Question: Which of the symptoms below is most commonly associated with the patient’s condition?

Context: She complains of recurrent headaches and involuntary weight loss, which she attributes to a constant pain along the right side of her jaw that occasionally radiates to her right eye.

Context: Today, her blood pressure is 135/90 mm Hg, heart rate is 88/min, respiratory rate is 15/min, and temperature is 36.6°C (97.9°F).

Choices:
A. Limb muscle weakness
B. Neck stiffness
C. Diplopia
D. Shock-like pain in face

Answer: Neck stiffness

1. A 55-year-old woman visits her primary care provider for concerns of frequent headaches.

2. She complains of recurrent headaches and involuntary weight loss.

3. She attributes the headaches and weight loss to a constant pain along the right side of her jaw that occasionally radiates to her right eye.

4. Her past medical history includes diabetes mellitus type 2 and chronic glomerulonephritis resulting in stage II chronic kidney disease.

5. Her mother passed away in her 70s and had been diagnosed with multiple sclerosis at the age of 50.

10. The right side of her face is painful to palpation from her jaw to the right side of her scalp.

1. She complains of recurrent headaches.

2. She complains of involuntary weight loss.

3. She attributes her symptoms to a constant pain along the right side of her jaw.

4. The pain occasionally radiates to her right eye.

5. Her past medical history includes diabetes mellitus type 2.

6. Her past medical history includes chronic glomerulonephritis resulting in stage II chronic kidney disease.

8. Her mother had been diagnosed with multiple sclerosis at the age of 50.

13. The right side of her face is painful to palpation from her jaw to the right side of her scalp.


Question: Which of the following additional findings is most strongly associated with this patient’s condition?

Context: His gait is normal.

Choices:
A. Abdominal bruit
B. Asymmetric upper extremity pulses
C. Continuous machine-like murmur
D. Costovertebral tenderness

Answer: Abdominal bruit

1. A 66-year-old man presents to his primary care provider for a routine checkup.

2. He says that he feels well overall but has experienced some intermittent back pain and vague epigastric pain over the past 6 months.

3. He also has experienced cramping in both legs that is worse whenever he walks for long periods of time.

4. He has a history of poorly controlled hypertension, diabetes mellitus, recurrent renal stones, and major depressive disorder.

5. He takes lisinopril, nifedipine, metformin, glyburide, and fluoxetine.

6. He has a 55-pack-year smoking history and drinks alcohol socially.

7. His temperature is 98.4°F (36.9°C), blood pressure is 155/85 mmHg, pulse is 92/min, and respirations are 16/min.

8. On exam, he is well-appearing and in no acute distress.

9. A normal S1 and S2 are heard on auscultation.

10. He has no abdominal tenderness to palpation.

11. A light pulsatile mass is felt in the mid-epigastrium.

12. Achilles and patellar reflexes are 2+ bilaterally.

2. He has experienced intermittent back pain over the past 6 months

3. He has experienced vague epigastric pain over the past 6 months

4. He has experienced cramping in both legs

5. Cramping is worse whenever he walks for long periods of time

6. He has a history of poorly controlled hypertension

7. He has a history of diabetes mellitus

8. He has a history of recurrent renal stones

9. He has a history of major depressive disorder

15. He has a 55-pack-year smoking history

23. A normal S1 is heard on auscultation

24. A normal S2 is heard on auscultation

25. He has no abdominal tenderness to palpation

26. A light pulsatile mass is felt in the mid-epigastrium

27. Achilles reflexes are 2+ bilaterally

28. Patellar reflexes are 2+ bilaterally


Question: A mutation in which of the following proteins most likely contributed to this patient’s condition?

Context: He is unresponsive and pulseless.

Context: The patient had no past medical history other than a heart murmur as a child and he took no medications.

Choices:
A. Myosin heavy chain
B. Dystrophin
C. Fibrilin
D. Elastin

Answer: Myosin heavy chain

1. A 17-year-old male collapses 25 minutes into a soccer game.

3. Despite adequate resuscitation by a bystander, the patient is pronounced dead when the ambulance arrives.

4. The patient had no past medical history other than a heart murmur as a child.

6. His family history is notable for an uncle who died suddenly of unknown causes at the age of 25.

3. The patient was resuscitated by a bystander.

4. The patient was pronounced dead when the ambulance arrived.

5. The patient had a heart murmur as a child.

6. The patient had no past medical history other than a heart murmur.

8. The patient's family history includes an uncle who died suddenly at the age of 25.

9. The cause of the uncle's death is unknown.


Question: Which of the following findings is most likely on ultrasound?

Context: A 36-year-old woman, gravida 3, para 2, at 31 weeks' gestation comes to the emergency department because of painless, bright red vaginal bleeding for one day.

Context: She has not felt any contractions.

Choices:
A. Retroplacental hematoma
B. Adnexal bleeding
C. Placenta over the cervical os
D. Gestational sac in a dilated cervix

Answer: Placenta over the cervical os

1. A 36-year-old woman comes to the emergency department.

4. She has painless, bright red vaginal bleeding for one day.

6. Her other children were delivered by Cesarean section.

7. The Cesarean section was due to breech position.

8. Fetal heart rate is reactive with no decelerations.

2. Her other children were delivered by Cesarean section because of breech position.

3. Fetal heart rate is reactive with no decelerations.


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

Context: A 24-year-old man is brought to the emergency department for bowling at a local bowling alley while inappropriately dressed.

Context: The patient refused to speak with police and was seen conversing with inanimate objects in the back of the police car.

Choices:
A. Dehydration
B. Dopamine blockade
C. Inadequate evaporative cooling
D. Infection

Answer: Dopamine blockade

1. A 24-year-old man is brought to the emergency department.

2. The patient was bowling at a local bowling alley while inappropriately dressed.

3. The patient refused to speak with police.

4. The patient was seen conversing with inanimate objects in the back of the police car.

5. The patient states that his clothes were contaminated by assassins who have been tracking him for years.

6. The patient refuses to answer any further questions, and continues to whisper toward someone else.

7. The patient has a past medical history of homelessness, alcohol abuse, marijuana use, and cocaine abuse.

8. Physical exam is notable for a healthy young man who seems mistrustful of all hospital personnel.

9. The patient is started on a medication and is transferred to the psychiatric inpatient unit.

10. The patient’s condition improves, but he still often speaks of a contamination that is on his clothes and skin that is coming from external parties.

11. The patient is started on a new medication.

12. He is then sent to group therapy, followed by physical activity in the yard.

13. The physician is called over when the patient is found down in the recreation yard while he was exercising.

14. The patient is not responsive, and his limbs seem to resist passive force.

15. His temperature is 104°F (40°C), pulse is 112/min, blood pressure is 140/90 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air.

1. The patient refused to speak with police.

2. The patient was seen conversing with inanimate objects in the back of the police car.

3. The patient states that his clothes were contaminated by assassins who have been tracking him for years.

4. The patient refuses to answer any further questions.

5. The patient continues to whisper toward someone else.

6. The patient has a past medical history of homelessness, alcohol abuse, marijuana use, and cocaine abuse.

7. Physical exam is notable for a healthy young man who seems mistrustful of all hospital personnel.

8. The patient is started on a medication and is transferred to the psychiatric inpatient unit.

9. The patient’s condition improves, but he still often speaks of a contamination that is on his clothes and skin that is coming from external parties.

10. The patient is started on a new medication.

11. The patient is sent to group therapy, followed by physical activity in the yard.

12. The physician is called over when the patient is found down in the recreation yard while he was exercising.

14. The patient's limbs seem to resist passive force.

15. The patient's temperature is 104°F (40°C).

17. The patient's blood pressure is 140/90 mmHg.

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

19. The patient's oxygen saturation is 95% on room air.


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

Context: The patient is started on haloperidol and most of his symptoms improve dramatically; however, he continues to refuse to eat food from the hospital as he believes it to be contaminated.

Context: The patient stays on the inpatient psychiatric unit and lab values are drawn and return as follows: |  | Serum: | Na+: 135 mEq/L | K+: 3.0 mEq/L | Cl-: 92 mEq/L | HCO3-: 22 mEq/L | BUN: 7 mg/dL | Ca2+: 8.4 mg/dL | Creatinine: 0.6 mg/dL | Glucose: 70 mg/dL |  | That patient is started on an intravenous solution containing potassium chloride and is closely monitored.

Context: Lab values are ordered again the following day and return as follows: |  | Serum: | Na+: 137 mEq/L | K+: 2.9 mEq/L | Cl-: 95 mEq/L | HCO3-: 22 mEq/L | BUN: 8 mg/dL | Ca2+: 9.0 mg/dL | Creatinine: 1.0 mg/dL | Glucose: 77 mg/dL |  | The patient is continued on IV fluids and his clinical symptoms seem to further improve.

Choices:
A. Discharge the patient on IM haloperidol
B. IV fluids containing potassium
C. IV fluids containing magnesium
D. Increase oral intake

Answer: IV fluids containing magnesium

General Psychiatry
General Emergency Medicine

1. A 23-year-old male presents to the emergency department after he was found naked wandering his neighborhood.

2. The patient is disheveled and has not bathed in months.

3. The patient has a past medical history of alcohol abuse and schizophrenia that is well controlled with haloperidol.

4. The patient is started on haloperidol and most of his symptoms improve dramatically.

5. The patient continues to refuse to eat food from the hospital as he believes it to be contaminated.

6. The patient stays on the inpatient psychiatric unit.

7. Lab values are drawn and return as follows: Serum Na+: 135 mEq/L, K+: 3.0 mEq/L, Cl-: 92 mEq/L, HCO3-: 22 mEq/L, BUN: 7 mg/dL, Ca2+: 8.4 mg/dL, Creatinine: 0.6 mg/dL, Glucose: 70 mg/dL.

8. The patient is started on an intravenous solution containing potassium chloride and is closely monitored.

9. His oral intake also seems to be improving.

10. Lab values are ordered again the following day and return as follows: Serum Na+: 137 mEq/L, K+: 2.9 mEq/L, Cl-: 95 mEq/L, HCO3-: 22 mEq/L, BUN: 8 mg/dL, Ca2+: 9.0 mg/dL, Creatinine: 1.0 mg/dL, Glucose: 77 mg/dL.

11. The patient is continued on IV fluids and his clinical symptoms seem to further improve.

12. Repeat labs the following three days remains largely unchanged.

13. The patient's symptoms improve and he is determined to be at his baseline in terms of functioning.

1. The patient is disheveled and has not bathed in months.

2. The patient has a past medical history of alcohol abuse.

3. The patient has a past medical history of schizophrenia.

4. The patient's schizophrenia is well controlled with haloperidol.

5. The patient is started on haloperidol and most of his symptoms improve dramatically.

6. The patient continues to refuse to eat food from the hospital as he believes it to be contaminated.

7. The patient stays on the inpatient psychiatric unit.

8. Lab values are drawn and return as follows: Serum: Na+: 135 mEq/L, K+: 3.0 mEq/L, Cl-: 92 mEq/L, HCO3-: 22 mEq/L, BUN: 7 mg/dL, Ca2+: 8.4 mg/dL, Creatinine: 0.6 mg/dL, Glucose: 70 mg/dL.

