Question: Which histological finding would place her at the highest risk of developing esophageal adenocarcinoma in the near future?

Context: A 48-year-old woman presents to the doctor’s office complaining of frequent episodes of severe heartburn and chest pain.

Context: It feels like food is getting stuck in her throat somewhere.

Context: The physician feels that the patient has acid reflux and recommends upper gastrointestinal endoscopy and a trial of omeprazole.

Context: Several biopsies are taken during the endoscopy: one from the distal esophagus, one from the gastroesophageal junction, and one from the body of the stomach.

Choices:
A. The presence of inflammatory cells in the body of the stomach
B. The presence of metaplasia at the Z line
C. The presence of goblet cells at the Z line
D. The presence of high grade dysplasia at the Z line

Answer: The presence of high grade dysplasia at the Z line

1. A 48-year-old woman presents to the doctor's office.

2. She is complaining of frequent episodes of severe heartburn and chest pain.

3. She feels like food is getting stuck in her throat somewhere.

4. She wakes up at night in fits of coughing and in pain.

5. Antacids and other over the counter remedies do not improve the discomfort.

6. The physician feels that the patient has acid reflux.

7. The physician recommends upper gastrointestinal endoscopy and a trial of omeprazole.

8. Several biopsies are taken during the endoscopy.

9. One biopsy is taken from the distal esophagus.

10. One biopsy is taken from the gastroesophageal junction.

11. One biopsy is taken from the body of the stomach.

1. Patient feels like food is getting stuck in her throat.

2. Patient wakes up at night in fits of coughing and in pain.

3. Antacids and other over the counter remedies do not improve the discomfort.

4. Physician feels that the patient has acid reflux.

5. Physician recommends upper gastrointestinal endoscopy.

6. Physician recommends a trial of omeprazole.

7. Several biopsies are taken during the endoscopy.

8. One biopsy is taken from the distal esophagus.

9. One biopsy is taken from the gastroesophageal junction.

10. One biopsy is taken from the body of the stomach.


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

Context: A 26-year-old man comes to the physician because of a 3-week history of malaise and recurrent fever.

Context: He has also had a 4.5-kg (10-lb) weight loss over the past 3 months.

Context: He appears ill.

Context: His temperature is 39°C (102.2°F).

Context: Laboratory studies show a hemoglobin concentration of 9.1 g/dL, leukocyte count of 2,900/mm3, and platelet count of 108,000/mm3.

Choices:
A. Tsetse fly
B. Sand fly
C. Freshwater snail
D. Anopheles mosquito

Answer: Sand fly

1. A 26-year-old man comes to the physician.

2. He has a 3-week history of malaise and recurrent fever.

3. He has had a 4.5-kg (10-lb) weight loss over the past 3 months.

4. He came back from his honeymoon in Kenya 6 months ago.

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

8. Physical examination shows generalized lymphadenopathy.

9. Physical examination shows hepatosplenomegaly.

10. Laboratory studies show a hemoglobin concentration of 9.1 g/dL.

11. Laboratory studies show a leukocyte count of 2,900/mm3.

12. Laboratory studies show a platelet count of 108,000/mm3.

1. He has had a 4.5-kg (10-lb) weight loss over the past 3 months.

2. He came back from his honeymoon in Kenya 6 months ago.

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

6. Physical examination shows generalized lymphadenopathy and hepatosplenomegaly.

7. Laboratory studies show a hemoglobin concentration of 9.1 g/dL.

8. Laboratory studies show a leukocyte count of 2,900/mm3.

9. Laboratory studies show a platelet count of 108,000/mm3.


Question: Which best describes the principal action(s) of prazosin?

Context: A 68-year-old Caucasian male presents to your office complaining of urinary hesitancy and decreased urinary flow.

Context: His blood pressure is measured to be 168/95.

Context: You prescribe prazosin.

Choices:
A. Relaxation of urinary sphincter and reduction of peripheral vascular resistance
B. Relaxation of urinary sphincter and suppression of renin release
C. Contraction of urinary bladder wall smooth muscle and suppression of renin release
D. Contraction of urinary bladder wall smooth muscle and reduction of peripheral vascular resistance

Answer: Relaxation of urinary sphincter and reduction of peripheral vascular resistance

1. A 68-year-old Caucasian male presents to your office.

2. The patient is complaining of urinary hesitancy and decreased urinary flow.

3. The patient's blood pressure is measured to be 168/95.

1. Blood pressure is measured to be 168/95.


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

Context: Although he has had several previous hospital admissions and received multiple courses of antibiotic therapy, he continues to get sick.

Context: The boy’s medical history is significant for neonatal sepsis and recurrent episodes of pyoderma and otitis media.

Context: The patient’s HIV status is negative and his complete blood count, T cell and B cell counts, immunoglobulin profile, and complement tests are within normal limits.

Choices:
A. CD4+ cell count
B. Bone marrow biopsy
C. Dihydrorhodamine (DHR) test
D. Adenosine deaminase levels

Answer: Dihydrorhodamine (DHR) test

1. A 4-year-old boy is referred to the infectious disease clinic for recurrent pneumonia.

2. He has had several previous hospital admissions and received multiple courses of antibiotic therapy.

4. On his most recent hospital admission, the boy presented with mild fever, right-sided chest pain, and yellow-colored sputum.

5. He had difficulty breathing and diminished breath sounds on the right side of the chest.

6. A CT scan of the thorax revealed multiple right-sided ground-glass opacities.

7. Sputum cultures grew Aspergillus galactomannan.

8. The boy’s medical history is significant for neonatal sepsis.

9. He has had recurrent episodes of pyoderma and otitis media.

10. His younger brother had recurrent purulent skin infections before he died of an otogenic brain abscess at the age of 2.

11. His mother says that skin infections are common in the male members of her family.

12. The patient’s HIV status is negative.

13. His complete blood count, T cell and B cell counts, immunoglobulin profile, and complement tests are within normal limits.

1. The patient has had several previous hospital admissions.

2. The patient has received multiple courses of antibiotic therapy.

3. On his most recent hospital admission, the boy presented with mild fever.

4. On his most recent hospital admission, the boy presented with right-sided chest pain.

5. On his most recent hospital admission, the boy presented with yellow-colored sputum.

6. The patient had difficulty breathing.

7. The patient had diminished breath sounds on the right side of the chest.

8. A CT scan of the thorax revealed multiple right-sided ground-glass opacities.

9. Sputum cultures grew Aspergillus galactomannan.

10. The boy’s medical history is significant for neonatal sepsis.

11. The boy’s medical history is significant for recurrent episodes of pyoderma.

12. The boy’s medical history is significant for recurrent episodes of otitis media.

13. The patient's younger brother had recurrent purulent skin infections.

14. The patient's younger brother died of an otogenic brain abscess at the age of 2.

15. The patient's mother says that skin infections are common in the male members of her family.

16. The patient’s HIV status is negative.

17. The patient’s complete blood count is within normal limits.

18. The patient’s T cell and B cell counts are within normal limits.

19. The patient’s immunoglobulin profile is within normal limits.

20. The patient’s complement tests are within normal limits.


Question: Which of the following will most likely be found on physical exam?

Context: He was found on the ground by his daughter earlier today, and he was last known to be without neurological deficits two hours prior to presentation.

Context: His temperature is 99°F (37.2°C), blood pressure is 185/105 mmHg, pulse is 102/min, and respirations are 18/min.

Context: A non-contrast head CT is performed, which demonstrates a hypodense lesion affecting the left medial frontal and parietal lobe.

Choices:
A. Contralateral hemiparesis
B. Contralateral lower extremity weakness
C. Hemineglect
D. Wernicke aphasia

Answer: Contralateral lower extremity weakness

1. A 72-year-old man is being transported by emergency medical services to the emergency department for a stroke code.

2. He was found on the ground by his daughter earlier today.

3. He was last known to be without neurological deficits two hours prior to presentation.

9. The CT demonstrates a hypodense lesion affecting the left medial frontal and parietal lobe.

1. He was found on the ground by his daughter earlier today.

2. He was last known to be without neurological deficits two hours prior to presentation.

8. The head CT demonstrates a hypodense lesion affecting the left medial frontal and parietal lobe.


Question: This medication is associated with an increased risk of which of the following complications?

Context: A 33-year-old G1P0 at 39 weeks gestation is admitted to the labor and delivery floor for induction of labor.

Context: She feels well and is no acute distress.

Context: She is accompanied by her husband.

Context: Her past medical history is notable for major depressive disorder and generalized anxiety disorder.

Context: She takes sertraline.

Context: Her temperature is 99.2°F (37.3°C), blood pressure is 120/75 mmHg, pulse is 95/min, and respirations are 18/min.

Context: To initiate labor induction, the obstetrician injects the patient with a hormone that is endogenously made in the hypothalamus and released by the posterior pituitary.

Choices:
A. Placental abruption
B. Vasa previa
C. Placenta accreta
D. Preeclampsia

Answer: Placental abruption

4. Patient is admitted to labor and delivery floor for induction of labor.

5. Patient feels well and is in no acute distress.

6. Patient is accompanied by her husband.

7. Patient has past medical history of major depressive disorder and generalized anxiety disorder.

9. Patient's temperature is 99.2°F (37.3°C).

10. Patient's blood pressure is 120/75 mmHg.

13. Obstetrician injects patient with hormone endogenously made in hypothalamus and released by posterior pituitary to initiate labor induction.

1. She feels well and is in no acute distress.

3. Her past medical history includes major depressive disorder and generalized anxiety disorder.

9. The obstetrician injects the patient with a hormone to initiate labor induction.


Question: Which drug has been prescribed?

Context: A 57-year-old Caucasian male presents to your office with heart palpitations and shortness of breath.

Context: He fails standard pharmacologic therapy and you refer to cardiology, where he is started on an antiarrhythmic medication.

Context: The action of this agent results in a longer action potential duration, an increased effective refractory period, and a longer QT interval.

Choices:
A. Flecanide
B. Mexiletine
C. Diltiazem
D. Sotalol

Answer: Sotalol

General Cardiology
Cardiovascular Disease

1. A 57-year-old Caucasian male presents to office with heart palpitations and shortness of breath.

2. On exam, he is tachycardic and his rhythm is irregularly irregular.

3. He fails standard pharmacologic therapy.

5. Started on an antiarrhythmic medication.

6. Action of this agent results in a longer action potential duration.

7. Action of this agent results in an increased effective refractory period.

8. Action of this agent results in a longer QT interval.

2. On exam, the patient's rhythm is irregularly irregular.

3. The patient fails standard pharmacologic therapy.

4. The patient is referred to cardiology.

5. In cardiology, the patient is started on an antiarrhythmic medication.

6. The action of the antiarrhythmic medication results in a longer action potential duration.

7. The action of the antiarrhythmic medication results in an increased effective refractory period.

8. The action of the antiarrhythmic medication results in a longer QT interval.


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

Context: A 2-year-old girl is brought to the physician because of abdominal distention and twitching of her feet, which her mother noticed a week ago.

Context: The patient has also had a low-grade fever for 5 days.

Context: Her temperature is 38.1°C (100.6°F), pulse is 128/min, and blood pressure is 135/82 mm Hg.

