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

Context: A 41-year-old woman presents with acute right flank pain for the past 6 hours.

Context: She says the pain is severe, colicky, ‘comes in waves’, and is localized to the right flank.

Context: She also has associated nausea and vomiting.

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

Context: On physical examination, she is writhing in pain and moaning.

Context: There is severe right costovertebral angle tenderness.

Context: Aggressive IV fluid hydration is started, and ondansetron is administered.

Choices:
A. Renal ultrasound
B. 24-hour urine chemistry
C. Potassium citrate
D. Hydrocodone/acetaminophen

Answer: Hydrocodone/acetaminophen

2. Patient has had acute right flank pain for the past 6 hours.

3. Patient describes the pain as severe, colicky, and ‘coming in waves’.

4. Pain is localized to the right flank.

5. Patient has associated nausea and vomiting.

7. Vital signs are within normal limits.

8. On physical examination, patient is writhing in pain and moaning.

9. Severe right costovertebral angle tenderness is present.

11. Noncontrast CT of abdomen and pelvis reveals a 4-mm-diameter radiopaque stone obstructing the right ureteropelvic junction.

12. Aggressive IV fluid hydration is started.

1. The patient reports severe, colicky pain localized to the right flank.

3. The patient experiences associated nausea and vomiting.

5. Vital signs are within normal limits.

6. On physical examination, the patient is writhing in pain and moaning.

7. Severe right costovertebral angle tenderness is present.

8. Gross hematuria is present on urinalysis.

9. A noncontrast CT of the abdomen and pelvis reveals a 4-mm-diameter radiopaque stone obstructing the right ureteropelvic junction.

10. Aggressive IV fluid hydration is started.


Question: Which of the following drugs has the most similar mechanism to inflixmab?

Context: A 36-year-old female presents with a 6-month history of stiffness in her joints.

Context: She reports bilateral knee pain that is worse in the morning prior to activity and stiffness of the fingers in both hands.

Context: Anti-CCP antibody tests are positive.

Context: Over several months, the patient's symptoms prove unresponsive to NSAIDs and methotrexate, and the decision is made to begin infliximab.

Choices:
A. Imatinib
B. Cyclophosphamide
C. Trastuzumab
D. Allopurinol

Answer: Trastuzumab

2. She has a 6-month history of stiffness in her joints.

4. The knee pain is worse in the morning prior to activity.

5. She has stiffness of the fingers in both hands.

6. Anti-CCP antibody tests are positive.

7. The patient's symptoms are unresponsive to NSAIDs and methotrexate.

8. The decision is made to begin infliximab.

1. The patient reports bilateral knee pain.

2. The knee pain is worse in the morning prior to activity.

3. The patient experiences stiffness of the fingers in both hands.

4. Anti-CCP antibody tests are positive.

5. The patient's symptoms are unresponsive to NSAIDs.

6. The patient's symptoms are unresponsive to methotrexate.

7. The decision is made to begin infliximab.


Question: Which of the following is the best explanation for this patient’s improvement in symptoms?

Context: A 55-year-old man presents to the emergency department with chest pain that started 1 hour ago and has not been improving.

Context: He has a past medical history of diabetes, hypertension, and obesity.

Context: His temperature is 98.5°F (36.9°C), blood pressure is 147/68 mmHg, pulse is 130/min, respirations are 13/min, and oxygen saturation is 100% on room air.

Context: The patient is given nitroglycerin, and his chest pain improves.

Choices:
A. Coronary artery vasodilation
B. Decreased adrenergic tone
C. Mu receptor agonism
D. Preload reduction

Answer: Preload reduction

Interventional Cardiology
Cardiovascular Disease

1. A 55-year-old man presents to the emergency department with chest pain.

2. The chest pain started 1 hour ago and has not been improving.

3. The patient has a past medical history of diabetes, hypertension, and obesity.

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

9. Physical exam is notable for jugular venous distension and bilateral lower extremity pitting edema.

9. Physical exam notable for jugular venous distension

10. Physical exam notable for bilateral lower extremity pitting edema


Question: This increase in serum lactate is necessary to regenerate an essential cofactor for which of the following enzymes?

Context: Baseline serum lactate levels at rest are recorded and repeat levels are obtained directly after a 1000-meter sprint.