9. The patient is started on an intravenous solution containing potassium chloride and is closely monitored.

10. The patient's oral intake seems to be improving.

11. Lab values are ordered again the following day and return as follows: Serum: Na+: 137 mEq/L, K+: 2.9 mEq/L, Cl-: 95 mEq/L, HCO3-: 22 mEq/L, BUN: 8 mg/dL, Ca2+: 9.0 mg/dL, Creatinine: 1.0 mg/dL, Glucose: 77 mg/dL.

12. The patient is continued on IV fluids and his clinical symptoms seem to further improve.

13. Repeat labs the following three days remains largely unchanged.

14. The patient's symptoms improve and he is determined to be at his baseline in terms of functioning.


Question: Without treatment, which of the following is this patient most likely to develop?

Context: A 2-year-old girl is brought to the physician because of high-grade fever and crying while passing urine.

Context: Urine dipstick shows leukocyte esterase; urinalysis shows WBCs.

Context: A voiding cystourethrogram is shown.

Choices:
A. Renal cell carcinoma
B. Hypotension
C. Renal scarring
D. Nephrotic syndrome

Answer: Renal scarring

1. A 2-year-old girl is brought to the physician.

2. Four months ago, she was treated for a febrile urinary tract infection with cefixime.

3. There is no family history of serious illness.

6. Physical examination shows no abnormalities.

7. Urine dipstick shows leukocyte esterase.

9. Urine culture shows Escherichia coli.

10. Escherichia coli is sensitive to cefixime.

11. A voiding cystourethrogram is shown.

12. The girl is crying while passing urine.

1. Four months ago, she was treated for a febrile urinary tract infection with cefixime.

2. There is no family history of serious illness.

3. Her temperature is 39.2°C (102.6°F) and pulse is 123/min.

4. Physical examination shows no abnormalities.

5. Urine dipstick shows leukocyte esterase.

7. Urine culture shows Escherichia coli sensitive to cefixime.


Question: What is the most likely diagnosis?

Choices:
A. Avoidant personality disorder
B. Major depressive disorder
C. Schizoid personality disorder
D. Schizotypal personality disorder

Answer: Schizoid personality disorder

1. A 37-year-old man presents to his primary care physician with a chief complaint of diarrhea.

2. The patient states that his symptoms have worsened recently.

3. He works as a farmer and is dressed in tattered and old denim.

4. He lives alone, and this is the first time he has come to town in years.

5. The patient’s diet is mostly dairy products and some meat products.

6. He denies any systemic symptoms and states that diarrhea tends to occur right after a meal.

7. He also claims that at times he struggles to fall asleep, and sometimes he feels he lacks energy.

8. The patient is instructed to avoid consuming dairy products for a week and to return with a report of his symptoms.

9. As you set up the return appointment with this patient you notice that he is rather emotionless.

10. He also states that he lacks anybody that he can list as an emergency contact so he leaves that section of his medical forms blank.

1. The patient's symptoms have worsened recently.

2. The patient works as a farmer and is dressed in tattered and old denim.

3. The patient lives alone and has not come to town in years.

4. The patient's diet is mostly dairy products and some meat products.

5. The patient denies any systemic symptoms and states that diarrhea tends to occur right after a meal.

6. The patient struggles to fall asleep at times and feels he lacks energy.

7. The patient is instructed to avoid consuming dairy products for a week and to return with a report of his symptoms.

8. The patient appears rather emotionless during the appointment.

9. The patient lacks anybody that he can list as an emergency contact and leaves that section of his medical forms blank.


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

Context: The patient’s daughter states that he can cook and clean up after himself and only needs help paying bills.

Context: Yesterday the patient seemed fine; however, this morning she noticed that he struggled to perform simple tasks and was forgetful while cooking, leaving the stove on.

Context: They recently returned from a trip to Mexico and admit to drinking unfiltered water and eating local cuisines while abroad.

Context: His temperature is 97.5°F (36.4°C), blood pressure is 187/118 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 100% on room air.

Choices:
A. Alzheimer dementia
B. Lewy body dementia
C. Normal pressure hydrocephalus
D. Vascular dementia

Answer: Vascular dementia

1. A 77-year-old man presents to the emergency department with a change in his mental status.

2. The patient's daughter states that he can cook and clean up after himself and only needs help paying bills.

4. This morning she noticed that he struggled to perform simple tasks and was forgetful while cooking, leaving the stove on.

5. They recently returned from a trip to Mexico.

6. They admit to drinking unfiltered water and eating local cuisines while abroad.

7. The patient has a past medical history of hypertension and diabetes.

12. His oxygen saturation is 100% on room air.

1. The patient's daughter states that he can cook and clean up after himself and only needs help paying bills.

3. This morning she noticed that he struggled to perform simple tasks and was forgetful while cooking, leaving the stove on.

4. They recently returned from a trip to Mexico.

5. They admit to drinking unfiltered water and eating local cuisines while abroad.

6. The patient has a past medical history of hypertension and diabetes.

11. His oxygen saturation is 100% on room air.


Question: Which of the following most likely accounts for this patient’s dyspnea?

Context: A 65-year-old male with a past medical history of left ventricular hypertrophy presents to the emergency room because of a history of progressive shortness of breath and a cough productive of frothy pink sputum.

Context: The patient denies fever, chills, or any recent infection.

Context: A radiograph of the chest shows septal lines and areas of opacification in both lung fields (see image). | .

Choices:
A. Destruction of interalveolar septa
B. Excess mucous production in bronchiolar epithelium
C. A collection of air in the pleural space
D. Alveolar and interstitial fluid accumulation

Answer: Alveolar and interstitial fluid accumulation

Pulmonary Disease
Cardiovascular Disease
Cardiology

2. Patient has a past medical history of left ventricular hypertrophy.

3. Patient presents to the emergency room due to progressive shortness of breath and a cough productive of frothy pink sputum.

4. Physical examination reveals crackles at the lung bases bilaterally.

5. Patient denies fever, chills, or any recent infection.

6. Radiograph of the chest shows septal lines and areas of opacification in both lung fields.

1. Physical examination reveals crackles at the lung bases bilaterally.

4. The patient denies any recent infection.

5. A radiograph of the chest shows septal lines.

6. A radiograph of the chest shows areas of opacification in both lung fields.


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

Context: A 42-year-old man is brought to the emergency department because of several episodes of black, tarlike stool and lightheadedness over the past couple of days.

Context: He drinks 4 beers daily.

Choices:
A. Double-balloon enteroscopy
B. Colonoscopy
C. Laparotomy
D.
Angiography
"

Answer: Colonoscopy

2. Patient has had several episodes of black, tarlike stool and lightheadedness over the past couple of days.

3. Patient had an appendectomy at the age of 16.

4. Patient has hypertension and tension headaches.

6. Patient is currently taking amlodipine and naproxen.

7. Patient's temperature is 36.7°C (98°F).

9. Patient's blood pressure is 100/70 mm Hg.

10. Lungs are clear to auscultation bilaterally.

11. Abdomen is soft, nondistended, and nontender.

12. Liver is palpated 3 cm below the right costal margin.

13. Patient's hemoglobin concentration is 10 g/dL.

14. Intravenous fluid resuscitation is begun.

15. Esophagogastroduodenoscopy is performed, which does not show bleeding.

1. He underwent an appendectomy at the age of 16.

2. He has hypertension and tension headaches.

4. Current medications include amlodipine and naproxen.

5. His temperature is 36.7°C (98°F), pulse is 100/min, and his blood pressure is 100/70 mm Hg.

6. The lungs are clear to auscultation bilaterally.

7. The abdomen is soft, nondistended, and nontender.

8. The liver is palpated 3 cm below the right costal margin.

9. His hemoglobin concentration is 10 g/dL.

10. Intravenous fluid resuscitation is begun.

11. An esophagogastroduodenoscopy is performed, which does not show bleeding.


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

Context: He quit drinking 5 years ago.

Context: He does not smoke cigarettes.

Context: Serum studies show: | Creatinine 1.1 mg/dL | Calcium 11.8 mg/dL | Phosphorus 2.1 mg/dL | Magnesium 1.6 mg/dL | Total protein 6 g/dL | Albumin 3.1 g/dL | AST 53 U/L | ALT 43 U/L | .

Choices:
A. Serum parathyroid-related protein level
B. Urine and serum protein electrophoresis
C. Serum parathyroid hormone level
D. X-ray of the chest

Answer: Serum parathyroid hormone level

1. A 68-year-old man comes to the physician because of constipation and decreased appetite during the past several months.

2. In the past 2 weeks, he has also noticed an increasing frequency of urination.

3. He has not had any dysuria or flank pain.

5. He has a history of calcium pyrophosphate crystal arthritis.

6. He has a history of alcoholic cirrhosis.

7. Current medications include hydrochlorothiazide.

8. Current medications include rifaximin.

9. Current medications include lactulose.

10. Current medications include naproxen as needed for the joint pain.

13. His vital signs are within normal limits.

14. Physical examination shows decreased bowel sounds but is otherwise unremarkable.

15. Serum studies show creatinine 1.1 mg/dL.

16. Serum studies show calcium 11.8 mg/dL.

17. Serum studies show phosphorus 2.1 mg/dL.

18. Serum studies show magnesium 1.6 mg/dL.

19. Serum studies show total protein 6 g/dL.

20. Serum studies show albumin 3.1 g/dL.

1. In the past 2 weeks, he has noticed an increasing frequency of urination.

2. He has not had any dysuria or flank pain.

3. He has a history of hypertension, calcium pyrophosphate crystal arthritis, and alcoholic cirrhosis.

4. Current medications include hydrochlorothiazide, rifaximin, lactulose, and naproxen as needed for the joint pain.

7. His vital signs are within normal limits.

8. Physical examination shows decreased bowel sounds but is otherwise unremarkable.

9. Serum studies show: Creatinine 1.1 mg/dL, Calcium 11.8 mg/dL, Phosphorus 2.1 mg/dL, Magnesium 1.6 mg/dL, Total protein 6 g/dL, Albumin 3.1 g/dL, AST 53 U/L, ALT 43 U/L.


Question: Which of the following tests would most likely confirm the diagnosis in this patient?

Context: A 68-year-old African American male presents to his primary care provider complaining of progressively worsening back pain.

Context: The pain is localized to the lower back and sometimes wakes him up from sleep.

Context: He has a history of hypertension and admits to a 50 pack-year smoking history.

Context: Further questioning reveals that he has also experienced fatigue and an unintentional weight loss of 18 pounds over the past year.

Choices:
A. Renal biopsy
B. Fine needle aspiration of the thyroid
C. Transrectal ultrasound-guided prostate biopsy
D. Chest radiograph

Answer: Transrectal ultrasound-guided prostate biopsy

General Orthopaedic Surgery
Orthopaedic Sports Medicine

1. A 68-year-old African American male presents to his primary care provider.

2. He is complaining of progressively worsening back pain.

3. The pain is localized to the lower back.

4. The pain sometimes wakes him up from sleep.

6. He admits to a 50 pack-year smoking history.

8. He has experienced an unintentional weight loss of 18 pounds over the past year.

9. Laboratory analysis is notable for an elevated alkaline phosphatase.

10. A radiograph of the patient’s spine demonstrates multiple sclerotic lesions in the lumbar vertebral bodies.

1. The pain is localized to the lower back.

2. The pain sometimes wakes him up from sleep.

4. He admits to a 50 pack-year smoking history.

6. He has experienced unintentional weight loss of 18 pounds over the past year.

7. Laboratory analysis is notable for an elevated alkaline phosphatase.

8. A radiograph of the patient’s spine demonstrates multiple sclerotic lesions in the lumbar vertebral bodies.


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

Context: A 75-year-old man presents to his primary care physician because he has been experiencing increasing muscle and joint pain over the last 3 months.

