Question: Which of the following is the most likely explanation for his positive Candida culture?

Context: A 24-year-old medical student presents to urgent care with cough and rhinorrhea.

Context: He has been learning about HIV and immunosuppression in medical school, and he is worried that he is seriously ill.

Context: He has no significant medical history, and he is sexually active with his girlfriend.

Context: He consumes alcohol on weekends but does not use tobacco or other recreational drugs.

Context: He candidly reports that, in microbiology lab, he cultured his own sputum on Sabouraud agar, and Candida grew on the agar.

Context: You perform a nasal viral swab, which confirms that he has a rhinovirus infection.

Choices:
A. HIV virus infection
B. Xerostomia
C. Surreptitious drug use
D. Benign Candida colonization

Answer: Benign Candida colonization

3. Patient presents to urgent care with cough and rhinorrhea.

4. Patient has been learning about HIV and immunosuppression in medical school.

5. Patient is worried that he is seriously ill.

6. Patient has no significant medical history.

7. Patient is sexually active with his girlfriend.

8. Patient consumes alcohol on weekends.

9. Patient does not use tobacco or other recreational drugs.

10. Patient cultured his own sputum on Sabouraud agar, and Candida grew on the agar.

11. Examination of the oropharynx does not show any abnormalities.

12. Nasal viral swab confirms that patient has a rhinovirus infection.

1. He has been learning about HIV and immunosuppression in medical school.

2. He is worried that he is seriously ill.

3. He has no significant medical history.

4. He is sexually active with his girlfriend.

6. He does not use tobacco or other recreational drugs.

7. In microbiology lab, he cultured his own sputum on Sabouraud agar.

9. Examination of the oropharynx does not show any abnormalities.

10. A nasal viral swab confirms that he has a rhinovirus infection.


Question: Which of the following medications would be most appropriate to assist the patient with her symptoms at this time?

Context: She has observed an increase in the frequency of her cough over the past few months and also the production of yellowish sputum on several occasions.

Context: She has never had the will to quit.

Context: Her respiratory rate is 18/min, pulse is 85/min, and blood pressure is 110/70 mm Hg.

Choices:
A. Albuterol
B. Fluticasone
C. Doxycycline
D. Prednisone

Answer: Albuterol

1. A 57-year-old woman comes to her physician with a persistent cough.

2. She has observed an increase in the frequency of her cough over the past few months.

3. She has also observed the production of yellowish sputum on several occasions.

4. She says that sputum production is greater in the morning compared to the rest of the day.

5. She has been a chain smoker for about 35 years now, smoking close to 3 packs a day.

7. Over the last 2 years, she has had this cough and doesn't recall being free of it for 3 months at a stretch.

8. On examination, there is a slight expiratory wheeze in the lower lung fields.

12. Her forced expiratory volume in the first second is 83% at this time.

13. Her FEV1/FVC post-bronchodilator ratio is 0.65.

14. Based on these findings, her physician recommends that she quit smoking.

15. She is also advised to take pneumococcal and influenza vaccinations over the next few months.

1. She has observed an increase in the frequency of her cough over the past few months.

2. She has observed the production of yellowish sputum on several occasions.

3. Sputum production is greater in the morning compared to the rest of the day.

4. She has been a chain smoker for about 35 years.

6. She has never had the will to quit smoking.

7. Over the last 2 years, she has had a cough and doesn't recall being free of it for 3 months at a stretch.

14. Her physician recommends that she quit smoking based on these findings.

15. She is advised to take pneumococcal and influenza vaccinations over the next few months.


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

Context: A 56-year-old woman presents to her primary care physician for dizziness.

Context: She says that her symptoms began approximately 1 month prior to presentation and are associated with nausea and ringing of the ears.

Context: She describes her dizziness as a spinning sensation that has a start and end and lasts approximately 25 minutes.

Context: This dizziness is severe enough that she cannot walk or stand.

Context: Her symptoms are fluctuating, and she denies any tunnel vision or feelings of fainting.

Context: However, she has abruptly fallen to the ground in the past and denied losing consciousness.

Context: Medical history is significant for a migraine with aura treated with zolmitriptan, type 2 diabetes managed with metformin, and hypertension managed with lisinopril.

Context: Her blood pressure is 125/75 mmHg, pulse is 88/min, and respirations are 16/min.

Context: On physical exam, when words are whispered into her right ear, she is unable to repeat the whispered words aloud; however, this is normal in the left ear.

Context: Air conduction is greater than bone conduction with Rinne testing, and the sound of the tuning fork is loudest in the left ear on Weber testing.

Choices:
A. Benign paroxysmal positional vertigo
B. Meniere disease
C. Migraine
D. Transient ischemic attack

Answer: Meniere disease

Neurology with Special Qualification in Child Neurology

2. Patient presents to primary care physician for dizziness.

3. Symptoms began approximately 1 month prior to presentation.

4. Symptoms associated with nausea and ringing of the ears.

5. Dizziness described as a spinning sensation with a start and end, lasting approximately 25 minutes.

6. Dizziness severe enough that patient cannot walk or stand.

8. Patient denies tunnel vision or feelings of fainting.

9. Patient has abruptly fallen to the ground in the past and denied losing consciousness.

10. Medical history significant for migraine with aura treated with zolmitriptan.

11. Medical history significant for type 2 diabetes managed with metformin.

12. Medical history significant for hypertension managed with lisinopril.

16. When words are whispered into right ear, patient is unable to repeat the whispered words aloud.

17. When words are whispered into left ear, patient is able to repeat the whispered words aloud.

18. Air conduction is greater than bone conduction with Rinne testing.

19. Sound of tuning fork is loudest in left ear on Weber testing.

1. Symptoms began approximately 1 month prior to presentation

2. Symptoms are associated with nausea and ringing of the ears

3. Dizziness is described as a spinning sensation with a start and end

4. Dizziness lasts approximately 25 minutes

5. Dizziness is severe enough that the patient cannot walk or stand

7. Denies tunnel vision or feelings of fainting

8. Has abruptly fallen to the ground in the past

10. Medical history includes migraine with aura treated with zolmitriptan

11. Medical history includes type 2 diabetes managed with metformin

12. Medical history includes hypertension managed with lisinopril

16. Unable to repeat whispered words aloud when whispered into the right ear

17. Normal response when whispered into the left ear

19. Sound of the tuning fork is loudest in the left ear on Weber testing


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

Context: A 3086-g (6-lb) male newborn is delivered at 39 weeks' gestation to a 29-year-old woman.

Context: Initial examination shows micrognathia, a broad nasal bridge, short philtrum, and a cleft palate.

Choices:
A. Deletion in chromosome 7
B. Deletion in chromosome 22
C. Nondisjunction of chromosome 21
D. Nondisjunction of chromosome 13

Answer: Deletion in chromosome 22

1. A 3086-g (6-lb) male newborn is delivered.

2. The newborn is delivered at 39 weeks' gestation.

4. Initial examination shows micrognathia.

5. Initial examination shows a broad nasal bridge.

6. Initial examination shows a short philtrum.

7. Initial examination shows a cleft palate.

8. Intermittent muscle spasms are seen predominantly in the hands and feet.

9. A harsh systolic murmur is heard over the lower left sternal border.

1. Initial examination shows micrognathia.

2. Initial examination shows a broad nasal bridge.

3. Initial examination shows a short philtrum.

4. Initial examination shows a cleft palate.

5. Intermittent muscle spasms are seen predominantly in the hands and feet.

6. A harsh systolic murmur is heard over the lower left sternal border.


Question: Serum studies are most likely to show which of the following findings?"

Context: A 37-year-old woman comes to the emergency department because her eyes have had a yellow discoloration and she has had dark urine for the past 3 days.

Context: She has also had fever, itching, and severe fatigue.

Context: She reports having symptoms of the stomach flu a week ago, which resolved with over-the-counter medication.

Context: She does not use illicit drugs.

Context: She appears ill.

Context: Cardiopulmonary examination is normal.

Context: Laboratory studies show: | Hemoglobin 11.6 g/dL | Leukocyte count 10,300/mm3 | Platelet count 256,000/mm3 | ESR 19 mm/hr | Prothrombin time 13 seconds | Serum | Urea nitrogen 28 mg/dL | Glucose 89 mg/dL | Creatinine 0.7 mg/dL | Bilirubin | Total 8 mg/dL | Direct 4 mg/dL | ALP 80 U/L | AST 312 U/L | ALT 569 U/L | An ultrasound of the abdomen shows no abnormalities.

Choices:
A. Anti-mitochondrial antibodies
B. Perinuclear anti-neutrophil cytoplasmic antibodies
C. Anti-HAV IgM
D. Anti-HEV IgG

Answer: Anti-HAV IgM

1. A 37-year-old woman comes to the emergency department.

2. She has had a yellow discoloration in her eyes for the past 3 days.

3. She has had dark urine for the past 3 days.

4. She has had fever, itching, and severe fatigue.

5. She had symptoms of the stomach flu a week ago, which resolved with over-the-counter medication.

6. She does not have diarrhea but says her stools are whitish in appearance.

7. She has no personal history of serious illness.

9. She drinks an average of 2 beers on weekends.

11. She has been sexually active with the same partner for 12 years and uses condoms consistently.

12. She works as a flight attendant for an international airline.

14. Her temperature is 39.3°C (102.7°F).

17. Examination shows scleral icterus, excoriation marks over her extremities, and parched lips.

18. The liver is tender on palpation; there is no splenomegaly.

19. Cardiopulmonary examination is normal.

20. Laboratory studies show: Hemoglobin 11.6 g/dL, Leukocyte count 10,300/mm3, Platelet count 256,000/mm3, ESR 19 mm/hr, Prothrombin time 13 seconds, Serum Urea nitrogen 28 mg/dL, Glucose 89 mg/dL, Creatinine 0.7 mg/dL, Bilirubin Total 8 mg/dL, Direct 4 mg/dL, ALP 80 U/L, AST 312 U/L, ALT 569 U/L.

21. An ultrasound of the abdomen shows no abnormalities.

1. She has had fever, itching, and severe fatigue.

2. She had symptoms of the stomach flu a week ago, which resolved with over-the-counter medication.

3. She does not have diarrhea but says her stools are whitish in appearance.

4. She has no personal history of serious illness.

5. She does not smoke and drinks an average of 2 beers on weekends.

7. She has been sexually active with the same partner for 12 years and uses condoms consistently.

8. She works as a flight attendant for an international airline.

10. Her temperature is 39.3°C (102.7°F), pulse is 64/min, and blood pressure is 132/82 mm Hg.

11. Examination shows scleral icterus, excoriation marks over her extremities, and parched lips.

12. The liver is tender on palpation; there is no splenomegaly.

13. Cardiopulmonary examination is normal.

14. Laboratory studies show: Hemoglobin 11.6 g/dL, Leukocyte count 10,300/mm3, Platelet count 256,000/mm3, ESR 19 mm/hr, Prothrombin time 13 seconds, Serum Urea nitrogen 28 mg/dL, Glucose 89 mg/dL, Creatinine 0.7 mg/dL, Bilirubin Total 8 mg/dL, Direct 4 mg/dL, ALP 80 U/L, AST 312 U/L, ALT 569 U/L.

