past 3 months.

5. Her past medical history includes laparoscopic cholecystectomy for acute cholecystitis 2 years previously.

6. Her mother and father have hypertension.

7. Her father had myocardial infarction at the age of 68 years.

8. She takes no medications and denies smoking.

10. Her blood pressure in the office after more than 10 minutes of rest was 153/89 mm Hg in her left arm and 145/90 mm Hg in her right arm.

11. A review of her medical record reveals that her blood pressure was 142/92 mm Hg at her visit 1 year ago.

2. She checks her blood pressure regularly while working in the wards.

3. Her blood pressure readings range between 163/101 and 156/94 mm Hg.

4. She has been exercising and following a low-fat, low-salt diet for the past 3 months.

7. Her father had a myocardial infarction at the age of 68 years.

10. She drinks 3 glasses of wine a week.

11. Her blood pressure in the office after more than 10 minutes of rest was 153/89 mm Hg in her left arm and 145/90 mm Hg in her right arm.

12. Her blood pressure was 142/92 mm Hg at her visit 1 year ago.


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

Context: He does not experience pain when cycling but notices the pain when standing or walking.

Context: He is requesting pain medication and a doctor's note to take off work for the week as his symptoms are disrupting his life.

Choices:
A. Bamboo appearance of the spine on radiography
B. Muscular tenderness with perispinal palpation
C. Multiple doctors visits for other unrelated problems
D. Narrowing of the lumbar spinal canal on MRI

Answer: Narrowing of the lumbar spinal canal on MRI

Orthopaedic Sports Medicine
General Orthopaedic Surgery

1. A 55-year-old man presents to his primary care physician for back pain.

2. The patient states that his back pain is worse in the morning and improves with certain activities.

3. He does not experience pain when cycling.

4. He notices the pain when standing or walking.

5. 2 months prior to presentation he was lifting heavy boxes and furniture into his daughter's new home.

7. He is requesting a doctor's note to take off work for the week.

8. His symptoms are disrupting his life.

1. The patient's back pain is worse in the morning.

2. The patient's back pain improves with certain activities.

3. The patient does not experience pain when cycling.

4. The patient notices the pain when standing or walking.

5. Two months prior to presentation, the patient was lifting heavy boxes and furniture.

6. The patient is requesting pain medication.

7. The patient is requesting a doctor's note to take off work for the week.


Question: WBC 15.2 x  10°/L | Hemoglobin 13.4 g/dL | Platelets 185 x 109/L | Prostate-specific antigen (PSA) 10 ng/mL | What is the most likely cause of the patient’s symptoms?

Context: A 75-year-old man presents to the emergency department from his doctor’s office with a 2-day history of urinary hesitancy, fever, and chills.

Context: He additionally notes that he has been getting up frequently during the night to urinate.

Context: For the last 2 years, it has taken him longer than usual to initiate urination and his stream has gotten weaker.

Context: He has a history of hypertension for which he takes losartan.

Context: His blood pressure is 128/84 mm Hg, heart rate is 84/min, respiratory rate is 14/min, and temperature is 38.2°C (100.8°F).

Context: Significant laboratory results are as follows: | .

Choices:
A. Prostate cancer
B. Pyelonephritis
C. Nephrolithiasis
D. Prostatitis

Answer: Prostatitis

2. Patient has a 2-day history of urinary hesitancy, fever, and chills.

3. Patient has been getting up frequently during the night to urinate.

4. Patient has a history of hypertension for which he takes losartan.

5. Patient's blood pressure is 128/84 mm Hg.

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

8. Patient's temperature is 38.2°C (100.8°F).

9. No costovertebral angle tenderness is present on physical examination.

10. Patient declines rectal examination.

11. Significant laboratory results are present.

1. He has been getting up frequently during the night to urinate.

2. For the last 2 years, it has taken him longer than usual to initiate urination.

10. No costovertebral angle tenderness is present on physical examination.

11. The patient declines rectal examination.

12. Significant laboratory results are present.


Question: This patient's skin lesions are most likely associated with which of the following?

Context: A 6-year-old boy is brought to the physician for evaluation of bilateral erythematous skin lesions on the flexures of the elbows and knees.

Context: He has been scratching the areas frequently.

Context: He has had similar lesions intermittently for the last 2 years.

Choices:
A. Reversible decrease in FEV1/FVC ratio
B. IgA anti-tissue transglutaminase antibodies
C. Hepatocyte infection with hepatitis C virus
D. Pencil-in-cup deformity of the fingers

Answer: Reversible decrease in FEV1/FVC ratio

General Dermatology
Pediatric Dermatology

1. A 6-year-old boy is brought to the physician for evaluation.

2. The evaluation is for bilateral erythematous skin lesions on the flexures of the elbows and knees.

3. The boy has been scratching the areas frequently.

4. The boy has had similar lesions intermittently for the last 2 years.

5. A photograph of the lesions on the back of the knees is shown.

1. The patient has been scratching the areas frequently.

2. The patient has had similar lesions intermittently for the last 2 years.

3. A photograph of the lesions on the back of the knees is shown.


Question: Which of the following molecules is responsible for this reaction?

Context: An important step in the formation of thyroid hormones is the formation of I2 via oxidation of I-.

Choices:
A. Thyroid deiodinase
B. Thyroid peroxidase
C. Perchlorate
D. Propylthiouracil

Answer: Thyroid peroxidase

1. An important step in the formation of thyroid hormones.

1. An important step in the formation of thyroid hormones is the formation of I2.

2. The formation of I2 occurs via oxidation of I-.


Question: This patient’s history is most consistent with which of the following conditions?

Context: A 29-year-old woman presents to her primary care provider for a normal check-up at the prompting of her mother.

Context: A review of her medical record indicates that she has endured several episodes of verbal and physical abuse from her prior relationships which she suggested “were all her fault.” She has had 4 prior serious relationships and reports that she has not been single for more than a few days in the last 10 years.

Choices:
A. Avoidant personality disorder
B. Dependent personality disorder
C. Histrionic personality disorder
D. Paranoid personality disorder

Answer: Dependent personality disorder

1. A 29-year-old woman presents to her primary care provider for a normal check-up.

2. Her mother prompted her to go for the check-up.

3. When asked how she is doing, she replies that she feels depressed.

4. Upon further questioning, she states that she feels “worthless” now that her ex-boyfriend left her 2 days ago.

5. She has been sitting in his bed all day trying to call him but he is not answering her calls.

6. She says that she will never find another man like him and feels like she should just “disappear” rather than continue living without him.

7. She also reports that she can hear his voice when he’s not around, especially at night before she goes to bed.

8. She denies having any other friends and has some social anxiety, particularly in large groups of people.

9. A review of her medical record indicates that she has endured several episodes of verbal and physical abuse from her prior relationships.

10. She suggested that the abuse was “all her fault.”

11. She has had 4 prior serious relationships.

12. She reports that she has not been single for more than a few days in the last 10 years.

13. On exam, she is unkempt with poor self-care.

2. She feels "worthless" after her ex-boyfriend left her 2 days ago.

3. She has been sitting in his bed all day trying to call him but he is not answering her calls.

4. She feels like she should just "disappear" rather than continue living without him.

5. She can hear his voice when he's not around, especially at night before she goes to bed.

6. She denies having any other friends and has social anxiety, particularly in large groups of people.

7. She has endured several episodes of verbal and physical abuse from her prior relationships.

8. She suggested that the abuse "were all her fault."

9. She has had 4 prior serious relationships.

10. She has not been single for more than a few days in the last 10 years.

11. On exam, she is unkempt with poor self-care.


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

Context: The patient’s laboratory studies are ordered as seen below. |  | Serum: | Na+: 140 mEq/L | Cl-: 103 mEq/L | K+: 5.3 mEq/L | HCO3-: 25 mEq/L | BUN: 33 mg/dL | Glucose: 168 mg/dL | Creatinine: 1.8 mg/dL | Ca2+: 10.0 mg/dL | Troponin: < 0.05 mcg/L |  | A chest CT angiogram, an echocardiogram (ECG), and a second troponin are ordered and are all unremarkable.