Choices:
A. Hodgkin lymphoma
B. Hepatoblastoma
C. Nephroblastoma
D. Neuroblastoma

Answer: Neuroblastoma

2. Mother noticed abdominal distention and twitching of feet a week ago.

3. Patient has had a low-grade fever for 5 days.

4. Patient has not had a bowel movement in 3 days.

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

6. Patient is at the 40th percentile for height and 20th percentile for weight.

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

9. Patient's blood pressure is 135/82 mm Hg.

10. Examination shows an irregular palpable mass that crosses the midline of the abdomen.

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

12. There are erratic movements of the eyes.

13. 24-hour urine collection shows elevated homovanillic acid and vanillylmandelic acid levels.

1. The patient has had a low-grade fever for 5 days.

2. She has not had a bowel movement in 3 days.

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

4. She is at the 40th percentile for height and 20th percentile for weight.

8. Examination shows an irregular palpable mass that crosses the midline of the abdomen.

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

10. There are erratic movements of the eyes.

11. A 24-hour urine collection shows elevated homovanillic acid and vanillylmandelic acid levels.


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

Context: A 53-year-old man is brought to the emergency department by his wife after the sudden onset of dizziness, nausea, and left-sided weakness.

Context: His blood pressure is 165/95 mm Hg.

Context: A CT scan of the head shows a small lesion in the left lateral pons that involves the nucleus of a cranial nerve that exits the brain at the middle cerebellar peduncle.

Choices:
A. Ptosis and inability to look up with the right eye
B. Winging of the left scapula and weakness turning the head to the right
C. Difficulty chewing and deviation of the jaw to the left
D. Inability to smell vanilla or coffee

Answer: Difficulty chewing and deviation of the jaw to the left

1. A 53-year-old man is brought to the emergency department by his wife.

2. The man has sudden onset of dizziness, nausea, and left-sided weakness.

4. Neurological examination shows decreased muscle tone and hyperreflexia in the right upper and lower extremities.

5. His gait is unsteady, and he falls to the left when attempting to walk.

6. Finger-to-nose testing shows dysmetria on the left side.

7. A CT scan of the head shows a small lesion in the left lateral pons.

8. The lesion involves the nucleus of a cranial nerve.

9. The cranial nerve exits the brain at the middle cerebellar peduncle.

2. Neurological examination shows decreased muscle tone in the right upper and lower extremities.

3. Neurological examination shows hyperreflexia in the right upper and lower extremities.

5. He falls to the left when attempting to walk.

8. The lesion involves the nucleus of a cranial nerve that exits the brain at the middle cerebellar peduncle.


Question: Which of the following would you expect to see upon chest X-ray:

Context: A 38-year-old African American female presents to her primary care physician with uveitis, cough, and arthralgias in her ankles and legs.

Context: Bloodwork reveals elevated angiotensin converting enzyme levels, and skin PPD testing shows no observable induration after 48 hours.

Context: The patient demonstrates reduced FEV1 and FVC upon spirometry.

Context: FEV1/FVC is 85%.

Choices:
A. Enlarged hilar lymph nodes
B. Kerley B Lines
C. Bilateral diaphragmatic elevation.
D. Fluid in alveolar walls

Answer: Enlarged hilar lymph nodes

4. Patient presents to primary care physician with uveitis, cough, and arthralgias in ankles and legs.

5. Bloodwork reveals elevated angiotensin converting enzyme levels.

6. Skin PPD testing shows no observable induration after 48 hours.

7. Patient demonstrates reduced FEV1 and FVC upon spirometry.

1. Bloodwork reveals elevated angiotensin converting enzyme levels.

2. Skin PPD testing shows no observable induration after 48 hours.

3. The patient demonstrates reduced FEV1 upon spirometry.

4. The patient demonstrates reduced FVC upon spirometry.


Question: A mutation of which of the following genes is most likely responsible for this patient's condition?

Context: A previously healthy 41-year-old man comes to the physician for evaluation of a 1-month history of painless, intermittent bleeding on defecation, which he discovered while wiping.

Context: His younger sister was recently diagnosed with endometrial cancer, and his mother was diagnosed with gastric cancer at 58 years of age.

Choices:
A. MLH1
B. TP53
C. DCC
D. KRAS

Answer: MLH1

Colon and Rectal Surgery
Colorectal Surgery

General Colon and Rectal Surgery
General Colorectal Surgery

1. A 41-year-old man comes to the physician for evaluation of a 1-month history of painless, intermittent bleeding on defecation.

2. He discovered the bleeding while wiping.

3. His younger sister was recently diagnosed with endometrial cancer.

4. His mother was diagnosed with gastric cancer at 58 years of age.

5. Physical examination shows no abnormalities.

6. Test of the stool for occult blood is positive.

7. Colonoscopy shows a tumor in the ascending colon.

8. Histopathologic examination of the tumor shows a mucinous, poorly-differentiated adenocarcinoma.

1. His younger sister was recently diagnosed with endometrial cancer.

2. His mother was diagnosed with gastric cancer at 58 years of age.

3. Physical examination shows no abnormalities.

4. Test of the stool for occult blood is positive.

5. Colonoscopy shows a tumor in the ascending colon.

6. Histopathologic examination of the tumor shows a mucinous, poorly-differentiated adenocarcinoma.


Question: This medication has which of the following mechanisms of action?

Context: A 49-year-old woman presents to her pulmonologist for a follow-up visit.

Context: She reports a longstanding history of chronic dyspnea and fatigue.

Context: Her past medical history is notable for asthma.

Context: She was recently trialed on nifedipine but stopped due to severe lower extremity edema.

Context: She does not smoke and does not drink alcohol.

Context: Her physician recommends starting a medication to slow the patient’s clinical worsening that requires regular monitoring of liver function tests.

Choices:
A. Endothelin-1 receptor antagonist
B. Beta-2-adrenergic receptor agonist
C. Phospholipase A2 antagonist
D. Phosphodiesterase type 5 antagonist

Answer: Endothelin-1 receptor antagonist

2. Patient has longstanding history of chronic dyspnea and fatigue.

3. Patient has past medical history of asthma.

4. Patient has known mutation in BMPR2 gene.

5. Patient was recently trialed on nifedipine but stopped due to severe lower extremity edema.

8. Patient's temperature is 99.4°F (37.4°C).

9. Patient's blood pressure is 135/80 mmHg.

12. Physical examination reveals increased P2 on cardiac auscultation.

13. Physician recommends starting medication to slow patient's clinical worsening.

14. Medication requires regular monitoring of liver function tests.

1. She reports chronic dyspnea and fatigue.

2. Her past medical history includes asthma.

3. She has a known mutation in the BMPR2 gene.

4. She was trialed on nifedipine but stopped due to severe lower extremity edema.

6. Her temperature is 99.4°F (37.4°C), blood pressure is 135/80 mmHg, pulse is 80/min, and respirations are 20/min.

7. Physical examination reveals an increased P2 on cardiac auscultation.

8. Her physician recommends starting a medication to slow clinical worsening that requires regular monitoring of liver function tests.


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

Context: A 14-year-old girl is brought to the physician by her mother for the evaluation of recurrent episodes of nose bleeding for several months.

Context: Vital signs are within normal limits.

Context: Laboratory studies show: | Hemoglobin 11 g/dL | Hematocrit 34% | Leukocyte count 7,000/mm3 | Platelet count 180,000/mm3 | Prothrombin time 13 sec | Partial thromboplastin time 45 sec | Fibrin split products negative | The bleeding time is 10 minutes.

Choices:
A. Oral prednisone
B. Intravenous immunoglobulins
C. Tranexamic acid
D. Desmopressin

Answer: Desmopressin

1. A 14-year-old girl is brought to the physician by her mother.

2. The girl has had recurrent episodes of nose bleeding for several months.

3. The episodes occur unexpectedly and stop after a few minutes by elevating the upper body and bending the head forward.

4. The girl's menses occur at regular 27-day intervals with heavy flow.

5. Her last menstrual period was 3 weeks ago.

6. Vital signs are within normal limits.

7. Physical examination shows no abnormalities.

8. Laboratory studies show a hemoglobin level of 11 g/dL.

9. Laboratory studies show a hematocrit level of 34%.

10. Laboratory studies show a leukocyte count of 7,000/mm3.

11. Laboratory studies show a platelet count of 180,000/mm3.

12. Laboratory studies show a prothrombin time of 13 sec.

13. Laboratory studies show a partial thromboplastin time of 45 sec.

14. Laboratory studies show fibrin split products are negative.

15. Laboratory studies show a bleeding time of 10 minutes.

1. The episodes occur unexpectedly and stop after a few minutes by elevating the upper body and bending the head forward.

2. Menses occur at regular 27-day intervals with heavy flow.

3. Her last menstrual period was 3 weeks ago.

4. Vital signs are within normal limits.

5. Physical examination shows no abnormalities.

6. Laboratory studies show: Hemoglobin 11 g/dL.

7. Laboratory studies show: Hematocrit 34%.

8. Laboratory studies show: Leukocyte count 7,000/mm3.

9. Laboratory studies show: Platelet count 180,000/mm3.

10. Laboratory studies show: Prothrombin time 13 sec.

11. Laboratory studies show: Partial thromboplastin time 45 sec.

12. Laboratory studies show: Fibrin split products negative.


Question: Which of the following is the most probable cause of the newborn’s condition?

Context: A 29-year-old G3P2 undergoes a cesarean section at 38 weeks gestation and delivers a boy weighing 4570 g with Apgar scores of 5 and 8 at 1 and 5 minutes, respectively.

Context: The newborn’s heart rate is 122/min, the respiratory rate is 31/min, and the temperature 36.4℃ (97.5℉).

Context: On examination, the newborn is pale, lethargic, diaphoretic, and has poor muscular tone.

Choices:
A. Microangiopathy
B. Hyperinsulinemia
C. Hyperglycemia
D. Polycythemia

Answer: Hyperinsulinemia

3. Patient underwent cesarean section at 38 weeks gestation.

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

7. Current pregnancy was complicated by gestational diabetes with poor glycemic control.

9. Newborn's respiratory rate is 31/min.

10. Newborn's temperature is 36.4℃ (97.5℉).

11. On examination, newborn is pale, lethargic, diaphoretic, and has poor muscular tone.

12. Liver is 2 cm below the right costal margin.

1. The current pregnancy was complicated by gestational diabetes with poor glycemic control.

3. The newborn’s respiratory rate is 31/min.

4. The newborn’s temperature is 36.4℃ (97.5℉).

6. On examination, the newborn is lethargic.

7. On examination, the newborn is diaphoretic.

8. On examination, the newborn has poor muscular tone.

9. The liver is 2 cm below the right costal margin.


Question: What medication is the patient most likely taking?

Context: A 19-year-old woman is brought to the emergency department by ambulance after experiencing a first-time seizure.

Context: She as preparing for an exam at her college’s library, in her normal state of health and collapsed.

Context: Past medical history is significant for major depressive disorder.

Context: Family medical history is insignificant for neurological disorders.

Context: Instead, for the past 10 days, she has been taking her roommate’s antidepressant medication instead.