Context: He says that he also feels increasingly fatigued and weak despite no change to his daily routine.

Context: His past medical history is significant for an infection when he was 12 years of age that led to 2 months of paralysis and mechanical ventilation through a tracheostomy tube.

Context: At the time, he developed the paralysis after 3 days of fever and sore throat.

Context: He recalls that he was still able to feel everything and was embarrassed that his daily activities had to be performed for him by caregivers.

Choices:
A. DNA virus
B. Enveloped (-) stranded RNA virus
C. Naked (+) stranded RNA virus
D. Naked (-) stranded RNA virus

Answer: Naked (+) stranded RNA virus

1. A 75-year-old man presents to his primary care physician.

2. He has been experiencing increasing muscle and joint pain over the last 3 months.

3. He also feels increasingly fatigued and weak despite no change to his daily routine.

4. His past medical history is significant for an infection when he was 12 years of age.

5. The infection led to 2 months of paralysis and mechanical ventilation through a tracheostomy tube.

6. He developed the paralysis after 3 days of fever and sore throat.

7. He recalls that he was still able to feel everything.

8. He was embarrassed that his daily activities had to be performed for him by caregivers.

1. He feels increasingly fatigued and weak.

2. There has been no change to his daily routine.

3. His past medical history includes an infection at 12 years old.

4. The infection led to 2 months of paralysis.

5. Mechanical ventilation was required through a tracheostomy tube.

6. The paralysis developed after 3 days of fever and sore throat.

7. He was still able to feel everything during the paralysis.

8. Caregivers had to perform his daily activities for him.


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

Context: A 2-year-old boy was rushed to the emergency department in the early morning by his mother because he was unresponsive to deep pain stimuli.

Context: The patient’s mother said that he has been suffering from a fever, cough and runny nose for the last 10 days.

Context: When she gave him the medication yesterday, the patient had 3 episodes of vomiting and his condition rapidly worsened.

Context: Significant hepatomegaly is noted.

Choices:
A. Decrease in beta-oxidation
B. Increase in gluconeogenesis
C. Increase in beta-oxidation
D. Increase in glycolysis

Answer: Decrease in beta-oxidation

Neurology with Special Qualification in Child Neurology

1. A 2-year-old boy was rushed to the emergency department in the early morning by his mother.

2. The patient's mother said he has been suffering from a fever, cough and runny nose for the last 10 days.

3. 2 days ago, they visited a free clinic and received medication.

4. When she gave him the medication yesterday, the patient had 3 episodes of vomiting.

5. His condition rapidly worsened this morning, and he did not wake up, even after multiple attempts.

6. On physical examination, the patient is febrile, hypotensive, and tachycardic.

7. Peripheral pulses are 1+, and his extremities are pale and cool to touch.

8. Pupils are equal and slowly reactive to light.

1. The patient has been suffering from a fever, cough, and runny nose for the last 10 days.

2. Two days ago, they visited a free clinic and received medication.

3. When the patient was given the medication yesterday, he had 3 episodes of vomiting and his condition rapidly worsened.

4. This morning, the patient did not wake up, even after multiple attempts.

5. On physical examination, the patient is febrile, hypotensive, and tachycardic.

6. Peripheral pulses are 1+ and his extremities are pale and cool to touch.

7. Pupils are equal and slowly reactive to light.


Question: Which of the following drugs has a mechanism of action that is similar to the pathophysiology of this patient's disease?

Context: A 24-year-old patient presents to your gastroenterology practice on a referral from her primary care provider.

Choices:
A. Omeprazole
B. Bismuth
C. Octreotide
D. Magnesium hydroxide

Answer: Magnesium hydroxide

1. A 24-year-old patient presents to a gastroenterology practice.

2. The patient was referred by her primary care provider.

3. The patient has been experiencing postprandial bloating and abdominal pain for one year.

4. Symptoms occur following the ingestion of milk products.

1. The patient has been experiencing postprandial bloating for one year.

2. The patient has been experiencing abdominal pain for one year.

3. The symptoms occur following the ingestion of milk products.


Question: In which location is dimeric IgA most likely to be found in highest concentrations?

Choices:
A. Colostrum
B. Blood from the fetus
C. Blood from the mother
D. Fetal bone marrow

Answer: Colostrum


Question: If this patient's symptoms are allowed to progress without intervention, which of the following would be expected to occur?

Context: Vital signs are stable.

Context: Neurological exam reveals that his right pupil is dilated and his right lid is drooping.

Choices:
A. Right sided hemiparesis
B. Down and in gaze of the right pupil
C. Right sided homonymous hemianopsia.
D. Right eye with an inability to abduct

Answer: Right sided hemiparesis

1. A 25-year-old man presents to the ER after a street fight.

2. His girlfriend reports that he was struck with a bat in the head.

3. After the initial hit, she reported that he briefly lost consciousness but then was normal for several hours.

4. Since then, he has been rapidly decompensating.

5. He is grabbing his head in pain and his mental status is altered.

7. Neurological exam reveals that his right pupil is dilated.

8. Neurological exam reveals that his right lid is drooping.

1. His girlfriend reports that he was struck with a bat in the head.

2. After the initial hit, she reported that he briefly lost consciousness but then was normal for several hours.

3. Since then, he has been rapidly decompensating.


Question: Which of the following was the portal of entry for the most likely causal organism?

Context: A 7-year-old girl is brought to the emergency department because of diffuse abdominal pain and multiple episodes of vomiting for 2 hours.

Context: On arrival, she is unresponsive.

Context: Her temperature is 40.3°C (104.5°F) and palpable blood pressure is 45 mm Hg.

Choices:
A. Nasopharynx
B. Genital mucosa
C. Choroid plexus
D. Gastrointestinal tract

Answer: Nasopharynx

General Pediatrics
Pediatric Gastroenterology

1. A 7-year-old girl is brought to the emergency department.

2. She has diffuse abdominal pain and multiple episodes of vomiting for 2 hours.

3. She started developing fever, headache, and neck pain 3 days ago.

7. Physical examination shows diffuse purpuric skin lesions.

8. In spite of all appropriate therapy, she dies shortly thereafter.

9. Autopsy shows massive parenchymal hemorrhage of the adrenal glands.

1. She started developing fever, headache, and neck pain 3 days ago.

5. Physical examination shows diffuse purpuric skin lesions.

6. In spite of all appropriate therapy, she dies shortly thereafter.

7. Autopsy shows massive parenchymal hemorrhage of the adrenal glands.


Question: Which of the following, if seen microscopically, would indicate that her calf myocytes are more likely to recover without permanent damage?

Context: A 50-year-old female comes to the emergency department with sudden onset left-sided calf pain starting 20 minutes ago.

Context: Upon arrival to the emergency department, her blood pressure is 150/91 mmHg, pulse is 100/min, and respirations of 22/min.

Choices:
A. Cellular swelling
B. Mitochondrial vacuolization
C. Nuclear pyknosis
D. Fragmented cells and debris

Answer: Cellular swelling

Cardiology
General Pathology
Cardiovascular Disease

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

2. She has sudden onset left-sided calf pain starting 20 minutes ago.

3. Her past medical history is notable for diabetes, hypertension, and chronic atrial fibrillation controlled on an anti-arrhythmic.

4. Upon arrival to the emergency department, her blood pressure is 150/91 mmHg.

7. Examination of the leg reveals a pale left calf with diminished dorsalis pedis and posterior tibial pulses.

8. Prompt intervention relieves the patient’s symptoms.

1. Her past medical history includes diabetes, hypertension, and chronic atrial fibrillation.

2. Her chronic atrial fibrillation is controlled on an anti-arrhythmic.

3. Upon arrival to the emergency department, her blood pressure is 150/91 mmHg.

4. Upon arrival to the emergency department, her pulse is 100/min.

5. Upon arrival to the emergency department, her respirations are 22/min.

6. Examination of the leg reveals a pale left calf.

7. Examination of the leg reveals diminished dorsalis pedis pulses.

8. Examination of the leg reveals diminished posterior tibial pulses.

9. Prompt intervention relieves the patient’s symptoms.


Question: Damage to which of the following structures is most likely responsible for this patient's current symptoms?

Context: A 56-year-old man comes to the physician because of progressive worsening of vision in both his eyes over the past 6 months.

Context: He reports that he first noticed some blurring of his vision and glare in the evenings, which have both gotten worse in this period.

Context: He works as a tower crane operator and spends most of his day outdoors.

Context: A photograph of the eye is shown.

Choices:
A. Aqueous humor
B. Vitreous body
C. Lens
D. Retina

Answer: Lens

1. A 56-year-old man comes to the physician.

2. His vision has been progressively worsening over the past 6 months.

3. He first noticed blurring of his vision and glare in the evenings.

4. His vision has gotten worse in this period.

7. Ophthalmologic examination shows visual acuity of 20/100 in both eyes.

1. He first noticed blurring of his vision and glare in the evenings.

2. The symptoms have worsened over time.

5. Ophthalmologic examination shows visual acuity of 20/100 in both eyes.


Question: What is the most likely pathology giving rise to this patient’s condition?

Context: A 25-year-old man presents to the clinic with the complaint of yellow discoloration of his skin.

Context: He reports that the discoloration appeared gradually over the past 5 days.

Context: He does not have any other complaints.

Context: He never had similar symptoms before.

Context: Liver function tests reveal: | Total bilirubin level 5 mg/dL | Direct bilirubin level 0.4 mg/dL | Aspartate aminotransferase (AST) 25 U/L | Alanine aminotransferase (ALT) 15 U/L | .

Choices:
A. Decreased conjugation of bilirubin by uridine-diphosphate glucuronyltransferase
B. Bile duct obstruction
C. Hemolysis
D. Decreased transport of bile into the bile canaliculi

Answer: Decreased conjugation of bilirubin by uridine-diphosphate glucuronyltransferase

2. Patient has yellow discoloration of skin.

3. Discoloration appeared gradually over the past 5 days.

5. Patient never had similar symptoms before.

6. Patient's past medical history is significant for a recent flu infection.

7. Patient missed work for a week due to the flu infection.

8. Physical exam is significant for yellow sclera and slight yellowish discoloration of the skin over the face and neck.

10. Direct bilirubin level is 0.4 mg/dL.

11. Aspartate aminotransferase (AST) is 25 U/L.

12. Alanine aminotransferase (ALT) is 15 U/L.

1. The discoloration appeared gradually over the past 5 days.

2. He does not have any other complaints.

3. He never had similar symptoms before.

4. Past medical history is only significant for a recent flu infection that was so bad that he missed work for a week.

5. Physical exam is significant for yellow sclera and slight yellowish discoloration of the skin over the face and neck.

6. Liver function tests reveal: Total bilirubin level 5 mg/dL.

7. Liver function tests reveal: Direct bilirubin level 0.4 mg/dL.

8. Liver function tests reveal: Aspartate aminotransferase (AST) 25 U/L.

9. Liver function tests reveal: Alanine aminotransferase (ALT) 15 U/L.


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

Context: A 17-year-old girl is brought to the physician by her father because of concerns about her behavior.