Context: A lumbar puncture is performed and based on the results the patient is subsequently started on acyclovir.

Choices:
A. Bolus of IV fluids
B. Calcium gluconate
C. Hemodialysis
D. No further interventions needed

Answer: Bolus of IV fluids

Neurocritical Care
General Emergency Medicine
Neurology

1. A 65-year-old man presents to the emergency department with confusion and chest pain.

2. He states his symptoms started after he landed on a return flight from Brazil.

3. Since then, the patient states that he feels anxious, short of breath, and has pleuritic chest pain.

4. The patient has a past medical history of diabetes and chronic kidney disease.

5. His medications include insulin, lisinopril, aspirin, and atorvastatin.

6. His temperature is 101°F (38.3°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 96% on room air.

7. Physical exam is notable for a confused man.

17. A chest CT angiogram, an echocardiogram (ECG), and a second troponin are ordered and are all unremarkable.

18. The patient’s chest pain resolves with diazepam.

20. Based on the results of the lumbar puncture, the patient is subsequently started on acyclovir.

1. Symptoms started after returning from Brazil

2. Feels anxious, short of breath, and has pleuritic chest pain

3. Past medical history of diabetes and chronic kidney disease

4. Medications include insulin, lisinopril, aspirin, and atorvastatin

5. Temperature is 101°F (38.3°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 96% on room air

6. Physical exam is notable for a confused man

7. Laboratory studies show: Na+: 140 mEq/L, Cl-: 103 mEq/L, K+: 5.3 mEq/L, HCO3-: 25 mEq/L, BUN: 33 mg/dL, Glucose: 168 mg/dL, Creatinine: 1.8 mg/dL, Ca2+: 10.0 mg/dL, Troponin: < 0.05 mcg/L

8. Chest CT angiogram, echocardiogram (ECG), and second troponin are all unremarkable

10. Lumbar puncture is performed and patient is subsequently started on acyclovir


Question: Which of the following is the most likely underlying etiology of this patient's condition?

Context: A 52-year-old homosexual man presents to the emergency department because of sudden right loin pain accompanied by nausea and vomiting.

Context: His temperature is 36.9°C (98.4°F), the blood pressure is 137/92 mm Hg, and the pulse is 95/min.

Context: Physical examination reveals right flank tenderness and 2+ edema of both legs up to the knees.

Context: Laboratory results are shown: | Serum creatinine 2.2 mg/dL | Urine dipstick 4+ protein | Urine analysis 20–25 red cells/high power field | .

Choices:
A. Acute pyelonephritis
B. Hypertensive kidney disease
C. Membranous nephropathy
D. Penile cancer

Answer: Membranous nephropathy

1. A 52-year-old homosexual man presents to the emergency department.

2. He has sudden right loin pain accompanied by nausea and vomiting.

3. He has essential hypertension for 3 years for which he takes bisoprolol.

4. He has a remote history of intravenous drug use.

8. Physical examination reveals right flank tenderness.

9. Physical examination reveals 2+ edema of both legs up to the knees.

10. Doppler ultrasonography shows an enlarged, echogenic right kidney with the absent venous signal.

13. Urine analysis shows 20–25 red cells/high power field.

1. He has essential hypertension for 3 years.

2. He takes bisoprolol for his essential hypertension.

3. He has a remote history of intravenous drug use.

7. Physical examination reveals right flank tenderness.

8. Physical examination reveals 2+ edema of both legs up to the knees.

9. Doppler ultrasonography shows an enlarged, echogenic right kidney.

10. Doppler ultrasonography shows the absent venous signal in the right kidney.

11. Laboratory results show serum creatinine 2.2 mg/dL.

12. Laboratory results show urine dipstick 4+ protein.

13. Laboratory results show urine analysis 20–25 red cells/high power field.


Question: Angiography would most likely show a dissection in which of the following vessels?

Context: A 53-year-old woman is brought to the emergency department for a 2-hour history of balance problems.

Context: She was gardening when she suddenly felt very dizzy and she quickly called for her husband.

Context: When she tried to stand up they found she was very unsteady and unbalanced, so her husband carried her to the car.

Context: In the emergency department, while lying in bed, she complains of a room-spinning sensation; when she sits up, she sways to the right.

Context: She has a past medical history of hypertension, polycystic ovarian syndrome, and type 2 diabetes mellitus.

Choices:
A. Anterior cerebral artery
B. Middle cerebral artery
C. Vertebral artery
D. Anterior spinal artery

Answer: Vertebral artery

1. A 53-year-old woman is brought to the emergency department.

2. She has a 2-hour history of balance problems.

3. She was gardening when she suddenly felt very dizzy.

5. When he arrived, she was sitting on the ground, swaying back and forth but overall leaning to the right.

6. When she tried to stand up they found she was very unsteady and unbalanced.

8. In the emergency department, while lying in bed, she complains of a room-spinning sensation.

9. When she sits up, she sways to the right.

10. She is unable to walk more than 3 steps without falling.

11. Finger-nose-finger and heel-knee-shin testing are abnormal.

12. She has a past medical history of hypertension.

13. She has a past medical history of polycystic ovarian syndrome.

14. She has a past medical history of type 2 diabetes mellitus.

15. All of her vital signs are all within normal limits.

1. She was gardening when she suddenly felt very dizzy.

3. When he arrived, she was sitting on the ground, swaying back and forth.

4. She was overall leaning to the right.

5. When she tried to stand up, they found she was very unsteady and unbalanced.

7. In the emergency department, while lying in bed, she complains of a room-spinning sensation.

8. When she sits up, she sways to the right.

9. She is unable to walk more than 3 steps without falling.

10. Finger-nose-finger testing is abnormal.

15. All of her vital signs are within normal limits.


Question: Which of the following best describes this cause of the patients symptoms after treatment?

Context: A 65-year-old man with squamous cell carcinoma of the lung presents with a sodium of 118 and an altered mental status.

Context: He is started on 3% normal saline over the next several hours.

Context: The patient’s mental status improves and and a repeat sodium six hours later is 129.

Context: Three days after treatment he demonstrates quadriparesis and dysarthria.

Choices:
A. Lateral medullary syndrome
B. Medial medullary syndrome
C. Osmotic demyelination syndrome
D. Hypercalcemia

Answer: Osmotic demyelination syndrome

1. A 65-year-old man has squamous cell carcinoma of the lung.

6. His sodium level is 129 six hours later.

7. Three days after treatment he has quadriparesis and dysarthria.

1. The patient is started on 3% normal saline over the next several hours.

2. The patient's mental status improves.

3. A repeat sodium six hours later is 129.

4. Three days after treatment, the patient demonstrates quadriparesis and dysarthria.


Question: Which of the following is the most likely trigger for her current episode?

Context: A 27-year-old woman presents to the emergency department with severe wheezing, which started an hour ago.

Context: She informs the doctor that she has had mild persistent asthma for the last 2 years and is on inhaled corticosteroids, and uses them regularly.

Context: She has not experienced asthma symptoms for the last 2 months and there is no history of non-compliance.

Context: She mentions that her present symptoms came on about 20 minutes after her last meal.

Context: When the doctor makes specific inquiries, she recollects items in her lunch, which included canned milk product, commercially available roasted peanuts, homemade celery salad, and wine.

Context: She also mentions that she took a tablet of acetaminophen immediately after the meal because her legs were aching since morning, which she attributes to her morning walk at 6 am the same day.

