Question: Which of the following laboratory tests should be performed in this patient prior to initiating treatment?

Context: A 32-year-old man from the Czech Republic is brought to the emergency department by his girlfriend with a 2-day history of yellowing of the skin.

Context: His girlfriend also reports a several-week history of anorexia, nausea without vomiting, and diffuse low-grade abdominal pain.

Context: He is a frequent injection drug user.

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

Context: He is grossly confused and somnolent.

Context: Physical examination is notable for scleral icterus and diffuse jaundice; when asked to hold his hands in wrist extension, a flapping movement is observed.

Choices:
A. Hepatitis D serologies
B. HIV ELISA
C. PPD skin test
D. Lumbar puncture

Answer: Hepatitis D serologies

1. A 32-year-old man from the Czech Republic is brought to the emergency department by his girlfriend.

2. His girlfriend reports a 2-day history of yellowing of the skin and a several-week history of anorexia, nausea without vomiting, and diffuse low-grade abdominal pain.

3. He is a frequent injection drug user.

5. He is grossly confused and somnolent.

6. Physical examination is notable for scleral icterus and diffuse jaundice.

7. When asked to hold his hands in wrist extension, a flapping movement is observed.

8. Liver function tests show alanine aminotransferase 1,830 U/L, aspartate aminotransferase 1,377 U/L, and direct bilirubin 15 mg/dL.

9. Coagulation studies reveal an international normalized ratio of 3.8.

10. On serological testing, HBsAg is positive, and HBsAb is negative.

1. His girlfriend reports a several-week history of anorexia.

2. His girlfriend reports a several-week history of nausea without vomiting.

3. His girlfriend reports a several-week history of diffuse low-grade abdominal pain.

4. He is a frequent injection drug user.

6. He is grossly confused and somnolent.

7. Physical examination is notable for scleral icterus.

8. Physical examination is notable for diffuse jaundice.

9. A flapping movement is observed when asked to hold his hands in wrist extension.

10. Liver function tests show alanine aminotransferase 1,830 U/L.

11. Liver function tests show aspartate aminotransferase 1,377 U/L.

12. Liver function tests show direct bilirubin 15 mg/dL.

13. Coagulation studies reveal an international normalized ratio of 3.8.

14. On serological testing, HBsAg is positive.

15. On serological testing, HBsAb is negative.


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

Context: A 63-year-old woman with a history of adult polycystic kidney disease and COPD presents to her optometrist after having difficulty watching a movie.

Context: She has no other complaints.

Context: She is accompanied by her daughter, who notes that her mother hasn’t been able to look at her since the previous day.

Context: On exam, her right eye has full range of motion, but her left eye is fixed in a down and outward position.

Choices:
A. Vascular abnormality
B. Seizure
C. Demyelinating disease
D. Impaired dopaminergic neurons

Answer: Vascular abnormality

1. A 63-year-old woman presents to her optometrist.

2. She has a history of adult polycystic kidney disease and COPD.

6. Her daughter notes that her mother hasn't been able to look at her since the previous day.

7. On exam, her right eye has full range of motion.

8. Her left eye is fixed in a down and outward position.

3. Her daughter notes that her mother hasn’t been able to look at her since the previous day.

4. On exam, her right eye has full range of motion.

5. Her left eye is fixed in a down and outward position.


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

Context: An 11-year-old boy presents to the office with his mother for the evaluation of weight loss, rash, and several weeks of bloating and diarrhea.

Context: There is a vesicular rash on the bilateral lower extremities which he says is ‘very itchy’.

Choices:
A. HLA-DQ2
B. Anti-tTG or gliadin antibodies
C. Anti-lactase antibodies
D. HLA-B27

Answer: Anti-tTG or gliadin antibodies

1. An 11-year-old boy presents to the office with his mother.

2. The evaluation is for weight loss, rash, and several weeks of bloating and diarrhea.

3. The mother states that the patient's father had similar symptoms at his age.

4. On physical examination, the patient is pale with dry mucous membranes.

5. There is a vesicular rash on the bilateral lower extremities.

6. The patient says the rash is 'very itchy'.

1. The mother states that the patient’s father had similar symptoms at his age.

2. On physical examination, the patient is pale with dry mucous membranes.

3. There is a vesicular rash on the bilateral lower extremities.

4. The patient says the rash is ‘very itchy’.


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

Context: A 23-year-old African American G1P0 woman at 18 weeks estimated gestational age presents with fatigue and lethargy.

Context: She says the symptoms onset gradually about 1 week ago and have progressively worsened.

Context: She has been otherwise healthy.

Context: Past medical history is unremarkable.

Context: She denies smoking, drug or alcohol use.

Context: The patient is afebrile and vital signs are within normal limits.

Context: Her physical examination is unremarkable.

Context: Her blood count shows the following: | Hemoglobin 10.8 g/dL | Red blood cell count 5.7 million/mm3 | Mean corpuscular volume (MCV) 76 μm3 | Red cell distribution width 12.4% (ref: 11.5–14.5%) | She is empirically started on ferrous gluconate tablets.

Context: Five weeks later, she shows no improvement in her hemoglobin level.

Context: Hemoglobin electrophoresis is normal.

Choices:
A. Iron deficiency anemia
B. Beta-thalassemia trait
C. Alpha-thalassemia trait
D. Folate deficiency anemia

Answer: Alpha-thalassemia trait

1. Patient is a 23-year-old African American G1P0 woman.

2. Patient is at 18 weeks estimated gestational age.

3. Patient presents with fatigue and lethargy.

4. Symptoms onset gradually about 1 week ago and have progressively worsened.

6. Past medical history is unremarkable.

7. Patient denies smoking, drug or alcohol use.

8. Patient is afebrile and vital signs are within normal limits.

9. Physical examination is unremarkable.

11. Red blood cell count is 5.7 million/mm3.

12. Mean corpuscular volume (MCV) is 76 μm3.

13. Red cell distribution width is 12.4% (ref: 11.5–14.5%).

14. Patient is empirically started on ferrous gluconate tablets.

15. Five weeks later, patient shows no improvement in her hemoglobin level.

16. Hemoglobin electrophoresis is normal.

1. Symptoms onset gradually about 1 week ago

5. Patient denies smoking, drug, or alcohol use

9. Blood count shows: Hemoglobin 10.8 g/dL

10. Blood count shows: Red blood cell count 5.7 million/mm3

11. Blood count shows: Mean corpuscular volume (MCV) 76 μm3

12. Blood count shows: Red cell distribution width 12.4% (ref: 11.5–14.5%)

13. Patient is empirically started on ferrous gluconate tablets

14. Five weeks later, no improvement in hemoglobin level

15. Hemoglobin electrophoresis is normal


Question: Which of the following structures was most likely injured during the surgery?

Context: A 26-year-old woman comes to the physician for a follow-up examination 1 week after undergoing rotator cuff repair surgery.

Context: There is normal passive range of motion of the shoulder, but she has difficulty externally rotating and abducting her right arm.

Choices:
A. Upper trunk of the brachial plexus
B. Axillary nerve
C. Lower trunk of the brachial plexus
D. Long thoracic nerve

Answer: Axillary nerve

1. A 26-year-old woman comes to the physician for a follow-up examination.

2. The follow-up examination is 1 week after undergoing rotator cuff repair surgery.

3. Physical examination of the right shoulder shows decreased sensation to pinprick and light touch over the lateral shoulder.

4. There is normal passive range of motion of the shoulder.

5. She has difficulty externally rotating her right arm.

6. She has difficulty abducting her right arm.

1. Physical examination of the right shoulder shows decreased sensation to pinprick.

2. Physical examination of the right shoulder shows decreased sensation to light touch over the lateral shoulder.

3. There is normal passive range of motion of the shoulder.

4. She has difficulty externally rotating her right arm.

5. She has difficulty abducting her right arm.


Question: Which of the following antibodies is most likely responsible for this patient’s condition?

Context: The urinalysis results are as follows: | pH 6.7 | Color dark brown | Red blood cell (RBC) count 12–14/HPF | White blood cell (WBC) count 3–4/HPF | Protein absent | Cast RBC and granular casts | Glucose absent | Crystal none | Ketone absent | Nitrite absent  | 24 hours of urine protein excretion 1 g |     His renal function test showed: | Sodium 136 mEq/L | Potassium 5.1 mEq/L | Chloride 101 mEq/L | Bicarbonate 22 mEq/L | Albumin 3.5 mg/ dL | Urea nitrogen 28 mg/dL | Creatinine 2.5 mg/dL | Uric Acid 6.8 mg/ dL | Calcium 8.7 mg/ dL | Glucose 111 mg/dL | HPF: high-power field | A kidney biopsy is obtained and the immunofluorescence shows linear immunoglobulin G (IgG) deposition in the glomeruli.

Choices:
A. Anti-neutrophil cytoplasmic antibody (c-ANCA)
B. Anti-phospholipid antibody
C. Anti-glomerular basement membrane antibody (anti-GBM)
D. Anti-dsDNA antibody

Answer: Anti-glomerular basement membrane antibody (anti-GBM)

1. A 25-year-old man presents to his primary care physician with complaints of coughing up blood in his sputum and dark-colored urine for 1 week.

2. There are streaks of blood intermixed with phlegm.

3. He also expresses concerns about his urine being grossly dark brown.

4. He denies any history of major bleeding from minor injuries.

5. He is currently not taking any medications.

6. His family history is negative for bleeding disorders.

7. The vital signs include blood pressure 160/100 mm Hg, pulse 88/min, temperature 36.8°C (98.2°F), and respiratory rate 11/min.

8. On physical examination, there are no significant clinical findings.

9. The urinalysis results show a pH of 6.7, color dark brown, RBC count 12–14/HPF, WBC count 3–4/HPF, protein absent, RBC and granular casts, glucose absent, crystal none, ketone absent, and nitrite absent.

10. 24 hours of urine protein excretion is 1 g.

11. His renal function test shows sodium 136 mEq/L, potassium 5.1 mEq/L, chloride 101 mEq/L, bicarbonate 22 mEq/L, albumin 3.5 mg/dL, urea nitrogen 28 mg/dL, creatinine 2.5 mg/dL, uric acid 6.8 mg/dL, calcium 8.7 mg/dL, and glucose 111 mg/dL.

12. A kidney biopsy is obtained and the immunofluorescence shows linear immunoglobulin G (IgG) deposition in the glomeruli.

1. Streaks of blood intermixed with phlegm

2. Concerns about urine being grossly dark brown

3. Denial of history of major bleeding from minor injuries

5. Family history negative for bleeding disorders

6. Vital signs: blood pressure 160/100 mm Hg, pulse 88/min, temperature 36.8°C (98.2°F), respiratory rate 11/min

7. No significant clinical findings on physical examination

8. Urinalysis results: pH 6.7, color dark brown, RBC count 12–14/HPF, WBC count 3–4/HPF, protein absent, cast RBC and granular casts, glucose absent, crystal none, ketone absent, nitrite absent, 24 hours of urine protein excretion 1 g

9. Renal function test results: sodium 136 mEq/L, potassium 5.1 mEq/L, chloride 101 mEq/L, bicarbonate 22 mEq/L, albumin 3.5 mg/dL, urea nitrogen 28 mg/dL, creatinine 2.5 mg/dL, uric acid 6.8 mg/dL, calcium 8.7 mg/dL, glucose 111 mg/dL

11. Immunofluorescence shows linear IgG deposition in the glomeruli


Question: Of the steps leading to the formation of this structure, which occurs first?