Context: She worries excessively about her weight and body image, and has frequent diarrhea.

Context: She is 170 cm (5 ft 7 in) tall and weighs 63.5 kg (140 lb); BMI is 22 kg/m2.

Context: She appears anxious but well.

Context: Vital signs are within normal limits.

Choices:
A. Parotid gland swelling
B. Elevated blood pressure
C. Right upper quadrant tenderness
D. Jugular venous distention

Answer: Parotid gland swelling

1. A 17-year-old girl is brought to the physician by her father.

2. She worries excessively about her weight and body image.

8. Vital signs are within normal limits.

9. Physical examination shows calluses on the knuckles of her right hand.

1. She worries excessively about her weight and body image.


Question: The most likely cause of these findings is a fracture of which of the following bones?

Context: A 36-year-old woman comes to the emergency department because of left wrist pain and swelling that started immediately after a fall.

Context: An x-ray of the wrist 2 days later is shown.

Choices:
A. Scaphoid
B. Ulna
C. Lunate
D. Hamate

Answer: Scaphoid

Surgery of the Hand
General Orthopaedic Surgery

1. A 36-year-old woman comes to the emergency department.

2. She has left wrist pain and swelling.

3. The pain and swelling started immediately after a fall.

4. She was walking her dog when the dog abruptly pulled away, causing her to fall forward onto both hands.

5. Physical examination shows left wrist pain with pinching and grasping, moderate swelling, and mild tenderness.

6. Her left thumb is placed in a thumb immobilization splint.

7. An x-ray of the wrist was taken 2 days later.

3. This caused her to fall forward onto both hands.

4. Physical examination shows left wrist pain.

5. Left wrist pain is associated with pinching and grasping.

6. There is moderate swelling in the left wrist.

7. There is mild tenderness in the left wrist.

8. Her left thumb is placed in a thumb immobilization splint.

9. An x-ray of the wrist was taken 2 days later.


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

Context: A 2200-g (4-lb 14-oz) newborn is delivered at term to a 37-year-old primigravid woman.

Context: Examination in the delivery room shows that he is at the 2nd percentile for head circumference and at the 10th percentile for length.

Context: He has a small jaw, small eyes, and low-set ears.

Context: He has seven fingers on each hand.

Context: Cleft lip and cleft palate are present.

Choices:
A. Fragile X syndrome
B. Trisomy 18
C. Fetal alcohol syndrome
D. Trisomy 13

Answer: Trisomy 13

1. A 2200-g (4-lb 14-oz) newborn is delivered at term.

2. The mother is a 37-year-old primigravid woman.

3. Apgar scores are 6 and 8 at 1 and 5 minutes, respectively.

4. Examination in the delivery room shows the newborn is at the 2nd percentile for head circumference.

5. Examination in the delivery room shows the newborn is at the 10th percentile for length.

9. There is a keyhole-shaped defect in the iris of the left eye.

10. The newborn has seven fingers on each hand.

11. There is an opening in the roof of the mouth extending into the soft and hard palate bilaterally.

12. Cleft lip and cleft palate are present.

13. A 3/6 holosystolic murmur is heard at the left lower sternal border.

15. There is a convex-shaped deformity of the plantar surface of the feet.

3. The baby is at the 2nd percentile for head circumference.

4. The baby is at the 10th percentile for length.

8. There is a keyhole-shaped defect in the iris of the left eye.

9. The baby has seven fingers on each hand.

10. There is an opening in the roof of the mouth extending into the soft and hard palate bilaterally.

11. Cleft lip and cleft palate are present.

12. A 3/6 holosystolic murmur is heard at the left lower sternal border.

13. The heels are prominent, with convex-shaped deformity of the plantar surface of the feet.


Question: Which of the following changes in the oxygen-hemoglobin curve would most likely be expected in this patient?

Context: A 55-year-old woman is rushed to the emergency department after being found lying unconscious in a burning house by a firefighter.

Context: No history can be obtained.

Choices:
A. The curve would be shifted left due to an increased oxygen binding affinity by hemoglobin.
B. The curve would be shifted left due to metabolic acidosis in peripheral tissues.
C. The curve would be unchanged because the partial pressure of oxygen is unchanged.
D. The curve would be shifted right due to decreased hemoglobin affinity for oxygen.

Answer: The curve would be shifted left due to an increased oxygen binding affinity by hemoglobin.

General Emergency Medicine
Critical Care Medicine
Pulmonary Disease

1. A 55-year-old woman is rushed to the emergency department.

2. She was found lying unconscious in a burning house by a firefighter.

6. Physical examination reveals soot all over her face.

7. Scattered wheezes can be heard on auscultation of the chest.

8. A thorough survey of the body shows no evidence of any burn injuries.

2. Her vital signs include pulse 130/min and respirations 16/min.

3. Physical examination reveals soot all over her face.

4. Scattered wheezes can be heard on auscultation of the chest.

5. A thorough survey of the body shows no evidence of any burn injuries.


Question: Of the following, which medication is most likely responsible for his presentation?

Context: A 73-year-old man with a past medical history significant for high blood pressure, hypothyroidism, and diabetes presents to the outpatient clinic.

Context: He complains of joint pain, muscle pain, and fatigue that has been present for the last several weeks.

Context: On examination, you notice a butterfly-shaped rash across the bridge of his nose and cheeks.

Context: He has a blood pressure of 124/72 mm Hg and heart rate of 64/min.

Choices:
A. Verapamil
B. Clonidine
C. Hydralazine
D. Terazosin

Answer: Hydralazine

General Internal Medicine
Hypertension Specialist

1. A 73-year-old man presents to the outpatient clinic.

2. His past medical history is significant for high blood pressure, hypothyroidism, and diabetes.

3. He complains of joint pain, muscle pain, and fatigue for the last several weeks.

4. On examination, there is a butterfly-shaped rash across the bridge of his nose and cheeks.

1. The patient complains of joint pain, muscle pain, and fatigue.

2. The symptoms have been present for the last several weeks.

3. On examination, a butterfly-shaped rash is noticed across the bridge of the nose and cheeks.

4. The patient has a blood pressure of 124/72 mm Hg.

5. The patient has a heart rate of 64/min.


Question: Which of the following set of laboratory findings would most likely be seen in this patient?

Context: A 65-year-old woman with a 6-month history of acute promyelocytic leukemia managed with all-trans-retinoic acid presents with severe abdominal pain, nausea, vomiting, and bloody urine.

Context: The patient states her symptoms onset acutely a few hours ago and has not improved.

Context: She describes the pain as severe, sharp and stabbing in character, and diffusely localized to the umbilical region, accompanied by nausea and vomiting.

Context: The patient also states that she noticed blood in her urine last time she urinated.

Context: Her vitals signs include: temperature 37.0°C (98.6°F), blood pressure 95/75 mm Hg, pulse 115/min, respiratory rate 23/min, and oxygen saturation 99% on room air.

Context: The cardiac exam is normal.

Context: Lungs are clear to auscultation.

Context: Laboratory results are pending.

Context: A peripheral blood smear is shown in the exhibit.

Choices:
A. PT: ↑ | PTT ↑ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↑ | Platelet count: ↓
B. PT: ↓ | PTT ↓ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓
C. PT: ↑ | PTT ↑ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓
D. PT: ↓ | PTT ↓ | Bleeding time: ↓ | Fibrin split products: ↓ | D-dimer: ↓| Fibrinogen: ↓ | Platelet count: ↓

Answer: PT: ↑ | PTT ↑ | Bleeding time: ↑ | Fibrin split products: ↑ | D-dimer: ↑| Fibrinogen: ↓ | Platelet count: ↓

2. Patient has a 6-month history of acute promyelocytic leukemia managed with all-trans-retinoic acid.

3. Patient presents with severe abdominal pain, nausea, vomiting, and bloody urine.

4. Symptoms onset acutely a few hours ago and have not improved.

5. Pain is severe, sharp and stabbing in character, and diffusely localized to the umbilical region, accompanied by nausea and vomiting.

6. Patient noticed blood in her urine last time she urinated.

7. No additional significant past medical history.

8. Temperature 37.0°C (98.6°F), blood pressure 95/75 mm Hg, pulse 115/min, respiratory rate 23/min, and oxygen saturation 99% on room air.

9. Patient is ill-appearing and in severe distress.

12. Abdomen is severely tender and out of proportion with physical exam findings.

13. Diffuse petechiae present over the entire body.

15. Peripheral blood smear is shown in the exhibit.

16. Contrast CT of the abdomen shows findings consistent with acute mesenteric ischemia.

1. The patient's symptoms onset acutely a few hours ago and has not improved.

2. The pain is severe, sharp, and stabbing in character, and diffusely localized to the umbilical region.

3. The pain is accompanied by nausea and vomiting.

4. The patient noticed blood in her urine last time she urinated.

5. No additional significant past medical history.

6. Vitals signs: temperature 37.0°C (98.6°F), blood pressure 95/75 mm Hg, pulse 115/min, respiratory rate 23/min, and oxygen saturation 99% on room air.

7. On physical examination, the patient is ill-appearing and in severe distress.

10. The abdomen is severely tender and out of proportion with physical exam findings.

11. There are diffuse petechiae present over the entire body.

13. A contrast CT of the abdomen shows findings consistent with acute mesenteric ischemia.


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

Context: A 32-year-old woman comes to the physician because of a throbbing left-sided headache that started 3 hours ago.

Context: A similar episode occurred last week.

Context: Visual acuity is 20/20.

Choices:
A. Intranasal dihydroergotamine and subcutaneous sumatriptan
B. Oral tramadol
C. Intravenous prochlorperazine
D.
Oral ketorolac and oral ergotamine
"

Answer: Intravenous prochlorperazine

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

2. She has a throbbing left-sided headache that started 3 hours ago.

3. Two hours ago, she took ibuprofen with no relief.

4. She has been vomiting every 20 minutes since the start of the headache.

5. She reports that she could not see very well for a few minutes this morning.

6. A similar episode occurred last week.

8. She has recently started taking an oral contraceptive.

9. Her vital signs are within normal limits.

10. Physical examination shows no abnormalities except mild sensitivity to light.

1. Two hours ago, she took ibuprofen with no relief.

2. She has been vomiting every 20 minutes since the start of the headache.

3. She reports that she could not see very well for a few minutes this morning.

4. A similar episode occurred last week.

5. She is otherwise healthy and has recently started taking an oral contraceptive.

6. Her vital signs are within normal limits.

7. Physical examination shows no abnormalities except mild sensitivity to light.


Question: Which of the following mechanisms best explains the effect of amiodarone on the coagulation profile of this patient?

Context: He has a past medical history of stroke and his current medications include warfarin.

Context: Physical examination is unremarkable.

Context: At the time of discharge, his medications include warfarin and amiodarone, and he is cautioned that his PT might be prolonged.