Choices:
A. Ara-h-1 protein
B. Food additive
C. Acetaminophen
D. Exercise

Answer: Food additive

2. Patient presents to the emergency department with severe wheezing.

4. Patient has had mild persistent asthma for the last 2 years.

5. Patient is on inhaled corticosteroids.

6. Patient uses inhaled corticosteroids regularly.

7. Patient has not experienced asthma symptoms for the last 2 months.

9. Symptoms came on about 20 minutes after last meal.

10. Last meal included canned milk product, commercially available roasted peanuts, homemade celery salad, and wine.

11. Patient took a tablet of acetaminophen immediately after the meal.

12. Patient's legs were aching since morning.

13. Patient attributes aching legs to morning walk at 6 am the same day.

14. Patient has never developed respiratory symptoms in response to milk protein, peanuts, or acetaminophen until now.

15. Skin prick testing for food allergens, performed a month back, was negative for all the common food allergens, including milk and peanuts.

1. She has had mild persistent asthma for the last 2 years.

2. She is on inhaled corticosteroids and uses them regularly.

3. She has not experienced asthma symptoms for the last 2 months.

4. There is no history of non-compliance with her medication.

5. Her present symptoms came on about 20 minutes after her last meal.

6. Her lunch included canned milk product, commercially available roasted peanuts, homemade celery salad, and wine.

7. She took a tablet of acetaminophen immediately after the meal.

8. She attributes her leg ache to her morning walk at 6 am the same day.

9. She has never developed respiratory symptoms in response to milk protein, peanuts, or acetaminophen until now.

10. Skin prick testing for food allergens performed a month back was negative for all common food allergens, including milk and peanuts.


Question: What is the chance the offspring will be a child WITHOUT sickle cell anemia?

Context: She states that both she and her husband have family histories of sickle cell disease.

Context: Based on previous genetic testing, they both also have a copy of the sickle cell gene from their parents, but neither of them has ever manifested symptoms associated with the disease.

Context: They want to conceive and are concerned about the chances that their child might have the disease.

Choices:
A. 1/2
B. 3/4
C. 1/4
D. 2/3

Answer: 3/4

Pediatrics
Medical Genetics and Genomics

Clinical Genetics and Genomics
Pediatric Genetics and Genomics
Pediatric Genetics

1. A 30-year old African-American woman comes into your office for pregnancy counseling with her husband.

2. She has a family history of sickle cell disease.

3. Her husband has a family history of sickle cell disease.

4. She has a copy of the sickle cell gene from her parents.

5. Her husband has a copy of the sickle cell gene from his parents.

6. Neither of them has ever manifested symptoms associated with the disease.

8. They are concerned about the chances that their child might have the disease.

1. The patient and her husband have family histories of sickle cell disease.

2. Both the patient and her husband have a copy of the sickle cell gene from their parents.

3. Neither the patient nor her husband has ever manifested symptoms associated with sickle cell disease.

4. The patient and her husband want to conceive.

5. They are concerned about the chances that their child might have sickle cell disease.


Question: Which of the following would be the closest match?

Context: He has a mildly distended abdomen.

Choices:
A. Donor B: tA5/A12, tB22/9, ttC4/C3
B. Donor A: tA7/A5, ttB8/B2, ttC3/C8
C. Donor E: tA7/A8, ttB9/B27, tC3/C4
D. Donor D: tA4/A7, ttB1/B8, ttC8/C3

Answer: Donor A: tA7/A5, ttB8/B2, ttC3/C8

1. A 52-year-old man presents to the clinic complaining of blood in his urine.

2. He had a mild respiratory illness 3 weeks ago.

3. Urinalysis reveals a high red blood cell count and casts in the urine.

4. A diagnosis of post-streptococcal glomerulonephritis is made.

5. The physician explains that the treatment is supportive and that the patient needs to follow up with him every two weeks.

6. Six weeks later, the patient returns to the clinic because he does not feel well; he has been experiencing malaise and fatigue.

7. On examination, his pulse is 98/min, blood pressure is 135/85 mm Hg, temperature is 36.6°C (98.0°F), and respiratory rate is 16/min.

9. Blood tests reveal that the patient’s creatinine level has increased from 1.2 mg/dL to 3.0 mg/dL over the last month.

10. He is referred to a nephrologist who diagnoses him with rapidly progressive glomerulonephritis (RPGN) and starts him on hemodialysis, as his potassium level has risen to 7 mEq/dL.

11. The patient is advised to undergo renal transplantation.

12. His human leukocyte antigen (HLA) genotype is A7/A5, B2/B9, C8/C3.

13. The first allele in each locus is the maternal form; the second is paternal.

14. Several potential donors are available for the renal graft.

1. He had a mild respiratory illness 3 weeks ago.

2. Urinalysis reveals a high red blood cell count and casts in the urine.

3. A diagnosis of post-streptococcal glomerulonephritis is made.

4. The physician explains that the treatment is supportive and that the patient needs to follow up with him every two weeks.

5. Six weeks later, the patient returns to the clinic because he does not feel well; he has been experiencing malaise and fatigue.

6. On examination, his pulse is 98/min, blood pressure is 135/85 mm Hg, temperature is 36.6°C (98.0°F), and respiratory rate is 16/min.

8. Blood tests reveal that the patient’s creatinine level has increased from 1.2 mg/dL to 3.0 mg/dL over the last month.

9. He is referred to a nephrologist who diagnoses him with rapidly progressive glomerulonephritis (RPGN) and starts him on hemodialysis, as his potassium level has risen to 7 mEq/dL.

10. The patient is advised to undergo renal transplantation.

11. His human leukocyte antigen (HLA) genotype is A7/A5, B2/B9, C8/C3.

12. The first allele in each locus is the maternal form; the second is paternal.

13. Several potential donors are available for the renal graft.


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

Context: An investigator is studying determinants of childhood obesity by observing a cohort of pregnant women with obesity.

Context: After delivery, he regularly records the height and weight of the cohort's children.

Context: The results of the correlation analysis between mean childhood BMI at 4 years of age and mean maternal BMI before pregnancy are shown.

Choices:
A. -0.45
B. 0.45
C. 0
D. -1.80

Answer: 0.45

Pediatric Endocrinology
Maternal
Neonatal

1. An investigator is studying determinants of childhood obesity.

2. The investigator is observing a cohort of pregnant women with obesity.

3. The investigator regularly records the height and weight of the cohort's children after delivery.

4. The investigator is conducting a correlation analysis between mean childhood BMI at 4 years of age and mean maternal BMI before pregnancy.

5. The results of the correlation analysis are shown.

1. After delivery, he records the height and weight of the cohort's children.

2. The results of the correlation analysis are between mean childhood BMI at 4 years of age and mean maternal BMI before pregnancy.


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

Context: Yesterday she ran 17 km (10.5 mile).

Context: She follows a vegan diet.

Context: She appears well.

Context: Her temperature is 36.6°C (98.0°F), blood pressure is 110/72 mm Hg, pulse is 70/min, and respirations are 14/min.

Context: Laboratory studies show: | Hemoglobin 9.8 g/dL | Mean corpuscular volume 91 fL | Lactate dehydrogenase 400 U/L | Platelet count 250,000/mm3 | Reticulocyte count 3% | Haptoglobin 23 mg/dL (N=41–165 mg/dL) | Serum | Iron 90 μg/dL | Ferritin 170 ng/mL | Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL) | Urinalysis shows trace blood but no RBCs.

Choices:
A. Extravascular hemolysis
B. Vitamin B12 deficiency
C. Intravascular hemolysis
D. Impaired heme synthesis

Answer: Intravascular hemolysis

1. A 25-year-old woman comes to the physician for a routine examination.

2. She is a recreational runner and for the past 3 months she has been training for a marathon.

4. Menses occur at regular 28-day intervals and last 6 days.

5. She drinks three to five beers when going out with friends.

12. Physical examination shows no abnormalities.

13. Laboratory studies show hemoglobin 9.8 g/dL.

18. Haptoglobin 23 mg/dL (N=41–165 mg/dL).

21. Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL).