Context: The lung of a 45-year-old Caucasian male who died from Mycobacterium tuberculosis infection reveals the following at autopsy (Image A).

Choices:
A. Th1 cell activation
B. Bacterium-mediated inhibition of phagosome-lysosome fusion
C. Formation of epithelioid cells
D. Formation of giant cells

Answer: Bacterium-mediated inhibition of phagosome-lysosome fusion

Medical Microbiology Pathology
General Pathology

1. The lung belongs to a 45-year-old Caucasian male.

2. The cause of death was Mycobacterium tuberculosis infection.

4. Image A was taken during the autopsy.

2. The male died from Mycobacterium tuberculosis infection.

3. The autopsy revealed specific findings in the lung.


Question: Which of the following recommendations is most appropriate at this time?

Context: A 57-year-old man comes to the physician because of a 3-month history of bloating and nausea after eating food.

Context: He has also had episodic abdominal pain during this period.

Context: He has osteoarthritis of the left knee.

Context: He drinks two to three beers daily.

Context: Current medications include ibuprofen.

Context: Vital signs are within normal limits.

Context: The lungs are clear to auscultation.

Context: pylori infection.

Choices:
A. Avoid drinking alcohol for the next 2 weeks
B. Begin prophylactic steroid therapy for anaphylaxis
C. Check liver enzymes in 2 weeks
D. Perform urea breath test in 2 weeks

Answer: Avoid drinking alcohol for the next 2 weeks

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

2. He has a 3-month history of bloating and nausea after eating food.

3. He has had episodic abdominal pain during this period.

4. He has osteoarthritis of the left knee.

5. There is no family history of serious illness.

6. He has smoked one pack of cigarettes daily for 21 years.

8. His current medications include ibuprofen.

9. He is allergic to amoxicillin and latex.

10. Vital signs are within normal limits.

11. The lungs are clear to auscultation.

12. Cardiac examination shows no abnormalities.

13. The abdomen is soft; there is mild tenderness to palpation over the epigastrium.

14. Rectal examination shows no abnormalities.

15. An esophagogastroduodenoscopy is performed.

16. It shows 3 shallow ulcers of the gastric mucosa.

17. Biopsy shows chronic inflammation of the gastric mucosa and Helicobacter pylori.

18. He is prescribed a 2-week course of antibiotics and omeprazole to treat the H. pylori infection.

2. He has osteoarthritis of the left knee.

3. There is no family history of serious illness.

4. He has smoked one pack of cigarettes daily for 21 years.

6. Current medications include ibuprofen.

7. He is allergic to amoxicillin and latex.

8. Vital signs are within normal limits.

10. Cardiac examination shows no abnormalities.

11. The abdomen is soft; there is mild tenderness to palpation over the epigastrium.

12. Rectal examination shows no abnormalities.

13. An esophagogastroduodenoscopy is performed and shows 3 shallow ulcers of the gastric mucosa.

14. Biopsy shows chronic inflammation of the gastric mucosa and Helicobacter pylori.

15. He is prescribed a 2-week course of antibiotics and omeprazole to treat the H. pylori infection.


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

Context: A 72-year-old man presents to his physician’s office with difficulty breathing and chronic fatigue.

Context: His recent blood count shows a hemoglobin level of 10.3 g/dl, hematocrit of 24%, serum ferritin level of 10 ng/ml, and a red cell distribution width of 16.5%.

Choices:
A. Colonoscopy
B. Vitamin B12 levels
C. Endoscopy
D. Iron supplementation

Answer: Colonoscopy

1. A 72-year-old man presents to his physician's office with difficulty breathing and chronic fatigue.

2. Over the past few months, he has felt that it is difficult to retain his energy throughout the day.

3. He is disturbed because he has to skip many social events because of his inability to participate.

4. He also says that lately, he has had difficulty catching his breath after walking for just a few blocks.

5. Other than well-controlled diabetes, his past medical history is insignificant.

6. On physical examination, moderate conjunctival pallor is noted.

7. His recent blood count shows a hemoglobin level of 10.3 g/dl.

8. His recent blood count shows a hematocrit of 24%.

9. His recent blood count shows a serum ferritin level of 10 ng/ml.

10. His recent blood count shows a red cell distribution width of 16.5%.

1. Over the past few months, he has felt that it is difficult to retain his energy throughout the day.

2. He is disturbed because he has to skip many social events because of his inability to participate.

3. He also says that lately, he has had difficulty catching his breath after walking for just a few blocks.

4. Other than well-controlled diabetes, his past medical history is insignificant.

5. On physical examination, moderate conjunctival pallor is noted.

6. His recent blood count shows a hemoglobin level of 10.3 g/dl.

7. His recent blood count shows a hematocrit of 24%.

8. His recent blood count shows a serum ferritin level of 10 ng/ml.

9. His recent blood count shows a red cell distribution width of 16.5%.


Question: What is the most likely injury?

Context: A 17-year-old rugby player limped into the emergency room and says he “rolled his ankle” while running during a game.

Context: You conclude that the mechanism involved ankle plantar flexion and inversion.

Context: Talar tilt test is negative.

Choices:
A. Anterior talofibular ligament (ATFL) sprain
B. Deltoid ligament sprain
C. Tibia fracture
D. Fibula fracture

Answer: Anterior talofibular ligament (ATFL) sprain

1. A 17-year-old rugby player limped into the emergency room.

2. The player said he "rolled his ankle" while running during a game.

3. The mechanism involved ankle plantar flexion and inversion.

4. There is no medial or lateral malleolus point tenderness.

5. Anterior drawer test of the ankle is positive.

1. Mechanism involved ankle plantar flexion and inversion.

2. No medial or lateral malleolus point tenderness.

3. Anterior drawer test of the ankle is positive.


Question: Which of the following statements concerning positive predictive value (PPV) is correct?

Choices:
A. PPV is the proportion of tests that are true positives; if disease prevalence is low, then PPV will be low.
B. PPV is the proportion of tests that are true positives; disease prevalence has no effect on PPV.
C. PPV is the proportion of tests that are false positives; if disease prevalence is low, then PPV will be low.
D. PPV is the proportion of tests that are false positives; if disease prevalence is high then PPV will be low.

Answer: PPV is the proportion of tests that are true positives; if disease prevalence is low, then PPV will be low.


Question: The organism that is most likely responsible for this patient's symptoms has which of the following structures?

Context: A 32-year-old man presents to the emergency department with fever, weight loss, and right upper quadrant pain.

Context: He says that he started experiencing nausea and fatigue after he returned from a honeymoon trip to Asia with his wife.

Context: Notably, she is 5 months pregnant with their first child.

Context: On presentation, his temperature is 100.8°F (38.2°C), blood pressure is 118/79 mmHg, pulse is 81/min, and respirations are 14/min.

Context: Physical exam reveals a jaundiced patient with a palpable liver edge as well as splenomegaly.

Context: After confirmation, the patient's wife is immediately tested as well because she is at a much higher risk of fatal complications from this infection.

Choices:
A. Enveloped dsDNA virus
B. Enveloped (-) RNA virus
C. Enveloped (+) RNA virus
D. Non-enveloped (+) RNA hepevirus

Answer: Non-enveloped (+) RNA hepevirus

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

2. He has fever, weight loss, and right upper quadrant pain.

3. He started experiencing nausea and fatigue after returning from a honeymoon trip to Asia with his wife.

4. His wife is 5 months pregnant with their first child.

5. On presentation, his temperature is 100.8°F (38.2°C).

9. Physical exam reveals a jaundiced patient with a palpable liver edge.

11. Labs are sent in order to confirm the diagnosis.

12. After confirmation, the patient's wife is immediately tested as well.

13. She is at a much higher risk of fatal complications from this infection.

1. The patient started experiencing nausea and fatigue after returning from a honeymoon trip to Asia with his wife.

2. The patient's wife is 5 months pregnant with their first child.

3. On presentation, the patient's temperature is 100.8°F (38.2°C).

4. On presentation, the patient's blood pressure is 118/79 mmHg.

5. On presentation, the patient's pulse is 81/min.

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

7. Physical exam reveals a jaundiced patient.

8. Physical exam reveals a palpable liver edge.

10. Labs are sent to confirm the diagnosis.

11. The patient's wife is immediately tested due to a higher risk of fatal complications from the infection.


Question: What medication should be administered to this patient?

Choices:
A. Flumazenil
B. Benzodiazepines
C. Dantrolene
D. Fomepizole

Answer: Benzodiazepines

1. A 59-year-old man presents to the emergency room with shortness of breath and swelling of his feet and legs.

2. He denies any past medical problems, surgeries, medications, or illicit drug use.

3. He reports drinking a few beers each night.

4. He is diagnosed with a first episode of congestive heart failure and is admitted to the hospital.

5. The next day, the nurse notices that his hands are shaky when he extends his arms.

6. The patient says that he couldn’t sleep the night before and that he feels restless, anxious, and slightly nauseated.

7. On the second night of admission the patient becomes agitated.

8. He is disoriented, cannot remember where he is, and appears globally confused.

9. His pulse is 125/min, blood pressure is 170/110 mmHg, and temperature is 101.7°F (38.7°C).

10. He is diaphoretic and his hands are shaking at rest.

11. He cries out in fear reporting voices whispering in his room and strange shadows passing over the walls.

1. The patient denies any past medical problems, surgeries, medications, or illicit drug use.

2. The patient reports drinking a few beers each night.

3. The patient is diagnosed with a first episode of congestive heart failure and is admitted to the hospital.

4. The nurse notices that the patient's hands are shaky when he extends his arms.

5. The patient says that he couldn’t sleep the night before and that he feels restless, anxious, and slightly nauseated.

6. On the second night of admission, the patient becomes agitated.

7. The patient is disoriented, cannot remember where he is, and appears globally confused.

8. The patient's pulse is 125/min, blood pressure is 170/110 mmHg, and temperature is 101.7°F (38.7°C).

9. The patient is diaphoretic and his hands are shaking at rest.

10. The patient cries out in fear reporting voices whispering in his room and strange shadows passing over the walls.


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

Context: A 49-year-old woman otherwise healthy presents to the outpatient department with swelling of the neck.

Context: Cervical lymphadenopathy is present.