Context: Today her blood pressure is 100/80 mm Hg, pulse 102/min, respirations 12/min and he BMI is 15 kg/m2.

Choices:
A. Bupropion
B. Gabapentin
C. Selegiline
D. Amitriptyline

Answer: Bupropion

1. A 19-year-old woman was brought to the emergency department by ambulance.

2. She was in her normal state of health and collapsed while preparing for an exam at her college’s library.

3. When she regained consciousness she was surrounded by students and staff.

4. The emergency personnel assessed her condition and brought her in.

5. Her past medical history is significant for major depressive disorder.

6. Her primary care physician prescribed a medication for her depression, but she has not taken it for several days because she was concerned about weight gain.

7. Her family medical history is insignificant for neurological disorders.

8. For the past 10 days, she has been taking her roommate’s antidepressant medication instead.

9. Her blood pressure is 100/80 mm Hg, pulse 102/min, respirations 12/min and BMI is 15 kg/m2.

10. Physical examination reveals pale and dry mucosa and conjunctiva, and lanugo on her arms and legs.

1. She was preparing for an exam at her college’s library.

2. She collapsed in her normal state of health.

3. When she regained consciousness, she was surrounded by students and staff.

6. Her primary care physician prescribed a medication for her depression.

7. She has not taken her prescribed medication for several days.

8. She was concerned about weight gain from the medication.

9. Her family medical history is insignificant for neurological disorders.

10. For the past 10 days, she has been taking her roommate’s antidepressant medication instead of her prescribed medication.

11. Today her blood pressure is 100/80 mm Hg.

15. Physical examination reveals pale and dry mucosa and conjunctiva.

16. Physical examination also reveals lanugo on her arms and legs.


Question: Which of the following intracellular changes is most likely to occur in renal vascular smooth muscle as a result of this drug?

Context: A 59-year-old man with long-standing hypertension is brought to the emergency department because of vomiting and headache for 2 hours.

Context: He reports that he has been unable to refill the prescription for his antihypertensive medications.

Context: His blood pressure is 210/120 mm Hg.

Choices:
A. Increased activity of protein kinase C
B. Increased activity of guanylate cyclase
C. Increased production of cyclic adenosine monophosphate
D. Increased intracellular concentration of calcium

Answer: Increased production of cyclic adenosine monophosphate

1. A 59-year-old man is brought to the emergency department.

3. He has been vomiting and has had a headache for 2 hours.

4. He has been unable to refill the prescription for his antihypertensive medications.

6. Fundoscopy shows bilateral optic disc swelling.

7. An ECG shows left ventricular hypertrophy.

8. Treatment with intravenous fenoldopam is begun.

1. The patient is unable to refill the prescription for his antihypertensive medications.

3. Fundoscopy shows bilateral optic disc swelling.

4. An ECG shows left ventricular hypertrophy.

5. Treatment with intravenous fenoldopam is begun.


Question: Of the following options, which underlying condition could cause this reaction?

Context: A 4-year-old boy is referred to the transfusion clinic with malaise, fever, bilateral conjunctivitis, erythema of the oral mucosa, macular rash of the trunk, and inguinal lymphadenopathy following several days of loose stool.

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

Context: He is rushed to the emergency department where his blood pressure is 85/48 mm Hg, heart rate is 120/min, respiratory rate is 26/min, and temperature is 37.0°C (98.6°F).

Context: A complete blood count is normal.

Choices:
A. Bruton's agammaglobulinemia
B. IgA deficiency
C. Hyper-IgM syndrome
D. Hyper-IgD syndrome

Answer: IgA deficiency

1. A 4-year-old boy is referred to the transfusion clinic.

2. He has malaise, fever, bilateral conjunctivitis, erythema of the oral mucosa, macular rash of the trunk, and inguinal lymphadenopathy.

3. He had several days of loose stool prior to referral.

4. He was born at 39 weeks gestation via spontaneous vaginal delivery.

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

6. Kawasaki’s disease is suspected and therapy with intravenous immunoglobulin and aspirin is initiated.

7. Later that day, the patient develops trouble breathing, facial flushing, and rapidly evolving pruritic abdominal rash.

8. He is rushed to the emergency department.

9. His blood pressure is 85/48 mm Hg, heart rate is 120/min, respiratory rate is 26/min, and temperature is 37.0°C (98.6°F).

10. On physical examination, the patient has severe facial edema and severe stridor, which can be heard without a stethoscope.

1. The boy was born at 39 weeks gestation.

2. The boy was born via spontaneous vaginal delivery.

3. The boy is up to date on all vaccines.

4. The boy is meeting all developmental milestones.

6. Therapy with intravenous immunoglobulin and aspirin is initiated.

7. The patient develops trouble breathing.

8. The patient develops facial flushing.

9. The patient develops rapidly evolving pruritic abdominal rash.

10. The patient's blood pressure is 85/48 mm Hg.

11. The patient's heart rate is 120/min.

12. The patient's respiratory rate is 26/min.

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

14. The patient has severe facial edema.

16. The patient's complete blood count is normal.


Question: What is the mode of inheritance for this patient's disease?

Context: He takes no medications.

Context: His blood pressure is 125/92 mm Hg, pulse is 90/min, respiratory rate 12/min, and temperature is 36.6°C (97.9°F).

Context: Laboratory testing shows: | Hematocrit 23% | Erythrocyte count 2.2 million/mm3 | Thrombocyte count  25,000/mm3 | A bone marrow biopsy shows decreased trilineage hematopoiesis and macrophages with a crinkled tissue-paper appearance.

Choices:
A. Autosomal dominant
B. X-linked recessive
C. Autosomal recessive
D. X-linked dominant

Answer: Autosomal recessive

Pediatrics
Medical Genetics and Genomics

General Medical Genetics and Genomics
Neuromuscular Medicine
General Pediatrics

1. A 19-year-old man presents to the physician due to progressively worsening weakness.

2. He also notes that he has been getting tired easily and frequently feels short of breath.

3. Additionally, he notes a protuberant belly that he cannot seem to reduce with diet and exercise.

4. His past medical history is significant for easy bruising since he was very young, requiring at least one transfusion when he was younger.

10. Physical examination reveals hepatomegaly and splenomegaly.

11. Several bruises can be seen on the inside of his arms and legs.

12. Laboratory testing shows a hematocrit of 23%.

13. Laboratory testing shows an erythrocyte count of 2.2 million/mm3.

14. Laboratory testing shows a thrombocyte count of 25,000/mm3.

15. A bone marrow biopsy shows decreased trilineage hematopoiesis and macrophages with a crinkled tissue-paper appearance.

1. Patient reports feeling tired easily and frequently experiences shortness of breath.

2. Patient has a protuberant belly that does not reduce with diet and exercise.

3. Patient has a history of easy bruising since childhood and required at least one transfusion when younger.

4. Patient is not taking any medications.

5. Patient's blood pressure is 125/92 mm Hg, pulse is 90/min, respiratory rate is 12/min, and temperature is 36.6°C (97.9°F).

6. Physical examination reveals hepatomegaly and splenomegaly.

7. Several bruises are visible on the inside of the patient's arms and legs.

8. Laboratory testing shows: Hematocrit 23%, Erythrocyte count 2.2 million/mm3, Thrombocyte count 25,000/mm3.

9. A bone marrow biopsy shows decreased trilineage hematopoiesis and macrophages with a crinkled tissue-paper appearance.


Question: What is the best next step in terms of managing this patient?

Context: A 1-day-old boy is brought to the emergency room by his parents for difficulty breathing.

Context: However, these episodes self-resolve after he curls up his legs.

Choices:
A. Administer warming blankets
B. Give prostaglandin E1
C. Immediate surgical repair
D. Obtain lumbar puncture for CSF analysis

Answer: Give prostaglandin E1

1. A 1-day-old boy is brought to the emergency room by his parents.

2. He was delivered at home via vaginal birth with no complications.

3. The mom received minimal prenatal care.

4. The mom wanted the most natural process for her child.

5. The mom reports that he has been relatively healthy.

6. He gets a little fussy when he feeds.

7. These episodes self-resolve after he curls up his legs.

8. A physical examination demonstrates a baby in acute distress.

9. Subcostal retractions and cyanosis at the distal extremities are present.

10. A 5/6 systolic ejection murmur is heard at the left upper sternal border.

1. He was delivered at home via vaginal birth with no complications.

2. The mom received minimal prenatal care as she wanted the most natural process for her child.

3. The mom reports that he has been relatively healthy expect for when he feeds he gets a little fussy.

4. These episodes self-resolve after he curls up his legs.

5. A physical examination demonstrates a baby in acute distress with subcostal retractions and cyanosis at the distal extremities.

6. A 5/6 systolic ejection murmur is heard at the left upper sternal border.


Question: Which medication would most likely further improve her lipid profile?

Context: Lab tests show the following: | Serum glucose (fasting) 95 mg/dL |     Serum electrolytes: | Sodium 140 mEq/L | Potassium 3.8 mEq/L | Chloride 101 mEq/L | Serum creatinine 0.8 mg/dL | Blood urea nitrogen 10 mg/dL | Cholesterol, total 180 mg/dL | HDL-cholesterol 42 mg/dL | LDL-cholesterol 70 mg/dL | Triglycerides 365 mg/dL |     Urinalysis:   | Glucose negative | Ketones negative | Leucocytes negative | Nitrites negative | RBC negative | Casts negative | .

Choices:
A. Niacin
B. Orlistat
C. Fenofibrate
D. Ezetimibe

Answer: Fenofibrate

Lipidology
Endocrinology, Diabetes, and Metabolism

1. A 40-year-old woman schedules an appointment for a routine medical check-up.

2. She admits to being careless about her health, but is motivated to improve.

3. She is working with a personal trainer at the gym and is following a weight reduction diet plan.

4. Despite a 20 kg (44 lb) weight loss over the last year, she still feels that she is fat.

5. She was a frequent binge drinker, but now she has reduced her alcohol consumption to a single glass of wine with dinner and an occasional beer on the weekend.

6. She also has a 15 pack-year smoking history, but quit 6 months ago after she developed a cough and shortness of breath that later improved.