22. Urinalysis shows trace blood but no RBCs.

2. She has been training for a marathon for the past 3 months.

3. Yesterday she ran 17 km (10.5 miles).

4. Her menses occur at regular 28-day intervals and last 6 days.

13. Laboratory studies show: Hemoglobin 9.8 g/dL.

14. Laboratory studies show: Mean corpuscular volume 91 fL.

15. Laboratory studies show: Lactate dehydrogenase 400 U/L.

16. Laboratory studies show: Platelet count 250,000/mm3.

17. Laboratory studies show: Reticulocyte count 3%.

18. Laboratory studies show: Haptoglobin 23 mg/dL (N=41–165 mg/dL).

19. Laboratory studies show: Serum Iron 90 μg/dL.

20. Laboratory studies show: Ferritin 170 ng/mL.

21. Laboratory studies show: Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL).


Question: Which personality disorder is most likely?

Context: After waiting an hour in the waiting room, he begins to berate the receptionist and demands to be seen by a doctor.

Context: During the exam, the patient brags that he recently had to quit his job because they did not appreciate his talent and drive.

Context: After a medical student declines his invitation for a date, he becomes very angry and throws supplies across the room.

Context: The physician manages the patient's physical injuries and begins to suspect the patient has a personality disorder.

Choices:
A. Narcissistic personality disorder
B. Avoidant personality disorder
C. Histrionic personality disorder
D. Obsessive-compulsive personality disorder

Answer: Narcissistic personality disorder

General Psychiatry
General Emergency Medicine

1. A 45-year-old man comes into the ED after a car accident.

2. He waits an hour in the waiting room.

3. He berates the receptionist and demands to be seen by a doctor.

4. He brags that he recently had to quit his job because they did not appreciate his talent and drive.

5. A medical student declines his invitation for a date.

6. He becomes very angry and throws supplies across the room.

7. The physician manages the patient's physical injuries.

8. The physician begins to suspect the patient has a personality disorder.

1. The patient waits for an hour in the waiting room.

2. The patient berates the receptionist.

3. The patient demands to be seen by a doctor.

4. The patient brags about recently quitting his job.

5. The patient claims his job did not appreciate his talent and drive.

6. The patient becomes angry after a medical student declines his date invitation.

7. The patient throws supplies across the room.

8. The physician manages the patient's physical injuries.

9. The physician suspects the patient has a personality disorder.


Question: The beneficial effect of this drug is most likely due to arrest in which of the following phases of the cell cycle?

Context: A 61-year-old man comes to the physician because of weight loss and a non-productive cough for 4 months.

Choices:
A. G2 phase
B. G1 phase
C. G0 phase
D. S phase

Answer: G1 phase

1. A 61-year-old man comes to the physician.

2. He has a non-productive cough for 4 months.

3. He has smoked 2 packs of cigarettes daily for 42 years.

4. A CT scan of the chest shows an irregular mass at the right hilum and axillary lymphadenopathy.

5. A biopsy of the mass obtained on bronchoscopy confirms the diagnosis of metastatic non-small cell lung cancer.

6. Results of a molecular diagnostic test show a microdeletion on the short arm of chromosome 7.

7. The physician recommends chemotherapy with erlotinib.

1. He has smoked 2 packs of cigarettes daily for 42 years.

2. A CT scan of the chest shows an irregular mass at the right hilum and axillary lymphadenopathy.

3. A biopsy of the mass obtained on bronchoscopy confirms the diagnosis of metastatic non-small cell lung cancer.

4. Results of a molecular diagnostic test show a microdeletion on the short arm of chromosome 7.

5. The physician recommends chemotherapy with erlotinib.


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

Context: A 52-year-old woman comes to the physician because of a 4-day history of painful swallowing and retrosternal pain.

Context: She was diagnosed with HIV infection 2 months ago; her medications include tenofovir, emtricitabine, and raltegravir.

Context: Vital signs are within normal limits.

Context: Empiric treatment is started.

Context: Esophagogastroduodenoscopy is performed and shows multiple round superficial ulcers in the distal esophagus.

Choices:
A. Adverse effect of medication
B. Degeneration of ganglion cells within the myenteric plexuses
C. Infection with herpes simplex virus
D. Infection with Candida species

Answer: Infection with herpes simplex virus

1. A 52-year-old woman comes to the physician.

2. She has a 4-day history of painful swallowing and retrosternal pain.

3. She was diagnosed with HIV infection 2 months ago.

4. Her medications include tenofovir, emtricitabine, and raltegravir.

5. Vital signs are within normal limits.

6. Physical examination of the oral cavity shows no abnormalities.

7. The patient's CD4+ T-lymphocyte count is 70/mm3 (N ≥ 500).

9. Two weeks later, she reports no improvement in symptoms.

10. Esophagogastroduodenoscopy is performed.

11. Esophagogastroduodenoscopy shows multiple round superficial ulcers in the distal esophagus.

1. The patient was diagnosed with HIV infection 2 months ago.

2. The patient's medications include tenofovir, emtricitabine, and raltegravir.

3. Vital signs are within normal limits.

4. Physical examination of the oral cavity shows no abnormalities.

5. The patient's CD4+ T-lymphocyte count is 70/mm3 (N ≥ 500).

7. Two weeks later, the patient reports no improvement in symptoms.

8. Esophagogastroduodenoscopy is performed.

9. The esophagogastroduodenoscopy shows multiple round superficial ulcers in the distal esophagus.


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

Context: Her mother has diverticulitis.

Context: The patient’s temperature is 99°F (37.2°C), blood pressure is 110/74 mmHg, pulse is 89/min, and respirations are 14/min with an oxygen saturation of 98% on room air.

Context: Labs are obtained, as shown below: |  | Leukocyte count: 10,000/mm^3 with normal differential | Hemoglobin: 13.5 g/dL | Platelet count: 200,000/mm^3 | Beta-human chorionic gonadotropin: Pending |  | A pelvic ultrasound demonstrates a small fluid collection in the cul-de-sac posterior to the uterus.

Choices:
A. Appendicitis
B. Endometriosis
C. Midcycle pain
D. Ruptured ectopic pregnancy

Answer: Midcycle pain

Emergency Medicine
Pediatrics
Obstetrics and Gynecology
General Surgery

General Emergency Medicine
General Pediatrics
General Surgery
General Obstetrics and Gynecology

1. An 18-year-old girl comes to the emergency room with abdominal pain.

2. She states that the pain started 6 hours ago, is 8/10, and localizes to the right lower abdomen.

3. She recalls a similar episode last month.

4. Her older brother was hospitalized 2 years ago for perforated appendicitis.

6. The patient got her first menstrual period at age 14.

7. Her periods occur regularly every 28 days.

8. Her last menstrual period was 2 weeks ago.

9. She is sexually active with multiple partners and uses condoms inconsistently.

10. The patient’s temperature is 99°F (37.2°C).

11. The patient’s blood pressure is 110/74 mmHg.

13. The patient’s respirations are 14/min with an oxygen saturation of 98% on room air.

14. On physical exam, the patient is in moderate distress.

15. There is lower abdominal tenderness with guarding.

16. A pelvic examination reveals clear mucous in the vaginal introitus, a mobile uterus, and tenderness of the right adnexa.