Choices:
A. Follicular carcinoma
B. Papillary carcinoma
C. Anaplastic carcinoma
D. Follicular adenoma

Answer: Papillary carcinoma

Otolaryngology
Internal Medicine
ENT (Otolaryngology)

General Otolaryngology
Endocrinology, Diabetes, and Metabolism

1. A 49-year-old woman is presenting to the outpatient department.

3. Family history is negative for any thyroid disorders.

4. Physical examination shows a nontender thyroid gland.

5. There is a nodule on the right side of the thyroid gland.

6. The thyroid gland is mobile on deglutition.

8. Fine needle aspiration and cytology show empty appearing nuclei.

11. The nuclei have branching structures.

1. Family history is negative for any thyroid disorders.

2. Physical examination shows a nontender thyroid gland with a nodule on the right side.

3. The thyroid gland is mobile on deglutition.

5. Fine needle aspiration and cytology show empty appearing nuclei with central clearing, nuclear grooves and branching structures interspersed with calcific bodies.


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

Context: A 33-year-old woman comes to the physician because of a 2-year history of intermittent episodes of pain in all her fingers bilaterally.

Context: The fingers become white when exposed to cold weather, then severely painful and numb once they warm up.

Context: She has generalized anxiety disorder.

Context: She appears anxious.

Context: Her temperature is 37.3°C (99.1°F), pulse is 92/min, and blood pressure is 116/72 mm Hg.

Context: Allen's test is negative.

Context: Her hemoglobin concentration is 14.4 g/dL, leukocyte count is 9,800/mm3, and platelet count is 156,000/mm3.

Choices:
A. Oral aspirin
B. Oral nifedipine
C. Oral epoprostenol
D. Oral prednisone

Answer: Oral nifedipine

2. Patient has a 2-year history of intermittent episodes of pain in all her fingers bilaterally.

3. Episodes are worse during the winter.

4. Fingers become white when exposed to cold weather, then severely painful and numb once they warm up.

5. Patient has started wearing gloves at all times to prevent these episodes.

6. Patient has generalized anxiety disorder.

7. Patient's mother has systemic lupus erythematosus.

8. Current medications include lorazepam and fluoxetine.

10. Patient's temperature is 37.3°C (99.1°F).

12. Patient's blood pressure is 116/72 mm Hg.

13. Examination of both hands shows no abnormalities.

15. Patient's hemoglobin concentration is 14.4 g/dL.

16. Patient's leukocyte count is 9,800/mm3.

17. Patient's platelet count is 156,000/mm3.

18. Serum electrolyte concentrations are within normal limits.

19. Nailfold capillary microscopy is normal.

1. The episodes are worse during the winter.

2. The fingers become white when exposed to cold weather.

3. The fingers then become severely painful and numb once they warm up.

4. She has started wearing gloves at all times to prevent these episodes.

5. She has generalized anxiety disorder.

6. Her mother has systemic lupus erythematosus.

7. Current medications include lorazepam and fluoxetine.

12. Examination of both hands shows no abnormalities.

14. Her hemoglobin concentration is 14.4 g/dL.

17. Serum electrolyte concentrations are within normal limits.

18. Nailfold capillary microscopy is normal.


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

Context: A 43-year-old man comes to the physician because of redness and swelling of his right leg.

Context: He has had fever and chills.

Context: He has a history of type 2 diabetes mellitus and underwent saphenous vein stripping and ligation in his right leg 3 years ago.

Context: He works as a security guard.

Context: He does not smoke or drink alcohol.

Context: His temperature is 38.7°C (101.7°F), pulse is 99/min, and blood pressure is 138/72 mm Hg.

Context: There is no inguinal lymphadenopathy.

Context: Toe web intertrigo is noted.

Choices:
A. Oral cephalexin therapy
B. Intravenous cefazolin therapy
C. Intravenous ciprofloxacin therapy
D. Subcutaneous heparin injection

Answer: Intravenous cefazolin therapy

1. A 43-year-old man comes to the physician.

2. He has redness and swelling of his right leg.

5. He has no chest pain or shortness of breath.

6. He has a history of type 2 diabetes mellitus.

7. He underwent saphenous vein stripping and ligation in his right leg 3 years ago.

10. His medications include metformin and sitagliptin.

11. His temperature is 38.7°C (101.7°F).

14. Examination shows an 8-cm, indurated, tender, warm, erythematous skin lesion with sharply demarcated margins.

15. There is no inguinal lymphadenopathy.

1. He reports that it is very painful to touch.

3. He has no chest pain or shortness of breath.

4. He has a history of type 2 diabetes mellitus.

5. He underwent saphenous vein stripping and ligation in his right leg 3 years ago.

8. His medications include metformin and sitagliptin.

12. Examination shows an 8-cm, indurated, tender, warm, erythematous skin lesion with sharply demarcated margins.

13. There is no inguinal lymphadenopathy.


Question: Of the following options, which is the next best step in patient management?

Context: A 52-year-old thoracic surgeon presents to his primary care physician with an eczematous dermatitis overlying his hands and forearms.

Context: He notes that he has recently started using a new type of surgical gloves.

Context: He notes that he washes his hands frequently, but he has never had issues with skin irritation before.

Context: On physical examination, there are erythematous plaques with areas of vesicles on his bilateral hands and dorsal forearms.

Choices:
A. Patch testing
B. KOH examination
C. Skin biopsy
D. Radioallergosorbent test

Answer: Patch testing

General Dermatology
Micrographic Dermatologic Surgery

1. A 52-year-old thoracic surgeon presents to his primary care physician.

2. He has an eczematous dermatitis overlying his hands and forearms.

3. He recently started using a new type of surgical gloves.

5. He has never had issues with skin irritation before.

6. On physical examination, there are erythematous plaques.

7. There are areas of vesicles on his bilateral hands and dorsal forearms.

1. The patient has recently started using a new type of surgical gloves.

2. The patient washes his hands frequently.

3. The patient has never had issues with skin irritation before.

4. On physical examination, there are erythematous plaques on the patient's bilateral hands and dorsal forearms.

5. There are areas of vesicles on the patient's bilateral hands and dorsal forearms.


Question: What is the most likely diagnosis?

Context: A 43-year-old woman presents to a new primary care physician complaining of anxiety.

Context: She has been worrying non-stop recently about the possibility that her husband will lose his job as a teacher.

Context: Her husband, who is present, assures the physician that his job is entirely secure and states that she has "fretted" for their entire marriage, though the exact topic causing her anxiety varies over time.

Context: She also worries excessively about everyday tasks, such as whether she will catch the train on time and whether their house in Southern California is sufficiently earthquake-proof.

Context: She endorses other symptoms including poor sleep (associated with racing thoughts about her various worries), fatigue, and impaired concentration at work, all of which have been present for at least the past year.

Context: Her vital signs are within normal limits and there are no abnormalities on physical exam.

Choices:
A. Social phobia
B. Agoraphobia
C. Posttraumatic stress disorder
D. Generalized anxiety disorder

Answer: Generalized anxiety disorder

2. Patient is presenting to a new primary care physician with anxiety.

3. Patient's husband is present and states that she has "fretted" for their entire marriage.

4. Patient worries excessively about everyday tasks, such as catching the train on time and whether their house is earthquake-proof.

5. Patient has no way to overcome these worries.

6. Patient endorses other symptoms including poor sleep, fatigue, and impaired concentration at work.

7. Symptoms have been present for at least the past year.

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

1. She has been worrying non-stop recently about the possibility of her husband losing his job as a teacher.

2. Her husband assures the physician that his job is entirely secure.

3. Her husband states that she has "fretted" for their entire marriage.

4. The exact topic causing her anxiety varies over time.

5. She worries excessively about everyday tasks, such as catching the train on time and the earthquake-proofing of their house in Southern California.

6. She has no way to overcome these worries.

7. She endorses other symptoms including poor sleep associated with racing thoughts about her worries.

8. She experiences fatigue and impaired concentration at work.

9. These symptoms have been present for at least the past year.

10. Her vital signs are within normal limits.

11. There are no abnormalities on physical exam.


Question: A biopsy of one of these areas of affected thyroid tissue is most likely to show which of the following?

Context: A 60-year-old woman comes to the physician because of palpitations and a 5.4-kg (11.9-lb) weight loss over the past 3 months.

Context: She appears anxious.

Context: Her pulse is 104/min and blood pressure is 148/101 mm Hg.

Choices:
A. Sheets of parafollicular cells surrounded by amyloid stroma
B. Follicle destruction with lymphocytic infiltrate and germinal center formation
C. Patches of enlarged follicular cells distended with colloid
D. Crowded follicular cells with scalloped colloid

Answer: Patches of enlarged follicular cells distended with colloid

Endocrinology, Diabetes, and Metabolism
Internal Medicine

General Endocrinology
Endocrinology, Diabetes, and Metabolism

1. A 60-year-old woman comes to the physician.

2. She has experienced a 5.4-kg (11.9-lb) weight loss over the past 3 months.

6. Physical examination shows warm skin, mild tremor, and an enlarged thyroid gland.

7. A thyroid scintigraphy scan shows several focal areas with increased uptake.

4. Physical examination shows warm skin.

5. Physical examination shows mild tremor.

6. Physical examination shows an enlarged thyroid gland.


Question: This patient is most likely experiencing toxicity from which of the following substances?"

Context: A 47-year-old man is brought to the emergency department 1 hour after his neighbor found him collapsed on his front porch in a pool of vomitus.

Context: His pulse is 103/min and respirations are 30/min.

Context: Serum studies show: | Na+ 137 mEq/L | Cl- 99 mEq/L | HCO3- 8 mEq/L | Osmolality 328 mOsm/kg | The difference between the calculated and observed serum osmolality is 32 mOsm/kg.

Context: Urinalysis shows oxalate crystals.

Choices:
A. Methanol
B. Ethylene glycol
C. Parathion
D. Aspirin

Answer: Ethylene glycol

1. A 47-year-old man is brought to the emergency department.

2. His neighbor found him collapsed on his front porch in a pool of vomitus 1 hour prior.

3. On arrival, he is oriented only to self.

6. Neurologic examination shows muscle spasms in the arms and jaw.

10. Serum studies show Osmolality 328 mOsm/kg.

11. The difference between the calculated and observed serum osmolality is 32 mOsm/kg.

1. On arrival, the patient is oriented only to self.

3. The patient's respirations are 30/min.

4. Neurologic examination shows muscle spasms in the arms and jaw.

5. Serum studies show: Na+ 137 mEq/L, Cl- 99 mEq/L, HCO3- 8 mEq/L, Osmolality 328 mOsm/kg.

6. The difference between the calculated and observed serum osmolality is 32 mOsm/kg.


Question: Which of the following is the most probable cause of his complaints?

Context: History is non-contributory.

Context: The vital signs are unremarkable.

Context: The laboratory values show a normal white blood cell (WBC) count and elevated alkaline phosphatase.