Choices:
A. Amiodarone induces CYP3A4 leading to a decreased effectiveness of warfarin
B. Amiodarone inhibits CYP2C9 leading to an increased risk of bleeding
C. Amiodarone causes hepatotoxicity which requires monitoring of the prothrombin time
D. Inorganic iodine from amiodarone decreases the effectiveness of warfarin

Answer: Amiodarone inhibits CYP2C9 leading to an increased risk of bleeding

General Cardiology
Cardiovascular Disease

1. A 66-year-old man presents with palpitation, syncope, and difficulty breathing.

2. He has a past medical history of stroke.

3. His current medications include warfarin.

4. Physical examination is unremarkable.

5. An ECG is performed and shows ventricular tachycardia.

6. The patient is treated successfully with amiodarone.

7. At the time of discharge, his medications include warfarin and amiodarone.

8. He is cautioned that his PT might be prolonged.

1. The patient has a past medical history of stroke.

2. The patient's current medications include warfarin.

3. Physical examination is unremarkable.

4. An ECG is performed and shows ventricular tachycardia.

5. The patient is treated successfully with amiodarone.

6. At the time of discharge, the patient's medications include warfarin and amiodarone.

7. The patient is cautioned that his PT might be prolonged.


Question: What is the most appropriate initial treatment for this patient?

Context: A 55-year-old woman presents to the emergency department with recent onset confusion and photophobia.

Context: Upon questioning her husband, you discover the patient has been sick over the past week with fevers and productive sputum.

Context: Her vital signs are Temperature 102.6 Pulse 80 Respirations 18 Blood Pressure 110/70.

Context: The physical exam is significant for lethargy and nuchal rigidity.

Context: A lumbar puncture is performed and demonstrates cloudy fluid with an opening pressure of 35 cm H20, cell count of 1500 cells/uL (neutrophil predominant), protein level of 50 mg/dL and glucose of 30 mg/dL.

Choices:
A. Acyclovir
B. Ceftriaxone and dexamethasone
C. Vancomycin, ceftriaxone, ampicillin and dexamethasone
D. Vancomycin, ceftriaxone and ampicillin

Answer: Vancomycin, ceftriaxone, ampicillin and dexamethasone

2. Patient presents to the emergency department with recent onset confusion and photophobia.

3. Patient has been sick over the past week with fevers and productive sputum.

8. Patient's physical exam is significant for lethargy and nuchal rigidity.

11. Lumbar puncture opening pressure is 35 cm H20.

12. Lumbar puncture cell count is 1500 cells/uL (neutrophil predominant).

13. Lumbar puncture protein level is 50 mg/dL.

14. Lumbar puncture glucose is 30 mg/dL.

15. Computed tomography scan demonstrates no space-occupying lesions.

1. The patient has been sick over the past week with fevers and productive sputum.

2. Vital signs: Temperature 102.6, Pulse 80, Respirations 18, Blood Pressure 110/70.

3. Physical exam shows lethargy and nuchal rigidity.

4. Lumbar puncture demonstrates cloudy fluid with an opening pressure of 35 cm H20.

5. Lumbar puncture shows cell count of 1500 cells/uL (neutrophil predominant).

6. Lumbar puncture reveals protein level of 50 mg/dL and glucose of 30 mg/dL.

7. Computed tomography scan demonstrates no space-occupying lesions.


Question: Which of the following pathological findings is most likely to be seen on the biopsy specimen?

Context: A 58-year-old male presents to his primary care physician complaining of a painless bump on his penis.

Context: He first noticed the lesion 1 year ago but was too embarrassed to mention the issue at his last annual physical exam.

Context: The lesion has since grown in size and has recently become more erythematous.

Context: He has hypertension treated with lisinopril.

Context: At age 45, he was successfully treated for phimosis with a steroid cream.

Context: He first engaged in sexual intercourse at age 14 and has had “too many sexual partners to count” in his lifetime.

Context: He smoked one pack of cigarettes daily for 30 years but quit 10 years ago.

Context: He drinks one alcoholic beverage daily.

Context: There is no inguinal lymphadenopathy.

Choices:
A. Atypical squamous cells with varying degrees of mitotic activity
B. Spirochetes on dark-field microscopy
C. Nonspecific inflammatory features with C. trachomatis amplification on PCR
D. Safety pin-shaped intracellular inclusions that appear purple on Giemsa stain

Answer: Atypical squamous cells with varying degrees of mitotic activity

2. Patient complains of a painless bump on his penis.

3. Patient first noticed the lesion 1 year ago.

4. Patient was too embarrassed to mention the issue at his last annual physical exam.

5. Lesion has grown in size and become more erythematous.

6. Patient has hypertension treated with lisinopril.

7. Patient was successfully treated for phimosis with a steroid cream at age 45.

8. Patient first engaged in sexual intercourse at age 14.

9. Patient has had "too many sexual partners to count" in his lifetime.

10. Patient smoked one pack of cigarettes daily for 30 years.

12. Patient drinks one alcoholic beverage daily.

13. Physical examination shows a nontender 5 mm x 5 mm ulcerated lesion with an erythematous base on the dorsum of the glans.

15. Excisional biopsy of the lesion is performed.

1. The patient first noticed the lesion 1 year ago.

2. The patient was too embarrassed to mention the issue at his last annual physical exam.

4. The lesion has recently become more erythematous.

5. The patient has hypertension treated with lisinopril.

6. At age 45, the patient was successfully treated for phimosis with a steroid cream.

7. The patient first engaged in sexual intercourse at age 14.

8. The patient has had “too many sexual partners to count” in his lifetime.

9. The patient smoked one pack of cigarettes daily for 30 years but quit 10 years ago.

10. The patient drinks one alcoholic beverage daily.

11. Physical examination shows a nontender 5 mm x 5 mm ulcerated lesion with an erythematous base on the dorsum of the glans.

12. There is no inguinal lymphadenopathy.

13. Excisional biopsy of the lesion is performed.


Question: His serum creatinine concentration is 1.6 mg/dL and blood urea nitrogen concentration is 20 mg/dL.This patient is at increased risk for which of the following complications?

Context: Three weeks ago he underwent emergent cardiac catheterization because of a myocardial infarction and had to stay at the hospital longer than expected because of decreased kidney function.

Context: He says his symptoms have since improved greatly and he now produces even more urine than before the procedure.

Choices:
A. Hypermagnesemia
B. Metabolic alkalosis
C. Hypernatremia
D. Hypokalemia

Answer: Hypokalemia

1. A 54-year-old man comes to the physician for a follow-up appointment.

2. Three weeks ago he underwent emergent cardiac catheterization because of a myocardial infarction.

3. He had to stay at the hospital longer than expected because of decreased kidney function.

4. He says his symptoms have since improved greatly.

5. He now produces even more urine than before the procedure.

1. Three weeks ago, he underwent emergent cardiac catheterization.

2. The reason for the cardiac catheterization was a myocardial infarction.

3. He had to stay at the hospital longer than expected.

4. The extended stay was due to decreased kidney function.

5. His symptoms have improved greatly since the procedure.

6. He now produces even more urine than before the procedure.


Question: WBC 2,500/mm3 | Platelets 95,000/mm3 | What is the most likely diagnosis?

Context: A 35-year-old woman visits her primary care provider with complaints of easy fatigability, breathlessness on exertion, and altered sensations in her lower limbs.

Context: Family history is noncontributory.

Context: Her CBC is as follows: | Hemoglobin 8.0 g/dL | MCV 112 fL | .

Choices:
A. Vitamin B12 deficiency
B. Folic acid deficiency
C. Vitamin C deficiency
D. Vitamin A deficiency

Answer: Vitamin B12 deficiency

2. Patient has complaints of easy fatigability, breathlessness on exertion, and altered sensations in her lower limbs.

3. Patient has a past medical history of hypertension.

4. Patient takes hydrochlorothiazide and lisinopril, ethinyl estradiol-progestin, and a multivitamin every day.

5. Patient's family history is noncontributory.

6. Patient drinks alcohol almost every day and smokes cigarettes when she drinks.

8. Patient's respiratory rate is 17/min.

9. Patient's blood pressure is 130/92 mm Hg.

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

11. Patient has marked pallor with slight bluing of her lips and distal fingertips.

12. Patient's heart has a regular rate and rhythm.

13. Patient's lungs are clear to auscultation bilaterally.

14. Patient has loss of touch, and vibration sense in both of her lower limbs.

15. Patient's CBC hemoglobin is 8.0 g/dL.

1. Past medical history is positive for hypertension.

2. She takes hydrochlorothiazide and lisinopril, ethinyl estradiol-progestin, and a multivitamin every day.

4. She drinks alcohol almost every day and smokes cigarettes when she drinks.

5. Today her heart rate is 95/min, respiratory rate is 17/min, blood pressure is 130/92 mm Hg, and temperature of 37.0°C (98.6°F).

6. Overall, she has marked pallor with slight bluing of her lips and distal fingertips.

7. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally.

8. Additionally, she has loss of touch, and vibration sense in both of her lower limbs.

9. Her CBC is as follows: Hemoglobin 8.0 g/dL, MCV 112 fL.


Question: The compound responsible for this patient’s clinical presentation has what mechanism of action?

Context: The patient’s blood pressure is 120/70 mmHg, respirations are 28/min, pulse is 120/min, and SaO2 is 98% on room air.

Context: The patient has no medical history and is not taking any medications.

Context: The patient has 1 alcoholic drink/week and does not use any other illicit drugs.

Choices:
A. Inhibits the electron transport chain
B. Inhibits acetylcholine esterase
C. Prevents acetylcholine release
D. DNA alkylation

Answer: Inhibits the electron transport chain

General Emergency Medicine
General Gastroenterology

1. A 40-year-old man is brought by his wife with nausea and vomiting.

2. He had been working for four hours on repairing his car with the garage shutter closed and the car running but did not lose consciousness.

3. The patient’s blood pressure is 120/70 mmHg.

4. The patient’s respirations are 28/min.

6. The patient’s SaO2 is 98% on room air.

8. The patient is not taking any medications.

9. The patient has 1 alcoholic drink/week.

10. The patient does not use any other illicit drugs.

11. Ophthalmologic exam reveals bilateral retinal hemorrhages.

1. He had been working for four hours on repairing his car with the garage shutter closed and the car running but did not lose consciousness.

2. The patient’s blood pressure is 120/70 mmHg.

3. The patient’s respirations are 28/min.

5. The patient’s SaO2 is 98% on room air.

7. The patient is not taking any medications.

8. The patient has 1 alcoholic drink/week.

9. The patient does not use any other illicit drugs.

10. Ophthalmologic exam reveals bilateral retinal hemorrhages.


Question: Which of these findings is most concerning regarding the severity of his hypovolemia?

Context: On exam, his temperature is 100.4°F (38.0°C), blood pressure is 102/80 mmHg, pulse is 95/min, and respirations are 14/min.

Context: Prior to the operation, the patient had a temperature of 98.8°F (37.1°C), blood pressure of 122/70 mmHg, and a pulse of 65/min.