17. Labs are obtained, as shown below: Leukocyte count: 10,000/mm^3 with normal differential.

18. Labs are obtained, as shown below: Hemoglobin: 13.5 g/dL.

19. Labs are obtained, as shown below: Platelet count: 200,000/mm^3.

20. Labs are obtained, as shown below: Beta-human chorionic gonadotropin: Pending.

21. A pelvic ultrasound demonstrates a small fluid collection in the cul-de-sac posterior to the uterus.

1. The patient's pain started 6 hours ago and is 8/10.

2. The pain localizes to the right lower abdomen.

3. The patient had a similar episode last month.

4. The patient's older brother was hospitalized 2 years ago for perforated appendicitis.

5. The patient's mother has diverticulitis.

9. The patient is sexually active with multiple partners and uses condoms inconsistently.

10. The patient's temperature is 99°F (37.2°C).

13. Her respirations are 14/min with an oxygen saturation of 98% on room air.

17. Labs: Leukocyte count is 10,000/mm^3 with normal differential.

20. Beta-human chorionic gonadotropin is pending.


Question: Which of the following cluster of differentiation markers will he need to use to identify these cells in the resected specimens?

Context: Further investigation reveals that most people in the area work in a glass factory, the region’s main source of employment.

Choices:
A. CD20
B. CD3
C. CD34
D. CD56

Answer: CD56

1. In a suburban town in Virginia, epidemiologists are alarmed by the increasing number of squamous cell lung cancer cases.

2. Most people in the area work in a glass factory, the region’s main source of employment.

3. A researcher is interested in studying the role of immunosurveillance in the pathogenesis of this lung cancer.

4. He postulates that tumor infiltration by natural killer (NK) cells has a better prognosis since they play a major role in immunosurveillance.

5. NK cells also kill tumor cells by the perforin-mediated destruction of cancerous cells.

6. The researcher is interested in studying tumor infiltration by NK cells in the resected specimen from patients within the cohort who have been diagnosed with stage 1 lung cancer.

1. Most people in the area work in a glass factory, the region’s main source of employment.

2. A researcher is interested in studying the role of immunosurveillance in the pathogenesis of lung cancer.

3. The researcher postulates that tumor infiltration by natural killer (NK) cells has a better prognosis.

4. NK cells play a major role in immunosurveillance.

5. NK cells kill tumor cells by the perforin-mediated destruction of cancerous cells.

6. The researcher is interested in studying tumor infiltration by NK cells in the resected specimen from patients within the cohort diagnosed with stage 1 lung cancer.


Question: What is the most likely diagnosis?

Context: A 26-year-old man presents to the office complaining of persistent back pain for the past 3 months.

Context: You saw the patient previously and prescribed NSAIDs and rest, but he has not improved.

Context: The patient states that his maternal grandfather had ‘back problems his whole life’, and he worries that he might have the same issues.

Context: An X-ray is performed and shows squaring of the vertebrae with longitudinal fibrous bands.

Choices:
A. Ehlers-Danlos syndrome
B. Osteosarcoma
C. Ankylosing spondylitis
D. Osteopetrosis

Answer: Ankylosing spondylitis

1. A 26-year-old man presents to the office.

2. He has been complaining of persistent back pain for the past 3 months.

3. The patient was previously prescribed NSAIDs and rest, but has not improved.

4. The patient's maternal grandfather had "back problems his whole life".

5. The patient worries that he might have the same issues.

7. The X-ray shows squaring of the vertebrae with longitudinal fibrous bands.

1. The patient was previously prescribed NSAIDs and rest.

3. The patient's maternal grandfather had back problems his whole life.

4. The patient worries that he might have the same issues.

6. The X-ray shows squaring of the vertebrae.

7. The X-ray shows longitudinal fibrous bands.


Question: Which of the following interventions would be most successful at achieving the task group’s mission?

Context: The task group would like to begin by decreasing the number of days given for narcotic pain medication prescriptions in the emergency department to at most 7 days instead of the hospital average of 21 days per prescription.

Choices:
A. Educating patients about appropriate narcotics dosing
B. Printing out and posting handouts detailing the dangers of narcotics
C. Sending an email to all providers notifying them of narcotics prescribing best practices
D. Changing the electronic medical record to only allow a maximum of 7 days per prescription

Answer: Changing the electronic medical record to only allow a maximum of 7 days per prescription

Health Care Administration, Leadership, and Management

1. A regional hospital system has decided to institute a new task group for quality improvement and patient safety.

2. The task group would like to begin by decreasing the number of days given for narcotic pain medication prescriptions in the emergency department.

3. The number of days given for narcotic pain medication prescriptions in the emergency department should be at most 7 days.

4. The hospital average for narcotic pain medication prescriptions is 21 days per prescription.

1. The task group wants to decrease the number of days for narcotic pain medication prescriptions in the emergency department.

2. The current hospital average for narcotic pain medication prescriptions is 21 days.

3. The task group aims to limit narcotic pain medication prescriptions to a maximum of 7 days in the emergency department.


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

Context: A 57-year-old man comes to the clinic complaining of nausea and 1 episode of vomiting during the past day.

Context: He denies any precipitating event except for a headache for which he took some acetaminophen yesterday.

Context: He has never had such symptoms before.

Context: His past medical history is significant for hypertension, biliary colic, and a past hospitalization for delirium tremens when he “tried to quit alcohol cold turkey.” When asked about his current alcohol intake, the patient looks away and mutters “just a couple of drinks here and there.” The patient reports mild abdominal pain that began this morning but denies vision changes, bowel changes, fever, or weight loss.

Choices:
A. Accumulation of N-acetyl-p-benzoquinone imine in the liver
B. Impaction of a gallstone in the ileus
C. Malignant overgrowth of glial cells in the brain
D. Obstruction of the cystic duct by gallstone

Answer: Accumulation of N-acetyl-p-benzoquinone imine in the liver

1. A 57-year-old man comes to the clinic.

2. He complains of nausea and 1 episode of vomiting during the past day.

3. He denies any precipitating event except for a headache.

4. The headache is described as bilateral, dull, and 8/10 in severity.

5. He has never had such symptoms before.

6. His past medical history is significant for hypertension, biliary colic, and a past hospitalization for delirium tremens.

7. He "tried to quit alcohol cold turkey" in the past.

8. When asked about his current alcohol intake, the patient looks away and mutters “just a couple of drinks here and there.”

9. The patient reports mild abdominal pain that began this morning.

10. He denies vision changes, bowel changes, fever, or weight loss.

11. Physical examination demonstrates tenderness at the right upper quadrant (RUQ) that does not worsens with inhalation.

1. Patient denies any precipitating event except for a headache for which he took acetaminophen yesterday.

2. The headache is described as bilateral, dull, and 8/10 in severity.

3. Patient has never had such symptoms before.

4. Past medical history includes hypertension, biliary colic, and a past hospitalization for delirium tremens.

5. Patient "tried to quit alcohol cold turkey."

6. Patient looks away and mutters "just a couple of drinks here and there" when asked about current alcohol intake.

7. Patient reports mild abdominal pain that began this morning.

8. Patient denies vision changes, bowel changes, fever, or weight loss.

9. Physical examination demonstrates tenderness at the right upper quadrant (RUQ) that does not worsen with inhalation.


Question: The patient's condition was most likely transmitted by which of the following vectors?"

Context: A 48-year-old patient comes to the physician because of a 4-day history fever, headaches, loss of appetite, and myalgia.

Context: His temperature is 39.5°C (103.1°F).

Context: Laboratory studies show: | Hemoglobin 14.1 g/dL | Leukocyte count 3,800/mm3 | Platelet count 85,000/mm3 | Serum | AST 48 U/L | ALT 52 U/L | Treatment with doxycycline is begun and the patient recovers.