Choices:
A. Glycogen phosphorylase
B. Glyceraldehyde-3 phosphate dehydrogenase
C. Phosphofructokinase-1
D. Pyruvate carboxylase

Answer: Glyceraldehyde-3 phosphate dehydrogenase

Endocrinology, Diabetes, and Metabolism
Sports Medicine

1. An investigator is studying energy metabolism in athletes.

2. Baseline serum lactate levels at rest are recorded.

3. Repeat levels are obtained directly after a 1000-meter sprint.

4. Compared to the baseline measurements, the serum lactate levels are significantly increased after the sprint.

1. Baseline serum lactate levels are recorded at rest.

2. Repeat serum lactate levels are obtained directly after a 1000-meter sprint.

3. Serum lactate levels are significantly increased after the sprint compared to the baseline measurements.


Question: Which of the following processes is responsible for the loss of these marked CD8+ cells?

Context: Once injected into the thymus, these cells bind tightly to MHC I self-antigen complexes.

Choices:
A. Positive selection
B. Negative selection
C. APC antigen presentation
D. IL-2 stimulation

Answer: Negative selection

1. A scientist is studying the development of CD8+ T cells.

2. In his experiments, he uses a radioactive isotope to mark a population of T cells.

3. The marked cells are injected into the thymus.

4. The marked cells bind tightly to MHC I self-antigen complexes.

5. Later in the experiment, the scientist cannot find any marked cells in the peripheral blood.

1. In his experiments, he uses a radioactive isotope to mark a population of T cells.

2. The radioactive isotope is injected into the thymus.

3. The marked cells bind tightly to MHC I self-antigen complexes.

4. The scientist cannot find any marked cells in the peripheral blood later in the experiment.


Question: Based on CXR and biopsy slides shown, you feel that all of the following would be consistent with her diagnosis EXCEPT?

Context: A 65-year-old woman who has smoked 2 packs per day for forty years comes to your practice complaining of a chronic cough, dyspnea, hemoptysis, and difficulty rising from a chair.

Choices:
A. Decreasing muscle strength with repetitive stimulation
B. Antibodies to presynaptic calcium channels
C. Dry mouth
D. Orthostatic hypotension

Answer: Decreasing muscle strength with repetitive stimulation

2. Patient has smoked 2 packs per day for 40 years.

3. Patient is complaining of a chronic cough.

5. Patient is complaining of hemoptysis.

6. Patient is complaining of difficulty rising from a chair.

2. She has smoked 2 packs per day for forty years.

6. She complains of difficulty rising from a chair.


Question: What is the most likely diagnosis?

Context: A 16-month-old boy is brought to the pediatrician after his parents noticed the appearance of a rash on his face, torso, and limbs.

Context: The boy has been ill for almost 2 weeks, initiating with fever, malaise, coryza, headache, nausea, diarrhea, and a rash on both of his cheeks.

Context: Physical examination is unremarkable except for an erythematous maculopapular rash on the face, trunk, and extremities with a reticular pattern (as shown in the photograph).

Choices:
A. Measles
B. Chickenpox
C. Erythema infectiosum
D. Roseola infantum

Answer: Erythema infectiosum

General Pediatrics
Pediatric Dermatology

1. A 16-month-old boy is brought to the pediatrician.

2. His parents noticed the appearance of a rash on his face, torso, and limbs.

3. The boy has been ill for almost 2 weeks.

4. The illness initiated with fever, malaise, coryza, headache, nausea, diarrhea, and a rash on both of his cheeks.

5. Physical examination is unremarkable except for an erythematous maculopapular rash on the face, trunk, and extremities.

6. The rash has a reticular pattern (as shown in the photograph).

1. The boy has been ill for almost 2 weeks.

2. The illness initiated with fever, malaise, coryza, headache, nausea, diarrhea, and a rash on both of his cheeks.

3. Physical examination is unremarkable except for an erythematous maculopapular rash on the face, trunk, and extremities.


Question: This patient’s symptoms are likely due to irritation of a nerve that passes through which of the following foramina?

Context: A 27-year-old woman presents to a neurologist complaining of facial pain.

Context: She reports that over the past 6 months, she has developed intermittent burning unilateral facial pain that happens over 10 seconds to 3 minutes.

Context: She is worried whenever she goes out that another attack will happen and she is sad that this has limited her ability to work as a lawyer.

Context: She takes an oral contraceptive pill.

Context: Her temperature is 98.6°F (37°C), blood pressure is 130/75 mmHg, pulse is 75/min, and respirations are 18/min.