15. An ultrasound of the abdomen shows no abnormalities.


Question: What is the mechanism of action of the drug which typically induces remission of this patient’s most likely condition?

Context: A 27-year-old man presents with diarrhea, fatigue and weight loss.

Context: He says he has been having occasional loose stools and abdominal pain for the past month, but he did not seek any medical attention because of work deadlines.

Context: He says the diarrhea is associated with cramping lower abdominal pain and an urgency to defecate.

Context: His stool is loose, occasionally blood-tinged, and contains mucus.

Context: He also says he feels fatigued and has lost 11 kg (24 lb) over the last 2 months.

Context: The patient denies any fever, sick contacts, or a history of recent travel.

Context: No significant past medical history.

Context: On physical examination, the patient has generalized pallor.

Context: A colonoscopy with biopsy is performed, which shows inflammation of the sigmoid colon and rectum.

Context: No evidence of granulomatous disease.

Choices:
A. Inhibition of prostaglandins and inflammatory cytokines
B. Antibody against tumor necrosis factor
C. Inhibition of cellular metabolism
D. Suppression of polymorphonuclear cell migration

Answer: Inhibition of prostaglandins and inflammatory cytokines

2. Patient has diarrhea, fatigue and weight loss.

3. Patient has had occasional loose stools and abdominal pain for the past month.

4. Patient did not seek medical attention due to work deadlines.

5. Diarrhea is associated with cramping lower abdominal pain and an urgency to defecate.

6. Stool is loose, occasionally blood-tinged, and contains mucus.

7. Patient feels fatigued and has lost 11 kg (24 lb) over the last 2 months.

8. Patient denies any fever, sick contacts, or a history of recent travel.

10. Family history is significant for colon cancer in his father, who died at the age of 50.

11. On physical examination, patient has generalized pallor.

12. Abdominal exam reveals mild tenderness to palpation in the left lower quadrant.

13. Laboratory investigations reveal microcytic anemia with an elevated ESR.

14. Colonoscopy with biopsy is performed, which shows inflammation of the sigmoid colon and rectum.

15. Biopsy shows a predominantly lymphoid infiltration of the mucosa and submucosa with multiple crypt abscesses.

16. No evidence of granulomatous disease.

1. Patient has been having occasional loose stools and abdominal pain for the past month.

2. Patient did not seek medical attention due to work deadlines.

3. Diarrhea is associated with cramping lower abdominal pain and an urgency to defecate.

4. Stool is loose, occasionally blood-tinged, and contains mucus.

5. Patient feels fatigued and has lost 11 kg (24 lb) over the last 2 months.

6. Patient denies fever, sick contacts, or a history of recent travel.

8. Family history is significant for colon cancer in his father, who died at the age of 50.

9. Patient has generalized pallor on physical examination.

10. Abdominal exam reveals mild tenderness to palpation in the left lower quadrant.

11. Laboratory investigations reveal microcytic anemia with an elevated ESR.

12. Colonoscopy with biopsy shows inflammation of the sigmoid colon and rectum.

13. Biopsy shows a predominantly lymphoid infiltration of the mucosa and submucosa with multiple crypt abscesses.

14. No evidence of granulomatous disease.


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

Context: Her temperature is 98.1°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 88/min, respirations are 16/min, and oxygen saturation is 98% on room air.

Context: A complete blood count with differential shows the following: |  | Hemoglobin: 10 g/dL | Hematocrit: 30% | Leukocyte count: 166,500/mm^3 | Segmented neutrophils 92% | Leukocyte alkaline phosphatase: Low | Platelet count: 92,000/mm^3 |  | A bone marrow biopsy is performed demonstrating infiltration with a large number of normal-appearing neutrophils.

Choices:
A. t(8;14)
B. t(9;22)
C. t(12;21)
D. t(15;17)

Answer: t(9;22)

1. A 61-year-old woman presents to your office complaining of mild fatigue and weight loss over the past 6 months.

2. She states she has felt generally unwell and has had decreased appetite during this time frame.

7. Oxygen saturation is 98% on room air.

8. Physical exam reveals splenomegaly and a nontender abdomen.

13. Leukocyte alkaline phosphatase: Low.

15. A bone marrow biopsy is performed demonstrating infiltration with a large number of normal-appearing neutrophils.

1. The patient has felt generally unwell.

2. The patient has had decreased appetite.

3. The patient's temperature is 98.1°F (36.7°C).

4. The patient's blood pressure is 122/80 mmHg.

6. The patient's respirations are 16/min.

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

9. Physical exam reveals a nontender abdomen.

14. Leukocyte alkaline phosphatase: Low.

16. A bone marrow biopsy demonstrates infiltration with a large number of normal-appearing neutrophils.


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

Context: His temperature is 97.6°F (36.4°C), blood pressure is 104/64 mmHg, pulse is 130/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Context: Laboratory values are ordered as seen below. |  | Serum: | Na+: 141 mEq/L | Cl-: 102 mEq/L | K+: 4.4 mEq/L | HCO3-: 14 mEq/L | BUN: 25 mg/dL | Glucose: 99 mg/dL | Creatinine: 1.4 mg/dL | Ca2+: 10.2 mg/dL |  | .

Choices:
A. Glutathione formation
B. Inhibition of alcohol dehydrogenase
C. Muscarinic antagonism
D. Removal via dialysis

Answer: Inhibition of alcohol dehydrogenase

1. A 44-year-old homeless man is brought to the emergency department after he was arrested when found intoxicated in someone's garage.

2. The patient is acutely altered and is covered in urine, stool, and vomit.

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

8. The patient is aroused with pain and begins answering basic questions.

9. He states his vision is blurry and he can't see anything.

2. The patient is covered in urine, stool, and vomit.

3. The patient's temperature is 97.6°F (36.4°C).

4. The patient's blood pressure is 104/64 mmHg.

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

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

9. The patient states his vision is blurry and he can't see anything.

10. Laboratory values are ordered as seen below.

17. Serum creatinine level is 1.4 mg/dL.


Question: Which of the following laboratory abnormalities would you expect to find in this patient?

Context: A 32-year-old construction worker is brought to the Emergency Department after a block of concrete crushed his right leg.

Context: Upon admission his vitals were stable.

Context: Distal right pulses are absent.

Choices:
A. Fractional excretion of sodium (FeNa+) > 2%
B. Urine osmolality > 500 mOsmol/kg
C. Red-tinted plasma
D. Elevated haptoglobin

Answer: Fractional excretion of sodium (FeNa+) > 2%

1. A 32-year-old construction worker is brought to the Emergency Department.

2. A block of concrete crushed his right leg.

3. His coworkers tried to remove the block, but it was not possible until firemen arrived on the scene 30 minutes after the incident.

4. His personal medical history is unremarkable.

5. Upon admission his vitals were stable.

6. On physical examination the man is unconscious.

7. His right leg is deformed with lacerations and hematomas.

8. There are at least two fractures and several areas of the muscle appear pulpified.

10. An X-ray of the right leg reveals several displaced fractures of the tibia and fibula.

11. Blood samples and a urine specimens are sent to the lab for analysis.

1. His coworkers tried to remove the block

2. It was not possible until firemen arrived on the scene 30 minutes after the incident

3. His personal medical history is unremarkable

4. Upon admission his vitals were stable

5. On physical examination the man is unconscious

6. His right leg is deformed with lacerations and hematomas

7. There are at least two fractures and several areas of the muscle appear pulpified

9. An X-ray of the right leg reveals several displaced fractures of the tibia and fibula

10. Blood samples and a urine specimens are sent to the lab for analysis


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

Context: A 42-year-old primigravida woman goes into labor at 37 weeks.

Context: After several hours of labor, a boy is born with multiple physical abnormalities including cleft palate, micrognathia, and low-set ears.

Choices:
A. Microdeletion of the long arm of chromosome 22
B. Microdeletion of the long arm of chromosome 7
C. Microdeletion of the short arm of chromosome 5
D. Adenosine deaminase deficiency

Answer: Microdeletion of the long arm of chromosome 22

1. A 42-year-old primigravida woman goes into labor.

2. The woman goes into labor at 37 weeks.

3. After several hours of labor, a boy is born.

4. The boy has multiple physical abnormalities including cleft palate, micrognathia, and low-set ears.

5. Imaging reveals an absence of the thymic shadow.

1. A boy is born after several hours of labor.

2. The boy has multiple physical abnormalities, including cleft palate, micrognathia, and low-set ears.

3. Imaging reveals an absence of the thymic shadow.


Question: When this drug is used long-term, which of the following complications can develop?

Context: A 20-year-old woman presents following a seizure 2 hours ago.

Context: She denies alcohol and drug use.

Choices:
A. Drug dependence
B. Drug-induced SLE
C. Renal failure
D. Liver failure

Answer: Drug-induced SLE

2. Patient presented 2 hours after a seizure.

3. Roommate described patient suddenly 'freezing', collapsing, and having jerky movements involving her entire body.

4. Patient cannot recall the episode but remembers 'seeing stars' before losing consciousness.

5. Patient was confused about where she was soon after the seizure.

6. Patient had urinated in her clothes when she regained consciousness.

7. Patient has had a persistent headache since the seizure.

8. Patient took acetaminophen before coming to the hospital.

9. Patient's past medical history is unremarkable.

10. Patient denies alcohol and drug use.

11. Physician started patient on an antiepileptic drug that acts in the motor cortex by blocking repeated activation of voltage-gated sodium channels.

12. Antiepileptic drug is also used in status epilepticus.

1. The patient's roommate describes seeing the patient suddenly 'freeze', collapse, and start having jerky movements involving her entire body.

2. The patient says she can not recall the episode but does remember 'seeing stars' before losing consciousness.

3. She remembers being confused about where she was soon after the seizure and had urinated in her clothes when she regained consciousness.

4. A persistent headache has troubled her since the seizure for which she took acetaminophen before coming to the hospital.

5. Her past medical history is unremarkable.

7. The physician starts her on an antiepileptic drug that acts in the motor cortex by blocking repeated activation of voltage-gated sodium channels and is also used in status epilepticus.


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

Context: The patient states that it is very painful for him to walk around, and he has significant pain in his right and left toes.

Context: The patient’s current medications include lisinopril, hydrochlorothiazide, insulin, metformin, fluoxetine, clonazepam, albuterol, home oxygen, varenicline, and fish oil and he is compliant with all medications.

Context: On physical exam, the patient’s toes appear pale and dirty.