Choices:
A. Lone star tick
B. Ixodes tick
C. Dog tick
D. Flea

Answer: Ixodes tick

1. A 48-year-old patient comes to the physician.

2. The patient has a 4-day history of fever, headaches, loss of appetite, and myalgia.

3. Two weeks ago, the patient went on a camping trip to Wisconsin.

4. The patient's temperature is 39.5°C (103.1°F).

5. Physical examination shows no rash or joint swelling.

6. Laboratory studies show a hemoglobin level of 14.1 g/dL.

7. Laboratory studies show a leukocyte count of 3,800/mm3.

8. Laboratory studies show a platelet count of 85,000/mm3.

9. Laboratory studies show an AST level of 48 U/L.

10. Laboratory studies show an ALT level of 52 U/L.

11. Treatment with doxycycline is begun.

13. A paired acute and convalescent indirect fluorescent antibody test confirms that the patient had anaplasmosis.

1. Two weeks ago, the patient went on a camping trip to Wisconsin.

3. Physical examination shows no rash or joint swelling.

4. Laboratory studies show: Hemoglobin 14.1 g/dL.

5. Laboratory studies show: Leukocyte count 3,800/mm3.

6. Laboratory studies show: Platelet count 85,000/mm3.

7. Laboratory studies show: Serum AST 48 U/L.

8. Laboratory studies show: Serum ALT 52 U/L.

9. Treatment with doxycycline is begun and the patient recovers.

10. A paired acute and convalescent indirect fluorescent antibody test confirms that the patient had anaplasmosis.


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

Context: She denies weight loss or dysphagia.

Context: Normal bowel sounds are appreciation.

Context: Fecal occult blood is negative.

Choices:
A. Start antibiotic therapy
B. Start omeprazole
C. Surgical fundiplication
D. Upper gastrointestinal endoscopy

Answer: Start omeprazole

1. A 42-year-old woman comes to the clinic complaining of upper abdominal pain.

2. Her symptoms started 1 month ago with vague abdominal discomfort following a meal at a steakhouse.

3. Since then the pain has progressed to the point that she has more than 5 episodes a week.

4. The pain is worse with eating but has not affected her appetite.

5. She also reports a burning sensation in her chest when she lies down at night after dinner.

7. She takes no medications except daily calcium supplements.

8. She drinks 2 glasses of wine per week and denies tobacco use.

9. Her blood pressure is 110/78, pulse is 72/min, and respirations are 13/min.

10. On physical examination, the patient’s abdomen is soft and non-distended.

11. Normal bowel sounds are appreciation.

12. There is mild epigastric tenderness but no guarding and no rebound.

1. Symptoms started 1 month ago with vague abdominal discomfort after a meal at a steakhouse.

2. Experiences more than 5 episodes of pain per week.

3. Pain worsens with eating but does not affect appetite.

4. Reports a burning sensation in the chest when lying down at night after dinner.

7. Drinks 2 glasses of wine per week and denies tobacco use.

8. Blood pressure is 110/78, pulse is 72/min, and respirations are 13/min.

9. On physical examination, the abdomen is soft and non-distended.

10. Normal bowel sounds are appreciated.

11. Mild epigastric tenderness but no guarding and no rebound.


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

Context: A 3-year-old boy presents to the pediatrician crying with ear pain and his temperature has been 101°F (38.3°C) for several days.

Context: Both tympanic membranes appear erythematous, and the left appears opaque and bulging with decreased mobility on pneumatic otoscopy.

Choices:
A. Amoxicillin
B. TMP-SMX
C. Tympanocentesis
D. Supportive therapy

Answer: Amoxicillin

2. Patient has been crying with ear pain.

3. Patient's temperature has been 101°F (38.3°C) for several days.

4. Patient's mother states other children at his daycare center have been having similar symptoms.

5. Patient was fed formula and was not breastfed.

6. Patient's mother smokes cigarettes daily.

7. On exam, patient is irritable and crying.

8. Patient frequently tugs on his left ear.

9. Both tympanic membranes appear erythematous.

10. Left tympanic membrane appears opaque and bulging.

11. Left tympanic membrane has decreased mobility on pneumatic otoscopy.

1. His mother states that other children at his daycare center have been having similar symptoms.

2. She further describes that he was fed formula and was not breastfed.

3. The mother admits that she smokes cigarettes daily.

4. On exam, the boy is irritable and crying, and frequently tugs on his left ear.

5. Both tympanic membranes appear erythematous.

6. The left tympanic membrane appears opaque and bulging.

7. Decreased mobility is observed on pneumatic otoscopy.


Question: Which of the following pathologic findings is she most likely to have?

Choices:
A. Follicular thyroid neoplasia
B. Silent thyroiditis
C. Chronic lymphocytic thyroiditis
D. Fibrous thyroiditis

Answer: Silent thyroiditis

Endocrinology, Diabetes, and Metabolism
Endocrinology

1. A 47-year-old G3P2 woman presents to her endocrinologist for a follow-up appointment.

2. Her last menstrual period was at the age of 35 years.

4. She cannot concentrate on her work or type properly on the keyboard because of an onset of tremor in her hands.

5. Her symptoms are taking a toll on her quality of life.

6. The patient’s blood pressure is 124/83 mm Hg.

8. The patient’s respirations are 17/min.

9. The patient’s temperature is 36.7°C (98.1°F).

10. On physical examination, there is a mild enlargement of the thyroid.

11. The gland is minimally firm in texture.

1. Her last menstrual period was at the age of 35 years.

2. She now feels fatigued and cannot concentrate on her work or type properly on the keyboard because of an onset of tremor in her hands.

3. Her symptoms are taking a toll on her quality of life.

4. The patient’s blood pressure is 124/83 mm Hg, pulse is 91/min, respirations are 17/min, and temperature is 36.7°C (98.1°F).

5. On physical examination, there is a mild enlargement of the thyroid; the gland is minimally firm in texture and is nontender.


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

Context: A 44-year-old woman is brought to the emergency department after she was found lying in the park mumbling to herself.

Context: She is lethargic and disoriented.

Context: Laboratory studies show: | Serum | Na+ 137 mEq/L | K+ 5.5 mEq/L | Cl- 120 mEq/L | Bicarbonate 15 mEq/L | Urea nitrogen 94 mg/dL | Creatinine 5.5 mg/dL | Glucose 92 mg/dL | .

Choices:
A. Administer lactulose
B. Hemodialysis
C. Restart methotrexate
D. Fluid restriction

Answer: Hemodialysis

1. A 44-year-old woman is brought to the emergency department.

2. She was found lying in the park mumbling to herself.

4. She has a 2-week history of increasing weakness, nausea, and vomiting.

5. She denies any recent alcohol or drug use.

6. She has a history of systemic lupus erythematosus.

7. She stopped taking methotrexate many years ago.

11. On mental status examination, she is confused and only oriented to person.

12. She is not oriented to place or time.

13. She is unable to name the days of the week backwards.

14. She exhibits moderate generalized weakness.

15. Physical exam shows jugular venous distention.

16. Physical exam shows pitting edema in the lower extremities.

17. Laboratory studies show serum Na+ 137 mEq/L.

18. Laboratory studies show serum K+ 5.5 mEq/L.

19. Laboratory studies show serum Cl- 120 mEq/L.

20. Laboratory studies show serum bicarbonate 15 mEq/L.

21. Laboratory studies show serum urea nitrogen 94 mg/dL.

22. Laboratory studies show serum creatinine 5.5 mg/dL.

23. Laboratory studies show serum glucose 92 mg/dL.

2. She has a 2-week history of increasing weakness, nausea, and vomiting.

3. She denies any recent alcohol or drug use.

4. She has a history of systemic lupus erythematosus but stopped taking methotrexate many years ago.

5. Her temperature is 37.3°C (99.1°F), pulse is 89/min, and blood pressure is 154/91 mm Hg.

6. On mental status examination, she is confused and only oriented to person, but not to place or time.

7. She is unable to name the days of the week backwards.

8. She exhibits moderate generalized weakness.

9. Physical exam shows jugular venous distention and pitting edema in the lower extremities.

10. Laboratory studies show: Serum Na+ 137 mEq/L, K+ 5.5 mEq/L, Cl- 120 mEq/L, Bicarbonate 15 mEq/L, Urea nitrogen 94 mg/dL, Creatinine 5.5 mg/dL, Glucose 92 mg/dL.


