Question: What is the most likely causative organism?

Context: You perform a KOH prep, and notice an abnormal smell.

Context: On microscopy in your office, you observe the findings in figure A. |  | .

Choices:
A. Trichomonas vaginalis
B. Candida albicans
C. Escherichia coli
D. Gardnerella vaginalis

Answer: Gardnerella vaginalis

1. A 24-year-old woman presents complaining of a new onset vaginal odor.

2. She reports that she is sexually active in a monogamous relationship with the same partner for two years.

5. On microscopy in your office, you observe the findings in figure A.

1. The patient reports being sexually active.

2. The patient is in a monogamous relationship.

3. The relationship has lasted for two years.

5. An abnormal smell was noticed during the KOH prep.

6. Microscopy was performed in the office.

7. Abnormal findings were observed in figure A.


Question: In addition to securing the airway, which of the following is the most appropriate next step in management?

Context: A 22-year-old woman is brought to the emergency department 4 hours after the ingestion of 25 tablets of an unknown drug in an attempt to commit suicide.

Context: Her temperature is 36.7°C (98°F), pulse is 41/min, respirations are 14/min, and blood pressure is 88/55 mm Hg.

Context: The abdomen is soft.

Choices:
A. Glucagon
B. Activated charcoal
C. Sodium bicarbonate
D. Hemodialysis

Answer: Glucagon

1. A 22-year-old woman was brought to the emergency department.

2. She had ingested 25 tablets of an unknown drug 4 hours prior.

3. The attempt was in an attempt to commit suicide.

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

9. She was confused and oriented only to person.

10. Her pupils were equal and reactive to light.

11. Examination showed cold, clammy extremities.

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

14. Fingerstick blood glucose concentration was 65 mg/dL.

15. ECG showed prolonged PR intervals and narrow QRS complexes.

16. Two large bore cannulas were inserted.

17. Intravenous normal saline, dextrose, and atropine were administered.

18. Five minutes later, pulse was 51/min.

19. Five minutes later, blood pressure was 95/61 mm Hg.

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

6. She is confused and oriented only to person.

7. The pupils are equal and reactive to light.

8. Examination shows cold, clammy extremities.

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

11. Fingerstick blood glucose concentration is 65 mg/dL.

12. ECG shows prolonged PR intervals and narrow QRS complexes.

13. Two large bore cannulas are inserted and intravenous normal saline, dextrose, and atropine are administered.

14. Five minutes later, pulse is 51/min and blood pressure is 95/61 mm Hg.


Question: The bacteria causing this patient's dental problems most likely exhibits which of the following properties?

Context: A 56-year-old patient reports a history of recurrent dental caries.

Choices:
A. Inhibition of growth on optochin sensitivity test
B. Production of dextrans from glucose
C. Presence of catalase enzyme
D. Soluble in bile

Answer: Production of dextrans from glucose

Pediatric Infectious Diseases
General Dermatology

2. Patient has a history of recurrent dental caries.

2. The patient has a history of recurrent dental caries.


Question: Which of the following autoantibodies is most likely to be present in this patient?"

Context: She also has generalized itching.

Context: Laboratory studies show: | Hemoglobin 14.1 g/dL | Leukocyte count 7,200/mm3 | Erythrocyte sedimentation rate 26 mm/h | Serum | Thyroid-stimulating hormone 4.2 μU/ml | Bilirubin | Total 1.7 mg/dL | Direct 1.0 mg/dL | Alkaline phosphatase 370 U/L | Aspartate aminotransferase 80 U/L | Alanine aminotransferase 46 U/L | Cholesterol 320 mg/dL | Gamma-glutamyl transferase 98 U/L (N = 5–50) | Magnetic resonance cholangiopancreatography shows no gallstones and no evidence of extrahepatic biliary obstruction.

Choices:
A. Anti-liver-kidney microsomal-1 antibodies
B. Anti-mitochondrial antibodies
C. Anti-smooth muscle antibodies
D. Perinuclear anti-neutrophil cytoplasmic antibodies

Answer: Anti-mitochondrial antibodies

1. A 40-year-old woman comes to the physician for a follow-up examination.

2. She says she has felt fatigued for about 3 months.

3. She does not have enough energy for her job as a physician's assistant and often has to lie down and rest during shifts.

4. She no longer adheres to her usual exercise routine because of exhaustion.

5. During this time, she has noticed that her stools are sometimes pale and foul smelling.

7. The patient does not have abdominal pain, fever, or weight loss.

8. She takes levothyroxine for hypothyroidism.

9. She has smoked one pack of cigarettes weekly for 20 years.

10. Physical examination shows no abnormalities.

11. Laboratory studies show: Hemoglobin 14.1 g/dL, Leukocyte count 7,200/mm3, Erythrocyte sedimentation rate 26 mm/h, Serum Thyroid-stimulating hormone 4.2 μU/ml, Bilirubin Total 1.7 mg/dL, Direct 1.0 mg/dL, Alkaline phosphatase 370 U/L, Aspartate aminotransferase 80 U/L, Alanine aminotransferase 46 U/L, Cholesterol 320 mg/dL, Gamma-glutamyl transferase 98 U/L (N = 5–50).

12. Magnetic resonance cholangiopancreatography shows no gallstones and no evidence of extrahepatic biliary obstruction.

13. Liver biopsy shows nonsuppurative destructive cholangitis with lymphocytic infiltration of portal areas and periductal granulomas.

1. The patient has felt fatigued for about 3 months.

2. She does not have enough energy for her job as a physician's assistant and often has to lie down and rest during shifts.

3. She no longer adheres to her usual exercise routine because of exhaustion.

4. The patient has noticed that her stools are sometimes pale and foul smelling.

6. The patient does not have abdominal pain, fever, or weight loss.

7. She takes levothyroxine for hypothyroidism.

8. She has smoked one pack of cigarettes weekly for 20 years.

9. Physical examination shows no abnormalities.

10. Laboratory studies show: Hemoglobin 14.1 g/dL, Leukocyte count 7,200/mm3, Erythrocyte sedimentation rate 26 mm/h, Serum Thyroid-stimulating hormone 4.2 μU/ml, Bilirubin Total 1.7 mg/dL, Direct 1.0 mg/dL, Alkaline phosphatase 370 U/L, Aspartate aminotransferase 80 U/L, Alanine aminotransferase 46 U/L, Cholesterol 320 mg/dL, Gamma-glutamyl transferase 98 U/L (N = 5–50).

11. Magnetic resonance cholangiopancreatography shows no gallstones and no evidence of extrahepatic biliary obstruction.

12. Liver biopsy shows nonsuppurative destructive cholangitis with lymphocytic infiltration of portal areas and periductal granulomas.


Question: Inhibition of which of the following best describes this drug’s mechanism of action?

Context: He has recently made lifestyle modifications, such as losing 4.5 kg (10 lb) but his erectile symptoms have not improved.

Choices:
A. 5-alpha reductase
B. cGMP phosphodiesterase
C. Estrogen receptors
D. Testosterone receptors

Answer: cGMP phosphodiesterase

1. A 73-year-old man seeks evaluation for difficulty developing and maintaining erections.

2. He has recently made lifestyle modifications, such as losing 4.5 kg (10 lb).

3. His erectile symptoms have not improved.

4. He was prescribed a drug by his physician.

1. He has recently made lifestyle modifications.


Question: Which of the following regions of the brain is most likely affected?

Context: A 65-year-old woman with hypertension comes to the emergency department because of sudden onset of a severe headache 2 hours ago.

Context: Her temperature is 35°C (95°F) and blood pressure is 189/115 mm Hg.

Context: A CT scan of the head shows a subarachnoid hemorrhage and she is started on appropriate pharmacotherapy.

Choices:
A. Ventral lateral thalamic nucleus
B. Pineal gland
C. Preoptic nucleus
D. Caudate nucleus

Answer: Preoptic nucleus

1. A 65-year-old woman comes to the emergency department.

3. She has sudden onset of a severe headache 2 hours ago.

6. A CT scan of the head shows a subarachnoid hemorrhage.

7. She is started on appropriate pharmacotherapy.

3. A CT scan of the head shows a subarachnoid hemorrhage.

4. She is started on appropriate pharmacotherapy.


Question: Which of the following should be tested weekly?

Context: A 35-year-old woman with a one-year history of auditory hallucinations and periods of anhedonia and amotivation is being seen by her psychiatrist.

Context: She was started on haloperidol at her last visit, but she was told to stop taking the medication since she developed muscle stiffness and spasms soon after taking the drug.

Context: Today, her temperature is 97.7°F (36.5°C), blood pressure is 132/76 mmHg, pulse is 98/min, and respirations are 12/min.

Context: The patient is now started on a new medication that will seek to avoid the same side effects as her previous one; however, she will need to come in for weekly testing.

Choices:
A. Electrocardiogram
B. Electrolytes
C. Gonadotropin releasing hormone
D. White blood cell count

Answer: White blood cell count

1. A 35-year-old woman has a one-year history of auditory hallucinations and periods of anhedonia and amotivation.

2. She was started on haloperidol at her last visit.

3. She was told to stop taking the medication since she developed muscle stiffness and spasms soon after taking the drug.

4. Today, her temperature is 97.7°F (36.5°C).

8. She is now started on a new medication that will seek to avoid the same side effects as her previous one.

9. She will need to come in for weekly testing.

1. The patient was started on haloperidol at her last visit.

2. She was told to stop taking the medication due to developing muscle stiffness and spasms soon after taking the drug.

7. The patient is now started on a new medication.

8. The new medication aims to avoid the same side effects as her previous one.

9. The patient will need to come in for weekly testing.


Question: Which of the following is the most common viral cause of this child's condition?

Context: A 9-year-old boy is brought to the emergency room by his concerned mother after he "urinated blood." The boy reports that, starting this morning, he experienced significant pain with urination and his urine appeared a bright red color.

Context: These symptoms were not present before today; however, he reports a cough, runny nose, and sore throat that started approximately 3 days ago.

Context: Vital signs are as follows: T 38.4 deg C, HR 101, BP 110/65, RR 14, SpO2 99%.

Context: Physical examination is significant for bilateral conjunctivitis, tenderness to suprapubic palpation, and a small amount of clotted blood is noted surrounding the urethral meatus.

Context: A urine sample is obtained, and urinalysis shows 3+ blood, and urine microscopy demonstrates gross blood with too many cells to count per high powered field.

Choices:
A. Parvovirus B19
B. Coronavirus
C. Adenovirus
D. Coxsackie A virus

Answer: Adenovirus

2. Patient was brought to the emergency room by his concerned mother.

4. Patient experienced significant pain with urination.

5. Patient's urine appeared a bright red color.

6. Symptoms were not present before today.

7. Patient reports a cough, runny nose, and sore throat that started approximately 3 days ago.

9. Physical examination is significant for bilateral conjunctivitis.

10. Physical examination is significant for tenderness to suprapubic palpation.

11. A small amount of clotted blood is noted surrounding the urethral meatus.

12. Urine sample obtained, and urinalysis shows 3+ blood.

13. Urine microscopy demonstrates gross blood with too many cells to count per high powered field.

1. Symptoms include cough, runny nose, and sore throat that started approximately 3 days ago.

3. Physical examination shows bilateral conjunctivitis, tenderness to suprapubic palpation, and clotted blood surrounding the urethral meatus.