Choices:
A. Foramen rotundum
B. Inferior orbital fissure
C. Jugular foramen
D. Superior orbital fissure

Answer: Foramen rotundum

Neurology with Special Qualification in Child Neurology

1. A 27-year-old woman presents to a neurologist.

3. She reports that over the past 6 months, she has developed intermittent burning unilateral facial pain.

4. The pain happens over 10 seconds to 3 minutes.

5. The pain is severe enough to completely stop her from her activities.

6. She is worried whenever she goes out that another attack will happen.

7. She is sad that this has limited her ability to work as a lawyer.

8. Her past medical history is notable for irritable bowel syndrome and polycystic ovarian syndrome.

9. She takes an oral contraceptive pill.

14. On exam, she is a well-appearing woman who is alert, oriented, and appropriately interactive.

15. Her pupils are 2 mm and reactive to light bilaterally.

16. Fundoscopic examination is unremarkable.

17. Her strength and range of motion are full and symmetric in her upper and lower extremities.

1. She reports developing intermittent burning unilateral facial pain over the past 6 months.

2. The pain lasts for 10 seconds to 3 minutes.

3. The pain is severe enough to completely stop her from her activities.

4. She is worried about another attack happening whenever she goes out.

5. She is sad that the pain has limited her ability to work as a lawyer.

6. Her past medical history includes irritable bowel syndrome and polycystic ovarian syndrome.

7. She takes an oral contraceptive pill.

12. On exam, she is a well-appearing woman who is alert, oriented, and appropriately interactive.

13. Her pupils are 2 mm and reactive to light bilaterally.

14. Fundoscopic examination is unremarkable.

15. Her strength and range of motion are full and symmetric in her upper and lower extremities.


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

Context: A 26-year-old man comes to the physician because of high-grade fever, fatigue, nausea, and headache for 4 days.

Context: The headache is constant and feels like a tight band around his head.

Context: He also reports that his eyes hurt while looking at bright lights.

Context: He has been taking acetaminophen and using cold towels to help relieve his symptoms.

Context: He works as an assistant for a nature camp organization but has been unable to go to work for 3 days.

Context: His immunization records are unavailable.

Context: His temperature is 38.5°C (101.3°F), pulse is 92/min, and blood pressure is 108/74 mm Hg.

Context: He is oriented to time, place, and person.

Context: There is no rash or lymphadenopathy.

Context: A lumbar puncture is done; cerebrospinal fluid analysis shows an opening pressure of 80 mm H2O, leukocyte count of 93/mm3 (78% lymphocytes), a glucose concentration of 64 mg/dL, and a protein concentration of 50 mg/dL.

Choices:
A. Borrelia burgdorferi
B. Mycobacterium tuberculosis
C. Herpes simplex virus 1
D. Coxsackievirus

Answer: Coxsackievirus

General Infectious Disease
Infectious Disease

2. Patient has high-grade fever, fatigue, nausea, and headache for 4 days.

3. Headache is constant and feels like a tight band around his head.

4. Eyes hurt while looking at bright lights.

5. Patient has been taking acetaminophen and using cold towels to help relieve his symptoms.

6. Patient works as an assistant for a nature camp organization.

7. Patient has been unable to go to work for 3 days.

8. Patient's immunization records are unavailable.

9. Patient's temperature is 38.5°C (101.3°F).

11. Patient's blood pressure is 108/74 mm Hg.

12. Patient is oriented to time, place, and person.

14. Flexion of the neck results in flexion of the knee and hip.

15. Lumbar puncture done; cerebrospinal fluid analysis shows an opening pressure of 80 mm H2O.

16. Leukocyte count of 93/mm3 (78% lymphocytes).

1. The patient reports a constant headache that feels like a tight band around his head.

2. The patient's eyes hurt when looking at bright lights.

3. The patient has been taking acetaminophen and using cold towels to relieve his symptoms.

4. The patient has been unable to go to work for 3 days.

5. The patient's immunization records are unavailable.

6. The patient's temperature is 38.5°C (101.3°F).

8. The patient's blood pressure is 108/74 mm Hg.

9. The patient is oriented to time, place, and person.

10. There is no rash or lymphadenopathy.

11. Flexion of the neck results in flexion of the knee and hip.

13. Cerebrospinal fluid analysis shows an opening pressure of 80 mm H2O.

14. Cerebrospinal fluid analysis shows a leukocyte count of 93/mm3 (78% lymphocytes).

15. Cerebrospinal fluid analysis shows a glucose concentration of 64 mg/dL.

16. Cerebrospinal fluid analysis shows a protein concentration of 50 mg/dL.


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

Context: A 4-year-old girl presents to the pediatrician’s office for a physical examination prior to starting preschool.

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

Context: She is up to date on all vaccines and is meeting all developmental milestones.

Context: Past medical history is noncontributory.

Context: She takes no medications but does take a chewable vitamin daily.

Context: She lives with her parents and older brother in a house.

Context: Today, her blood pressure is 110/65 mm Hg, heart rate is 90/min, respiratory rate is 22/min, and temperature of 37.0°C (98.6°F).