Question: The isolated hormone is most likely which of the following?

Context: An investigator is studying the secretion of gastrointestinal hormones before and after food intake.

Context: She isolates a hormone that accelerates the emptying of gastric contents into the duodenal bulb.

Choices:
A. Glucagon-like peptide
B. Gastrin
C. Cholecystokinin
D. Vasoactive intestinal peptide

Answer: Gastrin

1. An investigator is studying the secretion of gastrointestinal hormones.

2. The study is conducted before and after food intake.

4. The hormone accelerates the emptying of gastric contents.

5. The gastric contents are emptied into the duodenal bulb.

2. The hormone accelerates the emptying of gastric contents.

3. The acceleration occurs into the duodenal bulb.


Question: What is the most likely cause of her presentation?

Context: A 45-year-old woman presents to the office with a chief complaint of a cough that has persisted for a month and a half.

Context: She also has night fevers and has lost 5 kg (11 lb) in the last 2 months.

Context: Her vitals include: heart rate 82/min, respiratory rate 17/min, temperature 38.0°C (100.4°F), and blood pressure 107/80 mm Hg.

Choices:
A. Echinococcosis
B. Tuberculosis
C. Pulmonary thromboembolism
D. Heart failure

Answer: Tuberculosis

Pulmonary Disease
General Pulmonary Disease

1. A 45-year-old woman presents to the office.

2. Her chief complaint is a cough that has persisted for a month and a half.

4. She has lost 5 kg (11 lb) in the last 2 months.

5. She recently returned from a 6-month trip to Peru.

10. On auscultation, she has diminished respiratory sounds at the base of the right lung.

11. Chest radiography shows an opacity in the right apex.

2. She has lost 5 kg (11 lb) in the last 2 months.

3. She recently returned from a 6-month trip to Peru.

8. On auscultation, she has diminished respiratory sounds at the base of the right lung.

9. Chest radiography shows an opacity in the right apex.


Question: What is the most likely diagnosis?

Context: Past medical records are unavailable.

Context: His temperature is 37°C (98.6°F), the respiratory rate is 15/min, the pulse is 107/min, and the blood pressure is 92/67 mm Hg.

Context: His condition deteriorates overnight.

Context: His blood tests show:  | Serum | Albumin 3.2 gm/dL | Alkaline phosphatase 150 U/L | Alanine aminotransferase 76 U/L | Aspartate aminotransferase 155 U/L | Gamma-glutamyl transpeptidase 202 U/L | .

Choices:
A. Alcohol-related dementia
B. Hepatic encephalopathy
C. Delirium
D. Wernicke's encephalopathy

Answer: Wernicke's encephalopathy

General Emergency Medicine
Neurocritical Care

1. A 52-year-old homeless man is brought to the urgent care clinic with altered mental status and disorientation for the last day.

2. Past medical records are unavailable.

7. He has a flapping tremor of the wrists during attempted extension.

8. He is started on intravenous D5 1/2NS and blood is drawn for further testing.

9. His condition deteriorates overnight.

10. On re-examination the next morning, he has developed visual disturbances with a new horizontal nystagmus and a staggering gait.

11. His blood tests show: Serum Albumin 3.2 gm/dL.

12. His blood tests show: Alkaline phosphatase 150 U/L.

13. His blood tests show: Alanine aminotransferase 76 U/L.

14. His blood tests show: Aspartate aminotransferase 155 U/L.

15. His blood tests show: Gamma-glutamyl transpeptidase 202 U/L.

1. Past medical records are unavailable.

6. He has a flapping tremor of the wrists during attempted extension.

7. He is started on intravenous D5 1/2NS.

15. Gamma-glutamyl transpeptidase 202 U/L.


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

Context: A 27-year-old woman comes to the emergency department at 14 weeks gestation with abdominal pain.

Context: She states she has passed a large amount of blood from her vagina in the past 2 hours.

Context: Her vitals are within normal limits and she describes her abdominal pain as a 4/10.

Context: The patient states she does not want any invasive procedures in her workup but is accepting to necessary medical interventions.

Choices:
A. Admission and external fetal monitoring
B. Dilation and curettage
C. Expectant management
D. Transvaginal ultrasound

Answer: Expectant management

General Obstetrics and Gynecology
Maternal

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

3. She has passed a large amount of blood from her vagina in the past 2 hours.

5. She describes her abdominal pain as a 4/10.

6. Physical exam is notable for a dilated cervix.

7. The patient states she does not want any invasive procedures in her workup.

8. She is accepting to necessary medical interventions.

1. The patient has passed a large amount of blood from her vagina in the past 2 hours.

3. She describes her abdominal pain as a 4/10.

4. Physical exam is notable for a dilated cervix.

5. The patient does not want any invasive procedures in her workup.

6. The patient is accepting to necessary medical interventions.


Question: Which of the following genes was most likely mutated in this fetus?

Context: A 25-year-old female is admitted to the hospital for an intrauterine fetal demise (IUFD) during her 30th gestational week.

Context: The baby is delivered via C-section and the family wishes to conduct an autopsy to understand the reason for the IUFD and to better prepare for future pregnancies.

Context: On autopsy, the fetus is discovered to have severe facial abnormalities as well as a brain lacking the normal sagittal fissure.

Choices:
A. Hox
B. Wnt-7
C. Sonic hedgehog
D. BMP

Answer: Sonic hedgehog

1. A 25-year-old female is admitted to the hospital.

2. The patient is admitted for an intrauterine fetal demise (IUFD).

3. The patient is in her 30th gestational week.

4. The patient did not receive any prenatal care or screenings.

6. The family wishes to conduct an autopsy.

7. The purpose of the autopsy is to understand the reason for the IUFD and to better prepare for future pregnancies.

8. On autopsy, the fetus is discovered to have severe facial abnormalities.

9. On autopsy, the fetus is discovered to have a brain lacking the normal sagittal fissure.

1. The patient did not receive any prenatal care.

2. The patient did not receive any prenatal screenings.

3. The baby was delivered via C-section.

4. The family wishes to conduct an autopsy.

5. The reason for the IUFD is to be understood.

6. The autopsy is to better prepare for future pregnancies.

7. On autopsy, the fetus is discovered to have severe facial abnormalities.

8. On autopsy, the fetus is discovered to have a brain lacking the normal sagittal fissure.


Question: The following sets of measurements are taken every 10 minutes: | Plasma concentration of substance Excretion rate of substance | Set 1 0.1 mg/mL 60 mg/min | Set 2 0.15 mg/mL 90 mg/min | Set 3 0.2 mg/mL 104 mg/min | Set 4 0.25 mg/mL 110 mg/min | Set 5 0.3 mg/mL 116 mg/min | This patient was most likely administered which of the following substances?"

Context: She is administered an intravenous substance that does not undergo tubular reabsorption.

Choices:
A. Cystatin C
B. Glucose
C. Para-aminohippurate
D. Iohexol

Answer: Para-aminohippurate

1. A healthy 32-year-old woman enrolls in a study investigating kidney function.

2. Her renal plasma flow (RPF) is 600 mL/min.

3. She is administered an intravenous substance.

4. The intravenous substance does not undergo tubular reabsorption.

1. Renal plasma flow (RPF) is 600 mL/min.

2. She is administered an intravenous substance.

3. The substance does not undergo tubular reabsorption.


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

Context: She has no history of serious illness.

Context: Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 96/52 mm Hg.

Context: Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border that radiates towards the neck.

Choices:
A. Patent ductus arteriosus
B. Venous hum
C. Coronary artery fistula
D. Aortic stenosis

Answer: Venous hum

1. A 6-year-old girl is brought to the physician for a well-child examination.

2. She has no history of serious illness.

6. Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border.

7. The murmur radiates towards the neck.

8. The murmur disappears when she flexes her neck.

9. The remainder of the examination shows no abnormalities.

1. She has no history of serious illness.

5. Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border.