5. Urine microscopy demonstrates gross blood with too many cells to count per high powered field.


Question: Of the following proposed mechanisms, which one would best serve the researcher's purpose?

Context: He brainstorms several ideas but is informed by his mentor that only one of his ideas will most likely help him achieve the desired result.

Choices:
A. Decrease lactic acid production by skeletal muscle
B. Increase fetal hemoglobin concentration in circulation
C. Increase relaxed form hemoglobin in muscle capillaries
D. Increase taut form hemoglobin in muscle capillaries

Answer: Increase taut form hemoglobin in muscle capillaries

1. A young researcher wants to develop a method of increasing oxygen delivery to the peripheral tissues.

3. His mentor informs him that only one of his ideas will most likely help him achieve the desired result.

3. Only one of his ideas will most likely help him achieve the desired result.


Question: Administration of which of the following is most likely to have prevented this patient's current symptoms?

Context: Three months ago, he was diagnosed with pulmonary tuberculosis and started on antituberculosis therapy.

Context: His hemoglobin concentration is 10.4 g/dL and mean corpuscular volume is 76 μm3.

Choices:
A. Iron
B. Vitamin E
C. Folic acid
D. Pyridoxine

Answer: Pyridoxine

1. A 29-year-old man comes to the physician for a follow-up examination.

2. He has had numbness and tingling of his legs for the past 10 days.

3. Three months ago, he was diagnosed with pulmonary tuberculosis.

4. He started on antituberculosis therapy three months ago.

5. Examination shows dry scaly lips and cracks at the corner of the mouth.

6. Sensation to pinprick and light touch is decreased over the lower extremities.

7. His hemoglobin concentration is 10.4 g/dL.

8. His mean corpuscular volume is 76 μm3.

1. He has had numbness and tingling of his legs for the past 10 days.

2. Three months ago, he was diagnosed with pulmonary tuberculosis.

3. He started on antituberculosis therapy.

4. Examination shows dry scaly lips and cracks at the corner of the mouth.

5. Sensation to pinprick is decreased over the lower extremities.

6. Sensation to light touch is decreased over the lower extremities.


Question: Which investigation should be performed next in this patient?

Context: A 36-year-old woman presents with a 2-month history of urinary incontinence, accompanied by urgency, nocturia, and occasional hematuria.

Context: Her symptoms are present day and night and have no known triggers.

Context: A vaginal pessary is placed.

Context: The cervix is non-tender and mobile, the uterus is not enlarged, and the adnexa have no masses. | The urinalysis shows the following findings: |  Color:  Pale yellow |  Clarity:  Clear |  pH:  6.2 |  Specific gravity:  1.023 |  Glucose:  Negative |  Ketones:  Negative |  Nitrites:  Positive |  Leukocyte esterase:  Positive |  Bilirubin:  Negative |  Urinary bilirubin:  Negative |  Protein: Negative |  RBCs:  47 RBCs/hpf |  WBCs:  21 WBCs/hpf |  Epithelial cells:  27 squamous epithelial cells/hpf |  Casts:  5 hyaline casts/lpf |  Crystals:  Occasional urates |  Bacteria:  None noted |  Yeast:  None noted | The urinary culture is negative.

Choices:
A. Cystoscopy
B. Ultrasound examination
C. Cystometry
D. Pelvic CT scan

Answer: Ultrasound examination

2. Patient has a 2-month history of urinary incontinence, accompanied by urgency, nocturia, and occasional hematuria.

3. Symptoms are present day and night and have no known triggers.

4. Patient was diagnosed with grade 2 pelvic organ prolapse (cystocele) 1 year ago.

5. Patient is managed with pelvic floor training exercises and a vaginal pessary.

6. Patient is otherwise healthy and does not take any medications.

11. Physical examination is significant for suprapubic tenderness.

12. No costovertebral angle tenderness is present.

21. Urinalysis shows pale yellow color, clear clarity, pH 6.2, specific gravity 1.023, negative glucose, negative ketones, positive nitrites, positive leukocyte esterase, negative bilirubin, negative urinary bilirubin, negative protein, 47 RBCs/hpf, 21 WBCs/hpf, 27 squamous epithelial cells/hpf, 5 hyaline casts/lpf, occasional urates, no bacteria, and no yeast.

1. The patient's symptoms are present day and night and have no known triggers.

2. She was diagnosed with grade 2 pelvic organ prolapse (cystocele) 1 year ago, which is managed with pelvic floor training exercises and a vaginal pessary.

3. She is otherwise healthy and does not take any medications.

4. The blood pressure is 120/80 mm Hg, the heart rate is 67/min, the respiratory rate is 14/min, and the temperature is 36.8℃ (98.2℉).

5. The physical examination is significant for suprapubic tenderness.

6. No costovertebral angle tenderness is present.

7. There are no signs of vulvar inflammation, and no urethral or vaginal discharge.

8. The vaginal mucosa is normal and there is no cervical discharge.

10. The cervix is non-tender and mobile, the uterus is not enlarged, and the adnexa have no masses.

11. The urinalysis shows the following findings:

25. Epithelial cells: 27 squamous epithelial cells/hpf


Question: Which of the following is closest to the probability of a female and a male with normal vision having a daughter with red-green color blindness?

Context: The incidence of red-green color blindness in males in a certain population is 1/100.

Choices:
A. 1/100
B. 1/50
C. 98/100
D. 0

1. The incidence of red-green color blindness is 1/100.

2. The population is a certain population.

1. The incidence of red-green color blindness in males is 1/100.

2. The incidence is in a certain population.


Question: The most likely cause of this patient's condition is a defect in which of the following molecular structures?

Context: He is also concerned about fertility, as he and his wife have been trying to conceive for 5 years unsuccessfully.

Context: A CT scan of the chest is shown.

Choices:
A. IL-2R gamma chain
B. NADPH oxidase
C. CFTR protein
D. Dynein arm

Answer: Dynein arm

General Allergy and Immunology
Pediatric Pulmonology

1. A 31-year-old man comes to the physician for evaluation of chronic cough, sinus pain, and nasal discharge.

2. He has a history of frequent upper respiratory infections and recurrent sinusitis since childhood.

3. He and his wife have been trying to conceive for 5 years unsuccessfully.

4. Pulmonary examination shows crackles and wheezing throughout both lung fields.

1. He has a history of frequent upper respiratory infections since childhood.

2. He has a history of recurrent sinusitis since childhood.

4. Pulmonary examination shows crackles throughout both lung fields.

5. Pulmonary examination shows wheezing throughout both lung fields.


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

Context: A 3-year-old boy is brought to the emergency department because of abdominal pain and watery diarrhea for the past 3 days.

Context: This morning he also had nausea and his stool had a red tint.

Context: Four days ago, he and his parents returned home from a vacation, during which they visited a petting zoo and consumed many new foods.

Context: He lives with his family and they have cats and dogs at home.

Context: The patient attends daycare.

Context: His immunizations are up-to-date.

Context: His temperature is 38°C (100.4°F), pulse is 140/min, and blood pressure is 80/45 mm Hg.

Context: Examination shows dry mucus membranes.

Context: The abdomen is soft, and there is tenderness to palpation of the right lower quadrant with rebound.

Choices:
A. Hand-washing at daycare
B. Avoiding the consumption of undercooked pork
C. Avoiding the consumption of deli meats
D. Avoiding the consumption of unwashed vegetables

Answer: Avoiding the consumption of undercooked pork

2. Patient has had abdominal pain and watery diarrhea for the past 3 days.

5. Patient and his parents returned home from a vacation 4 days ago.

6. Patient and his family visited a petting zoo during the vacation.

7. Patient and his family consumed many new foods during the vacation.

9. Patient's family has cats and dogs at home.

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

12. Patient's temperature is 38°C (100.4°F).

14. Patient's blood pressure is 80/45 mm Hg.

17. Patient has tenderness to palpation of the right lower quadrant with rebound.

18. Stool culture grows Yersinia enterocolitica.

3. Four days ago, he and his parents returned home from a vacation.

4. During the vacation, they visited a petting zoo.

5. During the vacation, they consumed many new foods.

13. Examination shows dry mucus membranes.

15. There is tenderness to palpation of the right lower quadrant with rebound.

16. Stool culture grows Yersinia enterocolitica.


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

Context: A 61-year-old woman dies unexpectedly.

Context: Examination of the heart during autopsy shows hypertrophy of the left ventricular wall and enlargement of the left ventricular chamber.

Context: Microscopic examination shows lengthening of individual muscle fibers due to duplication of sarcomeres in series.

Choices:
A. Increased pulmonary arterial pressure
B. Decreased left ventricular contractility
C. Decreased left ventricular compliance
D. Increased left ventricular end diastolic volume

Answer: Increased left ventricular end diastolic volume

General Cardiology
Cardiovascular Disease

1. A 61-year-old woman dies unexpectedly.

2. She had not seen a physician in 10 years.

3. Examination of the heart during autopsy shows hypertrophy of the left ventricular wall.

4. Examination of the heart during autopsy shows enlargement of the left ventricular chamber.

5. Microscopic examination shows lengthening of individual muscle fibers.

6. Microscopic examination shows duplication of sarcomeres in series.

1. She had not seen a physician in 10 years.

2. Examination of the heart during autopsy shows hypertrophy of the left ventricular wall.

3. Examination of the heart during autopsy shows enlargement of the left ventricular chamber.

4. Microscopic examination shows lengthening of individual muscle fibers.

5. Microscopic examination shows duplication of sarcomeres in series.


Question: What is the mechanism of action of this drug?

Context: A 57-year-old man with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and obstructive sleep apnea presents to your office for routine screening.

Context: He reports compliance with his medications but admits to difficulty maintaining the diet and exercise routines discussed during his last visit.

Context: He does not have any other complaints.

Context: He drinks 3-4 beers on the weekends and does not smoke cigarettes.

Context: His current medications include metformin, atorvastatin, and hydrochlorothiazide.

Context: On physical examination, his temperature is 99°F (37.2°C), blood pressure is 130/85 mmHg, pulse is 85/min, and respirations are 18/min.

Context: Laboratory results are shown below: |  | Serum: | Na+: 138 mEq/L | Cl-: 100 mEq/L | K+: 3.9 mEq/L | HCO3-: 23 mEq/L | BUN: 13 mg/dL | Glucose: 160 mg/dL |  | You decide to start the patient on a medication that triggers insulin release.