Choices:
A. Osteomyelitis
B. Osteosarcoma
C. Ewing’s sarcoma
D. Chondrosarcoma

Answer: Osteosarcoma

1. A 13-year-old boy presents to the clinic for evaluation of pain, swelling, and redness in the left knee.

2. This began a month ago and has been progressively worsening.

3. He thinks his pain is due to playing soccer.

4. He is frustrated that the pain does not respond to Tylenol.

7. On examination, there is tenderness and warmth present over the knee with limitation of movement.

8. The laboratory values show a normal white blood cell (WBC) count.

9. The laboratory values show an elevated alkaline phosphatase.

10. A radiograph of the knee shows mixed lytic and blastic lesions.

2. The symptoms have been progressively worsening.

3. The patient attributes the pain to playing soccer.

4. The patient is frustrated that the pain does not respond to Tylenol.

5. The patient's medical history is non-contributory.

7. On examination, there is tenderness and warmth present over the knee.

8. On examination, there is limitation of movement in the knee.

9. Laboratory values show a normal white blood cell (WBC) count.

10. Laboratory values show elevated alkaline phosphatase.

11. A radiograph of the knee shows mixed lytic and blastic lesions.


Question: Which of the following is the most likely explanation for this patient’s clinical findings?

Context: Consequently, her recent medical history involves diabetic retinopathy as well as end-stage renal disease.

Context: Cranial nerve capacity is intact.

Context: Her electrocardiogram (ECG) is shown.

Choices:
A. Skipped dialysis appointment
B. Insulin supplementation
C. Administration of α-agonist
D. Alkalosis

Answer: Skipped dialysis appointment

1. A 55-year-old woman presents to the emergency department because of palpitations and generalized weakness.

2. She has a history of type 2 diabetes, for which she has been receiving medication for the past 15 years.

3. Her recent medical history involves diabetic retinopathy.

4. Her recent medical history also involves end-stage renal disease.

5. She is advised dialysis; however, she does not attend her regular dialysis sessions.

6. The physical examination shows motor strength of 3/5 in the upper limbs and 4/5 in the lower limbs.

8. Her electrocardiogram (ECG) is shown.

9. Medical management is initiated for the patient.

1. She has a history of type 2 diabetes.

2. She has been receiving medication for the past 15 years.

4. Her recent medical history involves end-stage renal disease.

6. She does not attend her regular dialysis sessions.

7. The physical examination shows motor strength of 3/5 in the upper limbs.

8. The physical examination shows motor strength of 4/5 in the lower limbs.

10. Her electrocardiogram (ECG) is shown.

11. Medical management is initiated for the patient.


Question: Based on Ranson’s Criteria, what is this patient’s overall risk of mortality, assuming all other relevant factors are negative?

Context: The laboratory evaluation on admission is significant for a serum glucose 241 mg/dL, aspartate aminotransferase (AST) 321 IU/dL, and leukocyte count 21,200/mL.

Choices:
A. 20%
B. 40%
C. 80%
D. 100%

Answer: 20%

1. A 59-year-old man presents to the emergency department with diffuse abdominal pain that radiates to his back, nausea, and vomiting.

2. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min.

3. The laboratory evaluation on admission is significant for a serum glucose 241 mg/dL.

4. The laboratory evaluation on admission is significant for an aspartate aminotransferase (AST) 321 IU/dL.

5. The laboratory evaluation on admission is significant for a leukocyte count 21,200/mL.

6. Within 3 days of admission with supportive care in the intensive care unit, the patient’s clinical condition begins to improve.

1. Vital signs: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, respiratory rate 14/min.

2. Laboratory evaluation on admission: serum glucose 241 mg/dL, aspartate aminotransferase (AST) 321 IU/dL, leukocyte count 21,200/mL.

3. Patient admitted to intensive care unit.

4. Patient's clinical condition begins to improve within 3 days of admission.


Question: What is the most likely diagnosis?

Context: He has no complaints at this time and his chronic hypertension is well controlled.

Context: You notice a .5cm papule on the patient's eyelid that has a pink pearly appearance, rolled borders, and overlying telangiectasias.

Context: On further questioning, you find out the patient was a door-to-door salesman and spent a lot of time outdoors, and he did not wear sunscreen.

Context: He has fair skin and blonde hair.

Context: The patient states that he first noticed the lesion about 6 months prior, and it has grown slightly since then.

Choices:
A. Squamous cell carcinoma
B. Keratoacanthoma
C. Verrucous carcinoma
D. Basal cell carcinoma

Answer: Basal cell carcinoma

1. A 68-year-old male presents to your office for his annual physical exam.

3. His chronic hypertension is well controlled.

4. You notice a .5cm papule on the patient's eyelid.

5. The papule has a pink pearly appearance.

7. The papule has overlying telangiectasias.

8. The patient was a door-to-door salesman.

9. The patient spent a lot of time outdoors.

13. The patient first noticed the lesion about 6 months prior.

14. The lesion has grown slightly since then.

1. The patient has no complaints at this time.

2. The patient's chronic hypertension is well controlled.

3. There is a .5cm papule on the patient's eyelid.

4. The papule has a pink pearly appearance.

6. The papule has overlying telangiectasias.

7. The patient was a door-to-door salesman.

8. The patient spent a lot of time outdoors.

12. The patient first noticed the lesion about 6 months prior.

13. The lesion has grown slightly since then.


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

Context: A 67-year-old woman is brought to the emergency room after complaining of back pain with a gradual loss of sensation in her lower extremities.

Context: She was recently diagnosed with radiosensitive metastatic breast cancer and was scheduled to receive chemotherapy and palliative surgery.

Context: Her temperature is 99.0°F (37.2°C), blood pressure is 133/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air.

Context: She demonstrates 2/5 strength of leg extension on the left and 1/5 on the right which is slightly worse than her baseline neurological exam taken 2 months ago.

Choices:
A. Biopsy
B. Chemotherapy
C. Radiation therapy
D. Surgical decompression

Answer: Radiation therapy

General Neurological Surgery
Neurosurgery

1. A 67-year-old woman is brought to the emergency room.

2. She is complaining of back pain with a gradual loss of sensation in her lower extremities.

3. She was recently diagnosed with radiosensitive metastatic breast cancer.

4. She was scheduled to receive chemotherapy and palliative surgery.

9. Her oxygen saturation is 98% on room air.

10. Physical exam is notable for decreased sensation bilaterally over the patient's lower extremities.

11. She demonstrates 2/5 strength of leg extension on the left.

12. She demonstrates 1/5 strength of leg extension on the right.

13. Her neurological exam taken 2 months ago was slightly better than her current exam.

14. Pain to her lumbar region worsens with coughing.

15. An initial CT scan of the spine does not demonstrate any unstable fractures of the spine.

16. A MRI of the spine is ordered and pending.

1. Patient diagnosed with radiosensitive metastatic breast cancer

2. Scheduled to receive chemotherapy and palliative surgery

8. Physical exam notable for decreased sensation bilaterally over lower extremities

9. Demonstrates 2/5 strength of leg extension on the left

10. Demonstrates 1/5 strength of leg extension on the right

11. Strength is slightly worse than baseline neurological exam taken 2 months ago

12. Pain to lumbar region worsens with coughing

13. Initial CT scan of the spine does not demonstrate any unstable fractures

14. MRI of the spine is ordered and pending


Question: What is the most likely diagnosis for this patient?

Context: An obese 50-year-old woman presents to the emergency department of a rural hospital due to chest pain for the last 12 hours.

Context: The pain is substernal, crushing in nature, radiating into her neck, and accompanied by profuse sweating.

Context: Her history is significant for hypertension, and she admits poor compliance with her medications.

Context: An ECG done at the clinic confirmed the presence of STEMI, and the patient was given aspirin.

Context: The ambulance was in an accident on the way to the hospital and by the time the patient reached the angiography suite, the cardiologist decided intervention should be delayed due to the late presentation.

Context: Also, the patient’s pain has improved.

Context: The patient is admitted and is stable for 3 nights with no dyspnea or edema.

Context: Her blood pressure is kept under control while in the hospital.

Context: On the fourth night, the patient becomes quite agitated and soon thereafter she is unresponsive.

Context: Her pulse cannot be palpated.

Context: She has an elevated JVP and upon auscultation, heart sounds are distant.

Choices:
A. Acute pericarditis
B. Left ventricular free wall rupture
C. Papillary muscle rupture
D. Pulmonary embolism

Answer: Left ventricular free wall rupture

3. Patient presents to the emergency department of a rural hospital.

4. Patient has had chest pain for the last 12 hours.

5. Pain is substernal, crushing in nature, radiating into her neck, and accompanied by profuse sweating.

6. Patient has a history of hypertension.

7. Patient admits poor compliance with her medications.

8. ECG done at the clinic confirmed the presence of STEMI.

10. Ambulance was in an accident on the way to the hospital.

11. By the time the patient reached the angiography suite, the cardiologist decided intervention should be delayed due to the late presentation.

13. Patient is admitted and is stable for 3 nights with no dyspnea or edema.

14. Patient's blood pressure is kept under control while in the hospital.

15. On the fourth night, the patient becomes quite agitated.

16. Soon thereafter, the patient is unresponsive.

19. Upon auscultation, heart sounds are distant.

4. The pain is accompanied by profuse sweating

5. Her history is significant for hypertension

6. She admits poor compliance with her medications

7. An ECG done at the clinic confirmed the presence of STEMI

9. The ambulance was in an accident on the way to the hospital

10. By the time the patient reached the angiography suite, the cardiologist decided intervention should be delayed due to the late presentation

13. The patient is stable for 3 nights with no dyspnea or edema

14. Her blood pressure is kept under control while in the hospital


Question: Which of the following is responsible for the exact mechanism of diapedesis that allows for inflammatory cells to enter the tissue space of this patient?

Context: A 20-year-old woman presents to the emergency department with painful swelling in the middle of her neck for the past 3 days.

Choices:
A. Adhesion
B. Margination
C. Transmigration and chemotaxis
D. Rolling

Answer: Transmigration and chemotaxis

1. A 20-year-old woman presents to the emergency department.

2. She has had painful swelling in the middle of her neck for the past 3 days.

3. She is not experiencing pain during swallowing, difficulty in breathing, or changes in her voice.

4. On examination, a red, 5 x 5 cm, exquisitely tender, non-pulsatile, fluctuating mass is present in the midline on the anterior aspect of the neck.

5. The patient is prepared for an incision and drainage of the neck abscess.

1. The patient is not experiencing pain during swallowing.

2. The patient is not experiencing difficulty in breathing.

3. The patient is not experiencing changes in her voice.

4. On examination, a red, 5 x 5 cm mass is present in the midline on the anterior aspect of the neck.

8. The patient is prepared for an incision and drainage of the neck abscess.


Question: Which of the following treatment strategies would be most appropriate for this patient?

Context: A 45-year-old G2P2 presents with episodes of urgency accompanied by an involuntary passage of urine.

Context: These symptoms take place during the day and night.

Context: The symptoms are not linked with physical exertion, laughing, or coughing.

Context: Her occupation does not involve weight lifting, but she says that sometimes it is very stressful for her.

Context: She denies any other genitourinary symptoms.

Context: She had  1 vaginal delivery and 1 cesarean section.

Context: She does not have a history of genitourinary or neurologic disorders.

Context: The weight is 91 kg (200.6 lb) and the height is 172 cm (5 ft 60 in).

Context: The vital signs are as follows: blood pressure, 128/75 mmHg; heart rate, 77/min; respiratory rate, 13/min; and temperature, 36.6℃ (97.9℉).