Choices:
A. Bipedal edema
B. Increased reflexes of the lower extremities
C. Loss of vibration sensation in the lower extremities
D. Calf pain after walking moderate distance

Answer: Calf pain after walking moderate distance

Neuromuscular Medicine
Peripheral Neuropathy

1. A 68-year-old man presents to his primary care physician for pain in his feet.

2. The patient states that it is very painful for him to walk around.

3. The patient has significant pain in his right and left toes.

4. The patient has a past medical history of obesity.

5. The patient has a past medical history of type II diabetes mellitus.

6. The patient has a past medical history of anxiety.

7. The patient has a past medical history of depression.

8. The patient has a past medical history of COPD.

9. The patient has a 30 pack-year smoking history.

10. The patient's current medications include lisinopril.

11. The patient's current medications include hydrochlorothiazide.

12. The patient's current medications include insulin.

13. The patient's current medications include metformin.

14. The patient's current medications include fluoxetine.

15. The patient's current medications include clonazepam.

16. The patient's current medications include albuterol.

17. The patient's current medications include home oxygen.

18. The patient's current medications include varenicline.

19. The patient's current medications include fish oil.

20. The patient is compliant with all medications.

21. On physical exam, the patient's toes appear pale and dirty.

22. When inspecting his toes, shallow wounds with a pale base devoid of granulation tissue can be appreciated.

23. The patient has decreased pinprick sensation in his lower extremities bilaterally.

24. Pulmonary exam is notable for a prolonged expiratory phase.

1. The patient experiences significant pain in his right and left toes.

2. The patient has a past medical history of obesity, type II diabetes mellitus, anxiety, depression, COPD, and a 30 pack-year smoking history.

3. The patient's current medications include lisinopril, hydrochlorothiazide, insulin, metformin, fluoxetine, clonazepam, albuterol, home oxygen, varenicline, and fish oil, and he is compliant with all medications.

4. On physical exam, the patient's toes appear pale and dirty.

5. Shallow wounds with a pale base devoid of granulation tissue can be appreciated when inspecting the patient's toes.

6. The patient has decreased pinprick sensation in his lower extremities bilaterally.

7. Pulmonary exam is notable for a prolonged expiratory phase.


Question: What additional finding would you expect from this patient?

Context: Per the patient, he was playing at his high-school football game when a member of the opposing team tackled him from behind, which resulted in him landing on his left arm.

Context: Physical examination demonstrates limited abduction secondary to pain and reduced muscle tone over the shoulder.

Choices:
A. Loss of sensation over the dorsal hand
B. Loss of sensation over the lateral 3 1/2 fingers
C. Loss of sensation over the lateral arm
D. Loss of sensation over the lateral forearm

Answer: Loss of sensation over the lateral arm

General Orthopaedic Surgery
Orthopaedic Sports Medicine

1. A 16-year-old man is brought to the emergency department for left arm pain.

2. The patient was playing at his high-school football game when a member of the opposing team tackled him from behind.

4. He felt a “popping” sensation and immediate, sharp pain at his left shoulder.

5. The patient is in mild distress and holds his arm against his abdomen.

6. Physical examination demonstrates limited abduction secondary to pain.

7. Physical examination demonstrates reduced muscle tone over the shoulder.

1. The patient was playing at his high-school football game.

2. A member of the opposing team tackled him from behind.

3. The tackle resulted in him landing on his left arm.

4. He felt a “popping” sensation in his left shoulder.

5. He experienced immediate, sharp pain in his left shoulder.

7. He holds his arm against his abdomen.

8. Physical examination demonstrates limited abduction secondary to pain.

9. Reduced muscle tone is observed over the shoulder.


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

Context: A 68-year-old woman is brought to the emergency room because of pain in her right shoulder after falling down the stairs in her apartment.

Context: Physical examination shows shortening of the right arm as well as tenderness and swelling over the right shoulder.

Choices:
A. Wrist extension
B. Elbow flexion
C. Arm abduction
D. Thumb adduction

Answer: Arm abduction

1. A 68-year-old woman is brought to the emergency room.

2. She fell down the stairs in her apartment.

3. She has a history of postmenopausal osteoporosis.

4. Her current medications are alendronate, vitamin D, and calcium supplementation.

6. Physical examination shows shortening of the right arm.

7. Physical examination shows tenderness and swelling over the right shoulder.

8. The range of motion of the right arm is limited by pain.

9. An x-ray of the right shoulder shows a fracture of the surgical neck of the humerus.

1. She has a history of postmenopausal osteoporosis.

2. Her current medications are alendronate, vitamin D, and calcium supplementation.

3. Physical examination shows shortening of the right arm.

4. Physical examination shows tenderness and swelling over the right shoulder.

5. The range of motion of the right arm is limited by pain.

6. An x-ray of the right shoulder shows a fracture of the surgical neck of the humerus.


Question: The platelet counts of repeated measurements are shown in ascending order: | Historical hemocytometer 55,000 57,000 62,000 76,000 77,000 82,000 92,000 Mean: 72,000 | Modern automated CBC analyzer 71,000 71,000 72,000 72,000 73,000 74,000 74,000 Mean: 72,000 | If the measurements on a modern automated CBC analyzer are considered accurate, which of the following conclusions can be drawn about the historical hemocytometer?"

Context: A hematologist has found a historical hemocytometer used during the 1960s.

Context: Out of curiosity, he decides to obtain platelet counts from his brother, who has idiopathic thrombocytopenic purpura (ITP), with both the historical hemocytometer and a modern automated CBC analyzer.

Choices:
A. Test lacks accuracy
B. Test lacks validity
C. Test lacks specificity
D. Test lacks precision

Answer: Test lacks precision

1. A hematologist has found a historical hemocytometer.

2. The historical hemocytometer was used during the 1960s.

3. The hematologist decides to obtain platelet counts from his brother.

4. His brother has idiopathic thrombocytopenic purpura (ITP).

5. The platelet counts will be obtained with both the historical hemocytometer and a modern automated CBC analyzer.

1. The man is curious about platelet counts.

2. The man's brother has idiopathic thrombocytopenic purpura (ITP).

3. The platelet counts are obtained from the man's brother.

4. The platelet counts are obtained using a historical hemocytometer.

5. The platelet counts are obtained using a modern automated CBC analyzer.


Question: Which of the following is the mechanism of action of the toxin causing this child's symptoms?

Context: A 9-year-old female child whose family recently emigrated from Afghanistan presents to the county hospital with difficulty swallowing and generalized muscle rigidity.

Context: Her parents note that although she is in severe pain she always appears to be smiling.

Context: After getting a detailed history from the parents, the residents comes to the conclusion that the child's clinical presentation is due to a lack of immunizations and a deep wound on her knee resulting from a fall six days ago.

Choices:
A. Inhibiting protein synthesis via ADP-ribosylation of elongation factor 2
B. Overactivating adenylate cyclase by ADP-ribosylation of the Gs alpha subunit
C. Overactivating adenylate cyclase by disabling the Gi subunit
D. Preventing release of GABA by cleaving of synaptobrevin 2

Answer: Preventing release of GABA by cleaving of synaptobrevin 2

1. A 9-year-old female child presents to the county hospital.

2. Her family recently emigrated from Afghanistan.

3. She has difficulty swallowing and generalized muscle rigidity.

4. Her parents note that she is in severe pain but always appears to be smiling.

5. The residents get a detailed history from the parents.

6. The residents come to the conclusion that the child's clinical presentation is due to a lack of immunizations.

7. The child has a deep wound on her knee resulting from a fall six days ago.

2. The child always appears to be smiling.

3. The child has a lack of immunizations.

4. The child has a deep wound on her knee.

5. The wound resulted from a fall six days ago.


Question: The area of the lung most likely affected by this patient's condition has which of the following characteristics?

Context: A 49-year-old obese man presents to the emergency department with a fever and a cough productive of bloody sputum.

Context: He has also been waking up at night frequently, which he attributes to sweating while asleep.

Context: He is also proud of recently losing some weight but denies actively trying to do so.

Context: He says that he has had these symptoms intermittently for the last several years but has not consistently sought treatment because his housing has been transient with periods of homelessness.

Context: He is started on a course of therapy and leaves against medical advice before his physician is able to explain the medications.

Context: He returns two days later because he is concerned that his eyes are bleeding.

Choices:
A. High perfusion, high ventilation, high V/Q ratio
B. High perfusion, high ventilation, low V/Q ratio
C. Low perfusion, low ventilation, high V/Q ratio
D. Low perfusion, low ventilation, low V/Q ratio

Answer: Low perfusion, low ventilation, high V/Q ratio

1. A 49-year-old man presented to the emergency department.

3. He had a fever and a cough productive of bloody sputum.

4. He was waking up at night frequently and attributed it to sweating while asleep.

5. He was proud of recently losing some weight but denied actively trying to do so.

6. He had these symptoms intermittently for the last several years.

7. He had not consistently sought treatment due to periods of homelessness.

8. He was started on a course of therapy.

9. He left against medical advice before his physician was able to explain the medications.

10. He returned two days later because he was concerned his eyes were bleeding.

1. He has been waking up at night frequently.

2. He attributes the waking up at night to sweating while asleep.

3. He is proud of recently losing some weight.

4. He denies actively trying to lose weight.

5. He has had symptoms intermittently for the last several years.

6. He has not consistently sought treatment for his symptoms.

7. His housing has been transient with periods of homelessness.

9. He left against medical advice before his physician could explain the medications.

11. He was concerned that his eyes are bleeding.


Question: What is the next best step in management?

Context: A 66-year-old male presents to clinic for a blood glucose level of 169 mg/dL taken at a local pharmacy.

Context: He is a farmer in rural Alabama and has not seen a doctor for decades.

Context: He wants to be in excellent shape prior to his trip to visit his daughter at college.

Context: His past medical history and family history are unknown, and he does not take any medications.

Context: His diet consists of pork products and he does not smoke.

Context: His temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 169/90 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air.

Context: Lab results are below: |  | Serum: | Na+: 145 mEq/L | Cl-: 100 mEq/L | K+: 4.9 mEq/L | HCO3-: 24 mEq/L | BUN: 18 mg/dL | Glucose: 211 mg/dL | Creatinine: 1.0 mg/dL | Ca2+: 10.0 mg/dL |  | He returns from his trip, complaining of cough.

Context: He denies any other symptoms.

Context: His temperature is 99.5°F (37.5°C), pulse is 101/min, blood pressure is 160/85 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air.

Context: Repeat lab results are below: |  | Serum: | Na+: 145 mEq/L | Cl-: 100 mEq/L | K+: 5.3 mEq/L | HCO3-: 24 mEq/L | BUN: 22 mg/dL | Glucose: 169 mg/dL | Creatinine: 1.2 mg/dL | Ca2+: 10.1 mg/dL |  | .

Choices:
A. Switch blood pressure medication to losartan
B. Switch blood pressure medication to hydrochlorothiazide
C. Azithromycin
D. Loratadine

Answer: Switch blood pressure medication to losartan

3. Patient is a farmer in rural Alabama.

4. Patient has not seen a doctor for decades.

5. Patient wants to be in excellent shape prior to trip to visit daughter at college.

6. Patient's past medical history and family history are unknown.

7. Patient does not take any medications.

8. Patient's diet consists of pork products.

10. Patient's temperature is 99.5°F (37.5°C).

12. Patient's blood pressure is 169/90 mmHg.

14. Patient's oxygen saturation is 97% on room air.

15. Patient is started on metformin, lisinopril, and a guided exercise program.

21. Patient's serum glucose is 211 mg/dL.

22. Patient's serum creatinine is 1.0 mg/dL.

24. Patient returns from trip complaining of cough.

26. Patient's temperature is 99.5°F (37.5°C).

28. Patient's blood pressure is 160/85 mmHg.

30. Patient's oxygen saturation is 98% on room air.

1. The patient is a farmer in rural Alabama.

2. The patient has not seen a doctor for decades.

3. The patient wants to be in excellent shape prior to his trip to visit his daughter at college.

4. The patient's past medical history and family history are unknown.

5. The patient does not take any medications.

6. The patient's diet consists of pork products and he does not smoke.

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

9. The patient's blood pressure is 169/90 mmHg.

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

11. The patient's oxygen saturation is 97% on room air.

12. The patient is started on metformin, lisinopril, and a guided exercise program.

13. Lab results show: Na+: 145 mEq/L, Cl-: 100 mEq/L, K+: 4.9 mEq/L, HCO3-: 24 mEq/L, BUN: 18 mg/dL, Glucose: 211 mg/dL, Creatinine: 1.0 mg/dL, Ca2+: 10.0 mg/dL.