7. She admits to trying various recreational drugs in the past.

8. On her last visit, she was started on rosuvastatin for an elevated cholesterol level.

9. She is sexually active with her partner and they have 2 children.

10. She is uncertain about her family history as she was raised in foster care.

11. The vital signs include: pulse 80/min, respirations 16/min, and blood pressure 122/80 mm Hg.

12. The physical examination reveals a visibly overweight woman with a body mass index (BMI) of 34 kg/m2.

13. The remainder of the examination yields no significant findings.

14. An electrocardiogram (ECG) and chest X-ray are both normal.

15. Lab tests show the following: Serum glucose (fasting) 95 mg/dL.

16. Serum electrolytes: Sodium 140 mEq/L.

17. Serum electrolytes: Potassium 3.8 mEq/L.

18. Serum electrolytes: Chloride 101 mEq/L.

1. She admits to being careless about her health

4. She is following a weight reduction diet plan

5. She has lost 20 kg (44 lb) over the last year

8. She has reduced her alcohol consumption to a single glass of wine with dinner and an occasional beer on the weekend

9. She has a 15 pack-year smoking history

10. She quit smoking 6 months ago after developing a cough and shortness of breath

11. She admits to trying various recreational drugs in the past

12. She was started on rosuvastatin for an elevated cholesterol level

13. She is sexually active with her partner

15. She is uncertain about her family history as she was raised in foster care

16. Her vital signs include: pulse 80/min, respirations 16/min, and blood pressure 122/80 mm Hg

17. She is visibly overweight with a body mass index (BMI) of 34 kg/m2

18. The remainder of the examination yields no significant findings

19. An electrocardiogram (ECG) and chest X-ray are both normal

20. Lab tests show: Serum glucose (fasting) 95 mg/dL, Serum electrolytes: Sodium 140 mEq/L, Potassium 3.8 mEq/L, Chloride 101 mEq/L, Serum creatinine 0.8 mg/dL, Blood urea nitrogen 10 mg/dL, Cholesterol, total 180 mg/dL, HDL-cholesterol 42 mg/dL, LDL-cholesterol 70 mg/dL, Triglycerides 365 mg/dL, Urinalysis: Glucose negative, Ketones negative, Leucocytes negative, Nitrites negative, RBC negative, Casts negative


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

Context: His past medical history is notable for an ST elevation myocardial infarction (STEMI) treated 1 year ago, an abdominal aortic aneurysm (AAA) treated 1 week ago, chronic obstructive pulmonary disease (COPD), asthma, obesity, hypertension, stroke treated 5 years ago, an atrial arrhythmia, diabetes, constipation, and post-traumatic stress disorder (PTSD).

Context: His temperature is 102.0°F (39°C), blood pressure is 197/128 mmHg, pulse is 135/min, respirations are 22/min, and oxygen saturation is 92% on room air.

Context: Laboratory values are ordered as seen below. |  | Hemoglobin: 14 g/dL | Hematocrit: 42% | Leukocyte count: 15,500/mm^3 with normal differential | Platelet count: 199,000/mm^3 |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.4 mEq/L | HCO3-: 22 mEq/L | BUN: 32 mg/dL | Glucose: 189 mg/dL | Creatinine: 1.9 mg/dL | Ca2+: 10.2 mg/dL | Lactate: 4.5 mg/dL | AST: 12 U/L | ALT: 10 U/L |  | .

Choices:
A. Abdominal aortic aneurysm repair complication
B. Atrial fibrillation
C. Obstruction of the small bowel
D. Ruptured appendix

Answer: Abdominal aortic aneurysm repair complication

1. A 59-year-old man presents to the emergency department with abdominal pain.

2. He states that it seemed to come on abruptly, though he does endorse feeling pain the past several days.

3. He has been experiencing bloody diarrhea as well as a subjective fever.

4. His past medical history is notable for an ST elevation myocardial infarction (STEMI) treated 1 year ago.

5. His past medical history is also notable for an abdominal aortic aneurysm (AAA) treated 1 week ago.

6. His past medical history is further notable for chronic obstructive pulmonary disease (COPD), asthma, obesity, hypertension, stroke treated 5 years ago, an atrial arrhythmia, diabetes, constipation, and post-traumatic stress disorder (PTSD).

11. His oxygen saturation is 92% on room air.

12. On physical exam, you note an obese man in distress.

13. Cardiopulmonary exam is notable for bilateral wheezes and a systolic murmur.

14. There is bilateral lower extremity pitting edema and venous stasis ulcers.

15. Abdominal exam reveals diffuse tenderness which the patient describes as 10/10 in severity.

16. Laboratory values show a hemoglobin of 14 g/dL.

17. Laboratory values show a hematocrit of 42%.

18. Laboratory values show a leukocyte count of 15,500/mm^3 with normal differential.

19. Laboratory values show a platelet count of 199,000/mm^3.

20. Laboratory values show a serum Na+ of 139 mEq/L.

21. Laboratory values show a serum Cl- of 100 mEq/L.

22. Laboratory values show a serum K+ of 4.4 mEq/L.

23. Laboratory values show a serum HCO3- of 22 mEq/L.

24. Laboratory values show a serum BUN of 32 mg/dL.

25. Laboratory values show a serum glucose of 189 mg/dL.

1. Patient reports sudden onset of symptoms but has been experiencing pain for several days

2. Patient has been experiencing bloody diarrhea and subjective fever

3. Past medical history includes ST elevation myocardial infarction (STEMI) 1 year ago, abdominal aortic aneurysm (AAA) treated 1 week ago, chronic obstructive pulmonary disease (COPD), asthma, obesity, hypertension, stroke treated 5 years ago, atrial arrhythmia, diabetes, constipation, and post-traumatic stress disorder (PTSD)

4. Patient's temperature is 102.0°F (39°C), blood pressure is 197/128 mmHg, pulse is 135/min, respirations are 22/min, and oxygen saturation is 92% on room air

5. Physical exam reveals an obese man in distress

6. Cardiopulmonary exam shows bilateral wheezes and a systolic murmur

7. Bilateral lower extremity pitting edema and venous stasis ulcers are present

8. Abdominal exam reveals diffuse tenderness described as 10/10 in severity by the patient

9. Laboratory values: Hemoglobin: 14 g/dL, Hematocrit: 42%, Leukocyte count: 15,500/mm^3 with normal differential, Platelet count: 199,000/mm^3, Serum: Na+: 139 mEq/L, Cl-: 100 mEq/L, K+: 4.4 mEq/L, HCO3-: 22 mEq/L, BUN: 32 mg/dL, Glucose: 189 mg/dL, Creatinine: 1.9 mg/dL, Ca2+: 10.2 mg/dL, Lactate: 4.5 mg/dL, AST: 12 U/L, ALT: 10 U/L


Question: Which of the following processes is most likely targeted by this drug?

Context: An investigator is studying an experimental treatment for HIV infection that inhibits the maturation of new HIV virions.

Context: Patients who are taking the drug are observed for several years and side effects are recorded.

Context: In addition, a significant portion of the patients who take the drug for several years shows increased fat accumulation in the neck with loss of subcutaneous fat in the face and extremities.

Choices:
A. Viral entry into host cell
B. Viral polypeptide cleavage
C. Viral budding from host cells
D. Reverse transcription of viral RNA

Answer: Viral polypeptide cleavage

1. An investigator is studying an experimental treatment for HIV infection.

2. The treatment inhibits the maturation of new HIV virions.

3. Patients who are taking the drug are observed for several years.

5. A correlation is established between the drug and the development of impaired glucose tolerance.

6. A significant portion of the patients who take the drug for several years shows increased fat accumulation in the neck.

7. There is loss of subcutaneous fat in the face and extremities.

1. Patients taking the drug are observed for several years.

3. A correlation is established between the drug and impaired glucose tolerance development.

4. A significant portion of patients taking the drug for several years shows increased fat accumulation in the neck.

5. There is loss of subcutaneous fat in the face and extremities in some patients taking the drug for several years.


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

Context: A 30-year-old G1P1 woman gives birth to a healthy infant at 39 weeks gestation.

Context: The mother attended all her prenatal visits and took all her appropriate prenatal vitamins.

Context: Her past medical history is notable for diabetes mellitus, for which she takes metformin.

Context: The infant's temperature is 99.2°F (37.3°C), blood pressure is 65/40 mmHg, pulse is 110/min, and respirations are 22/min.

Choices:
A. Decreased androgen receptor responsiveness
B. Impaired sense of smell
C. Long extremities
D. Testosterone-to-dihydrotestosterone ratio > 20

Answer: Testosterone-to-dihydrotestosterone ratio > 20

1. A 30-year-old G1P1 woman gave birth to a healthy infant at 39 weeks gestation.

2. The mother attended all her prenatal visits.

3. The mother took all her appropriate prenatal vitamins.

4. The mother's past medical history is notable for diabetes mellitus.

5. The mother takes metformin for her diabetes mellitus.

6. The infant's Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.

7. The infant's temperature is 99.2°F (37.3°C).

8. The infant's blood pressure is 65/40 mmHg.

10. The infant's respirations are 22/min.

11. On exam, the child has ambiguous genitalia.

12. A karyotype analysis demonstrates the presence of a Y chromosome.

13. Further workup reveals internal testes with normal levels of serum luteinizing hormone and testosterone.

1. The mother attended all her prenatal visits.

2. The mother took all her appropriate prenatal vitamins.

3. The mother has a past medical history of diabetes mellitus.

4. The mother takes metformin for diabetes mellitus.

5. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.

6. The infant's temperature is 99.2°F (37.3°C).

7. The infant's blood pressure is 65/40 mmHg.

9. The infant's respirations are 22/min.

10. On exam, the child has ambiguous genitalia.

11. A karyotype analysis demonstrates the presence of a Y chromosome.

12. Further workup reveals internal testes.

13. The internal testes have normal levels of serum luteinizing hormone and testosterone.


Question: Which of the following statements best describes the properties of drug A when compared to drug B?"

Context: An investigator is studying the pharmacokinetic properties of two novel inhalational anesthetics and reports the following findings. | Blood-gas partition coefficient Minimum alveolar concentration | Drug A 0.42 3.20% | Drug B 2.31 7.45% | .

Choices:
A. More blood soluble and faster induction of anesthesia
B. More potent and slower recovery from anesthesia
C. More lipid-soluble and faster recovery from anesthesia
D. Less potent and faster induction of anesthesia

Answer: More lipid-soluble and faster recovery from anesthesia

1. An investigator is studying the pharmacokinetic properties of two novel inhalational anesthetics.

2. The investigator reports the following findings.

3. The blood-gas partition coefficient for Drug A is 0.42.

4. The minimum alveolar concentration for Drug A is 3.20%.

5. The blood-gas partition coefficient for Drug B is 2.31.

6. The minimum alveolar concentration for Drug B is 7.45%.

2. The blood-gas partition coefficient for Drug A is 0.42.

3. The blood-gas partition coefficient for Drug B is 2.31.

5. The minimum alveolar concentration for Drug B is 7.45%.


Question: Which of the following best describes the mechanism of development of these skin lesions in this patient?

Context: A 56-year-old man presents to an initial visit to his primary care physician complaining of excessive fatigue, weight loss, and increased abdominal girth.

Context: He drinks about 2–4 glasses of wine with dinner and recalls having abnormal liver enzymes in the past.

Context: The skin lesion in this photo is present in on the face, arms, and upper trunk of the patient.

Choices:
A. Anastomoses between portal vein tributaries and the arterial system
B. Hormonal imbalance
C. Coagulation defects
D. Increase in serum ammonia

Answer: Hormonal imbalance

1. A 56-year-old man presents to an initial visit to his primary care physician.

2. He is complaining of excessive fatigue, weight loss, and increased abdominal girth.

3. He drinks about 2–4 glasses of wine with dinner.

4. He recalls having abnormal liver enzymes in the past.

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

6. Physical examination reveals shifting dullness, firm liver, and splenomegaly.

7. There is a skin lesion present on the face, arms, and upper trunk of the patient.

1. He drinks about 2–4 glasses of wine with dinner.

2. He recalls having abnormal liver enzymes in the past.

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

4. Physical examination reveals shifting dullness.

5. Physical examination reveals firm liver.

6. Physical examination reveals splenomegaly.

7. The skin lesion in the photo is present on the face, arms, and upper trunk of the patient.


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

Context: A 44-year-old man presents to the emergency department due to sudden chest pain and difficulty breathing for the past 3 hours.