6. The murmur radiates towards the neck.

7. The murmur disappears when she flexes her neck.

8. The remainder of the examination shows no abnormalities.


Question: What is the most appropriate management of this patient’s hyponatremia?

Context: A 72-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department with three-days of fever, cough, and shortness of breath.

Context: On physical exam, temperature is 101.3 deg F (38.5 deg C), pulse is 106/min, blood pressure is 148/92 mmHg, and respiratory rate is 24/min.

Context: Sodium level is 118 mEq/L.

Choices:
A. Hypertonic saline
B. Fluid restriction
C. Salt tablets
D. Demeclocycline

Answer: Fluid restriction

1. A 72-year-old man presents to the emergency department.

2. He has a history of hypertension and hyperlipidemia.

3. He has three days of fever, cough, and shortness of breath.

4. His temperature is 101.3 deg F (38.5 deg C).

8. Crackles are auscultated on the right lower lobe.

9. Chest radiograph demonstrates right lower lobe opacities concerning for consolidation.

11. He is admitted to the hospital on empiric antibiotics.

1. Temperature is 101.3 deg F (38.5 deg C)

5. Crackles are auscultated on the right lower lobe

6. Chest radiograph demonstrates right lower lobe opacities concerning for consolidation

8. Admitted to the hospital on empiric antibiotics


Question: Which of the following best explains these findings?

Context: He feels tired most of the time.

Context: He has no fever or weight loss.

Context: No lymphadenopathy is palpated.

Context: The laboratory studies show the following: | Hemoglobin 8.5 g/dL | Mean corpuscular volume 105 μm3 | Leukocyte count 4,500/mm3 | Platelet 160,000/mm3 | Abdominal ultrasonography shows no organomegaly or other pathologic findings.

Context: No blasts are seen.

Context: Marrow myeloblasts are 4% in volume.

Choices:
A. Acute myeloid leukemia
B. Aplastic anemia
C. Myelodysplastic syndrome
D. Primary myelofibrosis

Answer: Myelodysplastic syndrome

1. A 75-year-old man presents to the physician for a follow-up examination.

2. Over the last several months, he reports dyspnea when walking during his daily exercise routine.

5. He has no history of severe illness and takes no medications.

6. He does not smoke, drinks alcohol, or follow a particular diet.

7. The vital signs are within normal limits.

8. The physical examination reveals pale conjunctiva.

9. The examination of the heart, lungs, abdomen, and extremities shows no abnormalities.

11. The laboratory studies show the following: Hemoglobin 8.5 g/dL, Mean corpuscular volume 105 μm3, Leukocyte count 4,500/mm3, Platelet 160,000/mm3.

12. Abdominal ultrasonography shows no organomegaly or other pathologic findings.

13. The peripheral blood smear shows large and hypogranular platelets and neutrophils with hypo-segmented or ringed nuclei.

15. Bone marrow aspiration shows hypercellularity.

16. In addition, ring sideroblasts, hypogranulation, and hyposegmentation of granulocyte precursors, and megakaryocytes with disorganized nuclei are present.

17. Marrow myeloblasts are 4% in volume.

1. He reports dyspnea when walking during his daily exercise routine.

9. He does not follow a particular diet.

10. The vital signs are within normal limits.

11. The physical examination reveals pale conjunctiva.

12. The examination of the heart, lungs, abdomen, and extremities shows no abnormalities.

18. Abdominal ultrasonography shows no organomegaly or other pathologic findings.

19. The peripheral blood smear shows large and hypogranular platelets and neutrophils with hypo-segmented or ringed nuclei.

21. Bone marrow aspiration shows hypercellularity.

22. Ring sideroblasts, hypogranulation, and hyposegmentation of granulocyte precursors, and megakaryocytes with disorganized nuclei are present.

23. Marrow myeloblasts are 4% in volume.


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

Context: A 37-year-old man comes to the physician because of a 1-month history of a burning sensation in his chest.

Context: The sensation is most prominent when he is lying in bed, but it is also present after eating heavy meals.

Context: He also states his breath has an unpleasant odor in the morning.

Context: He has hypothyroidism.

Context: His father died of colon cancer and his mother has hypertension.

Context: He has smoked one pack of cigarettes daily for 15 years and drinks 2–3 beers on weekends.

Context: He is 170 cm (5 ft 7 in) tall and weighs 95 kg (210 lb); BMI is 32.9 kg/m2.

Context: Vital signs are within normal limits.

Choices:
A. Urea breath test
B. Proton-pump inhibitor
C. H2 receptor blocker
D. Barium swallow

Answer: Proton-pump inhibitor

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

2. He has a 1-month history of a burning sensation in his chest.

3. The sensation is most prominent when he is lying in bed.

4. The sensation is also present after eating heavy meals.

5. He states his breath has an unpleasant odor in the morning.

6. He has not lost any weight during this period.

10. He has smoked one pack of cigarettes daily for 15 years.

12. His medications include levothyroxine and an over-the-counter multivitamin.

16. Vital signs are within normal limits.

17. Physical examination shows no abnormalities.

1. The sensation is most prominent when he is lying in bed.

2. The sensation is also present after eating heavy meals.

3. He states his breath has an unpleasant odor in the morning.

4. He has not lost any weight during this period.

8. He has smoked one pack of cigarettes daily for 15 years.

10. His medications include levothyroxine and an over-the-counter multivitamin.

14. Vital signs are within normal limits.

15. Physical examination shows no abnormalities.


Question: Which of the following histopathologic findings would most likely be seen on the liver biopsy of this patient?

Context: He is vaccinated against hepatitis A and B and denies any recent travel abroad.

Choices:
A. Small drops of fat throughout the liver parenchyma
B. Normal histologic findings
C. Mononuclear cell infiltrate and apoptotic hepatocytes
D. Onion skin fibrosis (concentric periductal fibrosis)

Answer: Onion skin fibrosis (concentric periductal fibrosis)

1. A 36-year-old man presents with right upper quadrant pain, fatigue, and pruritus.

2. His past medical history is significant for ulcerative colitis diagnosed 5 years ago, which is well-managed medically.

3. He is vaccinated against hepatitis A and B.

5. On physical examination, mild jaundice of the skin is present.

6. An abdominal examination reveals significant hepatosplenomegaly.

7. A percutaneous liver biopsy is performed.

1. Past medical history includes ulcerative colitis diagnosed 5 years ago.

2. Ulcerative colitis is well-managed medically.

3. Vaccinated against hepatitis A and B.

5. Mild jaundice of the skin is present on physical examination.

6. Significant hepatosplenomegaly is revealed on abdominal examination.


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

Context: A 26-year-old man is brought to the emergency department because he has had abdominal pain, nausea, and vomiting for the past 2 hours.

Context: His temperature is 99.6°F (37.6°C), pulse is 80/min, respirations are 18/min, and blood pressure is 122/68 mm Hg.

Context: The lungs are clear to auscultation.

Choices:
A. Shigella dysenteriae
B. Staphylococcus aureus
C. Enterotoxigenic Escherichia coli
D. Bacillus cereus

Answer: Staphylococcus aureus

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

2. He has had abdominal pain, nausea, and vomiting for the past 2 hours.

3. He ate a sandwich and coleslaw from a deli about 1 hour before the symptoms began.

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

10. Cardiac examination shows no abnormalities.

11. Abdominal examination shows diffuse mild tenderness with no rigidity, rebound, or guarding.

12. The remainder of the examination shows no abnormalities.

1. He ate a sandwich and coleslaw from a deli about 1 hour before the symptoms began.

2. He has no history of serious illness and takes no medications.

8. Cardiac examination shows no abnormalities.

9. Abdominal examination shows diffuse mild tenderness with no rigidity, rebound, or guarding.

10. The remainder of the examination shows no abnormalities.