Context: On physical exam, she appears well developed and pleasant.

Context: She sits listening to the conversation and follows directions.

Context: Auscultation reveals a normal S1 but the S2 is split and remains split during inhalation and exhalation.

Context: Additionally, there is a medium pitched midsystolic murmur that is loudest between ribs 2 and 3 on the left side and a very soft diastolic rumble.

Choices:
A. Atrial septal defect
B. Coarctation of the aorta
C. Patent ductus arteriosus
D. Tetralogy of Fallot

Answer: Atrial septal defect

2. Patient was born at 39 weeks gestation via spontaneous vaginal delivery.

3. Patient is up to date on all vaccines and is meeting all developmental milestones.

4. Patient's past medical history is noncontributory.

5. Patient takes no medications but does take a chewable vitamin daily.

6. Patient lives with her parents and older brother in a house.

7. Patient's blood pressure is 110/65 mm Hg.

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

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

11. On physical exam, patient appears well developed and pleasant.

12. Patient sits listening to the conversation and follows directions.

13. Palpation of the heart reveals a mild parasternal heave.

15. Auscultation reveals S2 is split and remains split during inhalation and exhalation.

16. Auscultation reveals a medium pitched midsystolic murmur that is loudest between ribs 2 and 3 on the left side.

17. Auscultation reveals a very soft diastolic rumble.

2. She was born via spontaneous vaginal delivery

4. She is meeting all developmental milestones

5. Past medical history is noncontributory

8. She lives with her parents and older brother in a house

9. Today, her blood pressure is 110/65 mm Hg

13. On physical exam, she appears well developed and pleasant

14. She sits listening to the conversation

16. Palpation of the heart reveals a mild parasternal heave

18. The S2 is split and remains split during inhalation and exhalation

19. There is a medium pitched midsystolic murmur that is loudest between ribs 2 and 3 on the left side

20. There is a very soft diastolic rumble


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

Context: A 24-year-old man is brought to the emergency department after his head was hit with a bat during a baseball game.

Context: He is oriented to person and place.

Context: A CT scan of the head is shown.

Context: He withdraws from painful stimuli.

Choices:
A. Adminster hypotonic saline
B. Administer dexamethasone
C. Perform craniotomy
D. Perform brain MRI

Answer: Perform craniotomy

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

2. His head was hit with a bat during a baseball game.

3. His teammates state he was unresponsive after the incident but regained consciousness after 15 minutes.

4. The patient initially refused to go to the hospital and sat on the bench for the remainder of the game.

5. He initially appeared fine but became increasingly confused.

6. He appears lethargic but opens his eyes to loud verbal commands.

12. Examination shows an area of soft-tissue swelling over the left temporal region.

13. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.

15. After returning from the CT scan, the patient only opens his eyes to painful stimuli and responds to questions with incomprehensible sounds.

17. On repeat examination, the left pupil is 6 mm in diameter and reacts minimally to light.

18. The right pupil is 3 mm in diameter and reacts normally to light.

20. He is intubated in the emergency department.

1. His teammates state that he was unresponsive after the incident but regained consciousness after 15 minutes.

2. The patient initially refused to go to the hospital and sat on the bench for the remainder of the game.

3. He initially appeared fine but became increasingly confused.

4. He appears lethargic but opens his eyes to loud verbal commands.

6. His temperature is 37.1 (98.8°F), pulse is 78/min, respiratory rate is 16/min, and blood pressure is 148/87 mm Hg.

7. Examination shows an area of soft-tissue swelling over the left temporal region.

8. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.

10. After returning from the CT scan, the patient only opens his eyes to painful stimuli and responds to questions with incomprehensible sounds.

12. On repeat examination, the left pupil is 6 mm in diameter and reacts minimally to light.

13. The right pupil is 3 mm in diameter and reacts normally to light.

14. His respiratory rate is 10/min and he is intubated in the emergency department.


Question: Laboratory studies show: | Today 6 months ago | Hemoglobin A1c 6.2% 6.4% | Serum | Creatinine 1.3 mg/dL 1.1 mg/dL | Urine | Albumin:creatinine ratio (N < 30) 470 mg/g 260 mg/g | The addition of which of the following medications is most likely to have prevented this patient's progressively worsening renal function?"