14. The patient returns from his trip, complaining of cough.

15. The patient denies any other symptoms.

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

18. The patient's blood pressure is 160/85 mmHg.

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

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

21. Repeat lab results show: Na+: 145 mEq/L, Cl-: 100 mEq/L, K+: 5.3 mEq/L, HCO3-: 24 mEq/L, BUN: 22 mg/dL, Glucose: 169 mg/dL, Creatinine: 1.2 mg/dL, Ca2+: 10.1 mg/dL.


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

Context: Her prior medical history is significant for seasonal allergies and a broken arm at age 12 that was treated in a long arm cast.

Context: She has not had any major illnesses in the previous year and does not currently have any major complaints.

Context: Given her elevated blood pressure, she is prescribed captopril; however, 1 week later she presents to the emergency department with hypertensive urgency.

Choices:
A. Bilateral fibromuscular dysplasia
B. Conn syndrome
C. Renin secreting tumor
D. Unilateral fibromuscular dysplasia

Answer: Bilateral fibromuscular dysplasia

1. A 25-year-old woman presents to her primary care physician for her annual physical exam.

2. Her prior medical history is significant for seasonal allergies.

3. She had a broken arm at age 12 that was treated in a long arm cast.

4. She has not had any major illnesses in the previous year.

5. She does not currently have any major complaints.

6. On physical exam her blood pressure is found to be 152/95 mmHg.

7. Laboratory findings reveal elevated levels of renin and aldosterone.

8. Given her elevated blood pressure, she is prescribed captopril.

9. 1 week later she presents to the emergency department with hypertensive urgency.

10. At that point captopril is immediately stopped.

1. Prior medical history includes seasonal allergies and a broken arm at age 12.

2. Broken arm at age 12 was treated in a long arm cast.

3. No major illnesses in the previous year.

5. Blood pressure on physical exam is 152/95 mmHg.

6. Laboratory findings reveal elevated levels of renin.

7. Laboratory findings reveal elevated levels of aldosterone.

8. Prescribed captopril due to elevated blood pressure.

9. Presented to the emergency department with hypertensive urgency 1 week after starting captopril.

10. Captopril was immediately stopped at that point.


Question: Which of the following is a possible explanation for the group marked with the letter E?

Choices:
A. Lymphoma
B. End-stage kidney disease
C. Thyroidectomy
D. Multiple endocrine neoplasia

Answer: Lymphoma

1. An investigator is analyzing the serum calcium and parathyroid hormone levels of 100 patients.

2. A scatter plot of the findings is shown.

1. A scatter plot
2. The findings are shown


Question: Which of the following tests should be performed to confirm the diagnosis in this patient?

Context: A 56-year-old male is admitted to the emergency department with sudden onset of pain, left-sided scrotal swelling, and nausea.

Context: The patient states that the symptoms started three hours ago after he lifted up a heavy pack.

Context: He says that the swelling had been intermittently present for several years already and was most prominent when physically straining or coughing, but it had never been painful.

Context: Past medical history is unremarkable.

Context: Patient reports a 26-pack-year history of smoking.

Context: Vital signs are as follows: blood pressure 150/90 mm Hg, heart rate 85/min, respiratory rate 14/min, and temperature 37.8℃ (100℉).

Context: BMI is 32.9 kg/m2.

Context: Patient’s respiratory and cardiovascular exams are within normal limits.

Context: The abdomen is moderately distended.

Choices:
A. Ultrasonography
B. No further tests are needed
C. Fine needle biopsy
D. Laparoscopy

Answer: No further tests are needed

1. A 56-year-old male is admitted to the emergency department.

2. Patient has sudden onset of pain, left-sided scrotal swelling, and nausea.

3. Symptoms started three hours ago after he lifted up a heavy pack.

4. Swelling had been intermittently present for several years already.

5. Swelling was most prominent when physically straining or coughing, but it had never been painful.

6. Patient's past medical history is unremarkable.

7. Patient has a 26-pack-year history of smoking.

13. Patient's respiratory and cardiovascular exams are within normal limits.

15. There is a tender erythematous scrotal swelling on the left.

16. Swelling cannot be manually reduced.

1. The patient's symptoms started three hours ago after lifting a heavy pack.

2. The swelling had been intermittently present for several years and was most prominent when physically straining or coughing, but it had never been painful.

3. The patient's past medical history is unremarkable.

4. The patient reports a 26-pack-year history of smoking.

5. Vital signs: blood pressure 150/90 mm Hg, heart rate 85/min, respiratory rate 14/min, temperature 37.8℃ (100℉).

7. Patient's respiratory and cardiovascular exams are within normal limits.

9. There is a tender erythematous scrotal swelling on the left, which cannot be manually reduced.


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

Context: He was recently adopted from abroad and his parents want to establish care in the United States.

Context: His medical history is unclear and there are no records on any family history.

Context: On presentation, he is found to fall below the 5th percentile in height for his age with shortened 4th and 5th digits.

Context: Radiographs reveal decreased bone mineral density and several healing fractures.

Choices:
A. Decreased production of parathyroid hormone
B. Inadequate intake of vitamin D
C. Malabsorption of nutrients
D. Resistance to effects of parathyroid hormone

Answer: Resistance to effects of parathyroid hormone

1. A 6-year-old boy presents to a pediatrician for initial evaluation.

3. His parents want to establish care in the United States.

5. There are no records on any family history.

6. On presentation, he is found to fall below the 5th percentile in height for his age.

8. Physical exam reveals wrist spasms when his blood pressure is taken.

9. Radiographs reveal decreased bone mineral density.

10. Radiographs reveal several healing fractures.

2. His parents want to establish care in the United States.

4. There are no records on any family history.

5. On presentation, he is found to fall below the 5th percentile in height for his age.

7. Physical exam reveals wrist spasms when his blood pressure is taken.

8. Radiographs reveal decreased bone mineral density.

9. Radiographs also reveal several healing fractures.


Question: Which of the following physiologic mechanisms is primarily responsible for this patient's current presentation?

Context: A 12-year-old boy is brought to the emergency department with a 2-month history of increasing difficulty with physical activity.

Context: Specifically, he says that he gets short of breath quickly with exertion even though he used to participate in all activities without a problem.

Context: When asked, he endorses sometimes coughing up flecks of blood.

Context: His past medical history is unclear because he was recently adopted from abroad and has not yet established care.

Context: Physical exam reveals blue discoloration of his lips and fingernails as well as a holosystolic murmur best heard at the lower left sternal border.

Choices:
A. Increasing size of ventricular septal defect
B. Left ventricular outflow tract obstruction
C. New atrial septal defect
D. Pulmonary artery hypertension

Answer: Pulmonary artery hypertension

1. A 12-year-old boy is brought to the emergency department.

2. He has a 2-month history of increasing difficulty with physical activity.

3. He used to participate in all activities without a problem.

4. He endorses sometimes coughing up flecks of blood.

6. He was recently adopted from abroad and has not yet established care.

7. Physical exam reveals blue discoloration of his lips and fingernails.

8. Physical exam reveals a holosystolic murmur best heard at the lower left sternal border.

1. He gets short of breath quickly with exertion.

2. He used to participate in all activities without a problem.

3. He sometimes coughs up flecks of blood.


Question: Which of the following molecules make up part of the structure that was separated?

Context: He performs a northern blot to isolate nucleic acid sequences of interest.

Choices:
A. RNA polymerase
B. Transfer RNA
C. Ribosomal RNA
D. Mitochondrial RNA

Answer: Ribosomal RNA

1. A scientist isolates the rough endoplasmic reticulum from HeLa cells.

3. He isolates nucleic acid sequences of interest.

2. The purpose is to isolate nucleic acid sequences of interest.


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

Context: A 14-month-old girl is brought to the pediatrician after her parents noticed her being increasingly irritable with frequent vomiting for the past 2 weeks.

Context: Parents deny any history of fever.

Context: They recently immigrated to the country and, unfortunately, the mother did not receive prenatal care during pregnancy due to a lack of health insurance.

Context: A magnetic resonance imaging (MRI) of her brain shows an enlargement of the posterior fossa, cystic dilation of the 4th ventricle, and hypoplasia of the cerebellar vermis (see image).

Choices:
A. Chiari II malformation
B. Chiari III malformation
C. Dandy-Walker malformation
D. Klippel Feil syndrome

Answer: Dandy-Walker malformation

2. Parents noticed her being increasingly irritable with frequent vomiting for the past 2 weeks.

4. Parents recently immigrated to the country.

5. Mother did not receive prenatal care during pregnancy due to a lack of health insurance.

6. Physical examination is unremarkable except for a head circumference over 2 standard deviations larger than the mean for her age, and delay in meeting motor developmental milestones.

7. MRI of her brain shows an enlargement of the posterior fossa.

8. MRI of her brain shows cystic dilation of the 4th ventricle.

9. MRI of her brain shows hypoplasia of the cerebellar vermis.

2. They recently immigrated to the country.

3. The mother did not receive prenatal care during pregnancy due to a lack of health insurance.

4. Physical examination is unremarkable.

5. Head circumference is over 2 standard deviations larger than the mean for her age.

6. Delay in meeting motor developmental milestones.

8. MRI shows cystic dilation of the 4th ventricle.

9. MRI shows hypoplasia of the cerebellar vermis.


Question: Which of the following brain regions, if lesioned, would most likely result in no change in this patient’s symptoms?

Context: She says the episodes are typically triggered by hunger, mental stress, physical exertion, and lack of sleep, although many times the trigger is not known.

Context: The patient says that each episode usually lasts for 6–24 hours and is often accompanied by nausea, vomiting, and intolerance to light.