Context: The pain is felt in the retrosternal area and radiates up to his left shoulder and arm; it worsens on inspiration, and is relieved when he is leaning forward.

Context: An ECG is performed.

Choices:
A. Acute pericarditis
B. Aortic stenosis
C. Infective endocarditis
D. Myocardial infarction

Answer: Acute pericarditis

Cardiovascular Disease
General Emergency Medicine

1. A 44-year-old man presents to the emergency department.

2. He has had sudden chest pain and difficulty breathing for the past 3 hours.

3. The pain is felt in the retrosternal area and radiates up to his left shoulder and arm.

4. The pain worsens on inspiration and is relieved when he is leaning forward.

5. His heart rate is 61/min, respiratory rate is 16/min, temperature is 36.5°C (97.7°F), and blood pressure is 115/78 mm Hg.

6. Physical examination shows no abnormalities.

7. Pericardial friction rub is heard on auscultation.

8. Laboratory results show elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels.

1. The pain is felt in the retrosternal area and radiates up to his left shoulder and arm.

3. The pain is relieved when he is leaning forward.

8. Physical examination shows no abnormalities.

9. Pericardial friction rub is heard on auscultation.

10. Laboratory results show elevated erythrocyte sedimentation rate (ESR) levels.

11. Laboratory results show elevated C-reactive protein (CRP) levels.


Question: The bacteriostatic effect of this drug is most likely due to which of the following mechanisms?

Context: A 27-year-old woman comes to the physician because of a rash and headache.

Context: Her temperature is 38.2°C (100.8°F).

Choices:
A. Inhibition of initiation complex formation at the 30S ribosomal subunit
B. Inactivation of prokaryotic topoisomerase II and IV
C. Inhibition of tRNA binding site at the 30S ribosomal subunit
D. Inactivation of bacterial peptidyltransferase at the 50S ribosomal subunit

Answer: Inactivation of bacterial peptidyltransferase at the 50S ribosomal subunit

1. A 27-year-old woman comes to the physician.

2. She recently returned from a camping trip in North Carolina.

3. She has a severe allergy to doxycycline.

5. Physical examination shows a blanching erythematous rash and petechiae over both ankles and the soles of her feet.

7. The drug can cause fatal aplastic anemia.

1. She recently returned from a camping trip in North Carolina.

2. She has a severe allergy to doxycycline.

4. Physical examination shows a blanching erythematous rash and petechiae over both ankles and the soles of her feet.

5. A drug is prescribed that can cause fatal aplastic anemia.


Question: Which of these benefits can the physician ethically accept?

Context: The research of an academic physician helps to discover a novel small molecule that improves outcomes after myocardial infarction in animal models due to decreasing the severity of reperfusion injury.

Context: A pharmaceutical company then approached the university of this physician in order to sign an agreement allowing the molecule to proceed to clinical trials.

Context: After several years of work, the physician has obtained a wealth of new data from human trials and has published several high profile papers. |  | A major national conference then invites this physician to give a keynote presentation on his work with the novel small molecule.

Context: In order to prepare for this speech, the pharmaceutical company offers: | 1.

Context: A speaking honorarium | 2.

Context: Compensation for travel expenses | 3.

Context: Help with preparing slides for the speech |  | .

Choices:
A. 1 only
B. 1 and 2
C. 1 and 3
D. 1, 2, and 3

Answer: 1 and 2

1. An academic physician conducted research that discovered a novel small molecule that improves outcomes after myocardial infarction in animal models due to decreasing the severity of reperfusion injury.

2. A pharmaceutical company approached the university of this physician in order to sign an agreement allowing the molecule to proceed to clinical trials.

3. After several years of work, the physician has obtained a wealth of new data from human trials and has published several high profile papers.

4. A major national conference invited this physician to give a keynote presentation on his work with the novel small molecule.

5. The pharmaceutical company offered a speaking honorarium, compensation for travel expenses, and help with preparing slides for the speech.

1. A pharmaceutical company approached the university of a physician to sign an agreement allowing a molecule to proceed to clinical trials.

2. The physician has obtained new data from human trials and has published several high profile papers.

3. A major national conference invited the physician to give a keynote presentation on his work with the novel small molecule.

4. The pharmaceutical company offered a speaking honorarium to the physician.

5. The pharmaceutical company offered compensation for travel expenses to the physician.

6. The pharmaceutical company offered help with preparing slides for the speech to the physician.


Question: Which of the following options best describes the pathogenesis of edema in this patient?

Context: His temperature is 36.9°C (98.4°F), pulse rate is 88/min, blood pressure is 98/70 mm Hg, and respiratory rate is 20/min.

Context: Laboratory studies show: | Serum creatinine 0.8 mg/dL | Serum albumin 1.5 g/dL | Serum cholesterol 260 mg/dL | Serum C3 and C4 Normal | Urine protein/creatinine ratio 3.1 mg/mg | The patient is diagnosed with minimal change disease.

Choices:
A. Increased capillary hydrostatic pressure
B. Increased capillary permeability
C. Increased interstitial oncotic pressure
D. Decreased oncotic pressure gradient across capillary

Answer: Decreased oncotic pressure gradient across capillary

1. A 6-year-old boy is brought to the pediatrician with swelling around the eyes, lower extremity edema, and abdominal distension for the past 3 days.

2. There is no history of hematuria or decreased urine output.

7. On physical examination, 2+ pitting edema is present in the lower limbs and the periorbital region.

8. The abdomen is distended with a positive fluid wave.

9. Laboratory studies show serum creatinine 0.8 mg/dL.

10. Laboratory studies show serum albumin 1.5 g/dL.

11. Laboratory studies show serum cholesterol 260 mg/dL.

12. Laboratory studies show serum C3 and C4 Normal.

13. Laboratory studies show urine protein/creatinine ratio 3.1 mg/mg.

14. The patient is diagnosed with minimal change disease.

7. 2+ pitting edema present in lower limbs and periorbital region

9. Positive fluid wave on abdominal examination

14. Urine protein/creatinine ratio is 3.1 mg/mg


Question: This patient's condition is most likely associated with decreased production of which of the following substances?

Context: A 73-year-old woman is brought to the physician by her son because of a 2-year history of increasing forgetfulness.

Context: She does not remember her children's names; she cannot go outside the house unaccompanied because she forgets where she is and what she is supposed to do.

Context: She is oriented only to person.

Context: Her abstract reasoning is impaired.

Choices:
A. Gamma-aminobutyric acid
B. Acetylcholine
C. Norepinephrine
D. Dopamine

Answer: Acetylcholine

Neurology with Special Qualification in Child Neurology

1. A 73-year-old woman is brought to the physician by her son.

2. She has a 2-year history of increasing forgetfulness.

3. She does not remember her children's names.

4. She cannot go outside the house unaccompanied.

5. She forgets where she is and what she is supposed to do.

6. Her son reports that over the past year, she has withdrawn herself from social gatherings.

8. Mental status examination shows both impaired short- and long-term memory.

11. She appears indifferent about her memory lapses.

12. She says this is normal for someone her age.

1. She does not remember her children's names.

2. She cannot go outside the house unaccompanied because she forgets where she is and what she is supposed to do.

3. Her son reports that over the past year, she has withdrawn herself from social gatherings and avoids making conversation.

4. Mental status examination shows impaired short-term memory.

5. Mental status examination shows impaired long-term memory.

8. She appears indifferent about her memory lapses and says this is normal for someone her age.


Question: What type of medication would be best long-term for our patient?

Context: During an emergency room shift, you encounter a disheveled looking man claiming that he is President Kennedy’s love child and the FBI is out to get him.

Context: He also endorses that the aliens are responsible for his fathers death and that the aliens implanted a chip in his head to constantly speak to him.

Choices:
A. Quetiapine
B. Lithium
C. Fluoxetine
D. Chlorpromazine

Answer: Quetiapine

1. During an emergency room shift, you encounter a disheveled looking man.

2. The man claims that he is President Kennedy’s love child.

3. The man claims that the FBI is out to get him.

4. The man endorses that the aliens are responsible for his father's death.

5. The man claims that the aliens implanted a chip in his head to constantly speak to him.

6. Upon review of his medical record, you notice that he made a previous visit to the ER for a similar episode about 8 months ago.

7. Besides his eccentric demeanor and disorganized speech, his vitals and physical exam are all within in normal range.

8. No illicit substances were identified following a urinary toxicology screening.

1. The patient believes that aliens are responsible for his father's death.

2. The patient claims that aliens implanted a chip in his head to constantly speak to him.

3. The patient had a previous visit to the ER for a similar episode about 8 months ago.

4. The patient's vitals and physical exam are within normal range.

5. No illicit substances were found in the patient's urinary toxicology screening.


Question: What is the most likely pathological process seen in this type of infection?

Context: A 20-year-old man presents to an outpatient clinic with complaints of fever and sweating for 2 months.

Context: He says that he does not have the same appetite as before.

Context: He also complains of pleuritic chest pain and difficulty breathing, which is not nocturnal and is unrelated to position.

Choices:
A. Caseous necrosis
B. Liquefactive necrosis
C. Fat necrosis
D. Fibrinoid necrosis

Answer: Caseous necrosis

2. Patient has had fever and sweating for 2 months.

4. Patient has lost 2.7 kg (6.0 lb) in the last 2 months.

5. Patient has pleuritic chest pain and difficulty breathing.

6. Patient's chest pain and difficulty breathing is not nocturnal and is unrelated to position.

7. Patient has had a mild cough for several months.

8. Patient is afebrile with normal auscultatory findings on examination.

9. Chest X-ray reveals a right upper lobe homogeneous density.

10. Ziehl-Neelsen staining of sputum shows Mycobacterium tuberculosis.

1. He does not have the same appetite as before.

2. He lost 2.7 kg (6.0 lb) in the last 2 months.

3. He complains of pleuritic chest pain and difficulty breathing, which is not nocturnal and is unrelated to position.

4. He has had a mild cough for several months.

5. On examination, the patient is afebrile with normal auscultatory findings.

6. A chest X-ray reveals a right upper lobe homogeneous density.

7. Ziehl-Neelsen staining of sputum shows Mycobacterium tuberculosis.


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

Context: A 19-year-old man presents with a 10-day history of progressive lower back pain and leg weakness, followed by severe lower abdominal pain for the past 12-hours.

Context: He describes the back pain as moderate in intensity which radiates to both legs.

Context: The weakness has progressively increased, and he cannot ambulate without support.

Context: He is also complaining of fever but never checks it.

Context: He is a captain of the college basketball team and the back pain and lower limb weakness is preventing him from participating in practices or games.

Context: Past medical history is significant for schizophrenia and a suicide attempt.

Context: His vital signs include: blood pressure 128/84 mm Hg, temperature 38.8°C (101.8°F).

Context: Strength is 5 out of 5 in the upper limbs bilaterally and 3 out of 5 in the lower limbs bilaterally.

Context: Deep tendon reflexes are 2+ in the upper limbs while they are reduced in the lower limbs.