Choices:
A. Losartan
B. Aspirin
C. Atorvastatin
D. Amlodipine

Answer: Amlodipine

1. A 58-year-old woman comes to the physician for a routine follow-up examination.

2. She has a history of type 2 diabetes mellitus, hypertension, and asthma.

3. Last year, she received laser photocoagulation for proliferative retinopathy.

4. Her current medications include metformin, lisinopril, and an albuterol inhaler.

5. Her mother died of complications from diabetes.

6. She drinks 1 glass of wine daily with dinner and does not smoke.

11. Cardiopulmonary examination is unremarkable.

12. There is decreased sensation to monofilament testing of the plantar surfaces of both feet.

1. She has a history of type 2 diabetes mellitus, hypertension, and asthma.

2. Last year, she received laser photocoagulation for proliferative retinopathy.

3. Her current medications include metformin, lisinopril, and an albuterol inhaler.

4. Her mother died of complications from diabetes.

5. She drinks 1 glass of wine daily with dinner and does not smoke.

6. Her temperature is 37.2°C (99°F), pulse is 92/min, respirations are 14/min, and blood pressure is 152/98 mm Hg.

7. Cardiopulmonary examination is unremarkable.

8. There is decreased sensation to monofilament testing of the plantar surfaces of both feet.


Question: Which of the following is the most effective intervention for this patient's skin lesion?

Context: A 4-year-old boy is brought to the physician by his mother because of a rash on his hands and feet for the past two weeks.

Context: His mother has a history of eczema.

Context: His temperature is 37.8°C (100.1°F).

Choices:
A. Oral acyclovir
B. Supportive care
C. Topical permethrin
D. Topical clotrimazole

Answer: Topical permethrin

1. A 4-year-old boy is brought to the physician by his mother.

2. The boy has had a rash on his hands and feet for the past two weeks.

3. The rash is intensely pruritic, especially at night.

4. The boy has not had fever, headache, or diarrhea.

5. The boy's mother has a history of eczema.

6. The boy was due for an appointment later in the week to follow up on any potentially missing vaccinations.

7. The boy's temperature is 37.8°C (100.1°F).

8. Examination shows a maculopapular rash with linear patterns affecting the interdigital spaces of the fingers and toes.

9. The remainder of the examination shows no abnormalities.

1. It is intensely pruritic, especially at night.

2. He has not had fever, headache, or diarrhea.

4. The child was due for an appointment later in the week to follow up on any potentially missing vaccinations.

6. Examination shows a maculopapular rash with linear patterns affecting the interdigital spaces of the fingers and toes.

7. The remainder of the examination shows no abnormalities.


Question: Which of the following stages does this patient's behavior most likely represent?

Context: A 32-year-old man comes with his wife to the primary care physician because she is concerned about his drinking behavior.

Context: Specifically, he drinks 7 drinks every day and has abandoned many social activities that he previously enjoyed.

Context: In addition, he starts drinking in the morning because he feels shaky when he does not have a drink.

Context: When asked about his behavior, the man says that he knows that he probably should drink less but feels that he is not motivated enough to change.

Context: He says that perhaps the topic should be addressed again next year.

Choices:
A. Contemplation
B. Precontemplation
C. Preparation
D. Relapse

Answer: Contemplation

1. A 32-year-old man comes with his wife to the primary care physician.

2. His wife is concerned about his drinking behavior.

4. He has abandoned many social activities that he previously enjoyed.

6. He feels shaky when he does not have a drink.

7. When asked about his behavior, he says he knows he should drink less.

8. He feels he is not motivated enough to change.

9. He suggests the topic should be addressed again next year.

2. He has abandoned many social activities.

3. He starts drinking in the morning because he feels shaky without a drink.

4. He knows he should drink less but feels unmotivated to change.

5. He suggests addressing the topic again next year.


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

Context: An 18-month-old boy is brought to the emergency department 25 minutes after an episode of loss of consciousness.

Context: The brief shrill cry was followed by a period of expiration; he then turned blue, became unconscious, and briefly lost his muscle tone, before he stiffened and had jerky movements of his arms and legs for 15 seconds.

Context: Vital signs are within normal limits.

Context: He is alert and active.

Choices:
A. CT scan of the head
B. Echocardiography
C. Reassurance
D. Tilt table test

Answer: Reassurance

1. An 18-month-old boy was brought to the emergency department 25 minutes after an episode of loss of consciousness.

2. The episode began when the child's 4-year-old brother snatched a toy from him.

3. The child had a brief shrill cry, followed by a period of expiration.

4. He then turned blue, became unconscious, and briefly lost his muscle tone.

5. He then had jerky movements of his arms and legs for 15 seconds.

6. After this episode, he immediately regained consciousness.

7. Two weeks ago, he had a similar episode when his father refused to give him a juice box.

8. He has been healthy and has met all his developmental milestones.

9. His vital signs are within normal limits.

11. Cardiopulmonary examination shows no abnormalities.

12. Neurologic examination shows no focal findings.

1. The child began crying after his 4-year-old brother snatched a toy from him.

2. The brief shrill cry was followed by a period of expiration.

3. He then turned blue, became unconscious, and briefly lost his muscle tone.

4. He stiffened and had jerky movements of his arms and legs for 15 seconds.

5. After this episode, he immediately regained consciousness.

6. He had a similar episode 2 weeks ago when his father refused to give him a juice box.

7. He has been healthy and has met all his developmental milestones.

8. Vital signs are within normal limits.

10. Cardiopulmonary examination shows no abnormalities.

11. Neurologic examination shows no focal findings.


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

Context: A 67-year-old woman presents to the ophthalmologist with complaints of worsening visual loss.