Choices:
A. Red nucleus
B. Locus coeruleus
C. Nucleus raphe magnus
D. Periaqueductal gray

Answer: Red nucleus

1. A 28-year-old woman presents with a 3-year history of recurrent headaches.

2. The episodes are typically triggered by hunger, mental stress, physical exertion, and lack of sleep.

4. She describes her headaches as unilateral, severe, throbbing, and aggravated by movement.

5. Each episode usually lasts for 6–24 hours.

6. The episodes are often accompanied by nausea, vomiting, and intolerance to light.

1. Episodes are typically triggered by hunger.

2. Episodes are typically triggered by mental stress.

3. Episodes are typically triggered by physical exertion.

4. Episodes are typically triggered by lack of sleep.

6. Headaches are described as unilateral.

8. Headaches are described as throbbing.

9. Headaches are aggravated by movement.

10. Each episode usually lasts for 6–24 hours.

11. Episodes are often accompanied by nausea.

12. Episodes are often accompanied by vomiting.

13. Episodes are often accompanied by intolerance to light.


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

Choices:
A. Asthma
B. Congestive heart failure
C. Emphysema
D.
Asbestosis
"

Answer: Emphysema

Geriatric Medicine
General Internal Medicine

1. A 68-year-old man comes to the physician for a routine health maintenance examination.

2. He has had increasing shortness of breath and a productive cough for the past 1 year.

3. He can walk up a flight of stairs without stopping.

4. He has hypertension and his only medication is amlodipine.

5. He has a history of asthma during childhood.

6. He smoked 1 pack of cigarettes daily for 30 years but quit 16 years ago.

7. He used to work at a shipyard and retired 5 years ago.

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

12. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields.

13. Cardiac examination shows no murmurs, rubs, or gallops.

14. Spirometry shows an FEV1:FVC ratio of 63%.

16. His diffusing capacity for carbon monoxide (DLCO) is 40% of predicted.

1. He has had increasing shortness of breath and a productive cough for the past 1 year.

2. He can walk up a flight of stairs without stopping.

3. He has hypertension and his only medication is amlodipine.

4. He has a history of asthma during childhood.

5. He smoked 1 pack of cigarettes daily for 30 years but quit 16 years ago.

6. He used to work at a shipyard and retired 5 years ago.

7. His pulse is 98/min, respirations are 25/min and blood pressure is 134/88 mm Hg.

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

9. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields.

10. Cardiac examination shows no murmurs, rubs, or gallops.

11. Spirometry shows an FEV1:FVC ratio of 63% and an FEV1 of 65% of predicted.

12. His diffusing capacity for carbon monoxide (DLCO) is 40% of predicted.


Question: Which of the following substances was most likely elevated in his mother's serum during her pregnancy?

Context: A 9-year-old boy presents to his orthopedic surgeon for ongoing evaluation of his lower extremity deformities.

Context: Specifically, his hips have been dislocating over the last year despite bracing in hip-knee-ankle-foot orthoses.

Context: He is paralyzed from below the L2 nerve root and has difficulty with both bladder and bowel incontinence.

Context: He has had these abnormalities since birth due to a lower back lesion that required surgical closure during infancy.

Choices:
A. Alpha-fetoprotein
B. Beta-human chorionic growth hormone
C. Estriol
D. Sphingomyelin

Answer: Alpha-fetoprotein

1. A 9-year-old boy presents to his orthopedic surgeon.

2. His hips have been dislocating over the last year.

3. He has been wearing hip-knee-ankle-foot orthoses.

4. He is paralyzed from below the L2 nerve root.

5. He has difficulty with bladder and bowel incontinence.

6. He has had these abnormalities since birth.

7. He had a lower back lesion that required surgical closure during infancy.

1. His hips have been dislocating over the last year.

2. Dislocation occurred despite bracing in hip-knee-ankle-foot orthoses.

3. He is paralyzed from below the L2 nerve root.

4. He has difficulty with both bladder incontinence.

5. He has difficulty with bowel incontinence.

7. The abnormalities are due to a lower back lesion.

8. The lower back lesion required surgical closure during infancy.


Question: Which of the following is NOT necessary for PCR?

Context: PCR allows for amplification of a single piece of genetic material to produce trillions of idential copies.

Choices:
A. Taq polymerase
B. Reverse transcriptase
C. Primers
D. Target DNA strand

Answer: Reverse transcriptase

1. Polymerase chain reaction (PCR) has revolutionized the molecular biology field.

2. PCR allows for amplification of a single piece of genetic material.

3. Amplification of a single piece of genetic material produces trillions of identical copies.

1. PCR stands for polymerase chain reaction.

2. PCR allows amplification of genetic material.

3. PCR can produce trillions of identical copies of the genetic material.

4. PCR can amplify a single piece of genetic material.


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

Context: An investigator is studying the efficacy of antiviral drugs in infected human cells.

Context: In comparison with the control plates, the subsequent application of a guanosine analog to the experimental cell sets induces cell death in the virally infected cells but not in the healthy cells.

Choices:
A. Secretion of interferons by virally infected cells
B. Mutation of viral DNA polymerase
C. Phosphorylation by virally-encoded thymidine kinase
D. Inhibition of RNA-dependent DNA polymerase

Answer: Phosphorylation by virally-encoded thymidine kinase

1. An investigator is studying the efficacy of antiviral drugs.

2. Harvested human cells are inoculated onto four cell culture plates.

3. Live varicella-zoster virus (VZV) is administered to cells on two of the culture plates.

4. One healthy and one infected cell set are set aside as controls.

5. In comparison with the control plates, the subsequent application of a guanosine analog induces cell death in the virally infected cells.

6. The guanosine analog does not induce cell death in the healthy cells.

1. Harvested human cells are inoculated onto four cell culture plates.

2. Live varicella-zoster virus (VZV) is administered to cells on two of the culture plates.

3. One healthy and one infected cell set are set aside as controls.

4. The subsequent application of a guanosine analog to the experimental cell sets induces cell death in the virally infected cells.

5. The subsequent application of a guanosine analog to the experimental cell sets does not induce cell death in the healthy cells.


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

Context: A 13-year-old boy is brought to the physician because of pain and redness on his back for 2 days.

Context: He returned yesterday from a vacation to East Africa with his parents, where he took multiple rides on hot air balloons.

Context: Examination shows a tender, nonpruritic, erythematous rash with edema covering the extensor surface of both forearms, the shoulders, and the upper back, with small patches of skin exfoliation.

Choices:
A. Dress wound with wet gauze
B. Administer 2 liters of intravenous fluids
C. Apply topical mupirocin
D.
Apply aloe vera-based moisturizer
"

Answer:
Apply aloe vera-based moisturizer
"

1. A 13-year-old boy is brought to the physician.

2. He has had pain and redness on his back for 2 days.

3. He returned yesterday from a vacation to East Africa with his parents.

4. He took multiple rides on hot air balloons.

5. His vital signs are within normal limits.

6. Examination shows a tender, nonpruritic, erythematous rash with edema.

7. The rash covers the extensor surface of both forearms, the shoulders, and the upper back.

8. There are small patches of skin exfoliation.

9. The rash becomes pale when pressed and then rapidly regains color.

10. The remainder of the examination shows no abnormalities.

1. He returned yesterday from a vacation to East Africa with his parents.

2. He took multiple rides on hot air balloons during the vacation.

3. His vital signs are within normal limits.

4. Examination shows a tender, nonpruritic, erythematous rash with edema covering the extensor surface of both forearms, the shoulders, and the upper back.

5. Small patches of skin exfoliation are present in the affected areas.

6. The rash becomes pale when pressed and then rapidly regains color.

7. The remainder of the examination shows no abnormalities.


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

Context: A 55-year-old man comes to the emergency department because of headache, fever, chills, shortness of breath, and abdominal pain for 1 week.

Context: He also feels tired and nauseous.

Context: He has type 2 diabetes mellitus.

Context: Examination shows jaundice.

Context: Laboratory studies show: | Hemoglobin 9.2 g/dL | Leukocyte count 9,400/mm3 | Platelet count 90,000/mm3 | Serum | Na+ 137 mEq/L | Cl- 102 mEq/L | K+ 5.2 mEq/L | HCO3- 13 mEq/L | Glucose 69 mg/dL | Lactate dehydrogenase 360 U/L | Creatinine 0.9 mg/dL | Bilirubin | _ Total 4.2 mg/dL | _ Direct 0.8 mg/dL | AST 79 U/L | ALT 90 U/L | Urine | Blood 3+ | Protein trace | RBC 0–1/hpf | WBC 1–2/hpf | Arterial blood gas analysis on room air shows a pH of 7.31.

Choices:
A. Coombs test
B. Blood culture
C. Blood smear
D. Serology

Answer: Blood smear

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

2. He has been experiencing headache, fever, chills, shortness of breath, and abdominal pain for 1 week.

4. He returned from a trip to Botswana 2 weeks ago.

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

8. His only current medication is metformin.

13. Pulse oximetry on room air shows an oxygen saturation of 94%.

15. A few scattered inspiratory crackles are heard in the thorax.

16. The liver is palpated 2 cm below the right costal margin.

17. Laboratory studies show a hemoglobin of 9.2 g/dL.

18. Laboratory studies show a leukocyte count of 9,400/mm3.

19. Laboratory studies show a platelet count of 90,000/mm3.

20. Laboratory studies show a serum Na+ of 137 mEq/L.

21. Laboratory studies show a serum Cl- of 102 mEq/L.

22. Laboratory studies show a serum K+ of 5.2 mEq/L.

23. Laboratory studies show a serum HCO3- of 13 mEq/L.

24. Laboratory studies show a glucose of 69 mg/dL.

25. Laboratory studies show a lactate dehydrogenase of 360 U/L.

26. Laboratory studies show a creatinine of 0.9 mg/dL.

27. Laboratory studies show a total bilirubin of 4.2 mg/dL.

28. Laboratory studies show a direct bilirubin of 0.8 mg/dL.

29. Laboratory studies show an AST of 79 U/L.

30. Laboratory studies show an ALT of 90 U/L.

31. Laboratory studies show a urine blood of 3+.

2. He returned from a trip to Botswana 2 weeks ago.

4. He has smoked one pack of cigarettes daily for the past 30 years and drinks a glass of beer daily.

5. His only current medication is metformin.

6. His temperature is 39.3°C (102.8°F), pulse is 122/min, respirations are 28/min, and blood pressure is 109/84 mm Hg.

7. Pulse oximetry on room air shows an oxygen saturation of 94%.

9. A few scattered inspiratory crackles are heard in the thorax.

10. The liver is palpated 2 cm below the right costal margin.

11. Laboratory studies show: Hemoglobin 9.2 g/dL, Leukocyte count 9,400/mm3, Platelet count 90,000/mm3, Serum Na+ 137 mEq/L, Cl- 102 mEq/L, K+ 5.2 mEq/L, HCO3- 13 mEq/L, Glucose 69 mg/dL, Lactate dehydrogenase 360 U/L, Creatinine 0.9 mg/dL, Bilirubin Total 4.2 mg/dL, Bilirubin Direct 0.8 mg/dL, AST 79 U/L, ALT 90 U/L, Urine Blood 3+, Urine Protein trace, Urine RBC 0–1/hpf, Urine WBC 1–2/hpf.

12. Arterial blood gas analysis on room air shows a pH of 7.31.


Question: Which of the following was the most common finding in this cohort?

Context: A population study was conducted to evaluate coronary artery disease in the general population.

Context: A cohort of 700 patients underwent coronary angiography to evaluate the geographic distribution of coronary arteries throughout the heart.

Choices:
A. The SA node is supplied by a branch of the right coronary artery.
B. The AV node is supplied by a branch of the right coronary artery.
C. Right coronary artery dominance
D. A SA node is supplied by a branch of the left coronary artery.