Choices:
A. Nerve conduction studies
B. Psychiatric consultation
C. Spinal magnetic resonance imaging (MRI)
D. Ultrasound of kidneys, ureters, and bladder

Answer: Spinal magnetic resonance imaging (MRI)

2. Patient has 10-day history of progressive lower back pain and leg weakness.

3. Patient has severe lower abdominal pain for the past 12-hours.

4. Patient describes back pain as moderate in intensity which radiates to both legs.

5. Patient's weakness has progressively increased.

6. Patient cannot ambulate without support.

7. Patient is complaining of fever but never checks it.

8. Patient is captain of college basketball team.

9. Back pain and lower limb weakness is preventing patient from participating in practices or games.

10. Patient has past medical history of schizophrenia and a suicide attempt.

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

12. Patient's temperature is 38.8°C (101.8°F).

14. Strength is 5 out of 5 in upper limbs bilaterally and 3 out of 5 in lower limbs bilaterally.

15. Deep tendon reflexes are 2+ in upper limbs and reduced in lower limbs.

16. Sensitivity to pinprick is absent from below the umbilicus.

17. 1270 mL of urine is collected after placing a Foley catheter.

1. The patient describes the back pain as moderate in intensity.

3. The weakness has progressively increased.

4. The patient cannot ambulate without support.

6. The patient has not checked their fever.

7. The patient is a captain of the college basketball team.

8. The back pain and lower limb weakness are preventing the patient from participating in practices or games.

9. The patient's past medical history includes schizophrenia and a suicide attempt.

10. The patient's blood pressure is 128/84 mm Hg.

11. The patient's temperature is 38.8°C (101.8°F).

12. A mass is palpable in the lower abdomen.

13. The patient's strength is 5 out of 5 in the upper limbs bilaterally.

14. The patient's strength is 3 out of 5 in the lower limbs bilaterally.

15. The patient's deep tendon reflexes are 2+ in the upper limbs.

16. The patient's deep tendon reflexes are reduced in the lower limbs.

17. Sensitivity to pinprick is absent from below the umbilicus.

18. 1270 mL of urine is collected after placing a Foley catheter.


Question: Which of the following deposits would most likely be detected on the renal biopsy in this patient?

Context: His blood work shows mild anemia and urinalysis detects proteinuria at a level of 670 mg/24 h.

Context: A kidney biopsy is performed.

Choices:
A. Аβ amyloid
B. Calcitonin
C. AL amyloid
D. Mutated transthyretin

Answer: AL amyloid

1. A 72-year-old man is diagnosed with multiple myeloma.

3. Urinalysis detects proteinuria at a level of 670 mg/24 h.

2. Urinalysis detects proteinuria at a level of 670 mg/24 h.


Question: Which of the following options would be most appropriate for the management of this patient?

Context: A 29-year-old woman, gravida 1, para 0 at 11 weeks' gestation, comes to the physician because of a 2-day history of left lower-extremity pain and swelling.

Context: Her temperature is 37.9°C (100.2°F).

Context: She denies any trauma but says she has not been ambulating due to swelling and the pain in her lower extremities.

Choices:
A. Aspirin
B. Dipyridamole
C. Heparin
D. Warfarin

Answer: Heparin

General Obstetrics and Gynecology
Maternal

1. A 29-year-old woman is gravida 1, para 0 at 11 weeks' gestation.

2. She has a 2-day history of left lower-extremity pain and swelling.

5. She has not been ambulating due to swelling and the pain in her lower extremities.

6. Physical examination shows diffuse pain on palpation and swelling of the left leg, as well as warmth and tenderness.

7. Compression ultrasound shows poor compressibility of the femoral vein.

3. She has not been ambulating due to swelling and pain in her lower extremities.

4. Physical examination shows diffuse pain on palpation.

5. Physical examination shows swelling of the left leg.

6. Physical examination shows warmth and tenderness.


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

Context: A 65-year-old woman presents to the emergency department with a new-onset seizure.

Context: The patient works as a gardener is often dehydrated but drinks large volumes of water to compensate for her work.

Context: She does not wear protective gear or sunscreen while working.

Context: She has smoked 1.5 packs of cigarettes per day for the past 40 years.

Context: She drinks liquor before bed every night.

Context: The patient has a past medical history of hypertension and diabetes and recently lost 9 pounds.

Context: Physical exam is within normal limits.

Choices:
A. Glioblastoma multiforme
B. Infiltrating ductal carcinoma of the breast
C. Primary seizure disorder
D. Small cell carcinoma of the lung

Answer: Small cell carcinoma of the lung

1. A 65-year-old woman presented to the emergency department with a new-onset seizure.

2. The patient was at home watching television when she suddenly began jerking her limbs and not responding according to her partner.

4. The patient is often dehydrated but drinks large volumes of water to compensate for her work.

5. The patient does not wear protective gear or sunscreen while working.

6. The patient has smoked 1.5 packs of cigarettes per day for the past 40 years.

7. The patient drinks liquor before bed every night.

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

10. Physical exam is within normal limits.

1. The patient was at home watching television when she suddenly began jerking her limbs and not responding according to her partner.

2. The patient works as a gardener and is often dehydrated.

3. The patient drinks large volumes of water to compensate for her work.

4. The patient does not wear protective gear or sunscreen while working.

5. The patient has smoked 1.5 packs of cigarettes per day for the past 40 years.

6. The patient drinks liquor before bed every night.

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

9. Physical exam is within normal limits.


Question: What is inoculation of the tetanus vaccine able to stimulate the production of?

Context: A 32-year-old man presents to the emergency department after puncturing his foot while working on his garage last week.

Context: On examination, the patient’s jaw seems rigid, and his temperature is 38.3°C (100.9°F).

Choices:
A. Anti-tetanus antibodies
B. Allotype antibodies
C. Hypersensitive reaction type III
D. Idiotype antibodies

Answer: Allotype antibodies

General Emergency Medicine
Infectious Disease

1. A 32-year-old man presents to the emergency department.

2. He punctured his foot while working on his garage last week.

3. His past medical history is significant for bronchial asthma and seasonal allergies.

4. On examination, the patient's jaw seems rigid.

6. The puncture on the sole of his foot is 2 cm deep and 0.5 cm long.

7. The patient is immediately given tetanus immunoglobulin.

1. His past medical history includes bronchial asthma and seasonal allergies.

2. On examination, the patient's jaw appears rigid.

3. The patient's temperature is 38.3°C (100.9°F).

4. The puncture on the sole of his foot is 2 cm deep and 0.5 cm long.

5. The patient is immediately given tetanus immunoglobulin.


Question: Which of the following explains these findings?

Context: She has lost 20 kg (44 lb).

Context: A physical examination indicates that the body temperature is 37.8°C (100.0°F), the heart rate is 120/min, and the blood pressure is 130/80 mm Hg.

Context: She was agitated and experienced a fine tremor with warm moist palms; she also had increased deep tendon reflexes.

Context: No exophthalmos was noted.

Context: The laboratory tests revealed TSH < 0.01 mIU/L (normal: 0.5–4.0 mIU/L), T4: 57 pmol/L (normal: 10–25 pmol/L), T3: 24 pmol/L (normal 3.1–5.4 pmol/L).

Context: Complete blood count was normal.

Choices:
A. Exogenous thyroxine intake
B. Graves’ disease
C. Hashimoto’s thyroiditis
D. Pregnancy

Answer: Graves’ disease

Internal Medicine
Endocrinology, Diabetes, and Metabolism

Endocrinology, Diabetes, and Metabolism
General Endocrinology

1. A 28-year-old woman presents to the clinic with 2 months of palpitations, tremor, heat intolerance, insomnia, and loose bowel movements.

3. A physical examination indicates that the body temperature is 37.8°C (100.0°F).

6. The examination also reveals that a moderately-sized diffuse goiter and a bruit were present.

7. She was agitated and experienced a fine tremor with warm moist palms.

8. She also had increased deep tendon reflexes.

10. The laboratory tests revealed TSH < 0.01 mIU/L (normal: 0.5–4.0 mIU/L).

11. T4: 57 pmol/L (normal: 10–25 pmol/L).

12. T3: 24 pmol/L (normal 3.1–5.4 pmol/L).

14. A thyroid scan demonstrated diffusely increased uptake.

15. A high level of thyroid-stimulating immunoglobulin antibodies was detected.

2. The body temperature is 37.8°C (100.0°F).

5. A moderately-sized diffuse goiter and a bruit were present.

6. She was agitated and experienced a fine tremor with warm moist palms.

7. She had increased deep tendon reflexes.

9. The laboratory tests revealed TSH < 0.01 mIU/L (normal: 0.5–4.0 mIU/L).

10. T4: 57 pmol/L (normal: 10–25 pmol/L).

11. T3: 24 pmol/L (normal 3.1–5.4 pmol/L).

13. A thyroid scan demonstrated diffusely increased uptake.

14. A high level of thyroid-stimulating immunoglobulin antibodies was detected.


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

Context: A 45-year-old woman comes to the physician because of fatigue and irregular menstrual cycles for the past year.

Context: She also complains of recurrent sinus infections.

Context: During the past 6 months, she has had increased urinary frequency and swelling of her feet.

Context: She has also had difficulty lifting her 3-year-old niece for the past 3 weeks.

Context: She was recently diagnosed with depression.

Context: She works as a medical assistant.

Context: Her only medication is escitalopram.

Context: She appears tired.

Context: Laboratory studies show: | Serum | Na+ 150 mEq/L | K+ 3.0 mEq/L | Cl- 103 mEq/L | HCO3- 30 mEq/L | Urea nitrogen 19 mg/dL | Creatinine 0.9 mg/dL | Glucose 136 mg/dL | A 1 mg overnight dexamethasone suppression test shows a serum cortisol of 167 nmol/L (N < 50) and a 24-hour urinary cortisol is 425 μg (N < 300 μg).

Context: Serum ACTH is 169 pg/mL (N = 7–50).

Choices:
A. Adrenal carcinoma
B. Hypothyroidism
C. Small cell lung cancer
D. Adrenal adenoma

Answer: Small cell lung cancer

2. Patient has been experiencing fatigue and irregular menstrual cycles for the past year.

3. Patient has had recurrent sinus infections.

4. Patient has had increased urinary frequency and swelling of her feet for the past 6 months.

5. Patient has had difficulty lifting her 3-year-old niece for the past 3 weeks.

6. Patient was recently diagnosed with depression.

7. Patient works as a medical assistant.

8. Patient has smoked one half-pack of cigarettes daily for 25 years.

9. Patient drinks four beers on the weekends.

10. Patient's only medication is escitalopram.

12. Patient weighs 79 kg (175 lb); BMI is 31 kg/m2.

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

17. Patient's blood pressure is 140/82 mm Hg.

18. Physical examinations shows neck obesity and an enlarged abdomen.

19. Examination of the skin shows multiple bruises on her arms and legs.

20. There is generalized weakness and atrophy of the proximal muscles.

28. A 1 mg overnight dexamethasone suppression test shows a serum cortisol of 167 nmol/L (N < 50).

29. 24-hour urinary cortisol is 425 μg (N < 300 μg).