Choices:
A. Close potassium channels
B. Increase insulin sensitivity
C. Delay gastric emptying
D. Increase ATP generation

Answer: Close potassium channels

2. Patient has a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and obstructive sleep apnea.

3. Patient reports compliance with medications.

4. Patient has difficulty maintaining diet and exercise routines.

5. Patient does not have any other complaints.

6. Patient drinks 3-4 beers on the weekends.

8. Patient's current medications include metformin, atorvastatin, and hydrochlorothiazide.

9. Patient's temperature is 99°F (37.2°C).

10. Patient's blood pressure is 130/85 mmHg.

19. Patient is to be started on a medication that triggers insulin release.

1. Patient reports compliance with medications

2. Patient admits difficulty maintaining diet and exercise routines

3. Patient does not have any other complaints

6. Patient's current medications: metformin, atorvastatin, hydrochlorothiazide

7. Physical examination: temperature 99°F, blood pressure 130/85 mmHg, pulse 85/min, respirations 18/min

8. Laboratory results: Na+ 138 mEq/L, Cl- 100 mEq/L, K+ 3.9 mEq/L, HCO3- 23 mEq/L, BUN 13 mg/dL, Glucose 160 mg/dL

9. Decision to start patient on a medication that triggers insulin release


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

Context: A 28-year-old woman presents to the emergency department with fever and abdominal pain for the past several days.

Context: She says she feels like she has a slight fever.

Context: She denies nausea or vomiting.

Context: Physical examination shows pain in the right upper quadrant to deep palpation with rebound tenderness and guarding.

Context: A laparoscopy is performed which shows string-like, fibrous scar tissue in the perihepatic recesses.

Choices:
A. Giardia lamblia
B. Gardnerella vaginalis
C. Trichomonas vaginalis
D. Neisseria gonorrhoeae

Answer: Neisseria gonorrhoeae

General Infectious Disease
Infectious Disease

1. A 28-year-old woman presents to the emergency department.

2. She has had fever and abdominal pain for several days.

3. She feels like she has a slight fever.

5. Physical examination shows pain in the right upper quadrant to deep palpation.

6. Physical examination also shows rebound tenderness and guarding.

8. The laparoscopy shows string-like, fibrous scar tissue in the perihepatic recesses.

1. The patient feels like she has a slight fever.

2. The patient denies nausea or vomiting.

3. Physical examination shows pain in the right upper quadrant to deep palpation.

4. Physical examination shows rebound tenderness and guarding.

5. Laparoscopy reveals string-like, fibrous scar tissue in the perihepatic recesses.


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

Context: A 30-year-old woman comes to the emergency department because of a 1-day history of sharp chest pain radiating to the left shoulder.

Context: Examination shows a symmetric, erythematous rash on her nose and cheeks, and erythematous patches with scaling and plugged follicles over her hands.

Choices:
A. Increased distension of jugular veins during inspiration
B. 18 mm Hg decrease in systolic blood pressure during inspiration
C. Triphasic scratchy heart sound of varying intensity
D. Holosystolic blowing murmur heard best at the apex

Answer: Triphasic scratchy heart sound of varying intensity

1. A 30-year-old woman comes to the emergency department.

2. She has a 1-day history of sharp chest pain radiating to the left shoulder.

3. The pain worsens when she coughs, breathes deeply, or lies down.

4. She has had a mild fever and a cough for the past 2 days.

5. She takes ibuprofen for hip and knee pain, which started 4 months ago.

6. Examination shows a symmetric, erythematous rash on her nose and cheeks.

7. Examination shows erythematous patches with scaling and plugged follicles over her hands.

1. The pain worsens when she coughs, breathes deeply, or lies down.

2. She has had a mild fever and a cough for the past 2 days.

3. She takes ibuprofen for hip and knee pain, which started 4 months ago.

4. Examination shows a symmetric, erythematous rash on her nose and cheeks.

5. Examination shows erythematous patches with scaling and plugged follicles over her hands.


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

Context: A 22-year-old man comes to the physician because he has been increasingly worried and stressed in recent weeks.

Context: He started a marketing job three months ago, which involves traveling between Washington and California several times a year.

Context: Two months ago, he was supposed to fly to Seattle, but he experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane, causing him great embarrassment.

Context: He had never been on a plane before; his parents died in a plane crash when he was younger.

Context: He worries that he will lose his job.

Context: He takes no medications.

Context: His temperature is 37.2°C (99°F), pulse is 85/min, respirations are 12/min, and blood pressure is 130/80 mm Hg.

Context: His speech is normal and his thought process is organized.

Choices:
A. Oral paroxetine
B. Oral alprazolam
C. Observation
D. Cognitive behavioral therapy

Answer: Cognitive behavioral therapy

2. Patient has been increasingly worried and stressed in recent weeks.

3. Patient started a marketing job three months ago.

4. Job involves traveling between Washington and California several times a year.

5. Two months ago, patient experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane.

6. Patient had never been on a plane before.

7. Patient's parents died in a plane crash when he was younger.

8. A week ago, patient called in sick when he was supposed to go on a business trip.

9. Patient worries that he will lose his job.

10. Patient is otherwise well and has no history of serious illness.

12. Patient's temperature is 37.2°C (99°F).

15. Patient's blood pressure is 130/80 mm Hg.

16. Physical examination shows no abnormalities.

17. On mental status examination, patient is alert and cooperative.

19. Patient's thought process is organized.

20. Patient's memory, attention, and concentration are intact.

1. He started a marketing job three months ago.

2. The job involves traveling between Washington and California several times a year.

3. Two months ago, he was supposed to fly to Seattle.

4. He experienced nausea, palpitations, sweating, and shortness of breath and was unable to board the plane.

7. His parents died in a plane crash when he was younger.

8. A week ago, he called in sick when he was supposed to go on a business trip.

9. He worries that he will lose his job.

10. He is otherwise well and has no history of serious illness.

17. On mental status examination, he is alert and cooperative.

20. His memory, attention, and concentration are intact.


Question: What is the appropriate medication for this patient’s condition?

Context: A 52-year-old man presents to the office complaining of a 2-week history of fatigue, progressively worsening shortness of breath, and swelling of his lower legs and feet.

Context: The patient denies tobacco use although he does admit to drinking 8-10 beers, daily, for the past 10 years.

Context: He takes a low dose of aspirin daily, ever since he had an anterior myocardial infarction 2 years ago.

Context: The patient works as a financial consultant and frequently travels for work.

Context: The current temperature is 36.8°C (98.3°F), the pulse rate is 68/min, the blood pressure is 152/84 mm Hg, and the respiratory rate is 16/min.

Context: His weight is 102 kg (224 lb) and height 180 cm (5 ft 9 in).

Choices:
A. Nifedipine
B. Procainamide
C. Ibuprofen
D. Spironolactone

Answer: Spironolactone

General Internal Medicine
Cardiovascular Disease
Cardiology

2. Patient has a 2-week history of fatigue, progressively worsening shortness of breath, and swelling of his lower legs and feet.

3. Patient's past medical history is only significant for slightly elevated blood pressure.

5. Patient admits to drinking 8-10 beers daily for the past 10 years.

6. Patient takes a low dose of aspirin daily since he had an anterior myocardial infarction 2 years ago.

7. Patient works as a financial consultant and frequently travels for work.

8. Current temperature is 36.8°C (98.3°F).

14. Echocardiography demonstrates an ejection fraction of 35% and a thin left ventricular wall.

1. His past medical history is only significant for slightly elevated blood pressure.

3. He admits to drinking 8-10 beers daily for the past 10 years.

4. He takes a low dose of aspirin daily.

5. He had an anterior myocardial infarction 2 years ago.

6. The patient works as a financial consultant.

8. The current temperature is 36.8°C (98.3°F).

14. Echocardiography demonstrates an ejection fraction of 35%.

15. Echocardiography demonstrates a thin left ventricular wall.


Question: Which of the following medications was most likely used to treat this patient's symptoms?

Choices:
A. Oxybutynin
B. Dutasteride
C. Terazosin
D. Tadalafil

Answer: Dutasteride

1. A 70-year-old man comes to the physician for a follow-up evaluation.

2. Eight months ago, he presented with a 6-month history of increased urinary frequency, difficulty to initiate urination, and straining to maintain the urinary stream.

3. Digital rectal examination showed symmetrically enlarged, nontender prostate with rubbery texture.

4. Laboratory studies showed a prostate-specific antigen (PSA) level of 2 ng/mL.

5. Abdominal ultrasound showed a post-void residual urine volume of 250 ml and bladder wall thickening.

6. The patient received appropriate treatment.

7. His vital signs are within normal limits.

8. Laboratory studies now show a PSA level of 1 ng/mL.

1. Eight months ago, he presented with a 6-month history of increased urinary frequency, difficulty to initiate urination, and straining to maintain the urinary stream.

2. Digital rectal examination showed symmetrically enlarged, nontender prostate with rubbery texture.

3. Laboratory studies showed a prostate-specific antigen (PSA) level of 2 ng/mL.

4. Abdominal ultrasound showed a post-void residual urine volume of 250 ml and bladder wall thickening.

5. The patient received appropriate treatment.

6. His vital signs are within normal limits.

7. Laboratory studies now show a PSA level of 1 ng/mL.


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

Context: The patient also admits that he has had numerous loose, foul-smelling stools over the last few weeks with associated nausea.

Context: His blood pressure is 132/76 mm Hg, respiratory rate is 14/min, and heart rate is 75/min.

Choices:
A. H. pylori infection
B. Intestinal type gastric adenocarcinoma
C. NSAID induced peptic ulcer disease
D. Zollinger-Ellison syndrome

Answer: Zollinger-Ellison syndrome

1. A 53-year-old man presents to the office complaining of persistent abdominal pain.

2. He states that he has gained 4.5 kg (10.0 lb) because the pain is only relieved by eating.

3. The patient has had numerous loose, foul-smelling stools over the last few weeks with associated nausea.

4. He has taken some over the counter antacids without relief or change in symptoms.

8. Physical examination reveals mild tenderness to palpation of the upper abdomen.

1. The patient has gained 4.5 kg (10.0 lb) due to pain relief from eating.

2. The patient has experienced numerous loose, foul-smelling stools over the last few weeks with associated nausea.

3. The patient has taken over the counter antacids without relief or change in symptoms.

4. The patient's blood pressure is 132/76 mm Hg.

5. The patient's respiratory rate is 14/min.

7. Physical examination reveals mild tenderness to palpation of the upper abdomen.


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

Context: A 68-year-old man with advanced dementia is brought to the preoperative unit prior to an elective cholecystectomy for biliary colic.

Context: He begins yelling at unit staff and requests to leave.

Context: His designated medical power of attorney, who had previously signed the surgery consent forms, is present.

Choices:
A. Cancel the surgery and allow the patient to leave
B. Ask the patient about his concerns and try to address them
C. Call family members and schedule a family meeting
D. Perform cognitive screening evaluation

Answer: Ask the patient about his concerns and try to address them

Geriatric Medicine
Geriatrics
Anesthesiology
Internal Medicine

Geriatric Medicine
General Geriatric Medicine
General Geriatrics

1. A 68-year-old man has advanced dementia.

2. He was brought to the preoperative unit prior to an elective cholecystectomy for biliary colic.

3. He says he does not want the surgery anymore.

6. His designated medical power of attorney is present.

7. The medical power of attorney had previously signed the surgery consent forms.

1. He does not want the surgery anymore.

4. His designated medical power of attorney is present.

5. The medical power of attorney had previously signed the surgery consent forms.


Question: Which of the following pathogens should be considered before initiating treatment for the current episode?