Choices:
A. Decreased pulse pressure
B. Decreased systolic blood pressure
C. Increased heart rate
D. Increased temperature

Answer: Decreased systolic blood pressure

1. A 54-year-old man is hospitalized after a left hemicolectomy for colon cancer.

2. On postoperative day 1, his hemoglobin is noted on routine labs to have dropped overnight from 7.1 g/dL to 5.3 g/dL.

3. The patient does not report feeling any differently.

4. On exam, his temperature is 100.4°F (38.0°C).

5. On exam, his blood pressure is 102/80 mmHg.

7. On exam, his respirations are 14/min.

8. The patient’s urine output in his Foley bag has been 1.0 cc/kg/hr for the last 8 hours.

9. Prior to the operation, the patient had a temperature of 98.8°F (37.1°C).

10. Prior to the operation, the patient had a blood pressure of 122/70 mmHg.

11. Prior to the operation, the patient had a pulse of 65/min.

1. On postoperative day 1, the patient's hemoglobin dropped from 7.1 g/dL to 5.3 g/dL overnight.

2. The patient does not report feeling any differently.

3. On exam, the patient's temperature is 100.4°F (38.0°C).

4. On exam, the patient's blood pressure is 102/80 mmHg.

5. On exam, the patient's pulse is 95/min.

6. On exam, the patient's respirations are 14/min.

7. The patient's urine output in his Foley bag has been 1.0 cc/kg/hr for the last 8 hours.

8. Prior to the operation, the patient had a temperature of 98.8°F (37.1°C).

9. Prior to the operation, the patient had a blood pressure of 122/70 mmHg.

10. Prior to the operation, the patient had a pulse of 65/min.


Question: Which of the following embryologic structures eventually ends up within the visualized structure?

Choices:
A. Ductus venosus
B. Umbilical artery
C. Umbilical vein
D. Vitelline duct

Answer: Umbilical vein

General Obstetrics and Gynecology
General Surgery

1. An obese 45-year-old female presents to the emergency room complaining of abdominal pain.

2. She reports a 4-hour history of severe right upper quadrant pain following a fatty meal.

3. She has a history of multiple similar episodes over the past year.

4. An ultrasound of the right upper quadrant reveals gallstones.

5. Due to the recurrent nature of her disease, she undergoes an elective laparoscopic cholecystectomy.

6. While in the operating room, the surgeons use the laparoscope to visualize a structure connecting the liver to the anterior wall of the abdominal wall.

1. The patient reports a 4-hour history of severe right upper quadrant pain following a fatty meal.

2. The patient has a history of multiple similar episodes over the past year.

3. An ultrasound of the right upper quadrant reveals gallstones.

4. Due to the recurrent nature of her disease, the patient undergoes an elective laparoscopic cholecystectomy.

5. While in the operating room, the surgeons use the laparoscope to visualize a structure connecting the liver to the anterior wall of the abdominal wall.


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

Context: A 28-year-old woman presents with a recent history of severe headaches.

Context: The patient states that the headaches came on gradually about 1 week ago and have steadily worsened.

Context: She describes the headaches as severe, diffuse, and frequently causing nausea and vomiting, especially in the mornings.

Context: A review of systems is significant for fatigue and daytime sleepiness.

Context: Her temperature is 37.0°C (98.6°F), the blood pressure is 110/70 mm Hg, the pulse is 70/min, the respiratory rate is 16/min, and the oxygen saturation is 99% on room air.

Context: The cardiac exam is normal.

Context: Lungs are clear to auscultation.

Context: The neurological exam is normal.

Context: The ophthalmic exam reveals the indistinct margins of the optic disc, bilaterally.

Choices:
A. Genetics
B. Hydrocephalus
C. Intracranial mass
D. Infection

Answer: Hydrocephalus

2. Patient has a recent history of severe headaches.

3. Headaches came on gradually about 1 week ago.

5. Headaches are severe, diffuse, and frequently causing nausea and vomiting, especially in the mornings.

6. Past medical history is significant for bacterial meningitis, approx. one month ago, that was successfully treated.

7. Current medications are combined oral contraceptives and fluoxetine.

8. Review of systems is significant for fatigue and daytime sleepiness.

9. Family history is significant for her mother and aunt who suffer from migraines with aura.

14. Oxygen saturation is 99% on room air.

18. Ophthalmic exam reveals the indistinct margins of the optic disc, bilaterally.

1. The patient's headaches started gradually about 1 week ago and have worsened.

2. The patient describes the headaches as severe, diffuse, and causing nausea and vomiting, especially in the mornings.

3. The patient had bacterial meningitis approximately one month ago, which was successfully treated.

4. The patient's current medications are combined oral contraceptives and fluoxetine.

5. The patient experiences fatigue and daytime sleepiness.

6. The patient's mother and aunt suffer from migraines with aura.

7. The patient's temperature is 37.0°C (98.6°F), blood pressure is 110/70 mm Hg, pulse is 70/min, respiratory rate is 16/min, and oxygen saturation is 99% on room air.

8. The patient's cardiac exam is normal.

9. The patient's lungs are clear to auscultation.

10. The patient's neurological exam is normal.

11. The patient's ophthalmic exam reveals indistinct margins of the optic disc bilaterally.


Question: Of the following, which is the most likely cause of the patient’s symptoms:

Context: A 72-year-old presents to the Emergency Room with hemoptysis.

Context: Physical examination of the face is shown in Image A and is accompanied by left upper extremity edema.

Choices:
A. Pleural effusion
B. Superior sulcus tumor
C. Pulmonary embolus
D. Mass in the thoracic region of the spinal cord

Answer: Superior sulcus tumor

General Pulmonary Disease
General Pulmonology

1. A 72-year-old presents to the Emergency Room.

2. The patient has a history of smoking 1 pack of cigarettes a day for the past 30 years.

4. Physical examination of the face is shown in Image A.

5. The patient has left upper extremity edema.

1. He has smoked 1 pack of cigarettes a day for the past 30 years.

2. Physical examination of the face is shown in Image A.

3. The physical examination is accompanied by left upper extremity edema.


Question: A recent history of which of the following conditions would discourage the use of this drug?

Context: A 59-year-old man who was recently diagnosed with renal cell carcinoma comes to the physician for a follow-up evaluation.

Context: The physician recommends starting treatment with a chemotherapeutic agent that is also used to treat neovascular age-related macular degeneration.

Choices:
A. Interstitial lung disease
B. Chronic kidney disease
C. Platinum allergy
D. Gastrointestinal bleeding

Answer: Gastrointestinal bleeding

1. A 59-year-old man has been diagnosed with renal cell carcinoma.

2. The man is coming to the physician for a follow-up evaluation.

3. The physician is recommending starting treatment with a chemotherapeutic agent.

4. The chemotherapeutic agent is also used to treat neovascular age-related macular degeneration.

1. The physician recommends starting treatment.

2. The treatment involves a chemotherapeutic agent.

3. The chemotherapeutic agent is used to treat neovascular age-related macular degeneration.


Question: Which of the following statements is correct?

Context: A 36-year-old woman presents with a persistent cough productive of blood-streaked sputum, night sweats, and weight loss.

Context: No significant past medical history.

Choices:
A. If this patient is diagnosed with active pulmonary tuberculosis, it should be reported even without the patient’s consent, and the patient should receive isolation and treatment.
B. The patient has a right to privacy, so, without her consent, the physician can not report her case even if she is diagnosed with active pulmonary tuberculosis.
C. If this patient turns out to have active pulmonary tuberculosis, her case can stay unreported only if she agrees to stay home from work and remain isolated at home for her entire treatment period.
D. Only active pulmonary tuberculosis is a reportable disease.

Answer: If this patient is diagnosed with active pulmonary tuberculosis, it should be reported even without the patient’s consent, and the patient should receive isolation and treatment.

2. Patient has a persistent cough productive of blood-streaked sputum, night sweats, and weight loss.

3. Patient has no significant past medical history.

4. Patient denies any history of smoking, alcohol consumption, or recreational drug use.

5. Patient works as a nurse at a local hospital.

6. Patient lives in an apartment with her extended family.

7. Patient's blood pressure is 100/80 mm Hg.

9. Patient's respiratory rate is 17/min.

10. Patient's temperature is 35.9℃ (96.6℉).

11. Physical examination reveals dullness to percussion and diminished breath sounds over the upper lobe of the left lung.

12. Patient recently had contact with a patient with tuberculosis.

13. Patient is concerned she will lose her job if her case is reported.

2. She denies any history of smoking, alcohol consumption, or recreational drug use.

3. She works as a nurse at a local hospital and lives in an apartment with her extended family.

4. Her vital signs are a blood pressure of 100/80 mm Hg, heart rate of 94/min, respiratory rate of 17/min, and temperature of 35.9℃ (96.6℉).

5. Physical examination reveals dullness to percussion and diminished breath sounds over the upper lobe of the left lung.

6. During the discussion regarding the required workup, the patient tells the physician about recent contact with a patient with tuberculosis.

7. She asks the physician not to report her case because she is concerned she will lose her job.


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

Context: A 33-year-old woman gravida 2, para 1, at 35 weeks gestation is admitted to the hospital with fever and active labor.

Context: She reports a 2-day history of fluid leakage from the vagina without pain or vaginal bleeding.

Context: Her BMI is 18.2 kg/m2.

Context: Uterine palpation reveals tenderness.

Context: Her lungs are clear to auscultation.

Choices:
A. Amnioinfusion
B. Ampicillin and gentamicin
C. Intravenous betamethasone
D. Ritodrine hydrochloride

Answer: Ampicillin and gentamicin

Maternal
General Obstetrics and Gynecology

1. A 33-year-old woman is admitted to the hospital.

2. She is gravida 2, para 1, at 35 weeks gestation.

3. She has a 2-day history of fluid leakage from the vagina without pain or vaginal bleeding.

4. Her pregnancy has otherwise been uncomplicated.

5. She has attended many prenatal appointments.

6. She followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise.

7. Her previous pregnancy was complicated by a preterm delivery at 34 weeks gestation.

8. She has a 10-pack-year history of smoking before pregnancy.

9. She smoked 4 cigarettes daily during pregnancy.

10. Her temperature is 39.6°C (103.3°F).

14. Uterine palpation reveals tenderness.

15. Cervical examination indicates 100% effacement and 10 cm dilation.

16. Her lungs are clear to auscultation.

17. The baseline fetal heart rate is 180/min.

1. The patient reports a 2-day history of fluid leakage from the vagina without pain or vaginal bleeding.

2. Her pregnancy has otherwise been uncomplicated.

3. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise.

4. Her previous pregnancy was complicated by a preterm delivery at 34 weeks gestation.

5. The patient reports a 10-pack-year history of smoking before pregnancy and smoked 4 cigarettes daily during pregnancy.

6. At the hospital, her temperature is 39.6°C (103.3°F), blood pressure is 108/60 mm Hg, and pulse is 125/min.

8. Uterine palpation reveals tenderness.

9. Cervical examination indicates 100% effacement and 10 cm dilation.

10. Her lungs are clear to auscultation.

11. The baseline fetal heart rate is 180/min.


Question: Which of the following tests is comparatively less useful in assessing the function of the organ involved in this condition?

Context: A 49-year-old man, with a history of alcohol abuse over the last 2 decades, presents with a complaint of epigastric pain for about a year.

Context: He previously had one episode of acute pancreatitis for which he was hospitalized.

Context: His appetite is good, but he has a history of weight loss.