Context: The physical examination shows no abdominal masses and no costovertebral angle or suprapubic tenderness.

Context: On gynecologic examination, there are no vulvar lesions.

Context: The external urethral orifice appears normal.

Context: A Q-tip test is negative.

Context: The cervix is normally positioned, non-tender, movable, and without visible lesions.

Context: The uterus is not enlarged and the ovaries are not palpable.

Context: A urinalysis, urine culture, and ultrasound examination of the bladder were all normal.

Context: Cystometric studies show the following findings: |   Measured value Normal range | Residual volume 10 ml < 50 ml | Sensation-of-fullness volume 190 ml 200–225 ml | Urge-to-void volume 700 ml 400–500 ml | Involuntary contractions present absent | .

Choices:
A. Instillation of the urethral mesh sling
B. Topical estrogen therapy
C. Augmentation cystoplasty
D. Start her on a muscarinic antagonist

Answer: Start her on a muscarinic antagonist

Female Pelvic Medicine and Reconstructive Surgery

3. Patient has episodes of urgency accompanied by an involuntary passage of urine.

4. Symptoms take place during the day and night.

5. Symptoms are not linked with physical exertion, laughing, or coughing.

6. Patient's occupation does not involve weight lifting.

7. Patient says occupation is sometimes very stressful.

8. Patient denies any other genitourinary symptoms.

9. Patient had 1 vaginal delivery and 1 cesarean section.

10. Patient does not have a history of genitourinary or neurologic disorders.

11. Patient's weight is 91 kg (200.6 lb).

12. Patient's height is 172 cm (5 ft 60 in).

13. Patient's blood pressure is 128/75 mmHg.

15. Patient's respiratory rate is 13/min.

16. Patient's temperature is 36.6℃ (97.9℉).

17. Physical examination shows no abdominal masses.

18. Physical examination shows no costovertebral angle or suprapubic tenderness.

19. Gynecologic examination shows no vulvar lesions.

20. External urethral orifice appears normal.

22. Cervix is normally positioned, non-tender, movable, and without visible lesions.

25. Urinalysis, urine culture, and ultrasound examination of the bladder were all normal.

26. Cystometric studies show residual volume of 10 ml (normal range < 50 ml).

27. Cystometric studies show sensation-of-fullness volume of 190 ml (normal range 200–225 ml).

28. Cystometric studies show urge-to-void volume of 700 ml (normal range 400–500 ml).

29. Cystometric studies show presence of involuntary contractions (normal range absent).

1. Symptoms occur during the day and night.

2. Symptoms are not linked with physical exertion, laughing, or coughing.

3. Occupation does not involve weight lifting, but is sometimes stressful.

4. Denies any other genitourinary symptoms.

5. Had 1 vaginal delivery and 1 cesarean section.

6. No history of genitourinary or neurologic disorders.

7. Weight is 91 kg (200.6 lb) and height is 172 cm (5 ft 60 in).

8. Vital signs: blood pressure 128/75 mmHg, heart rate 77/min, respiratory rate 13/min, temperature 36.6℃ (97.9℉).

9. Physical examination shows no abdominal masses, costovertebral angle tenderness, or suprapubic tenderness.

10. Gynecologic examination shows no vulvar lesions, normal external urethral orifice, and negative Q-tip test.

11. Cervix is normally positioned, non-tender, movable, and without visible lesions.

12. Uterus is not enlarged and ovaries are not palpable.

13. Urinalysis, urine culture, and ultrasound examination of the bladder were all normal.

14. Cystometric studies show specific measured values and normal ranges for residual volume, sensation-of-fullness volume, urge-to-void volume, and presence of involuntary contractions.


Question: The patient's symptoms are most likely caused by disruption of which of the following steps in protein synthesis?

Context: A 4-year-old girl is brought to the physician with progressively worsening fever, malaise, and a sore throat.

Context: Her parents say “Our daughter has not received vaccinations because her body has to learn how to fight infections.” Her temperature is 38.5˚C (101.3 F).

Choices:
A. Folding of completed proteins
B. Translocation of the ribosome along the mRNA
C. Binding of tRNA to the A site
D. Release of completed protein from ribosome

Answer: Translocation of the ribosome along the mRNA

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

2. She has progressively worsening fever, malaise, and a sore throat.

3. Her parents say she has not received vaccinations because her body has to learn how to fight infections.

5. Physical examination shows marked cervical lymphadenopathy.

6. There are gray-white membranes over the tonsils and posterior pharynx.

7. The gray-white membranes bleed when scraped off.

1. Her parents say "Our daughter has not received vaccinations because her body has to learn how to fight infections."

3. Physical examination shows marked cervical lymphadenopathy.

4. There are gray-white membranes over the tonsils and posterior pharynx that bleed when scraped off.


Question: Which of the following therapies would have been first line for improving this patient’s symptoms early in the course of this disease?

Context: A 56-year-old man presents to his family physician for issues with his back that have persisted since he was in his 20’s.

Context: For the last 6 months, his neck has been very stiff and he has been unable to tilt his head backwards.

Context: He also has severe kyphosis and feels limited in his range of motion.

Context: He tries to get at least 8 hours of sleep each night, but he says he rarely feels rested.

Context: His cervical spine is moderately stiff; limitations are in extension, flexion, and rotation.

Context: There is also evidence of mild swelling of his wrist joints.

Context: Unfortunately, he did not seek medical care for years due to financial hardships.

Choices:
A. Infliximab
B. Indomethacin
C. Methotrexate
D. Sulfasalazine

Answer: Indomethacin

2. Patient has had back issues since his 20's.

3. Patient has had a stiff neck for the last 6 months.

6. Patient tries to get 8 hours of sleep each night.

7. Patient has no pain on active and passive movements.

8. Patient's cervical spine is moderately stiff.

9. Limitations in extension, flexion, and rotation.

10. Patient has mild swelling of his wrist joints.

11. Patient is sent for an X-ray of his lumbar spine.

12. Patient did not seek medical care for years due to financial hardships.

1. His neck has been very stiff for the last 6 months.

2. He has been unable to tilt his head backwards.

4. He feels limited in his range of motion.

5. He tries to get at least 8 hours of sleep each night.

6. He rarely feels rested despite getting 8 hours of sleep.

7. On examination, the patient has no pain on active and passive movements.

8. His cervical spine is moderately stiff.

9. Limitations are in extension, flexion, and rotation.

10. There is evidence of mild swelling of his wrist joints.

11. The patient is sent for an X-ray of his lumbar spine.

12. He did not seek medical care for years due to financial hardships.


Question: What is the most likely cause of this patient’s cervicitis?

Context: A 24-year-old woman visits the health services of her university for vaginal itching, dysuria, pelvic discomfort, and foul-smelling vaginal discharge.

Context: She states this is the eighth time she has had such symptoms within the last year, for which she and her sexual partners have received multiple courses of doxycycline and ceftriaxone or azithromycin and ceftriaxone.

Choices:
A. Chlamydia trachomatis
B. Mycoplasma hominis
C. Mycoplasma genitalium
D. Neisseria gonorrhoeae

Answer: Mycoplasma genitalium

1. A 24-year-old woman visited the health services of her university.

2. She had vaginal itching, dysuria, pelvic discomfort, and foul-smelling vaginal discharge.

3. This was the eighth time she had these symptoms in the last year.

4. She and her sexual partners had received multiple courses of doxycycline and ceftriaxone or azithromycin and ceftriaxone.

5. A pelvic examination showed a mucopurulent cervical discharge with cervical friability.

6. A vaginal wet-mount showed an elevated number of polymorphonuclear leukocytes.

1. The patient has experienced similar symptoms eight times in the past year.

2. The patient and her sexual partners have received multiple courses of doxycycline and ceftriaxone or azithromycin and ceftriaxone.

3. A pelvic examination revealed mucopurulent cervical discharge.

4. The cervical discharge showed cervical friability.

5. A vaginal wet-mount showed an elevated number of polymorphonuclear leukocytes.


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

Context: His mother states that over the past 6 hours he has been having intermittent episodes of inconsolable crying, during which he “grabs his abdomen and draws up his legs.” These episodes have been accompanied by nonbloody, nonbilious vomiting and reddish, mucoid bowel movements.

Context: He appears sleepy.

Context: He cries when his abdomen is palpated.

Context: An abdominal x-ray shows no free air.

Context: An abdominal ultrasonography is shown.

Choices:
A. Air enema
B. Appendectomy
C. Technetium-99m pertechnetate scan
D. Pyloromyotomy

Answer: Air enema

1. A previously healthy 11-month-old boy is brought to the emergency department for the evaluation of abdominal pain and vomiting.

2. His mother states that over the past 6 hours he has been having intermittent episodes of inconsolable crying, during which he “grabs his abdomen and draws up his legs.”

3. These episodes have been accompanied by nonbloody, nonbilious vomiting and reddish, mucoid bowel movements.

5. His temperature is 38.1°C (100.6°F), blood pressure 100/60 mm Hg, pulse is 110/min, and respirations are 24/min.

6. He cries when his abdomen is palpated.

7. The remainder of the examination shows no abnormalities.

8. A complete blood count shows a leukocyte count of 12,000/mm3.

9. Serum electrolyte levels are within normal limits.

10. An abdominal x-ray shows no free air.

11. An abdominal ultrasonography is shown.

1. His mother reports intermittent episodes of inconsolable crying over the past 6 hours.

2. During the episodes, he grabs his abdomen and draws up his legs.

3. The episodes are accompanied by nonbloody, nonbilious vomiting and reddish, mucoid bowel movements.

9. He cries when his abdomen is palpated.

10. The remainder of the examination shows no abnormalities.

11. A complete blood count shows a leukocyte count of 12,000/mm3.

12. Serum electrolyte levels are within normal limits.

13. An abdominal x-ray shows no free air.

14. An abdominal ultrasonography is shown.


Question: Which of the following best explains the findings in this patient?

Context: A 68-year-old man comes to the physician because of a 4-month history of bad breath and progressive difficulty swallowing solid food.

Context: An upper endoscopy is performed and a photomicrograph of a biopsy specimen obtained from the mid-esophagus is shown.

Choices:
A. Atrophy and fibrosis of the esophageal smooth muscle
B. Metaplastic transformation of esophageal mucosa
C. Neoplastic proliferation of squamous epithelium
D.
Eosinophilic infiltration of the esophageal walls
"

Answer: Neoplastic proliferation of squamous epithelium

1. A 68-year-old man comes to the physician.

2. He has a 4-month history of bad breath.

3. He has progressive difficulty swallowing solid food.

4. Physical examination shows no abnormalities.

6. A photomicrograph of a biopsy specimen is obtained from the mid-esophagus.

1. Physical examination shows no abnormalities.

3. A photomicrograph of a biopsy specimen is obtained from the mid-esophagus.


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

Context: A 43-year-old woman comes to the physician because of a 2-month history of progressive muscle pain and stiffness that worsens with exercise.

Context: She also has difficulty climbing stairs, getting out of chairs, and putting things on shelves or in cupboards.