Context: A 67-year-old man presents to his physician’s office with a progressive cough.

Context: It has been increasing in intensity over the past week.

Context: He has also been noticing an increase in the amount of sputum he usually produces, which is thick and yellow.

Context: He also complains of increased difficulty in breathing, more so than he previously experienced.

Context: He was diagnosed with chronic obstructive lung disease (COPD) about 3 years ago and has been on treatment for it since then.

Context: He doesn’t report any fever, chills, or night sweats.

Context: He has observed a foul smell to his sputum.

Context: His blood pressure is 100/65 mm Hg, the respirations are 23/min and the pulse is about 110/min.

Context: Currently, his FEV1 is around 48% of the normal predicted value.

Context: He is currently receiving a yearly influenza shot and has taken the pneumococcal vaccination at the time of his diagnosis.

Context: In spite of this, he has had acute exacerbations of his symptoms 4 times over the last year.

Context: His last episode was 2 months ago, for which he was treated with a short course of antibiotics.

Context: He is also currently receiving treatment for diabetes.

Choices:
A. S. pneumonia
B. H. influenzae
C. P. aeruginosa
D. Syncytial virus

Answer: P. aeruginosa

Pulmonary Disease
General Pulmonary Disease

2. Patient has a progressive cough for the past week.

3. Patient has increased sputum production, which is thick and yellow.

4. Patient has increased difficulty in breathing.

5. Patient was diagnosed with COPD 3 years ago and has been on treatment since then.

6. Patient does not report fever, chills, or night sweats.

8. Patient's blood pressure is 100/65 mm Hg.

11. Patient's FEV1 is 48% of the normal predicted value.

12. Patient receives a yearly influenza shot.

13. Patient has taken the pneumococcal vaccination at the time of diagnosis.

14. Patient has had 4 acute exacerbations of symptoms in the last year.

15. Patient's last episode was 2 months ago and was treated with a short course of antibiotics.

16. Patient is currently receiving treatment for diabetes.

1. The patient's symptoms have been increasing in intensity over the past week.

2. The patient has noticed an increase in the amount of sputum he usually produces, which is thick and yellow.

3. The patient complains of increased difficulty in breathing, more so than he previously experienced.

4. The patient was diagnosed with chronic obstructive lung disease (COPD) about 3 years ago and has been on treatment for it since then.

5. The patient doesn’t report any fever, chills, or night sweats.

6. The patient has observed a foul smell to his sputum.

7. The patient's blood pressure is 100/65 mm Hg, the respirations are 23/min, and the pulse is about 110/min.

8. Currently, the patient's FEV1 is around 48% of the normal predicted value.

9. The patient is currently receiving a yearly influenza shot and has taken the pneumococcal vaccination at the time of his diagnosis.

10. The patient has had acute exacerbations of his symptoms 4 times over the last year.

11. The patient's last episode was 2 months ago, for which he was treated with a short course of antibiotics.

12. The patient is also currently receiving treatment for diabetes.


Question: Which of the following structures is involved in the development of an epidural hematoma?

Context: A 27-year-old man who was involved in a motor vehicle collision is brought into the emergency room with a fractured skull.

Context: The paramedics report that the patient was conscious and lucid on the way to the hospital but now is unresponsive.

Context: His vitals are a blood pressure of 122/78 mm Hg, temperature of 37.0°C (98.6°F), pulse rate of 88/min, and respiratory rate of 14/min.

Choices:
A. Middle meningeal artery
B. Bridging cortical veins
C. Arteriovenous malformation
D. Lenticulostriate vessels

Answer: Middle meningeal artery

1. A 27-year-old man was involved in a motor vehicle collision.

2. The patient was conscious and lucid on the way to the hospital.

4. The patient's blood pressure is 122/78 mm Hg.

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

7. The patient's respiratory rate is 14/min.

8. A noncontrast CT scan of the head shows an epidural hematoma.

1. The paramedics reported the patient was conscious and lucid on the way to the hospital.

3. The patient's blood pressure is 122/78 mm Hg.

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

6. The patient's respiratory rate is 14/min.

7. A noncontrast CT scan of the head shows an epidural hematoma.


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

Context: A 54-year-old woman presents to the emergency department due to recent onset of a high fever, accompanied by severe headache and neck stiffness.

Context: She is currently on immunosuppressants after a kidney transplant performed 6 months ago.

Context: On presentation, her temperature is 102.2°F (39°C), blood pressure is 112/71 mmHg, pulse is 107/min, and respirations are 22/min.

Choices:
A. Anaerobic spore forming rods
B. Catalase-negative
C. Coagulase-positive
D. Tumbling motility in broth

Answer: Tumbling motility in broth

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

2. She has a high fever, severe headache, and neck stiffness.

3. Her past medical history is significant for rapidly progressive glomerulonephritis.

4. She is currently on immunosuppressants after a kidney transplant 6 months ago.

9. Physical exam reveals severe pain with neck flexion and reciprocal knee flexion.

10. Laboratory tests reveal a gram-positive organism with endotoxin.

1. Past medical history includes rapidly progressive glomerulonephritis.

2. Currently on immunosuppressants after a kidney transplant performed 6 months ago.

3. On presentation, temperature is 102.2°F (39°C).

4. On presentation, blood pressure is 112/71 mmHg.

6. On presentation, respirations are 22/min.

7. Physical exam reveals severe pain with neck flexion and reciprocal knee flexion.

8. Laboratory tests reveal a gram-positive organism with endotoxin.


Question: Which of the following antibiotics is recommended for this patient?

Context: A 2-year-old boy is brought to see the pediatrician by his mother due to a “bad” cough.

Context: He has no known allergies.

Context: His temperature is 38.5°C (100.5°F), pulse is 120/min, respirations are 33/min, blood pressure is 101/54 mm Hg, and oxygen saturation is 96% on room air.

Context: He has scattered petechiae on his face.

Choices:
A. Ceftriaxone
B. Cefotaxime
C. Erythromycin
D. Ampicillin

Answer: Erythromycin

1. A 2-year-old boy is brought to see the pediatrician by his mother.

2. The mother reports that he has been coughing so hard that he threw up on several occasions.

3. He is adopted and the mother does not know his vaccination history.

9. His oxygen saturation is 96% on room air.

10. The boy looks unwell with mild difficulty breathing.

11. He has a nonproductive cough multiple times followed by a “whoop” sound during the inhalation.

12. He has scattered petechiae on his face.

13. A nasopharyngeal swab is sent for culture and PCR.

1. The mother reports that he has been coughing so hard that he threw up on several occasions.

2. He is adopted and the mother does not know his vaccination history.

8. His oxygen saturation is 96% on room air.

9. The boy looks unwell with mild difficulty breathing and a nonproductive cough multiple times followed by a “whoop” sound during the inhalation.

10. He has scattered petechiae on his face.

11. A nasopharyngeal swab is sent for culture and PCR.


Question: What is the mechanism by which this organism causes diarrhea?

Context: A 19-year-old man returns from travel in South America.

Context: You suspect the causative organism to be Enterotoxigenic E.coli.

Choices:
A. Blocks the release of inhibitory neurotransmitters GABA and glycine
B. Blocks the presynaptic release of acetylcholine at the neuromuscular junction
C. Stimulates release of cytokines
D. Stimulates adenylate cyclase (increasing cAMP)

Answer: Stimulates adenylate cyclase (increasing cAMP)

1. A 19-year-old man returns from travel.

2. He presents complaining of profuse, watery diarrhea.

3. You suspect the causative organism to be Enterotoxigenic E. coli.

1. Patient presents with profuse, watery diarrhea.

2. Suspected causative organism is Enterotoxigenic E.coli.


Question: What histopathological findings would you expect to find in this patient?

Context: A 38-year-old man presents to the clinic for complaints of abdominal pain and diarrhea.

Context: He reports a long-standing history of the symptoms except for the time when he attempted a carbohydrate-free diet 5 years ago.

Context: The pain is described as stabbing, diffuse, 8/10, and is especially worse following food intake.

Context: Recently, he noticed some numbness and tingling of his feet but denies any bloody stool, nausea, vomiting, fevers, weight loss, or focal neurological deficits.

Choices:
A. Blunting of the intestinal villi at the ileum
B. Crypt abscesses at the descending colon
C. Noncaseating granulomas at the ileum
D. Normal gastric mucosa at the jejunum

Answer: Blunting of the intestinal villi at the ileum

1. A 38-year-old man presents to the clinic.

3. He has had these symptoms for a long time.

4. Five years ago, he attempted a carbohydrate-free diet.

5. The pain is described as stabbing, diffuse, 8/10.

6. The pain is worse following food intake.

7. He has noticed some numbness and tingling of his feet.

13. He denies any focal neurological deficits.

1. Patient reports long-standing history of symptoms

2. Symptoms improved when attempted carbohydrate-free diet 5 years ago

5. Patient noticed numbness and tingling in feet


Question: What is the histopathology of the most common large-artery complication of this disease?

Context: He has never been seen by a physician and reports that he has been in good health.

Context: You note a very tall, very thin male whose arm span is greater than his height.

Context: The patient reports that his father had a similar build but passed away suddenly in his 40s.

Choices:
A. Focal granulomatous inflammation with mural lymphocytes, macrophages, giant cells
B. Predominant neutrophilic infiltration with fibrinoid necrosis
C. Fibrinoid necrosis of blood vessel walls, endothelial swelling, and neutrophilic infiltrate in skin lesions
D. Cystic medial degeneration

Answer: Cystic medial degeneration

1. A 25-year-old male presents for a new primary-care visit.

2. He has never been seen by a physician.

3. He reports that he has been in good health.

4. The patient is very tall and very thin.

5. His arm span is greater than his height.

6. The patient's father had a similar build.

7. The patient's father passed away suddenly in his 40s.

8. You suspect a genetic disorder characterized by a defect in fibrillin-1.

1. The patient has never been seen by a physician.

2. The patient reports being in good health.

3. The patient is very tall and very thin.

4. The patient's arm span is greater than his height.

5. The patient's father had a similar build.

6. The patient's father passed away suddenly in his 40s.

7. The medical assistant suspects a genetic disorder.

8. The genetic disorder is characterized by a defect in fibrillin-1.


Question: Assuming the investigators intend to keep the level of significance at 5%, which of the following changes would be most effective to increase the statistical power?

Context: They conducted a pilot study in which 15 participants were randomized to receive intranasal ketamine while 15 participants were randomized to receive placebo.

Context: The investigators ultimately found no statistically significant difference in suicidality after 30 days of follow up with the level of significance fixed at 5%.