Context: She states that her vision is blurry.

Context: Driving has become difficult, particularly at night, as she experiences substantial glare and sees halos around lights.

Choices:
A. Age-related macular degeneration
B. Cataracts
C. Open-angle glaucoma
D. Refractive error

Answer: Cataracts

1. A 67-year-old woman presents to the ophthalmologist.

2. She has complaints of worsening visual loss.

3. She states that her vision is blurry.

4. Driving has become difficult, particularly at night.

7. On physical examination, there is absence of a red reflex.

1. The patient states that her vision is blurry.

2. Driving has become difficult for the patient, particularly at night.

3. The patient experiences substantial glare and sees halos around lights.

4. On physical examination, there is absence of a red reflex.


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

Context: A 30-year-old woman comes to the physician because of headaches and nausea for the past 3 weeks.

Context: During this period, she has also had a swishing sound in both ears, which decreases when she turns her head to either side.

Context: She has vomited twice in the past week.

Context: Hirsutism is present.

Context: Visual acuity is 20/20 in both eyes.

Context: There is esotropia of the left eye.

Choices:
A. Hyperpigmentation of palmar creases
B. Bilateral optic disc swelling
C. Raised intra-ocular pressure
D. Weakness of left upper and lower extremities

Answer: Bilateral optic disc swelling

2. Patient has had headaches and nausea for the past 3 weeks.

3. Headaches are holocranial and last up to several hours.

4. Patient has had a swishing sound in both ears, which decreases when she turns her head to either side.

5. Patient has had multiple episodes of blurring of vision and double vision for the past 2 weeks.

6. Patient has vomited twice in the past week.

7. Patient has nodular cystic acne and polycystic ovarian disease.

8. Current medications include an oral contraceptive, metformin, and isotretinoin.

9. Patient is 163 cm (5 ft 4 in) tall and weighs 89 kg (196 lb); BMI is 33.5 kg/m2.

10. Patient's temperature is 37.3°C (99.1°F), pulse is 70/min, and blood pressure is 128/82 mm Hg.

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

12. Examination shows acne over her cheeks and back.

14. Visual acuity is 20/20 in both eyes.

1. The headaches are holocranial and last up to several hours.

2. She has a swishing sound in both ears, which decreases when she turns her head to either side.

3. She has had multiple episodes of blurring of vision and double vision for the past 2 weeks.

4. She has vomited twice in the past week.

5. She has nodular cystic acne and polycystic ovarian disease.

6. Current medications include an oral contraceptive, metformin, and isotretinoin.

7. She is 163 cm (5 ft 4 in) tall and weighs 89 kg (196 lb); BMI is 33.5 kg/m2.

8. Her temperature is 37.3°C (99.1°F), pulse is 70/min, and blood pressure is 128/82 mm Hg.

9. She is oriented to time, place, and person.

10. Examination shows acne over her cheeks and back.

12. Visual acuity is 20/20 in both eyes.


Question: A history involving which of the following conditions is most likely to explain the administration of this drug instead of another nonsteroidal anti-inflammatory drug?

Context: A 64-year-old woman with knee osteoarthritis comes to the physician for a follow-up examination.

Context: She reports significantly improved pain control since starting celecoxib 1 month ago.

Choices:
A. Reye syndrome
B. Sulfa drug allergy
C. Glanzmann thrombasthenia
D. Gout

Answer: Glanzmann thrombasthenia

1. A 64-year-old woman comes to the physician for a follow-up examination.

3. She has been taking celecoxib for 1 month.

4. She reports significantly improved pain control since starting celecoxib.

1. Patient started taking celecoxib 1 month ago.

2. Patient reports significantly improved pain control since starting celecoxib.


Question: Which of the following drugs was administered?

Context: A 48-year-old woman is admitted to the hospital and requires anticoagulation.

Context: She is administered a drug that binds tightly to antithrombin III.