Context: She has had constipation, occasional headaches, and a 9-kg (20-lb) weight gain during the past year.

Context: Her pulse is 80/min and her blood pressure is 138/76 mm Hg.

Context: She has delayed tendon reflex relaxation, with a mounding of the muscle surface occurring just before relaxation.

Context: Creatine kinase level is 3,120 U/L.

Choices:
A. Serum TSH levels
B. Acetylcholine receptor antibody testing
C. Serum potassium levels
D. Temporal artery biopsy

Answer: Serum TSH levels

General Rheumatology
Neuromuscular Medicine

2. Patient has a 2-month history of progressive muscle pain and stiffness that worsens with exercise.

3. Patient has difficulty climbing stairs, getting out of chairs, and putting things on shelves or in cupboards.

4. Patient has had constipation, occasional headaches, and a 9-kg (20-lb) weight gain during the past year.

5. Patient has hypertension controlled with atenolol and amlodipine.

6. Patient has used calamine lotion for the past 6 months for dry skin.

8. Patient's blood pressure is 138/76 mm Hg.

9. Physical examination shows weakness of the proximal muscle groups.

10. Patient has delayed tendon reflex relaxation, with a mounding of the muscle surface occurring just before relaxation.

11. Patient's creatine kinase level is 3,120 U/L.

2. She has difficulty getting out of chairs.

3. She has difficulty putting things on shelves or in cupboards.

6. She has had a 9-kg (20-lb) weight gain during the past year.

7. She has hypertension controlled with atenolol and amlodipine.

8. She has used calamine lotion for the past 6 months for dry skin.

11. Physical examination shows weakness of the proximal muscle groups.

12. She has delayed tendon reflex relaxation.

13. She has a mounding of the muscle surface occurring just before relaxation.


Question: Which of the following genetic principles is most likely responsible for this patient's condition?

Context: A 34-year-old woman comes to the physician because of a rapidly growing lump in her right breast.

Choices:
A. Loss of heterozygosity in tumor suppressor gene
B. Methylation of a previously normal gene copy
C. Oncogenic transformation of a previously normal gene
D. Chronic exposure to carcinogenic material

Answer: Loss of heterozygosity in tumor suppressor gene

Internal Medicine
General Surgery
Obstetrics and Gynecology

Medical Oncology
Surgical Oncology
Gynecologic Oncology

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

2. She has a rapidly growing lump in her right breast.

3. Eight months ago, she underwent excision of a liposarcoma from the dorsum of her right forearm.

4. Her brother was diagnosed with osteosarcoma of the maxilla at the age of 22 years.

5. Her mother died at the age of 43 years from complications of acute myeloid leukemia.

6. She has smoked a pack of cigarettes daily for 7 years.

7. Examination shows a fixed, firm mass in the right breast with axillary lymphadenopathy.

8. A biopsy of the mass confirms the diagnosis of invasive ductal carcinoma.

1. Eight months ago, she underwent excision of a liposarcoma from the dorsum of her right forearm.

2. Her brother was diagnosed with osteosarcoma of the maxilla at the age of 22 years.

3. Her mother died at the age of 43 years from complications of acute myeloid leukemia.

4. She has smoked a pack of cigarettes daily for 7 years.

5. Examination shows a fixed, firm mass in the right breast with axillary lymphadenopathy.

6. A biopsy of the mass confirms the diagnosis of invasive ductal carcinoma.


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

Context: A 31-year-old woman comes to the doctor because of episodic nosebleeds and gingival bleeding for the past 2 weeks.

Context: Vital signs are within normal limits.

Context: HIV test is negative.

Choices:
A. Blood cultures
B. D-dimer testing
C. Hepatitis C antibody testing
D. Anti-platelet antibody testing

Answer: Hepatitis C antibody testing

2. Patient has had episodic nosebleeds and gingival bleeding for the past 2 weeks.

3. Patient has no history of serious illness.

5. Patient is sexually active with two male partners.

7. Vital signs are within normal limits.

8. Examination shows punctate, non-blanching macules on the chest.

9. The remainder of the examination shows no abnormalities.

10. Hemoglobin concentration is 13.1 g/dL.

13. Peripheral blood smear shows reduced platelets with normal morphology.

1. She has no history of serious illness and takes no medications.

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

3. Vital signs are within normal limits.

4. Examination shows punctate, non-blanching macules on the chest.

5. The remainder of the examination shows no abnormalities.

6. The hemoglobin concentration is 13.1 g/dL, leukocyte count is 6600/mm3, and platelet count is 28,000/mm3.

7. A peripheral blood smear shows reduced platelets with normal morphology.


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

Context: She was in her usual state of health until earlier this month when she started noticing more and more hair on her pillow in the morning.

Context: The problem has only been getting worse since then; she's even started pulling out clumps of hair when she shampoos in the morning.

Context: She has no other symptoms, and her past medical history is unremarkable.

Choices:
A. Alopecia areata
B. Secondary syphilis
C. Tinea capitis
D. Trichotillomania

Answer: Alopecia areata

1. A 40-year-old woman presents to the clinic for hair loss.

2. She was in her usual state of health until earlier this month.

3. She started noticing more and more hair on her pillow in the morning.

4. The problem has only been getting worse since then.

5. She's even started pulling out clumps of hair when she shampoos in the morning.

7. Her past medical history is unremarkable.

8. The physical exam is notable for smooth, circular, non-scarring, hairless patches across her scalp.

9. A firm tug on a bundle of hair causes almost all of the hair to be removed.

1. She was in her usual state of health until earlier this month.

2. She started noticing more and more hair on her pillow in the morning.

3. The problem has only been getting worse since then.

4. She's even started pulling out clumps of hair when she shampoos in the morning.

6. Her past medical history is unremarkable.

7. The physical exam is notable for smooth, circular, non-scarring, hairless patches across her scalp.

8. A firm tug on a bundle of hair causes almost all of the hair to be removed.


Question: Which of the following is the most likely karyotype abnormality in this infant?

Context: A 2-day-old girl born at 32 weeks gestation to a 42-year-old woman is being examined by a resident.

Context: The examination reveals a very small head circumference with low set ears, a prominent occiput, and a comparatively small mandible.

Context: A bilateral foot deformity is present.

Choices:
A. 47, XXX
B. Trisomy 21
C. Trisomy 18
D. 47, XXY

Answer: Trisomy 18

Pediatrics
Medical Genetics and Genomics

1. A 2-day-old girl was born at 32 weeks gestation.

3. The girl is being examined by a resident.

4. The examination reveals a very small head circumference.

5. The examination reveals low set ears.

6. The examination reveals a prominent occiput.

7. The examination reveals a comparatively small mandible.

8. A picture of the infant's fist is given.

9. A bilateral foot deformity is present.

1. The examination reveals a very small head circumference.

2. The examination reveals low set ears.

3. The examination reveals a prominent occiput.

4. The examination reveals a comparatively small mandible.

5. A picture of the infant’s fist is given below.

6. A bilateral foot deformity is present.


Question: This patient's cognitive symptoms are most likely the result of which of the following neuropathologic changes?

Context: He frequently has trouble remembering names of acquaintances, and has been requiring increasing amounts of assistance with getting dressed, cooking, and personal hygiene.

Context: Physical examination shows prominent epicanthal folds, low-set small ears, and a protruding tongue.

Context: Mental examination shows significant deficits in short- and long-term memory.

Choices:
A. Intracellular aggregations of alpha-synuclein
B. Multifocal deposition of excess copper
C. Synaptic build-up of abnormal prion protein
D. Extracellular accumulation of amyloid plaques

Answer: Extracellular accumulation of amyloid plaques

Neurology with Special Qualification in Child Neurology

1. A 44-year-old male is brought to the physician by his father.

2. Over the past year, the patient has become progressively forgetful and withdrawn.

3. He frequently has trouble remembering names of acquaintances.

4. He has been requiring increasing amounts of assistance with getting dressed, cooking, and personal hygiene.

5. He was diagnosed with a genetic disorder during infancy.

6. Physical examination shows prominent epicanthal folds.

7. Physical examination shows low-set small ears.

8. Physical examination shows a protruding tongue.

9. Mental examination shows significant deficits in short-term memory.

10. Mental examination shows significant deficits in long-term memory.

1. The patient has become progressively forgetful over the past year.

2. The patient has become progressively withdrawn over the past year.

3. The patient frequently has trouble remembering names of acquaintances.

4. The patient has been requiring increasing amounts of assistance with getting dressed.

5. The patient has been requiring increasing amounts of assistance with cooking.

6. The patient has been requiring increasing amounts of assistance with personal hygiene.

7. The patient was diagnosed with a genetic disorder during infancy.

8. Physical examination shows prominent epicanthal folds.

9. Physical examination shows low-set small ears.

10. Physical examination shows a protruding tongue.

11. Mental examination shows significant deficits in short-term memory.

12. Mental examination shows significant deficits in long-term memory.


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

Context: A previously healthy 75-year-old man comes to the physician with a 6-month history of fatigue, weight loss, and abdominal pain.

Context: He drinks 2 oz of alcohol on the weekends and does not smoke.

Context: He is retired but previously worked in a factory that produces plastic pipes.

Context: Abdominal examination shows right upper quadrant tenderness; the liver edge is palpable 2 cm below the ribs.

Context: A liver biopsy specimen shows pleomorphic spindle cells that express PECAM-1 on their surface.

Choices:
A. Cavernous hemangioma
B. Kaposi sarcoma
C. Angiosarcoma
D.
Cholangiocarcinoma
"

Answer: Angiosarcoma

1. A 75-year-old man comes to the physician.

2. He has a 6-month history of fatigue, weight loss, and abdominal pain.

3. He drinks 2 oz of alcohol on the weekends.

5. He previously worked in a factory that produces plastic pipes.

6. Abdominal examination shows right upper quadrant tenderness.

7. The liver edge is palpable 2 cm below the ribs.

8. A liver biopsy specimen shows pleomorphic spindle cells.

9. The spindle cells express PECAM-1 on their surface.

1. He drinks 2 oz of alcohol on the weekends.

4. He previously worked in a factory that produces plastic pipes.

5. Abdominal examination shows right upper quadrant tenderness.

6. The liver edge is palpable 2 cm below the ribs.

7. A liver biopsy specimen shows pleomorphic spindle cells.

8. The pleomorphic spindle cells express PECAM-1 on their surface.


Question: Which of the following muscles is responsible for the displacement of this segment?

Context: A 28-year-old man is brought to the emergency department 20 minutes after being involved in a bicycling accident.

Context: He refuses to move his right arm.

Context: An x-ray of the shoulder shows a fracture of the middle third of the clavicle with complete superior displacement of the medial clavicular segment.