Choices:
A. Decrease the sample size
B. Decrease the type II error rate
C. Increase beta
D. Increase the type I error rate

Answer: Decrease the type II error rate

1. A group of investigators is evaluating the efficacy of intranasal ketamine in decreasing acute suicidality in teenagers admitted to inpatient psychiatric units.

2. They conducted a pilot study in which 15 participants were randomized to receive intranasal ketamine.

3. 15 participants were randomized to receive placebo.

4. The investigators ultimately found no statistically significant difference in suicidality after 30 days of follow up.

5. The level of significance was fixed at 5%.

6. They suspect inadequate statistical power.

2. 15 participants received intranasal ketamine.

4. No statistically significant difference in suicidality was found after 30 days of follow-up.

6. The investigators suspect inadequate statistical power.


Question: Which of the following etiologies is the most likely cause of this patient’s neurologic findings?

Context: A 56-year-old man presents with severe back pain for the past hour.

Context: He says the pain started about 1 hour ago and has not improved.

Context: The patient describes the pain as sharp, 10/10, and located between his scapula.

Context: Past medical history is significant for hypertension, which he is noncompliant with medication.

Context: His vital signs are a blood pressure of 180/95 mm Hg and a pulse of 108/min.

Choices:
A. Brown-Séquard syndrome
B. Spinal cord compression
C. Anterior cord syndrome
D. Spinal epidural hematoma

Answer: Anterior cord syndrome

General Neurological Surgery
Spinal Cord Compression

2. Patient has severe back pain for the past hour.

3. Patient says pain started 1 hour ago and has not improved.

4. Patient describes pain as sharp, 10/10, and located between scapula.

5. Patient has past medical history of hypertension.

6. Patient is noncompliant with medication.

7. Patient's blood pressure is 180/95 mm Hg.

9. Patient has loss of pain and temperature sensation in lower trunk and extremities bilaterally.

10. Patient has strength of 4 out of 5 in all muscle groups in lower extremities bilaterally.

11. Contrast CT of chest reveals findings consistent with type B aortic dissection.

1. The patient reports that the pain started about 1 hour ago and has not improved.

2. The patient describes the pain as sharp and rates it as 10/10.

3. The pain is located between the patient's scapula.

4. The patient has a past medical history significant for hypertension.

5. The patient is noncompliant with medication for hypertension.

6. The patient's blood pressure is 180/95 mm Hg.

8. On physical examination, there is a loss of pain and temperature sensation in the lower trunk and extremities bilaterally.

9. Strength is 4 out of 5 in all muscle groups in the lower extremities bilaterally.

10. A contrast CT of the chest reveals findings consistent with a type B aortic dissection.


Question: This patient's condition is most likely caused by a defect in a gene encoding a protein that is normally involved in which of the following processes?

Context: A 7-year-old girl is brought to the physician by her mother because of a 6-month history of worsening fatigue and frequent upper respiratory tract infections.

Context: She is at the 2nd percentile for height and 10th percentile for weight.

Context: Physical examination shows pallor, diffuse hyperpigmented macules, absence of the radial bones, and hypoplastic thumbs.

Context: Her hemoglobin concentration of 8.7 g/dL, leukocyte count is 2,500/mm3, and platelet count is 30,000/mm3.

Choices:
A. Hydrolysis of glucocerebroside
B. DNA interstrand crosslink repair
C. Maturation of erythroid progenitor cells
D. Ras signal transduction pathway

Answer: DNA interstrand crosslink repair

1. A 7-year-old girl is brought to the physician by her mother.

2. She has a 6-month history of worsening fatigue and frequent upper respiratory tract infections.

3. She is at the 2nd percentile for height.

4. She is at the 10th percentile for weight.

6. Physical examination shows diffuse hyperpigmented macules.

7. Physical examination shows absence of the radial bones.

8. Physical examination shows hypoplastic thumbs.

9. Her hemoglobin concentration is 8.7 g/dL.

1. She is at the 2nd percentile for height.

2. She is at the 10th percentile for weight.

4. Physical examination shows diffuse hyperpigmented macules.

5. Physical examination shows absence of the radial bones.

6. Physical examination shows hypoplastic thumbs.

7. Her hemoglobin concentration is 8.7 g/dL.


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

Context: She has a history of acral vitiligo.

Context: Her blood pressure is 90/60 mm Hg, temperature is 35.9°C (96.6°F), and pulse is 90/min.

Context: On physical examination, she is obtunded, skin turgor is reduced, and her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks.

Context: Lab results are shown: | Random plasma glucose 40 mg/dL | Serum osmolarity 275 mOsm/kg H₂O | Serum sodium 130 mEq/L | Serum potassium 6 mEq/L | Urine sodium level 30 mEq/L | ECG shows normal sinus rhythm without ST-T wave changes.

Context: Dextrose 5% is given and random plasma glucose becomes 60 mg/dL, but her blood pressure is still the same.

Choices:
A. Intravenous calcium gluconate
B. ACTH stimulation test
C. Oral dehydroepiandrosterone (DHEA)
D. Normal saline and intravenous dexamethasone

Answer: Normal saline and intravenous dexamethasone

1. A 36-year-old woman is brought to the emergency department because of loss of consciousness.

2. Her husband says that she complained of vomiting and dizziness for 2 days, but did not seek medical care.

7. On physical examination, she is obtunded.

9. Her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks.

11. Serum osmolarity is 275 mOsm/kg H₂O.

15. ECG shows normal sinus rhythm without ST-T wave changes.

17. Random plasma glucose becomes 60 mg/dL.

18. Her blood pressure is still the same.

1. Her husband says she complained of vomiting and dizziness for 2 days but did not seek medical care.

6. On physical examination, she is obtunded.

8. Her oral mucosa is dry with hyperpigmented spots on the inner side of both cheeks.

9. Lab results: Random plasma glucose 40 mg/dL.

10. Lab results: Serum osmolarity 275 mOsm/kg H₂O.

11. Lab results: Serum sodium 130 mEq/L.

12. Lab results: Serum potassium 6 mEq/L.

13. Lab results: Urine sodium level 30 mEq/L.

14. ECG shows normal sinus rhythm without ST-T wave changes.

15. Dextrose 5% is given and random plasma glucose becomes 60 mg/dL.

16. Her blood pressure is still the same.


Question: What is the most likely diagnosis?

Context: Now, she is unable to feed herself and has recently started to point to objects she wants rather than asking.

Context: Vital signs are normal.

Context: The patient's mother reports that her 7-year-old son is doing well, and that they have no family history of mental retardation or other cognitive disorders.

Choices:
A. Angelman syndrome
B. Rett syndrome
C. Prader-Willi syndrome
D. McCune-Albright syndrome

Answer: Rett syndrome

1. A 4-year-old girl is seen by her pediatrician for developmental delay.

2. One year prior, the patient was able to ride a tricycle.

3. One year prior, the patient was able to stack 3 blocks.

4. One year prior, the patient was able to speak in short sentences.

6. Now, she has recently started to point to objects she wants rather than asking.

7. Physical exam reveals a well nourished child sitting in a stroller wringing her hands.

9. The patient's mother reports that her 7-year-old son is doing well.

10. The patient's mother reports that they have no family history of mental retardation.

11. The patient's mother reports that they have no family history of other cognitive disorders.

1. One year prior, the patient was able to ride a tricycle, stack 3 blocks, and speak in short sentences.

3. She has recently started to point to objects she wants rather than asking.

4. Physical exam reveals a well nourished child sitting in a stroller wringing her hands.

6. The patient's mother reports that her 7-year-old son is doing well.

7. They have no family history of mental retardation or other cognitive disorders.


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

Context: A 49-year-old woman visits the emergency department with the acute onset of severe shortness of breath.

Context: She also reports right-sided calf pain that developed after a 22-hour flight from Beijing to Los Angeles, and that, several hours after she felt pain in her calf, she began to have trouble breathing.

Context: Currently, her shortness of breath is so severe that she is unable to speak clearly or quickly, but she manages to deny any recent surgery or history of recent bleeding.

Context: The vital signs include: blood pressure 111/69 mm Hg, pulse 142/min, and respiratory rate 33/min.

Context: On observation, she is using accessory muscles to breathe.

Context: On auscultation, her lungs are clear and her heart rate is rapid but regular.

Context: Her right calf is swollen, warm, and tender.

Context: The arterial blood gas test result reveals a pH of 7.5, partial pressure of carbon dioxide (PCO2) 22 mm Hg, and a partial pressure of oxygen (PaO2) 47 mm Hg on 6 L of oxygen by nasal cannula.

Choices:
A. Unfractionated heparin
B. Streptokinase
C. Low molecular-weight heparin
D. Embolectomy

Answer: Streptokinase

2. Patient has acute onset of severe shortness of breath.

3. Patient has right-sided calf pain that developed after a 22-hour flight from Beijing to Los Angeles.

4. Patient felt pain in her calf several hours before having trouble breathing.

5. Patient denies any recent surgery or history of recent bleeding.

6. Patient's blood pressure is 111/69 mm Hg.

8. Patient's respiratory rate is 33/min.

9. Patient is using accessory muscles to breathe.

10. Patient's lungs are clear on auscultation.

11. Patient's heart rate is rapid but regular.

12. Patient's right calf is swollen, warm, and tender.

13. Arterial blood gas test result reveals a pH of 7.5.

14. Arterial blood gas test result reveals a PCO2 of 22 mm Hg.

15. Arterial blood gas test result reveals a PaO2 of 47 mm Hg on 6 L of oxygen by nasal cannula.

1. Patient reports right-sided calf pain after a 22-hour flight from Beijing to Los Angeles.

2. Patient developed trouble breathing several hours after feeling pain in her calf.

3. Patient's shortness of breath is severe, making it difficult for her to speak clearly or quickly.

4. Patient denies any recent surgery or history of recent bleeding.

5. Vital signs: blood pressure 111/69 mm Hg, pulse 142/min, respiratory rate 33/min.

6. Patient is using accessory muscles to breathe.

7. On auscultation, lungs are clear and heart rate is rapid but regular.

8. Patient's right calf is swollen, warm, and tender.

9. Arterial blood gas test result: pH 7.5, PCO2 22 mm Hg, PaO2 47 mm Hg on 6 L of oxygen by nasal cannula.


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

Context: A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor.

Context: She has had no prenatal care.

Context: The patient appears in acute distress.

Context: Her pulse is 98/min, respirations are 15/min, and blood pressure is 130/80 mm Hg.

Context: The abdomen is nontender and contractions are felt.

Choices:
A. Uterine rupture
B. Placenta previa
C. Placenta accreta
D.
Abruptio placentae
"

Answer: Placenta accreta

General Obstetrics and Gynecology
Placenta accreta
Placenta previa

1. A 37-year-old woman is admitted to the hospital in active labor.

6. Her three children were delivered by lower segment transverse cesarean section.

7. The patient appears in acute distress.

13. The fetus is in a cephalic presentation.

14. The fetal heart rate is reactive with no decelerations.

15. One hour following vaginal delivery, the placenta is not delivered.

16. Manual separation of the placenta leads to profuse vaginal bleeding.

17. A firm, nontender uterine fundus is palpated at the level of the umbilicus.

2. Her three children were delivered by lower segment transverse cesarean section.

3. The patient appears in acute distress.

9. The fetus is in a cephalic presentation.

10. The fetal heart rate is reactive with no decelerations.

11. One hour following vaginal delivery, the placenta is not delivered.

12. Manual separation of the placenta leads to profuse vaginal bleeding.

13. A firm, nontender uterine fundus is palpated at the level of the umbilicus.


Question: An MRI of the brain will reveal an atrophy of which of the following structure?