Answer: Right coronary artery dominance

2. The study was to evaluate coronary artery disease in the general population.

4. The patients underwent coronary angiography.

5. The angiography was to evaluate the geographic distribution of coronary arteries throughout the heart.

1. A cohort of 700 patients underwent coronary angiography.

2. The purpose was to evaluate the geographic distribution of coronary arteries.

3. The evaluation was conducted throughout the heart.


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

Context: A 24-year-old woman comes to the physician because of intermittent episodes of stabbing facial pain for 4 months.

Context: The pain occurs over her left cheek, is 9 out of 10 in intensity, radiates towards her mouth, and lasts around half a minute before subsiding.

Context: These episodes commonly occur when she washes her face, brushes her teeth, or eats a meal.

Context: She does not have visual disturbances, weakness of her facial muscles, or hearing loss.

Context: She had a tooth extracted about 2 months ago, but the facial pain has persisted.

Context: She has hypothyroidism and vitiligo.

Context: She appears anxious.

Context: Vital signs are within normal limits.

Choices:
A. Microvascular decompression
B. Botulinum toxin injection
C. Radiofrequency rhizotomy
D. Carbamazepine

Answer: Carbamazepine

2. Patient has intermittent episodes of stabbing facial pain for 4 months.

6. Pain lasts around half a minute before subsiding.

7. Episodes commonly occur when she washes her face, brushes her teeth, or eats a meal.

8. Patient does not have visual disturbances, weakness of her facial muscles, or hearing loss.

9. Patient had a tooth extracted about 2 months ago.

11. Patient has hypothyroidism and vitiligo.

12. Patient's mother has major depressive disorder.

13. Current medications include levothyroxine and a herbal cream.

15. Vital signs are within normal limits.

16. Cardiopulmonary examination shows no abnormalities.

17. Neurologic examination shows no focal findings.

2. The pain is 9 out of 10 in intensity.

4. The pain lasts around half a minute before subsiding.

5. The episodes commonly occur when she washes her face.

6. The episodes commonly occur when she brushes her teeth.

7. The episodes commonly occur when she eats a meal.

8. She does not have visual disturbances.

9. She does not have weakness of her facial muscles.

11. She had a tooth extracted about 2 months ago.

12. The facial pain has persisted after the tooth extraction.

15. Her mother has major depressive disorder.

16. Her current medications include levothyroxine and a herbal cream.

18. Vital signs are within normal limits.

19. Cardiopulmonary examination shows no abnormalities.

20. Neurologic examination shows no focal findings.


Question: Occlusion of which of the following arteries is the most likely cause of this patient's symptoms?

Context: A 67-year-old man is brought to the emergency department after the sudden onset of dizziness, blurry vision, and a raspy voice.

Context: He has type 2 diabetes mellitus, hypercholesterolemia, coronary artery disease, and hypertension.

Context: He drinks three to four beers daily.

Context: His temperature is 36.6°C (98°F), pulse is 85/min, respirations are 18/min, and blood pressure is 142/90 mm Hg.

Context: The pupil on the left is pinpoint.

Context: There is ptosis of the left eye.

Context: Horizontal nystagmus is present.

Context: The gag reflex is diminished.

Choices:
A. Right middle cerebral artery
B. Left posterior inferior cerebellar artery
C. Right internal carotid artery
D. Left posterior cerebral artery

Answer: Left posterior inferior cerebellar artery

2. Patient has sudden onset of dizziness, blurry vision, and raspy voice.

3. Patient has type 2 diabetes mellitus, hypercholesterolemia, coronary artery disease, and hypertension.

4. Patient has smoked two packs of cigarettes daily for 30 years.

5. Patient drinks three to four beers daily.

6. Patient's current medications include metformin, atenolol, lisinopril, furosemide, and aspirin.

7. Patient's temperature is 36.6°C (98°F).

10. Patient's blood pressure is 142/90 mm Hg.

11. Patient is alert and oriented to person, place, and time.

16. Patient falls towards left side when standing without support.

17. Patient has loss of pain and temperature sensation over left face and right trunk and limbs.

5. He has smoked two packs of cigarettes daily for 30 years.

7. His current medications include metformin, atenolol, lisinopril, furosemide, and aspirin.

12. He is alert and oriented to person, place, and time.

17. When he stands without support, he falls towards his left side.

18. There is loss of pain and temperature sensation over the left face and right trunk and limbs.


Question: What is the most likely cause of her recent mental impairment?

Context: A 67-year-old woman with a recently found hepatic carcinoma has been an inpatient for more than a week.

Context: The patient was known to drink often, but reported that she has not consumed alcohol in weeks leading up to her admission.

Context: She is not jaundiced and has no metabolic imbalance upon laboratory tests.

Choices:
A. Delirium
B. Substance abuse
C. Brain metastasis
D. Delirium tremens

Answer: Delirium

1. A 67-year-old woman has been an inpatient for more than a week.

2. She has a recently found hepatic carcinoma.

3. During morning rounds, she was abnormally disoriented to time and place along with a shortened attention span.

4. The overnight resident reports that she was coming in and out of this state for the past couple nights.

5. The patient was known to drink often.

6. She reported that she has not consumed alcohol in weeks leading up to her admission.

8. She has no metabolic imbalance upon laboratory tests.

1. During morning rounds, the patient was abnormally disoriented to time and place.

2. The patient had a shortened attention span.

3. The overnight resident reports that the patient was coming in and out of this state for the past couple nights.

4. The patient was known to drink often.

5. The patient reported that she has not consumed alcohol in weeks leading up to her admission.

7. The patient has no metabolic imbalance upon laboratory tests.


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

Context: A 51-year-old man comes to the physician because of recurrent episodes of dizziness, tinnitus, and hearing loss on the left side for 6 weeks.

Context: These episodes last for hours at a time and are associated with the sensation that the room is spinning.

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

Context: The Rinne test is positive bilaterally.

Choices:
A. Dislodged otoliths
B. Acoustic neuroma
C. Endolymphatic hydrops
D. Posterior inferior cerebellar artery infarction

Answer: Endolymphatic hydrops

1. A 51-year-old man comes to the physician.

2. He has recurrent episodes of dizziness, tinnitus, and hearing loss on the left side for 6 weeks.

3. The episodes last for hours at a time.

4. He has the sensation that the room is spinning.

5. He has no history of major medical illness.

7. Examination shows horizontal nystagmus to the left.

8. Weber test shows lateralization to the right ear.

9. The Rinne test is positive bilaterally.

1. The episodes last for hours at a time.

2. The episodes are associated with the sensation that the room is spinning.

3. He has no history of major medical illness.

5. Examination shows horizontal nystagmus to the left.

6. Weber test shows lateralization to the right ear.

7. The Rinne test is positive bilaterally.


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

Context: A 37-year-old farmer presents to the emergency department with acute onset of complaints of diarrhea, excessive tearing, and increased saliva production.

Context: He is concerned that he is dehydrated, as he has also been urinating with increased frequency over the past several hours.

Context: His temperature is 97.6°F (36.4°C), blood pressure is 111/64 mmHg, pulse is 60/min, respirations are 10/min, and oxygen saturation is 98% on room air.

Context: Physical exam is significant for a moderately agitated and diaphoretic man who demonstrates pinpoint pupils.

Choices:
A. Atropine
B. Diphenhydramine
C. Naloxone
D. Physostigmine

Answer: Atropine

1. A 37-year-old farmer presents to the emergency department.

2. Complaints of diarrhea, excessive tearing, and increased saliva production.

3. He is concerned that he is dehydrated.

4. He has been urinating with increased frequency over the past several hours.

9. Oxygen saturation is 98% on room air.

10. Physical exam is significant for a moderately agitated and diaphoretic man.

8. Physical exam significant for agitation and diaphoresis


Question: Arterial blood gas analysis on room air shows: | pH 7.52 | PCO2 25 mm Hg | PO2 65 mm Hg | O2 saturation 92% | Physical examination is most likely to show which of the following findings?"

Context: A 54-year-old woman comes to the emergency department because of sharp chest pain and shortness of breath for 1 day.

Context: She has been coughing intermittently, which worsens the pain.

Context: She has osteoporosis, for which she takes raloxifene.

Choices:
A. Unilateral swelling of the leg
B. Increased anteroposterior diameter of the thorax
C. Grouped vesicles on the right hemithorax
D. Absent left radial pulse

Answer: Unilateral swelling of the leg

Pulmonary Disease
General Pulmonary Disease

1. A 54-year-old woman comes to the emergency department.

2. She has sharp chest pain and shortness of breath for 1 day.

3. She has been coughing intermittently.

6. She takes raloxifene for her osteoporosis.

1. She has been coughing intermittently.

4. She takes raloxifene for osteoporosis.


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

Context: A previously healthy 18-year-old woman comes to the emergency department because of diarrhea and abdominal cramps since the previous evening.

Context: She recollects eating out 2 days ago.

Context: Examination shows dry mucous membranes.

Context: Abdominal examination is unremarkable.

Choices:
A. Rotavirus
B. Norovirus
C. Vibrio vulnificus
D. Bacillus cereus

Answer: Norovirus

1. A previously healthy 18-year-old woman comes to the emergency department.

2. She has had diarrhea and abdominal cramps since the previous evening.

3. She has had around 3–4 episodes of watery stools.

4. She feels nauseous and has vomited twice.

5. She recollects eating out 2 days ago.

6. She has been on a vegan diet for 6 months.

8. She has not traveled anywhere recently.

12. Examination shows dry mucous membranes.

13. Abdominal examination is unremarkable.

1. She has had around 3–4 episodes of watery stools.

2. She feels nauseous and has vomited twice.

3. She recollects eating out 2 days ago.

4. She has been on a vegan diet for 6 months.

5. She takes no medications and has not traveled anywhere recently.

6. Her temperature is 36.8°(98.2°F), pulse is 73/min, and blood pressure is 110/70 mm Hg.

7. Examination shows dry mucous membranes.

8. Abdominal examination is unremarkable.


Question: The patient’s condition is most likely associated with impaired formation of which of the following?

Context: His mother says, “Sometimes when my son forgets to flush, his urine leaves dark stains in the toilet.” She is unconcerned because her son already had dark-colored urine as a baby and he has never had any health issues.

Choices:
A. Cystathionine
B. Methylmalonate
C. Tyrosine
D. Maleylacetoacetate

Answer: Maleylacetoacetate

General Medical Genetics and Genomics
Clinical Genetics and Genomics

1. A 6-year-old boy is brought to the physician for a well-child examination.

2. He has no history of major medical illness.

3. His mother says, “Sometimes when my son forgets to flush, his urine leaves dark stains in the toilet.”

4. She is unconcerned because her son already had dark-colored urine as a baby and he has never had any health issues.

5. His vital signs are within normal limits.

6. Physical examination shows no abnormalities.

1. He has no history of major medical illness.

2. His mother says, “Sometimes when my son forgets to flush, his urine leaves dark stains in the toilet.”

3. She is unconcerned because her son already had dark-colored urine as a baby.


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

Context: A 72-year-old man presents with a recent episode of slurred speech and numbness in his left arm and left leg 2 hours ago that resolved completely within 45 minutes.