Context: He also complains of oily and bulky stools.

Context: He takes aluminum hydroxide gel and ranitidine for partial pain relief.

Context: Vital signs are stable.

Context: Abdominal CT scan is shown below.

Choices:
A. Secretin stimulation test
B. Serum amylase and lipase levels
C. Fecal elastase level
D. Magnetic resonance cholangiopancreatography (MRCP)

Answer: Serum amylase and lipase levels

2. Patient has a history of alcohol abuse for the last 2 decades.

3. Patient presents with a complaint of epigastric pain for about a year.

4. Patient had one episode of acute pancreatitis for which he was hospitalized.

5. Patient continued to drink 4–5 beers/day after he was discharged.

7. Patient has a history of weight loss.

8. Patient complains of oily and bulky stools.

9. Patient takes aluminum hydroxide gel and ranitidine for partial pain relief.

11. Routine physical exam and blood work are normal except for mild hypocalcemia.

1. He previously had one episode of acute pancreatitis.

2. He was hospitalized for the acute pancreatitis.

3. He continued to drink 4–5 beers/day after he was discharged.

6. He complains of oily and bulky stools.

7. He takes aluminum hydroxide gel for partial pain relief.

8. He takes ranitidine for partial pain relief.

11. Blood work is normal except for mild hypocalcemia.


Question: Which of the following diagnostic tests would be the most appropriate?

Context: A 34-year-old woman presents to the office due to a pulmonary embolism confirmed by computed tomography (CT) chest angiogram, which she was recently hospitalized for.

Context: She does not have any recent surgical trauma or travel history.

Context: She complains of having episodes where her fingers become white and then blue, and they are usually accompanied by pain in the same region.

Context: These episodes tend to happen more frequently during winter and have been ongoing for about 2 years now.

Context: She also had a spontaneous abortion at 12 weeks of gestation last year.

Context: She does not have a family history of venous thromboembolic disease.

Context: The vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg.

Context: The complete blood count (CBC) results are as follows: | Hemoglobin 14.2 g/dL | Hematocrit 39% | Leukocyte count 4,950/mm3 | Neutrophils 59% | Bands 3% | Eosinophils 1% | Basophils 0% | Lymphocytes 31% | Monocytes 4% | Platelet count 120,000/mm3 | The coagulation test results are as follows: | Partial thromboplastin time (activated) 56 seconds | Prothrombin time 15 seconds | Reticulocyte count 1.0% | Thrombin time < 2 seconds deviation from control | .

Choices:
A. Protein C
B. Factor-V-Leiden
C. Lupus anticoagulant
D. Protein S

Answer: Lupus anticoagulant

2. Patient was recently hospitalized for a pulmonary embolism confirmed by CT chest angiogram.

3. Patient does not have any recent surgical trauma or travel history.

4. Patient complains of episodes where her fingers become white and then blue, accompanied by pain in the same region.

5. Episodes tend to happen more frequently during winter and have been ongoing for about 2 years.

6. Patient had a spontaneous abortion at 12 weeks of gestation last year.

7. Patient does not have a family history of venous thromboembolic disease.

8. Vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg.

9. Physical examination is non-contributory.

10. CBC results: Hemoglobin 14.2 g/dL, Hematocrit 39%, Leukocyte count 4,950/mm3, Neutrophils 59%, Bands 3%, Eosinophils 1%, Basophils 0%, Lymphocytes 31%, Monocytes 4%, Platelet count 120,000/mm3.

11. Coagulation test results: Partial thromboplastin time (activated) 56 seconds, Prothrombin time 15 seconds, Reticulocyte count 1.0%, Thrombin time < 2 seconds deviation from control.

1. The patient does not have recent surgical trauma or travel history.

2. She experiences episodes where her fingers become white and then blue, accompanied by pain in the same region.

3. These episodes occur more frequently during winter and have been ongoing for about 2 years.

4. The patient had a spontaneous abortion at 12 weeks of gestation last year.

5. There is no family history of venous thromboembolic disease.

6. Vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg.

7. Physical examination is non-contributory.

8. Complete blood count (CBC) results: Hemoglobin 14.2 g/dL, Hematocrit 39%, Leukocyte count 4,950/mm3, Neutrophils 59%, Bands 3%, Eosinophils 1%, Basophils 0%, Lymphocytes 31%, Monocytes 4%, Platelet count 120,000/mm3.

9. Coagulation test results: Partial thromboplastin time (activated) 56 seconds, Prothrombin time 15 seconds, Reticulocyte count 1.0%, Thrombin time < 2 seconds deviation from control.


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

Context: A 36-year-old woman, gravida 3, para 2, at 34 weeks' gestation is brought to the emergency department for the evaluation of continuous, dark, vaginal bleeding that started one hour ago.

Context: She also reports severe lower abdominal pain.

Context: Her pulse is 100/min, respirations are 16/min, and blood pressure is 90/60 mm Hg.

Context: The abdomen is tender, and hypertonic contractions are felt.

Choices:
A. Emergency cesarean delivery
B. Elective cesarean delivery
C. Administration of terbutaline
D. Administration of oxytocin and normal vaginal birth

Answer: Emergency cesarean delivery

General Obstetrics and Gynecology
Maternal

4. Brought to the emergency department for evaluation of continuous, dark, vaginal bleeding that started one hour ago.

6. Pregnancy complicated by preeclampsia.

7. First two children delivered vaginally.

8. Current medications include methyldopa and a multivitamin.

14. Blood on the vulva and on the medial aspect of both thighs bilaterally.

16. Fetal heart rate is 170/min with several decelerations.

1. She reports severe lower abdominal pain.

2. Her current pregnancy was complicated by preeclampsia.

3. Her first two children were delivered vaginally.

4. Current medications include methyldopa and a multivitamin.

10. There is blood on the vulva and on the medial aspect of both thighs bilaterally.

11. The fetus is in a cephalic presentation.

12. The fetal heart rate is 170/min with several decelerations.


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

Context: A 16-year-old boy is brought to the emergency department because of severe left flank pain and nausea for 3 hours.

Choices:
A. Rhomboid crystals on urinalysis
B. Urinary pH of 7.8
C. Serum anti-Saccharomyces cerevisiae antibodies
D. Hexagon-shaped crystals on urinalysis

Answer: Hexagon-shaped crystals on urinalysis

1. A 16-year-old boy is brought to the emergency department.

2. He has severe left flank pain and nausea for 3 hours.

3. The pain is colicky and radiates towards his groin.

4. He drinks multiple glasses of iced tea every day.

5. He has had similar episodes of abdominal pain in the past.

6. His maternal uncle has a similar history of abdominal pain.

10. Examination shows a soft and nontender abdomen.

11. Left costovertebral angle tenderness is present.

12. An x-ray of the abdomen shows no abnormalities.

13. A urinary cyanide nitroprusside test is positive.

1. The pain is colicky and radiates towards his groin.

2. He drinks multiple glasses of iced tea every day.

3. He has had similar episodes of abdominal pain in the past.

4. His maternal uncle has a similar history of abdominal pain.

5. His temperature is 37.1°C (98.8°F), pulse is 103/min, and blood pressure is 108/72 mm Hg.

6. Examination shows a soft and nontender abdomen.

7. Left costovertebral angle tenderness is present.

8. An x-ray of the abdomen shows no abnormalities.

9. A urinary cyanide nitroprusside test is positive.


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

Context: A 57-year-old woman comes to the emergency department because of severe dyspnea, cough, and pleuritic chest pain for 20 minutes.

Context: The patient appears distressed.

Context: Her pulse is 112/min, respirations are 24/min, and blood pressure is 88/55 mm Hg.

Context: A CT scan of the chest is shown.

Choices:
A. Endovascular stent-grafting
B. Alteplase
C. Coronary angioplasty
D. Pericardiocentesis

Answer: Alteplase

Pulmonary Disease
General Emergency Medicine

1. A 57-year-old woman comes to the emergency department.

2. She has severe dyspnea, cough, and pleuritic chest pain for 20 minutes.

3. Three weeks ago, she underwent surgery for a total right knee replacement.

8. Examination shows jugular venous distention.

9. There is a mildly tender surgical scar on her right knee.

1. Three weeks ago, she underwent surgery for a total right knee replacement.

6. Examination shows jugular venous distention.

7. There is a mildly tender surgical scar on her right knee.


Question: What type of study has been used by the researchers in this example?

Context: From the hospital database, they identify 19,000 patients over the age of 20 with newly diagnosed pulmonary tuberculosis, as well as 72,000 patients without pulmonary tuberculosis for comparison purposes.

Choices:
A. Cohort study
B. Case-control study
C. Ecological study
D. Intervention study

Answer: Case-control study

1. A group of multidisciplinary researchers from a tertiary hospital decides to investigate whether there is an association between splenectomy and pulmonary tuberculosis.

2. From the hospital database, they identify 19,000 patients over the age of 20 with newly diagnosed pulmonary tuberculosis.

3. From the hospital database, they identify 72,000 patients without pulmonary tuberculosis for comparison purposes.

4. Both of these groups are matched for age, gender, and an index year when the condition was initially diagnosed.

5. The odds of pulmonary tuberculosis development associated with splenectomy and other comorbidities is estimated.

6. After controlling for all relevant confounders, the results show that splenectomy is associated with a two-fold higher incidence of pulmonary tuberculosis development.

7. There is also a synergistic effect between splenectomy and other comorbid conditions in the development of pulmonary tuberculosis.

1. 19,000 patients over the age of 20 have newly diagnosed pulmonary tuberculosis.

2. 72,000 patients without pulmonary tuberculosis are identified for comparison.

3. Both groups are matched for age, gender, and an index year of diagnosis.

4. The odds of pulmonary tuberculosis development associated with splenectomy and other comorbidities are estimated.

5. After controlling for relevant confounders, splenectomy is associated with a two-fold higher incidence of pulmonary tuberculosis development.

6. There is a synergistic effect between splenectomy and other comorbid conditions in the development of pulmonary tuberculosis.


Question: What is the best next step in evaluating this patient?

Context: She has gained 10 pounds over the past month but attributes it to her menopause.

Context: Past medical history is significant for asthma and seasonal allergies, and medications include a rescue inhaler and cetirizine as need.

Choices:
A. Beta-hCG levels
B. FSH levels
C. Thyroid peroxidase antibody titer
D. TSH levels

Answer: TSH levels

Internal Medicine
Endocrinology, Diabetes, and Metabolism

Endocrinology, Diabetes, and Metabolism
General Endocrinology

1. A 53-year-old woman presents to the clinic with complaints of fatigue.

2. She reports that over the past several months she has been lethargic and tired.

3. She has gained 10 pounds over the past month.

4. She attributes her weight gain to her menopause.

5. Her last menstrual period (LMP) was 1 year ago.

6. Past medical history is significant for asthma.

7. Past medical history is significant for seasonal allergies.

8. Medications include a rescue inhaler.

9. Medications include cetirizine as needed.

10. Review of systems is negative except for cold intolerance.

11. Review of systems is negative except for constipation.

1. The patient reports feeling lethargic and tired over the past several months.

2. She has gained 10 pounds in the past month and attributes it to her menopause.

3. Her last menstrual period (LMP) was 1 year ago.

4. Her past medical history includes asthma and seasonal allergies.

5. Her medications include a rescue inhaler and cetirizine as needed.

6. Review of systems is negative except for cold intolerance and constipation.


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

Context: A 33-year-old man presents to his primary care physician for fatigue, weight loss, and diffuse pruritus.