Context: A 40-year-old man is brought to the clinic by his wife with a complaint of behavioral changes for the past few months.

Choices:
A. Caudate nucleus
B. Cerebellum
C. Diffuse cortex
D. Frontal and temporal lobes

Answer: Caudate nucleus

Neurology with Special Qualification in Child Neurology

1. A 40-year-old man is brought to the clinic by his wife.

2. He has been exhibiting behavioral changes for the past few months.

3. He is irritable and gets angry with trivial matters.

4. He sometimes screams in the middle of the night and remains restless.

5. His wife has recently noticed that he is forgetting things and repeats the same question multiple times.

6. For the past few weeks, he is also having abnormal movements of his body, more prominent in the arms and hands.

7. His past medical history is unremarkable.

8. His father died at the age of 28 years old in a road traffic accident.

9. His grandmother had similar symptoms after her retirement.

10. He does not smoke, drink alcohol, or use illicit drugs.

11. The physical examination reveals a restless ill-groomed man.

12. He is having intermittent involuntary dance-like movements.

13. The slit-lamp ophthalmic examination is normal.

14. His mini-mental state examination (MMSE) score is 22/30.

15. The complete blood count, basic metabolic profile, thyroid profile, liver profile, serum vitamin B12, and ceruloplasmin levels are within normal range.

1. He is irritable and gets angry with trivial matters.

2. He sometimes screams in the middle of the night and remains restless.

3. His wife has recently noticed that he is forgetting things and repeats the same question multiple times.

4. For the past few weeks, he is also having abnormal movements of his body, more prominent in the arms and hands.

5. The past medical history is unremarkable.

6. His father died at the age of 28 years old in a road traffic accident.

7. His grandmother had similar symptoms after her retirement.

8. He does not smoke, drinks alcohol, or uses illicit drugs.

9. The physical examination reveals a restless ill-groomed man.

10. He is having intermittent involuntary dance-like movements.

11. The slit-lamp ophthalmic examination is normal.

12. His mini-mental state examination (MMSE) score is 22/30.

13. The complete blood count, basic metabolic profile, thyroid profile, liver profile, serum vitamin B12, and ceruloplasmin levels are within normal range.


Question: Which of the following statements best describes the study?

Context: The mean hemoglobin level for the normal weight group is 13.4 g/dL and 13.8 g/dL for the overweight group.

Choices:
A. If the null hypothesis is not true, 10% or more of the volunteers would not show any association between hemoglobin level and weight.
B. If the null hypothesis is not true, there is still a 10% probability to not get this difference of 0.4 g/dL or higher due to chance.
C. If the null hypothesis is true, there is still a 10% probability of not getting this difference of 0.4 g/dL or higher due to chance.
D. If the null hypothesis is true, there is a 10% probability to get this difference of 0.4 g/dL or higher due to chance.

Answer: If the null hypothesis is true, there is a 10% probability to get this difference of 0.4 g/dL or higher due to chance.

1. A researcher is studying the association between hemoglobin levels and BMI.

2. He divides volunteers who wish to participate into 2 groups based on their BMI, a normal weight group and an overweight group.

3. He then measures the hemoglobin level of all of the volunteers.

4. His null hypothesis is that there is no association between hemoglobin levels and body weight.

5. The mean hemoglobin level for the normal weight group is 13.4 g/dL.

6. The mean hemoglobin level for the overweight group is 13.8 g/dL.

7. He obtains a mean difference of 0.4 g/dL between the 2 groups.

8. He does an unpaired t-test and gets a p-value of 0.10.

1. Volunteers are divided into 2 groups based on their BMI: normal weight and overweight.

2. Hemoglobin levels of all volunteers are measured.

3. The null hypothesis is that there is no association between hemoglobin levels and body weight.

4. The mean hemoglobin level for the normal weight group is 13.4 g/dL.

5. The mean hemoglobin level for the overweight group is 13.8 g/dL.

6. The mean difference in hemoglobin levels between the 2 groups is 0.4 g/dL.

8. The p-value obtained from the t-test is 0.10.


Question: Which of the following embryologic structures most likely gave rise to the structure that was damaged in this patient?

Context: A 51-year-old female with a history of papillary thyroid carcinoma who is two weeks status-post thyroidectomy presents to her surgeon complaining of difficulty with her voice.

Context: Her temperature is 99°F (37.2°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 16/min.

Choices:
A. First branchial arch
B. Second branchial arch
C. Fourth branchial arch
D. Sixth branchial arch

Answer: Sixth branchial arch

2. Patient has a history of papillary thyroid carcinoma.

3. Patient is two weeks status-post thyroidectomy.

4. Patient presents to her surgeon complaining of difficulty with her voice.

5. Patient developed immediate hoarseness and difficulty speaking following the operation.

6. Hoarseness has not improved since the operation.

7. Patient's past medical history is notable for hypertension and obesity.

8. Patient's temperature is 99°F (37.2°C).

9. Patient's blood pressure is 120/80 mmHg.

12. Physical examination reveals a healing surgical scar without evidence of infection or dehiscence.

1. Following the operation, she developed immediate hoarseness and difficulty speaking.

2. The hoarseness has not improved since the operation.

3. Her past medical history is notable for hypertension and obesity.

8. Physical examination reveals a healing surgical scar without evidence of infection or dehiscence.


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

Context: Six days after admission to the hospital for treatment of infective endocarditis, a 64-year-old woman develops persistent ringing in both ears, lightheadedness, and nausea.

Context: When she turns her head, she sees the light on the ceiling swinging from side to side.

Context: She has congestive heart disease, hypertension, and coronary artery disease.

Context: She was treated for a cerebrovascular accident 7 years ago and has no residual deficits.

Context: Current medications include intravenous vancomycin and gentamicin, as well as oral aspirin, atenolol, furosemide, and lisinopril.

Context: While the patient fixates on a target, administration of brisk, horizontal head rotations to both sides results in corrective saccades to refixate back to the target.

Context: She has an unsteady gait.

Context: Muscle strength and sensation are normal.

Choices:
A. Decreased endolymph resorption
B. Suppurative labyrinthitis
C. Medication toxicity
D. Delirium

Answer: Medication toxicity

2. Patient has been admitted to the hospital for 6 days for treatment of infective endocarditis.

3. Patient has persistent ringing in both ears, lightheadedness, and nausea.

4. When patient turns her head, she sees the light on the ceiling swinging from side to side.

5. Patient has congestive heart disease, hypertension, and coronary artery disease.

6. Patient was treated for a cerebrovascular accident 7 years ago and has no residual deficits.

7. Patient is currently taking intravenous vancomycin and gentamicin, as well as oral aspirin, atenolol, furosemide, and lisinopril.

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

9. Cardiac examination shows a grade 3/6 holosystolic murmur along the left lower sternal border.

10. When patient fixates on a target, administration of brisk, horizontal head rotations to both sides results in corrective saccades to refixate back to the target.

12. Patient's muscle strength and sensation are normal.

1. She sees the light on the ceiling swinging from side to side when she turns her head.

5. She was treated for a cerebrovascular accident 7 years ago.

6. She has no residual deficits from the cerebrovascular accident.

7. Her current medications include intravenous vancomycin.

8. Her current medications include intravenous gentamicin.

9. Her current medications include oral aspirin.

10. Her current medications include oral atenolol.

11. Her current medications include oral furosemide.

12. Her current medications include oral lisinopril.

13. Her vital signs are within normal limits.

14. Cardiac examination shows a grade 3/6 holosystolic murmur along the left lower sternal border.

15. Administration of brisk, horizontal head rotations to both sides results in corrective saccades while the patient fixates on a target.


Question: Which of the following cardiac conditions are the most likely long-term consequence of the patient’s clinical presentation and hospitalization?

Context: A patient with congestive heart failure with viral myocarditis due to coxsackievirus infection presents to a local hospital for treatment and then returns home.

Choices:
A. Concentric hypertrophy
B. Dilated cardiomyopathy
C. Endarteritis obliterans
D. Hypertrophic cardiomyopathy

Answer: Dilated cardiomyopathy

1. A patient presents to a local hospital.

2. The patient has congestive heart failure.

4. The cause of the viral myocarditis is coxsackievirus infection.

1. The patient has congestive heart failure.

3. The viral myocarditis is due to coxsackievirus infection.

4. The patient presents to a local hospital for treatment.

5. The patient returns home after treatment.


Question: This patient should be screened for abnormalities in which of the following organs?

Context: His mother has no complaints.

Choices:
A. Adrenal glands
B. Bone
C. Eyes
D. Kidneys

Answer: Kidneys

1. A 5-year-old male presents to the pediatrician with his mother for a well child visit.

3. The patient is doing well in preschool and appears to be ready for kindergarten.

4. He can begin to sound out letters and write out his first name.

5. He has many friends at school and enjoys playing with his older siblings.

6. The patient’s past medical history is notable for birth weight in the 99th percentile and unexplained hypoglycemia in the first week of life.

7. The patient’s mother denies any family history of genetic syndromes or malignancy.

8. The patient’s height and weight are in the 99th percentile.

9. On physical exam, the patient has an enlarged tongue with no other dysmorphic features.

10. He also has the physical exam findings seen in Figures A and B.

2. The patient is doing well in preschool and appears to be ready for kindergarten.

3. He can begin to sound out letters and write out his first name.

4. He has many friends at school and enjoys playing with his older siblings.

5. The patient’s past medical history is notable for birth weight in the 99th percentile and unexplained hypoglycemia in the first week of life.

6. The patient’s mother denies any family history of genetic syndromes or malignancy.

7. The patient’s height and weight are in the 99th percentile.

8. On physical exam, the patient has an enlarged tongue with no other dysmorphic features.

9. He also has the physical exam findings seen in Figures A and B.


Question: What type of tissue is causing the scar to form on my abdomen?" The physician promptly answers:

Context: A first-year medical student undergoes a surgical procedure involving a midline laporotomy incision.

Context: The patient presents back to the surgeon approximately 3 months later and asks the surgeon: ".

Choices:
A. Keratin
B. Type 1 collagen
C. Type 2 collagen
D. Type 4 collagen

Answer: Type 1 collagen

1. A first-year medical student underwent a surgical procedure.

2. The surgical procedure involved a midline laporotomy incision.

3. The patient presented back to the surgeon approximately 3 months later.

4. The patient asked the surgeon a question.

1. The patient presents back to the surgeon.

2. The patient presents approximately 3 months later.

3. The patient asks the surgeon a question.


Question: The patient’s lesion is likely composed of functional cells from which of the following regions:

Context: Her blood pressure is 180/140 mm Hg, and serum potassium is 3.2 mEq/L.