Context: He says he was having breakfast when he noticed that he had difficulty talking and the left side of his body was numb.

Context: Past medical history is significant for type 2 diabetes mellitus, hypertension, and ischemic heart disease.

Context: He had a coronary artery bypass graft 12 years ago and a percutaneous intervention 3 years ago.

Context: His vital signs include: blood pressure 143/97 mm Hg, pulse 80/min, oxygen saturation 98% on room air.

Context: Higher mental functions are intact.

Context: Muscle strength is 5 out of 5l in both upper and lower limbs bilaterally.

Context: The sensation is intact.

Context: Cerebellar signs are absent and his gait is normal.

Choices:
A. Add clopidogrel and discharge the patient
B. Admit the patient for observation and workup
C. Discharge now and ask him to visit again when symptoms reoccur
D. Start antiepileptic drugs

Answer: Admit the patient for observation and workup

2. Patient had an episode of slurred speech and numbness in his left arm and left leg 2 hours ago that resolved completely within 45 minutes.

3. Patient was having breakfast when he noticed difficulty talking and numbness on left side of body.

4. Patient denies any past similar symptoms.

5. Patient has past medical history of type 2 diabetes mellitus, hypertension, and ischemic heart disease.

6. Patient had coronary artery bypass graft 12 years ago and percutaneous intervention 3 years ago.

7. Patient is currently taking aspirin, metformin, nitrates, and rosuvastatin.

8. Patient's blood pressure is 143/97 mm Hg, pulse 80/min, oxygen saturation 98% on room air.

9. Patient is alert and oriented with higher mental functions intact.

10. Muscle strength is 5 out of 5 in both upper and lower limbs bilaterally.

1. The patient was having breakfast when he noticed difficulty talking and numbness on the left side of his body.

2. The patient denies any past similar symptoms.

3. Past medical history includes type 2 diabetes mellitus, hypertension, and ischemic heart disease.

4. The patient had a coronary artery bypass graft 12 years ago and a percutaneous intervention 3 years ago.

5. Current medications are aspirin, metformin, nitrates, and rosuvastatin.

6. Vital signs: blood pressure 143/97 mm Hg, pulse 80/min, oxygen saturation 98% on room air.

7. On physical examination, the patient is alert and oriented.

9. Muscle strength is 5 out of 5 in both upper and lower limbs bilaterally.

11. Cerebellar signs are absent and gait is normal.


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

Context: His temperature is 37°C (98.6°F), pulse is 126/min, respirations are 30/min and shallow, and blood pressure is 84/44 mm Hg.

Context: He is unresponsive to painful stimuli.

Context: The lungs are clear to auscultation.

Context: Laboratory studies show: | Serum | Na+ 146 mmol/L | K+ 7.7 mmol/L | Cl- 111 mmol/L | Urea nitrogen 5.8 mmol/L | Glucose 83 mg/dL | Lactate 11.2 mmol/L | Serum osmolality 379 mosm/kg | Arterial blood gas analysis shows: | pH 6.69 | pCO2 53 mm Hg | pO2 84 mm Hg | HCO3- 4.3 mmol/L | The patient is intubated and fluid resuscitation is begun.

Choices:
A. N-acetylcysteine
B. Fomepizole
C. Naloxone
D. Flumazenil

Answer: Fomepizole

Medical Toxicology
General Emergency Medicine

1. A 29-year-old man is brought to the emergency department after being found unresponsive at home.

2. The patient's roommate says that the patient had previously been feeling well.

3. The patient and his roommate had a celebration the night before, where they drank homemade liquor.

8. Pulse oximetry on room air shows an oxygen saturation of 96%.

9. He is unresponsive to painful stimuli.

10. The pupils are 3 mm, equal, round, and reactive to light.

11. The lungs are clear to auscultation.

12. Cardiac examination shows a grade 2/6 systolic murmur along the left parasternal border.

13. Laboratory studies show: Na+ 146 mmol/L, K+ 7.7 mmol/L, Cl- 111 mmol/L, Urea nitrogen 5.8 mmol/L, Glucose 83 mg/dL, Lactate 11.2 mmol/L, Serum osmolality 379 mosm/kg.

14. Arterial blood gas analysis shows: pH 6.69, pCO2 53 mm Hg, pO2 84 mm Hg, HCO3- 4.3 mmol/L.

1. The patient's roommate says that the patient had previously been feeling well.

2. The patient and his roommate had a celebration the night before, where they drank homemade liquor.

5. His respirations are 30/min and shallow.

7. Pulse oximetry on room air shows an oxygen saturation of 96%.

8. He is unresponsive to painful stimuli.

9. The pupils are 3 mm, equal, round, and reactive to light.

10. The lungs are clear to auscultation.

11. Cardiac examination shows a grade 2/6 systolic murmur along the left parasternal border.

12. Laboratory studies show: Serum Na+ 146 mmol/L, K+ 7.7 mmol/L, Cl- 111 mmol/L, Urea nitrogen 5.8 mmol/L, Glucose 83 mg/dL, Lactate 11.2 mmol/L, Serum osmolality 379 mosm/kg.

13. Arterial blood gas analysis shows: pH 6.69, pCO2 53 mm Hg, pO2 84 mm Hg, HCO3- 4.3 mmol/L.

14. The patient is intubated and fluid resuscitation is begun.


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

Context: A 22-year-old woman presents with an episodic history of swelling of the face, hands, and neck and a single episode of difficulty swallowing.

Context: She also has a history of frequent, severe abdominal pain.

Context: At the time of her visit, her blood pressure is 126/84 mm Hg, heart rate is 82/min, and respiratory rate is 15/min.

Choices:
A. DiGeorge syndrome
B. Hereditary angioedema
C. Paroxysmal nocturnal hemoglobinuria
D. Chediak-Higashi syndrome

Answer: Hereditary angioedema

2. Patient has episodic history of swelling of the face, hands, and neck.

3. Patient has a single episode of difficulty swallowing.

4. Patient has a history of frequent, severe abdominal pain.

5. Patient's blood pressure is 126/84 mm Hg.

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

8. Physical examination is unremarkable except for a swollen right hand.

9. Imaging studies are normal and do not reveal any cause of her pain.

10. Patient's C1 inhibitor level is less than 6% of the reference value.

1. She has a history of frequent, severe abdominal pain.

2. At the time of her visit, her blood pressure is 126/84 mm Hg.

3. At the time of her visit, her heart rate is 82/min.

4. At the time of her visit, her respiratory rate is 15/min.

5. Physical examination is unremarkable except for a swollen right hand as shown in the image below.

6. Imaging studies are normal and do not reveal any cause of her pain.

7. Her C1 inhibitor level is less than 6% of the reference value.


Question: Which of the following is the most appropriate statement by the physician at this time?

Context: A 60-year-old man calls his hospital and asks to speak to his physician about laboratory test reports ordered because of a 3-month history of abdominal fullness and generalized fatigue.

Context: The referral note shows that he was constipated for the previous week.

Context: His abdominal examination had shown distention, and a 7-cm, hard, irregular, nontender mass was palpable on rectal examination.

Context: His colonoscopy report reveals a low anterior circumferential rectal lesion.

Context: An MRI of the pelvis shows a rectal mass with involvement of the prostate and seminal vesicles.

Context: A brief review of the results shows that an endoscopic biopsy confirms the clinical diagnosis of advanced rectal adenocarcinoma.

Context: His serum carcinoembryonic antigen concentration is 21.0 ng/mL (N < 2.5).

Choices:
A. """Your lab reports show that you have a locally advanced rectal adenocarcinoma"""
B. """Would you like to know all the details of your diagnosis, or would you prefer I just explain to you what our options are?"""
C. """I would like to meet later today at 4:00 PM so that we have enough time to discuss the lab results. If you'd like a friend or family member to accompany you, feel free to bring them along."""
D. """You must be be curious as to why all these tests were ordered, and you may even be anxious about the results."""

Answer: """I would like to meet later today at 4:00 PM so that we have enough time to discuss the lab results. If you'd like a friend or family member to accompany you, feel free to bring them along."""

1. A 60-year-old man called his hospital.

2. He asked to speak to his physician about laboratory test reports.

3. The laboratory test reports were ordered because of a 3-month history of abdominal fullness and generalized fatigue.

4. The referral note showed that he was constipated for the previous week.

5. His abdominal examination had shown distention.

6. A 7-cm, hard, irregular, nontender mass was palpable on rectal examination.

7. His colonoscopy report revealed a low anterior circumferential rectal lesion.

8. An MRI of the pelvis showed a rectal mass with involvement of the prostate and seminal vesicles.

9. A brief review of the results showed that an endoscopic biopsy confirmed the clinical diagnosis of advanced rectal adenocarcinoma.

10. His serum carcinoembryonic antigen concentration was 21.0 ng/mL (N < 2.5).

11. The physician was tasked with delivering the diagnosis to the patient.

1. The referral note shows constipation for the previous week.

2. Abdominal examination showed distention.

3. A 7-cm, hard, irregular, nontender mass was palpable on rectal examination.

4. Colonoscopy report reveals a low anterior circumferential rectal lesion.

5. MRI of the pelvis shows a rectal mass with involvement of the prostate and seminal vesicles.

6. Endoscopic biopsy confirms the clinical diagnosis of advanced rectal adenocarcinoma.

7. Serum carcinoembryonic antigen concentration is 21.0 ng/mL (N < 2.5).

8. The physician is tasked with delivering the diagnosis to the patient.


Question: Prior to discharge, administration of which of the following is most appropriate in this patient?

Context: A 50-year-old man has a kidney transplantation for end-stage renal disease in the setting of long-standing polycystic kidney disease.

Choices:
A. Azithromycin
B. Trimethoprim-sulfamethoxazole
C. Acyclovir
D. Varicella vaccine

Answer: Trimethoprim-sulfamethoxazole

1. A 50-year-old man has a kidney transplantation.

2. The transplantation is for end-stage renal disease.

3. The end-stage renal disease is in the setting of long-standing polycystic kidney disease.

4. His postoperative course is uncomplicated.

5. He smoked one pack of cigarettes daily for 20 years.

9. Current medications include basiliximab, mycophenolate mofetil, and prednisone.

10. His vital signs are within normal limits.

11. On physical examination, the surgical incisions appear clean and intact.

1. His postoperative course is uncomplicated.

2. He had smoked one pack of cigarettes daily for 20 years but quit 5 years ago.

3. He does not drink alcohol or use illicit drugs.

4. Current medications include basiliximab, mycophenolate mofetil, and prednisone.

5. His vital signs are within normal limits.

6. On physical examination, the surgical incisions appear clean and intact.


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

Context: A 28-year-old woman, gravida 1, para 0, at 32 weeks' gestation comes to the physician for a prenatal visit.

Context: She has had no prenatal care.

Context: She emigrated from China 5 years ago and cannot recall all of her vaccinations.

Context: She appears well.

Context: Serum studies show: | Anti-hepatitis A IgM antibody negative | Anti-hepatitis A IgG antibody positive | Hepatitis B surface antigen negative | Anti-hepatitis B surface antibody positive | Hepatitis B core antigen negative | Anti-hepatitis B core antibody negative | .