Choices:
A. Aspirin
B. Warfarin
C. Dabigatran
D. Enoxaparin

Answer: Enoxaparin

1. A 48-year-old woman is admitted to the hospital.

4. The drug binds tightly to antithrombin III.

2. The drug binds tightly to antithrombin III.


Question: Which of the following best describes the properties of the most likely virus involved?

Context: A 20-year-old woman comes to the physician because of a 2-day history of low-grade fever and painful lesions on her left index finger.

Context: Two weeks ago, she had a painful rash on the right labia majora that resolved without treatment.

Context: Physical examination shows tender lymphadenopathy of the left epitrochlear and right inguinal region.

Choices:
A. Naked virus with a double-stranded, circular DNA structure
B. Naked virus with a single-stranded, positive sense, linear RNA structure
C. Enveloped virus with a double-stranded, linear DNA structure
D. Enveloped virus with a partially double-stranded, circular DNA structure

Answer: Enveloped virus with a double-stranded, linear DNA structure

1. A 20-year-old woman comes to the physician.

2. She has a 2-day history of low-grade fever.

3. She has painful lesions on her left index finger.

4. Two weeks ago, she had a painful rash on the right labia majora.

6. Physical examination shows tender lymphadenopathy of the left epitrochlear region.

7. Physical examination shows tender lymphadenopathy of the right inguinal region.

8. A photograph of the left index finger is shown.

1. Two weeks ago, she had a painful rash on the right labia majora.

2. The painful rash resolved without treatment.

3. Physical examination shows tender lymphadenopathy of the left epitrochlear region.

4. Physical examination shows tender lymphadenopathy of the right inguinal region.

5. A photograph of the left index finger is shown.


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

Context: A 37-year-old man comes to the emergency department because of unsteady gait that started after waking up that morning.

Context: He works as a logger in Washington.

Context: The patient appears pale.

Context: He is alert and responsive.

Choices:
A. Perform enzyme‑linked immunosorbent assay
B. Administer doxycycline
C. Administer botulism antitoxin
D. Locate and remove tick

Answer: Locate and remove tick

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

2. His gait became unsteady after waking up that morning.

3. He has no fever, chills, headache, or myalgia.

5. His younger sister has multiple sclerosis.

12. Examinations shows intact cranial nerves.

13. There is bilateral flaccid paralysis of his lower extremities.

14. Lower extremity deep tendon reflexes are absent.

16. He is admitted to the intensive care unit.

17. Assisted breathing is started because of respiratory weakness.

1. He has no fever, chills, headache, or myalgia.

3. His younger sister has multiple sclerosis.

6. His temperature is 37°C (98.9°F), pulse is 100/min, respirations are 11/min, and blood pressure is 136/86 mm Hg.

7. Examinations shows intact cranial nerves.

8. There is bilateral flaccid paralysis of his lower extremities.

9. Lower extremity deep tendon reflexes are absent.

10. The patient develops tachypnea and is admitted to the intensive care unit.

11. Assisted breathing is started because of respiratory weakness.


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

Context: He says he has been having trouble falling asleep for as long as he can remember, but it has become increasingly worse after he and his wife moved to their new house.

Context: His wife even had to cancel the housewarming party that was planned for the neighbors because of her husband’s behavior.

Choices:
A. Respond in a straightforward manner, be honest and non-threatening
B. Encourage the patient to inform the police
C. Set rules and be firm with adhering to them
D. Refer this patient to another physician

Answer: Respond in a straightforward manner, be honest and non-threatening

1. A 43-year-old man presents requesting a sleep aid for long-standing insomnia.

2. He has been having trouble falling asleep for as long as he can remember.

3. His insomnia has become increasingly worse after he and his wife moved to their new house.

4. He claims that his new neighbors are jealous of his huge swimming pool and are trying to sabotage it while he sleeps.

5. His wife had to cancel the housewarming party that was planned for the neighbors.

6. When probed further on this topic, the patient accuses the physician of being angry and hostile.

1. The patient has been having trouble falling asleep for as long as he can remember.

2. The sleep troubles have become worse after the patient and his wife moved to their new house.

3. The patient claims that his new neighbors are jealous of his huge swimming pool.

4. The patient believes that his neighbors are trying to sabotage his swimming pool while he sleeps.

5. The patient's wife had to cancel the housewarming party planned for the neighbors due to her husband's behavior.


Question: Which of the following medications was most likely given to this patient?

Context: A 22-year-old man presents to the emergency room after an altercation with the police.

Context: On physical examination, the patient is disoriented, does not respond to questioning, and appears to be reacting to internal stimuli.

Context: Laboratory tests are performed, which are all within normal limits, including a toxicology screen.

Context: The patient becomes aggressive and is given a medication to address his acute psychotic episode.