Context: Plasma renin levels are abnormally low.

Choices:
A. Zona glomerulosa
B. Zona fasciculata
C. Adrenal medulla
D. Posterior pituitary

Answer: Zona glomerulosa

1. A 40-year-old female complains of muscle weakness.

4. Her plasma renin levels are abnormally low.

5. A CT scan of her abdomen reveals a 3 cm lesion in her right adrenal gland.

3. Plasma renin levels are abnormally low.

4. A CT scan of her abdomen reveals a 3 cm lesion in her right adrenal gland.


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

Context: A 75-year-old woman is brought to the physician by her daughter because of a 1-month history of fatigue and a 3.5-kg (7-lb) weight loss.

Context: The thyroid gland is not palpable.

Choices:
A. Graves disease
B. Exogenous levothyroxine use
C. Granulomatous thyroiditis
D. Iodine exposure

Answer: Exogenous levothyroxine use

1. A 75-year-old woman is brought to the physician by her daughter.

2. She has a 1-month history of fatigue and a 3.5-kg (7-lb) weight loss.

3. She has a history of hypertension, hyperlipidemia, and Alzheimer's dementia.

4. She lives with her daughter and requires assistance with all of her banking and meal preparation.

6. There is no other history of serious illness in the family.

7. She does not remember the names of her medications but says she takes them every day.

8. Her pulse is 114/min and blood pressure is 148/101 mm Hg.

9. Physical examination shows warm skin and a tremor.

11. The serum thyroid stimulating hormone level is undetectable.

12. Histological examination of a thyroid biopsy shows follicular atrophy.

1. The patient has a history of hypertension, hyperlipidemia, and Alzheimer's dementia.

2. She lives with her daughter and requires assistance with all of her banking and meal preparation.

3. Her daughter has hypothyroidism but there is no other history of serious illness in the family.

4. She does not remember the names of her medications but says she takes them every day.

5. Her pulse is 114/min and blood pressure is 148/101 mm Hg.

6. Physical examination shows warm skin and a tremor.

8. The serum thyroid stimulating hormone level is undetectable.

9. Histological examination of a thyroid biopsy shows follicular atrophy.


Question: Which of the following types of shock best describes this patient's condition?

Context: A 42-year-old man is brought to the emergency department by EMS from the scene of an automobile accident, where he appeared to be an unrestrained passenger.

Context: His temperature is 98.6°F (37°C), pulse is 120/min, blood pressure is 75/44 mmHg, and respiratory rate is 22/min.

Context: He has marked jugular venous distention and bibasilar crackles on pulmonary auscultation with equal air entry bilaterally.

Context: The patient is admitted to the intensive care unit and hemodynamic monitoring is established, which reveals a pulmonary capillary wedge pressure (PCWP) of 22 mmHg (normal range 8-12 mmHg), central venous pressure (CVP) of 12 cmH2O (normal range 4-12 cmH2O), cardiac output (CO) of 2.2 L/min (normal range 4-8 L/min), and systemic vascular resistance (SVR) of 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5).

Choices:
A. Cardiogenic
B. Anaphylactic
C. Neurogenic
D. Obstructive

Answer: Cardiogenic

2. Patient was brought to the emergency department by EMS from the scene of an automobile accident.

3. Patient appeared to be an unrestrained passenger.

4. Patient is confused and unable to answer questions.

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

7. Patient's blood pressure is 75/44 mmHg.

8. Patient's respiratory rate is 22/min.

9. Patient has bruising over his sternum and left chest, with tenderness to palpation.

10. Cardiac auscultation reveals normal heart sounds with no murmurs, rubs, or gallops.

11. Patient has marked jugular venous distention.

12. Patient has bibasilar crackles on pulmonary auscultation with equal air entry bilaterally.

13. Abdominal and cranial nerve exams are within normal limits.

14. Patient's extremities are cool with prolonged capillary refill.

16. Patient is admitted to the intensive care unit.

17. Hemodynamic monitoring is established.

18. Pulmonary capillary wedge pressure (PCWP) is 22 mmHg (normal range 8-12 mmHg).

19. Central venous pressure (CVP) is 12 cmH2O (normal range 4-12 cmH2O).

20. Cardiac output (CO) is 2.2 L/min (normal range 4-8 L/min).

21. Systemic vascular resistance (SVR) is 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5).

1. The patient is confused and unable to answer questions.

6. On physical exam, there is bruising over his sternum and left chest, with tenderness to palpation.

7. Cardiac auscultation reveals normal heart sounds with no murmurs, rubs, or gallops.

8. He has marked jugular venous distention.

9. He has bibasilar crackles on pulmonary auscultation with equal air entry bilaterally.

10. Abdominal and cranial nerve exams are within normal limits.

11. His extremities are cool with prolonged capillary refill, and he is diaphoretic.

12. The patient is admitted to the intensive care unit.

13. Hemodynamic monitoring is established.

14. The pulmonary capillary wedge pressure (PCWP) is 22 mmHg (normal range 8-12 mmHg).

15. The central venous pressure (CVP) is 12 cmH2O (normal range 4-12 cmH2O).

16. The cardiac output (CO) is 2.2 L/min (normal range 4-8 L/min).

17. The systemic vascular resistance (SVR) is 1800 dynes/seconds/cm^-5 (normal range 700–1600 dynes/seconds/cm^-5).


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

Context: A 23-year-old man comes to the emergency department complaining of 10/10 abdominal pain.

Context: It started about 3 hours ago with no obvious precipitating factor.

Context: He denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes but endorses “red-colored urine” for the past day.

Choices:
A. Hereditary defect of amino acid transporter in the kidney
B. Infection with urease positive bacteria
C. Presence of antibodies to the glomerular basement membrane
D. Thinning and splitting of the glomerular basement membrane

Answer: Hereditary defect of amino acid transporter in the kidney

1. A 23-year-old man comes to the emergency department.

2. He is complaining of 10/10 abdominal pain.

3. He describes the pain as sharp, stabbing, intermittent, and concentrated at the left lower quadrant.

4. The pain started about 3 hours ago with no obvious precipitating factor.

5. He reports multiple similar episodes in the past but they have all resolved within 1 hour or so.

6. He denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes.

7. He endorses “red-colored urine” for the past day.

8. He just returned from an extensive hiking trip in Colorado.

9. A radiograph of the abdomen was unremarkable.

1. The patient describes the pain as sharp, stabbing, intermittent, and concentrated at the left lower quadrant.

2. The pain started about 3 hours ago with no obvious precipitating factor.

3. The patient reports multiple similar episodes in the past, but they have all resolved within 1 hour or so.

4. The patient denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes but endorses “red-colored urine” for the past day.

5. The patient just returned from an extensive hiking trip in Colorado.

6. A radiograph of the abdomen was unremarkable.


Question: Which of the following is a side-effect of definitive treatment for this patient?

Context: A 33-year-old African American woman presents to the emergency department due to diffuse pain and fatigue.

Context: The woman states that she feels like her bones and muscles diffusely hurt.

Context: She also has experienced some abdominal pain as well and states that she has trouble focusing.

Context: The patient has a past medical history of sickle cell disease for which she takes hydroxyurea.

Context: Her temperature is 98.1°F (36.7°C), blood pressure is 119/59 mmHg, pulse is 130/min, respirations are 16/min, and oxygen saturation is 98% on room air.

Choices:
A. Dilute urine
B. Peaked T-waves on ECG
C. QT shortening on ECG
D. Tetany

Answer: Tetany

Endocrinology, Diabetes, and Metabolism
General Internal Medicine
Rheumatology

1. A 33-year-old African American woman presents to the emergency department.

2. The woman states that she has diffuse pain and fatigue.

3. She also has experienced some abdominal pain.

5. The patient has a past medical history of sickle cell disease.

6. The patient takes hydroxyurea for her sickle cell disease.

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

8. The patient's blood pressure is 119/59 mmHg.

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

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

12. Laboratory values are ordered and are currently pending.

1. The woman feels diffuse bone and muscle pain.

4. The patient has a past medical history of sickle cell disease.

5. She takes hydroxyurea for sickle cell disease.

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

11. Laboratory values are ordered and pending.


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

Context: A 40-year-old man with psoriatic arthritis comes to the physician because of progressively worsening pain and stiffness in both of his hands and feet for the past 3 weeks.

Context: Physical examination shows scaly plaques on both elbows and limited range of motion of most of the larger joints.

Choices:
A. Suppression of the bone marrow
B. Decreased ionization by the glomeruli
C. Formation of antidrug antibodies
D. Increased acetylation by the liver

Answer: Formation of antidrug antibodies

1. A 40-year-old man has psoriatic arthritis.

2. He has been experiencing progressively worsening pain and stiffness in both of his hands and feet for the past 3 weeks.

3. His psoriatic arthritis had been well-controlled with adalimumab for several years prior to this.

4. His only other medication is omeprazole.

5. Physical examination shows scaly plaques on both elbows.

6. Physical examination shows limited range of motion of most of the larger joints.

1. His psoriatic arthritis had been well-controlled with adalimumab for several years.

2. His only other medication is omeprazole.

3. Physical examination shows scaly plaques on both elbows.

4. Physical examination shows limited range of motion of most of the larger joints.


Question: This abnormal lab finding was most likely caused by increased activity of which of the following mediators?

Context: A 35-year-old African American female presents to the emergency department with a three day history of cough, chest pain, and fever.

Context: Upon presenting to the emergency department, her temperature is 101.4 °F (38.5 °C), blood pressure is 110/80 mmHg, pulse is 95/min, and respirations are 24/min.

Context: The patient undergoes lab tests in the emergency department that demonstrate an elevated level of C-reactive protein.

Choices:
A. IL-12
B. IL-8
C. IL-6
D. IL-2

Answer: IL-6

1. A 35-year-old African American female presents to the emergency department.

2. She has a three day history of cough, chest pain, and fever.

3. Her temperature is 101.4 °F (38.5 °C).

7. Lung auscultation reveals crackles over the left lung base.

8. Chest radiograph reveals a dense consolidation in the left lower lung.

9. The patient undergoes lab tests in the emergency department.

10. The lab tests demonstrate an elevated level of C-reactive protein.

1. Upon presenting to the emergency department, her temperature is 101.4 °F (38.5 °C).

5. Lung auscultation reveals crackles over the left lung base.

6. Chest radiograph reveals a dense consolidation in the left lower lung.

7. The patient undergoes lab tests in the emergency department.

8. The lab tests demonstrate an elevated level of C-reactive protein.


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

Context: He has no shortness of breath.

Context: He drinks 1–2 beers a week.