Context: The patient has a past medical history of multiple admissions for severe abdominal pain and bloody diarrhea as well as several episodes of ascending cholangitis which were successfully treated.

Context: He is currently a member of Alcoholics Anonymous.

Context: His temperature is 98.2°F (36.8°C), blood pressure is 124/75 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 99% on room air.

Context: Physical exam is otherwise notable for pruritis, jaundice, and scleral icterus.

Choices:
A. Ascending cholangitis
B. Cholangiocarcinoma
C. Cirrhosis
D. Colon cancer

Answer: Cholangiocarcinoma

2. Patient presents with fatigue, weight loss, and diffuse pruritus.

3. Patient has past medical history of multiple admissions for severe abdominal pain and bloody diarrhea.

4. Patient has past medical history of several episodes of ascending cholangitis.

5. Patient is currently a member of Alcoholics Anonymous.

6. Patient's temperature is 98.2°F (36.8°C).

7. Patient's blood pressure is 124/75 mmHg.

10. Patient's oxygen saturation is 99% on room air.

11. Urinalysis is notable only for a dark urine sample with no red blood cells present.

12. Rectal exam reveals pale stool and grossly visible blood.

13. Physical exam is notable for pruritis, jaundice, and scleral icterus.

1. The patient has a past medical history of multiple admissions for severe abdominal pain and bloody diarrhea.

2. The patient has a past medical history of several episodes of ascending cholangitis which were successfully treated.

3. The patient is currently a member of Alcoholics Anonymous.

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

5. The patient's blood pressure is 124/75 mmHg.

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

8. The patient's oxygen saturation is 99% on room air.

9. Urinalysis is notable only for a dark urine sample with no red blood cells present.

10. A rectal exam reveals pale stool and grossly visible blood.

11. Physical exam is notable for pruritis, jaundice, and scleral icterus.


Question: Which of the following must be done before beginning treatment with a TNF inhibitor?

Context: She undergoes subsequent testing, and is found to have anti-citrullinated protein antibodies.

Context: Her physician is concerned for rheumatoid arthritis, and discusses treatment with a biologic disease-modifying anti-rheumatic agent. |  | .

Choices:
A. Confirm diagnosis with a test for rheumatoid factor
B. Confirm diagnosis with elevated ESR and CRP
C. Test for latent mycobacterial infection
D. Obtain a radiograph demonstrating osteophytes

Answer: Test for latent mycobacterial infection

1. A 43-year-old female presents with several years of pain and stiffness in her wrists and hands.

2. Her symptoms have been getting progressively worse.

3. She reports that her hands feel stiff for an hour or more after awaking in the morning.

5. She is found to have anti-citrullinated protein antibodies.

6. Her physician is concerned for rheumatoid arthritis.

7. Her physician discusses treatment with a biologic disease-modifying anti-rheumatic agent.

1. Her symptoms have been getting progressively worse.

2. She reports that her hands feel stiff for an hour or more after awaking in the morning.

4. She is found to have anti-citrullinated protein antibodies.

5. Her physician is concerned for rheumatoid arthritis.

6. Her physician discusses treatment with a biologic disease-modifying anti-rheumatic agent.


Question: Which of the following is the most crucial in the development of this patient’s condition?

Context: A 65-year-old man is brought to the emergency department with a complaint of right-sided numbness for 5 hours.

Context: The gait is normal.

Context: The blood sugar is 221 mg/dL.

Context: The CT scan of the head is normal.

Choices:
A. Emboli from deep leg veins with a patent foramen ovale
B. Leakage of blood from intracranial vessel due to uncontrolled hypertension
C. Lipohyalinosis of small penetrating arteries due to chronic hypertension
D. Significant stenosis of the left carotid artery

Answer: Lipohyalinosis of small penetrating arteries due to chronic hypertension

2. Patient has right-sided numbness for 5 hours.

3. Numbness started in right-side of face and progressed to same side arm and leg within 30 minutes.

4. Patient denies limb weakness, walking difficulty, vision problem, or vertigo.

5. Patient had similar symptoms 5 months ago that were resolved within 10 minutes.

6. Past medical history includes type 2 diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia.

7. Medication list includes allopurinol, amlodipine, aspirin, glimepiride, lisinopril, and rosuvastatin.

9. Other vital signs are within normal limits.

10. No facial droop or slurring of speech noted on examination.

11. Muscle strength is normal in all 4 limbs with normal tone and deep tendon reflexes.

12. Decreased pinprick sensation and proprioception on right arm and leg.

16. MRI of head with diffusion-weighted imaging reveals 15 mm diffusion restriction in left thalamus.

1. The numbness started in the right-side of the face and has progressed to the same side arm and leg within 30 minutes.

2. He denies limb weakness, walking difficulty, vision problem, or vertigo.

3. He had similar symptoms 5 months ago that were resolved within 10 minutes.

4. The past medical history includes type 2 diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia.

5. The medication list includes allopurinol, amlodipine, aspirin, glimepiride, lisinopril, and rosuvastatin.

6. The blood pressure is 165/102 mm Hg, and the rest of the vital signs are within normal limits.

7. On examination, there are no facial droop and slurring of the speech noted.

8. The muscle strength is normal in all 4 limbs with a normal tone and deep tendon reflexes.

9. There is a decreased pinprick sensation and proprioception on the right arm and leg.

13. The MRI of the head with diffusion-weighted imaging reveals a 15 mm diffusion restriction in the left thalamus.


Question: Which of the following physiologic changes will occur when the patient takes this medication?

Context: He reports that he recently started a new job that involves regular public speaking and is very stressed before every public speaking event.

Context: He does not smoke or drink alcohol.

Context: His temperature is 98.6°F (37°C), blood pressure is 110/65 mmHg, pulse is 85/min, and respirations are 17/min.

Context: He is alert and fully oriented.

Choices:
A. Decreased cardiac output and decreased peripheral resistance
B. Decreased cardiac output and increased peripheral resistance
C. Increased cardiac output and decreased peripheral resistance
D. Increased cardiac output and increased peripheral resistance

Answer: Decreased cardiac output and increased peripheral resistance

1. A 23-year-old man presents to a psychiatrist for evaluation of situational anxiety.

2. He reports that he recently started a new job that involves regular public speaking.

3. He is very stressed before every public speaking event.

4. He describes developing a rapid heart rate and diaphoresis that interferes with his ability to speak well.

5. He has no past medical history and takes no medications.

11. On exam, he is well-appearing and appropriately conversational.

13. The patient is prescribed propranolol to take before major public speaking events.

1. The patient recently started a new job involving regular public speaking.

2. The patient experiences stress before every public speaking event.

3. The patient reports developing a rapid heart rate and diaphoresis during public speaking.

4. The patient has no past medical history.

6. The patient does not smoke or drink alcohol.

7. The patient's temperature is 98.6°F (37°C).

8. The patient's blood pressure is 110/65 mmHg.

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

11. On exam, the patient is well-appearing and appropriately conversational.

12. The patient is alert and fully oriented.


Question: Which of the following is the best initial step in the management of this patient's condition?

Context: A 69-year-old woman is brought into the emergency room by family members after they noted that she had become increasingly lethargic over the past 3 days.

Context: Her temperature is 39.5°C (103.1°F), the blood pressure is 75/40 mm Hg, the heart rate 130/min, the respiratory rate 24/min, and the oxygen saturation is 89% on room air.

Context: Her skin is warm to the touch.

Context: White blood cell count is 15,000/mm3 and her urinalysis is positive for nitrites and leukocyte esterase.

Choices:
A. Intramuscular adrenaline
B. Intravenous hydrocortisone
C. Assessment of airway, breathing, and circulation
D. Intravenous noradrenaline

Answer: Assessment of airway, breathing, and circulation

1. A 69-year-old woman is brought into the emergency room by family members.

2. She had become increasingly lethargic over the past 3 days.

7. Her oxygen saturation is 89% on room air.

8. On examination, she is severely ill, drowsy, and unable to speak.

10. Her white blood cell count is 15,000/mm3.

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

5. The oxygen saturation is 89% on room air.

8. On examination, she is unable to speak.

10. White blood cell count is 15,000/mm3.

11. Her urinalysis is positive for nitrites.

12. Her urinalysis is positive for leukocyte esterase.


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

Context: A 28-year-old G2P1 woman at 29 weeks gestation presents to the obstetrician after noticing red spots on her undergarments over the past week.

Context: Her vaginal bleeding has not been painful; however, she is concerned that it has persisted.

Context: Her previous child was born by cesarean section and she is currently taking folate and a multivitamin.

Context: She endorses feeling fetal movements.

Context: Her temperature is 98.9°F (37.2°C), blood pressure is 120/84 mmHg, pulse is 88/min, respirations are 17/min, and oxygen saturation is 99% on room air.

Choices:
A. Placenta percreta
B. Placenta previa
C. Placental abruption
D. Uterine rupture

Answer: Placenta previa

3. Patient has noticed red spots on her undergarments over the past week.

4. Patient's vaginal bleeding has not been painful.

5. Patient's previous child was born by cesarean section.

6. Patient is currently taking folate and a multivitamin.

7. Patient endorses feeling fetal movements.

8. Patient's temperature is 98.9°F (37.2°C).

9. Patient's blood pressure is 120/84 mmHg.

12. Patient's oxygen saturation is 99% on room air.

13. Physical exam is notable for a gravid uterus and non-tender abdomen.

14. Speculum exam reveals a closed cervical os and a small amount of blood.

1. Her vaginal bleeding has not been painful.

2. She is concerned that the bleeding has persisted.

3. Her previous child was born by cesarean section.

4. She is currently taking folate and a multivitamin.

5. She endorses feeling fetal movements.

10. Her oxygen saturation is 99% on room air.

11. Physical exam is notable for a gravid uterus.

12. Physical exam is notable for a non-tender abdomen.

13. Speculum exam reveals a closed cervical os.

14. Speculum exam reveals a small amount of blood.


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

Context: She has hypertension.

Context: Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 16/min, and blood pressure is 134/88 mm Hg.

Context: Her speech is clear.

Choices:
A. Cerebellar lesion
B. Inferior frontal gyrus lesion
C. Upper motor neuron lesion
D. Thalamus lesion

Answer: Upper motor neuron lesion

1. A 57-year-old woman comes to the emergency department 1 hour after experiencing a distressing 10-minute episode of stuttering during a business meeting.

3. She has smoked 2 packs of cigarettes daily for 30 years.

4. Current medications include fosinopril and hydrochlorothiazide.

9. She is oriented to person, place, and time.

11. When she is asked to hold both arms fully extended at shoulder level with palms upwards and eyes closed, her right palm turns inwards and downwards.

2. She has smoked 2 packs of cigarettes daily for 30 years.

3. Current medications include fosinopril and hydrochlorothiazide.

8. She is oriented to person, place, and time.

10. When asked to hold both arms fully extended at shoulder level with palms upwards and eyes closed, her right palm turns inwards and downwards.