Context: An hour later, he is found in a sustained rigid posture in his bed, with his eyes in a fixed upward gaze.

Choices:
A. Citalopram
B. Haloperidol
C. Phenelzine
D. Alprazolam

Answer: Haloperidol

1. A 22-year-old man presents to the emergency room.

2. The police were called because the man was acting erratically in public.

3. On physical examination, the patient is disoriented.

4. The patient does not respond to questioning.

5. The patient appears to be reacting to internal stimuli.

7. The laboratory tests are all within normal limits.

10. The patient is given a medication to address his acute psychotic episode.

11. An hour later, the patient is found in a sustained rigid posture in his bed.

12. The patient's eyes are in a fixed upward gaze.

1. The police were called because the man was acting erratically in public.

2. On physical examination, the patient is disoriented.

3. The patient does not respond to questioning.

4. The patient appears to be reacting to internal stimuli.

6. The laboratory tests are all within normal limits.

7. The laboratory tests include a toxicology screen.

9. The patient is given a medication to address his acute psychotic episode.

10. An hour later, the patient is found in a sustained rigid posture in his bed.

11. The patient's eyes are in a fixed upward gaze.


Question: Which of the following antibiotic therapies would be most suitable for this patient?

Context: A 42-year-old man is brought to the emergency department by his wife with chills and a temperature of 38.5°C (101.3°F) for the past 2 days.

Context: The patient’s wife mentions that he recently injured his leg 5 days ago, after which she noticed that his calf was swollen, red, and painful.

Context: She says there was no pus, but that her husband was in excruciating pain.

Context: His vital signs include: temperature 38.9°C (102.1°F), blood pressure 110/75 mm Hg, and  respiratory rate 18/min.

Context: On physical examination, there is a tender mass over the left calf which is red and inflamed.

Context: Blood and wound cultures are taken.

Context: The patient is started on empiric antibiotics with vancomycin, but shows no improvement.

Choices:
A. IV nafcillin
B. Dicloxacillin
C. IV daptomycin
D. Doxycycline

Answer: IV daptomycin

2. Patient has had chills and a temperature of 38.5°C (101.3°F) for the past 2 days.

4. Patient's calf was swollen, red, and painful.

6. Patient's vital signs include temperature 38.9°C (102.1°F), blood pressure 110/75 mm Hg, and respiratory rate 18/min.

7. Physical examination reveals a tender mass over the left calf which is red and inflamed.

9. Patient is started on empiric antibiotics with vancomycin.

11. Culture results reveal that the causative organism is resistant to the current antibiotic as well as penicillin.

1. The patient injured his leg 5 days ago.

2. The patient's wife noticed swelling, redness, and pain in his calf after the injury.

3. There was no pus present in the calf.

4. The patient was in excruciating pain.

5. The patient's temperature is 38.9°C (102.1°F).

6. The patient's blood pressure is 110/75 mm Hg.

7. The patient's respiratory rate is 18/min.

8. A tender mass is found over the left calf during physical examination.

11. The patient is started on empiric antibiotics with vancomycin.

12. The patient shows no improvement with the antibiotics.

13. Culture results reveal that the causative organism is resistant to the current antibiotic as well as penicillin.


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

Context: A 63-year-old man presents to the emergency department with the sudden onset of excruciating chest pain, which he describes as a tearing sensation

Context: He was diagnosed with essential hypertension 20 years ago, but he is not compliant with his medications

Context: On physical examination, the temperature is 37.1°C (98.8°F), heart rate is 95/min, and blood pressure is 195/90 mm Hg in the right arm and 160/80 mm Hg in the left arm

Context: The pulses are absent in his right leg and diminished in his left leg

Context: A chest X-ray shows a widened mediastinum.

Choices:
A. CT scan
B. Surgery
C. D-dimer
D. Intravenous ultrasound

Answer: CT scan

General Cardiology
Cardiovascular Disease

A 63-year-old man presents to the emergency department.

He is experiencing sudden, excruciating chest pain.

He describes the pain as a tearing sensation.

He was diagnosed with essential hypertension 20 years ago.

He is not compliant with his hypertension medications.

His physical examination reveals a temperature of 37.1°C (98.8°F).

His blood pressure is 195/90 mm Hg in the right arm.

His blood pressure is 160/80 mm Hg in the left arm.

The blood pressure difference between his arms is 35/10 mm Hg.

1. Diagnosed with essential hypertension 20 years ago

5. Blood pressure is 195/90 mm Hg in the right arm

6. Blood pressure is 160/80 mm Hg in the left arm

9. Chest X-ray shows widened mediastinum