Choices:
A. Plan normal vaginal delivery at term
B. Determine hepatitis B e antigen serum level
C. Administer hepatitis B vaccine to mother
D. Perform liver biopsy of mother

Answer: Plan normal vaginal delivery at term

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

2. She is gravida 1, para 0, at 32 weeks' gestation.

4. She emigrated from China 5 years ago.

5. She cannot recall all of her vaccinations.

7. Physical examination shows a uterus consistent in size with a 32-week gestation.

8. Anti-hepatitis A IgM antibody is negative.

9. Anti-hepatitis A IgG antibody is positive.

10. Hepatitis B surface antigen is negative.

11. Anti-hepatitis B surface antibody is positive.

12. Hepatitis B core antigen is negative.

13. Anti-hepatitis B core antibody is negative.

2. She emigrated from China 5 years ago.

3. She cannot recall all of her vaccinations.

5. Physical examination shows a uterus consistent in size with a 32-week gestation.

6. Serum studies show: Anti-hepatitis A IgM antibody negative.

7. Serum studies show: Anti-hepatitis A IgG antibody positive.

8. Serum studies show: Hepatitis B surface antigen negative.

9. Serum studies show: Anti-hepatitis B surface antibody positive.

10. Serum studies show: Hepatitis B core antigen negative.

11. Serum studies show: Anti-hepatitis B core antibody negative.


Question: Which of the following is a potential side effect of this medication?

Context: During the visit, the patient asks her physician for help quitting smoking cigarettes.

Context: She has unsuccessfully tried quitting several times previously and has also failed prior attempts with meditation and exercise.

Choices:
A. Seizure
B. Sexual dysfunction
C. Suicidal ideation
D. Tachycardia

Answer: Suicidal ideation

General Internal Medicine
General Family Medicine

1. A 58-year-old woman presents to her family physician for an annual checkup.

2. The patient asks her physician for help quitting smoking cigarettes.

3. She has unsuccessfully tried quitting several times previously.

4. She has also failed prior attempts with meditation and exercise.

5. The physician prescribes a partial agonist of the nicotinic receptor to aid the patient in cessation.

1. The patient asks her physician for help quitting smoking cigarettes during the visit.

2. She has unsuccessfully tried quitting several times previously.

3. She has also failed prior attempts with meditation and exercise.

4. The physician prescribes a partial agonist of the nicotinic receptor to aid the patient in cessation.


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

Context: A 57-year-old man with chronic obstructive pulmonary disease comes to the emergency department because of leg swelling for 2 weeks.

Choices:
A. Left-sided systolic heart failure
B. Ventricular septal defect
C. Chronic occlusion of the pulmonary vessels
D. Chronic hypoxic vasoconstriction

Answer: Chronic hypoxic vasoconstriction

1. A 57-year-old man with chronic obstructive pulmonary disease comes to the emergency department.

2. He has smoked 2 packs of cigarettes daily for the past twenty years.

3. His vital signs are within normal limits.

4. Physical examination shows jugular venous distention.

5. Physical examination shows hepatomegaly.

6. Physical examination shows pitting edema of both lower extremities.

7. Cardiac examination shows a regular heart rate.

8. Cardiac examination shows normal heart sounds.

9. Auscultation of the lungs shows scattered wheezing without crackles.

10. Left ventricular ejection fraction is 60%.

1. He has smoked 2 packs of cigarettes daily for the past twenty years.

2. His vital signs are within normal limits.

3. Physical examination shows jugular venous distention, hepatomegaly, and pitting edema of both lower extremities.

4. Cardiac examination shows a regular heart rate and normal heart sounds.

5. Auscultation of the lungs shows scattered wheezing without crackles.

6. Left ventricular ejection fraction is 60%.


Question: What is the most likely diagnosis?

Context: A young Mediterranean teen brings her 4-year-old little brother to the Emergency Room because of a high temperature.

Context: Their parents are on their way to the hospital, but, in the meantime, she provides some of the history.

Context: This morning, she had trouble awakening him, and she noticed some swelling and redness around his right ankle.

Context: He had to receive extra vaccinations as an infant, and he takes an antibiotic everyday.

Context: On exam in the ED, his temperature is 102.4 deg F (39.1 deg C), blood pressure is 90/60 mmHg, pulse is 123/min, and respirations are 22/min.

Context: He is lethargic, and his exam is noteworthy for erythema and edema in an area surrounding his distal shin.

Choices:
A. Dactylitis
B. Avascular necrosis
C. Osteomyelitis
D. Thrombophlebitis

Answer: Osteomyelitis

General Pediatrics
Pediatric Infectious Diseases

1. A young Mediterranean teen brings her 4-year-old little brother to the Emergency Room.

2. Their parents are on their way to the hospital.

3. She explains that he has been running a fever and limping for the past week.

4. This morning, she had trouble awakening him.

5. She noticed some swelling and redness around his right ankle.

6. In terms of his past medical history, she knows he has something wrong with his blood.

7. He had to receive extra vaccinations as an infant.

9. On exam in the ED, his temperature is 102.4 deg F (39.1 deg C).

14. His exam is noteworthy for erythema and edema in an area surrounding his distal shin.

1. Their parents are on their way to the hospital.

2. She explains that he has been running a fever and limping for the past week.

3. This morning, she had trouble awakening him.

4. She noticed some swelling and redness around his right ankle.

5. He has something wrong with his blood.

6. He had to receive extra vaccinations as an infant.

8. On exam in the ED, his temperature is 102.4 deg F (39.1 deg C).

13. His exam is noteworthy for erythema and edema in an area surrounding his distal shin.


Question: Which of the following is the next best step in management of the patient’s condition?

Context: He is a truck driver.

Context: Fluid analysis is shown below: |  | Serum: | Albumin: 4.0 g/dL |  | Ascitic fluid: | Color: Yellow | Leukocyte count: 100/mm^3 with 50% neutrophils | Protein: 2.3 g/dL | Albumin: 1.9 g/dL |  | A culture is pending.

Choices:
A. Atenolol
B. Ceftriaxone
C. Propranolol
D. Transjugular intrahepatic portosystemic shunt

Answer: Propranolol

1. A 47-year-old man comes to the emergency department complaining of weight gain and abdominal discomfort.

2. He states that over the past month he has gained 10 lbs.

3. This week he began experiencing mild, diffuse abdominal discomfort.

4. He denies nausea, vomiting, constipation, or diarrhea.

5. The patient has not seen a physician in years and takes no medications.

7. He states that he drinks a 6-pack of beer per night.

8. On physical examination, there is jaundice, hepatomegaly, and a positive fluid wave.

9. An abdominal ultrasound reveals cirrhosis, portal vein dilation, and moderate ascites.

10. He undergoes a paracentesis that relieves his symptoms.

11. Fluid analysis of serum shows albumin of 4.0 g/dL.

12. Fluid analysis of ascitic fluid shows color of yellow, leukocyte count of 100/mm^3 with 50% neutrophils, protein of 2.3 g/dL, and albumin of 1.9 g/dL.

14. He is discharged and instructed to follow-up with a gastroenterologist for an upper endoscopy.

15. Upper endoscopy reveals multiple, small non-bleeding esophageal varices.

1. The patient has gained 10 lbs over the past month.

2. The patient began experiencing mild, diffuse abdominal discomfort this week.

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

4. The patient has not seen a physician in years and takes no medications.

6. The patient drinks a 6-pack of beer per night.

7. On physical examination, there is jaundice, hepatomegaly, and a positive fluid wave.

8. An abdominal ultrasound reveals cirrhosis, portal vein dilation, and moderate ascites.

9. The patient undergoes a paracentesis that relieves his symptoms.

10. Fluid analysis shows serum albumin at 4.0 g/dL, ascitic fluid color as yellow, leukocyte count at 100/mm^3 with 50% neutrophils, ascitic fluid protein at 2.3 g/dL, and ascitic fluid albumin at 1.9 g/dL.

12. The patient is discharged and instructed to follow-up with a gastroenterologist for an upper endoscopy.

13. Upper endoscopy reveals multiple, small non-bleeding esophageal varices.


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

Context: An 8-month-old boy is brought to the office by his mother for recurrent infections.

Context: There is no fever but the mother adds that the boy is not eating very well.

Context: His mother denies any history of infection during her pregnancy and was tested negative for HIV.

Choices:
A. Adenosine deaminase deficiency
B. Hypoxanthine-guanine phosphoribosyl transferase (HGPRT) deficiency
C. HIV infection
D. Purine nucleoside phosphorylase deficiency

Answer: Adenosine deaminase deficiency

Immunology and Allergy
Immunology (Pediatric Immunology)
Immunology

1. An 8-month-old boy is brought to the office by his mother.

2. Over the past 2 months, the boy had multiple visits to the urgent care clinic for respiratory, ear, and skin infections.

3. His mother is concerned about the health of her child.

4. Currently, the child had a runny nose for the last 2 days.

6. The mother adds that the boy is not eating very well.

7. His mother denies any history of infection during her pregnancy.

8. His mother was tested negative for HIV.

10. The patient’s respiratory rate is 14/min.

11. The patient’s temperature is 36.7°C (98.0°F).

12. On physical exam, there are decreased lung sounds in the left lower lobe.

13. A chest X-ray reveals an absent thymic shadow.

14. The chest X-ray fails to show any lung pathology.

15. There is no history of similar symptoms in the families of either parent.

1. The boy had multiple visits to the urgent care clinic for respiratory, ear, and skin infections over the past 2 months.

2. The mother is concerned about the health of her child.

3. The child had a runny nose for the last 2 days.

4. There is no fever, but the boy is not eating very well.

5. The mother denies any history of infection during her pregnancy and was tested negative for HIV.

6. The patient’s heart rate is 90/min, respiratory rate is 14/min, and temperature is 36.7°C (98.0°F).

7. On physical exam, there are decreased lung sounds in the left lower lobe.

8. A chest X-ray reveals an absent thymic shadow and fails to show any lung pathology.

9. There is no history of similar symptoms in the families of either parent.


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

Context: A 4-year-old girl is brought to the physician because of a nonpruritic, painless rash on her face for 5 days.

Context: She was born at term and has been healthy since.

Context: Her development is adequate for her age and immunizations are up-to-date.

Context: She appears healthy and well-nourished.

Context: Her temperature is 37°C (98.6°F) and pulse is 90/min.

Choices:
A. Potassium hydroxide preparation
B. Oral cephalexin therapy
C. Skin biopsy
D. Topical mupirocin therapy

Answer: Topical mupirocin therapy

2. Patient has a nonpruritic, painless rash on her face for 5 days.

4. Patient has been healthy since birth.

5. Patient's 62-year-old maternal grandmother has bullous pemphigoid.

6. Patient's development is adequate for her age.

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

8. Patient appears healthy and well-nourished.

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

11. Examination shows a nontender rash on the right side of the patient's face.

12. An image of the patient's lower face is shown.

13. The remainder of the examination shows no abnormalities.

3. Her 62-year-old maternal grandmother has bullous pemphigoid.

4. Her development is adequate for her age.

10. Examination shows a nontender rash on the right side of the patient's face.

11. An image of the patient's lower face is shown.

12. The remainder of the examination shows no abnormalities.