Choices:
A. Follow-up x-ray of the chest in 12 months
B. Positron emission tomography
C. CT scan of the chest
D. Reassurance

Answer: CT scan of the chest

General Orthopaedic Surgery
Orthopaedic Sports Medicine

1. A 50-year-old man comes to the physician after a fall on a flight of stairs earlier that day.

2. He slipped, causing him to fall and hit the handrail with the lateral part of his chest.

4. He returned from a 10-day trip to South Africa 4 weeks ago.

5. He smoked one pack of cigarettes daily for 10 years but stopped 18 years ago.

10. Examination shows normal breath sounds bilaterally.

11. The left lateral chest wall is tender to palpation.

12. An x-ray of the chest shows no fracture.

13. There is a 5-mm lesion in the right upper lung field.

14. There are no previous x-rays of the patient available.

1. He slipped, causing him to fall and hit the handrail with the lateral part of his chest.

3. He returned from a 10-day trip to South Africa 4 weeks ago.

4. He smoked one pack of cigarettes daily for 10 years but stopped 18 years ago.

6. His temperature is 37.1°C (98.8°F), pulse is 78/min, and blood pressure is 126/72 mm Hg.

7. Examination shows normal breath sounds bilaterally.

8. The left lateral chest wall is tender to palpation.

9. An x-ray of the chest shows no fracture; there is a 5-mm lesion in the right upper lung field.

10. There are no previous x-rays of the patient available.


Question: White blood cell (WBC) count  1,500/mm3 | Platelets 300,000/mm3 | Which of the following organisms is most likely responsible for this patient’s condition?

Context: A 62-year-old woman presents to a clinic with complaints of a worsening rash on her back, fevers with chills, and rigor for 2 days.

Context: She denies any headaches, nausea, or vomiting.

Context: Laboratory studies show: | Hemoglobin 8.4 g/dL | .

Choices:
A. Pseudomonas aeruginosa
B. Streptococcus pneumoniae
C. Haemophilus influenzae
D. Streptococcus pyogenes

Answer: Pseudomonas aeruginosa

2. Patient has a worsening rash on her back, fevers with chills, and rigor for 2 days.

3. Patient denies any headaches, nausea, or vomiting.

4. Patient is currently on chemotherapy for multiple myeloma, which was diagnosed last year.

5. On examination, there were multiple punched-out ulcers covered in crusts surrounded by raised, violaceous margins on her back. Some of the lesions have black necrotic centers.

6. Vital signs include: temperature 38.8°C (102.0°F), respirations 24/min, pulse 110/min, and blood pressure 100/90 mm Hg.

7. Laboratory studies show: Hemoglobin 8.4 g/dL.

1. The patient denies any headaches, nausea, or vomiting.

2. She is currently on chemotherapy for multiple myeloma, which was diagnosed last year.

3. On examination, there were multiple punched-out ulcers covered in crusts surrounded by raised, violaceous margins on her back.

4. Some of the lesions have black necrotic centers.

5. The vital signs include: temperature 38.8°C (102.0°F), respirations 24/min, pulse 110/min, and blood pressure 100/90 mm Hg.

6. Laboratory studies show: Hemoglobin 8.4 g/dL.


Question: Which of the following enzymes is most likely inhibited by this toxin?

Context: The mushrooms in the soup had been picked from his family's backyard, and samples of mushrooms were sent to the lab for analysis.

Choices:
A. DNA gyrase
B. RNA polymerase II
C. RNA polymerase I
D. RNA polymerase III

Answer: RNA polymerase II

1. An 8-year-old boy developed nausea, abdominal pain, and watery diarrhea 6 hours after consuming homemade mushroom soup.

2. The boy is rushed to the emergency department.

3. He is severely dehydrated and his blood pressure is 60/40 mm Hg.

4. He is managed with intravenous fluids and other supportive treatment.

5. The mushrooms in the soup had been picked from his family's backyard.

6. Samples of mushrooms were sent to the lab for analysis.

7. The lab reports confirmed that the mushrooms contained some kind of toxin.

1. The boy is rushed to the emergency department.


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

Context: A 6-year-old girl is brought to the physician because of generalized fatigue and dark urine for 4 days.

Context: Her temperature is 37°C (98.6°F) and blood pressure is 132/89 mm Hg.

Context: Her serum creatinine is 1.7 mg/dL.

Context: Urine studies show: | Blood 2+ | Protein 2+ | RBC 12–14/hpf with dysmorphic features | RBC casts numerous | .

Choices:
A. Granular subepithelial immune complex deposition
B. Systemic amyloid protein aggregation
C. Anti-type IV collagen antibody formation
D. DNA-anti-DNA antibody immune complex formation

Answer: Granular subepithelial immune complex deposition

1. A 6-year-old girl is brought to the physician.

2. She has had generalized fatigue and dark urine for 4 days.

3. Four weeks ago, she was treated with cephalexin for a skin infection.

6. Physical examination shows 1+ pretibial edema bilaterally.

10. Urine studies show: RBC 12–14/hpf with dysmorphic features.

11. Urine studies show: RBC casts numerous.

1. Four weeks ago, she was treated with cephalexin for a skin infection.

4. Physical examination shows 1+ pretibial edema bilaterally.

8. Urine studies show: RBC 12–14/hpf with dysmorphic features.

9. Urine studies show: RBC casts numerous.


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

Context: A 7-year-old girl is brought to the physician by her mother for a 6-month history of irritability.

Context: She has no history of significant illness and is up-to-date on her immunizations.

Context: She appears markedly lethargic.

Context: Her hemoglobin concentration is 9.2 g/dL and mean corpuscular volume is 76 μm3.

Choices:
A. Necator americanus
B. Enterobius vermicularis
C. Trichuris trichiura
D. Taenia solium

Answer: Necator americanus

1. A 7-year-old girl is brought to the physician by her mother.

2. She has a 6-month history of irritability.

3. She has no history of significant illness.

4. She is up-to-date on her immunizations.

6. Her vital signs are within normal limits.

7. Physical examination shows subconjunctival pallor.

8. Her hemoglobin concentration is 9.2 g/dL.

9. Her mean corpuscular volume is 76 μm3.

10. A photomicrograph of a wet stool mount is shown.

1. She has no history of significant illness.

2. She is up-to-date on her immunizations.

4. Her vital signs are within normal limits.

5. Physical examination shows subconjunctival pallor.

6. Her hemoglobin concentration is 9.2 g/dL.

7. Her mean corpuscular volume is 76 μm3.

8. A photomicrograph of a wet stool mount is shown.


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

Context: A 15-year-old girl is brought to the physician by her mother because of a 3-day history of lower abdominal pain.

Context: Menarche has not yet occurred.

Choices:
A. Labial adhesions
B. Androgen insensitivity
C. Endometriosis
D. Imperforate hymen

Answer: Imperforate hymen

2. Patient was brought to the physician by her mother.

3. Patient has a 3-day history of lower abdominal pain.

4. Patient has had multiple similar episodes of abdominal pain over the past 9 months.

5. Each episode of abdominal pain has lasted for 4–5 days.

6. Patient has not yet experienced menarche.

7. Examination shows suprapubic tenderness to palpation.

8. Pubic hair and breast development are Tanner stage 4.

9. Pelvic examination shows bulging, bluish tissue 1 cm inside the vaginal introitus.

1. Over the past 9 months, she has had multiple similar episodes of abdominal pain, each lasting for 4–5 days.

3. Examination shows suprapubic tenderness to palpation.

4. Pubic hair and breast development are Tanner stage 4.

5. Pelvic examination shows bulging, bluish tissue 1 cm inside the vaginal introitus.


Question: In addition to symptomatic treatment, which of the following antiviral drugs would most likely benefit this patient?

Context: A 6-year-old boy presents with high fever, sore throat, and cough for the past day.

Context: The patient’s mother also says he is complaining of generalized muscle aches and chills.

Context: Past medical history is significant for childhood asthma, managed with inhaled mometasone furoate.

Context: The patient’s temperature is 39.1°C (102.3°F), pulse is 120/min, and respiratory rate is 20/min.

Context: On physical examination, his oropharynx is erythematous with mild swelling of the pharyngeal tonsils.

Choices:
A. Amantadine
B. Ribavirin
C. Rimantadine
D. Oseltamivir

Answer: Oseltamivir

2. Patient has high fever, sore throat, and cough for the past day.

3. Patient is complaining of generalized muscle aches and chills.

4. Patient has past medical history of childhood asthma, managed with inhaled mometasone furoate.

5. Patient's temperature is 39.1°C (102.3°F).

7. Patient's respiratory rate is 20/min.

8. Patient's oropharynx is erythematous with mild swelling of the pharyngeal tonsils.

9. Chest auscultation reveals crepitus over the lung bases bilaterally.

10. Patient has no signs of respiratory distress.

11. Rapid diagnostic testing for influenza B infection in this patient is positive.

1. The patient's mother reports that he is complaining of generalized muscle aches and chills.

2. The patient has a past medical history significant for childhood asthma, managed with inhaled mometasone furoate.

3. The patient's temperature is 39.1°C (102.3°F).

5. The patient's respiratory rate is 20/min.

6. On physical examination, the patient's oropharynx is erythematous with mild swelling of the pharyngeal tonsils.

7. Chest auscultation reveals crepitus over the lung bases bilaterally.

8. There are no signs of respiratory distress.

9. Rapid diagnostic testing for influenza B infection in this patient is positive.


Question: Which of the following is most likely to be below the normal range in her blood due to her current condition?

Context: A 38-year-old woman presents to the emergency department with nausea and progressive right upper quadrant abdominal pain for the past day.

Context: For the past year, she has had occasional pain in her right upper quadrant which is often relieved on its own after a few hours.

Context: She was recently diagnosed with multiple gallstones for which she underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago.

Context: Past medical history is otherwise unremarkable.

Context: Vital signs include blood pressure 110/68 mm Hg, pulse 98/min, temperature 36.2°C (97.2°F), and respiratory rate 11/min.

Context: Laboratory tests are pending.

Choices:
A. Trypsinogen
B. C-reactive protein
C. Glucose
D. Calcium

Answer: Calcium

2. Patient presents with nausea and progressive right upper quadrant abdominal pain for the past day.

3. Patient has had occasional pain in her right upper quadrant for the past year, which is often relieved on its own after a few hours.

4. Patient was recently diagnosed with multiple gallstones.

5. Patient underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago.

6. Patient's past medical history is otherwise unremarkable.

7. On physical examination, there is tenderness over the epigastrium with no guarding or rebound.

8. Patient's vital signs include blood pressure 110/68 mm Hg, pulse 98/min, temperature 36.2°C (97.2°F), and respiratory rate 11/min.

10. Imaging study of the abdomen confirms the most likely diagnosis.

1. She has had occasional pain in her right upper quadrant for the past year.

2. The pain is often relieved on its own after a few hours.

3. She was recently diagnosed with multiple gallstones.

4. She underwent an elective uncomplicated endoscopic retrograde cholangiopancreatography (ERCP) 3 days ago.

5. Her past medical history is otherwise unremarkable.

6. On physical examination, there is tenderness over the epigastrium.

7. There is no guarding or rebound on physical examination.

13. An imaging study of the abdomen confirms the most likely diagnosis.