Choices:
A. Trapezius
B. Subclavius
C. Pectoralis major
D. Sternocleidomastoid

Answer: Sternocleidomastoid

1. A 28-year-old man is brought to the emergency department.

2. He was involved in a bicycling accident 20 minutes prior.

3. He complains of severe pain over the front of his right shoulder.

5. Physical examination shows supraclavicular swelling and bruising.

6. The shoulder's range of motion is limited by pain.

7. An x-ray of the shoulder shows a fracture of the middle third of the clavicle.

8. The x-ray shows complete superior displacement of the medial clavicular segment.

1. Patient complains of severe pain over the front of his right shoulder.

2. Patient refuses to move his right arm.

3. Physical examination shows supraclavicular swelling and bruising.

4. Shoulder's range of motion is limited by pain.

5. X-ray of the shoulder shows a fracture of the middle third of the clavicle.

6. X-ray shows complete superior displacement of the medial clavicular segment.


Question: Echocardiography of this patient will most likely show which of the following?

Context: She does not smoke or drink alcohol.

Choices:
A. Rapid early diastolic filling and impaired late diastolic filling
B. Impairment of both early and late diastolic filling with respiratory variation of ventricular filling
C. Abnormal myocardial texture, and restrictive diastolic dysfunction
D. Dilated left and/or right ventricle and low ejection fraction

Answer: Impairment of both early and late diastolic filling with respiratory variation of ventricular filling

Congestive Heart Failure and Transplant Cardiology

1. A 49-year-old woman presents to her oncologist with progressive difficulty breathing at rest, decreased exercise tolerance, and ankle swelling bilaterally for the past 2 weeks.

2. She was diagnosed with breast cancer 4 years ago which was treated with radical mastectomy, radiation, and aggressive chemotherapy.

4. Her family history is positive for breast cancer in her elder sister.

5. Vital signs include: blood pressure 85/50 mm Hg, temperature 36.7°C (98.1°F), and a regular pulse of 110/min.

6. The physician notices that, with inspiration, the radial pulse becomes weak.

7. On physical examination, she looks anxious and tachypneic.

8. Jugular venous pressure is 14 cm and heart sounds are distant.

9. Lungs are clear and 1+ pedal edema is noted.

10. Her chest X-ray is shown in the exhibit.

1. Diagnosed with breast cancer 4 years ago

2. Treated with radical mastectomy, radiation, and aggressive chemotherapy

4. Family history positive for breast cancer in elder sister

8. Radial pulse becomes weak with inspiration


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

Context: A 5-year-old boy is brought to the physician because of high-grade fever and generalized fatigue for 5 days.

Choices:
A. Staphylococcal scalded skin syndrome
B. Juvenile idiopathic arthritis
C. Granulomatosis with polyangiitis
D.
Kawasaki disease
"

Answer:
Kawasaki disease
"

General Pediatrics
Pediatric Infectious Diseases

1. A 5-year-old boy is brought to the physician.

2. He has had high-grade fever and generalized fatigue for 5 days.

3. Two days ago, he developed a rash on his trunk.

4. He returned from a family hiking trip to Montana 1 week ago.

5. His immunization records are unavailable.

9. Examination shows injection of the conjunctivae bilaterally.

10. The tongue and pharynx are erythematous.

11. Tender cervical lymphadenopathy is present on the left.

12. There is a macular rash over the trunk and extremities.

13. Bilateral knee joints are swollen and tender.

15. Cardiopulmonary examination shows no abnormalities.

1. Two days ago, he developed a rash on his trunk.

2. He returned from a family hiking trip to Montana 1 week ago.

3. His immunization records are unavailable.

4. His temperature is 39.8°C (103.6°F), pulse is 111/min, and blood pressure is 96/60 mm Hg.

5. Examination shows injection of the conjunctivae bilaterally.

6. The tongue and pharynx are erythematous.

7. Tender cervical lymphadenopathy is present on the left.

8. There is a macular rash over the trunk and extremities.

9. Bilateral knee joints are swollen and tender; range of motion is limited by pain.

10. Cardiopulmonary examination shows no abnormalities.


Question: This patient’s condition is likely due to a lesion in which of the following locations?

Context: A 61-year-old female presents to the emergency room for a headache and vision loss.

Context: She also says she cannot see out of part of her eye.

Context: Her past medical history is notable for hypertension, hyperlipidemia, and a prior myocardial infarction.

Choices:
A. Optic nerve
B. Pituitary gland
C. Parietal lobe
D. Temporal lobe

Answer: Temporal lobe

2. Patient presents to the emergency room for a headache and vision loss.

3. Patient has a 3-hour history of acute-onset dull headache.

4. Patient cannot see out of part of her eye.

5. Patient's past medical history is notable for hypertension, hyperlipidemia, and a prior myocardial infarction.

6. Patient takes enalapril, atorvastatin, aspirin, and metoprolol.

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

8. Patient has 5/5 strength and full sensation to light touch in her bilateral upper and lower extremities.

9. Patient's brachioradialis, triceps, patellar, and Achilles reflexes are symmetric and 2+ bilaterally.

10. Fundoscopic examination reveals a normal retina.

11. Visual field examination demonstrates an inability to see in the superior right visual field.

1. She reports a 3-hour history of acute-onset dull headache.

2. She cannot see out of part of her eye.

3. Her past medical history includes hypertension, hyperlipidemia, and a prior myocardial infarction.

4. She takes enalapril, atorvastatin, aspirin, and metoprolol.

5. On exam, she is alert and oriented to person, place, and time.

6. She has 5/5 strength and full sensation to light touch in her bilateral upper and lower extremities.

7. Her brachioradialis, triceps, patellar, and Achilles reflexes are symmetric and 2+ bilaterally.

8. Fundoscopic examination reveals a normal retina.

9. Visual field examination demonstrates an inability to see in the superior right visual field.


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

Context: A 37-year-old G2P1001 presents to her obstetrician’s office at 31 weeks gestation for decreased fetal movement over the last day.

Context: She states that although she occasionally feels some movement, it is decreased from baseline.

Context: She denies any gush of fluid, vaginal bleeding, or painful contractions.

Context: This pregnancy has been complicated by gestational diabetes for which the patient was prescribed insulin.

Context: She reports not always taking postprandial fingersticks; therefore, she infrequently uses her insulin.

Context: She also had a urinary tract infection in the first trimester that was successfully treated with nitrofurantoin.

Context: The patient has a past medical history of obesity and rosacea, and she had an uncomplicated spontaneous vaginal delivery six years ago.

Choices:
A. Non-stress test
B. Biophysical profile
C. Contraction stress test
D. Cervical exam

Answer: Non-stress test

4. Patient has decreased fetal movement over the last day.

5. Patient occasionally feels some movement, but it is decreased from baseline.

6. Patient denies any gush of fluid, vaginal bleeding, or painful contractions.

9. Patient does not always take postprandial fingersticks.

10. Patient infrequently uses her insulin.

11. Patient had a urinary tract infection in the first trimester.

12. Patient was successfully treated with nitrofurantoin.

13. Patient has a past medical history of obesity and rosacea.

14. Patient had an uncomplicated spontaneous vaginal delivery six years ago.

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

16. Patient's blood pressure is 148/71 mmHg.

20. Patient has a fundal height of 33 centimeters.

21. Initial attempt with Doppler ultrasound is unable to detect fetal heart tones.

1. The patient occasionally feels some movement, but it is decreased from baseline.

2. The patient denies any gush of fluid, vaginal bleeding, or painful contractions.

3. The pregnancy has been complicated by gestational diabetes, and the patient was prescribed insulin.

4. The patient reports not always taking postprandial fingersticks and infrequently uses her insulin.

5. The patient had a urinary tract infection in the first trimester, successfully treated with nitrofurantoin.

6. The patient has a past medical history of obesity and rosacea.

7. The patient had an uncomplicated spontaneous vaginal delivery six years ago.

8. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 148/71 mmHg, pulse is 75/min, and respirations are 14/min.

9. The patient appears comfortable and has a fundal height of 33 centimeters.

10. An initial attempt with Doppler ultrasound is unable to detect fetal heart tones.


Question: Which of the following is the most likely predisposing factor for this patient’s current condition?

Context: A 59-year-old man is brought to the emergency department by his wife because of fever, chills, night sweats, and generalized fatigue for 2 weeks.

Context: His temperature is 39.1°C (102.4°F).

Context: He appears ill.

Context: Physical examination shows a grade 3/6 mid-diastolic murmur at the left sternal border, and crackles at both lung bases.

Context: Blood cultures show gram-positive, catalase-negative, gamma-hemolytic cocci in chains that are unable to grow in a 6.5% NaCl medium.

Choices:
A. Periodontal disease
B. Colon cancer
C. Valve replacement
D. Urinary tract infection

Answer: Colon cancer

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

2. He has been experiencing fever, chills, night sweats, and generalized fatigue for 2 weeks.

5. Physical examination shows a grade 3/6 mid-diastolic murmur at the left sternal border.

6. Physical examination also shows crackles at both lung bases.

7. A transesophageal echocardiography shows a 12 mm vegetation on the aortic valve.

8. Blood cultures show gram-positive, catalase-negative, gamma-hemolytic cocci in chains.

9. The cocci are unable to grow in a 6.5% NaCl medium.

3. Physical examination shows a grade 3/6 mid-diastolic murmur at the left sternal border.

4. Physical examination shows crackles at both lung bases.

5. A transesophageal echocardiography shows a 12 mm vegetation on the aortic valve.

6. Blood cultures show gram-positive, catalase-negative, gamma-hemolytic cocci in chains.

7. The blood cultures are unable to grow in a 6.5% NaCl medium.


Question: What diagnostic test should this patient receive?

Context: A 65-year-old woman presents to her family doctor to reestablish care since her retirement from her corporate job and loss of her employer-sponsored health insurance.

Context: She states that she has not had time for regular check-ups.

Context: She exercises 3-4 times a week and consumes red meat sparingly.

Context: She drank and smoked cigarettes socially with coworkers but never at home or on vacation.

Context: She wakes up with achy wrists and elbows that she suspects is from years of using a computer keyboard.

Context: She completed menopause at age 52.

Context: Her family history is notable for coronary artery disease on her father's side and colon cancer on her mother's side.

Context: She last had a colonoscopy 5 years ago that revealed no abnormal findings.

Context: Her vital signs are within normal limits and her physical exam is grossly unremarkable.

Choices:
A. Chest radiograph
B. Colonoscopy
C. Mammography
D. Pelvic ultrasound

Answer: Mammography

2. Patient recently retired from a corporate job and lost employer-sponsored health insurance.

3. Patient has not had time for regular check-ups.

6. Patient drank and smoked cigarettes socially with coworkers, but not at home or on vacation.

7. Patient wakes up with achy wrists and elbows, which she suspects is from years of using a computer keyboard.

8. Patient completed menopause at age 52.

9. Patient's family history is notable for coronary artery disease on her father's side and colon cancer on her mother's side.

10. Patient last had a colonoscopy 5 years ago that revealed no abnormal findings.

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

12. Patient's physical exam is grossly unremarkable.

1. She has not had time for regular check-ups.

4. She drank and smoked cigarettes socially with coworkers.

5. She never drank or smoked at home or on vacation.

6. She wakes up with achy wrists and elbows.

7. She suspects it is from years of using a computer keyboard.

9. Her family history includes coronary artery disease on her father's side.

10. Her family history includes colon cancer on her mother's side.

12. The colonoscopy revealed no abnormal findings.

13. Her vital signs are within normal limits.

14. Her physical exam is grossly unremarkable.


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

Context: A 52-year-old woman comes to the physician because of mild fatigue and dizziness for the past 2 days.