31. High-dose dexamethasone suppression test shows a serum cortisol level of 164 nmol/L (N < 50).

1. The patient complains of recurrent sinus infections.

2. Over the past 6 months, she has experienced increased urinary frequency and swelling of her feet.

3. She has had difficulty lifting her 3-year-old niece for the past 3 weeks.

4. The patient was recently diagnosed with depression.

6. The patient has smoked one half-pack of cigarettes daily for 25 years and drinks four beers on the weekends.

8. She is 160 cm (5 ft 3 in) tall and weighs 79 kg (175 lb); BMI is 31 kg/m2.

10. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 18/min, and blood pressure is 140/82 mm Hg.

11. Physical examination shows neck obesity and an enlarged abdomen.

12. Examination of the skin shows multiple bruises on her arms and legs.

13. There is generalized weakness and atrophy of the proximal muscles.

14. Laboratory studies show: Serum Na+ 150 mEq/L, K+ 3.0 mEq/L, Cl- 103 mEq/L, HCO3- 30 mEq/L, Urea nitrogen 19 mg/dL, Creatinine 0.9 mg/dL, Glucose 136 mg/dL.

15. A 1 mg overnight dexamethasone suppression test shows a serum cortisol of 167 nmol/L (N < 50) and a 24-hour urinary cortisol is 425 μg (N < 300 μg).

17. Subsequently, a high-dose dexamethasone suppression test shows a serum cortisol level of 164 nmol/L (N < 50).


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

Context: A 39-year-old woman, gravida 3, para 2, at 39 weeks' gestation is admitted to the hospital with leakage of fluid and contractions.

Context: She noticed the fluid leak about an hour ago and has no associated bleeding.

Context: Contractions have been about 20 minutes apart.

Context: On admission, she is dilated 2 cm, 50% effaced, and at -2 station.

Context: Spontaneous rupture of membranes is confirmed and she is monitored by external tocodynamometer.

Context: Repeat evaluation after 2 hours shows dilation of 6 cm , 70% effacement, and -1 station.

Context: Four hours later, her pelvic exam shows no changes and she has 4 strong contractions every 10 minutes.

Context: The fetal heart rate is 120/min, with moderate accelerations and no late or variable decelerations.

Choices:
A. Cesarean delivery
B. Assisted vaginal delivery
C. Amnioinfusion
D.
Intrauterine pressure catheter
"

Answer: Cesarean delivery

4. Patient has leakage of fluid and contractions.

5. Patient noticed fluid leak about an hour ago.

7. Contractions are about 20 minutes apart.

8. On admission, patient is dilated 2 cm, 50% effaced, and at -2 station.

9. Spontaneous rupture of membranes is confirmed.

10. Patient is monitored by external tocodynamometer.

11. Repeat evaluation after 2 hours shows dilation of 6 cm, 70% effacement, and -1 station.

12. Four hours later, pelvic exam shows no changes.

13. Patient has 4 strong contractions every 10 minutes.

15. Fetal heart rate has moderate accelerations.

16. Fetal heart rate has no late or variable decelerations.

1. She noticed the fluid leak about an hour ago

3. Contractions have been about 20 minutes apart

7. Spontaneous rupture of membranes is confirmed

8. She is monitored by external tocodynamometer

9. Repeat evaluation after 2 hours shows dilation of 6 cm

12. Four hours later, her pelvic exam shows no changes

13. She has 4 strong contractions every 10 minutes

15. The fetal heart rate shows moderate accelerations

16. There are no late or variable decelerations


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

Context: A 32-year-old homeless man presents to the emergency department with dyspnea, left-sided chest pain, chills, and a productive cough over the last week or so.

Context: He does not have medical insurance and has not seen a doctor for many years.

Context: He states that has a productive cough with yellow sputum with flecks of blood.

Context: He drinks 6 beers a night and does not smoke or take illicit drugs.

Context: Temperature is 37.8°C (100.0°F), blood pressure is 124/90 mm Hg, pulse is 92/min, and respiration rate is 16/min.

Context: On physical examination, tactile fremitus is increased and there is a dullness to percussion over the lower part of the left lung.

Context: No murmurs are heard.

Choices:
A. Supplemental oxygen
B. IV antibiotics and thoracentesis
C. Inhaled bronchodilators
D. Upper endoscopy

Answer: IV antibiotics and thoracentesis

General Emergency Medicine
Pulmonary Disease

3. Patient presents with dyspnea, left-sided chest pain, chills, and a productive cough over the last week or so.

4. Patient has not had medical insurance and has not seen a doctor for many years.

5. Patient's chest pain increases with inspiration.

6. Patient's chest pain does not radiate or worsen with movement.

7. Patient has a productive cough with yellow sputum with flecks of blood.

9. Patient does not smoke or take illicit drugs.

10. Patient's temperature is 37.8°C (100.0°F).

11. Patient's blood pressure is 124/90 mm Hg.

13. Patient's respiration rate is 16/min.

14. On physical examination, tactile fremitus is increased.

15. On physical examination, there is a dullness to percussion over the lower part of the left lung.

16. On physical examination, no murmurs are heard.

17. Oral examination reveals poor dentition.

18. Chest X-ray reveals a large left lobar opacification with extensive pleural effusion.

2. He has not seen a doctor for many years.

3. His chest pain increases with inspiration.

4. The pain does not radiate or worsen with movement.

5. He has a productive cough with yellow sputum with flecks of blood.

7. He does not smoke or take illicit drugs.

12. On physical examination, tactile fremitus is increased.

13. There is a dullness to percussion over the lower part of the left lung.

15. Oral examination reveals poor dentition.

16. Chest X-ray reveals a large left lobar opacification with extensive pleural effusion.


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

Context: A 43-year-old woman presents with left calf pain.

Context: A D-dimer level is positive.

Choices:
A. Fibromyalgia
B. Oral contraceptives
C. Protein C deficiency
D. Protein S deficiency

Answer: Oral contraceptives

Orthopaedic Sports Medicine
General Internal Medicine
Vascular Medicine

2. Patient presents with left calf pain.

3. Patient denies any previous episodes of such pain.

4. Patient has past medical history of cervical carcinoma treated with cryosurgery with no evidence of recurrence.

5. Patient is currently taking an estrogen-containing oral contraceptive and a multivitamin.

6. Patient has a 40-pack-year smoking history, but no alcohol or recreational drug use.

7. Patient is afebrile and her vital signs are within normal limits.

8. On physical examination, her left calf is swollen, erythematous, and tender to palpation.

1. She denies any previous episodes of such pain.

2. Past medical history is significant for cervical carcinoma treated with cryosurgery with no evidence of recurrence.

3. Current medications are an estrogen-containing oral contraceptive and a multivitamin.

4. The patient reports a 40-pack-year smoking history, but no alcohol or recreational drug use.

5. The patient is afebrile and her vital signs are within normal limits.

6. On physical examination, her left calf is swollen, erythematous, and tender to palpation.


Question: Assuming all other parameters remain constant, which of the following is most likely to decrease the volume of retrograde blood flow in this patient?

Context: A 53-year-old woman with hypertension and hyperlipidemia comes to the physician because of a 3-month history of progressively worsening shortness of breath.

Context: Her pulse is 92/min, respirations are 22/min, and blood pressure is 110/70 mm Hg.

Context: Cardiac examination shows a grade 3/6 holosystolic murmur at the apex that radiates to the axilla and an extra heart sound during early diastole.

Choices:
A. Increase in atrioventricular orifice size
B. Increase in left ventricular inotropy
C. Decrease in systemic vascular resistance
D. Increase in left ventricular end-diastolic pressure

Answer: Decrease in systemic vascular resistance

1. A 53-year-old woman comes to the physician.

2. She has hypertension and hyperlipidemia.

3. She has a 3-month history of progressively worsening shortness of breath.

7. Cardiac examination shows a grade 3/6 holosystolic murmur at the apex.

9. There is an extra heart sound during early diastole.

4. Cardiac examination: Grade 3/6 holosystolic murmur at the apex

6. Extra heart sound: During early diastole


Question: What is the most likely cause of his symptoms?

Context: A 66-year-old man presents to his primary care physician with abdominal pain in the setting of progressively worsening constipation.

Context: He complains of epigastric pain that waxes and wanes, and expressed concern that he has not defecated for the past 5 days.

Context: Upon further questioning, he relates that he has been taking three of his wife's multivitamins each day for the past three weeks to "combat a cold." Vital signs are within normal limits.

Context: Physical exam reveals an abdomen with nonspecific tenderness to deep palpation without rebound tenderness, hyperpercussion, or flank tenderness.

Choices:
A. Magnesium overdose
B. Iron overdose
C. Potassium overdose
D. Folic acid overdose

Answer: Iron overdose

1. A 66-year-old man presents to his primary care physician with abdominal pain.

2. The abdominal pain is in the setting of progressively worsening constipation.

3. He complains of epigastric pain that waxes and wanes.

4. He has not defecated for the past 5 days.

5. He has been taking three of his wife's multivitamins each day for the past three weeks.

6. Vital signs are within normal limits.

7. Physical exam reveals an abdomen with nonspecific tenderness to deep palpation.

8. There is no rebound tenderness, hyperpercussion, or flank tenderness.

3. Patient has not defecated for the past 5 days

4. Patient has been taking three of his wife's multivitamins each day for the past three weeks

5. Patient took multivitamins to combat a cold

7. Physical exam reveals nonspecific tenderness in the abdomen to deep palpation

8. No rebound tenderness, hyperpercussion, or flank tenderness


Question: Which of the following findings in the nephron best describes the tubular osmolality, compared with serum, in this patient?

Context: Two days after undergoing transsphenoidal removal of a pituitary macroadenoma, a 35-year-old woman reports increased thirst and frequent urination.

Context: The surgery was uncomplicated.

Context: Her serum sodium concentration is 153 mEq/L and serum glucose concentration is 92 mg/dL.

Choices:
A. Distal ascending loop of Henle is hypertonic
B. Proximal convoluted tubule is hypertonic
C. Collecting duct is hypotonic
D. Distal convoluted tubule is hypertonic

Answer: Collecting duct is hypotonic

1. A 35-year-old woman underwent transsphenoidal removal of a pituitary macroadenoma.

2. Two days after the surgery, the woman reported increased thirst and frequent urination.

4. Neurologic examination showed no abnormalities.

5. The woman's serum sodium concentration was 153 mEq/L.

6. The woman's serum glucose concentration was 92 mg/dL.

2. Neurologic examination shows no abnormalities.

3. Her serum sodium concentration is 153 mEq/L.

4. Her serum glucose concentration is 92 mg/dL.


Question: This patient's symptoms are most likely caused by obstruction at which of the following locations?

Context: A 67-year-old woman comes to the physician because of a 5-day history of episodic abdominal pain, nausea, and vomiting.

Context: She is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); her BMI is 34 kg/m2.

Context: Her temperature is 38.1°C (100.6°F).

Context: Physical examination shows dry mucous membranes, abdominal distension, and hyperactive bowel sounds.