Context: She says she has ""very high blood sugar” and has had similar episodes often in the past 2 years, for which she has visited multiple doctors around the city.

Context: She has also purchased a home glucose monitoring device, which she uses daily.

Context: She is not on any treatment.

Context: She appears anxious.

Context: Vital signs are normal.

Context: Random serum glucose is 128 mg/dL.

Choices:
A. Somatic symptom disorder
B. Unipolar major depression
C. Illness anxiety disorder
D. Impaired glucose homeostasis

Answer: Illness anxiety disorder

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

2. She has mild fatigue and dizziness for the past 2 days.

3. She has not been to work since yesterday due to her symptoms.

4. She says she has "very high blood sugar".

5. She has had similar episodes often in the past 2 years.

6. She has visited multiple doctors around the city.

7. She has purchased a home glucose monitoring device.

9. Since the symptoms began, she has become socially withdrawn.

10. She spends much of her time at home researching diabetes on the internet.

11. One week ago, she took a day off work because of her symptoms.

13. She has had 3 laboratory test reports.

14. All show normal fasting and post-meal blood glucose levels.

15. Her father and brother have diabetes mellitus type 2.

18. Physical examination shows no abnormalities.

1. She has not been to work since yesterday due to her symptoms.

2. She says she has "very high blood sugar” and has had similar episodes often in the past 2 years.

3. She has visited multiple doctors around the city for her symptoms.

4. She has purchased a home glucose monitoring device, which she uses daily.

5. Since the symptoms began, she has become socially withdrawn and spends much of her time at home researching diabetes on the internet.

6. One week ago, she took a day off work because of her symptoms.

8. She has had 3 laboratory test reports that all show normal fasting and post-meal blood glucose levels.

9. Her father and brother have diabetes mellitus type 2.

12. Physical examination shows no abnormalities.


Question: Which of the following is most likely to have prevented this infant's condition?"

Context: A 4800 g (10.6 lb) male newborn is delivered at term to a 35-year-old woman, gravida 1, para 1.

Context: Vital signs are within normal limits.

Context: Laboratory studies show: | Hematocrit 66% | Leukocyte count 9000/mm3 | Serum | Na+ 142 mEq/L | Cl- 103 mEq/L | K+ 5.1 mEq/L | HCO3- 20 mEq/L | Urea nitrogen 8 mg/dL | Glucose 34 mg/dL | Creatinine 0.6 mg/dL | .

Choices:
A. Avoidance of soft cheeses
B. Administration of insulin
C. Abstinence from cocaine
D. Avoidance of cat feces

Answer: Administration of insulin

Maternal
Neonatal
Maternal–Fetal Medicine

1. A 4800 g male newborn is delivered at term.

2. The mother is 35 years old and gravida 1, para 1.

3. Significant lateral neck traction is required during delivery.

4. Apgar scores are 9 and 9 at 1 and 5 minutes, respectively.

5. Vital signs are within normal limits.

6. At rest, the baby's right shoulder is adducted and internally rotated.

7. The baby cries with passive movement of the arm.

1. Significant lateral neck traction is required during delivery.

2. Apgar scores are 9 and 9 at 1 and 5 minutes, respectively.

3. Vital signs are within normal limits.

4. At rest, his right shoulder is adducted and internally rotated.

5. The baby cries with passive movement of the arm.

6. Laboratory studies show: Hematocrit 66%

7. Laboratory studies show: Leukocyte count 9000/mm3

8. Laboratory studies show: Serum Na+ 142 mEq/L

9. Laboratory studies show: Serum Cl- 103 mEq/L

10. Laboratory studies show: Serum K+ 5.1 mEq/L

11. Laboratory studies show: Serum HCO3- 20 mEq/L

12. Laboratory studies show: Serum Urea nitrogen 8 mg/dL

13. Laboratory studies show: Serum Glucose 34 mg/dL

14. Laboratory studies show: Serum Creatinine 0.6 mg/dL


Question: Which of the following is the most sensitive test for diagnosing pregnancy at this time?

Context: She and her husband are trying to conceive, and they have had frequent sexual intercourse over the past month.

Context: Her menstrual cycles occur at regular 28-day intervals, and her last menstrual period began 25 days ago.

Choices:
A. Serum testing
B. Transvaginal ultrasound
C. Transabdominal Doppler ultrasound
D. Urine testing

Answer: Serum testing

1. A 30-year-old woman comes to the physician for evaluation of successful conception.

2. She and her husband are trying to conceive.

3. They have had frequent sexual intercourse over the past month.

4. Her menstrual cycles occur at regular 28-day intervals.

5. Her last menstrual period began 25 days ago.

1. She and her husband are trying to conceive.

2. They have had frequent sexual intercourse over the past month.

3. Her menstrual cycles occur at regular 28-day intervals.

4. Her last menstrual period began 25 days ago.


Question: Which of the following is also most likely associated with the auscultatory findings in this patient?

Context: A 25-year-old healthy man presents to the physician for an annual checkup.

Context: He doesn’t have any concerns and feels completely healthy.

Context: He recently started a new job and has been working out at a gym regularly.

Context: He does not smoke cigarettes, drinks occasionally, and does not use illicit substances.

Context: His vital signs include: pulse 80/min, respirations 14/min, and blood pressure 120/80 mm Hg.

Choices:
A. Decreased venous return
B. Increased intrapleural pressure
C. Increased right ventricular output
D. Increased systemic blood pressure

Answer: Increased right ventricular output

1. A 25-year-old man presents to the physician for an annual checkup.

2. He does not have any concerns and feels completely healthy.

4. He has been working out at a gym regularly.

11. Physical examination is significant for a splitting of the second heart sound heard on inspiration but not on expiration.

1. The patient doesn't have any concerns.

2. The patient feels completely healthy.

3. The patient recently started a new job.

4. The patient has been working out at a gym regularly.

5. The patient does not smoke cigarettes.

7. The patient does not use illicit substances.

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

10. The patient's blood pressure is 120/80 mm Hg.

11. The physical examination is significant for a splitting of the second heart sound heard on inspiration but not on expiration.


Question: Which of the following will increase the intensity of this patient’s murmur?

Context: A 79-year-old man presents to his primary care physician complaining of progressive shortness of breath on exertion for the past 2 months.

Context: He was first aware of having to catch his breath while gardening, and he is now unable to walk up the stairs in his house without stopping.

Context: He has had type 2 diabetes mellitus for 30 years, for which he takes metformin and sitagliptin.

Context: His blood pressure is 110/50 mm Hg, the temperature is 37.1°C (98.8°F), and the radial pulse is 80/min and regular.

Choices:
A. Squatting
B. Standing up from a sitting position
C. Diuretics
D. Volume depletion

Answer: Squatting

2. Patient is complaining of progressive shortness of breath on exertion for the past 2 months.

3. Patient first noticed shortness of breath while gardening.

4. Patient is unable to walk up stairs without stopping.

5. Patient has type 2 diabetes mellitus for 30 years.

6. Patient takes metformin and sitagliptin for diabetes.

7. Patient's blood pressure is 110/50 mm Hg.

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

9. Patient's radial pulse is 80/min and regular.

10. Physical examination reveals loud systolic murmur at right upper sternal border with radiation to carotid arteries.

1. He first noticed difficulty catching his breath while gardening.

2. He is unable to walk up the stairs in his house without stopping.

3. He has had type 2 diabetes mellitus for 30 years.

4. He takes metformin and sitagliptin for his diabetes.

7. His radial pulse is 80/min and regular.

8. On physical examination, there is a loud systolic murmur at the right upper sternal border with radiation to the carotid arteries.


Question: Which of the following is the best prophylactic treatment for this patient’s most likely diagnosis?

Context: A 47-year-old woman presents with intermittent throbbing headaches.

Context: She says that she has had at least 1–2 every week for the last 3 months.

Context: She says the headaches usually last for several hours and are made worse by the presence of light.

Context: She endorses nausea with occasional vomiting during the most severe episodes.

Context: She denies any seizures, loss of consciousness, or focal neurologic deficits.

Context: Her past medical history is significant for myocardial infarction (MI) 1 year ago, status post percutaneous transluminal coronary angioplasty complicated by residual angina, and severe asthma, managed medically.

Context: A physical examination is unremarkable.

Choices:
A. Amitriptyline
B. Valproic acid
C. Propranolol
D. Ibuprofen

Answer: Valproic acid

Headache Medicine
Vascular Neurology
General Neurology

2. Patient has had intermittent throbbing headaches for the last 3 months, 1-2 per week.

3. Pain is severe, pulsatile, and localized to the right frontotemporal and periorbital areas.

4. Headaches usually last for several hours and are made worse by the presence of light.

5. Patient endorses nausea with occasional vomiting during the most severe episodes.

6. Patient denies any seizures, loss of consciousness, or focal neurologic deficits.

7. Patient's past medical history is significant for MI 1 year ago, status post percutaneous transluminal coronary angioplasty complicated by residual angina, and severe asthma, managed medically.

8. Patient is afebrile, and vital signs are within normal limits.

9. Physical examination is unremarkable.

10. Noncontrast CT scan of the head appears normal.

1. The patient reports having at least 1–2 headaches every week for the last 3 months.

2. She describes the pain as severe, pulsatile, and localized to the right frontotemporal and periorbital areas.

3. The headaches usually last for several hours and are exacerbated by the presence of light.

4. She experiences nausea with occasional vomiting during the most severe episodes.

5. The patient denies any seizures, loss of consciousness, or focal neurologic deficits.

6. Her past medical history includes myocardial infarction (MI) 1 year ago, status post percutaneous transluminal coronary angioplasty complicated by residual angina, and severe asthma, managed medically.

7. The patient is afebrile, and the vital signs are within normal limits.

8. A physical examination is unremarkable.

9. A noncontrast computed tomography (CT) scan of the head appears normal.


Question: What conditions can the given test predict?

Context: He tells her that the test includes extracting a blood sample to determine the chances of having certain genetic conditions.

Choices:
A. Trisomy 21, Ebstein anomaly
B. Trisomy 21, trisomy 13, trisomy 18, fetal sex
C. Trisomy 21, trisomy 13, spina bifida
D. Trisomy 21, spina bifida

Answer: Trisomy 21, trisomy 13, trisomy 18, fetal sex

1. A 37-year-old 11-week primigravida will soon undergo a prenatal evaluation.

2. The doctor wants to exclude chromosomal abnormalities with a test.

3. The test includes extracting a blood sample.

4. The blood sample is used to determine the chances of having certain genetic conditions.

5. This process involves analyzing fetal DNA in the mother’s blood.

1. The doctor wants to exclude chromosomal abnormalities with a test.

2. The test includes extracting a blood sample.

3. The blood sample is used to determine the chances of having certain genetic conditions.

4. The process involves analyzing fetal DNA in the mother’s blood.