Choices:
A. Third part of the duodenum
B. Distal ileum
C. Proximal jejunum
D. Pancreatic duct

Answer: Distal ileum

1. A 67-year-old woman comes to the physician.

2. She has a 5-day history of episodic abdominal pain, nausea, and vomiting.

3. She has coronary artery disease and type 2 diabetes mellitus.

4. She takes aspirin, metoprolol, and metformin.

9. Physical examination shows dry mucous membranes.

10. Physical examination shows abdominal distension.

11. Physical examination shows hyperactive bowel sounds.

12. Ultrasonography of the abdomen shows air in the biliary tract.

10. Physical examination shows dry mucous membranes.

11. Physical examination shows abdominal distension.

12. Physical examination shows hyperactive bowel sounds.

13. Ultrasonography of the abdomen shows air in the biliary tract.


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

Context: A 47-year-old man presents to his ophthalmologist for abnormal vision.

Context: The patient was discharged from the hospital 2 weeks ago after a motor vehicle accident where he was given 1L of blood.

Context: He also underwent several surgical procedures including enucleation of the right globe and exploratory abdominal laparotomy to stop internal bleeding.

Context: Currently, he states that he has noticed decreased vision in his left eye.

Context: His temperature is 98.9°F (37.2°C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 97% on room air.

Context: Physical exam is notable for 20/200 vision in the patient's left eye, which is worse than usual.

Choices:
A. Anterior uveitis
B. Normal post-operative visual adaptations
C. Seasonal allergies
D. Sympathetic ophthalmia

Answer: Sympathetic ophthalmia

2. Patient was discharged from hospital 2 weeks ago after motor vehicle accident.

4. Patient underwent enucleation of right globe and exploratory abdominal laparotomy.

5. Patient has noticed decreased vision in left eye.

6. Patient has past medical history of poorly controlled diabetes, asthma, and atopic dermatitis.

7. Patient's temperature is 98.9°F (37.2°C).

8. Patient's blood pressure is 167/108 mmHg.

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

12. Patient's vision in left eye is 20/200.

13. Patient's left eye appears red and irritated.

1. The patient was discharged from the hospital 2 weeks ago after a motor vehicle accident.

3. The patient underwent enucleation of the right globe.

4. The patient underwent exploratory abdominal laparotomy to stop internal bleeding.

5. The patient has noticed decreased vision in his left eye.

6. The patient has a past medical history of poorly controlled diabetes, asthma, and atopic dermatitis.

7. The patient's temperature is 98.9°F (37.2°C).

8. The patient's blood pressure is 167/108 mmHg.

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

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

12. The patient's physical exam is notable for 20/200 vision in the left eye.

13. The patient's left eye appears red and irritated.


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

Context: A 26-year-old female presents to her primary care physician with several months of mood swings, which she feels are affecting her work and personal relationships.

Context: She states that on roughly a quarter of days each month, she feels highly irritable, sensitive to criticism and rejection, and easily saddened.

Context: She also feels that her appetite varies greatly, and on the days when she is particularly emotional, she also feels especially hungry.

Context: As a result of these symptoms, her performance at work has suffered, and her boyfriend has been complaining that she is difficult to live with.

Context: She is anxious that she cannot “get my mood under control.” The patient has no past medical history, regular periods every 28 days, and no obstetric history.

Context: She uses condoms for contraception.

Context: At this visit, the patient’s temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 130/76 mmHg, and respirations are 13/min.

Context: Physical exam is unremarkable.

Choices:
A. Selective serotonin reuptake inhibitor
B. Combined oral contraceptive therapy
C. Serotonin-norepinephrine reuptake inhibitor
D. Cognitive behavioral therapy

Answer: Selective serotonin reuptake inhibitor

2. Patient has been experiencing mood swings for several months.

3. Patient feels highly irritable, sensitive to criticism and rejection, and easily saddened on roughly a quarter of days each month.

4. Patient's appetite varies greatly on days when she is particularly emotional.

5. Patient's performance at work has suffered.

6. Patient's boyfriend has been complaining that she is difficult to live with.

7. Patient is anxious that she cannot "get my mood under control."

9. Patient has regular periods every 28 days.

11. Patient uses condoms for contraception.

12. Patient's mother has major depressive disorder.

13. Patient's father has hypertension and coronary artery disease.

14. Patient's temperature is 98.4°F (36.9°C).

16. Patient's blood pressure is 130/76 mmHg.

18. Patient appears slightly anxious but has overall normal affect.

19. Patient is pleasantly conversational.

20. Patient's physical exam is unremarkable.

1. The patient experiences irritability, sensitivity to criticism and rejection, and sadness on roughly a quarter of days each month.

2. She also experiences varying appetite and increased hunger on emotional days.

3. Her work performance has suffered due to these symptoms.

4. Her boyfriend has complained about her being difficult to live with.

5. The patient is anxious about not being able to control her mood.

6. She has no past medical history, regular 28-day periods, and no obstetric history.

8. Her mother has major depressive disorder, and her father has hypertension and coronary artery disease.

9. At the visit, her temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 130/76 mmHg, and respirations are 13/min.

10. She appears slightly anxious but has overall normal affect and is pleasantly conversational.


Question: In addition to restarting medications for his hypertension and diabetes, what of the following is most appropriate treatment for the patient’s symptoms?

Context: A 63-year-old male presents to the emergency department complaining of worsening nausea.

Context: He reports that the nausea began several months ago and is accompanied by occasional bloating and heartburn.

Context: He reports that he frequently feels full even after eating only a little at each meal, and occasionally he will vomit if he eats too much.

Context: A review of systems is notable for occasional headaches, tingling in his distal extremities, and constipation.

Context: His medical history is significant for Parkinson’s disease diagnosed 3 years ago, hypertension diagnosed 8 years ago, and type II diabetes mellitus diagnosed 10 years ago.

Context: The patient reports that he was given prescriptions for both his blood pressure and diabetes medications, but he has not taken either for months because one of them was causing erectile dysfunction.

Context: He reports he regularly takes his levodopa.

Choices:
A. Ondansetron
B. Scopolamine
C. Proton-pump inhibitor
D. Erythromycin

Answer: Erythromycin

3. Patient presents to emergency department with worsening nausea.

5. Symptoms include occasional bloating and heartburn.

6. Patient frequently feels full after eating only a little.

7. Patient occasionally vomits if he eats too much.

8. Vomit is non-bloody and contains bits of undigested food.

9. Review of systems is notable for occasional headaches, tingling in distal extremities, and constipation.

10. Medical history is significant for Parkinson's disease diagnosed 3 years ago.

11. Medical history is significant for hypertension diagnosed 8 years ago.

12. Medical history is significant for type II diabetes mellitus diagnosed 10 years ago.

13. Patient was given prescriptions for blood pressure and diabetes medications, but has not taken either for months.

15. Endoscopy is performed, which rules out cancer.

1. The patient reports nausea that began several months ago.

2. The nausea is accompanied by occasional bloating and heartburn.

3. The patient frequently feels full even after eating only a little at each meal.

4. Occasionally, the patient will vomit if he eats too much.

5. The vomit is non-bloody and contains bits of undigested food.

6. A review of systems is notable for occasional headaches, tingling in distal extremities, and constipation.

7. The patient has a medical history significant for Parkinson’s disease diagnosed 3 years ago, hypertension diagnosed 8 years ago, and type II diabetes mellitus diagnosed 10 years ago.

8. The patient was given prescriptions for both blood pressure and diabetes medications but has not taken either for months due to one of them causing erectile dysfunction.

9. The patient regularly takes his levodopa.

10. An endoscopy is performed, which rules out cancer.


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

Context: A 27-year-old Japanese man presents to the emergency department with diarrhea.

Context: The patient states that whenever he goes out to eat he experiences bloating, flatulence, abdominal cramps, and watery diarrhea.

Context: Today, his symptoms started after he went out for frozen yogurt.

Context: The patient is otherwise healthy and is not currently taking any medications.

Context: His temperature is 98.0°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 81/min, respirations are 13/min, and oxygen saturation is 99% on room air.

Context: Physical exam demonstrates a nontender abdomen and an unremarkable rectal exam with guaiac-negative stools.

Choices:
A. Hydrogen breath test
B. Lactose-free diet
C. Loperamide
D. Stool osmotic gap

Answer: Lactose-free diet

2. Patient presents to emergency department with diarrhea.

3. Patient experiences bloating, flatulence, abdominal cramps, and watery diarrhea when going out to eat.

4. Symptoms started today after going out for frozen yogurt.

5. Patient is otherwise healthy and not taking any medications.

6. Patient's temperature is 98.0°F (36.7°C).

7. Patient's blood pressure is 122/80 mmHg.

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

11. Physical exam demonstrates a nontender abdomen.

12. Rectal exam is unremarkable with guaiac-negative stools.

1. The patient experiences bloating, flatulence, abdominal cramps, and watery diarrhea when going out to eat.

2. Symptoms started after the patient went out for frozen yogurt.

4. The patient is not currently taking any medications.

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

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

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

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

10. Physical exam demonstrates a nontender abdomen.

11. Physical exam demonstrates an unremarkable rectal exam with guaiac-negative stools.


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

Context: A 29-year-old woman presents to her primary care physician with worsening fatigue and lightheadedness over the past several months.

Context: She states that she has felt easily fatigued and has experienced several falls during this time frame as well.

Context: She drinks 5 to 8 drinks per day and works as a waitress.

Context: Her temperature is 98.2°F (36.8°C), blood pressure is 114/64 mmHg, pulse is 98/min, respirations are 12/min, and oxygen saturation is 98% on room air.

Context: Laboratory studies are ordered as seen below. |  | Hemoglobin: 9.0 g/dL | Hematocrit: 29% | Leukocyte count: 6,700/mm^3 with normal differential | Platelet count: 199,400/mm^3 | Methylymalonic acid: 1.0 umol/L (normal < 0.40 umol/L) |  | .

Choices:
A. Alcohol use
B. Folate deficiency
C. Iron deficiency
D. Vitamin B12 deficiency

Answer: Vitamin B12 deficiency

2. Patient has been experiencing worsening fatigue and lightheadedness over the past several months.

3. Patient has felt easily fatigued and has experienced several falls during this time frame.

4. Patient drinks 5 to 8 drinks per day and works as a waitress.

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

6. Patient's blood pressure is 114/64 mmHg.

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

10. Laboratory studies show hemoglobin of 9.0 g/dL.

11. Laboratory studies show hematocrit of 29%.

12. Laboratory studies show leukocyte count of 6,700/mm^3 with normal differential.

13. Laboratory studies show platelet count of 199,400/mm^3.

14. Laboratory studies show methylymalonic acid of 1.0 umol/L (normal < 0.40 umol/L).

1. The patient has felt easily fatigued.

2. The patient has experienced several falls.

3. The patient drinks 5 to 8 drinks per day.

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

6. The patient's blood pressure is 114/64 mmHg.

8. The patient's respirations are 12/min.

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

10. The patient's hemoglobin level is 9.0 g/dL.

11. The patient's hematocrit level is 29%.

12. The patient's leukocyte count is 6,700/mm^3 with normal differential.

13. The patient's platelet count is 199,400/mm^3.

14. The patient's methylymalonic acid level is 1.0 umol/L (normal < 0.40 umol/L).